Best Investment for a Healthier World


HealthRise Lessons from the Field: Creating “Coordinated Care Hubs” to Serve Underserved Populations in Minnesota

By Chanza Baytop, Abt Associates

HealthRise is a five-year, $17-million global effort with funding and thought leadership from the  Medtronic Foundation designed to expand access to care for cardiovascular disease (CVD) and diabetes among underserved populations in Brazil, India, South Africa and the United States. Led by Abt Associates and partners, including global evaluation partner, IHME, HealthRise aims to contribute to the World Health Organization’s goal of reducing premature mortality associated with chronic, non-communicable diseases (NCDs) by 25% by 2025 through the implementation and evaluation of innovative, scalable, and sustainable community-based demonstration projects. These projects empower patients, strengthen frontline health workers and advance policies to increase the detection, management and control of CVD and diabetes. The projects address key barriers to care faced by underserved populations by strengthening health care delivery and extending care into community and home-based settings.  In this interview, Charlie Mandile, executive director of HealthFinders Collaborative (HFC) in Minnesota shares his experiences as one of the first local partners to implement HealthRise demonstration projects. 

Please describe the work that HealthFinders Collaborative (HFC) conducted prior to HealthRise.

Since it began, HFC has worked with local health systems to provide care to marginalized and underserved populations. We are a community health center that provides care for those who are without health insurance, underinsured, or otherwise falling through the cracks. For a long time we’ve been viewed as the safety net for our community and have picked up where traditional medical care has left off. We were able to build from this position of working across the health system to identify gaps and provide people with access to the health system. It was a natural next step to participate in HealthRise because it fills a critical community need to coordinate care and support patients in their context, in ways that none of the providers are able to do alone.

Describe the most innovative feature of your program.

We are combining frontline health workers (and all that we define them as – community health workers, community paramedics, patient advocates, and community organizers) with medical teams to create a “coordinated care hub” that exists in the community, unites all of their work, and facilitates communications across the team and the community. This strategy of partnering emerging, community-based professionals with traditional medical teams to extend their reach in a coordinated, efficient and reliable way makes for a potentially innovative model. We are hoping we can contribute to the broader conversation on population health in a way that transcends insurers, health systems, and organizational partnerships and allows many different perspectives to come together to support patient health in communities.

How did you engage clinical facilities to support the HealthRise Program?

It was an interesting, natural evolution. We were already caring for their patients in the community, supporting them in their neighborhoods, and going out to patients with services. We had longstanding partnerships and were interested in how we could work together more. When HealthRise arose to address diabetes and hypertension, it gave us an opportunity to build on the capacity that we already created so we could see an effective extension of their reach beyond their walls.

What do you think motivated your clinical partners to participate in this partnership and what keeps them involved in HealthRise?

HFC is grounded in the belief and practice that it is our communities, our patients, and their families that really know what is best for their health. We committed to organizing our care and services around that principle, and in a way that is beneficial to health systems. Collaborating with us allows the clinical partners to get connected to the community and to capitalize on the trust and relationships that HFC has established. We were able to structure partnerships and engage in conversations in ways that allowed the community to give feedback to the healthcare providers, and I think the care providers found a lot of value in that. In working with the population, we connect community leaders and clinical partners so they can enhance their services. The other important element is the idea that HFC and HealthRise are extensions of their reach beyond the clinical partner’s walls. Clinical partners are aware that what matters in the treatment of chronic diseases, like cardiovascular disease and diabetes, is happening outside of their exam rooms. HFC has prioritized being an easy, efficient, and reliable extension for our clinical partners into the community so the doctors, nurses, and care team view us as a resource. This is a critical relationship that has allowed us to build these partnerships with the health systems.

Did you experience some hesitation with those you invited to participate in HealthRise? If so, where did it come from and how did you deal with those issues?

We did encounter some reservations and found out very quickly that there were a lot of groups working on some form of coordinated care or patient-centered approach. I think they initially found us duplicative or figured we were offering something that they were already embarking upon. Care coordination from a hospital or healthcare system perspective is very different from the way HFC interprets it to be. We spent a lot of time educating them on how HealthRise could be an effective tool for their existing patient-centered care projects and as way to extend their reach and capacity into the community. It was a lot about showing them the gaps that existed and explaining to them how we could build on their existing efforts.

Please describe how you educated clinical partners on the gaps between the care coordination services that they provide vs. the care coordination services provided in HealthRise.

From a clinic perspective, their care coordination focused on things like ensuring patients made it to the pharmacy to pick up medication, barriers to making lab appointments, comprehensive support for referral services, etc., and challenges faced by the patients are handled on a case-by-case basis. HFC’s expanded definition of care coordination includes providing resources that patients can tap into immediately (e.g. access to community health workers who are well-versed on both health and non-health related issues impacting their communities) which can be a benefit to them as they manage their diabetes or cardiovascular disease. This involved introducing the community-based aspect of care coordination to clinical partners in a way that was accessible, reliable, and effective.

Please share any technical challenges that you may be facing in the program.

We’ve learned that the key to our HealthRise program is sharing information. We’ve spent a lot of time and resources in figuring out ways to accurately and efficiently share information across partners. I think one of the innovative things about HealthRise is that it transcends payors, healthcare systems, and organizations. Getting everybody to go in the same direction around a patient is critical and difficult. We’ve faced some challenges but I think we have good systems in place, both technology and otherwise, to make sure we can serve the patients that we service through the coordinated care hub.

Is there anything else that you’d like to share with other HealthRise local partners about your planning experiences?

We’ve designed HealthRise to be of value and service to our clinical partners. Whether it’s pitching the care coordination hub in a certain way, or modifying elements of the program, a lot of our early work sought to emphasize HFC’s desire to be an effective extension of the work being conducted by the clinical partners. We wanted them to view us as a resource for their care team which was crucial in the early phases of the project. Clinics and hospitals are busy with their own work, and when someone from the outside offers them another program that they intuitively understand and want to be a part of, they have to ensure that it is in line with their resources and priorities. For the first several months, we not only spent a lot of time understanding the needs of our clinical partners, but also educating them on how we could plug into their existing systems in order to build their capacity.

How is HealthRise designed to ensure successful elements?

HFC is developing the capacity to make the HealthRise care coordination financially viable and billable. Furthermore, we are explicitly engaging community health stakeholders such as the Department of Public Health, hospitals, and health systems to collaborate in a way that returns value to them.