Vail Place’s Role in the Minnesota SIM Project

Vail Place’s Role in the Minnesota SIM Project

Total Care Collaborative – Accountable Communities for Health

The Accountable Community for Health (ACH) project between Vail Place and North Memorial Health is building a system of care for adults experiencing behavioral health disorders and co-occurring physical health diseases. The ACH reaches out to patients based on their health conditions, barriers to health improvement, and the overall pattern of utilization of health care and community-based services. The ACH is improving case management, referrals, and post-discharge follow up for patients hospitalized at North Memorial’s psychiatric unit—a high-risk population with high healthcare utilization.

Under the ACH approach, Vail Place staff work directly with North Memorial caregivers to engage patients in case management services at admission and ensure patients receive the required support post-discharge. The ACH has aligned workflows between clinic staff, care coordinators, and community paramedics. The ACH is also using a “hot-spotting” approach that will use data and referrals to identify additional patients that might benefit from collaborative care. Care teams are using a collaborative space at North Memorial to coordinate services for the clients.

The ACH is part of a $45 million State Innovation Model (SIM) cooperative agreement awarded to the Minnesota Departments of Health and Human Services and recently concluded after four and a half years. The SIM agreement has helped implement innovative health care reform throughout Minnesota.

Examples of SIM accomplishments include:
  • Over 460,000 Minnesotans now receive care through a Medicaid accountable care organization called an Integrated Health Partnership (IHP).
  • 60% of patients in Minnesota receive care that is patient-centered and coordinated across settings.
  • 57% of providers are health care home or behavioral health home certified.
  • 15 Accountable Communities for Health were established and several projects have succeeded in sustaining efforts.

Information on Minnesota’s SIM project includes final evaluation findings and a project directory, Minnesota Forward: Carrying on Minnesota’s Accountable Health Model.

Learn more about the Total Care Collaborative and the SIM cooperative here.