Hennepin Health: A Care Delivery Paradigm for New Medicaid Beneficiaries

Hostetter M, Klein S, McCarthy D
Publication Year: 2016
Patient Need Addressed: Behavioral health, Care Coordination/Management, Chronic Conditions, Financial insecurity, Food insecurity, Homelessness/housing, Substance Use, Transportation
Population Focus: Low income, Medicaid beneficiaries
Demographic Group: Adult
Intervention Type: Partnership, Service redesign, Staff design and care management
Type of Literature: Grey

In partnership with social service agencies and nonprofits, this Medicaid accountable care organization proactively identifies members most at risk and provides them with care coordination and social support.

Low-income Medicaid beneficiaries with complex and unmet care needs related to serious mental illnesses, substance abuse problems, and other nonmedical challenges.

New approaches are needed to reach and serve those newly eligible for Medicaid, who often use emergency departments as their main source of care.

Patients have a single point of contact for navigating both the healthcare and social services systems. Reduces need for acute care and thus medical costs, enabling shared savings and reinvestment. Early results suggest this approach may also reduce costs for jails and other publicly funded services.

This work is extremely time- and resource-intensive, and may require payment reform and broader community participation to spread.

Insights Results

Overview of model

  • Hennepin Health, a safety net accountable care organization (ACO), was launched in 2012 as a Medicaid demonstration project in Hennepin County, Minnesota
  • ACO includes 4 partners: 1) County Human Services and Public Health Department; 2) Hennepin County Medical Center; 3) Metropolitan Health Plan; and 4) NorthPoint Health and Wellness Center (a Federally Qualified Health Center)
  • The model aims to reduce medical costs for poorest and most troubled patients by aligning services and pooling resources of organizations, not by creating new programs or looking for new sources of funding
  • Target population: Medicaid beneficiaries aged 21-64: poor, childless adults who became eligible under the state’s 2011 Medicaid expansion. Members are mostly male, with mental illness and/or substance abuse problems and half are unstably housed, living in a homeless shelter, or on the street. More than one third have multiple chronic conditions, most commonly diabetes, asthma, and hypertension
  • Key program features: 1) Proactive risk identification: through claims and medical record reviews, ACO identifies patients who would benefit from additional clinical and social services (e.g., patient has multiple address changes indicating unstable housing). Patients also given lifestyle assessment to understand social challenges (e.g., access to transportation, telephone, dental care, food); 2) Use of unconventional multidisciplinary teams: Teams include staff not traditionally found in clinical settings, who offer services not reimbursed by Medicaid. Teams are made up of nurse care coordinator, advanced practice provider, and a social worker supported by psychologists, addiction counselors, and a physician. Housing and social services navigators, vocational services counselors, and emergency services medical staff also serve patients; 3) Partnerships with local organizations to address non-medical needs: A team of housing and social service navigators secure priority admission for members to the county’s group residential housing. Hennepin also partners with local non-profits that have expertise in finding appropriate substance abuse treatment. Rise, Inc. also provides vocational counseling to help members become financially independent; 4) Financing: Hennepin Health’s health plan receives per-member-per-month Medicaid payments to cover the costs of medical, dental, and behavioral health services as well as some care coordination services Hennepin ACO is led by a county, with each of the 4 partners taking on full financial risk
  • After identification, patients enrolled through outreach from community health leaders. Outreach may include calls, or reaching out to patients wherever outreachers can find them
  • High-risk members (identified through diagnoses and lifestyle risk assessment scores) may be referred to ambulatory intensive care unity, which provides primary care and behavioral health services through multidisciplinary teams


    • Emergency department visits decreased by 9.1% between 2012 and 2013, while hospital admissions remained stable and outpatient visits increased by 3.3%
    • In 2012, ACO partners made an initial investment of $1.6 million to pay for new staff and data infrastructure. It has been able to achieve savings each year; medical costs have fallen on average about 11% each year since 2012
      Key Takeaways
    • New models of care for newly eligible Medicaid beneficiaries may be more effective than traditional care management approaches in engaging patients and reducing total costs. Hennepin shows that success takes significant resources and long-term investment in individuals; timing of interventions is also critical (e.g., reaching out to members before they’re released from a residential drug treatment program or prison)
    • Scaling this approach may take payment reform: To scale programs such as this, risk adjustment for social determinants, both in quality measurement and payment models, may be necessary
    • A community-wide approach is needed to care for the most vulnerable patients: Investing in mental health and other social services has the potential to save the healthcare system money, but also improve the community by keeping individuals out of jail and off the street
    • Greater investment in social services throughout people’s lifespans may prevent some from becoming high-need, high-cost patients: Hennepin Health is an effort to tilt the balance toward greater social support and less costly preventive and primary care. However, life experiences of members, especially those in early childhood, suggest that investment in social services early on may have benefits