Strategies 3.1.2:
Utilize evidence-based models and advanced care planning to support care coordination in preventing disease complications.

Strategy from the 2011-2020 Minnesota Heart Disease and Stroke Prevention Plan

CHW and Heart Disease Quality Improvement Initiative*
The Minnesota Heart Disease and Stroke Prevention Unit and two Federally Qualified Health Centers, designed and implemented a Community Health Worker pilot program. The three-year program utilized CHWs to help patients manage their heart disease risk factors.  One clinic primarily served urban Native Americans in Minneapolis and the other clinic targeted medically uninsured, underinsured and underserved residents of St. Paul. The CHWs worked with patients to assess and eliminate socio-economic or health systems’ barriers that inhibits successful chronic disease management. Project completed in 2011.

Contact: Sueling Schardin
Phone: (651) 201-4051
Website: Community Health Workers and Heart Disease Quality Improvement

Community Health Worker Alliance*
The mission of the Alliance is to provide a one stop shop where CHWs and CHW stakeholders work together to advance the profession of the CHW throughout Minnesota.  The Alliance’s core principals are to incorporate the role of the CHW in the health and social service sectors to decrease health disparities by reducing the social economic risk factors for the underserved population in Minnesota.

Contact: Joan Cleary
Website: Minnesota Community Health Worker Alliance

Health Care Homes Program
A "health care home," also called a "medical home," is an approach to primary care in which primary care providers, families and patients work in partnership to improve health outcomes and quality of life for individuals with chronic health conditions and disabilities.

The development of health care homes in Minnesota is part of the health reform legislation passed in 2008. The legislation includes payment to primary care providers for partnering with patients and families to provide coordination of care.

Phone: (651) 201-5421
Website: Health Care Homes

HealthPartners Research Foundation
MDH provided funds to the HealthPartners Research Foundation to improve coronary artery disease care through a systems change project.

Contact: Mary Jo Mehelich
Phone: (651) 201-5419

Heart of New Ulm Project

The Heart of New Ulm project's goal is to reduce the number of heart attacks that occur in the New Ulm area over the next 10 years by helping residents improve their health risks, such as physical activity, nutrition, obesity, or tobacco use, among others. The project will involve community education, medical interventions and environmental changes. The project is being led by Allina Hospitals & Clinics and the Minneapolis Heart Institute Foundation.

Contact: Minneapolis Heart Institute Foundation
Website: Heart Beat Back: the Heart of New Ulm Project

Minnesota Health Plans - Disease Management and Care Management Programs
Minnesota’s health plans offer a variety of services through their disease and care management programs.

NorthPoint Health & Wellness Center and SagePlus CHW Project*
The SagePlus Program provides heart-health services. SagePlus patients receive free tests for blood pressure, cholesterol, glucose and body mass index, free life-style coaching on topics such as diet, exercise and smoking cessation, as well as a monthly newsletter and fun activities that offer rewards for physical activity and healthy eating. SagePlus services are available at a limited number of Sage clinics throughout the state. Heart health services are not available separately from breast and cervical screening services.

Program ended in 2013

Stratis Health - Cardiac Care Learning Collaborative
Collaborative participants will look at ways to improve cardiac health for their patients and communities and will target four specific cardiac measures: 1) Appropriate low-dose aspirin therapy use in patients with ischemic vascular disease, 2) Blood pressure control in patients with hypertension, 3) LDL-C control among adults with ischemic vascular disease and 4) Tobacco cessation screening and counseling.

Contact: Jerri Hiniker
Phone: (952) 853-8540

Performance Improvement Project
Stratis Health provides facilitation and consultation to the health plans in developing, implementing, and evaluating each of the improvement initiatives. Stratis Health serves as a neutral party to combine and analyze aggregate data from health plans and members to evaluate PIP implementation processes and project impact.

Website: Health Plan Performance Improvement Projects

University of Minnesota School of Pharmacy

A pharmacy coordinated program to enhance medication use in chronic cardiovascular disease in a rural Minnesota community is being developed for implementation in 2012.

Contact: Jim Peacock
Phone: (651) 201-5405

If you would like to report current activity around this strategy, please contact Sueling Schardin at (651) 201-4051 or

* Addresses health disparities




Updated Thursday, June 12, 2014 at 06:44AM