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Or dispatching THT’s Clinical Care Coordination team to the streets to listen to patients and guide them to community resources, which can help reduce unnecessary trips to the emergency department. Or to avoid violence.” The story of one client whom Paulson refers to as “Lady B” speaks volumes about the linkage between overutilization of health care resources and underutilization of community services.“The health care system wants them to be healthier, but often that’s not a person’s most important need,” notes Paulson. Lady B had visited the ER 465 times in a 12-month period, says Paulson.“The needs of patients who suffer from alcohol dependence may not be the same as those with opiate dependence,” he says.“So, we need to be very precise about understanding the problem, then design interventions to meet the needs of those subgroups.” Those interventions may be inside or outside the health care system. Francis Medical Center’s diabetes education program out of the hospital and into churches, where THT delivers an evidence-based curriculum about healthy activity and nutrition.Add in a high prevalence of mental illness and substance abuse, then layer it all over a mélange of cultural, language, and health literacy barriers.

These include payment models that directly or indirectly encourage coordination with non–health care services; highly targeted data analysis; and shared savings for federally qualified health centers (FQHCs).

At one FQHC, West Side Community Health Services, where Fournier is CEO, a staff member may personally accompany a patient to a specialist’s office if necessary, then follow up with the patient to make sure he is getting needed services.

Many of the patients attributed to FUHN’s ACO have mental health or substance abuse needs, or both.

In 2013, FUHN became one of the first of six Medicaid ACOs in Minnesota’s Integrated Health Partnerships demonstration.

“It was pretty gutsy, and the fact that we didn’t have a large integrated health care delivery system took people by surprise,” says Jaeson Fournier, FUHN’s board treasurer and immediate past chairman.

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“The health care system wants them to be healthier, but often that’s not a person’s most important need.” The ACO’s activities build on THT’s community health assessment, developed from hospital utilization data and 300 one-on-one interviews conducted in the community.

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