Hennepin Health: a care delivery paradigm for new Medicaid beneficiaries

Commonwealth Fund
Publication year:
Place of publication:
New York

This case study examines the Hennepin Health’s approach to care delivery. In partnership with social service agencies and non-profits, this Medicaid accountable care organisation (ACO) proactively identifies members most at risk and provides them with care coordination and social support. Key programme features are: proactive risk identification, using algorithms to analyse new members’ past medical histories (including records of hospital and emergency department visits and diagnoses) and identify those most likely to incur high costs; care coordination for high-risk members; use of unconventional multidisciplinary teams, including social workers and housing and social services navigators; and partnerships with local organizations to address nonmedical needs. The paper suggests that Hennepin Health’s efforts have improved access to primary care for its members and reduced use of acute care. Emergency department visits decreased by 9.1 percent between 2012 and 2013, while hospital admissions remained stable. Over the same period, outpatient visits increased by 3.3 percent. The paper sets out key insights and lessons: 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; scaling this approach may take payment reform; it takes a communitywide approach to care for the most vulnerable residents; greater investment in social services throughout people’s lifespans may prevent some from becoming high-need, high-cost patients (Edited publisher abstract)

Subject terms:
integrated care, case studies, risk assessment, multidisciplinary teams;
Content type:
practice example
United States
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