Hennepin Health Newsletter: June 2014


June 2014



Ross Owen
Deputy Director

Julie Bluhm
Clinical Program Manager

Lori Imsdahl
Operations Coordinator


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Hennepin Health is an innovative health care delivery program that was launched in January 2012.

The 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.

Hennepin Health members receive care from a multidisciplinary care coordination team. Other innovative features include a common electronic health record, and tiered care that is based upon a member’s identified needs.

Find eligibility and enrollment information at the MNsure website.


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

Member Spotlight: Ron


Ron is a Hennepin Health member who lives in an interim housing unit that Hennepin Health is leasing from the Minneapolis Public Housing Authority. This interim housing project is funded through Hennepin Health’s reinvestment initiative funds. To be eligible for the project, a Hennepin Health member must be homeless — and either in inpatient care or recently discharged from inpatient care — with high risk for hospital readmission due to lack of housing and social supports.

The project provides select Hennepin Health members with as many as 90 days of housing in an individual, studio apartment in the Elliot Twins Building in Minneapolis’ Elliot Park neighborhood. While housed, members receive in-home nursing and/or case management supports to meet their medical and mental health needs. The Hennepin Health social services navigation team also assesses members' housing needs and helps them secure supportive housing placements after their stay in Elliot Twins.

Here's Ron’s story:

Ron’s symptoms began in November 2012: dizziness, impaired vision, lethargy, weight loss, and thirst.

The 55-year-old had the sense that something was wrong. But he didn’t go to the doctor right away.

Ron’s familiar with pain. He’s done construction and janitorial-type work most of his life and it’s entailed plenty of physical discomfort. Maybe that’s why he toughed it out initially. But after three months, he’d had enough and he made an appointment at Hennepin County Medical Center’s Brooklyn Center Clinic.

The day of that appointment — February 25, 2013 — is now seared in his mind. That Monday, Ron recounted his symptoms to a physician and she ordered lab work. Before he left, technicians took samples of Ron’s blood and urine.

That night, at 8:56 p.m., Ron was home, preparing for bed, when he received a phone call from his doctor. She told him his lab results were abnormal. His blood sugar levels were off the charts. She told him he needed to go to the emergency room immediately; if he went to sleep he might not wake up.

Ron describes it this way: “God was in the Brooklyn Center Clinic at nine o’clock that night.”

The diagnosis

Ron was diagnosed with latent autoimmune diabetes of adults (LADA), also known as slow onset type 1 diabetes and diabetes type 1.5. LADA is a subset of diabetes that progresses slower than type 1; many patients don’t develop it until they’re in their thirties or older.


Since his diagnosis, Ron carries this backpack with him everywhere. The backpack contains gummy bears and other food that he can eat if his blood sugar levels suddenly plunge.

Though there’s a diagnosis, Ron’s case continues to dumbfound physicians. For instance, despite his disease, many of his health metrics — like weight, cholesterol, and blood pressure — remain stellar. And, although diabetics may experience large blood sugar fluctuations, Ron’s are particularly extreme. For instance, on June 1, 2013 (according to medical paperwork he showed us), his blood sugar oscillated between 36 and 586 mg/dl in a single day. And while sitting in his apartment with us on June 2, 2014, his glucose monitor registered 397 mg/dl. To put that in perspective, The American Diabetes Association recommends that a person’s blood sugar levels be between 70 to 130 mg/dl when fasting and less than 180 mg/dl after eating a meal.  

Ron recalls a day when he went to get his levels tested. “When [the technicians] pricked my finger, they asked me why my hands were dirty,” he says. When he explained it was because he’d been at work all day, no one believed him, because his readings were so far outside the norm.

Life as a diabetic

Because he has an “extreme” fear of needles, Ron says that pricking his skin to test his blood sugar level is particularly difficult. He dreads the mornings because “the first thing I have to do [when I wake up] is be uncomfortable.”

But that’s not the half of it.

Shortly after being diagnosed last year, Ron lost the job he’d held for nine and a half years. He says his boss saw him trembling as he came down a ladder and deemed it too dangerous for him to continue working. (Although Ron has been able to find other jobs, it’s been a challenge to gain rapport with employers because he can’t always commit to eight- to ten-hour workdays as before, and he usually doesn’t know until the morning if he’ll feel well enough to come into work. As he’s discovered, “Who is going to hire me when I have to take time off?”)

After his diagnosis, Ron’s condition worsened and in the summer of 2013, he experienced a diabetic coma.

His unemployment benefits finally ran out.

And on September 15, 2013, he became homeless.

Homelessness and Hennepin Health

While he was homeless, Ron lived with friends and at the Salvation Army.

Kim Evers — a certified diabetes educator at Hennepin County Medical Center’s Whittier Clinic — has worked with Ron. While he was homeless, Evers witnessed Ron’s health deteriorating and she attributes his homelessness to some of that deterioration.

More broadly, Evers believes that poor health and homelessness is a “vicious cycle” with both factors influencing the other. That is, Ron’s homelessness contributed to his poor health and his poor health contributed to his homelessness.

Why is homelessness so challenging for people with medical concerns? Evers weighs in, from a diabetic standpoint:

  • Nutrition is paramount for a diabetic, but the food that is most accessible in shelters and on the streets is often highly processed and sugar-laden, devoid of nutrition.
  • Insulin needs to be kept cold to prevent spoiling, but homeless people may not have access to a refrigerator.
  • It’s important for diabetics to maintain a regular meal schedule, but this may be difficult to do when a person is transient.
  • Diabetics may get tired easily and need to rest, but some shelters require people to vacate during the day and it may be unsafe or unfeasible to sleep on the streets.
  • Homeless life is stressful. Stress hormones cause blood sugar levels to rise.

Many health care experts and organizations are now acknowledging the link between health and homelessness, Hennepin Health among them. In 2012, Hennepin Health used some of its reinvestment initiative funds to rent out transitional housing units in an apartment complex that is owned by the Minneapolis Public Housing Authority.

As detailed above, the contract specifies that Hennepin Health will prioritize members who are homeless — and either in inpatient care or recently discharged from inpatient care — with high risk for hospital readmission due to lack of housing and social supports.

In April, Evers contacted Neri Diaz, M.S.W, L.G.S.W, Whittier Clinic senior social worker. Evers remembers telling Diaz, “Ron just can’t be homeless any more. This is dangerous. We have got to do more for him.” Diaz contacted Hennepin Health’s social services navigation team, asking that Ron be considered for a vacant unit in Elliot Twins. Evers wrote a letter to Hennepin Health to document the medical necessity of the housing support.

Ron moved in on May 6. 

Ron's bedroom

Ron's studio apartment at Elliot Twins

Since moving in

While he was homeless, Ron reveals that his diet — like the diets of so many people who experience homelessness — consisted almost entirely of inexpensive, highly processed food that was bought at convenience stores and fast-food restaurants or served at the shelter. 

As a result, the meal he prepared on May 6 — in the kitchen of his studio apartment — was the first “home cooked meal” he’d eaten since September 15, the day he became homeless. Ron’s insulin is now refrigerated and he has been able to rest when he needs to. Since he has been housed, Ron has not been hospitalized.

Ron's kitchen

Ron's kitchen at Elliot Twins

Refrigerated insulin

Ron's insulin, refrigerated

But many challenges remain.

Ron explains that he wakes up blind some days (a symptom of low blood sugar). He has stage two kidney failure. He’s got neuropathy in his right foot and it’s numb. And despite consulting with many doctors and taking the medications prescribed him, he continues to experience extreme blood sugar fluctuations.

Ron says that the housing Hennepin Health has provided him is “wonderful,” but acknowledges that the road ahead is still a challenge. Hennepin Health believes that housing is an important part of keeping members healthy and is currently trying to secure long-term supportive housing for Ron.    

Do you know a Hennepin Health patient who might meet the criteria to participate in the Minneapolis Public Housing Authority/Hennepin Health interim housing project? If so, please contact Kim Nguyen, Hennepin Health social services supervisor, at Kim.Nguyen@hennepin.us

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Provider Spotlight: Katherine Vickery

Kate Vickery

Katherine Vickery, M.D., M.Sc. recently completed the Robert Wood Johnson Foundation Clinical Scholars Program and joined Hennepin County Medical Center as a clinician-investigator in the Division of General Medicine and Family Medicine. While in the Clinical Scholars Program, Vickery began conducting research on Hennepin Health.

The two-year Clinical Scholars Program gives physicians the opportunity to conduct research — and to work with communities, organizations, practitioners, and policymakers — on some of America’s most important health care issues.

Clinical scholars complete a master’s degree at one of four institutions — the University of California, Los Angeles; the University of Pennsylvania; Yale University; or the University of Michigan. (Vickery studied at the latter.) They also have supported time to focus on research projects. Vickery’s research will analyze how Hennepin Health has impacted the health care and the lives of its members.

The Start

Vickery first heard about Hennepin Health from Kate Neuhausen, a physician friend and co-clinical scholar. Neuhausen had written a profile on Hennepin County Medical Center’s Coordinated Care Center and had met Jennifer DeCubellis, assistant county administrator, at a conference in Washington D.C. Intrigued, Vickery reached out to DeCubellis and Ross Owen, Hennepin Health deputy director, and together they developed a research proposal.

Giselle Corbie-Smith, Vickery’s National Advisory Council (NAC) mentor through the Clinical Scholars Program — a renowned professor at the University of North Carolina-Chapel Hill — was also encouraging. Corbie-Smith completed a visiting professorship at Hennepin County Medical Center and has spent her career trying to eliminate health care disparities; she told Vickery that working with Hennepin Health would put her “at the cutting edge of the cutting edge” of health care reform. 

The Research

Vickery’s research consists of two projects. The first will compare health care utilization and cost of Hennepin Health enrollees to other, similar Medicaid patients in Hennepin and Ramsey counties. The control group will consist of Ramsey county Medicaid patients who met eligibility criteria for Hennepin Health but could not enroll because they live in a different county. This project uses Medicaid claims data from the Minnesota Department of Human Services.

The second project will use interviews with patients and providers — along with claims data — to determine which individuals seem to benefit the most from Hennepin Health and why.

Vickery is in the final stages of data validation and cleaning and in the early stages of analyses. She expects preliminary results this summer.

A team of Hennepin Health partners have supported Vickery in conducting this work including Ross Owen, M.P.A., Hennepin Health deputy director, and from Hennepin County Medical Center: Dana Soderlund, M.P.H., Hennepin Health data analyst; Scott Shimotsu, PhD, senior health care data analyst; Mark Linzer, M.D. director of the Division of General Internal Medicine; Pam Clifford, R.N., M.P.H. director of the Center for Health Care Innovation; and Nancy Garrett, PhD, chief analytics officer.

Future Work

Earlier this year, Vickery learned that she is going to stay at Hennepin County Medical Center beyond her Robert Wood Johnson fellowship; she was hired as a clinician-investigator with a primary appointment in internal medicine and a secondary appointment in family medicine. The new role, which starts this month, is 75 percent research and 25 percent clinical. In her clinical capacity, Vickery will practice out of the Coordinated Care Center.

In addition to her other responsibilities, Vickery chairs Hennepin Health’s newly-founded Research and Publications Committee. In its first months, the committee created a repository of scholarly and non-scholarly publications about Hennepin Health. The committee also provides oversight for research and publications efforts that are in-progress and fields ideas for future endeavors. 

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NorthPoint Health & Wellness' 2014 reinvestment initiative

NorthPoint staff

A sampling of NorthPoint staff. From left to right: Steve Wilson, Anisa Kovacevic, Paul Erickson, Catherine McCoy, Lanette Howze, Pa Yang, Hugo Trejo, and Carla Lucas

In January, NorthPoint initiated an outreach and care coordination program that was funded as a Hennepin Health reinvestment initiative. Through the program, NorthPoint has hired additional outreach and care coordination staff to connect unengaged Hennepin Health members to primary care, dental care, and more. As part of this initiative, NorthPoint holds a group visit each Thursday from 1:30 to 3:30 p.m. Typically, five to 10 people attend. The group visit is an opportunity for people to learn about Hennepin Health services, meet NorthPoint staff, receive a consultation from a physician, get same-day access to dental and behavioral health appointments, and more.

Inside a NorthPoint group visit

On a Thursday in early April, it’s raining and the group visit turnout — four people — is lower than normal. After an intake, patients are funneled into a conference room where a table is covered in sandwiches and fruit; NorthPoint hopes that the food (and a small-denomination gift card that is given to patients at the end of their visit) will motivate people to attend. People eat while they wait for Dr. Paul Erickson to give an orientation.

NorthPoint’s medical director since 2006, Erickson feels an affinity to North Minneapolis; he grew up less than a mile from NorthPoint near the intersection of Penn and Glenwood avenues.

When Erickson arrives, he explains that NorthPoint has been a fixture in north Minneapolis since 1967. Formally known as Pilot City, the Federally Qualified Health Center (FQHC) was one of 13 original neighborhood service programs (NSPs) started across the country as part of President Johnson’s war on poverty. NSPs were designed to be multi-purpose centers, places where low-income and disenfranchised people could receive health and human services.

Erickson summarizes the myriad of services available at NorthPoint. There’s dental, laboratory, pharmacy, optometry, radiology, nutritional, housing, financial, medical, and behavioral health services (to name a few). There are resources for people who are struggling with chemical dependency and domestic violence. There’s even a food shelf and a computer lab in the facility. 

Food shelf

The NorthPoint food shelf stocks emergency food packages, monthly food supplies, baby food, diapers, fresh produce, and miscellaneous non-food items.

“We really believe in primary care at NorthPoint,” Erickson says. Getting regular primary care can “make you healthy.”

“I’m 46 and I’ve never had a ‘regular doctor,’” admits a patient.

Erickson encourages everyone to establish a primary care provider, even if they’ve never had one before.

“But what if I don’t have a way to get to my appointments?” asks another.

Erickson explains that Hennepin Health offers its patients single-ride bus passes to get to their medical appointments. As of March 1, 2014, Hennepin Health patients who have four or more medical appointments per month are eligible for a 31-day Metro Transit bus pass, which they can pick up at Metropolitan Health Plan.

Then Erickson runs through some of the things a person can do to stay healthy. There are preventive screenings — breast, cervical, colon, and prostate. There are immunizations. There are checks for cholesterol, blood pressure, and blood sugar. And then there’s exercise.

“I’ve been a doctor for 30 years, and if I could prescribe one thing it would be exercise,” Erickson says. He asks everyone to describe his or her workout regimen.

One patient looks embarrassed when he admits that he doesn’t exercise. “But I use public transportation, so I’m always jumping on and off buses,” he says.

“Sometimes when I’m on the bus I’ll pull the [stop request] buzzer two or three blocks early and walk,” Erickson replies. “Walking is underrated.”

Another patient is more serious about working out. “I find that the only way to be successful with exercise is to put it on your calendar like an appointment,” she tells the group.

After Erickson leaves, patients receive briefings about different NorthPoint service areas. Kristy Singlestad, B.A., NorthPoint dietician, has brought props, including small bags of sugar and fake food. 


Kristy Singlestad

Using the bags, Singlestad shows patients how many teaspoons of sugar are in Pepsi and other beverages. Using the fake food, Singlestad demonstrates the composition of a healthy meal plate, explaining that it should contain approximately 50 percent produce. She then tells patients about an opportunity to put more produce on their plates: starting May 16 (and continuing through September 19), NorthPoint will be distributing free fruit and vegetables in its parking lot at 1315 Penn Avenue North every other Friday from 9 a.m. to noon. (Those dates are May 16 and 30; June 6 and 20; July 18; August 1, 15 and 29; and September 5 and 19. For more information, or to volunteer, call 612-767-9162.)

After Singlestad’s presentation, other staff explain NorthPoint’s dental services, community health workers, and behavioral health services. 

dental presentation

Ifrah Rashad, NorthPoint dental assistant, gives a presentation to Hennepin Health members

Afterward, every patient gets a one-on-one consultation with Erickson. They can also have an on-the-spot dental or behavioral health appointment. (Services available at the dental appointment include cleanings, screenings, and X-rays.) There's also the opportunity to schedule a primary care or other type of appointment. 


Stephanie Valek, NorthPoint dental hygienist, teaches a Hennepin Health member about oral hygiene

Community outreach — connecting people to group visits and more

Lanette Howze and Steve Wilson are community health workers who were hired through NorthPoint’s reinvestment initiative.

Howze and Wilson do much of their work outside the clinic, finding unengaged people and connecting them to primary care, dental care, and more. According to Wilson: "We walk along Broadway Avenue and Lyndale Avenue, we talk to everyone, we go into places like McDonald’s, Footlocker, Bojangles’, probation offices, parks, and shelters."

Street Outreach

Lanette Howze and Steve Wilson

Another component of their outreach is establishing relationships with humanitarian organizations in the Twin Cities. Some of the organizations they’ve connected with include Youth Link, Turning Point, Sharing and Caring Hands, and StreetWorks Outreach Collaborative.

Wilson describes his work as “developing an infrastructure of referrals, of people and organizations that know about [NorthPoint and Hennepin Health].”

Howze and Wilson bring a wealth of experience to their jobs. Wilson has been doing street outreach for over 10 years with organizations like The Bridge for Runaway Youth, Lutheran Social Services, and the YMCA. Howze has a more clinical background: she’s worked at Cedar Riverside Clinic and is knowledgeable about Epic (the electronic health record used by Hennepin Health). Julie Knudsen, R.N., NorthPoint health care home and care coordination supervisor, notes that their different areas of expertise make them a “great team.”


Before NorthPoint initiated the group visit model, there were two ways to be seen by a provider: make an appointment or walk into the clinic. (The latter is not always reliable.). The group visit model offers patients a third way to access care.

CHW and dental assistant

Ifrah Rashid (left) and Anisa Kovacevic, NorthPoint community health worker, have both contributed to NorthPoint's reinvestment initiative success.

As of June 1, 2014, NorthPoint had engaged 246 Hennepin Health patients through their reinvestment initiative. This is 44 percent of their annual engagement goal of 557 patients.

Here are some other outcomes:

  • 132 patients newly engaged via NorthPoint’s dental clinic  (54 percent of their annual goal)
  • Nine Rule 25 Assessments completed for chemical dependency treatment
  • 68 outreach events/sessions completed
  • 1,234 encounter tallies via outreach events/sessions
  • 92 integrated group visits completed 
  • 64 medical long visits (30 minutes or longer) completed with a medical provider
  • 248 internal referrals made across the campus as a result of NorthPoint’s integrated services model

In November 2014, Hennepin Health will evaluate NorthPoint’s reinvestment initiative on process measurements like the number of completed referrals and Rule 25 Assessments. Hennepin Health will also look at the pre- and post-primary care and emergency department utilization rates of patients engaged via the initiative. 

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Upcoming NorthPoint member event


Sylvia Cuellar, D.D.S., NorthPoint dentist

NorthPoint is holding a Hennepin Health member event on Tuesday, June 24 through Thursday, June 26 from 8 a.m. to 3:30 p.m. on all three days. Participants will receive a dental exam, medical screening, behavioral health screening, complimentary refreshments, gift bag, resource information, and more. Hennepin Health members should call NorthPoint at 612-543-2500 to RSVP. Walk-ins are welcome, too.

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