A new report from The Commonwealth Fund demonstrates how Hennepin Health, a Medicaid Accountable Care Organization (ACO) in Minneapolis, Minn. is breaking new ground in creating partnerships to address the range of health and social needs of the most at-risk members in their community. As consumer advocates look at models that address social determinants of health and payment policies that will support such models, this case study is a must-read.

Hennepin County Medical Center has long served the low-income and uninsured community in the Twin Cities and has grappled with how to meet the needs of the most vulnerable, many of whom have needs that go far beyond medical care alone. So, in 2012 they launched a Medicaid ACO demonstration project to create a new model of care for Medicaid beneficiaries who suffer from debilitating mental health problems, chemical dependencies, and other hallmarks of poverty, trauma and social isolation. The ACO includes four partners: the county’s human services and public health department; Hennepin County Medical Center, a public teaching hospital; Metropolitan Health Plan, a county-run Medicaid managed care plan; and NorthPoint Health and Wellness Center, a federally qualified health center. 

Using a care team approach whose members may include physicians, nurses, social workers, a psychologist and a substance use specialist, Hennepin Health was able to reduce ER visits and achieve significant savings. Hennepin’s efforts to identify and engage high-risk patients are key to its success, since the ACO is financially responsible for all of its enrolled members. Patients enrolled in care coordination programs also are given a lifestyle assessment to help staff understand their social challenges.

Last year, I had the privilege of sitting in on a team meeting at the Coordinated Care Center at Hennepin. Seeing this person-centered model at work, with all medical, social and behavioral issues being discussed by team members who exhibited high mutual regard for the expertise each brings, was truly inspiring. The Commonwealth report concludes that this is a model that can be replicated elsewhere, but doing so requires: a long-term investment; that state Medicaid agencies look at risk adjustment for social determinants of health, both in quality measures and payment models; and a community-wide approach to providing compassionate care for the most vulnerable high-need populations.