Origin Story

We had a mission.

The Jackson Care Hub's journey began in 2016 with the mission to address the social drivers of health (SDoH). This initiative stemmed from the State Innovation Model (SIM) grant which aimed to establish clinical-community linkages across sectors to better serve all patients. This was a tall order, but we were ready.

In the years preceding SIM, Jackson built a culture of inter-agency coordination and support. Multiple collaborative groups applied methods like Collective Impact and ABLe Change. These entities had different names and targeted different problems, but each group shared a commitment to improve care for everyone in Jackson through meaningful systems change.

When the SIM opportunity arrived, we focused our collaborative efforts on SDOH needs. Between January 2017 and March 2020, 136 people from 46 agencies attended 116 meetings lasting a total of 8,843 hours to develop the integrated Jackson Care Hub model we use today. Collectively, our community partners invested 26,460 hours of meeting time to design the first version of the Care Hub! We saw a gap.

Jackson’s healthcare providers, social services, and community organizations came together to rethink the approach. They recognized that simply asking if someone had stable housing, transportation, or food security wasn’t enough. The real question was: Do you need help? That shift—from status to need—transformed everything.

Many organizations assumed they were already addressing these social needs in their intake forms. But when Jackson's team reviewed those forms, they found a crucial gap: while partners were asking whether someone had housing or transportation, they weren’t asking whether the person needed help with it. That discovery changed the course of the work.

We saw the need.

The Jackson Care Hub launched a collaboratively developed system featuring a shared SDOH screening tool, integrated IT platform, and standardized workflows used across agencies. For our partners, this meant a powerful new way to coordinate care. For our clients, it meant there was no wrong door to help: everyone could access the integrated network of Care Hub resources from any partner agency.

As the work progressed, the data took shape. True, many partners had collected SDOH data within their own agencies before the Care Hub. However, this was the first time all agencies had a shared source of community-wide data describing needs across sectors. The implications were profound. While individual organizations were supporting individual clients, this was not enough to create a systemic response to the root causes of persistent needs. We were helping people, but not fixing the system.

We expanded our focus.

The community had developed a powerful tool to connect clients to existing resources. But the Jackson Care Hub needed to do more. The integrated design established a standard process to identify SDOH needs and generate streamlined referrals to the most appropriate organizations.This is a crucial service for our community.

But identifying needs and making referrals was just the beginning. Now, we accept the call to do more. By analyzing the data collected through the Jackson Care Hub, we are able to uncover trends, track outcomes, and pinpoint gaps in services. This data-driven approach enables us to not only respond to individual needs but also inform community planning, advocate for resources, and continuously improve the system. Ultimately, applying real-time data allows us to move from simply connecting clients to existing resources toward proactively developing new and better resources so that everyone in Jackson can thrive.

We continue to grow.

One of the most important aspects of the Jackson Care Hub is that it is not owned by any one partner or agency. It is community-governed and community-grown. The Care Hub belongs to the people and organizations that use it to serve, and the clients and residents that use it to thrive. Authentic community engagement constantly shapes our evolution.

"This is not just an IT platform—it’s a dynamic ecosystem powered by the connections and relationships in our community."

The ongoing cycle of reflection and improvement ensures that Care Hub will remain a responsive, adaptive, and relevant tool for care coordination and systems change for years to come.

By reducing reliance on emergency departments, empowering local organizations, and fostering collaboration across sectors, the Jackson Care Hub is helping define what it means to build a healthier, more connected future.

We model what’s possible.

Today, the Jackson Care Hub stands as a leading example of how communities can effectively integrate healthcare and social services to create lasting, positive change. What began as a straightforward screening tool has evolved into a robust, interconnected system—one that not only addresses the immediate needs of residents but also anticipates and shapes the resources required for a healthier future.

Driven by a vision where every single person can thrive, the Jackson Care Hub is redefining what it means to foster a healthier, more connected community. By uniting organizations across sectors such as healthcare, housing, transportation, and education, the Care Hub ensures that residents have streamlined access to essential services, coordinated care, and ongoing support. This collaborative model is setting a new standard for building resilient communities and advancing well-being for all.