System-Based Projects

We conduct projects about the structure of health care delivery and how that shapes the experience of patients and providers.


This 2014 Hennepin Health Reinvestment Initiative aimed to establish care team huddles comprised of: a primary care provider, medical assistant, nurse, community health worker and social worker, in the HCMC Medicine Clinic. Huddles met monthly to review patients at risk for health inequities and develop a care plan for them. Evaluation of the program is underway to examine if patients who were discussed had fewer hospitalizations and Emergency visits.


Hennepin Health evaluation

The Commonwealth Fund supports this mixed methods evaluation of the Hennepin Health Accountable Care Organization. This project is in partnership with principal investigator Nathan Shippee, PhD from the University of Minnesota’s School of Public Health and John Connett, PhD, and Jeremiah Menk, MS from the University of Minnesota’s Biostatistical Design and Analytics Center.


Measuring Totally Accountable Care

In this project, CPPE staff partner with Hennepin County with support from the Center for Health Care Strategies, Inc to examine multi-service using adults in the county. By joining health care, housing, criminal justice, and behavioral health/social service case management data, we are examining health and social risk and service use patterns to identify high need high cost individuals. 


Safety net payment reform project

With funding from the Robert Wood Johnson Foundation, we are developing a survey instrument to measure the impact of payment reform on providers, staff, and patients in primary care clinics serving low resource patients. We are combining literature review with key informant interviews to define how each stakeholder group wants to be engaged in changes to improve the health care system. 

High-risk families and kids on Medicaid

Low income children and adults face a number of social stressors including homelessness, food insecurity, barriers to high quality education, limited job opportunities, and increased risk of family violence and other adverse childhood experiences (ACEs). All of these exposures increase lifetime risk for costly health care and social service use and poor mental and physical health. With the help of cross-sector advisory committee, we are developing a new care model for high-risk families and children on Medicaid, focusing on improving coordination and communication between county and clinical services.