Our Service in Action
The Jackson Care Hub is more than just a referral system—it’s a powerful coordination tool designed to meet today’s needs while shaping tomorrow’s care.
When a resident visits a healthcare provider in Jackson, they’re offered a Social Drivers of Health (SDoH) screening. If they report a need and consent to help, the Hub activates: connecting them to a Community Health Worker, who guides them through a personalized support plan. From there, referrals are made to local partner agencies, who update the system with the outcome—creating a closed-loop process where care is tracked and coordinated across medical and social services.
But the Hub doesn’t stop there. Every screening and referral contributes to a larger data picture. By analyzing trends across 200,000+ screenings each year, the Jackson Care Hub identifies gaps in community resources—and works with partners to build what’s missing.
The result? A system that not only connects people to care, but helps the community grow stronger, more connected, and more responsive over time.
Backbone Support for a Holistic System of Care
The Jackson Care Hub is an integrated IT platform. We leverage this tool to support a network of clinical and social service providers across Jackson. But IT alone is not the answer. The full scope of the Jackson Care Hub is to establish a broad social commitment between partners that facilitates the community-wide integration of resources, processes, and decisions.
This is long-term work that requires systemic change. We help our community align towards better client care by building integrated services, standardizing inter-agency coordination, and driving systems change through data-informed collaboration.
Pillars of Support
Technology
Networks
Data
Technology that Works
At the core of the Care Hub is a shared IT platform. The system was designed by users via a collaborative community-wide process. Current users participate in learning groups to provide ongoing feedback that drives continuous improvement to our tools and processes. We are committed to providing a human-centered resource that serves our clients while also supporting efficient workflows within our partner agencies.
We are proud to partner with RiverStar to host the Jackson Care Hub. RiverStar's experience creating solutions for Whole Person Population Health is a valuable contribution to our network. The extensive options for customizability within the RiverStar platform empowers us to create a tool that is optimized to serve Jackson.
An essential part of the Jackson Care Hub model is the exchange of social needs data between healthcare and social service providers. This flow of information creates the clinical-community linkages that empower care agencies across the community to collaborate in support of our shared clients. We are proud to partner with our local healthcare providers to integrate social needs screenings into routine standards of care, embedding needs and referral data directly into the electronic health record.
Michigan 211 serves as our resource directory. A secure API integration provides real time information to our team of Community Health Workers within the Jackson Care Hub user interface. This relationship ensures that our clients have access to accurate information about local resources.
Together, the Jackson Care Hub network, RiverStar, local electronic medical records, and Michigan 211 power a closed-loop referral process, ensuring that referrals are managed, outcomes are tracked, and no one is left behind.
Networks that Align
Technology doesn't build trust. People do.
The Care Hub works because of the people who use it: clinicians, community health workers, case managers, service providers, nonprofit leaders, and more. The Jackson Care Hub staff provides comprehensive training, ongoing support, and assisted coordination of services to all users. New users receive thorough onboarding and training sessions to ensure they are comfortable navigating the platform and utilizing its features to their full potential. The Hub staff provides continuous technical assistance and troubleshooting support, so users always have help when they need it.
To foster effective collaboration, the Care Hub staff facilitates coordination between organizations through shared communication channels, referral tracking, and real-time updates. We keep our network connected. Our Learning Communities meet monthly. These generative conversations keep everyone up to date on best practices and new functionalities, while identifying opportunities for improvement to the IT and shared processes.
The Jackson Care Hub manages users to meet collectively defined quality standards. All service partners have access to ongoing performance dashboards to monitor internal performance and track network functioning. Shared platforms run on trust. Each partner must rely on the collective strength of the network to effectively and compassionately serve its clients. The Hub provides transparent metrics to ensure a high quality product.
Through ongoing network support, the Jackson Care Hub team empowers its diverse network of users to serve the community more effectively, ensuring that everyone in Jackson has what they need.
Data that Matters
We do more than connect individuals to essential services, we leverage insights from our platform to shape the future of care in Jackson.
By systematically analyzing real-time data, we identify where community needs remain unmet, which services are experiencing strain, and where persistent gaps exist within the local support system. This data-driven approach enables us to collaborate with community leaders and partners to advocate for additional resources, develop targeted services, and inform policy decisions that directly address the realities faced by residents.
Our commitment extends beyond simply screening and referring individuals; we strive to ensure that interventions lead to meaningful outcomes. The truth is, referring someone to a food pantry does not mean they have reliable access to nutritious meals. Likewise, referring someone to a housing-voucher waitlist is not the same as guaranteeing they have a safe place to sleep tonight. Our focus is on measurable long-term impact—ensuring that our collective action leads to tangible improvements in people’s lives.