Hennepin Health Newsletter: August 2014


August 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

The Hennepin County Adult Corrections Facility

In 2014, Hennepin Health was awarded a grant from The Minneapolis Foundation to embed a Rise, Inc., employment consultant at the Hennepin County Adult Corrections Facility in Plymouth. A community health worker from Hennepin County Medical Center is also supporting the project. This is one of the first initiatives of its kind in the United States.


Rise, Inc., Hennepin County Medical Center, and Adult Corrections Facility staff collaborate 

Hennepin Health believes that linking incarcerated people to employment and clinic resources in advance of their release can save the county as well as the broader health care system money by preventing repeat incarceration, emergency department and inpatient hospital admissions, and more.

Fast facts

  • The Adult Corrections Facility provides short-term custody and programming for adult offenders convicted of felony, gross misdemeanor, and misdemeanor offenses. The maximum sentence is two years.
  • The facility books 5,000 people per year; the average length of stay is 46 days.
  • The facility can hold 477 offenders — 399 in the men’s section and 78 in the women’s.
  • One in 26 people in Hennepin County is on probation. 

Jessica Robey

Jessica Robey, a Rise, Inc., employment consultant, started work on this project in March. She currently spends two to three days per week at the Adult Corrections Facility.


Jessica Robey

Every few weeks, Lori Imsdahl, Hennepin Health operations coordinator, reviews the roster of people who are at the facility and identifies residents who were on Hennepin Health at some point since the program’s inception. Robey then targets people on Imsdahl’s list.

Robey meets with clients in the Resource Room at the Adult Corrections Facility. She determines their employment goals and helps them craft a resume. Then they search for jobs on Robey’s laptop. If they’re eligible, she helps them apply for work furlough. Clients on work furlough can leave the facility to search for employment, interview, and — if they secure employment — go to work.

Robey has been helping high-needs clients find employment since 2010. Immediately after she graduated from the University of Minnesota-Duluth with a bachelor’s degree in sociology and criminology, Robey joined AmeriCorps and was placed with Rise, Inc. After her year of service, she continued working with the employment agency. Today she splits her time between the Adult Corrections Facility and helping adults with fetal alcohol syndrome. 

One of Robey’s biggest challenges has been engaging people after their release. Most of her clients have behavioral health and chemical dependency issues, and, on top of that, they’re often homeless and don’t have a cell phone. All of these factors make it difficult for her to locate them out in the community. 


The Minneapolis South Workforce Center, where Robey sometimes meets her clients

Initially, she targeted clients who were days away from their release, but she’s found more success by shifting her efforts to clients who won’t be released for at least four to six weeks. She’s noticed that when she has time to build a relationship with someone, they’re more likely to contact her out in the community.

In June, the Minnesota Organization for Habilitation and Rehabilitation recognized Robey as Job Coach of the Year for the Twin Cities Metro area.

In July, Robey placed her first client from the Adult Corrections Facility in a job. His name is Paul.


When Paul met Robey in the Adult Corrections Facility, he was serving 120 days for second-degree assault after an altercation with his brother. Robey helped Paul apply for jobs — including a janitorial position at a local L.A. Fitness — and work furlough.

After L.A. Fitness contacted him for an interview, Paul met Robey at Walmart where she bought him a professional-looking shirt and pair of pants. When he was notified that he got the job, she helped him fill out pre-employment paperwork.

Paul was released from the Adult Corrections Facility on Friday, July 11, and started work the following Monday.  

In mid-August, Hennepin Health called Paul on the phone. He said that work is going well. He gets along with his co-workers. His manager told him he’s “doing a good job,” that “they’re happy with me,” and that “they’re going to keep me,” he explained.

Paul is a repeat offender, but he believes that 2014 is a turning point in his life. My involvement with Hennepin Health and Rise, Inc. is “my second chance” and “the good Lord’s doing,” as he put it.  

Paul is living with a relative in Minneapolis, and he receives treatment at the Hennepin County Mental Health Center for behavioral health and chemical dependency issues. He’s also involved in Connections, the same group that Charles, a Hennepin Health member we profiled in May 2014, has found helpful. Providers at the Mental Health Center gave Paul a gym membership, and he exercises regularly.

“How are things with your brother?” we asked Paul.

“I love him. He forgave me. Today, I took my brother to the gym with me,” Paul said.

In a few weeks Paul is getting married. He met his fiancée well before he went to the Adult Corrections Facility; she “went through the whole process,” and “visited me every day,” he said.

Paul has a message for people in the Adult Corrections Facility: “If you want to take a chance, good things can happen to you. It’s up to you to make it. You have to take these opportunities. Anybody can do it if they put in the effort.” Paul is interested in accompanying Robey to the Adult Corrections Facility to share his story with other offenders.

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Hennepin County Health Innovation Highlights event with Representative Keith Ellison

On August 13, local, state, and federal health care leaders met at NorthPoint Health and Wellness Center to discuss health reform efforts in Hennepin County. The initiative they highlighted was Hennepin Health.


Speakers included U.S. Representative Keith Ellison; Lucinda Jesson, Minnesota Department of Human Services commissioner; Mike Opat, Hennepin County commissioner; Stella Whitney-West, NorthPoint chief executive officer; and Ross Owen, Hennepin Health deputy director. 


A sampling of Minnesota's elected officials were in attendance

Minnesota Senator Al Franken taped a video message for the event in which he noted that, “Minnesota’s homegrown innovation sets an example for the whole country. Hennepin Health is a great example.” 


Lucinda Jesson addresses the audience

Jennifer DeCubellis, Hennepin County assistant county administrator for health, emceed. DeCubellis told the audience that she believes that there are enough dollars invested in the health care system; it’s the way we spend those dollars that counts. In addition to medical and behavioral health spending, Hennepin Health continues to invest dollars in social services (like housing and employment supports) and attributes some of its success to this integration.

Owen quantified this success by sharing Hennepin Health’s improved health care utilization outcomes. 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.


He also discussed a recent evaluation of Hennepin Health’s housing program. 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). The findings showed that:

  • 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

Check out the Hennepin Health care coordination video that was shown at the event.

keith ellison

Keith Ellison with event attendees

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Medicine Clinic huddles

The Medicine Clinic “huddles” at Hennepin County Medical Center are a 2014 Hennepin Health reinvestment initiative. The project is sponsored by Mark Linzer, M.D., director of the division of internal medicine, and is facilitated by Azra Thakur, M.P.H., general internal medicine research coordinator. Sara Poplau, B.S., another research coordinator, has also been involved.

During a typical huddle, a multi-disciplinary care team meets to discuss two to three patients, brainstorm ways to help them, and craft a plan of action. The care team includes primary care providers, community health workers, R.N.s, R.N. clinical care coordinators, licensed practical nurses, medical assistants, and social workers. 


A care team conducts a huddle

Linzer, Thakur, and Poplau rolled out the huddles in the Green Firm (one of the Medicine Clinic’s three firms, or sub-units) in April 2014. They plan to initiate huddles on Blue and Yellow Firms in August and September 2014. They are also in discussions with Hennepin County Medical Center leadership to promote one R.N. on each firm to “lead R.N.” to facilitate huddles on their respective firms.

Between April and June, Green Firm staff discussed 46 patients at 23 huddles. The patients are a combination of Hennepin Health members and non-members. They were chosen because the care team identified them as high-need.  

According to Thakur, huddle outcomes include:

  • Connecting patients with care coordination resources and education in order to divert them from unnecessary crisis care
  • Improved care coordination communication across multiple levels of end-of-life care
  • Successfully transitioning patients from primary care in the Green Firm to Senior Care

Thakur believes that the huddles are ultimately changing the culture in Medicine Clinic by providing staff a welcoming, supportive environment in which to discuss complex patients. “Staff feel supported in caring for patients, and that they do not need to address the patient’s care all on their own,” she says.

Anne Pereira, M.D., echoes this sentiment. “I’ve been here a decade,” she said, “and this has been a big improvement. We’re all pulling together.”

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Linda Peterson

In June, Linda Peterson, Hennepin County Medical Center’s manager of case management, won Mpls. St. Paul Magazine's 2014 Outstanding Nurse Award in the administrative leadership category.

In her role at Hennepin County Medical Center, Peterson supervises 38 R.N. clinical care coordinators and two principal office specialists. Peterson is also a member of Hennepin Health's Care Model Committee and Care Coordination Subcommittee. 

linda peterson

Linda Peterson

Seven people nominated Peterson for the award. In their nominations, they called her a “true collaborator,” a “wonderful listener,” “calm,” “consistent,” “knowledgeable,” and “poised.” “She allows for venting,” one person noted.

Mpls. St. Paul magazine received 600 nominations in 13 categories. Peterson was one of 62 finalists who were invited to attend the awards ceremony at the Golden Valley Country Club on June 25.

awards ceremony

Peterson explains that she favors a participatory and collaborative style of leadership. “The people doing the front line work need to be part of the design and decisions,” she said.

When it comes to patients, Peterson believes that it’s important to “look at the patient as a whole.” Everyone has different needs; there are “no cookie cutter cases.” As a result, care coordinators need to be adept at problem solving and critical thinking. 

“Knowing the benefit set is important,” Peterson also said. “We are here to maximize the patients’ benefits.” 

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New additions to Hennepin Health administrative team

Hennepin Health recently hired three new staff. They are Michelle Soplata, L.S.W.; DeAnna Hayden, M.S.; and Aliduh Shireh, L.M.F.T. They joined Hennepin Health’s social services navigation team which is led by Kim Nguyen, M.S.W., L.I.S.W.

new hires

Kim Nguyen (front) with Michelle Soplata, Aliduh Shireh, and DeAnna Hayden

Here’s a picture of our new team:

hennepin health administrative team

As always, thank you for supporting our work.

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