Hennepin Health is a Medicaid Accountable Care Organization (ACO) based in Hennepin County, Minnesota that began integrating the delivery of health and social services to a subset of the county’s Medicaid population in 2012. Hennepin Health began with the goal of increasing the use of preventive care and reducing preventable hospital admissions and emergency department visits by addressing beneficiaries’ other needs alongside their healthcare needs.
The program originally targeted individuals between the ages of 21 and 64 without dependents earning up to 75% FPL who gained coverage under the Medicaid expansion, but has since been expanded to children and families. Individuals in Hennepin County may choose Hennepin Health as one of their managed care options when selecting a health plan. Hennepin Health is also the default health plan for eligible beneficiaries who do not select a health plan.
Hennepin begins by identifying high-risk members via a Member Lifestyle Assessment. Those who are deemed high-risk are then sought after by Hennepin Health staff and social workers. High-risk members are then referred to a Coordinated Care Center, which is an ambulatory intensive care unit and provides primary care and behavioral health services through multidisciplinary teams that include a nurse care coordinator, an advanced practice provider, as well as a social worker.
Hennepin Health initially estimated that on average, high-risk members would need to continue receiving care from the Coordinated Care Center for three to six months. However, they have found that patients need more care for longer periods of time before transitioning to their Access Clinic, which provides team-based primary care for patients that are not at high enough risk to be admitted to the Coordinated Care Center.
The ACO also partners with local nonprofits and social service agencies to help its members find housing. The organization has a “housing first” approach, in which it seeks housing for members as its first priority, then begins to work on securing services for mental health, substance use disorder treatment, employment assistance, and other lifestyle health services.