Hennepin Health Newsletter: April 2014


April 2014



Ross Owen
Deputy Director

Julie Bluhm
Clinical Program Manager

Lori Imsdahl
Operations Coordinator

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Hennepin Health, an innovative healthcare delivery program, is a collaboration between Hennepin County Medical Center (HCMC), NorthPoint Health and Wellness Center (NorthPoint), Metropolitan Health Plan (MHP), and Human Services and Public Health Department (HSPHD) of Hennepin County


For more information about Hennepin Health visit www.hennepin.us/ healthcare

Partner Spotlight: Hennepin County Medical Center


Hennepin County Medical Center (HCMC) is one of Hennepin Health’s four partners. In addition to its location in downtown Minneapolis, HCMC has several neighborhood clinics. They include primary care clinics in Brooklyn Center, Brooklyn Park, Richfield, Saint Anthony, Golden Valley, and in Minneapolis’ Whittier neighborhood and on East Lake Street. There is also an HCMC retail clinic in the Walmart store in Bloomington.

 Hennepin County Medical Center is a:

  • Level 1 adult trauma center and level 1 pediatric trauma center
  • System of primary care and retail clinics
  • Teaching hospital
  • Safety net hospital for low-income, the uninsured, and vulnerable populations
  • Major employer in Hennepin County


HCMC’s mission:

“We partner with our community, our patients and their families to ensure access to outstanding care for everyone, while improving health and wellness through teaching, patient and community education, and research.”

Jon Pryor, M.D., M.B.A., HCMC chief executive officer

Jon Pryor, M.D., M.B.A, was named HCMC’s CEO on April 1, 2013. Read on for some notes from a Hennepin Health interview with Dr. Pryor.


What people involved in Hennepin Health should know about HCMC

Dr. Pryor believes that HCMC’s mission statement (above) can tell a person a lot about the organization, especially:

  • Community. The word is used twice in the mission statement. HCMC strives to partner with people and organizations within the community and to extend its work beyond the hospital and clinics.
  • Treat patients where they live and work. Clinics are distributed throughout Hennepin County. Convenience is paramount. HCMC offers walk-in options and is exploring ways to bring health care into the workplace. Eight of HCMC’s clinics are certified health care homes.

Reforms that HCMC has rolled out

Dr. Pryor believes that one of HCMC’s unique features is its history of innovation and reform. Some examples of innovative, reform-minded ideas that HCMC has implemented include:

  • Coordinated Care Center. The CCC is a primary care clinic that caters to complex patients with a history of frequent hospitalizations. CCC services include walk-in access for new issues, medical follow-up after hospitalization, oversight by clinic pharmacists, and attention to a patient’s behavioral health and social needs. In 2013, the CCC won a National Association of Public Hospitals (NAPH) Gage Award for population health improvement.   
  • Community paramedics. HCMC uses community paramedics. Community paramedicine is a health care outreach effort designed to reach underserved populations. Community paramedics provide primary, pre-hospital, and post-hospital care. This approach can minimize costs to providers and patients. Read this article about HCMC community paramedic David Johnson, C.P., CCEMT-P.
  • Center for Healthcare Innovation. Directed by Pamela Clifford, R.N., M.P.H., the Center for Healthcare Innovation is engaged in initiatives to improve health care strategy, innovation, and process improvement. Clifford has been actively involved in Hennepin Health’s implementation. 

CCC staff

Staff at the Coordinated Care Center. From left to right: Deborah Nugent, Sarah Bruemmer, Susan Gjersvik, and Mary Kuzel.


Thoughts about Hennepin Health

Dr. Pryor believes that Hennepin Health’s four partners create a synergy, accomplishing more as a group than they could as individual entities.

Dr. Pryor explains that he’s always looking for opportunities to deliver health care in new, more effective ways. He has a background in medical research, and he admires that Hennepin Health is continuously monitoring and evaluating itself on key outcomes like health care utilization. He believes that Hennepin Health’s focus on continuous improvement has led to “good care today and better care tomorrow.”

Revelations made during a career in health care

One revelation that Dr. Pryor says he’s had about health care during his career is that health care is not physician centric. Rather, it’s a team approach. He believes that it “takes a village” to improve the health of an individual or community. He’s also realized that health care delivery must extend beyond the hospital and clinic and out into the community. Meeting an individual’s social needs (e.g., food and housing) can greatly improve their overall health.  

Clinic Spotlight: HCMC Medicine Clinic

Medicine Clinic

Medicine Clinic is located at HCMC’s downtown facility, on level 7 of the Purple Building.

Staff at this primary care clinic take an integrative approach to health care; a patient’s medical, behavioral health, and social needs are all considered.

The Hennepin Health connection:

Several staff at Medicine Clinic helped launch Hennepin Health in January 2012 and remain involved in the program. Here are two:

  • Mark Linzer, M.D., director of the division of general internal medicine. Linzer co-leads Hennepin Health’s care model committee. Dr. Linzer also sponsors one of Hennepin Health’s reinvestment initiatives, a population health management program based on team huddles.
  • DeAnn Rice, R.N., P.H.N., practice manager for Medicine Clinic. A member of Hennepin Health’s care model committee, Rice gave input into the makeup of Hennepin Health’s care coordination team. She also championed Epic dashboards that help providers see a list of patients who are currently hospitalized, recently discharged from the emergency department, and due to come in for an appointment within five days. Rice believes that the Hennepin Health model has been beneficial to HCMC as a whole; it’s helped the medical facility integrate care coordination into all of its facilities.

Medicine Clinic Staff

Staff at Medicine Clinic. From left to right: Mary Ellen Chinander, Mark Linzer, Eugene Galybrek, Susan Burns, and Patricia Brown.

Medicine Clinic protocol is shaped by Hennepin Health. Here are some examples:

  • Before staff at Medicine Clinic start accepting patients each morning, they generate a list of Hennepin Health members who have an appointment that day. Then, they huddle for 30-minutes to discuss these patients.
  • Medicine Clinic staff help Hennepin Health patients fill out a lifestyle overview. The survey asks questions that help care coordinators identify a patient’s medical, behavioral health, and social needs. Care coordinators and Hennepin Health patients use the findings when they are crafting a patient’s care plan.

Insights from Medicine Clinic’s care coordination team:

Mary Ellen Chinander, R.N., clinical care coordinator, tries to incorporate “teachable moments” into every encounter she has with a patient. Teachable moments, she explains, are opportunities to talk to a patient about behaviors that aren’t serving them well, and to empower a patient to take personal responsibility for their health.

She recalls a teachable moment she had with a Hennepin Health member. The member had a history of frequent hospitalizations for mental health concerns and alcohol abuse. He was trying to regain control of his health so that he could hold a job. One day, the member told Chinander that he was determined to keep all of his outpatient appointments because he realized that the more outpatient appointments he kept, the less he would need to be hospitalized or use the emergency department. Chinander was quick to congratulate the member for making this connection. 

Eugene Galybrek, R.N., clinical care coordinator, says that his work at Medicine Clinic boils down to building relationships and building trust. He’s worked with many patients who were initially resistant to making the lifestyle changes that their providers suggested. However, as their relationship and trust in Galybrek grew, they were more inclined to follow-through and take personal initiative.

To make an appointment at HCMC’s Medicine Clinic, call (612) 873-6963. 

Member Spotlight: Jorge


Jorge (right) with a friend.

Jorge emigrated from Mexico to Minnesota in 1999. At a recent meeting with Hennepin Health staff, he explained that he used to have a wife, a brother, and a son. And he used to work as a food shelf coordinator for Pillsbury United Communities. Then, 2010 and 2011 came along.

In 2010, at the height of the recession, Jorge was laid off. That same year, his wife died unexpectedly. Jorge spiraled into depression. He became homeless, took to wandering the streets, and was often crying.

One day, Jorge was crying at Saint Olaf Catholic Church in downtown Minneapolis when a female parishioner approached and took him to the hospital.

A doctor diagnosed Jorge with severe clinical depression. He was prescribed medications, and he began receiving regular care at Fairview Medical Center. For a few months, he was stable again.

Then, in 2011, there were more blows. Jorge’s younger brother passed away from complications related to drug and alcohol abuse. Jorge also received news that his son, an Army soldier on his second deployment to Afghanistan, had died in combat.

Jorge stopped taking his medications consistently, and his depression symptoms returned. One day, he was again crying at Saint Olaf Catholic Church when a priest approached and took him to HCMC. There, it was determined that he was eligible for Hennepin Health.

Jorge was introduced to Lucky Ahmed, a community health worker at HCMC’s Medicine Clinic. Jorge had stopped caring about his appearance, and he recalls that the first thing Lucky did was give him a voucher to get a haircut. She also gave him a bag of food and toiletries, had him fill out a lifestyle overview, and helped him establish care at Medicine Clinic.

Once Jorge was connected to Hennepin Health’s care coordination team, his recovery began. He started to receive care from Susan Burns, L.I.C.S.W., social worker; Lisa Legrand, Ph.D., senior psychology fellow; Seth Silbert, M.D., Ph.D., staff physician ophthalmology; Karen Leaman, R.N., psychiatric clinical nurse specialist, and others. Each individual helped Jorge with various aspects of his health care.

Susan Burns, Jorge’s social worker, believes that Hennepin Health’s care coordination model—which “looks at health in a way that is not so purely medical” but also considers an individual’s behavioral health and social needs—makes all the difference.   

According to Burns, addressing a social need—that of getting Jorge housed at Exodus Residence—was the intervention that improved his health the most. Prior to Exodus, Jorge was homeless and sleeping on the floor of an acquaintance’s house. The other people in the house abused drugs and alcohol. Jorge was at a critical point in his recovery and he worried that if didn’t move out, he could go down the same path as his younger brother.

Medication compliance has also been key to Jorge’s recovery. Within two weeks of taking his medication consistently, Jorge was already feeling better. Inspired to get a job, he enrolled in Learning In Style, a school in south Minneapolis that caters to adult immigrants and refugees. Here, he’s taking classes to improve his computer, English language, and writing skills. After he graduates this summer, Jorge intends to start school at the University of Minnesota. 

Learning in Style

People receiving instruction at Learning in Style.

Jorge already has a bachelor’s degree in psychology and a master’s degree in social science teaching, but both degrees are from Mexico. As a result, his teaching license is not valid in Minnesota. Recently, however, Jorge showed his transcripts to admissions counselors at the University of Minnesota. They’ve determined that if Jorge finishes his classes at Learning in Style and takes two years of coursework at the University of Minnesota, he can earn a Minnesota teaching license.   

In addition to teaching, Jorge is interested in becoming a family therapist or a community health worker and working with people in recovery. He reveals that the part of his job at Pillsbury United Communities that he found most rewarding was discovering the needs of people who came in to use the food shelf and referring them to community resources that could improve their lives.

Burns isn’t surprised by Jorge’s career aspirations. Jorge’s mother was a health care provider in Mexico, she explains, and he grew up with her example of helping struggling people. Jorge, says Burns, “has a lovely model” for how to live a life. “You don’t forget the people who guided and supported you and you use these experiences to help others.” Recently, Burns overhead Jorge talking to another patient at Medicine Clinic about food shelf opportunities in the Twin Cities.

As counterintuitive as it sounds, Jorge believes that there is an upside to struggling with medical, behavioral health, and social problems; according to him, they’re “opportunities to make a change.”

Jorge has a message to Hennepin Health: “I want to thank all of you. I feel fortunate and blessed. You changed my life.”

Provider Spotlight: Markus Klimenko


Markus Klimenko is the program manager for Hennepin County’s Housing and Homeless Initiative. Nestled within Hennepin County’s Human Services and Public Health Department, HHI has a lofty goal: ensure that all Hennepin Health members have access to housing.

Klimenko explains that his job involves building partnerships with Hennepin County housing providers and working with these providers to supply housing for homeless residents. There are currently 8,500 housing and housing service opportunities available through HHI.

In addition to increasing the supply of housing in the county, HHI is also building a “specialized housing tool.” The e-government initiative, Klimenko explains, will allow housing navigators to view housing vacancies in real-time.

A long-time member of Hennepin Health’s care model committee, Klimenko has advised Hennepin Health’s partners on housing policy and housing opportunities within the county.

Klimenko also helped build Hennepin Health’s housing navigation team. From January 2012 to December 2013, the team placed 150 Hennepin Health members in housing. Hennepin Health is currently analyzing these members’ medical claims to determine how placement in housing affected their emergency department, inpatient hospitalization, and outpatient utilization. Hennepin Health is also in the process of hiring additional housing navigation staff.

Klimenko believes that housing a person can be transformative. “Housing policy is health policy,” he says.

New Member Event

Hennepin Health held its first new member event on March 26 at the Grain Exchange Building in downtown Minneapolis. Hennepin Health invited people who had joined the program between January 1 and March 1, 2014. Approximately 40 members attended.

New Member Event 1

The goals of the event were to orient members to Hennepin Health resources, educate them on how to establish care, and introduce them to some of Hennepin Health’s providers.

Staff from across the Hennepin Health partnership volunteered at the event. Special thanks to:

New Member Event 2

Were you there? Do you have suggestions on how to improve future events? If so, email Lori Imsdahl, Hennepin Health operations coordinator at lori.imsdahl@hennepin.us

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