November 2019, Volume XXXIII, No 8

Special Focus: Rural Health

Social disparities in Greater Minnesota

Health happens in communities

aria, a patient with type 2 diabetes, was challenged to manage her condition despite the best efforts of HealthFinders Collaborative (HFC), a charitable health center in Rice County that sees underserved patients experiencing barriers to accessing health care. Maria eventually developed retinopathy and partial blindness. HFC providers had given her regular 60-minute appointments, bilingual/low-literacy educational materials, teach-back instruction, and frequent check-ins between appointments. She was enrolled in our evidence-based diabetes management program and attended monthly classes where she received free supplies, insulin, and medications, as well as group education. We had the time and resources to bend over backwards to help Maria manage her diabetes—effectively taking concerns about access to care off the table—yet her diabetes progressed.

She is just one of the patients served by HFC since it opened in 2005 as a church-basement free clinic, then grew into to a health center with programs that span the continuum of care. While clinical care has always been at the heart of our model, we have built programs around the concept that health happens in communities. Despite generous support from volunteer clinicians and partners, many of our underserved patients still struggle.

Social factors are critical supports of health, not obstacles.

In Maria’s case, it became clear that what constituted her illness was driven by factors outside of our clinical programs. Collectively, these social determinants impacted her health at least as much as access to care or insulin.

A bleak picture

Minnesota has some of the most disparate, inequitable health outcomes in the country, disproportionately affecting marginalized groups and populations of color. Rice County—home to twice the state average of Latino immigrants and one of the largest Somali refugee communities outside of the Twin Cities—is no exception. Over two-thirds of the students in the Faribault school district qualify for free and reduced lunch, and the disparity between Latino and white poverty is among the highest in the state. These populations in rural Faribault are poised to grow, with over 30% of the births to non-white families, and the school district recently becoming majority non-white.

Rural institutions, including health care, have been slow to adapt to these changing demographics, exacerbating existing inequities. Recent community health needs assessments have highlighted social determinants, access to care, and chronic disease among the top priorities. Inadequate transportation, insufficient housing stock, and public policy have been slow to adapt to changing community needs, and racism and structural barriers are more visible and accentuated in small rural communities. Health insurance coverage gaps, real and perceived financial barriers, and complex health care systems further complicate the picture.

Banding together

Since its inception, HFC has coordinated with community members to address the significant and persistent gaps in health care for the underserved and uninsured in Rice County. Over the years, we have only deepened our relationship with our patient community and continually ask our patients: “What makes you healthy?” The most common answers demonstrate that patients define their health in terms of their children, family, religion, work, and neighborhoods—not clinics, medications, and lab monitoring. In response, HFC built programs around the idea that social factors are critical supports of health, not obstacles.

Our work was quickly transformed to one of building health, rather than building a clinic. We set about with a belief in the power of our patient communities to know what makes them healthy. We connect community development with health access to build programs in direct response to identified needs. Assets-based community development strategies are deployed alongside evidence-based chronic disease management.

By 2016, we had expanded to main street locations in both Northfield and Faribault, with community-embedded wellness programs that include exercise and nutrition classes, neighborhood-based chronic disease management programs, a teen and family health program, and a comprehensive oral health and dental clinic. We became an access point as much as a safety net, with advocates to help patients navigate local social service resources and health insurance enrollment.

But we still had patients like Maria.

Enter community health workers

A period of regular visits from a community health worker (CHW) was what finally turned the corner on Maria’s disease, bringing her A1C down from a persistent 14 to its current 7. Maria’s success was not unique: in the last 12 months the percentage of diabetics with A1C ≤ 8 went from 42% to 61%, a major improvement in a short time. Since 2016, the mean change in A1C among individual diabetics went from +.6 to now -.4.

CHWs are trusted, knowledgeable frontline health personnel who typically come from the communities they serve. They bridge cultural and linguistic barriers, expand access to coverage and care, and improve health outcomes by building trust and bridging community and clinical settings. An emerging workforce, CHWs are known by several titles, such as outreach worker, care guide, community health advisor, peer educator, promotora (in Latino communities) and community health representative (in American Indian communities). CHWs provide outreach, health education, care coordination, and advocacy for underserved patients of all ages.

Since hiring a Latina and a Somali CHW in 2016, we have learned how to best incorporate this new resource with clinical teams, particularly for patients with chronic disease. By going into patient homes, or sitting with patients in community settings, CHWs have uncovered challenges invisible within the clinic, and uncovered patient questions or misunderstandings not apparent to clinicians. Our providers took time, leveraged every available resource, and honed their skills on health coaching and motivational interviewing. However, there was still a gap in patient health.

Community health workers have uncovered challenges invisible within the clinic.

Integrating CHWs with clinical care teams, however, has taken some work. Differences in training, documentation, and the relative novelty of CHWs make intentional brokering of information across contexts essential as we move forward. While we are still learning how to best merge these two worlds, CHWs are the critical nexus between community, patients, and providers.

CHWs have assets that health care providers often lack: time to support patients in their context and on their terms, freedom to innovate, the ability to combine health care resources with local culture, and more. CHWs leverage trust to engage communities in their own health, and are particularly well-positioned to address social determinants of health.

In addition to their individual patient visits, our CHWs lead monthly group diabetes classes that combine didactic evidence-based diabetes management curriculum with peer-based support strategies at community-based locations.

Partnering with local health providers

Critical to our model from the beginning has been broad partnerships across our local health care system. Health systems have provided in-kind diagnostic imaging and labs since our inception, and as we have grown our capacity, their support continues to be essential. More than charity care, HFC works hard to fill gaps and extend the reach of health systems into the local communities they are challenged to reach and serve.

For example, we have developed referral relationships with care teams at local health system clinics for underserved patients who might benefit from community-embedded care. We work hard to become an extension of their team, ensuring that we are more than simply a referral source but also close the loop back to the clinical team to ensure they are engaged with community care. CHWs play a central role in this process, creating a space of cultural relevance and trust for partners to engage hard-to-reach communities with messages around health care utilization, end-of-life care, prenatal care, women’s wellness, reproductive health, chronic disease care, and more.

One of our CHWs is an invaluable member of Mayo Clinic Health System’s (MCHS) OB team. After visits at MCHS, she follows up with patients at home, checking on them at regular intervals. She then brings her findings to the Mayo team to work together to reduce miscommunication. Because of our CHW’s leadership, physicians have not only changed how they are able to care for this population, but have avoided significant complications, transfers to tertiary care centers, and adverse outcomes in measurable ways.

Allina Health similarly engaged HFC’s CHWs to support their social determinants project, leveraging our CHWs to more effectively connect Allina Health patients with community resources in support of social determinants of health.

By the numbers

We recently conducted a comprehensive return on investment (ROI) study to quantify the value of this partnership. Rigorous econometric analysis using hospital and HFC data found an ROI of 16.5 ROI: every dollar invested in HFC produced more than $16 of value in the community and for patients. Furthermore, at each of the two hospitals, one emergency room visit was prevented per day, and one unnecessary inpatient admission was prevented per week.

This return on investment study demonstrates how clinic systems and community organizations might be able to come together to drive value in their evolving context of population health, value-based initiatives, and margin pressures.

Summing up

HFC continues to be the nexus for the local health care system, convening a monthly meeting of executive leadership from two hospitals and five clinics across three systems, as well as public health and pharmacy partners. The nascent group, normally competitors, is identifying solutions for increasing collaboration for low-income and underserved populations.

Maria’s CHW, Raquel Rendon, said, “We don’t come with judgement or tell them what to do, we’re there to help them accomplish their goals. That really gives people meaning. It helps them gain confidence again and feel empowered to be able to care for themselves.”

Charlie Mandile, MA, is the executive director of HealthFinders Collaborative (HFC), where he has provided strategic direction and leadership since 2010. He has been on the board of Northfield Hospital and Clinics since 2013 and is a member of the Statewide Innovation Model Practice Transformation Workgroup, as well as several local coalitions. 


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© Minnesota Physician Publishing · All Rights Reserved. 2019


Charlie Mandile, MA, is the executive director of HealthFinders Collaborative (HFC), where he has provided strategic direction and leadership since 2010. He has been on the board of Northfield Hospital and Clinics since 2013 and is a member of the Statewide Innovation Model Practice Transformation Workgroup, as well as several local coalitions.