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Q&A: How is HealthRise Filling the Gaps in Chronic Disease Care?

InsightHow can we reach underserved people with chronic health care needs in the U.S.? A community health provider says communication and information sharing are two keys.

Chanza BaytopCharlie Mandile is executive director of HealthFinders Collaborative in Minnesota, one of the first local partners to implement initiatives for HealthRise, a five-year, $17-million global effort with funding and thought leadership from the Medtronic Foundation to expand access to care for cardiovascular disease (CVD) and diabetes among underserved populations in Brazil, India, South Africa and the United States.

Led by Abt Associates and its partners, including global evaluation partner, IHME, HealthRise aims to contribute to the World Health Organization’s goal of reducing premature mortality associated with chronic, non-communicable diseases (NCDs) by 25 percent by 2025 through the implementation and evaluation of innovative, scalable, and sustainable community-based demonstration projects.

Chanza Baytop, senior associate at Abt Associates, and the global deputy project director and U.S. project director for HealthRise, spoke with Mandile recently.*

Chanza Baytop: What kind of work did HealthFinders Collaborative do before HealthRise?

Charlie Mandile: Since it began, HealthFinders Collaborative (HFC) has worked with local health systems to provide care to marginalized and underserved populations. We are a community health center that has been viewed as the safety net for our community and has picked up where traditional medical care left off. It was a natural next step to participate in HealthRise because it fills a critical community need to coordinate care and support patients in their context in ways that none of the providers are able to do alone.

Baytop: What is the most innovative feature of your program?

Mandile: We are combining frontline health workers – including community health workers, community paramedics, patient advocates, and community organizers, and others — with medical teams to create a coordinated care hub, unite all of their work, and facilitate communications across the team and the community. This strategy of partnering community-based professionals with traditional medical teams to extend their reach in a coordinated, efficient, and reliable way makes for a potentially innovative model.

Abt Associates and HealthFinders Collaborative: Working to Help the Underserved in Minnesota 

Abt Associates coordinates global and country-level programs for HealthRise, a five-year, $17-million program funded by the Medtronic Foundation that supports community-based demonstration projects to expand access to care and management of chronic, non-communicable diseases, such as cardiovascular disease and diabetes. HealthRise works in the U.S., India, South Africa, and Brazil.

HealthRise is working through a partnership in Minnesota – HealthFinders Collaborative – to target under-insured and uninsured populations in the county, including Latino immigrants and Somali refugees. HealthFinders Collaborative works with a range of hospitals and clinics to implement HealthRise in Rice County, Minn. HFC serves as the “community care coordination hub” to coordinate diabetes and cardiovascular disease care across the four health systems in the county. The hub is supported by a team of front-line health workers, including community paramedics, community health workers, patient advocates and community organizers.

Baytop: How did you engage clinical facilities to support the HealthRise program?

Mandile: It was an interesting, natural evolution. We already were caring for their patients in the community, supporting them in their neighborhoods, and going out to patients with services. We had longstanding partnerships and were interested in how we could work together more. HealthRise’s focus on diabetes and hypertension gave us an opportunity to build on the capacity that we already created so we could see an effective extension beyond their walls.

Baytop: What do you think motivated your clinical partners to participate in this partnership? What keeps them involved in HealthRise?

Mandile: HFC is grounded in the belief that our communities, our patients, and their families really know what is best for their health. We committed to organizing our care and services around that principle. Collaborating with us allows the clinical partners to get connected to the community and to capitalize on the trust and relationships that HFC has established. We were able to structure partnerships and engage in conversations that allowed the community to give feedback to the healthcare providers, and I think the care providers found a lot of value in that.
The other important element is the idea that HFC and HealthRise are extensions of their reach beyond the clinical partner’s four walls. Clinical partners know what matters in the treatment of chronic diseases, like cardiovascular disease and diabetes, is happening outside of their exam rooms. HFC has prioritized being an easy, efficient, and reliable extension for our clinical partners into the community so the doctors, nurses, and care team view us as a resource.

Baytop: Did you experience some hesitation with those you invited to participate in HealthRise? If so, where did it come from and how did you deal with those issues?

Mandile: We did encounter some reservations and found out very quickly that there were a lot of groups working on some form of coordinated care or patient-centered approach. I think they initially found us duplicative. Care coordination from a hospital or healthcare system perspective is very different from the HFC interpretation. We spent a lot of time explaining how HealthRise could help their existing patient-centered care projects and extend their reach into the community.

Healthcare being provided to a man

A patient has a hypertension screening at a clinic run by HealthFinders Collaborative in Minnesota, one of the first local partners to implement initiatives for HealthRise, a five-year global effort to expand access to care for cardiovascular disease (CVD) and diabetes among underserved populations in Brazil, India, South Africa and the United States.

The Medtronic Foundation provides funding and thought leadership to HealthRise, which is led by Abt Associates and its partners, including global evaluation partner, the Institute for Health Metrics and Evaluation (IHME).  Baytop: How did you educate clinical partners on the gaps between their care coordination services and the ones provided by HealthRise?

Mandile: From a clinic perspective, their care coordination focused on things like ensuring patients made it to the pharmacy to pick up medication, barriers to making lab appointments, comprehensive support for referral services, etc., and challenges faced by the patients are handled on a case-by-case basis.

HFC’s expanded definition of care coordination includes providing resources that patients can tap into immediately – such as access to community health workers who are well-versed on both health and non-health related issues impacting their communities – which can be a benefit to them as they manage their diabetes or cardiovascular disease. This involved introducing the community-based aspect of care coordination to clinical partners in a way that was accessible, reliable, and effective.

Baytop: What technical challenges have you faced in the program?

Mandile: We’ve learned that the key to our HealthRise program is sharing information. We’ve spent a lot of time and resources in figuring out ways to accurately and efficiently share information across partners. One of the innovative things about HealthRise is that it transcends payors, healthcare systems, and organizations. Getting everybody to go in the same direction around a patient is critical and difficult. We’ve faced some challenges, but I think we have good systems in place, using technology and other tools, to serve patients through the coordinated care hub.

*This interview has been edited for length and clarity.

Read more about HealthRise:

North America
South & Central Asia
Sub-Saharan Africa
Latin America & the Caribbean
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