This article is part of State of Health, a series about how Michigan communities are rising to address health challenges. It is made possible with funding from the Michigan Health Endowment Fund.

An older adult living with bipolar disorder, Anthony* was about to be evicted from his Grand Rapids home in public housing. Thanks to a Grand Valley State University (GVSU) Kirkhof College of Nursing Family Health Center satellite location within his building, he connected with resources that enabled him to not only keep his home but also provided more effective medications, employment, and ongoing counseling. This is just one example of how Michigan organizations are innovating to address social determinants of health (SDOH) – the non-medical factors that influence people's health – in alignment with the state of Michigan's Social Determinants of Health Strategy.

Other programs addressing SDOH have included an Ascension St. Joseph Foundation program that connects rural pregnant women with a community health worker/health coach, as well as Calvin University's Lay Ambassadors for Mental Health in Grand Rapids. All three initiatives are supported by grants from the Michigan Health Endowment Fund.

In Grand Rapids, Calvin University's Lay Ambassadors for Mental Health program builds on the university nursing program's long-running relationships with under-resourced neighborhoods.

"The Lay Ambassador program is made up of women who mostly live in or close to each of those neighborhoods or have grown up and worked in those neighborhoods," says Gail Zandee, Calvin University associate professor of nursing and community partnership coordinator. "They are known by the four neighborhoods we're in, and they have lived experiences matching those they're seeking to serve."

Most of the Lay Ambassadors took part in another Calvin University Nursing Program outreach initiative, Women Supporting Women. This program launched in 2010 through community-based participatory research, meaning that community members came up with the idea for the program. Because subsequent surveys of neighborhood residents indicated mental health was one of residents' top five concerns, these women proposed the idea of offering peer mental health supports as a way to address mental health and prevent crises.

"These women stepped forward and said, 'We want more training so we can share this with others in our communities.' It's really about residents of those neighborhoods being the drivers of health care," Zandee says. "We listen, we walk alongside, and we try to implement what residents want. They're the real drivers and the creators of this whole idea."
Lay Ambassador Datasha Chapman.
One barrier to mental health care in these communities is elevated stigma in Black and Latinx communities. Cultural messages about mental health, historical trauma around health care in general, and language barriers all contribute to this stigma.

"The ambassadors are particularly attuned to that stigma, and particularly equipped to address it in the context that it originated from," says Mary Molewyk Doornbos, Calvin University professor of nursing. "They don't see persons who look like them when they try to access the health care system. We've heard from the mental health ambassadors that this is a particularly difficult issue for them in their communities. So, they go straight down to the neighborhoods with information to combat that stigma."
Lay Ambassador Tabitha Williams.
Doornbos and Zandee note that a lot of the interactions between the ambassadors and neighborhood residents happen in informal settings — the grocery store, church, workplace, and other heavily trafficked spaces.

"When it's a conversation in the grocery store, after church, or with my next-door neighbor, the whole context feels safer," Zandee says. "The ambassadors are well regarded. They're trusted members of the community. If they suggest something, it's oftentimes incorporated because of the sense that 'They understand me. They understand my culture.'"

Josie Guillen, a lay ambassador since 2020, works in Grand Rapids' Burton Heights, a predominantly Latinx community. She's retired from a 38-year career in Grand Rapids Public Schools.

"I've worked with students, parents, and families pretty much all my life," Guillen says. "And I just love to give back to the community and help out in any way that I can."
Lay Ambassador Josie Guillen.
Guillen shares the story of one woman she worked with whose husband died of COVID-19 after collapsing in their house and going into a coma. Guillen and her fellow ambassadors visited the woman regularly, helping her navigate an intense grieving process.
 Connecting expectant parents to care beyond the clinic visit

When patients initiate prenatal care at Ascension St. Joseph Hospital Women's Clinic in Tawas City, patient navigator and nurse Alissa Parnicky meets with them to provide education that empowers them to make informed decisions about their pregnancy. Parnicky also connects patients with a community health worker (CHW) who acts as their health coach throughout the birthing year.
Alissa Parnicky holds a child.
"We want our patients to genuinely know that we care about them, and we want them to have the very best care possible," Parnicky says. "When you're in a rural area, you have limited resources. The majority of patients are unaware of what services are even offered. Patients who are uninsured, underinsured, insured by Medicaid, or who screen positive for social determinants of health-related needs — we invite them to participate in the program."

Most of the expectant parents live in rural Iosco County but some come from rural Alcona, Alpena, and Oscoda counties. The CHW health coach develops a trusting relationship with each patient, serves as a liaison between the patient and their provider, facilitates referrals as needed, ensures that the patients are able to keep their scheduled appointments, and alleviates barriers to care. The CHW meets with the patients at the clinic, at the county health department, or in their homes.

"They go in there for the pregnant mom, but then sometimes realize, 'Okay, this is something that we need to work on as a family unit," Parnicky says. "The community health workers can make referrals for the family unit through their health department, so that's pretty awesome."

Screening patients for SDOH informs the CHWs on what types of resources the patients and their families need, whether that be covering the cost of health care and medications, transportation to doctor's appointments, healthy food, help with utility payments, or housing. The screening also helps identify depression and anxiety. 

"I was born and raised in this community, so I know firsthand the barriers and struggles that women face," Parnicky says. "Women need a safe place where they can be respected and vulnerable without judgment. Women need compassion and empathy. Life can be challenging — we all go through unexpected circumstances. When we're supported and loved by others, we can not only overcome the barrier, but we can shine brighter than we first thought possible."

Better than a house call

The GVSU Kirkhof College of Nursing project that helped Anthony stay in his home established Family Health Center satellite locations serving older adults within two Grand Rapids public housing communities. Behavioral health became a focus when it became apparent that nearly half of the residents receiving primary care had some type of behavioral health or mental health need.
Dr. Della Hughes.
"If you don't have enough mental health capacity to get out of bed, you're not going to worry about your blood pressure or your diabetes or go to get that mammogram," says Dr. Della Hughes, nurse practitioner and assistant professor at Kirkhof College of Nursing. "Our team had social workers, a psychologist, psychiatric mental health nurse practitioners, and therapies such as P.T. and O.T. We offered nutritional services and we even went as far as working with different drug reps and Medicaid and Medicare care managers. The [Michigan Health Endowment Fund] grant allowed us to really expand those interprofessional connections."

In addition, a storage room at one of the public housing communities has been converted into a telehealth room with comfortable furnishings and a huge screen for health care appointment video conferencing.

While the Family Health Center will be closing on Nov. 30, Hughes notes that the satellite locations will continue to care for the residents as Cherry Health and Catherine's Health Center will step in to provide services. Meanwhile, new grant funding will allow Kirkhof College of Nursing to develop a similar program that focuses on children.
Dr. Christina Quick.
"We have this model of care that we've followed, and we've seen great success with vulnerable populations," says Dr. Christina Quick, assistant professor, Kirkhof College of Nursing. "We would like to translate that into future care models that address families and potentially seek new opportunities for how we care for our children who are in foster care or who have been adopted, recognizing that those youth have greater rates of chronic health care needs, mental and behavioral health care needs, and developmental needs and often aren't well established with primary care."

These are only a few examples of Michigan projects addressing root causes of community health concerns by looking at the social and economic determinants of health. As these models demonstrate proven success, even more of the state's private and public health systems will be able to replicate them and extend the lessons learned to improve health for the state's most vulnerable residents. 

*Name changed to protect patient confidentiality.

Estelle Slootmaker is a working writer focusing on journalism, book editing, communications, poetry, and children's books. You can contact her at Estelle.Slootmaker@gmail.com or www.constellations.biz.

Mental Health Lay Ambassadors photos by Tommy Allen. All other photos courtesy of the subjects.