Ross Owen Explains Hennepin Health's Unconventional Care Team and Clinic Structure

Hennepin Health’s integrated approach to care coordination for complex patients requires a broader definition of care teams and clinics, explained Ross Owen, health strategy director of Hennepin County.

Transcript (slightly modified)

How do Hennepin Health’s coordinated care center and access clinic complement one another?

The coordinated care center is one of the longest-standing components of our care model, and it’s really intended for the most medically and socially complex individuals that we serve. People tend to end up in the coordinated care center because they have been high utilizers of emergency department and hospital services. We’ve seen excellent outcomes in taking care of those folks in a team-based ambulatory care model, but our clinicians have also realized that there are a lot of folks who appear to be part of that rising or emerging risk population, who if we do nothing different, are likely to rise to the level of need in the coordinated care center, or CCC.

The access clinic is a more recent innovation that’s intended to take folks who are becoming higher utilizers of the emergency department or are having problems with being discharged from the hospital, and to really bring them in and assess them and kind of do triage for what is the right level of care coordination or the type of support that those individuals need.

So, the 2 clinics actually share physical space and work very closely together, but are intended to really provide more of a continuum of complex care, rather than waiting until people end up in that extreme priority or extreme complexity group.

Why are more unconventional care teams necessary to best serve Hennepin Health’s population?

For the Medicaid expansion population that Hennepin Health has primarily served through its history, what we’ve found is that often it’s a healthcare or a condition need that’s bringing them into the healthcare system, but it’s really a social need or something that’s more related to the time they spend outside of the healthcare system that makes it very difficult for our traditional clinic teams to address that need.

We’ve found that it isn’t going to be particularly useful for us to try to manage diabetes or congestive heart failure, for example, if somebody doesn’t have access to reliable food or a safe place to sleep. By really augmenting our teams to include community health workers that can help us understand that social need and making available other members of the care team, like community-based social workers, job support counselors, and case managers, we find that we can really manage those social needs more intentionally and actually make it much easier for our traditional medical providers to do healthcare and medicine more effectively.