Hennepin Health Newsletter: July 2014


July 2014



Ross Owen
Deputy Director

Julie Bluhm
Clinical Program Manager

Lori Imsdahl
Operations Coordinator


Facebook icon

Like us on Facebook


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

2014: A mid-year recap

On January 1, Hennepin Health celebrated its two-year anniversary. Our innovative, award-winning health care program serves adults ages 21 to 64 in Hennepin County with no dependents who are earning at or below 133 percent of the federal poverty guideline.

Due in part to the passage of the Affordable Care Act, Hennepin Health has seen its membership increase significantly over the past six months. Currently, our program enrolls over 8,800 members.


Charles attends a Mental Illness Chemical Dependency (MICD) treatment group at the Hennepin County Mental Health CenterIn the May Hennepin Health newsletter, Charles shared his recovery story. 

Hennepin Health is a partnership between Hennepin County Medical Center, NorthPoint Health and Wellness Center, Metropolitan Health Plan, and the Hennepin County Human Services and Public Health Department.

Check out these articles about our partners that appeared in previous newsletters:

NorthPoint Health and Wellness Center
Hennepin County Medical Center
Hennepin County Human Services and Public Health Department
            Hennepin County Housing and Homeless Initiative
            Hennepin County Mental Health Center
            Hennepin County Public Health Promotion
            Hennepin County Intensive Case Management Team

Now in our third year, Hennepin Health continues to vet, pilot, and evaluate creative — and in some cases never-before-tried —approaches to health care delivery.  Many of these approaches involve integrating social services into the existing medical and behavioral health paradigm.

care coordination staff

Care coordination staff at Hennepin County Medical Center's Medicine Clinic.

Here’s a mid-2014 recap:

Community outreach and engagement

One of our 2014 priorities was to engage our providers and members better. Here are some examples of targeted outreach initiatives.

Monthly newsletter

Launched in January, we currently deliver our electronic newsletter to about 600 people. Here we highlight the work of our partners and providers. We also share member stories, performance outcomes, upcoming events, and changes in program protocol. If you’re interested in being added to the distribution list, email lori.imsdahl@hennepin.us

Note: archived newsletters are available for view on our external website at http://www.hennepin.us/healthcare in the “Hennepin Health newsletters” drawer.

Facebook page

In February, we created a Facebook page, and we try to post each week. “Like” us at https://www.facebook.com/hennepinhealthcare

Care coordination trainings

Since December 2013, we’ve held trainings for our care coordination staff every two to three months. Topics have included motivational interviewing and transitions in care. If you’d like to attend a future training, email lori.imsdahl@hennepin.us

Member events

In March, we held our first member event at Metropolitan Health Plan. The event targeted recent enrollees, and about 40 members attended. We’d like to host more events in the future, and we’re open to suggestions about format and venue. 

member event

Member advisory committee

Hennepin Health has had a member advisory committee since 2012, and the committee’s feedback continues to shape program protocol. For instance, beginning this April, Hennepin Health offers 31-day Metro Transit passes to members with four or more medical appointments per month; this is a result of committee member feedback which stressed the importance of transportation.  

Reinvestment initiatives

Reinvestment initiatives are projects that are funded by unspent health care dollars. At the end of each year, Hennepin Health selects the next year's reinvestment initiatives from a stack of proposals submitted to us by staff from our partner organizations.

These projects fill medical, behavioral health, and social services gaps in the system, gaps that our care coordination staff have identified through their direct interaction with members. The hope is that reinvestment initiatives will yield additional cost savings by improving health care quality and diverting members from costly crisis care.

2014 reinvestment initiatives

In January, Hennepin Health launched seven 2014 reinvestment initiatives.

Each quarter, we meet with our reinvestment initiative sponsors to discuss project progress. Currently, all 2014 reinvestment initiatives have launched.

huddle time

One of our 2014 reinvestment initiatives – sponsored by Mark Linzer, M.D. — funds a staff person to facilitate “huddle time” at Hennepin County Medical Center’s Medicine Clinic. During “huddle time,” providers meet to craft plans to improve population management and patient quality of care.

Check out these articles about our 2014 reinvestment initiative projects that appeared in previous newsletters:

            Care coordination at the Mental Health Center

            NorthPoint outreach and care coordination program


These NorthPoint staff have executed new and expanded outreach and care coordination efforts as a result of a 2014 reinvestment initiative. 

2013 Reinvestment initiatives

Two 2013 reinvestment initiatives – the Supported Vocational Services Program with Rise, Inc., and the Emergency Department In Reach Program with RESOURCE Chemical and Mental Health — launched in the summer of 2013 and have continued into 2014. 

Dana Soderlund, M.P.H, Hennepin Health data analyst, is currently conducting an evaluation on both reinvestment initiatives and expects results by the end of July.


Patrick Meacham (left), a Rise, Inc., employment consultant, works with a Hennepin Health patient. 

ed in reach

Courtney has had success working with Hennepin Health's Emergency Department In Reach program with RESOURCE Chemical and Mental Health.

In February 2014, Hennepin Health launched its Interim Housing Project, a collaboration with the Minneapolis Public Housing Authority.

To be eligible for the project, a Hennepin Health member must be homeless — and either in inpatient care or recently discharged — 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. 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. 

elliot twins

A Hennepin Health member's studio apartment at Elliot Twins.


This member, who has diabetes type 1.5, can now refrigerate his insulin.

Hennepin County leadership also continue discussions on a Hennepin County sobering center, another 2013 Hennepin Health reinvestment initiative.

Check out these articles about our 2013 reinvestment initiatives that appeared in previous newsletters:

ED in reach program with RESOURCE Chemical and Mental Health

Hennepin County sobering center

Interim housing project with Minneapolis Public Housing Authority

Supported vocational services program with Rise, Inc.

Committees and Subcommittees

Hennepin Health committees and subcommittees provide leadership for the program. Committees and subcommittees are task-based and meet every two to six weeks. 

Here are some 2014 committee and subcommittee highlights:

Care Model Committee and Care Coordination Subcommittee

Julie Bluhm, L.I.C.S.W., Hennepin Health clinical program manager, chairs the Care Model Committee and Care Coordination Subcommittee. Bluhm has solicited feedback and worked to make both groups more task-based and worthwhile for participants.

One task the subcommittee recently tackled was redefining the role of the Primary Coordinator (formerly known as the Single Accountable Individual). Many Hennepin Health members are assigned a Primary Coordinator, and this individual links them to medical, behavioral health, and social services, and assists them in navigating the health care system.  

Analytics Committee

This year, the Hennepin Health Analytics Committee has continued to focus on improving the integrity of the data warehouse (an electronic system that stores patient and claims information). For example, they’ve standardized patient identifiers and made sure that there are no patients missing from the data warehouse.

The Analytics Committee has also overseen the creation of an automated predictive risk score that will be viewable to providers in Epic (the electronic health record). This predictive risk score will help care coordination staff prioritize their patient caseload better.


Calendar year 2012 versus calendar year 2013

Between 2012 and 2013, the rate of emergency department use per 1,000 Hennepin Health members declined by 9.1 percent and the rate of inpatient hospital admissions declined by 3.2 percent.

Meanwhile, the rate of outpatient visits (which includes primary care) increased by 2.5 percent. This is desirable, since the program hopes that members will use primary care as their main source of care rather than acute care settings.

These utilization changes are depicted in the graphs below.

Emergency department utilization:

ed utilization

Inpatient utilization:


Outpatient utilization:


Housing navigation

Since its inception, Hennepin Health has offered supportive housing for homeless and precariously housed members. When clinic-based care coordination teams identify a homeless or precariously housed member, they can make a housing referral to Hennepin Health’s social services navigation team.

Hennepin Health’s social services navigators then assess the member’s situation and match them to supportive housing options in the community.

In 2014, Hennepin Health looked at members who were housed in 2012 and 2013. To be included in the evaluation, members needed to be enrolled in Hennepin Health for a minimum of three months before and after they were housed.

The evaluation looked at 112 members’ per-member per-month (PMPM) utilization rates and approved costs before and after placement in housing (adjusted for length of enrollment). Here are the findings:

  • Members used the emergency department 55 percent less often after placement in housing, with associated costs reduced by 52.3 percent
  • Members were admitted to a hospital 28.8 percent less often after placement in housing, with associated costs reduced by 72 percent


Hennepin Health continues to be mentioned in scholarly and non-scholarly publications. We've authored some of the pieces. For instance, Ross Owen, Hennepin Health deputy director, wrote an article on health care data sharing that appeared on the Center for Health Care Strategies, Inc., website. Jennifer DeCubellis, Hennepin County administrator-health, co-authored an article on social services that ran in Health Affairs Blog.

Our newly formed Research and Publications Committee has provided oversight of publications efforts.


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.


Vickery’s research consists of two projects. These projects, which are in progress, will analyze how Hennepin Health has impacted the health care and the lives of its members.

Learn more about Vickery and her research.

Awards and recognition

In June, the Association of Community Affiliated Plans (ACAP) recognized Hennepin Health with its Supporting the Safety Net Award. ACAP is an affiliation of 57 health care plans whose mission is to improve the health of vulnerable populations. ACAP’s Supporting the Safety Net Award is given out annually to a community-based organization or individual “whose work goes clearly beyond the norm and whose services are recognized as best practices that stand as a model for replication.”

ross acap

Ross Owen, Hennepin Health deputy director, accepts the Supporting the Safety Net Award on behalf of Hennepin Health.

This award follows on the heels of others we’ve received, including the:


Linda Berglin, Hennepin County public policy program manager, accepts the Local Government Innovation Award on behalf of Hennepin Health.

In addition, our partners and providers continue to receive accolades for their work. In July, Linda Peterson, Hennepin County Medical Center social work supervisor, won Mpls.St. Paul Magazine’s 2014 Outstanding Nurse Award (in the administrative leadership category). 


Linda Peterson

On the horizon

The Coordinated Care Center is in the process of moving into a larger space in Hennepin County Medical Center’s Shapiro building. HCMC’s Access Clinic (which will provide walk-in care for our members) will be co-located in the center. This was made possible via 2013 and 2014 Hennepin Health reinvestment initiatives. 


Staff at the Coordinated Care Center

Due to a grant from the Minneapolis Foundation, Hennepin Health was able to embed a Rise, Inc., employment consultant at the Hennepin County Adult Correctional Facility in Plymouth. We believe that linking incarcerated people to clinics and employment resources in advance of their release can save the county costs by preventing repeat incarceration, emergency department and inpatient hospital admissions, and more. This is one of the first projects of its kind in the country.


Rise, Inc., Hennepin County Medical Center, and Adult Correctional Facility staff collaborate on initiatives at the Adult Correctional Facility

Thank you and feedback

Thank you for your support of our program.

What would you like to see in upcoming newsletters? How can we improve Hennepin Health? Please contact lori.imsdahl@hennepin.us with your thoughts.