摘要：Hennepin Health provides integrated medical and social services to low-income Medicaid patients in a large county located in Minneapolis, Minnesota. Data sharing is critical to program operations along with care coordination provided by community health workers. Early evidence indicates fewer emergency department visits and increased use of outpatient primary care. By focusing on prevention, coordination, and team-based care, the county hopes to improve individuals’ quality of life while reducing costs through better care management and reductions in emergency department use. Hennepin Health represents a new model of integrated care targeted to low-income individuals with complex health and social needs—needs very similar to the Affordable Care Act Medicaid expansion population. The program is supported by enhanced data integration to better coordinate medical care with other needed social services in a capitated Accountable Care Organization (ACO) framework. The positive outcomes achieved and the ability to reinvest in the model have helped to garner political support and have motivated providers and care teams who see the opportunities to make a difference in the lives of a largely disenfranchised patient population. Hennepin Health provides an integrated care management model that other care plans can use to improve care and lower costs for the Medicaid expansion population under the Affordable Care Act.
