Case Study: Partnering to Improve Health and Wellbeing via Community Based Care Coordination in Rural Minnesota

Winona Health

Winona Health is an independent, community-owned, and vertically integrated healthcare system designed to care for people through all stages of life. Located in Winona, Minnesota, a beautiful, rural area nestled among the bluffs of the Mississippi River, Winona Health delivers care to residents of southeastern Minnesota, and Trempealeau and Buffalo counties in Wisconsin. The system is one of the area’s largest employers, with nearly 1,100 staff members including more than 90 physicians and associate providers across a 49-bed hospital, primary and specialty care clinics, urgent care, assisted living and long-term care residences.

Community Health Needs Assessment + Community Listening Sessions

Conducting a Community Health Needs Assessment (CHNA) is an important step in monitoring and improving community health, a goal Winona Health shares with various community stakeholders. The assessment opens doors for greater collaboration among community partners by strengthening relationships and promoting a more efficient use of resources.

Research has shown that a person’s health is, to a great extent, determined by factors outside the traditional walls of healthcare. Early community discussions and findings on the 2016 CHNA identified gaps in health equity, social determinant of health needs (SDOH), and concerning trends with obesity, mental health, and alcohol and substance abuse. Food insecurity in families rose as one singular area of focus, recognizing that early gaps may lead to downstream economic, health and social consequences and other inequities. For example, results from the 2016 CHNA revealed that 14% of the population who completed the mailed randomized survey compared to 56% of the immigrant and refugee population worried about food running out. Another significant discovery found 28% of Winona County children were eligible for free lunch, but only a fraction received free or reduced-price lunches, which indicated a service gap to more vulnerable students. Accompanying studies showed that 35-37% of Winona kids reported they had to skip meals because of insufficient family money, 11% of Winona residents were food insecure, and 19.5% of people in Winona lived below the federal poverty level. Equally concerning trends expressed during listening sessions included chronic stress related to financial pressures and locating affordable housing; the difficulty of finding and navigating support services; societal stigmas; and the hopeless feeling of being stuck in an endless cycle.

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