Health care payment and delivery models that challenge providers to be accountable for outcomes have fueled interest in community-level partnerships that address the behavioral, social, and economic determinants of health. We describe how Hennepin Health--a county-based safety-net accountable care organization in Minnesota--has forged such a partnership to redesign the health care workforce and improve the coordination of the physical, behavioral, social, and economic dimensions of care for an expanded community of Medicaid beneficiaries. Early outcomes suggest that the program has had an impact in shifting care from hospitals to outpatient settings. For example, emergency department visits decreased 9.1 percent between 2012 and 2013, while outpatient visits increased 3.3 percent. An increasing percentage of patients have received diabetes, vascular, and asthma care at optimal levels. At the same time, Hennepin Health has realized savings and reinvested them in future improvements. Hennepin Health offers lessons for counties, states, and public hospitals grappling with the problem of how to make the best use of public funds in serving expanded Medicaid populations and other communities with high needs.

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.

Childless adults in the Medicaid expansion population have complex social and behavioral needs. This study compared the cross-sector involvement of Medicaid expansion enrollees who were high health care utilizers to that of other expansion enrollees in Hennepin County, Minnesota. We examined forty-six months of annualized utilization and cost data for expansion-eligible residents with at least twelve months of enrollment (N = 70,134) across health care, housing, criminal justice, and human service sectors. High health care utilizers, approximately 7 percent of our sample, were disproportionately American Indian, younger, and significantly more likely than other expansion enrollees to have mental health (88.1 percent versus 48.0 percent) or substance use diagnoses (79.2 percent versus 29.6 percent). Total cross-sector public spending was nearly four times higher for high health care users ($25,337 versus $6,786), and their non-health care expenses were 2.4 times higher ($7,476 versus $3,108). High levels of cross-sector service use suggest that there are opportunities for collaboration that may result in cost savings across sectors.

Hennepin Health, a Medicaid accountable care organization, began serving early expansion enrollees (very low-income childless adults) in 2012. It uses an integrated care model to address social and behavioral needs. We compared health care utilization in Hennepin Health with other Medicaid managed care in the same area from 2012 to 2014, controlling for demographics, chronic conditions, and enrollment patterns. Homelessness and substance use were higher in Hennepin Health. Overall adjusted results showed Hennepin Health had 52% more emergency department visits and 11% more primary care visits than comparators. Over time, modeling a 6-month exposure to Hennepin Health, emergency department and primary care visits decreased and dental visits increased; hospitalizations decreased nonsignificantly but increased among comparators. Subgroup analysis of high utilizers showed lower hospitalizations in Hennepin Health. Integrated, accountable care under Medicaid expansion showed some desirable trends and subgroup benefits, but overall did not reduce acute health care utilization versus other managed care.