Sessions

Ashley Kitchen, PhD; ACET, Inc.

Many reservations in the GPA are in USDA classified food deserts. Sedentary lifestyles, unhealthy shopping habits guided by poverty, limited availability and high costs of traditional foods, and inadequate access to fruits and vegetables contribute to poor nutrition and high obesity rates among those who live on reservations. The existing chronic disease prevention and intervention resources are not tailored to tribal communities in the GPA. When people see themselves reflected in the resources, they are more likely to adopt healthy behaviors and take healthy actions.

Sheila Kennedy, DNP, APRN, CNM; Southside Community Health Services

Southside Community Health Services started a home visiting program in 2020 to address the needs of pregnant patients who were at high risk of poor or suboptimal pregnancy outcomes, including preterm deliveries, small for gestational age babies, uncontrolled GDM, operative deliveries, and peripartum mood disorders. Our patients were reluctant to have nurses from an outside agency do home visits so we created our own program. We recognize that as a community clinic, our patients put a huge amount of trust in us and we have a responsibility to meet them where they are. The maternal and neonatal outcomes of patients who participate in our program outperform expected risk-factor-based outcomes for MN.

Dr. Robsan Tura, PhD, MPH, MA, CHES; Minnesota Department of Health

CHW models respond to policy changes that impact safety net providers by strengthening local health systems’ capacity to maintain access, quality, and reimbursement. Studies have shown that CHWs reduce emergency room visits and hospitalizations, particularly among Medicaid and uninsured populations, offering significant cost savings and improving care quality. CHWs offer concrete strategies to adapt to a changing health environment. Their community-rooted approach enhances patient engagement, chronic disease management, and health education. CHWs amplify the impact of safety net providers. This presentation will showcase global and local CHW interventions as models to improve health outcomes. The presenter will highlight successful case studies — such as Brazil’s Family Health Strategy, which integrates CHWs into national primary care teams, and local Minnesota CHW programs targeting chronic disease — to provide a blueprint for scale-up and sustainability. These examples offer practical tools and inspiration for attendees seeking to enhance their own programs.

Kate Murray, MPH; Minnesota Department of Health

Rodolfo Gutierrez, PhD, MS; HACER MN

Infection-associated chronic conditions (IACCs) are a lasting and under-recognized impact of respiratory viruses like influenza. In Minnesota, potentially 375,000 people, including 14,000 children, have experienced symptoms lasting 3 months to over five years after infection. Long-lasting symptoms include cognitive impairment, debilitating fatigue, shortness of breath, loss of smell and taste, and more. Additional chronic conditions associated with these infections include post-exertional malaise (PEM), postural orthostatic tachycardia syndrome (POTS), and myalgic encephalomyelitis / chronic fatigue syndrome (ME/CFS). Despite the burden associated with IACCs, this is an emerging area little understood by safety net providers and communities, and it is becoming more difficult to address. A concerted effort is needed by health care providers, communities, employers, schools, and public health to raise and maintain awareness in the community, educate and train providers to recognize and manage IACCs, monitor the burden of IACCs in our communities, bolster support services, and facilitate work and school accommodations for disabilities. New strategies, policies, interventions, and resources need to be developed and implemented, especially within safety net health systems and the communities they serve.

Yeng M. Yang, MD, MBA, FAAP; HealthPartners

This presentation will delve into the application of care that incorporates different diets in diabetes care. Participants will acquire strategies to enhance patient care by addressing the unique needs of patients with various diets. The session will emphasize the use of practical tools for identifying and integrating relevant resources for patients in diabetes management. Attendees will gain insights into improving communication and fostering better health outcomes. By the conclusion of this session, healthcare providers will be equipped to incorporate these care practices into their routine interactions.

Reuben Moore; Minnesota Community Care

Dr. Steve Calvin; The Minnesota Birth Center

In the US, we spend more on pregnancy care per capita than any other country—with worse outcomes. About 40% of all births in this country (and in Minnesota) utilize the public funds of Medicaid as their insurance payer. Those mothers and babies deserve the full range of safe, culturally sensitive pregnancy care options. In Minnesota, an innovative solution is on the way in a merger of the Minnesota Birth Center and Minnesota Community Care, an FQHC.

Since 2012, the Minnesota Birth Center has provided excellent clinical outcomes for more than 5000 mother/baby pairs in a comprehensive collaborative model of care. Care is provided in midwife-led independent birth centers located in Minneapolis and St. Paul that are accredited and state-licensed. If clinically necessary, care is provided in nearby hospitals by the primary midwife and collaborating physicians. Clinical outcomes are excellent, patient satisfaction is high, all for a reasonable cost.

In 2023, Minnesota Community Care midwives delivered 680 babies, all in a hospital setting. Among the patients currently at MCC, some would prefer to deliver in a home-like setting (Birth Center) and are also eligible from a risk standpoint. Offering this option, that would allow prenatal care in an FQHC and delivery in a Birth Center, is a novel continuity of care option. It honors patient preferences, and recognizes choice in birth settings. Higher risk patients still receive the benefit of midwifery care but in collaboration with obstetrical care in a hospital setting. This allows for high touch and high tech as needed.

Lara Pratt; Community-University Health Center (CUHCC)

Abidqani Abdi, BA, CHW; Community-University Health Center (CUHCC)

Luis Mendez, BA, CHW; Community-University Health Center (CUHCC)

At CUHCC, Community Health Workers (CHWs) play a vital role in quality initiatives to improve health outcomes related to hypertension, diabetes and cancer screening. In 2024, 40% of CUHCC’s patients had uncontrolled hypertension and 25% had uncontrolled diabetes. Currently, 49% of eligible patients are up-to-date on cervical cancer screening and less than one-third of patients received colorectal or breast cancer screening. Between 2023 and 2025, CUHCC has developed a CHW service model that systematically integrates CHWs into clinical care and quality initiatives. Today, they conduct outreach to close care gaps and they provide 1-on-1 CHW services in the clinic and via home visits where they provide health education, self-management support and connection to resources. In this session, the CHW team will describe its evolution, their clinic’s workflows for delivering and documenting their services. They will share data on their impact on chronic disease and cancer screening efforts and their creative strategies for overcoming challenges in the clinic and the community.

Jessica Hultgren, MA; Minnesota Department of Human Services, SUD Policy Team

Randi Callahan, MA; Minnesota Department of Health, Overdose Prevention Unit

Medications for opioid use disorder (MOUD) are considered the gold-standard of treatment for opioid use disorder. Yet, less than 30% of MHCP members with a documented opioid use disorder received MOUD in 2023. State data demonstrate there are significant regional gaps in MOUD access. Stable patients with opioid use disorder can receive treatment in primary care settings using the same models that exist for managing other chronic conditions. Safety net providers have potential to significantly increase access to this life-changing medication for their patient population.

Kat Donnelly, FNP, RN, PHN; Minnesota Community Care

Mobile primary care at Healthcare for the Homeless is able to offer acute care and preventative screening to unsheltered people, with about 800 visits per year. This intervention allows for unsheltered people to access more care. The mobile clinic also works with non-medical outreach partners to combine our trusted relationships with people and increase access to social services.

Rachael McGraw, DNP, RN; Minnesota Department of Health

The Minnesota Maternal Mortality Review Committee examines all deaths of Minnesota residents who die during pregnancy and up to one year after the end of a pregnancy. Committee members make recommendations about the cases that are aimed at health care systems, policy makers, providers, and communities with the goal of improving health outcomes for families in our state. This summer, the committee will publish the first report that includes 5 years of case data. This larger pool of cases gives us an opportunity for more and deeper analysis of maternal death in Minnesota. This session will share the data, themes, and actions from that five-year report, highlighting recommendations for changes at all levels with a focus on the community level. The health and well-being of mothers is essential to the health of families in Minnesota and there are many opportunities to contribute to change for the better. Through person-centered care, changes to health care access and health care delivery, and improved policies, change is possible.

Shawna Hedlund, MPH; Minnesota School-Based Health Alliance

Connie Sheehan, BA; Minnesota School-Based Health Alliance

Faith Adeola; Minnesota School-Based Health Alliance

Over 25,000 students are seen yearly in Minnesota's 35 SBHCs. SBHCs have expanded in rural and outer Metro communities faster in the past 3 years than any time earlier in the past 50. These are students with unmet medical, mental health, and dental care needs. SBHCs in MN are predominantly located in the highest quartile of socially vulnerable communities in MN. This presentation will explore the massive growth of SBHCs since 2022 and the impact of the rising demand for SBHCs. The presenters will illuminate both state and federal policy that is fostering sustainability and the role of FQHCs.

Devin Lavey, MS; Minneapolis Health Department

Kate Henschel, RD, CSOWN, LD; Fairview Health Services

This session will explore the implementation of a produce prescription program and the promotion of fruit and vegetable incentive programs, emphasizing the development of a Food Resource Navigator program, partnering with local farmers and community-based organizations, ensuring accessibility, and providing educational materials to improve participant engagement.

Erin Collins, MPH; Native American Community Clinic

LaTrese VanBuren Thompson; University of Minnesota Physicians Broadway Family Medicine Clinic

Samantha Lucas-Pipkorn, MPH; Hennepin County Public Health

Heart disease is the leading cause of death in the United States. Research suggests that FoodRx or VeggieRx programs can increase access to nutritious foods, improve overall health, and decrease food insecurity so patients can better manage their health. The Hennepin County Board of Commissioners is invested in making an impact and has authorized $1 million in 2024 and 2025 for initiatives to support women’s heart health.

The Native American Community Clinic (NACC) and Broadway Family Medicine are two of seven clinics currently funded through the Hennepin County Women’s Heart Health Initiative.

Rachel Pilliod, MD; Minnesota Perinatal Quality Collaborative (MNPQC), Allina Health

Cassie Mohawk, MPH, CHES; Minnesota Perinatal Quality Collaborative (MNPQC)

Historically, Perinatal Quality Collaboratives focused their efforts within clinical settings: obstetrics, gynecology, and emergency departments. While critical, Minnesota Perinatal Quality Collaborative (MNPQC) recognizes that perinatal health is shaped by experiences beyond hospital walls: in clinics, community organizations, and homes. MNPQC was developed with this broader lens, aiming to improve perinatal outcomes through community-centered strategies both in and outside of the hospital.

MNPQC gathers multidisciplinary professionals to collaborate on pressing perinatal health concerns, such as hemorrhage, substance use, hypertension, and mental health, through tailored Quality Improvement (QI) programs: Initiatives, Community of Learnings, ECHOs, and Sprints. These programs are informed by a statewide hospital survey and designed with awareness of providers’ time and capacity constraints, making them adapt to today’s evolving healthcare landscape. Through the Patient Family Partner (PFP) Program and targeted Patient Experience Surveys (MOSTaRE and Hypertension), MNPQC integrates lived experiences into its work. Tools such as the Mistreatment Index (MIST) and Measures of Respect (MOR) help assess respectful maternity care—a vital but often overlooked dimension of quality. To address gaps in care, MNPQC launched the Minnesota Perinatal Resource Map and List in June 2024. With over 1,000 views since its release, this living tool connects families and providers to local resources, from birthing centers and doulas to domestic violence supports, demonstrating how community partnerships can help address health outcomes.

Tanya Heitzinger, MA; Minnesota Disability Determination Services

Social Security Disability is a monthly cash benefit available to those who qualify for the program. There are often many questions and myths regarding the application and qualification process regarding this program. We will provide crucial information and resources regarding the overall program, applying for the program, working while on benefits, and advocating for patients who are applying for benefits.

Nora Sande, MBA, CASP; Open Door Health Center

Aimmie Borrelli; Open Door Health Center

Screening rates for HIV and breast, cervical, and colorectal cancers were below state benchmarks due to a large number of challenges, including lack of awareness, patient education, transportation, insurance coverage, language barriers, and access to care. This also helped to identify opportunities for better systems, workflow integration and tracking in the electronic health record (EHR). With support from the Minnesota Department of Health (MDH) and the Minnesota Association of Community Health Centers (MNACHC) as part of the Sage Cancer Screening Quality Improvement Program, Open Door Health Center (ODHC) implemented evidence-based interventions for patient and provider reminders and barrier reduction strategies.

We took an organizational approach to make this a comprehensive, integrated project to improve patient completion of all preventative screenings.

Erin McHenry Wolf, BA; Minnesota Department of Health

Greg Welk, PhD; Iowa State University

Physical activity can play a significant role in health. The lifestyle factor impacts things like blood pressure, blood sugar, weight, mood, mental health symptoms, and more. It can also help manage pain and stiffness associated with arthritis.

Most people want to move more, and most health care professionals want to encourage patients to be more active. However, embedding lifestyle change into clinical care can be daunting and cumbersome. The Minnesota Department of Health and Iowa State University both lead state-level projects funded by the CDC and focused on integrating physical activity into patient care workflows and connecting patients to community-led evidence-based programs and resources.

This presentation will highlight the two care models that embed physical activity and movement into chronic disease treatment. The Iowa model will focus on support from the community settings, and the Minnesota model will highlight clinical approaches.

Julia Tindell, MPH; Minnesota Department of Health

There is substantial research describing the dynamics and effects of intimate partner violence (IPV), human trafficking (HT), and exploitation and related co-morbid health and behavioral health outcomes for survivors. In this session, attendees will learn how the evidence-based CUES intervention can be implemented in healthcare settings to initiate conversations with patients about healthy relationships and violence. They will also discuss the benefits of collaborating with domestic violence advocacy programs to ensure patients have access to holistic care.

Kristin Godfrey Walters, MPH; Minnesota Department of Health

CHWs make a tangible impact on the lives of both patients and providers. CHWs can provide patient navigation, advocacy, social support, and health education that can result in powerful health behavior changes. CHWs provide literal and linguistic access to health clinics, community and social services, and community and patient support. These outcomes can only be achieved if CHW positions can be sustained over time. To make a CHW program launch and succeed, organizational readiness, training, and financing are necessary components. Statewide policy, funding, and planning efforts in MN from 2023-2025 have led to new resources and technical assistance available to CHWs and safety-net providers to facilitate successful CHW programs. This includes additional training opportunities for CHWs and CHW employers, and organizational readiness tools and support for supervisors and administrators to support and grow the CHW profession internally, even before hiring.

Alyssa Palmer; Southside Community Health Services

Southside Community Health Services (SCHS) has mastered clinical quality through reconnecting to our why and serving our patients as if they are our own family. With a new clinic on the horizon where all of our services will be provided under one roof, it was time for us to elevate and expand our thinking. We have begun to tiptoe into a new version of integrated care. Once only thought of as combined medical and behavioral health services, we have expanded our definition of integrated care to provide whole person healthcare, acknowledging the significant partnership of all systems when it comes to wellbeing: medical, behavioral health, dental, vision, and social systems. We have piloted numerous ways to begin this expansion and are eager to share our successes and challenges we've encountered on our continued journey.