Winona Health – Community Care Network

Winona, MN
December 2017

Overview
Winona Health’s Community Care Network (CCN) was developed to expand our impact: to improve health and quality of life, prevent unnecessary hospitalizations and emergency department (ED) visits, and thereby reduce health care costs. In partnership with Winona State University, Winona Health also trains students to become health coaches. They learn to help people struggling with chronic health or mental health conditions, which negatively impact all areas of their lives.

CCN clients range in age from 18 to 96, with an average age of 58. More than half suffer from hypertension, obesity, and depression, and nearly half have diabetes. Clients are typically coping with multiple chronic conditions. Volunteer health coaches make “house calls” as nonclinical members of a client’s care team. In an increasingly specialized health care system, health coaches are the familiar faces who can help clients with the big picture of their overall health.

The CCN is unique in that it embodies a social as well as a medical model of care. The focus is not only on the client’s medical health, but also on issues around housing, food, utilities, and social connectedness. The CCN empowers clients to take ownership of their health conditions and supports them in their efforts to make changes in all areas of their life. Coaches support clients with tools and resources to maintain holistic health.

Impact
Since the program began in 2012, the CCN client base has grown to nearly 200 people served by the CCN team. Today, along with a clinical team that includes 3.6 FTE multidisciplinary staff, 70 student coaches have made more than 6,000 visits and phone calls to clients. In the first two years of the program, ED visits declined by 88 percent to 91 percent, and readmissions to the hospital dropped 85 percent to 94 percent among CCN clients.

For CCN clients who have been enrolled in the program for at least one year, the average medical savings has been $18,907 per client when comparing the year before and the year after CCN enrollment. Total health care dollar savings over the course of one year have been more than $1.1 million.

Lessons Learned
Like many health care systems, Winona Health had patients who cycled repeatedly through the ED or experienced multiple hospital admissions. The CCN has given us a deeper understanding of the issues these clients face in their lives. By employing a social model, rather than an exclusively medical one, we address not only health needs but also the interconnected social, financial and emotional components of holistic health.

Future Goals
We will continue to positively impact our population’s health while decreasing the costs of care. We’re expanding our CCN by incorporating Care Coordination Services so we can serve even more clients—improving the health and well-being of those at risk.

Contact: Betsy Midthun
Vice President, Community Engagement
Telephone: 507-457-4116
Email: bmidthun@winonahealth.org