Health Care Homes Sustainability Roadmap
Partnerships
Many Minnesotans do not have easy or equitable access to care. There is growing recognition of the impact of social factors influencing health and the importance of community partnerships to address them.
Traditional and non-traditional partnerships are paramount to sustaining the Health Care Homes (HCH) model of care and improving patient outcomes in meaningful ways. One goal of the program is to increase collaboration between primary care and community resources to support whole person care, population health, and health equity. Relationships between the certified HCH clinic, other health care providers, payers, and community entities creates pathways connecting patients to needed services and resources. Referrals to and collaboration with partners through these new connections is crucial to improving health and wellbeing for patients and families. Access to accurate, up-to-date information about shared patients ensures effective, coordinated care and can lead to increased patient safety.
Strategies
- Build partnerships with internal and external, traditional and non-traditional cohorts who will collaborate to improve the engagement, experience, health equity, and outcomes of the populations served.
- Initiate conversations, or strengthen existing partnerships, with payers to explore collective actions and projects aimed to improve the health outcomes of those individuals served by both organizations.
- Participate in community health assessments, using the data to inform organizational strategies and improvement plans, integrate community health efforts, and share responsibility in the community-based health improvement efforts. You can find out what health priorities your communities are working on here | MN Department of Health.
- Connect with grants and other collaborative projects whose goals and objectives align with existing priorities and work within the organization. An organization’s assigned HCH Practice Improvement Specialist can note these priorities during check-ins and regular conversations and assist with connecting to such opportunities.
Resources
- Call to Action: Addressing Health-Related Social Needs in Communities Across the Nation | U.S. Department of Health and Human Services (PDF)
- The importance of cross-sector partnerships in enabling better health outcomes | Viewpoint
- How to improve: Model for Improvement | Institute for Healthcare Improvement
- Strengthening Health Care-Community Partnerships with ROI Insights to Better Address Social Needs | Center for Health Care Strategies
- Minnesota Statewide Health Assessment | MN Department of Health
- Assessment and Planning Toolkit| MN Department of Health
Stories
Children’s Minnesota, the largest pediatric health system in the state, knows that good health requires more than good health care. Kids’ experiences at home, in school, and in their neighborhoods are the biggest drivers of overall health and well-being.
As part of a comprehensive model of care, the Community Connect program addresses the broader social determinants of health, connecting families in the Minneapolis and St. Paul Primary Care Clinics to existing community resources, including food pantries and benefit programs, transportation services, legal assistance, housing support, early childhood education programs, employment search assistance and much more.
How Community Connect works
The process begins when families at primary care appointments fill out a simple yes-or-no form that asks about their access to nutritious food, adequate housing and other social needs. Screening responses trigger real-time referrals to the team of resource navigators who work with the family to determine which resources may be most helpful. The resource navigators tap into a network of community partners, facilitate warm hand-offs, and then continue to support the family to ensure they have access to the resources they need to be healthy.
Particular attention is given to families of color and Native American families who experience greater disparities in health outcomes.
Community Connect intentionally hires people from the communities to ensure cultural congruency that allows families to comfortably have sensitive conversations in their own language.
The proof is in the data
During the pandemic the positive screen rate increased from 26% between 2020 to 2021 to 34%. Community Connect continues to see a consistent increase in positive screen rates. During the second quarter of 2023 that positive screen rate increased to 41%.
Almost 5,050 families enrolled in the program in 2021 and 2022 and the largest need, reflecting over half of the families served, is food household goods resources.
A robust evaluation of Community Connect data has clearly demonstrated that addressing social determinants of health improves the health of kids, giving them a strong foundation to thrive. Across program participants, the following was noted:
- Increased preventative care services and well-child visits.
- Decreased emergency room visits.
- Increased well-controlled asthma.
- Increased patient/family satisfaction and self-reported improvement of family health and well-being.
The Community Connect program received an MDH HCH Innovation Award in 2019 and was recently selected as a top finalist for the inaugural Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity by The Joint Commission and Kaiser Permanente.
St. Luke’s, an HCH organization with 10 clinics at Level 3 certification, partnered with Churches United in Ministry (CHUM) to offer safe, long-term housing for homeless seniors in Duluth, Minnesota.
CHUM is Duluth’s primary food shelf and emergency shelter service. In 2021, CHUM started leasing the first floor of the two-floor Duluth Inn and was able to provide 22 apartment units for homeless seniors in downtown Duluth.
Recognizing the need for additional housing in the community, St. Luke’s joined CHUM in the project and purchased the building, which is now called the St. Francis Apartments.
Through the partnership, St. Luke’s owns and maintains the building while CHUM provides the programing. The number of individuals provided housing has grown nearly fourfold, from 11 residents to 40 individuals now being provided a safe, warm place to call home.
In addition to housing, the project ensures each resident of St. Francis Apartments is provided with access to resources such as food preparation and/or food subsidies, basic housing needs including bed, linen, housekeeping and laundry, and help with personal needs such as accessing health services. Special preference is given to people who are 65 and older, veterans, and those with disabilities.
CHUM Executive Director John Cole said the need for housing in the Duluth area is great.
“Having this resource is crucial to helping our most vulnerable adults get the help they need,” Cole said. “It’s exciting to be able to grow and make progress on this challenging issue in our community.”
As part of its HCH program, St. Luke’s screens for social determinants of health (SDOH) during clinic visits. Questions assess needs related to food insecurity, utilities, housing, transportation, childcare, assistance, and safety. When a patient screens positive for one or more of these SDOH, referrals are placed to a community partner to ensure needs are addressed and on-going assistance is provided. The St. Francis Apartments are one such partnership which has, and continues to, benefit patients.
“We know that having stable housing is foundational to good health,” Dr. Nick Van Deelen, Co-President/CEO and Chief Medical Officer for St. Luke’s, said when the St. Francis Apartments opened. “In addition to our health care experience, we have a lot of expertise with building management and maintenance. We bring this experience and additional financial resources to the project, while CHUM brings a wealth of experience in helping connect people with housing and providing supportive services. This is a great way we can work together to create a healthier Duluth.”
Note: The St. Francis Apartment project involved additional collaboration with and support of the City of Duluth, the Duluth Housing & Redevelopment Authority, Blue Cross Blue Shield, Greater MN Housing Fund, One Roof Community Housing, St. Louis County and many others.
About St. Luke’s: St. Luke’s is a regional healthcare system serving approximately 500,000 residents of northeastern Minnesota, northwestern Wisconsin, and the western Upper Peninsula of Michigan. It includes St. Luke’s Hospital in Duluth, Lake View Hospital in Two Harbors, two ambulatory surgery centers, and more than 40 primary care and specialty clinics throughout the region, plus eCare Express Clinics.
The HCH program thanks St. Luke’s for sharing their experiences and insight.
For more than 125 years, Gillette Children's Hospital has focused its efforts on some of the toughest challenges in pediatric medicine – brain, bone and movement conditions that require specialized care. As a global leader in care and research, one of Gillette’s core missions has been to discover new treatment options for children who have disabilities.
Recently, Gillette concluded work on a five-year federal grant to support the implementation of parent advisor roles within its research process improvement team. The grant included financial reimbursement and training for parents serving in these positions.
“As a researcher, it was an amazing model,” said clinical scientist Rhonda Cady, RN, PhD. “Family Voices of Minnesota helped our clinical team learn how to work collaboratively with parent advisors and the model ended up being so impactful that we now believe it is critical to have paid parent advisors as part of our complex care program process improvement team.”
Gillette’s success with parent advisors led to the development of the Family Engagement in Research (FER) program. FER recruits, hires, trains, and compensates patients and parents for their lived experience expertise. After some training, program participants then work with Gillette research and clinical staff as equal partners on research projects and as advisors to organizational programs.
“Our parent advisors are essential to all that we do,” Tori Bahr, MD, MedPeds Complex Care confirmed. “I think we have all learned so much over the last five years having them as a part of our clinic.
“We are currently conducting a mapping session on how complex care works and how patients come in,” Bahr added. “The goal is to determine what to do when they're ready to move on from here and how we graduate them from complex care. Parent advisors are at every single meeting.”
Bahr noted that the process began with research and clinical staff asking about the patient experience. Things have now progressed to the point where staff proactively ask how a process works behind the scenes and how staff can make it work better.
“As a group, I feel like we can't do anything without running it by the parent advisors,” Bahr acknowledged. “Now we consider if we should make a change before first getting input from our parent advisors, knowing that their input is needed. It’s been transformative to learn that just because it works great for the provider, it doesn't necessarily mean that it's going to translate into great care.”
Bahr now considers parent advisors and their role to be woven into the fabric of the clinic’s work.
“Ultimately, I can't praise our parent advisors enough,” Bahr concluded. “They are incredible human beings.”
Rhonda Cady, RN, PhD