Successful models Coordination of Care

Successful Model for Rural and Underserved Communities

NorthPoint Health & Wellness

Geographic Area: North Minneapolis

NorthPoint is the first Federally Qualified Health Center that the Minnesota Department of Health certified as a health care home. In early fall 2011, NorthPoint completed the first year of participation and submitted the annual re-certification application.

As a multispecialty medical, dental and mental health center and human service agency, becoming certified as a health care home was a natural step. NorthPoint’s clinics offer a comprehensive array of primary care services, including family practice, obstetrics, internal medicine, pediatrics and specialty care. In addition, NorthPoint provides full-service dentistry and behavioral health services. NorthPoint also provides teen services at North High School and Plymouth Christian Youth Center.

Ancillary services include optometry, nutrition services, laboratory, a full-service pharmacy and radiology. Because many North Minneapolis residents experience barriers to health care, NorthPoint facilitates services with transportation, culturally competent and multilingual staff, translation services, assistance in applying for public programs, and a sliding fee scale. NorthPoint also offers a number of advocacy and outreach programs including nutrition counseling; a WIC office; Healthy Start for pregnant women; diabetes support groups; a smoking cessation program; Breathe Free North—a smoke free homes social marketing program; chemical dependency assessments; charter school screening; and dental education programs.

Health Care Home
NorthPoint’s health care home initiative is a primary care based model. A care team provides and coordinates high quality, planned, patient/family-centered health care promotion (acute and preventive) and chronic condition management. Patients play a major role in this program by agreeing to health care goals and following through on their personal health maintenance activities. The focus is typically on adult patients with multiple acute/chronic conditions such as diabetes, asthma, cardiovascular/hypertension and depression. The health care home strategy views health care expenses up front as producing a good return on investment (reducing costs later) by improving the overall health of patients (using a preventative care model). NorthPoint has enthusiastically embraced this strategy and has a team of staff members who continuously monitor and refine the process.

The success of this program to date is due to a number of factors including:
  • Communicating frequently and effectively among the team, staff, and management
  • Applying complementary industry best practices
  • Monitoring outcomes
  • Having a focused effort and detail plan
  • Seeking and gaining external funding to support health care home development activities.

In 1965, Minneapolis documented poverty and need in the inner city, which was particularly acute in North Minneapolis. To address these needs, Minneapolis began a city-wide community action program called Decision ’67, coinciding with the Neighborhood Services Program (NSP) begun through President Lyndon Johnson’s War on Poverty. Under NSP, five federal agencies collaborated to establish 13 multipurpose service agencies, called Pilot City projects, in poor neighborhoods across the country—including Minneapolis.

By June 1967, planning for the Minneapolis Pilot City program was underway, and included representation from the Northside Federation, an umbrella group representing 78 Northside resident groups, agencies and institutions. Pilot City Health Center opened in January 1969 and by March had seen 1,200 patients. Dental and mental health services were soon added. In keeping with the original model to create access to health care, economic development, education and social justice, in 1974 a new human services buildings was completed, allowing Pilot City to expand and house programs such as Big Brother, Big Sisters; Putting It All Together (program to motivate unemployed single mothers); University of Minnesota Extension classes; Minnesota’s largest energy assistance program; Metropolitan Visiting Nurses Association; furniture pickup; and a tool lending program.

During the 1970s, Pilot City Health Center was transitioned to Hennepin County while Pilot City Regional Center remained a separate entity. But in 2004, Pilot City Health Services was reunited with Pilot City Regional Center and renamed NorthPoint Health & Wellness Center. This merger was designed to improve patient care by integrating health and human services on the NorthPoint campus—providing a one-stop for clients’ social, physical and mental health needs. Currently, NorthPoint Health & Wellness Center is both a department of Hennepin County and a private nonprofit organization with a unique model of shared governance. 


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Updated Wednesday, October 26, 2011 at 01:51PM