Retirements Acknowledged-
We'll Miss You 

This issue of the HCH Connection marks the retirement of three valued members of our program whose dedication, expertise, and leadership have helped shape Health Care Homes for many years. As they begin this next chapter, we want to thank them for their outstanding service, collaboration, and friendship. Their contributions have left a lasting impact on our program and the many colleagues, clinics, and communities they have supported.

Congratulations and best wishes to Georgia Anderson, Joan Kindt, and Rosemarie Rodriguez-Hager on their well-earned retirements!

(Photo left to right: Georgia Anderson, Rosemarie Rodriguez-Hager, & Joan Kindt)

At Neighborhood HealthSource (NHS), a certified Health Care Home (HCH) serving Minneapolis's Northeast, Northside, and North Metro, the Community Health Team is not a supporting act — it’s central to how the clinic delivers care. With 19 community outreach staff, NHS has built one of the most expansive Community Health workforces among HCH-certified clinics in the state. The breadth of what that team does reflects both the complexity of the community’s needs and the clinic's commitment to meeting them.

Several NHS Community Health Workers (CHWs) have gained experience through the Minnesota Community Health Worker Alliance’s Apprenticeship Program, a paid one-year internship combining on-the-job mentorship with active community outreach. Sophie Baggett, a CHW Program Manager, started as an apprentice in 2024 and now leads a team working across multiple grant-funded initiatives. Three current apprentices lead projects focused on opioid response and in-clinic resource navigation.

CHW roles at NHS vary widely. Some staff focus on in-clinic work, collecting social determinants of health data and connecting patients with resources. Others lead community outreach and take on grant management alongside frontline work. Many outreach staff also participate in grant writing — a deliberate strategy to build sustainability into the program itself.

NHS CHWs conduct outreach at unhoused encampments in North Minneapolis and Anoka County. The harm reduction team provides opioid prevention and response services at encampments and partner locations, offering Narcan training several times a month. CHW staff also work directly in schools, bringing health education and navigation into the places where young people spend their days.

When increased ICE enforcement activity began affecting patient attendance in early 2026, the CHW team adapted quickly — connecting patients with telehealth and distributing resource packets covering food resources, emergency shelter, and clinic programs to patients who could no longer travel safely. Deepened community partnerships followed, including connections with HOPE Avenue shelter, Sanctuary Haven, and Salem Church.

NHS's walk-in STI testing program has drawn patients from as far as two hours away. A childhood immunization outreach initiative uses mobile health records and direct patient contact to close vaccination gaps. One of the team's newest projects is a partnership with Mayo Clinic's FAITH! program, promoting cardiovascular health and digital health equity in African American communities through faith-based institutions.

"Everyone ends up wearing a lot of hats. But that's also what makes this team so responsive to what the community actually needs." At NHS, that responsiveness isn't incidental — it's the model.

Fairview Mesaba Clinic Primary Care recently completed a comprehensive Lung Cancer Screening (LCS) Facilitation Project in collaboration with the University of Minnesota’s Minnesota Cancer Clinical Trials Network (MNCCTN). Led by University of Minnesota pulmonologist Dr. Abbie Begnaud, the initiative aimed to increase completion of lung cancer screening by strengthening staff education, improving documentation practices, and increasing awareness of screening eligibility criteria across care teams.

(Photo left to right: Dr. Lauren Tomlinson, Tina Seline, & Dr. Kasey Kapella)

The project followed a structured, six-session facilitation curriculum designed to enhance workflows and support consistent identification of patients eligible for screening. Sessions focused on understanding current LCS eligibility guidelines, improving tobacco history documentation within Epic, strengthening shared decision-making and ordering processes, managing incidental and suspicious findings, and reinforcing evidence-based smoking cessation strategies. Together, these sessions equipped clinic staff with practical tools to integrate lung cancer screening more seamlessly into routine primary care workflows.

Prior to participating in the facilitation project, Fairview Mesaba Clinics were already leaders in lung cancer screening rates among both M Health Fairview and external sites. The goal of the project was to build on that success by increasing low-dose cat scan (LDCT) ordering rates by 25 percent through improved tobacco history documentation during patient rooming. The care teams met—and exceeded—this goal. Enhanced documentation led to more accurate identification of eligible patients and measurable increases in both LDCT orders and completed screenings. Comparison of baseline and post-facilitation data demonstrated clear progress toward the project’s defined targets.

A deeper review of data from the Hibbing clinic site highlighted the importance of accurate and complete documentation in advancing early detection efforts. Findings showed that approximately 8,300 primary care patients may be eligible for lung cancer screening, with eligibility evenly distributed across gender and age groups. While the majority of eligible patients had quit smoking, documentation gaps remained a key barrier to screening:

• Only 17% of patients had shared clinical decision-making billing documented
• 19% of former smokers lacked sufficient smoking history documentation

These insights reinforced how improved documentation practices can significantly expand identification of patients at elevated risk for lung cancer and ensure they are offered appropriate screening.

In the past year alone, more than 1,000 LDCT exams were completed at Fairview Mesaba Clinics. As a result of the project’s efforts, over 38 suspicious findings were identified—each representing a potential opportunity for earlier diagnosis and intervention. The Lung Cancer Screening Facilitation Project underscores how targeted education, consistent workflows, and strong documentation practices can meaningfully improve screening access and advance health equity through early detection.

Join health care leaders from across Minnesota for the first annual Health Care Homes (HCH) Sustainability Summit. Healthcare executives, providers, payers, finance professionals and policy makers will convene for one-hour sessions. Each session will feature dynamic speakers and panelists committed to sustaining high-quality, high-value primary care.

Dates and Topics

• Thursday, September 17 at 8 am: Healthcare Workforce Innovation, Culture, and Community Care
  • Featuring Dr Victor Montori, Clinician, Researcher and Healthcare Innovator
• Thursday, September 24 at 8 am: The Sustainability Equation: Blended Revenue, Value, and Impact
  • A panel discussion focused on reimbursement models, cost savings, alternative strategies, and payer perspectives.
• Thursday, October 1 at 8 am: Health Care Homes as a Sustainability Lever
  • A panel discussion focused on leveraging the benefits of the HCH model in networks and ACOs, community partnerships, and integrated team-based care models.