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POLICY BRIEFMay 2018savings is a common feature of most ACO systems in the country. To date, Hennepin Health has realized savingseach year; however, financial reserves required by regulators are in place in the event that losses are ever incurred.At the state level in Minnesota, there have been efforts to incorporate social factors into future ACO payments andquality standards, but details have not yet been finalized.Improving system performance: A percentage of ACO savings is set aside each year for “reinvestmentinitiatives,” where partners can submit ideas for start-up funds to test new approaches. A governance committeethen reviews and selects those most likely to improve the system from an annual slate of proposals. Some of thesedemonstration programs have included funding a care coordinator at the mental health clinic, providing vocationalservices at a community-based program, having a community paramedic at the largest adult homeless shelter overthe weekend, expanding outreach at NorthPoint Health, and developing an inpatient medicine consultation servicefor patients with substance use disorders. Initial funding from Hennepin Health lasts for a defined period of up totwo years, but ongoing funding is dependent on one of the partnering agencies (HHS, HSPHD or NorthPoint);hence, demonstrating cost-savings and/or health improvements is vital to justify ongoing support and ess Clinic”One of the most successful reinvestment initiatives has been the HHS-Hennepin Health“Access Clinic,” which serves patients who need a broader range of clinical services inorder to access appropriate care. In this program, an HHS multidisciplinary team includesa community health worker, an alcohol and drug counselor, a social worker, a nurse carecoordinator, a clinical pharmacist, a psychologist, a nurse practitioner, and two part-timephysicians (one of whom is also the HCH Medical Director and provides care in HCHshelter-based clinics). The Access Clinic team targets those patients who do not have amedical home, use the emergency department (ED) and hospital for services that can bebetter delivered in other settings (e.g., chronic disease management, mild illnesses, etc.),are homeless, and/or have untreated mental health or addiction disorders. Started in2014, the Access Clinic reduced health care costs by nearly 2 million in the first year andimproved patient care by facilitating routine health services in a non-emergency setting.For the 266 members included in this pilot, ED use decreased by 42% (and related costswent down by 56%). At the same time, costs related to outpatient care went up only 13%,making this a very successful pilot. After the initial reinvestment start-up funds fromHennepin Health expired, HHS has continued to support the Access Clinic using its ownfunds. 7Sharing savings with ACO partners: After funding is set aside for piloting reinvestment initiatives, HennepinHealth distributes any further savings accrued to the ACO across the three partners (HHS, HSPHD and Northpoint)based on the number of primary care provider and care coordination visits documented in the EHR. Both face-toface visits and administrative time are considered in this formula (e.g., phone calls, chart reviews, referral work,etc.). HHS, which includes the hospital and is the largest provider of primary care services, typically receives 85%of the distributed savings. NorthPoint Health Center and HSPHD typically split the remaining 15%. While HSPHDreceives a small portion of funding, the HCH program accounts for a large segment its encounters. Including social determinants of health and coordinated careOne key to Hennepin Health’s focus on social determinants of health rests with its support for an 11-person carecoordination team employed through the ACO, linked to its clinics, and based in the community. Comprised of foursocial service navigators, two nurses, four short-term intensive case managers and one employment specialist, thisteam works with individuals who are referred through the EHR for additional support. Patients who need housing,are not engaged in care, or have other social services needs, are referred to this team from a wide range of sources(medical providers, community service providers, etc.). The team then looks at the medical record, meets with the4Medicaid Accountable Care Organizations: A Case Study with Hennepin Health

POLICY BRIEFMay 2018patient, conducts a needs assessment, and develops a care plan. In total, the team gets about 300 referrals a year tohelp navigate social services, identify housing, and meet other critical needs that cannot be addressed by medicalproviders during traditional office visits.The intensive case managers on this team also workclosely with emergency department staff to identify“The Hennepin Health system has been amazing infrequent users and connect them to outpatient care, helpproviding the little tangible things that people need thatwith appointment reminders, drive clients tomake such an impactful difference.”appointments, complete paperwork and assist with– Holly Sandefer, Short-term Case Managerbenefits, attend court, navigate housing placements, andother needed tasks. Monthly bus passes and mobilephones are tangible ACO/health plan benefits that help assist clients who need help with transportation andcommunication. The nurses on the care coordination team oversee a disease management program that provideshealth education and other services to those with chronic health conditions.All members of the care coordination team share access to the EHR and are able to document their work and seehow clients have been interacting with the system, whether they have missed appointments, or need help accessingbenefits. This access to data gives the team a bigger picture of what is happening with the client and what gaps needto be addressed. From there, they are able to add information to the patient’s record to inform the clinical team’sdecision-making.Focus on housing: A critical role for the care coordination team is to help secure housing for Hennepin Healthmembers who are homeless. The social service navigators are employed by HSPHD, embedded in the health planleadership structure, and partner with others on the team to focus on high-need individuals. The goal is to identifythose whose housing instability is contributing to high medical costs and significant vulnerability. The navigatorsreceive referrals through the EHR from the partner organizations and identify options that best fit each individualwith regard to eligibility, needs, and preferences. They help connect to the Continuum of Care Coordinated EntrySystem when appropriate, and support the other steps required to successfully obtain housing, such as find housingvacancies and complete applications, and then communicate back to other members of the care team. In someinstances, Hennepin County contracts with housing providers include a provision that Hennepin Health memberswill be prioritized whenever possible.PatientHighlightMr. Tewodros Michael (“Teddy”) is a 52-year old client of Hennepin Health, and a patient at theAccess Clinic where he works with numerous care team members. Previously married, stablyhoused and working as a cab driver, Teddy had a stroke in 2015 and entered a nursing home. Bythe time he was discharged, Teddy was alone, unable to work, had no resources, and ended up atthe Salvation Army homeless shelter in October 2016. During the year he lived at the shelter, thecare coordination teams from HCH and Hennepin Health partnered with the Access Clinic,ensuring Teddy had transportation to his many primary care and specialty appointments so hecould better manage his diabetes, chronic kidney disease, hypertension, mood disorder, andcoronary artery disease. The teams also helped Teddy obtain housing, food stamps, and cashassistance, as well as set up his medications each week. When Teddy moved into his newapartment in January 2018, the care team was able to use flexible funds to stock his cabinets withgroceries, and he continues to be supported by a visiting nurse from Hennepin Healthcare Systemwho helps with medication and diabetes management. He is currently being evaluated so he canget more help from long-term supports like a personal care attendant and an adult day program.Asked where Teddy would be without the care team’s work, his case manager believes he wouldstill be at the shelter, not accessing care; instead, he is now at home and thriving.“My life is a big difference from before. Now, if I want to read, I can read. If I want to go outside, Ican go outside. If I want to pray, I can pray. That’s what freedom is.” – Teddy Michael5Medicaid Accountable Care Organizations: A Case Study with Hennepin Health

POLICY BRIEFMay 2018 Communicating patient risk and need across systemsThe common link between all partners is the shared EHR that contains the inpatient dashboards. Here, providersand care coordination staff can see patient service utilization information (to include hospital admissions/dischargesand upcoming appointments), learn the patient’s care team members (primary care provider and care managementstaff), and identify the patient’s chronic disease and preventive health indicators.A referral system within the EHR links theclinical team and the care coordination teams.“Because HCH and the other partners in Hennepin Health,The process does not require clinical staff toNorthPoint and Hennepin County Medical Center all share anexit out of the medical record in order to makeEHR, it makes all our work more valuable when we are able tothe referral (no paper referral forms, nosee and document patient care together.”faxing, no phone calls), which is time– Stephanie Abel, Project Director, Health Care for the Homelessstamped and immediately assigned to a carecoordination team member for follow-up.Subsequent information is then entered backinto the EHR so the clinical provider can easily see new information about social service needs and any progressmade in meeting those needs. Additionally, providers across the partner organizations can communicate within theEHR through ‘in-basket messaging,’ a direct messaging function to share patient care information. For example, anHCH provider who notes escalating blood pressure on a patient can message his/her cardiologist and attach thepatient chart. These types of referral and messaging functions allow providers to more seamlessly coordinate care.The EHR used across Hennepin Health partners also stratifies patients into four automated predictive risk tiersbased on demographic and clinical data using the CMS Hierarchical Condition Categories (HCC) tool, though thistool does not include social determinants of health. 8 To the extent that services are delivered within the Hennepinsystem (which includes its operated clinics, hospital, health plan, and corrections facilities), this allows health risksto be tracked over time regardless of coverage status. Using this information, which is visible on the dashboard,Hennepin can better match patients to the most appropriate types of clinical care based on the complexity of theirhealth and social needs.Sharing EHR information across key areas of care has many benefits. For clinicians, it means they have additionalpartners providing relevant patient information in one place; and it prevents duplication of services because theycan already see what labs, tests or other procedures have been completed and what social services needs must beaccommodated in the medical plan. Because referrals for social work, care coordination and case management canoccur across the partner agencies within the same EHR, valuable clinical time is not spent trying to determine whois working with the patient, how to contact them and connect by phone to coordinate care. The result is moreinformed treatment plans. For administrators, a shared EHR avoids the costs associated with duplicated care andallows for a deeper data analysis on patient needs so more targeted interventions can be developed. For patients, ashared EHR allows them to receive better care coordination across both health and social needs, improves thequality of care they receive, and improves their experience and satisfaction with the health care system. Tracking outcome measures and cross-sector service utilizationAs a Medicaid managed care entity, Hennepin Health reports Healthcare Effectiveness Data and Information Set(HEDIS) measures common to Medicaid programs nationally. 9 This dataset includes 30 measures related toprevention and screening, chronic disease management, access to care measures, and utilization measures (seeAppendix A for the full list). Those of particular relevance to serving people who are homeless include follow-upafter inpatient mental health hospitalization, medical management for those on antidepressants, access topreventive/ambulatory health care, and initiation of alcohol/drug treatment.Because a shared data system is a key strength of the Hennepin Health ACO model, it is possible to better assesspatient needs because information is available across multiple service areas. An analysis conducted on all new6Medicaid Accountable Care Organizations: A Case Study with Hennepin Health

POLICY BRIEFMay 2018Hennepin County Medicaid-enrolled adults without dependent children between March 2011 and December 2014showed that many receive services from numerous other agencies. About two-thirds received help from otherhuman services programs (e.g., food assistance), about one-third were also involved in the criminal justice system,and 13% got help from housing or shelter services (see Figure 1). Further analysis shows that 8% were involved inall four sectors (health, housing, human services and criminal justice systems)—calling attention to a subset ofpatients who most likely need intensive interventions that address a wide range of issues. 10 High users were morethan three times more likely to use housing and shelter services compared to those who did not use the healthsystem frequently. 11 Because data systems are shared among county departments, it is easier to assess serviceutilization beyond Hennepin Health (as a health plan) to understand needs and service use more broadly.Figure 1. Cross-Sector Involvement of Hennepin County Medicaid Expansion EnrolleesSource: Center for Health Care Strategies, 2017. Note: This figure accounts for 98,292 Hennepin CountyMedicaid Expansion enrollees.Challenges & Next StepsWhile there are a number of benefits to the Hennepin Health system, three key challenges were identified in areasaffecting patients experiencing homelessness. First, the care coordination team previously was able to determinehousing placements for patients and develop relationships with landlords. The local continuum of care (CoC) thatoperates the coordinated entry system is responsible for this work, which takes the decision-making outside theHennepin Health system. The CoC screening tool used to establish eligibility for housing need is not alwaysaligned with clinical assessments, and does not include the broader range of housing needed by some of the mostvulnerable patients (e.g., group homes, assisted living, nursing homes, etc.). To help mitigate this, the carecoordination team interacts regularly with CoC staff so that when housing becomes available for someone on theircaseload, they can help with placement.Second, sustainability for reinvestment projects remains an issue, as illustrated by the Community Paramedicinitiative at the Salvation Army Harbor Light Center, an emergency shelter with 500 beds located in downtownMinneapolis. Started in 2014 with 154,000 from Hennepin Health to reduce 911 calls from the shelter duringevenings and weekends, the program decreased calls by 24% and helped those staying at the shelter with woundcare, medication management, and service navigation.12 After the initial reinvestment funds from Hennepin Healthexpired, responsibility for the program moved to HHS, which discontinued the program in 2016 amid difficultiesdemonstrating cost savings. This example illustrates a familiar challenge of continuity of support for programs thatappear to be promising.7Medicaid Accountable Care Organizations: A Case Study with Hennepin Health

POLICY BRIEFMay 2018Third, while Hennepin Health does pay for supportive services, it does not pay for housing. The need for housingfar exceeds the availability of U.S. Housing and Urban Development (HUD) or other public funds allocated. As anACO, Hennepin Health is limited in its ability to solve the community’s lack of affordable housing. However, as acounty government-based ACO, Hennepin Health is able to inform how local government contracts with housingproviders, prioritizes placement in available housing using health care needs as a priority factor, and develops newhousing stock to address unmet needs. Hennepin Health will continue to pursue strategies that blend fundingstreams, with an increasing focus on total costs and health outcomes at the system level.Amid these challenges, Hennepin Health is continuing to evolve its ACO model in several ways. It is makingimprovements to the EHR that allow for easier referrals for medical transportation and other services, faster priorauthorizations for medical services, and better data sharing capabilities between team members. As a second areafor continued improvement, Hennepin Health is refining its process for identifying priority populations anddeveloping strategies specific to these high-risk groups (e.g., pregnancy-related risks, people who are homeless,patients with rising risk scores, etc.). A third area of focus is to determine outcomes measures beyond thoserequired for HEDIS reporting, which may include qualitative self-assessment of health and quality of life,engagement in care, utilization patterns and identifying and addressing key social determinants of health.Lessons LearnedFor other states or entities looking to implement an ACO model within its Medicaid system, Hennepin Health andHCH leadership staff offer four lessons learned as advice based on their experience:1. Embed the HCH care model in the design: Before the ACO, there was little attention to the needs ofpeople who are homeless, and the HCH program’s value as a care model may not have been fullyappreciated. Since, HCH staff have been included in system design and development, which includes morebroadly incorporating a fully integrated approach to patient-centered care rooted in harm reduction; a focuson social determinants of health; and care coordination. This has better infused the HCH model throughoutthe Hennepin Health system.2. Share data: While Hennepin Health has an easier time sharing data and coordinating services because theyare all part of county operations and linked via a common EHR system, sharing data can also beaccomplished through a series of provider contracts and data-sharing agreements. Having a managed careplan that recognizes social determinants of health and partners so actively with a care coordination teamcould also be implemented in other health systems.3. Engage early in the process: If they had to do it over again, HCH leadership would have been activeearlier in the process to promote the HCH model of care and propose that the ACO fund additional HCHstaff to track outcomes [completed appointments, fewer emergency department (ED) visits, medicationcompliance, etc.]. Initial uncertainty over meeting these outcome measures may have inadvertentlycontributed to a delay in decision-making and other providers getting care coordination contracts forservices that mirror long-standing HCH practices.4. Demonstrate the value of the HCH care model: Define the niche for the HCH in your community and bevery specific a

human services. 3. Hennepin County Human Services and Public Health Department (HSPHD): the county social services and health departments. The HCH program is located within the Public Health function and ha