How coordinated care is improving outcomes in Minnesota’s health care programs

Highly individualized, holistic care connects members to resources, removes barriers, and addresses the social drivers of health

Imagine you were about to hike an unfamiliar trail in Minnesota’s Northwoods. You might wonder how difficult the trail is, how long it will take, what kind of gear you might need, and whether there are places to rest along the way. At the trailhead, a park ranger greets you and asks if you have any questions and offers you a trail guide. What would you do? Enlist the support of the trail guide or take your chances and start walking?

When it comes to dealing with a health challenge, many Minnesotans prefer to have a guide to help provide support, so they do not have to go it alone.

That’s where care coordination comes in. Minnesota’s nonprofit managed care organizations (MCOs) provide care coordination as a unique benefit for members who are covered by state programs, like Medical Assistance and MinnesotaCare. Through care coordination, members receive highly individualized, holistic care to support their health and wellbeing.

Because many of the factors that support health and wellbeing happen outside the clinic’s walls—like housing, transportation, education, and access to healthy food, good jobs, and childcare—care coordinators focus on addressing these social drivers of health, connecting members to resources, and removing barriers to care. Care coordinators take the time to get to know members, understand their goals and needs, and connect them to the right resources at the right time.

Minnesota’s leadership in delivering Medicaid through managed care

Nearly forty years ago, Minnesota was an early adopter of the managed care model, which began as an innovative partnership between the state nonprofit plan community and providers to address severe access issues, a fragmented health care system, and growing and unpredictable costs. The model has helped the state improve access to care and provides much needed support to Minnesotans and has been replicated across the country. Forty-three other states now utilize managed care to support their public program enrollees, with both North Carolina and Oklahoma moving the Medicaid programs to managed care just this year. More states are moving toward managed care because of the high-quality care enrollees receive and the budget stability gained by the state.

Integrating services for Minnesota seniors

One example of Minnesota’s leadership in this area is Minnesota Senior Health Options (MSHO), a fully-integrated Medicare and Medicaid managed care service delivery system which provides those who are eligible for Medicare and Medicaid-funded services (or dual eligible) a full suite of services to ensure they get the care they need to maintain their best health.

“Sometimes it’s just a matter of connecting the person with the right resource at the right time,” said Janice Hubert, care coordinator at HealthPartners. “Part of care coordination is gathering the pieces together and helping our clients come up with a plan that’s going to work for them to help manage their healthcare, so they can be the healthiest they can be, and manage the best way that they can.”

MSHO assigns members a care coordinator who helps them identify their goals and how to best meet them as well as find the services they need when they need them. Over time, research shows members tend to have fewer preventable hospital stays and fewer trips to the emergency department. Further, members with chronic diseases were able to obtain more community-based services or assisted living care.1

By helping seniors navigate appointments, coordinating transportation for clinic visits, and providing education about chronic disease management, care coordinators ensure enrollees get the right care when they need it. By reducing emergency department visits, hospital stays and trips to see physician specialists, coordinators are reducing health care costs.

For example, a hospital system in Wisconsin found that for every $1 invested in care coordination for their highest-risk population, the hospital realized an $8 reduction in health care charges. When managed appropriately, inpatient visits were less frequent, less critical, and were, on average, 30% shorter. 2

Leveraging data to connect enrollees with the right care at the right time

Care coordinators also play a critical role helping reduce fragmented care in the delivery of both physical and behavioral health services. They work to connect enrollees with the appropriate level of high-quality care when they need it. The net result can be a better experience for members, with better care at a lower cost.

They might use a variety of strategies. For example, care coordinators use data to identify at-risk members and determine their care needs. They reach out and engage with members in their communities and work together to make their care more efficient and effective. Care coordinators can identify plan members who are using care services at a high rate and develop a management plan that addresses the underlying health conditions that might be contributing. For example, identifying and addressing diabetes, asthma, or high blood pressure in the primary care setting with chronic disease management strategies could prevent some of those emergency room visits or hospital stays.3

Care coordinators make things easier for individuals by helping them navigate the complex health care landscape, get them connected to needed medical care, behavioral services, and community-based supports. In short, they are the trail guides that help members find their way to better health and wellness.

Watch the video to learn more about how care coordination is enhancing the patient experience, reducing the cost of care, and improving the health of communities throughout Minnesota.

For more information on this topic and to learn more, check out our Fact Sheets on Managed Care and Care Coordination.


  1. Wayne L. Anderson, and Zhanlian Feng, “Minnesota Managed Care Longitudinal Data Analysis,” Minnesota Managed Care Longitudinal Data Analysis (Office of the Assistant Secretary for Planning and Evaluation (ASPE), March 30, 2016),
  2. “U.S. Department of Health and Human Services Assistant Secretary – ASPE,” INNOVATIVE MEDICAID MANAGED CARE COORDINATION PROGRAMS FOR CO-MORBID BEHAVIORAL HEALTH AND CHRONIC PHYSICAL HEALTH CONDITIONS: FINAL REPORT (U.S. Department of Health and Human Services Assistant Secretary for Planning and Evaluation Office of Disability, Aging and Long-Term Care Policy, May 2015),
  3. Ibid.