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

Minnesota 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

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

HealthPartners Research Foundation
MDH provided funds to the HealthPartners Research Foundation to improve coronary artery disease care through a systems change project. Project completed October 2012.

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

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.

MDH - SagePlus Program*
SagePlus provides low-income, underinsured or uninsured 40-64 year old women with knowledge, skills, and opportunities to improve their diet, physical activity, and other life habits to prevent, delay or control cardiovascular and other chronic diseases.  After an initial screening, which includes blood pressure, blood glucose, lipids, and weight, women receive risk reduction information tailored to their results and are offered the opportunity to participate in a year-long effort to improve their heart health.  Women may choose to work on diet, physical activity, tobacco cessation, or other health behaviors that impact their heart health.  Women who agree to commit to lifestyle change are assisted in designing specific, achievable, measurable steps to reach their goals.  SagePlus provides counseling, support, encouragement, as well as coordinating two optional activities designed to help women become more active and to increase their fruit and vegetable consumption. Program ended on 06/30/2013.

Phone: 651-201-5600

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.


University of Minnesota Community Pharmacy Project

A pharmacy coordinated program to enhance medication use in chronic cardiovascular disease in a rural Minnesota community is being implemented in Marshall, MN. The project aims to create a community-wide cooperative of a health-system, pharmacies and employers focused on enhancing cardiovascular health.

Jeannine Conway

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, 11-Jul-2013 09:39:47 CDT