Ottawa Pathways to Better Health:
The Faces Behind a Healthier Ottawa County

Impact of our $150,000 community health worker grant

Based on the findings of the 2015 Ottawa County Health Needs Assessment, the 2015 Community Health Improvement Plan (CHIP) was developed by a collaborative group of community health stakeholders to hone in on the most important needs and opportunities for improving health in our community.

The CHIP points to three high priority local health needs: access to healthcare, recognition and treatment of mental health conditions, and healthy behaviors around nutrition and exercise.

Local hospitals, healthcare providers, the county health department, and numerous community health organizations engaged in the development of strategies to address each of the high priority areas.

As our local healthcare community begins to take action in these three areas, we know that funding is a huge factor in our collective ability to implement this work. CFHZ and the Grand Haven Area Community Foundation (GHACF) jointly committed $160,000 to establish a new “Healthy Ottawa Fund” which leveraged a $330,000 grant from the Michigan Health Endowment Fund to invest in new and expanded programs which advance positive action on the CHIP.

Ottawa Pathways to Better Health, a collaborative effort between hospitals, health care and human service agencies in Ottawa County, received a $150,000 grant from our Healthy Ottawa Fund. It is based on a community health worker model that has been successfully implemented across the country.

A community health worker is a trained front-line public health worker who is a trusted member of and/or has an unusually close understanding of the community served. The workers serve as a link between high-risk populations and the appropriate health and social services in the community. Not only can this model lead to a greater understanding of the health and human services available within Ottawa County, but it will positively address the other high priority health needs of mental health and healthy behaviors.

This new program began in February 2017 and assists eligible individuals with accessing community services, thereby improving their health outcomes and decreasing unnecessary hospitalizations and emergency department visits.

Pictured: some of Ottawa County’s community health workers (L to R): 
Judy Kettring, Maria Merino, Shandra Smith, Brittney Brown, Glorie Orozco
photo credit: deVries photography

Ottawa Pathways to Better Health accepts clients on a referral basis through CareHub which can be accessed online through the Ottawa County website or by phone. Following a referral, a relationship between the community health worker and the participant begins. The participants are assessed through regular visits from their community health worker, who will work with the participant by administering a checklist to identify needs, set goals, assess progress, help reduce barriers, and provide education and support. This checklist serves to identify a relevant pathway that the community health worker and client can then work on completing together. Some of these identified pathways include the need for a primary care physician, insurance, housing, food, and transportation.

The role of the Community Health Worker is not to provide direct healthcare or human services, but to assist, under the supervision of a registered nurse and/or social worker, in the navigation of the health and human services system in order to best connect their clients with the resources that are available to them.

Why it matters:

While there are many strategies being implemented into action on the three priority areas identified in the Health Improvement Plan, this community health worker model has the potential to positively impact all three priority issues.

There has been great collaboration in the early stages of local efforts to plan for this community health worker model. As the effort now shifts to implementation, these collaborative partnerships have become even more important. The tremendous potential for success hinges on a high level of commitment to working together and aligning efforts over an extended period of time among many different players in our local healthcare field.

Pathways to Better Health is an evidence-based model that has been tested in a number of other communities. It has been proven to not only improve health outcomes for patients but save millions in reduced health care costs.

A community health worker’s job is proactive, walking side by side with community members as they navigate their healthcare needs, helping the individuals to learn to use the health system in the most efficient and effective ways possible. Community health workers are trusted members of the communities they serve, often having ethnicity, language, culture and life experiences in common with their clients. This relationship allows the workers to act as a bridge between the people they serve and the healthcare system.

Lowering community healthcare costs while at the same time helping residents live healthier lives is truly a win-win for any community and one that we are thrilled to be replicating here in the Holland/Zeeland area.
Do you know someone who could benefit from a community health worker? Contact the Ottawa Pathways to Better Health to learn more at (616)393–5601 or make a referral to the CareHub at: or call (866) 291–8691

Featured in the Community Foundation’s Spring 2017 newsletter. Written by CFHZ’s Communications Manager Nicole Paquette and community impact intern Jessica Lynch in 2017 — we believe that stories of impact are timeless and always relevant.