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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 Center. In 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 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 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.
 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.
 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.
 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.
Outcomes
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:
 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
Publications
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.
Research
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 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.
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