Hennepin Health Newsletter: December 2014


December 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

Hennepin Health Access Clinic

Access Clinic

In 2014, Hennepin County Medical Center launched its Hennepin Health Access Clinic on the first floor of the Shapiro Building. The clinic serves Hennepin Health members and is co-located within HCMC’s award-winning Coordinated Care Center.

The Hennepin Health Access Clinic provides patients a short-term link to care before they choose a health care homeAt the clinic, short appointment wait times and walk-in care is the norm. People receive care from a multidisciplinary team that includes a community health worker, licensed alcohol and drug counselor, nurse practitioner, and physicians. The clinic is also in the process of bringing on board a social worker and an R.N. clinical care coordinator.

access clinic

People come to the clinic in several ways. Here are a few:

  • Hennepin Health Access Clinic staff review a list of Hennepin Health patients. They identify patients who have no primary care provider and are high users of crisis care. Then they reach out to these individuals with an engagement letter or phone call. If the patient is currently admitted to Hennepin County Medical Center, staff will visit them.
  • Patients are referred by a network of care coordination staff who work in Hennepin County Medical Center’s Acute Psychiatric Services and Emergency Department, as well as non crisis care settings like inpatient and ambulatory care.
  • Patients are referred by staff at Health Care for the Homeless, including Sierra Jackson, a Hennepin County Medical Center community health worker who is embedded there.
  • Patients are referred by TJ Redig from Hennepin Health’s ED In Reach Program.
  • By interfacing with an array of county and community partners in real time.


front desk

Here are four clinic staff:

Kate Hust, M.D.

kate hust

Kate Hust left Minnesota to practice medicine in New Orleans. In July, she returned, in part because of Hennepin County Medical Center’s “innovative primary care.” She describes the patients she sees at the Hennepin Health Access Clinic as “medically and psychosocially complex individuals” who often don’t understand how to use primary care and, as a result, may rely on the emergency department and other crisis care settings for their needs. With this in mind, one of the goals of the clinic, Hust explains, is to create a “bridge” for patients between crisis care and a more traditional primary care clinic like Whittier Clinic, Richfield Clinic, Downtown Medicine Clinics, and others. When patients come to the Hennepin Health Access Clinic, they immediately receive “well-rounded care,” Hust said. Then, after a few months, staff help them transition to another primary care clinic.

Hust said that working at the clinic has reinforced her belief that providers who want to engage their patients “need to identify that part of a patient’s health care that is most important to the patient.” That something — like a bottle of shampoo or a pair of socks — might not seem that important to the provider, said Hust, but attending to that need “makes the patient feel like they are being cared for.”

Brett Baker, L.A.D.C

Brett Baker

Early in his career, Brett Baker worked at Cedar Ridge, an inpatient alcohol and drug treatment center for men in Stillwater. “[While there], I often wondered how patients got to the severity of use that they were at, what led them there,” Baker said. Eventually he transitioned to an outpatient treatment facility and later joined the Hennepin Health Access Clinic. These varied experiences make him an excellent resource.

Baker places his work under six umbrellas:

  • Help patients recognize their withdrawal symptoms.
  • Teach patients how chemicals affect their physical health.
  • Teach patients how chemicals affect their mental health.
  • Use motivational interviewing techniques to help patients recognize that chemical use is problematic and to help them determine steps they’re willing to take to improve their lives.
  • Help patients identify things in their lives that make them vulnerable to relapse (e.g., a family member who uses).
  • Connect patients to care or to a recovery environment (e.g., complete chemical dependency assessments, help homeless patients find supportive housing).

Baker encounters many people with co-occurring disorders. When asked why this is prevalent, he explains that some people began using chemicals to cope with their behavioral health issues, but that the reasons why both occur simultaneously are often hard to decipher, especially when a patient began using as an adolescent.

Many patients with co-occurring disorders want to know what came first, the chicken or the egg, Baker explained, “but I don’t always have a good answer.” Instead, it’s usually better for a person to focus on improving their life in the here and now. “I use this analogy: If you drive your car off a bridge and into a river, do you stop and say, ‘How did I fall into the water?’” Baker said. “No, you swim out.”

Another thing that Baker sees is relapse, even when a client has been to treatment. “Sobriety is an extremely difficult thing to achieve,” he said. But he stresses that relapse, and multiple stints in treatment, don’t necessarily equate to failure. “Most people gain a little more sobriety after each treatment,” he explained. “They gain knowledge and learn coping skills. [People experience] a series of light bulb moments on the road to sobriety.”

About the Hennepin Health Access Clinic, Baker said, “I think we’re assessing the population well and meeting individuals’ wrap-around, complex needs. I can’t think of a service that we’re not offering that I see a consistent need for.”

Mia Debbins, community health worker

mia debbins

Mia Debbins has worked at Hennepin County Medical Center for 24 years. In the past, she’s held roles that were similar to a community health worker, doings things like assisting people with their discharge from inpatient care, helping people procure food and clothing, and working with the homeless. As a result, moving to the Hennepin Health Access Clinic in June was “a natural transition.”

Debbins notes that one of the most important things she does is administer a “Life Style Overview” to every new patient. The LSO includes questions about transportation, food, physical activity, dental, housing, social support, tobacco use, readiness to change, and other aspects of a person’s life. The LSO "reveals information about a patient that they may not have thought to tell us or that we may not have thought to ask them,” Debbins explained. Using the LSO helps providers tailor the care they provide to the client. It also helps the provider use the time they have with the client more efficiently since they can identify, right off the bat, specific areas of need.

The people who Debbins works with are often experiencing a myriad of health care concerns. Despite that, “I can’t think of one patient I’ve met who isn’t lovely,” she said.

Koleena Johnson, P.N.P. 

Koleena Johnson

Koleena Johnson has a history of working with patients with complex needs. Prior to the Hennepin Health Access Clinic, she worked at Hennepin County Medical Center’s General Internal Medicine Clinic and, before that, as a public health nurse at Health Care for the Homeless.

The Hennepin Health population, like other complex populations Johnson has served, is “not necessarily the most medically complex,” she said, “but mental illness, chemical dependency, and complex social situations like lack of adequate income or housing affect their health to a jarring degree.” That’s why providing them integrated care via a multidisciplinary team — a mainstay of the clinic — is so effective.

Johnson reveals that when she’s practiced in less team-based settings the work often felt “task-oriented” with the tasks “based on job class.” However, with the Hennepin Health Access Clinic’s team approach, it’s different. “Our work is the patient, not the task,” Johnson said, “because we have a shared experience of each patient.”

One of Johnson’s philosophies is that “no change happens without relationships, particularly relationships between the patient and the provider.” This philosophy is embraced at the Hennepin Health Access Clinic where staff begin to build relationships with patients from the get-go, in some cases even before a patient sets foot in the clinic.

Johnson explains that staff reach out to potential patients with an engagement letter, telephone call, or visit. Once they come in, they’ll “usually check in with the same one or two front desk people and meet with the same provider every time,” she said. This consistency allows for deeper relationships and “makes a person more comfortable accessing health care.” Many people use the emergency department for routine health care simply because they find it “overwhelming and inconvenient” to assess primary care, Johnson said. “We believe that if [we create an environment where] patients trust us and have rapid access to care that they might come to our clinic.”   

Although the clinic is new, Johnson already has success stories. One of her patients, who is homeless, frequented the emergency department several times per month — usually in an altered mental state. More often than not, he was simply trying to rest and stay warm. Once linked to the clinic, the man began working with Baker on his chemical health issues. Debbins helped him get a shelter voucher. And Johnson “caught him up” on his medical issues. He hasn’t been to the emergency department since September.  

Johnson describes the work being carried out by Hennepin Health and the Hennepin Health Access Clinic — with its focus on primary and preventative care — as “innovative.” “In our current health care delivery system, we often find ourselves spending health care dollars when people are very sick and are being hospitalized repeatedly,” Johnson said. “Spending money on the front end to be proactive versus on the back end to be reactive” is a model that has “not often been used,” she said. “This is a really courageous way to use health care dollars.”  

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Member Spotlight: Darcy


“I’m an alcoholic,” said Darcy. “The bottle has pretty much dominated my adult life.”

Between the ages of 21 and 35, 57-year-old Darcy went to alcohol treatment four times. “I would have my sober periods,” he recalls, “but it was a revolving door type of thing.”

The repercussions were staggering.

For instance, though Darcy has experience in a myriad of skilled and semi-skilled jobs (and has worked in factories, machine shops, print shops, warehouses, mailrooms and more) he’s lost them all, including a position he held for eight years. “Just about every job I lost was alcohol related,” he admitted.

The recession didn’t help, either. Everything became “more competitive,” Darcy said. At the time, Darcy lived at 32nd Street and Garfield Avenue, but paying his rent became increasingly difficult. “I could see it coming,” he said; in July 2012, he became homeless.

Darcy stayed at Harbor Light when he was homeless. While there, he sent out several housing applications and, on February 21, 2013, he moved into Exodus Residence.

Several months later, Darcy got another housing opportunity when the property manager at the Salvation Army’s Hope Harbor informed him of a vacant unit. Darcy had submitted a Hope Harbor application in 2012, while homeless — and had all but forgotten it. 

hope harbor

So, on February 19, 2014, Darcy moved into a unit on the fifth floor of Hope Harbor, where he currently resides. The efficiency apartment has linoleum floors, a bathroom, bookshelf, and kitchen appliances, and it overlooks I-394 and Target Field.

Hope Harbor, a 96-unit supportive housing complex in downtown Minneapolis, is home to low-income single adults and the chronically homeless. In addition to apartments, the facility has offices where case managers help residents with job searching, addiction counseling, medical needs, budgeting, and more. Residents pay rent on a sliding scale. Those unable to pay stay for free. Darcy said he’s been able to start rebuilding his life here. 

hope harbor front desk

For example, after many years of working with Alcoholics Anonymous, Darcy now recognizes the psychology behind his disease. “AA uses the words ‘powerful,’ ‘baffling’ and ‘cunning’ to describe alcohol,” Darcy said. “[For alcoholics], alcohol is both a physical and a mental craving, but [after treatment] I don’t lust after it as much anymore.” Darcy has been sober since July 2013.

Through his affiliation with Hennepin Health, Darcy is also receiving care for Type 2 diabetes — a condition he was diagnosed with in January 2008.

A regular at Hennepin County Medical Center’s Whittier Clinic, Darcy interacts with a number of health care professionals, including Melissa Kaufhold, a community health worker. Kaufhold helps Darcy set up medical appointments and check on refills. She connected him to a diabetes nurse who gave him a glucose meter. Kaufhold is also someone to talk to. She always asks, “Is there anything else I can do for you?” Darcy said.

In the months ahead, Darcy’s goals are to maintain stable housing, remain sober, and continue to manage his diabetes.

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Accountable Communities for Health Grant

In December, Hennepin Health was awarded an Accountable Communities for Health grant from the Minnesota Department of Health.

The target population for this grant is the corrections population in Hennepin County. Many people in this population experience — or are at high risk for — homelessness, unemployment, behavioral health issues, and recidivism. A high number are disconnected from primary care and community health resources and are using costly crisis care instead.

Through this grant, Hennepin Health will employ a multi-pronged approach to address these issues and to reduce health disparities within the target population. Hennepin County government and community entities will collaborate on the project. They include:

Keep up-to-date on our progress by reading the newsletter and connecting with us via our Facebook page.

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Thank You

Thank you

With 2014 at a close, we would like to thank you for supporting our work. Because of you, we’ve achieved many goals this year. Stay tuned for the January newsletter in which we’ll provide a 2014 recap and share some of the exciting things that are on tap for Hennepin Health in 2015 (including a slew of new reinvestment initiatives).

Wishing you a safe and happy holiday season.

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