About the CHIR

Jackson’s Community Health Improvement Region (CHIR) functions as a distributed network with multiple collective impact collaboratives or ‘strands’ (Health Improvement Organization, Financial Stability Network, and Cradle to Career Education Network) working together to leverage shared infrastructure that supports a systems change approach to community well-being. The Jackson CHIR membership currently consists of membership from over 100 agencies with close to 400 active members who agree with the following common values:

  • Equity
  • Authentic Engagement
  • Continuous Learning

The Health Improvement Organization Coordinating Council (HIO CC) serves as the CHIR governance body.  

CHIR Goals and Strategies

Primary Aims

  • Reduce Emergency Department Utilization
  • Reduce Unmet Social Needs
  • Reduce Disparities in Health Outcomes

System Change Targets

  • Convenient triage and access to right care, right place, right time’
    • Behavioral health coordination
    • Crisis R&R
    • Redesign of 24/7 after hours call center and expansion of alternative visits
  • Effective linkage to needed services based on reliable social needs screening, referral and navigation systems
    • Community Clinical Linkages
  • Affordable community solutions for social barriers that affect appropriate access
    • Community Living Room
  • Culturally competent systems responsive to client feedback
    • Community Engagement Corps
    • Cross-Cultural Conversations
  • Coordinated community resourcing with aligned incentives and ability to re- invest shared savings
    • Employer-driven healthcare design and financing models
    • Realignment of community resources to support co-case management across multiple providers
    • Shared risk/savings models with local clinically integrated networks and CHIR community service providers

Current Efforts

Jackson continues to build an Integrated System of Care, a “no wrong door” approach to identify, assess, assist and follow up with those we serve. Seventeen primary care practices and 12 community organizations have completed over 38,000 screens for social needs since June 2018. More than 3400 referrals for food, housing, job training and other social needs have been made on behalf of Jackson County residents.

A Jackson County Health Department employee shared this success story of using the Jackson Care Hub screening and referral tool to connect a patient to needed resources:

“I just had a client give good feedback about the hub! She was here today for treatment and told me that the hub screening was really successful. She was able to get into the Center for Family Health and was assisted with applying for Medicaid, schedule an appointment with a PCP there AND get her first ever pap smear! She high fived me twice and was really excited to receive the call back and assistance from the hub referrals. She also got two vaccinations and expedited partner therapy for her partner through the sexual health clinic!"


For more information: 
Laurie Gustafson
lgustaf1@hfhs.org, 517-205-7507