Innovation in Population Health: Knute Nelson Walker Methodist’s Approach to Connected Communities

Posted on August 29, 2024 by Gina DiMaggio

Knute Nelson Walker Methodist (KNWM), leveraging a grant from the LeadingAge Minnesota Foundation, has developed a Connected Communities project to address the social determinants of health for seniors across five counties in west central Minnesota, focusing on whole-person health through care management, mental health support and technology.

Their work demonstrates how community-level interventions can significantly impact seniors' health and well-being beyond traditional medical care.

Social Determinates of Health

Only 20% of health outcomes are influenced by our medical care. The remaining 80% is determined by the Social Determinants of Health, which include factors like our living conditions, social interactions, and access to nutritious food. KNWM has taken up the challenge of influencing this 80% at a community level for our seniors, demonstrating its commitment to their well-being.

About Knute Nelson Walker Methodist’s Connected Communities project

Four years ago (prior to Knute Nelson and Walker Methodist merging), Knute Nelson embarked on a mission to establish a comprehensive system that supports the whole-person health and well-being of older adults and their caregivers. They have developed a collaborative, cross-sector system of care and support services, aiming to meet the physical, emotional, and social needs of seniors. The Connected Communities grant they received was instrumental in launching this work across five counties in west central Minnesota and is known as Lakes Area Connected Communities. As part of this process, they identified five pillars that serve as the foundation of their work, ensuring a holistic approach to senior care.

Recognizing that many aging adults were struggling to navigate the complexities of our healthcare system, they developed, implemented, and refined a navigation assistance and care management process. This supports aging adults through access to appropriate healthcare and community programs and resources. A key focus has been on advanced care planning, caregiver support, evidence-based program referral, behavioral health, reducing isolation, well-being engagement, social determinants of health, and action planning.

Recognizing large gaps in mental health support programming in the region, they implemented approaches around professional education opportunities for healthcare and community-based organizations, including suicide prevention, opioid disorder, and naloxone training, and the investment in certifying staff to deploy Mental Health First Aid and PEARLS (Program to Encourage Active, Rewarding Lives) throughout the region. These offerings have touched well over one hundred professionals and supported countless aging adults, caregivers, and families.

Other programming that has proven to be beneficial towards advancing the collective vision for the Lakes Area Connected Communities program include:

• Introduction of technology to support clinical and social care needs
• Introspective and community-based analysis of diversity, equity, inclusion, and belonging efforts to support the needs of our aging members and create opportunities for paths into workforce options
• Sponsoring/supporting of crucial community initiatives to sustain community-engagement around age-friendly community initiatives.

KNWM has been fortunate to learn from community members, partners, and payers. Listening to the valuable insights shared has been essential for serving their community in ways that fill needs and avoid duplication. Connected Communities has created many new opportunities for population health work within the regions of service for KNWM, demonstrating that collective creativity breeds opportunity and inspiration for change. It’s helped them build relationships and work collaboratively to advance shared goals in their community, as well as secure additional grants from other funders to expand on this work.

Wellbeing is much more than medical care. KNWM is leading the way in ensuring seniors have the resources to be healthy and live their best lives. We can’t wait to see how this work blossoms into the future.

The Lakes Area Connected Community model at work

Mary was referred to KNWM’s care management program by a concerned family member. One of their care managers met with Mary and learned that her priority was to finish an application she had previously received for Medical Assistance. The care manager helped her understand the form and how to complete it, aiding her in accessing supportive funding. Once she had access to these programs, the care manager collaborated with Mary and her new county worker to identify and arrange essential services that allowed her to remain in her home.

Mary was also coordinating complex medical services for an upcoming procedure. The care manager set her up with remote vitals monitoring, which allowed her primary care provider to receive comprehensive vitals reports. She also accompanied Mary to essential physician visits, helped her understand information from the doctor’s visit, and ensured clear communication between Mary, her medical providers, and her county worker. Before Mary worked with her care manager, she felt overwhelmed trying to navigate care systems and meet her needs. Now she knows where to turn for guidance and support!

Interested in bringing a Connected Communities project to your community?

The Connected Communities grant opportunity is currently open and available to LeadingAge Minnesota members outside the seven-county Twin Cities metro area. Grants will be awarded up to $600,000. To learn more, read the RFP and details about the grant opportunity.