North Rising

Partnership: North Rising is a collaboration between Pillsbury United Communities and North Memorial Health Care

©2015 Pillsbury United Communities North Minneapolis 3

©2015 Pillsbury United Communities 4 North Minneapolis is MN’s most severe food desert 67,000 residents 30 convenience stores 1 supermarket ALDIso low cub foods hwy 55 hwy 100 I-94 downtown north minneapolis mississippi river

©2015 Pillsbury United Communities Food 5 Improve access to nutritious, affordable food close to home. Healthcare Community Expand access to health services where residents live and shop. Nurture a culture of health through services, events and education.

26,783 residents either have pre-diabetes or diabetes living in area codes 55411,55412,55430 Only 14% with total awareness of risk or status 2061 patients of North Memorial Health Care resding in and with hypertension Only 25% with hypertension meeting optimal care goal of BP of <140/ patients of NMHC residing in and with diabetes 30% are not meeting optimal care goal of A1C <8 34% are not meeting optimal care goal of LDL <100 Problem Statement:

1.Increase the screening and diagnosis of pre-diabetes and diabetes for residents of Camden and Near North neighborhoods by 14% by July Increase outcome indicators representing the management and control of diabetes and vascular disease of North Memorial patients living in Near North and Camden neighborhoods by 60% by July 2018 Objectives:

Approach 1: Increase individual health-seeking adherence behaviors regarding diabetes and CVD through patient empowerment and a reduction in barriers to care.

Relationship-based care Initial screening at Cub Foods and other locations, such as churches, PUC’s community centers and in patient’s homes Provide an incentive for screening, nutrition and management to promote healthy eating

CHW or CP assist individuals in connecting to primary care clinic, including scheduling appointments and arranging transportation to clinic – social media, text messaging, and other creative means

When connected to primary care clinic, North Rising’s Care Team is activated a.Behavioral coaching – including smoking cessation, exercise, nutrition b.Referral to self-management support programs c.Support groups led by target population d.Medication Therapy Management – medication intervention

Approach 2: Improve the capacity and effectiveness of frontline health workers to reach, engage, and follow up with those living with diabetes or CVD.

Equipping frontline workers with technology that makes lab draws, continual monitoring, and medication review possible in the homes or at public locations

Health Care Team Formation North Rising Program Manager 2 CHWs Community Paramedics Medication Therapy Management pharmacist accountable to an Accountable Care Organization and a Community Based Organization

Dual training – from a healthcare system and community organization

Health Care Team trained and oriented from the premise that relationships matter Full integration of CHW into the Care Team model

Innovation Collaboration: MTM Pharmacists, Providers, and two “emerging professionals”: community paramedics and community health workers Advancing the concepts of accountable care through direct engagement of community partners. Model that extends clinic care to community and home-based settings Developing a process for screening and follow up that is focused on continued engagement

Key Staff Adair Mosley, Chief of Staff, Pillsbury United Communities Emilie Hedlund, Care Coordination Manager, North Memorial Health Care Naomi Sadighi, Project Manager

Timeline Recruit and hire Community Health Workers Identify MTM, CP and MD for Health Care Team Formation Establish relationships with community partners that will host CHW for screenings Key staff attend Food Access Summit – Duluth, MN Onboarding of staff (training tools, EPIC database, culture and motivational interviewing) Health Care Team Training (evaluation, data collection, documentation, and continuous improvement) Start screening February 1, 2016