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Schedule H, Part V, Section B, Line 3E
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We continue to believe that to have the greatest impact on our communities, we need to take a targeted approach. By focusing on specific issues and communities, we can understand and begin to address the root causes of health inequity in a more meaningful way. Our 2024 CHNA resulted in a reaffirmation, and better understanding, of the significant barriers that make our three priority need areas so difficult to address. We used these barriers to refine and better define the priority needs. Based on our improved understanding of the needs and conversations with advisory groups, we have adjusted the title of one of our priority needs from 2021. Healing, connectedness, and mental health is now Cultivating trust, belonging and healing. Although this change removed Mental Health from the title of this priority, we will lean into accessing mental health services as a part of the priority need "Navigating and accessing care and resources". We recently completed our 2024-2026 Community Health Needs Assessment (CHNA). Three key areas have been identified as the greatest needs in our community - and the greatest opportunities to make a real difference through collaboration and connection: * Accessing and navigating care and resources * Addressing structural racism and barriers to equity * Cultivating trust, belonging and healing Importantly, one thing we heard from the community and saw in the data is that the social determinants of health impact some populations more than others. Based on what we learned during our assessment process, we are prioritizing two populations: racial and ethnic populations experiencing health disparities and people experiencing poverty. The people in these groups are all ages, and they live everywhere from the countryside to the city. We will intentionally seek out the needs and perspectives of these populations that experience greater health inequities, in order to partner with them on building solutions and removing barriers. Many specific concerns fall under each of these areas of need. We used barriers identified in the local communities to help guide us in creating and expanding relevant programs and focused services.
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Schedule H, Part V, Section B, Line 5 Facility , 1
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Facility , 1 - University of Minnesota Medical Center. As Fairview conducts our required CHNA process, led by Fairview's Community Advancement department, we are guided by the approaches and principles developed by the Center for Community Health Equity, which was launched in August 2022. As part of the center, we are building on our existing community engagement by creating an infrastructure that builds trusting partnerships and enables community voice to inform and influence our organization. For example: Fairview developed a Center for Community Health Equity Model of Community Engagement. The model articulates our approach to community engagement, community voice, and community partnerships as we work to advance community health equity. The center is developing a set of standard practices for collecting community voice to influence our social determinants of health initiatives without adding undue burden to the communities we seek to serve. The center's role as a convener and developer of community-informed best practices helps us keep equity at the center of our thinking as we study and evaluate our processes and engagement approaches. The M Health Fairview Center for Community Health Equity is an extension of the work being done in community by of our Community Advancement team. The center creates space for M Health Fairview and community partners to work alongside one another toward a shared goal of improving the health of the communities we serve and to which we belong. Together, we can apply equity-centered, culturally responsive approaches as we identify challenges and opportunities, create or expand programs and partnerships, and then scale or deepen learnings and successes across our system and the communities we serve. Located within the Fairview Community Health and Wellness Hub, the center formalizes the system's efforts to innovate and work with the community in reducing racial and other disparities in community health outcomes. The following strategies are helping us achieve this vision: 1. Addressing the social determinants of health (health behaviors and economic and social conditions that impact overall health) as well as individual social risks and social needs through the creation and expansion of programs; initiatives; collaborations; research; and policy, system, and environmental work. 2. Strengthening a community engagement infrastructure that builds trusting partnerships and enables community voice to inform and influence both inside and outside of our health system walls. 3. Transforming internal structures to create an antiracist and inclusive environment and to build community health by building wealth, knowledge, and capacity. This work would not be possible without the support of trusted community partners and our neighbors. The M Health Fairview Center for Community Health Equity's work is grounded in key principles that guide the ways in which we work with community, including: * Focus on community voice and trust - lifting up especially those who have historically been underrepresented and marginalized. * Commitment to collaboration - bringing community insights and priorities into our health system to address social determinants of health and advance health equity. * Transformation through action - transforming communities, health systems, and the broader ecosystem through innovation and continuous improvement. * Thank you to the experts from across our health system who give of their time and talents on the Center for Community Health Equity Work Group. This leadership group is helping shape and guide our work. * Michele Allen, MD, MS Associate Professor, Department of Family Medicine and Community Health Endowed Chair of Health Equity Research Director, Program in Health Disparities Research MPI, Center for Chronic Disease Reduction and Equity Promotion Across Minnesota (C2DREAM) Director, Community Engagement to Advance Research and Community Health (CEARCH), CTSI * Damien Fair, PA-C, PhD Co-Director, Masonic Institute for the Developing Brain Professor, Division of Clinical Behavioral Neuroscience, University of Minnesota Medical School Faculty, Department of Pediatrics Professor, Institute of Child Development * David Haynes, PhD Assistant Professor, Institute for Health Informatics at the University of Minnesota * Abe Jacob, MD Chief Quality Officer, M Health Fairview Associate Professor, Division of Pediatric Hospital Medicine, University of Minnesota Medical School Faculty, Department of Pediatrics Pediatrician, Internal Medicine, and Pediatric Hospitalist * Jim Letts, MD Family Medicine Provider, M Health Fairview Clinic - Roselawn * Katie Lingras, PhD, LP Director for Inclusive Excellence and Well-Being, Associate Professor, University of Minnesota Medical School * Will Nicholson, MD Vice President of Medical Affairs, M Health Fairview * Ana Nunez, MD, FACP Vice Dean, Diversity, Equity and Inclusion, University of Minnesota Medical School Professor of Medicine, Division of General Internal Medicine Integration Strategist, Clinical and Translational Science Institute * Chris Warlick, MD, PhD Department Head for the Department of Urology, University of Minnesota Medical School The programs and partnerships we have built and co-developed to respond to these needs are deeply embedded in our local communities. Our current assessment and implementation cycle gives us the opportunity to: Continue to build momentum, expanding our networks and collaborations to better understand one another's needs and assets. More deeply integrate the voices of those who are disproportionately impacted by the social determinants of health and the voices of historically marginalized communities in articulating barriers and building solutions. Lean into our unique culturally and linguistically relevant programs and initiatives. As we conduct our 2024 CHNA, we are taking a series of steps to improve our assessment process, keeping in mind the impact of the data collection process itself on the communities we serve. As we engage in bidirectional conversation and partnerships with community organizations that represent our priority populations and others, we are sensitive to the burden that incorporating the community's perspectives places on members of those communities and the organizations that serve them. In response, we are implementing several practices: We are offering grants to community-based organizations that are representing a priority population in our system community advisory council and stipends to the community-based organizations that are cohosting the health systemwide virtual community conversations with us. We are reviewing our outreach strategies, carefully planning, and partnering with others to avoid over surveying, over relying on the same voices or representatives, and asking the same questions assessment cycle after assessment cycle. Fairview has invested in subscriptions to tools, such as Spark Maps, which enable our health system to utilize and respond more effectively to requests for community data. Fairview has taken a leadership role in the Center for Community Health (CCH), a collaborative with health plans, hospitals, and public health agencies in Minnesota's seven-county metropolitan area. The CCH's member organizations will share data and processes to identify health needs and implement innovative approaches to advance community health, wellbeing, and equity. We are among the community partners supporting the Minnesota Homeless Study, a point-in-time study by Wilder Research that collects single-night counts of people experiencing homelessness across the state. Fairview also works with Wilder on the triennial Minnesota Reservation Homelessness Study. The study is conducted in partnership with six American Indian reservations in Minnesota. Fairview has had representation on the planning team and provided financial sponsorship for the Bridge to Health Survey. The survey has been an important source of data on the health status of adults in northeastern Minnesota and Douglas County, Wisconsin, for more than two decades. We have been involved and supported collaborations particularly related to data and assessment in the medical center and children's hospital community. For example, Fairview staff participate on the Highrise Health Alliance housing team convened by the Minneapolis Health Department and the Minneapolis Public Housing Authority (MPHA). Staff are also a part of the Hennepin County Community Health Improvement Partnership (CHIP) is a coalition of partners from across the community using a collaborative approach to improving people's health. CHIP is committed to equity and informed by data and is focused on community mental well-being and housing stability.
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Schedule H, Part V, Section B, Line 5 Facility , 2
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Facility , 2 - University of Minnesota Medical Center. Our overall engagement approach is guided by four key considerations: 1. Fairview is focusing on building and deepening our engagement infrastructure, putting structures in place that will guide our long-term community engagement efforts. 2. We must implement tactics that gather both breadth and depth of engagement, bringing as many community members as possible into the conversation and yet also seeking to develop a deep understanding of nuances within each need. 3. Our priority needs are systemwide, and we approach our assessment process from a system level. However, each local community Fairview serves is unique, and we recognize, honor, and prioritize local nuances - in context, in populations, and in our understanding of both - so we can respond most appropriately within each locality. This dual system/local approach enables us to maximize our efforts' impact across the region we serve. 4. As we look to our local communities and seek to meet them where they are, we benefit from engaging with multiple perspectives: those of our community members, our patients, and our employees. To do this, we must take into consideration a variety of approaches, modes, and preferences to best fit the needs of these three groups. As we build our multiyear assessment engagement approach, having a single guiding model of community engagement helps us maintain alignment across the organization as we plan and conduct our work. The Center for Community Health Equity engagement spectrum, based on the International Association for Public Participation's Spectrum of Public Participation, was collaboratively developed through interviews with local organizations, community members, Fairview employees, and other stakeholders. Our engagement spectrum depicts five progressively more intensive levels of community engagement: inform, consult, involve, collaborate, and community led. The model includes examples of each level of community engagement, to clarify what each level could look like in practice. It is important to recognize that no level is inherently better than another level - a more intensive engagement is not appropriate in all situations. Rather, each level is equally valid and appropriate for certain activities and at certain times. During our current assessment process, we used the Center for Community Health Equity engagement spectrum to help ensure that we are using strategies and tactics across the spectrum. Our intent is to build the capacity of stakeholders, community organizations, and other influencers to partner with our health system most effectively, enabling them to promote their community's interests to improve the broader community's health and wellbeing. Using the engagement spectrum as a model goes beyond merely incorporating community voice into Fairview's priority need areas. Its goal is to guide and frame co-development of community engagement activities and guide our implementation planning. The phrase "engagement infrastructure" refers to the mechanisms through which we are sharing and receiving bidirectional feedback on an ongoing basis. Like our hospital's physical infrastructure, our engagement infrastructure is composed of enduring, permanent parts of our health system. We are continuing to build a community engagement infrastructure that supports trusting partnerships and enables community voice to inform and influence the organization. Each hospital community has a Local Community Advisory Committee. We have been committed to and honored with a bidirectional, long-term commitment from our local community advisory committees, which have existed in various iterations for over 30 years. The local community advisory committee's role is to: Advise and inform health improvement plans and collaborative programs. Guide local insight and voice for CHNAs and action plans. Monitor progress toward the goals outlined in the CHNA implementation strategy. Review the local CHNA report. Each committee comprises members from, or representatives of, groups such as public health departments, medically underserved communities. communities experiencing poverty, populations experiencing health and/or racial disparities, community-based organizations, and schools. The System Community Advisory Council spans the entire health system and incorporates the need for internal representation, local representation, and representation from organizations that represent our priority populations. Its role is to: Advise the health system on the CHNA process and prioritization model from a systemwide perspective. Guide health system insight and ensure the voice of priority populations remains at the center of all discussions. Provide guidance and expertise in development of implementation strategy plans. Employee Resource Groups (ERGs), are voluntary, employee-led groups that aim to foster a diverse, inclusive workplace. They focus on impacting four important areas: community connection, organizational impact, meaningful change, and people development. ERGs supported the CHNA process by providing feedback and suggestions and supporting dissemination and recruitment of the data and engagement approaches. There are currently nine ERGs representing different affinities. Patient Family Advisory Councils bring together patient and family advisors along with staff to share insights and experiences to help Fairview improve. These committees help validate the current state, understand existing obstacles, and test ideas to overcome those barriers. During this CHNA cycle, our Patient Family Advisory Committees consulted on ways to approach community conversations, specifically our Town Halls. The process of centering community voice enables us to use the CHNA process to bring the perspectives of the communities we serve back to the organization in an actionable format. By using various data gathering methodologies, we gain a better understanding of the top barriers and concerns among the people we serve. This process is also a crucial avenue for adding nuance, understanding how our communities' needs shift among different geographical areas, generations, and cultural communities. Listening and learning sessions: Fairview has held community listening and learning sessions through the HOPE Commission since 2020. These sessions hold a mirror to Fairview, assessing where we are today and helping us understand how we can make lasting change. Sessions were held in 2020 to hear from employees, in 2021 and 2022 to hear from patients, and in 2023 and 2024 to hear from community members. In June 2022, after identifying a gap in participants from previous listening and learning sessions, we expanded these listening and learning sessions to include patients with limited English proficiency. Sessions were held in Somali, Spanish, Hmong, Karen, and American Sign Language. Prior to these sessions, there were limited mechanisms for patients with limited English proficiency to provide feedback about the care they were receiving. This series was an effort to bring more voices to the table and create inclusive opportunities for patients to express their needs and concerns.
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Schedule H, Part V, Section B, Line 5 Facility , 3
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Facility , 3 - University of Minnesota Medical Center. Systemwide virtual conversations: We held a series of systemwide virtual conversations focused on the priority need healing, connectedness, and mental health and what that specifically looks like for youth (April 2024), aging adults (March 2024), and Indigenous populations (June 2024). These conversations were open to all, and their goal was to collect and share learnings and resources with participants. The conversations included presentations from community partners about their work, followed by small group discussions that provided valuable perspectives informing our understanding of population-specific needs, strengths, and future state visioning tied to healing, connectedness, and mental health. CHNA surveys To gather input from a broad set of stakeholders on local strengths and the top needs of communities each of the respective stakeholders serves, we developed two aligned, but distinct, surveys. The surveys gathered feedback about: Patient and community members' top barriers to care, social determinants of health needs, and social needs. The unique barriers and assets for patients in one of our priority populations (racial or ethnic populations experiencing health disparities and people experiencing poverty). Barriers that providers and community partners face in responding to the social determinants of health-related needs of patients as well as existing assets and resources available. The surveys were distributed to care team members and partner organizations, including faith leaders. Surveys were administered from mid-February to the end of March. We heard from 472 individuals across our hospital communities and our health system, with 296 responses from care team members and 176 responses from community organizations. Community Health and Healing Summit: Celebrating Culture, Building Connections, Guiding Action - The Community Health and Healing Summit, held in July 2024, aimed to propel our 10-year vision for a healthier Minnesota forward. The summit was a collaborative event bringing stakeholders together to work collectively on prioritizing needs and barriers to health in our communities. It blended the power of community and cultural healing with activities designed to collect participants' insights to not only shape our priorities but to actively drive positive change in our communities. Stakeholder interviews: From May to July 2024, we conducted stakeholder interviews with various Fairview care team members in both acute sites and clinics, including nurses, physicians, schedulers, social workers, care coordinators, and clinic managers. The interviews were guided by the results of our CHNA survey and aimed to gather more in-depth information and stories about the top barriers that had showed up most frequently during the survey. Facilitated conversations: We conducted a variety of facilitated conversations across the health system, a few examples of which are summarized in this section. The goal of these activities is to gain a fuller, more nuanced picture of topic-specific or population-specific perspectives over time. By holding these conversations on an ongoing basis, we ensure that our assessment process and our aligned programmatic or initiative-related work is responding to and engaging with communities in real time. Food is Medicine community conversations: As a part of our Food is Medicine initiative, we partnered with community-based organizations to host a community conversation in each hospital's service area. The goal was to learn more about the community's needs and strengths related to access to healthy food and the role of Fairview as a healthcare provider. In the fall 2023, we held eight Food is Medicine community conversations across different hospital geographies that were attended by 75 organizations representing sectors across the food scape including food shelves, farmers, social services organizations, schools, and municipalities. Town halls: In November and December 2023, we hosted five town hall sessions that were open to the public and geared toward local government relations offices, the business community, community-based organizations, trade groups, civic groups, and rotaries. Each town hall provided an opportunity for community members to receive updates from Fairview, participate in a question-and-answer session with Fairview leaders, and engage in discussions regarding barriers to health and trust in healthcare organizations. East Side Health and Well-being Collaborative: In February 2024, we joined the East Side Health and Well-being Collaborative's meeting as well as the collaborative's mental health and stress resilience work group meeting. In both meetings, we held facilitated conversations about the CHNA process and priority need areas in the community. During the meeting with the mental health and stress resilience work group, we focused on the healing, connectedness, and mental health priority area. Through ongoing partnership and programmatic conversations, we are vetting and refining our understanding of the identified priorities and the responses that would best address them. As a foundational part of program planning and evaluation, Community Advancement staff members are continuously soliciting feedback from community partners and program participants. We capture this information on an ongoing basis and use it to provide valuable context, driving insights into the needs of the communities we serve. Primary data methods: Fairview staff developed standardized tools, processes, instructions, protocols, and training for facilitators, interviewers, and note takers. We compiled, cleaned, and analyzed all primary data. A note taker captured all community input, and when possible, conversations were also recorded. Secondary community data: Claritas is a widely used national demographic estimation tool. Estimates and projections are provided at a zip code level including, but not limited to, population based on age, sex, ethnicity, and income. Spark Maps is a paid subscription that provides mapping and assessment tools that include a large database of indicators, data cleaning, benchmarking, and contextual information. The Bridge to Health Survey has been an important source of data on the health status of adults in northeastern Minnesota and Douglas County, Wisconsin, for more than two decades. The survey is conducted every five years, with the last survey administered in 2020. The Minnesota Student Survey is one of the longest-running youth surveys in the nation. It is a triennial survey that began in 1989. The data used in this report is from 2019. The Area Deprivation Index (ADI) is based on a measure created by the Health Resources and Services Administration over three decades ago, and has since been refined, adapted, and validated to the census block group neighborhood level by Amy Kind, MD, PhD, and her research team at the University of Wisconsin - Madison. Health Trends Across Communities in Minnesota (HTAC) uses information from electronic health records to help fill gaps in the information available to health professionals, organizations, policymakers, and community members to promote health in Minnesota. HTAC is a collaboration among health systems, public health departments, health organizations, and health plans in Minnesota. HTAC uses summary reports from electronic health records on a range of chronic, behavioral, and mental health conditions. The information comes from 11 health systems that make up the Minnesota Electronic Health Record Consortium (MNEHRC). Information from the MNEHRC represents approximately 90% of healthcare for Minnesotans, which makes HTAC a powerful tool to describe the health of many communities. Minnesota Department of Health, County Health Tables were used to look at 2020 county-level top causes of death and premature death.
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Schedule H, Part V, Section B, Line 7 Facility , 1
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Facility , 1 - University of Minnesota Medical Center. The Community Health Needs Assessment Report for University of Minnesota Medical Center are located at: https://stcr-prd-cd.fairview.org/-/media/Files/Local-Health-Needs-Final/2024-CHNA-ReportUniversity-of-Minnesota-Medical-Center-and-Masonic-Childrens-HosptialFinal.ashx?_ga=2.65119470.1125495304.1755693668-XXX-XX-XXXX.1700485972 The Community Health Needs Assessment and Implementation Strategy for University of Minnesota Medical Center are located at: https://stcr-prd-cd.fairview.org/-/media/Files/Local-Health-Needs/CHNA-Implementation-Strategy-Reports-2025/CHNA-Implementation-Strategy-Report-20252027University-of-Minnesota-Medical-Center-and-Masonic-Child.ashx?_ga=2.XXX-XX-XXXX.1125495304.1755693668-XXX-XX-XXXX.1700485972
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Schedule H, Part V, Section B, Line 11 Facility , 1
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Facility , 1 - University of Minnesota Medical Center. Our triennial Community Health Needs Assessment (CHNA) process provides an important opportunity to engage with and understand our community, analyze what has changed since the last assessment, and prioritize together with the community the issues we must urgently address to improve wellbeing and resilience. As part of the 2021 CHNA process, we reexamined and built upon the extensive community insights shared during our 2018 CHNA, while also surveying the community for current and emerging needs. This work continued in 2024 as we conducted our triennial assessment, further exploring the barriers experienced by community that tie to priority needs. Our 2021 CHNA used social determinants of health (SDOH) as a lens through which we frame our understanding of our community's most significant health needs. A social determinants of health lens enables us to identify inequitable distribution of resources and access that negatively impacts health. Through this lens we looked at both qualitative and quantitative data. Quantitative data included data points related to demographics, physical environment, socioeconomic factors, healthcare, and health outcomes. We collected additional community voice data by convening a broad array of stakeholders, with special focus on the priority populations - racial or ethnic populations experiencing health disparities and persons experiencing poverty. University of Minnesota Medical Center (the medical center) and Masonic Children's Hospital (the children's hospital) has a community advisory committee (CAC) that is involved in the CHNA process. The committee is comprised of local community and organizational leaders, such as local public health entities, social services organizations, higher education institutions, school districts, and local businesses. The assessment process also included discussions with our community advisory council, listening and learning sessions, and key stakeholder interviews. Throughout this process, community members, local business leaders, government representatives, nonprofit and community organizations, and content experts shared their voices and perspectives about their community's health needs. By bringing together both the qualitative and quantitative data, we established a prioritization process through which we could identify the community health needs that, if effectively addressed, would have the greatest positive impact on our communities and particularly on our priority populations. We prioritized areas of need based on four broad criteria: 1) Has this need been voiced by the community? Has this need been vetted by the community? 2) Does this need align with Fairview's strategies and priorities? 3) Does this need align with existing public health strategies and community health assessments? 4) Does this need build upon Fairview's 2018 CHNA priority needs? The medical center and the children's hospital identified three system-wide priority need areas, and will collaborate with other Fairview hospitals, medical centers, and shared business and clinical services to address these priorities. Our specific response varies by hospital based on the ways the priority needs manifest across a given community, as well as the partnerships-both ongoing and new-that we have developed to address those needs. The three identified needs are: 1) Navigating and accessing care and resources, 2) Addressing structural racism and barriers to equity, and 3) Healing, connectedness, and mental health. Each priority has a set of anticipated impacts, described in more detail below, and can be found in the University of Minnesota Medical Center and Masonic Children's Hospital CHNA Implementation Strategy Report (2022-2024). We also identified two priority populations that reach across the lifespan and impact all geographies from rural to urban: 1) Racial or ethnic populations experiencing health disparities and 2) People experiencing poverty. As a healthcare organization that works closely with our community advisory committees and community partners, we have listened to community and learned valuable lessons over the past few decades. This has guided us in the development of the Fairview Health Services 2022-2024 implementation strategies. In particular, we learned that: 1) Despite best efforts, health needs and health inequities continue to grow and deepen, 2) Collective action is critical, and 3) Transformational change requires a sustained and focused commitment. In response to our 2021 Community Health Needs Assessment, Fairview hospitals and medical centers worked collaboratively with local and statewide organizations to address our communities' most pressing needs. In addition, Fairview put forth a 2032 vision of increased community health equity. This vision is supported by three strategies designed to address the priority need areas in distinct ways while collectively moving us closer to achieving our goals. The three strategies are: Strategy 1: Addressing Social Determinants of Health (SDOH) - Addressing the SDOH, individual social risks, and social needs through the creation and expansion of programs, initiatives, collaborations, and research, as well as policy, system, and environmental work. Strategy 2: Community engagement infrastructure - Creating a community engagement infrastructure that builds trusting partnerships and enables community voice to inform and influence our health system. Strategy 3: Inclusive institution - Transforming internal structures to create an antiracist and inclusive environment and to build community health by building community wealth. For this three-year cycle, we are implementing strategies to work toward distinct, anticipated impacts for each priority need and to build upon our 10-year vision of increased community health equity by 2032. For more information, the University of Minnesota Medical Center and Masonic Children's Hospital CHNA Implementation Strategy Report outlines the major strategies and actions we will deploy throughout the 2022-2024 assessment cycle as well as the ties between the medical center and children's hospital CHNA implementation strategies, anticipated impacts, and key responses. Fairview's mission and vision extend beyond traditional healthcare settings, driving a healthier future for the communities we serve. Significant efforts towards Strategy 1 (Addressing SDOH) occurred over the first three years of our 10-year vision. These efforts are demonstrated through three social determinants of health initiatives: 1) Food is Medicine: Using the healing power of food to nourish our patients, enrich our communities, and transform our systems, 2) Housing is Health: Using the protective power of housing to support patient health and build thriving communities, and 3) Connection is Cure: Strengthening the connection between patients and the healthcare system to address social isolation and improve community mental health and wellbeing. These initiatives are key responses that intersect all three priority needs and are also synergistic. Relationship with our partners. Fairview has a long partnership with the University of Minnesota and University of Minnesota Physicians, now represented in the M Health Fairview brand. Together, we offer access to breakthrough medical research and specialty expertise as part of a continuum of care that reaches all ages and health needs. Policy, systems, and environmental change initiatives are implemented across the health system (hospitals, clinics, specialty care) and in some instances, across the M Health Fairview partners, to create sustainable and lasting change to advance health equity and community wellbeing. Where indicated, community responses as a part of Strategy 2 (Community engagement infrastructure) and Strategy 3 (Inclusive institution) represent the work of Fairview in collaboration with the other M Health Fairview partners. Community action plan. The medical center and children's hospital has an annual CHNA action plan that supports our vision of increased community health equity, rolls up to our system CHNA implementation strategies, and addresses priority needs. The Fairview Health Services Community Action Plan details the specific and measurable steps we will take during the year to drive change. Program lists by hospital can be found in the appendix. The System Community Action Plan is updated annually and includes impacts from previous years.
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Schedule H, Part V, Section B, Line 11 Facility , 2
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Facility , 2 - University of Minnesota Medical Center. Evaluation of impact. To best evaluate our impact and track progress towards our anticipated impacts, we use a multi-tiered and tailored evaluation approach. Our work is grounded in understanding core information about our communities. This includes identifying and understanding the community needs being addressed, the population or community being affected, current and/or potential partners to work with to address the need, and the impacts we anticipate. Community needs are determined in several ways. In addition to being determined through our formal CHNA process, we respond to emerging needs brought to us by community partners or public health, or those discovered through patient or community data showing significant health disparities. We have standardized several key measures to assess whether we are meeting the needs of the CHNA priority populations, focusing our efforts on equity and participant satisfaction. A subset of established programs and initiatives are set up and supported for deeper evaluation. We have found that one-size-fits-all, evidence-based approaches may not be a good fit for some of our diverse communities. In response to the unique and differing needs of our community members, our programs are co-developed with community, center on the needs of specific populations, and often incorporate unique local tactics. We approach evaluation from a similar perspective by building evaluation approaches informed by our partners and considering strategies that are culturally and linguistically appropriate, allowing us to determine if the programs reflect the values we set out to embody. Fairview is guided by the Centers for Disease Control and Prevention (CDC) model for program evaluation, establishing primary outcomes, process measures, and demographics. We evaluate program impact and success from a variety of approaches using both qualitative and quantitative data. For many of the programs described here, we are reporting our reach or outputs through counts on a variety of levels that meet the rigor required for grant and contract reporting. In addition, we offer a diverse set of programs that vary on the spectrum of "low touch and high count" to "high touch and lower count." More generally put, the effort and impacts of the programs are not the same. This is a purposeful approach as we want a variety of programs that are appropriate to address the community and population-specific needs. We provide outcomes for programs here when we are able, acknowledging not all programs run on a calendar year, and analysis may not be complete for some of the programs on which we do deeper evaluation. Fairview is currently in the process of building an evaluative approach and capacity for our 10-year vision, increasing community health equity, and our three social determinants of health initiatives: Housing is Health, Food is Medicine, and Connection is Cure. Part of this evaluative approach is a monthly social determinants of health dashboard. University of Minnesota Medical Center 2024 Implementation Strategy Progress Highlights. The following highlights our implementation strategy work for each of our three priority needs. In this first three-year CHNA cycle working towards our 10-year vision of increased community health equity, the primary way we are directly addressing the three priority needs is through Strategy 1 (Addressing SDOH). Through this strategy, we create programs and partner with community organizations to address social risk factors, social needs, and social determinants of health. Strategy 2 (Engagement infrastructure) and Strategy 3 (Inclusive institution) focus on building infrastructure and creating system changes so that we can more effectively respond to these priority needs in the future, as well as any emerging needs. Strategy 1 - Addressing Social Determinants of Health (SDOH) Priority Need: Navigating and accessing care and resources. University of Minnesota Medical Center has a variety of programs that work as a part of Strategy 1 (Addressing SDOH) to address barriers related to navigating and accessing care and resources. Through this strategy, the medical center and the children's hospital Action Plan programs work towards two anticipated impacts to address this priority need: 1) Remove barriers to care by providing community-placed care, co-located services, and navigation supports that address cultural and language barriers and 2) Increase awareness of, knowledge about, and access to healthcare and community-based resources that support opportunities for health and wellbeing. The following is more information on a selection of programs from the system community action plan that are working to meet the two anticipated impacts. Fairview System Key Initiative Highlights. The Community Clinical Care initiative involves multiple community-based clinical programs, including Fairview's Minnesota Immunization Networking Initiative (MINI), blood pressure checks, and oral health services. All services are multi-sector, community collaborations that provide care and education to the uninsured, under-served, and communities facing health disparities in the greater Twin Cities area. The Community Clinical Care team provides clinical care in trusted community settings at no cost and improves equitable access to vaccines and other services across various populations. The programs ensure a culturally and linguistically appropriate experience in a safe and trusted environment in partnership with over 250 faith-based and grassroots community partners, serving clients at local churches, mosques, temples, schools, community centers, food pantries, and homeless shelters. Across the system in 2024, the community clinical care team provided blood pressure and oral health services at 241 events, including 103 events in the medical center and children's hospital community, providing 418 blood pressure checks, and 696 dental fluoride applications. The team also hosted 443 vaccination clinics across the system in 2024. There were 5,525 free COVID-19 vaccine doses and 6,190 free flu shots administered. Of those participants who shared their identity, 72% of people who received a COVID-19 vaccine identified as a person of color and 35% indicated a language other than English as their preferred language. In the medical center and the children's hospital community specifically, there were 265 MINI clinics at which 3,226 COVID-19 shots and 2,855 flu shots were administered. In August 2024, MINI received an invitation to publish an article in the special Public Health issue of the New England Journal of Medicine discussing their cross-sectoral, equity-based approach to COVID-19 response. Later in the year, they published a similar article in the Journal of Public Health Management & Practice, this time focusing specifically on reducing vaccination barriers for refugee, immigrant, and migrant communities during the COVID-19 pandemic. MINI also presented at the 2024 North American Refugee Health Conference. The Fairview Community Health and Wellness Hub (The Hub) opened in 2022. The Hub is a first-of-its-kind center that addresses health disparities while providing a range of critical healthcare services and community resources alongside trusted local partners. The Hub provides a variety of services to the community, including primary care, mental healthcare, enrichment options for seniors, food access programs, and community gathering spaces. We bring our own services together with local organizations to make it easier for people to access what they need to thrive. Throughout the year, 7,090 individuals attended 176 events or meetings at the Hub. Eighty-three of the events were public and partner events, reaching 3,263 individuals. Ninety-three events were internal Fairview events. Additionally, we hosted nine Hub Partnership Coordination Meetings, as well as one-on-one check-ins with each of the partners. These meetings serve to deepen our understanding of the diverse missions, visions, and impacts of each Hub partner, fostering better alignment and collaboration. In 2025, we plan to transition to quarterly in-person partnership meetings. This strategic move aims to enhance our collaborative efforts and drive impactful initiatives. The Cultural broker program was co-developed in 2016 in partnership with Fairview's East Side Health and Well-being Collaborative. Cultural brokers help bridge cultural gaps through supporting individuals and families as they navigate schools, healthcare, and other mainstream systems to ultimately build self-sufficiency. The cultural brokers identify with the racial and/or ethnic communities they serve, so they can more easily build trust and have a greater impact on the communities' health.
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Facility , 3 - University of Minnesota Medical Center. The program comprises six cultural brokers who are Fairview employees located at five respective partner organizations representing different cultural communities: African American, American Indian, Hispanic/Latino, Hmong, and Karen. The program has one cultural broker that is hosted at CLUES Minneapolis, located in the community surrounding the medical center and the children's hospital. This cultural broker serves the Hispanic/Latino community. Across the system, cultural brokers served 510 new clients total, resulting in 4,431 encounters. In the medical center and the children's hospital community they served 69 new clients with 251 encounters. Health Commons is a drop-in health and wellness center that began in 2011. It is dedicated to serving those in the Harrison/North Minneapolis neighborhood, Cedar-Riverside neighborhood, and the East Side of St. Paul (opened in 2023). All locations serve highly diverse communities with residents identifying as African American, Asian, Somali, Oromo, Korean, as well as older adults (65+). It is a Fairview-convened program managed in collaboration with other community organizations. The mission of Health Commons is to provide services based on respect, relationship building, hospitality, and collaboration. The program strives to connect health and hope for the community to live healthier lives. Services include drop-in hours where a nurse or doctor is available for a one-on-one consultation, massage, aromatherapy, and healthy living classes on topics such as nutrition, exercise, chronic disease, and emotional health. There are also physical activity classes such as Zumba and yoga, food distributions, and supply giveaways. The services are free of charge and open to the community. Based on a 2024 sample survey of the Cedar Riverside and Harrison/North Minneapolis locations, over half of the participants (53.5%) have been attending Health Commons for 8+ years, many are publicly insured (76.1%) and nearly half of participants are aged 45-74 (49.3%). Overall, participants have experienced a positive impact through Health Commons - 94.4% agree or strongly agree they are more connected to others in the community, 60.5% say they are more connected to resources, and 67.7.1% say they are making positive changes toward a healthier lifestyle. In 2024, there were 14,716 visits to the three Health Commons locations combined, with 13,644 of those visits being to Cedar Riverside and The Living Room in the medical center and the children's hospital community. In 2024, we continued to expand our work relating to opioid overdose prevention in partnership with the Steve Rummler Hope Network. Fairview's Community Clinical Care team trained several staff members to become naloxone educators, who can then train others. Educators train community members on how to recognize an opioid overdose, what naloxone (Narcan) is and how it works, how to administer naloxone to someone experiencing an overdose, and information about Steve's Law/MN's Good Samaritan and Naloxone Law. In total, there were 39 naloxone trainings where 944 individuals were trained in 2024. In addition, Fairview opened a fourth naloxone access point (NAP) site that provides free kits, extending this important resource to Greater Minnesota. NAP sites are stocked with nasal Narcan and intramuscular naloxone kits, many of which are packed at Fairview volunteer events. In 2024, 12,995 such kits were packed and distributed across our hospital communities. The Community Clinical Care team plans on opening several additional NAP sites in 2025. Fairview hired two Food Resource Navigators in 2024, exemplifying the intersection of Strategy 1 (Addressing SDOH) and navigating and accessing care and resources. Food Resource Navigators serve as experts both in Fairview's Food is Medicine programs, as well as community food resources and government programs such as SNAP and Market Bucks. Rolled out in select clinics across the system, Food Resource Navigators receive clinical referrals when a patient screens positive for food insecurity and expresses interest in being connected with additional support or resources. In 2024, our Food Resource Navigators received 561 referrals across the system, including 206 from the medical center and children's hospital service area. Of those referrals, 84% of individuals were connected with internal and/or external resources. Over the next several years, this role will be expanded to additional clinics. In this way, we can support patients in navigating the complex landscape of healthcare and social services. Priority Need: Addressing Structural Racism and Barriers to Equity. University of Minnesota Medical Center and Masonic Children's Hospital, in alignment with Strategy 1 (Addressing SDOH), has a variety of programs, events, and community education as a part of the Community Action Plan that work toward the anticipated impact: Develop, grow, and sustain programs, educational offerings, partnerships, and initiatives to address structural racism and barriers to equity. Fairview System Key Initiative Highlights. One of the Fairview social determinants of health initiatives, Food is Medicine, utilizes the knowledge and resources of a large healthcare institution to work towards meeting the immediate needs of our patients, while also transforming the food system into something just, equitable, and sustainable. The initiative aims to 1) Nourish our patients: Advance food security to reduce health disparities and diet-related health conditions. 2) Enrich our communities: Cultivate trusting and engaged partnerships to build and share resources, assets, and capacity. 3) Transform our systems: Nurture just and equitable food systems to ensure health equity. These approaches are framed to increase health equity through focused efforts to serve patients who have been historically marginalized by providing culturally appropriate food options and reducing food insecurity in a manner that upholds dignity and empowers the local food system. Clinically, it enables providers to serve patients experiencing food insecurity through a menu of distinct programs comprising an innovative wrap-around approach. One or more of the Food is Medicine programs-a selection of which are described below-are available to patients in 52+ clinics and 8 acute sites across the health system. One of the Food is Medicine initiative programmatic responses is the fresh food prescription program, which distributes fresh, locally grown produce from three farm partners (Hmong American Farmers Association, Naima's Farm, and Women's Environmental Institute) via a weekly food box. The boxes also contain proteins, whole grains, and pantry staples, as well as a newsletter with community resources and tips for healthy cooking and eating. Crucially, the program offers home delivery to address transportation barriers. In 2024, 31 clinics participated in the fresh food prescription program across Fairview hospital and medical center communities, eight being in the medical center and children's hospital community. Almost one third (31%) of program participants identified as Asian, 17% as Black, and 2% as Hispanic/Latino. While just 70% of participants speak English as a preferred language, 7% had a preferred language of Hmong, 14% Karen, and 1% Spanish. Most participants had public insurance (79%) or were uninsured (2%). Fairview's food voucher program provides patients with vouchers to redeem at either the Twin Cities Mobile Market or Fare for All program. The program runs year-round and offers rolling enrollment. Throughout the year, 443 patients redeemed vouchers for groceries, including 143 from the medical center and children's hospital community. Additionally, we provide shelf-stable food resources for those with an immediate need. The shelf-stable food bags were incorporated into the medical center and children's hospital for the first time in 2024. The bags come in six different varieties tailored to meet the preferences of diverse cuisines and circumstances. In 2024 there were 6042 shelf-stable bags distributed at 37 sites across the system. There were also 258 food resource packets distributed that contained information about local food resources along with immediate food support. In November 2024, Fairview and local partners hosted the third annual Harvest at the Hub, welcoming 312 households to the Fairview Community Health and Wellness Hub. The event consisted of a food giveaway with turkeys, fresh produce, and other holiday staples, a community resource fair, a vaccine clinic, and other health and wellbeing services.
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Facility , 4 - University of Minnesota Medical Center. Another of the Fairview social determinants of health initiatives, Housing is Health also responds to the priority need of structural racism and barriers to equity. The Housing is Health initiative aims to use the protective power of housing to support patient health and build thriving communities. We approach this initiative with clinically connected programs, supportive community partnerships, contribution of time and expertise to collaboratives, and efforts to impact policy. For example, Fairview partners with Our Savior's Community Services to provide critical follow-up care and temporary housing for people who are unsheltered after a hospital stay. Patients are referred by the medical center and sheltered at Our Saviors. Additionally, a nurse provides care, and patients receive wrap-around services and social work support. In 2024, 50 patients were provided support through this program. As a part of Housing is Health, we are also proud to have helped launch Healthcare for Housing (HC4H). HC4H grew out of the Housing and Health Equity Fellowship and consists of seven health providers and payers. We also strengthened our housing advocacy activities in 2024; we chair the policy workgroup for HC4H, participated in Homeless Day on the Hill at the Minnesota State Capitol, and submitted letters of support for multiple housing initiatives. In September and October 2024, teams from across the system participated in two Twin Cities Habitat for Humanity builds. Volunteers contributed 300 hours for the Carter Work Project build. During our annual build week with Twin Cities Habitat for Humanity, staff contributed 560 volunteer hours. Priority Need: Healing, Connectedness, and Mental Health. The medical center and the children's hospital works toward the anticipated impact: develop, grow, and sustain programs, educational offerings, partnerships, and initiatives, address barriers to healing, connectedness and mental health through Strategy 1 (Addressing SDOH) and the Community Action Plan. Fairview System Key Initiative Highlights. In response to the priority need of healing, connectedness, and mental health, we have a body of work that makes up the Connection is Cure initiative. Connection is Cure aims to build trust through social connections, center linguistic and cultural diversity, and bridge silos across our hospital system and communities to transform medical practice. As a part of Connection is Cure, we hosted virtual conversations in 2024 around how we can improve mental health services for specific populations: Native patients, youth, and older adults. Three conversations were held-one for each respective population-reaching a total of 108 community members. Other gatherings fostering healing, connectedness, and mental health were held in 2024 as well, including a Heal the Healers event. Exemplifying the integration of traditional healthcare with ancestral and cultural practices, the Heal the Healers event united local healers and caregiving professionals for a transformative day of self-care, learning, and the revival of ancestral practices. Our goal was to empower practitioners and community workers with activities that foster self-care, ensuring they remain strong and resilient for the communities they serve. This and other healing events laid the groundwork for the Community Health and Healing Summit, convened as part of our innovative approach to the Community Health Needs Assessment. Over 100 participants gathered for a day of learning about the health conditions in their local communities, seeking to understand the efforts of the system and collective community in addressing these issues. For many attendees, the event also served as a welcoming introduction to cultural and non-traditional healing practices; individuals had the opportunity to experience these practices firsthand while learning about their application within the community and our health system. As part of our commitment to addressing barriers to healing, connectedness, and mental health, we also launched our Birth Justice Initiative, a cross-departmental effort to advance equity and inclusion in birthing experiences. Focused on eliminating racial bias in maternal healthcare and improving patient outcomes, the Birth Justice Initiative is making systemic changes to improve the quality of healthcare for all pregnant persons. Their research and advocacy led to the removal of race-based maternal health screening tools, which can accidentally introduce bias into medical decision-making. Additionally, part of the design of a new prenatal and postpartum clinical care map includes screening all pregnant patients for social determinants of health and lead exposure, empowering healthcare providers to act early to address these concerns. In 2024, departments participating in the Birth Justice Initiative interviewed 649 people who gave birth in the Fairview health system and gathered input from doulas. Based on their feedback, we plan to rewrite policies to enhance culturally congruent care, tailoring maternal healthcare to the specific cultural values of each patient. Additionally, we are responding to the need for healing, connectedness, and mental health with a variety of evidence-based programs, as well as trainings and education sessions. Feeding Hope is a series of virtual one-hour learning sessions focused on positive, hopeful topics that support wellbeing in the general community. This series is offered in partnership with all Fairview's hospitals and medical centers and is open to anyone across all of Fairview's communities. In 2024, across Fairview hospitals and medical centers there were two sessions held with 60 attendees total. Healthy Outcomes from Positive Experiences (H.O.P.E.) training is a 60-90-minute session focused on the science of H.O.P.E providing a framework for positive experiences as a mitigating factor in Adverse Childhood Experiences and trauma. In 2024, in the medical center and the children's hospital community there was one session with a total of 37 attendees. The Faith Community Nursing program makes programs and services available to faith community nurses to hold in their congregation. Additionally, $750 mini grants are provided from Fairview Foundation to faith community nurses, as well as resources such as health education materials and resources, and networking opportunities. In 2024 across the system there were 20 mini grants awarded. In the medical center and the children's hospital community, 10 mini grants were awarded to faith community nurses. Psychological First Aid is an evidence-informed training for the broader community as well as professionals. Trainees learn how to support healthy recovery for individuals following a traumatic event, public health emergency, natural disaster, or personal crisis. The curriculum integrates public health, community health, and individual psychology by drawing upon skills the trainees probably already have. Psychological First Aid is a two-hour training. In 2024, in the medical center and the children's hospital community, there were three classes (two in Spanish) offered with 82 participants attending. A Creative Look at Self-Care (formerly Refresh and Reset your Resiliency) promotes resiliency skills, offers wellness-care tools for mind, body, and spirit, and encourages the development of a personal plan for self-care. In 2024, in the medical center and the children's hospital community, there were two classes offered with 57 participants attending. Together, Fairview's Strategy 1 (Addressing SDOH) initiatives and the programs outlined within our action plans comprise a strategic, innovative, and equity-minded approach to community health. We take great care to co-design programmatic responses with the communities impacted by them and collaborate with a broad range of community organizations and other multisectoral partners to address the social determinants of health. In recognition of our commitment to this work, Fairview advanced as a finalist for the American Hospital Association's Foster G. McGaw Prize. Five programs were profiled in Fairview's award submission: Minnesota Immunization Networking Initiative; East Side Health and Well-being Collaborative; Fair Table, Fairview's Food is Medicine initiative; Health Commons; and our Cultural Broker program. It is a great honor to be considered for this award; it serves as motivation to work harder than ever to advance health equity, and to intentionally do so in authentic partnership with the communities we serve.
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Facility , 5 - University of Minnesota Medical Center. In addition to Strategy 1 (Addressing SDOH) and the programmatic work included on our Action Plans, we strive to reduce health disparities and increase community health equity through two additional system strategies. While Strategy 1 (Addressing SDOH) allows us to directly respond to the three prioritized needs from our community health needs assessment, Strategy 2 (Engagement infrastructure) and Strategy 3 (Inclusive institution) focus on building the structures and systems for us to do the work more capably. Strategy 2 - Engagement Infrastructure Addressing our three priority needs while also responding to emerging needs requires an infrastructure that supports building and sustaining strong community partnerships and allows for ongoing, trusting exchanges between Fairview and community members. The importance of this is manifest in Strategy 2 (Engagement infrastructure): Creating community engagement infrastructure that builds trusting partnerships and enables community voice to inform and influence the institution. The anticipated impacts for this strategy are: 1) Build and expand feedback systems for patients and community members; embed process improvement in the health system's response to community voice and 2) Create sustainable structures to convene and engage community voice around addressing social determinants of health. While Fairview boasts an extensive engagement infrastructure already, we continued to bolster the work we do to expand feedback systems and sustainable convening structures. Core to this is building and sustaining trusting partnerships. Our medical center and children's hospital Community Advisory Committee (CAC) met through the year to offer input and provide local insight and expertise. Notably, 2024 marks the first year since the COVID-19 pandemic in which we convened our CACs in-person, celebrating the joy of being together in the same room and the spirit of collaboration that it fosters. To enhance the work of each hospital CAC, in 2024 we revitalized our System Community Advisory Council. Spanning the entire health system, the System CAC incorporates the need for internal representation, local representation, and representation from organizations that represent our priority populations. While it plays a large role in advising the CHNA process and implementation, it also ensures the voice of priority populations remain at the center of all discussions and decisions. The System CAC met five times in 2024, providing guidance and insights throughout the Community Health Needs Assessment process. We also continued convening the East Side Health and Well-being Collaborative (the Collaborative). For almost a decade, the Collaborative has created intentional space for ongoing listening and relationship building with community partners and community members. Collaborative partners met six times in 2024 and hosted a community celebration with food, music, cultural performances, and resources for over 300 community members. The Collaborative serves to support and uplift its partner organizations as well. In 2024, member organization CLUES purchased a space from First Lutheran Church to operate an intergenerational childcare/adult day program. First Lutheran Church and Collaborative member Indigenous Roots also donated space to World Youth Connect for their youth programming. By facilitating these sorts of connections, the East Side Health and Well-being Collaborative enables everyone to better serve their communities, together. A central part of our community voice work and philosophy, the M Health Fairview Center for Community Health Equity (the Center) was launched in August 2022. The Center guides our efforts to gather community voice and tie the learnings back into the organization. Throughout 2024, we hosted three Center Community Health Equity Work Group meetings to hold strategic discussions on issues of relevance to the center. The Center for Community Health Equity also presented a session at the 2024 American Hospital Association's annual conference. This session focused on the lessons we learned from conducting community input sessions for community members with limited English proficiency, giving us the opportunity to socialize best practices and learn from the experiences of other healthcare systems. Over the course of the year, the Center continued to build out its SDOH platform and community engagement framework, guiding the implementation of the 2024 Community Health Needs Assessment approach. Enabling community voice, particularly the voices of priority populations, to influence and inform the health system is integral to Strategy 2 (Engagement infrastructure). In 2024, the Center for Community Health Equity and Fairview's Quality Improvement team began a joint enterprise to incorporate community voice into the way in which we define, implement, and measure healthcare quality. Members of the East Side Health and Well-being Collaborative and the System Community Advisory Committee gave input regarding what "quality "quality care" means to them, informing the development of the system's ambulatory care composite (high priority quality measures). The priorities yielded by their insights will drive organizational work for the next several years as we work to deliver the highest quality of care to our patients and community. Building our engagement infrastructure involves connecting broadly with community as well as building our capacity to engage with complex and intersectional groups. We are building a set of population health equity initiatives, one of which is the Native Health Equity Initiative (NHEI). As part of this body of work, in 2024 Fairview staff stood up the Indigenous Healing Circle Employee Resource Group to create sacred space for Native employees and patients and reconcile disparities unique to our Native relatives. Fairview also developed a system-wide land acknowledgement to raise awareness of how inequities have impacted the geographies and people we serve and guide us in our work to advance equity and inclusion. The land acknowledgement was published in our 2024 Community Health Needs Assessment report. Throughout our Native health equity efforts, we also hosted a Healing in Four Directions Powwow for more than 350 community members from across the state with partners including St. Paul Public Schools Indian Education, South St. Paul Public Schools Indian Education, Minnesota Indian Affairs Council, and the American Indian Family Center. Later in the year, we participated in the 2024 American Indian Day on the Hill and sponsored Indigenous Peoples Night with the Minnesota Aurora soccer team in collaboration with Northern Indigenous Games and Twin Cities Native Lacrosse. Community outreach in 2024 included providing mobile nursing services at four local powwows and events, including the Indigenous People's Health Fair. As part of the effort to incorporate Native health equity into systems and processes, Fairview reviewed its smudging policy and updated educational tools, providing training at acute care sites about the ritual and how it can be practiced in a clinical setting.
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Facility , 6 - University of Minnesota Medical Center. Strategy 3 - Inclusive Institution To successfully address our three priority needs and improve the health and wellbeing of our priority populations, it is imperative that we are guided by Strategy 3 (Inclusive institution): Transforming internal structures to create an antiracist and inclusive environment and to build community health by building community wealth. The anticipated impacts tied to Strategy 3 (Inclusive institution) are: 1) Build internal and external processes and structures to provide spaces that are safe and welcoming to all, responsive to community needs, and based on a culture of inclusion, 2) Use an antiracist approach and work to identify and eliminate racism by changing systems, organizational structures, policies, practices, and attitudes, and 3) Leverage everyday business practices to build community wealth, promoting economic and racial equity and justice. Key achievements in alignment with Strategy 3 include the launch of standardized social determinants of health patient screenings (e.g., food security, housing stability) at all ambulatory care sites. In 2024, 414,359 primary care patients across the system completed social determinants of health screenings. We also implemented targeted interventions to improve healthcare disparities, resulting in marked improvement in breast cancer and colon cancer screening rates. In particular, breast cancer screening rates improved among Karen, Hmong, and Somali patients because of six mobile mammography events. Additionally, we are building capacity across the system for more individuals and teams to participate in the Intercultural Development Inventory. Operational improvements driven by the Equity Strategy Office identify and address experience and outcome gaps for employee sub-groups and within patient care and outcomes. Improvements include related dashboarding and reporting across all organizational performance dimensions. This reporting informs the creation of actions plans to mitigate and address identified gaps and create line of sight to progress being made. In 2024, pathways were created to collate and incorporate voices and insights from the patients, employees, and community members Fairview serves. These pathways are being piloted and operationalized in 2025. Robust and strategic efforts across Patient Safety, Human Resources, and Customer Experience to identify and address multiple forms of harm were also supported. In addition, during 2024, units across the organization operationalized systems to identify and prevent potential gaps in care and outcomes across patient populations. Our anchor strategy works to advance health equity by investing in the social and economic wellbeing of the communities we serve through our everyday business practices. The strategy focuses on local and diverse hiring, purchasing and investing, and serving and leading with trusted community partners. Fairview's Workforce Partnerships team addresses the social determinants of health by helping people secure employment with family-sustaining wages and benefits, achieve success in their jobs, and learn new skills. The team also focuses on inclusive, local hiring, resulting in a healthcare team that represents the communities we serve. Supply Chain leaders launched a Supplier Diversity program, including updating request for proposal language, creating a new webpage, and identifying potential diverse vendors. Fairview also has a robust social corporate responsibility program including employee volunteerism, memberships, affiliations, and sponsorships. In 2024, there were 13 systemwide employee volunteerism events hosted, including Habitat for Humanity and Twin Cities Pride. Additionally, Fairview staff sit on boards and are members of a diverse set of community organizations. Fairview's sponsorship program is aligned with our commitment to advancing health equity. Our organization provides sponsorships to support local community organizations aligned with our system's priorities. To increase diversity and trust in clinical trials, the Center for Community Health Equity partnered with Fairview Frontiers to develop a community engagement strategy and improve representation in clinical trials. Together, they presented "Integrating Cultural Considerations for Research Participants" to the University of Minnesota research managers, providing education on the importance of diverse participation in research and how to do so thoughtfully and equitably. Fairview Frontiers also appeared at four different community events for "Research 101," informing community members about the process, benefits, and challenges of participating in a research study. Together, Fairview Frontiers and the Center for Community Health Equity are working to engage the community more directly in clinical research with the aim of improving both the process and the outcome of such studies. Significant needs not addressed. Prioritizing needs identified by our communities allows us to develop upstream strategies that will have a large and lasting impact in our communities. The priority needs we have identified will ultimately be positively impacted by addressing their root causes. The following needs were not directly addressed because these issues are outside the scope at this time: cost of care, insurance and medications, childcare, and employment benefits. The following needs were not directly addressed because they fall outside of the scope of the Community Health Needs Assessment Implementation Strategy: clinic/hospital hours, limited time spent with provider, and limited specialty care. This feedback was shared with the appropriate teams to address as part of clinical care.
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Facility , 1 - University of Minnesota Medical Center. The Minnesota Attorney General agreement was used in the determination of the eligibility for financial assistance.
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Facility , 1 - University of Minnesota Medical Center. The organization attaches a summary of the policy to billing invoices and also communicates to patients during admission, financial counseling and collection calls that there is a financial assistance program and that an application can be provided to them. A summary of the Financial Assistance Policy is posted in various locations in the hospital.
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Facility , 1 - University of Minnesota Medical Center. Pursuant to Treas. Reg. Section 1.501(r)-6(c), University of Minnesota Medical Center made reasonable efforts to determine whether an individual was FAP-eligible for care by satisfying the requirements of Section 1.501(r)-6(c)(3).
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We continue to believe that to have the greatest impact on our communities, we need to take a targeted approach. By focusing on specific issues and communities, we can understand and begin to address the root causes of health inequity in a more meaningful way. Our 2024 CHNA resulted in a reaffirmation, and better understanding, of the significant barriers that make our three priority need areas so difficult to address. We used these barriers to refine and better define the priority needs. Based on our improved understanding of the needs and conversations with advisory groups, we have adjusted the title of one of our priority needs from 2021. Healing, connectedness, and mental health is now Cultivating trust, belonging and healing. Although this change removed Mental Health from the title of this priority, we will lean into accessing mental health services as a part of the priority need "Navigating and accessing care and resources". We recently completed our 2024-2026 Community Health Needs Assessment (CHNA). Three key areas have been identified as the greatest needs in our community - and the greatest opportunities to make a real difference through collaboration and connection: * Accessing and navigating care and resources * Addressing structural racism and barriers to equity * Cultivating trust, belonging and healing Importantly, one thing we heard from the community and saw in the data is that the social determinants of health impact some populations more than others. Based on what we learned during our assessment process, we are prioritizing two populations: racial and ethnic populations experiencing health disparities and people experiencing poverty. The people in these groups are all ages, and they live everywhere from the countryside to the city. We will intentionally seek out the needs and perspectives of these populations that experience greater health inequities, in order to partner with them on building solutions and removing barriers. Many specific concerns fall under each of these areas of need. We used barriers identified in the local communities to help guide us in creating and expanding relevant programs and focused services.
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Facility , 1 - Fairview Southdale Hospital. As Fairview conducts our required CHNA process, led by Fairview's Community Advancement department, we are guided by the approaches and principles developed by the Center for Community Health Equity, which was launched in August 2022. As part of the center, we are building on our existing community engagement by creating an infrastructure that builds trusting partnerships and enables community voice to inform and influence our organization. For example: Fairview developed a Center for Community Health Equity Model of Community Engagement. The model articulates our approach to community engagement, community voice, and community partnerships as we work to advance community health equity. The center is developing a set of standard practices for collecting community voice to influence our social determinants of health initiatives without adding undue burden to the communities we seek to serve. The center's role as a convener and developer of community-informed best practices helps us keep equity at the center of our thinking as we study and evaluate our processes and engagement approaches. The M Health Fairview Center for Community Health Equity is an extension of the work being done in community by of our Community Advancement team. The center creates space for M Health Fairview and community partners to work alongside one another toward a shared goal of improving the health of the communities we serve and to which we belong. Together, we can apply equity-centered, culturally responsive approaches as we identify challenges and opportunities, create or expand programs and partnerships, and then scale or deepen learnings and successes across our system and the communities we serve. Located within the Fairview Community Health and Wellness Hub, the center formalizes the system's efforts to innovate and work with the community in reducing racial and other disparities in community health outcomes. The following strategies are helping us achieve this vision: 1. Addressing the social determinants of health (health behaviors and economic and social conditions that impact overall health) as well as individual social risks and social needs through the creation and expansion of programs; initiatives; collaborations; research; and policy, system, and environmental work. 2. Strengthening a community engagement infrastructure that builds trusting partnerships and enables community voice to inform and influence both inside and outside of our health system walls. 3. Transforming internal structures to create an antiracist and inclusive environment and to build community health by building wealth, knowledge, and capacity. This work would not be possible without the support of trusted community partners and our neighbors. The M Health Fairview Center for Community Health Equity's work is grounded in key principles that guide the ways in which we work with community, including: * Focus on community voice and trust - lifting up especially those who have historically been underrepresented and marginalized. * Commitment to collaboration - bringing community insights and priorities into our health system to address social determinants of health and advance health equity. * Transformation through action - transforming communities, health systems, and the broader ecosystem through innovation and continuous improvement. * Thank you to the experts from across our health system who give of their time and talents on the Center for Community Health Equity Work Group. This leadership group is helping shape and guide our work. * Michele Allen, MD, MS Associate Professor, Department of Family Medicine and Community Health Endowed Chair of Health Equity Research Director, Program in Health Disparities Research MPI, Center for Chronic Disease Reduction and Equity Promotion Across Minnesota (C2DREAM) Director, Community Engagement to Advance Research and Community Health (CEARCH), CTSI * Damien Fair, PA-C, PhD Co-Director, Masonic Institute for the Developing Brain Professor, Division of Clinical Behavioral Neuroscience, University of Minnesota Medical School Faculty, Department of Pediatrics Professor, Institute of Child Development * David Haynes, PhD Assistant Professor, Institute for Health Informatics at the University of Minnesota * Abe Jacob, MD Chief Quality Officer, M Health Fairview Associate Professor, Division of Pediatric Hospital Medicine, University of Minnesota Medical School Faculty, Department of Pediatrics Pediatrician, Internal Medicine, and Pediatric Hospitalist * Jim Letts, MD Family Medicine Provider, M Health Fairview Clinic - Roselawn * Katie Lingras, PhD, LP Director for Inclusive Excellence and Well-Being, Associate Professor, University of Minnesota Medical School * Will Nicholson, MD Vice President of Medical Affairs, M Health Fairview * Ana Nunez, MD, FACP Vice Dean, Diversity, Equity and Inclusion, University of Minnesota Medical School Professor of Medicine, Division of General Internal Medicine Integration Strategist, Clinical and Translational Science Institute * Chris Warlick, MD, PhD Department Head for the Department of Urology, University of Minnesota Medical School The programs and partnerships we have built and co-developed to respond to these needs are deeply embedded in our local communities. Our current assessment and implementation cycle gives us the opportunity to: Continue to build momentum, expanding our networks and collaborations to better understand one another's needs and assets. More deeply integrate the voices of those who are disproportionately impacted by the social determinants of health and the voices of historically marginalized communities in articulating barriers and building solutions. Lean into our unique culturally and linguistically relevant programs and initiatives. As we conduct our 2024 CHNA, we are taking a series of steps to improve our assessment process, keeping in mind the impact of the data collection process itself on the communities we serve. As we engage in bidirectional conversation and partnerships with community organizations that represent our priority populations and others, we are sensitive to the burden that incorporating the community's perspectives places on members of those communities and the organizations that serve them. In response, we are implementing several practices: We are offering grants to community-based organizations that are representing a priority population in our system community advisory council and stipends to the community-based organizations that are cohosting the health systemwide virtual community conversations with us. We are reviewing our outreach strategies, carefully planning, and partnering with others to avoid over surveying, over relying on the same voices or representatives, and asking the same questions assessment cycle after assessment cycle. Fairview has invested in subscriptions to tools, such as Spark Maps, which enable our health system to utilize and respond more effectively to requests for community data. Fairview has taken a leadership role in the Center for Community Health (CCH), a collaborative with health plans, hospitals, and public health agencies in Minnesota's seven-county metropolitan area. The CCH's member organizations will share data and processes to identify health needs and implement innovative approaches to advance community health, wellbeing, and equity. We are among the community partners supporting the Minnesota Homeless Study, a point-in-time study by Wilder Research that collects single-night counts of people experiencing homelessness across the state. Fairview also works with Wilder on the triennial Minnesota Reservation Homelessness Study. The study is conducted in partnership with six American Indian reservations in Minnesota. Fairview has had representation on the planning team and provided financial sponsorship for the Bridge to Health Survey. The survey has been an important source of data on the health status of adults in northeastern Minnesota and Douglas County, Wisconsin, for more than two decades. We have been involved in and supported collaborations particularly related to data and assessment in the medical center and children's hospital community. For example, Fairview staff participate on the Highrise Health Alliance housing team convened by the Minneapolis Health Department and the Minneapolis Public Housing Authority (MPHA). Staff are also a part of the Hennepin County Community Health Improvement Partnership (CHIP) is a coalition of partners from across the community using a collaborative approach to improving people's health. CHIP is committed to equity and informed by data and is focused on community mental well-being and housing stability.
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Facility , 2 - Fairview Southdale Hospital. Our overall engagement approach is guided by four key considerations: 1. Fairview is focusing on building and deepening our engagement infrastructure, putting structures in place that will guide our long-term community engagement efforts. 2. We must implement tactics that gather both breadth and depth of engagement, bringing as many community members as possible into the conversation and yet also seeking to develop a deep understanding of nuances within each need. 3. Our priority needs are systemwide, and we approach our assessment process from a system level. However, each local community Fairview serves is unique, and we recognize, honor, and prioritize local nuances - in context, in populations, and in our understanding of both - so we can respond most appropriately within each locality. This dual system/local approach enables us to maximize our efforts' impact across the region we serve. 4. As we look to our local communities and seek to meet them where they are, we benefit from engaging with multiple perspectives: those of our community members, our patients, and our employees. To do this, we must take into consideration a variety of approaches, modes, and preferences to best fit the needs of these three groups. As we build our multiyear assessment engagement approach, having a single guiding model of community engagement helps us maintain alignment across the organization as we plan and conduct our work. The Center for Community Health Equity engagement spectrum, based on the International Association for Public Participation's Spectrum of Public Participation, was collaboratively developed through interviews with local organizations, community members, Fairview employees, and other stakeholders. Our engagement spectrum depicts five progressively more intensive levels of community engagement: inform, consult, involve, collaborate, and community led. The model includes examples of each level of community engagement, to clarify what each level could look like in practice. It is important to recognize that no level is inherently better than another level - a more intensive engagement is not appropriate in all situations. Rather, each level is equally valid and appropriate for certain activities and at certain times. During our current assessment process, we used the Center for Community Health Equity engagement spectrum to help ensure that we are using strategies and tactics across the spectrum. Our intent is to build the capacity of stakeholders, community organizations, and other influencers to partner with our health system most effectively, enabling them to promote their community's interests to improve the broader community's health and wellbeing. Using the engagement spectrum as a model goes beyond merely incorporating community voice into Fairview's priority need areas. Its goal is to guide and frame co-development of community engagement activities and guide our implementation planning. The phrase "engagement infrastructure" refers to the mechanisms through which we are sharing and receiving bidirectional feedback on an ongoing basis. Like our hospital's physical infrastructure, our engagement infrastructure is composed of enduring, permanent parts of our health system. We are continuing to build a community engagement infrastructure that supports trusting partnerships and enables community voice to inform and influence the organization. Each hospital community has a Local Community Advisory Committee. We have been committed to and honored with a bidirectional, long-term commitment from our local community advisory committees, which have existed in various iterations for over 30 years. The local community advisory committee's role is to: Advise and inform health improvement plans and collaborative programs. Guide local insight and voice for CHNAs and action plans. Monitor progress toward the goals outlined in the CHNA implementation strategy. Review the local CHNA report. Each committee comprises members from, or representatives of, groups such as public health departments, medically underserved communities. communities experiencing poverty, populations experiencing health and/or racial disparities, community-based organizations, and schools. The System Community Advisory Council spans the entire health system and incorporates the need for internal representation, local representation, and representation from organizations that represent our priority populations. Its role is to: Advise the health system on the CHNA process and prioritization model from a systemwide perspective. Guide health system insight and ensure the voice of priority populations remains at the center of all discussions. Provide guidance and expertise in development of implementation strategy plans. Employee Resource Groups (ERGs), are voluntary, employee-led groups that aim to foster a diverse, inclusive workplace. They focus on impacting four important areas: community connection, organizational impact, meaningful change, and people development. ERGs supported the CHNA process by providing feedback and suggestions and supporting dissemination and recruitment of the data and engagement approaches. There are currently nine ERGs representing different affinities. Patient Family Advisory Councils bring together patient and family advisors along with staff to share insights and experiences to help Fairview improve. These committees help validate the current state, understand existing obstacles, and test ideas to overcome those barriers. During this CHNA cycle, our Patient Family Advisory Committees consulted on ways to approach community conversations, specifically our Town Halls. The process of centering community voice enables us to use the CHNA process to bring the perspectives of the communities we serve back to the organization in an actionable format. By using various data gathering methodologies, we gain a better understanding of the top barriers and concerns among the people we serve. This process is also a crucial avenue for adding nuance, understanding how our communities' needs shift among different geographical areas, generations, and cultural communities. Listening and learning sessions: Fairview has held community listening and learning sessions through the HOPE Commission since 2020. These sessions hold a mirror to Fairview, assessing where we are today and helping us understand how we can make lasting change. Sessions were held in 2020 to hear from employees, in 2021 and 2022 to hear from patients, and in 2023 and 2024 to hear from community members. In June 2022, after identifying a gap in participants from previous listening and learning sessions, we expanded these listening and learning sessions to include patients with limited English proficiency. Sessions were held in Somali, Spanish, Hmong, Karen, and American Sign Language. Prior to these sessions, there were limited mechanisms for patients with limited English proficiency to provide feedback about the care they were receiving. This series was an effort to bring more voices to the table and create inclusive opportunities for patients to express their needs and concerns.
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Facility , 3 - Fairview Southdale Hospital. Systemwide virtual conversations: We held a series of systemwide virtual conversations focused on the priority need healing, connectedness, and mental health and what that specifically looks like for youth (April 2024), aging adults (March 2024), and Indigenous populations (June 2024). These conversations were open to all, and their goal was to collect and share learnings and resources with participants. The conversations included presentations from community partners about their work, followed by small group discussions that provided valuable perspectives informing our understanding of population-specific needs, strengths, and future state visioning tied to healing, connectedness, and mental health. CHNA surveys To gather input from a broad set of stakeholders on local strengths and the top needs of communities each of the respective stakeholders serves, we developed two aligned, but distinct, surveys. The surveys gathered feedback about: Patient and community members' top barriers to care, social determinants of health needs, and social needs. The unique barriers and assets for patients in one of our priority populations (racial or ethnic populations experiencing health disparities and people experiencing poverty). Barriers that providers and community partners face in responding to the social determinants of health-related needs of patients as well as existing assets and resources available. The surveys were distributed to care team members and partner organizations, including faith leaders. Surveys were administered from mid-February to the end of March. We heard from 472 individuals across our hospital communities and our health system, with 296 responses from care team members and 176 responses from community organizations. Community Health and Healing Summit: Celebrating Culture, Building Connections, Guiding Action - The Community Health and Healing Summit, held in July 2024, aimed to propel our 10-year vision for a healthier Minnesota forward. The summit was a collaborative event bringing stakeholders together to work collectively on prioritizing needs and barriers to health in our communities. It blended the power of community and cultural healing with activities designed to collect participants' insights to not only shape our priorities but to actively drive positive change in our communities. Stakeholder interviews: From May to July 2024, we conducted stakeholder interviews with various Fairview care team members in both acute sites and clinics, including nurses, physicians, schedulers, social workers, care coordinators, and clinic managers. The interviews were guided by the results of our CHNA survey and aimed to gather more in-depth information and stories about the top barriers that had showed up most frequently during the survey. Facilitated conversations: We conducted a variety of facilitated conversations across the health system, a few examples of which are summarized in this section. The goal of these activities is to gain a fuller, more nuanced picture of topic-specific or population-specific perspectives over time. By holding these conversations on an ongoing basis, we ensure that our assessment process and our aligned programmatic or initiative-related work is responding to and engaging with communities in real time. Food is Medicine community conversations: As a part of our Food is Medicine initiative, we partnered with community-based organizations to host a community conversation in each hospital's service area. The goal was to learn more about the community's needs and strengths related to access to healthy food and the role of Fairview as a healthcare provider. In the fall 2023, we held eight Food is Medicine community conversations across different hospital geographies that were attended by 75 organizations representing sectors across the food scape including food shelves, farmers, social services organizations, schools, and municipalities. Town halls: In November and December 2023, we hosted five town hall sessions that were open to the public and geared toward local government relations offices, the business community, community-based organizations, trade groups, civic groups, and rotaries. Each town hall provided an opportunity for community members to receive updates from Fairview, participate in a question-and-answer session with Fairview leaders, and engage in discussions regarding barriers to health and trust in healthcare organizations. East Side Health and Well-being Collaborative: In February 2024, we joined the East Side Health and Well-being Collaborative's meeting as well as the collaborative's mental health and stress resilience work group meeting. In both meetings, we held facilitated conversations about the CHNA process and priority need areas in the community. During the meeting with the mental health and stress resilience work group, we focused on the healing, connectedness, and mental health priority area. Through ongoing partnership and programmatic conversations, we are vetting and refining our understanding of the identified priorities and the responses that would best address them. As a foundational part of program planning and evaluation, Community Advancement staff members are continuously soliciting feedback from community partners and program participants. We capture this information on an ongoing basis and use it to provide valuable context, driving insights into the needs of the communities we serve. Primary data methods: Fairview staff developed standardized tools, processes, instructions, protocols, and training for facilitators, interviewers, and note takers. We compiled, cleaned, and analyzed all primary data. A note taker captured all community input, and when possible, conversations were also recorded. Secondary community data: Claritas is a widely used national demographic estimation tool. Estimates and projections are provided at a zip code level including, but not limited to, population based on age, sex, ethnicity, and income. Spark Maps is a paid subscription that provides mapping and assessment tools that include a large database of indicators, data cleaning, benchmarking, and contextual information. The Bridge to Health Survey has been an important source of data on the health status of adults in northeastern Minnesota and Douglas County, Wisconsin, for more than two decades. The survey is conducted every five years, with the last survey administered in 2020. The Minnesota Student Survey is one of the longest-running youth surveys in the nation. It is a triennial survey that began in 1989. The data used in this report is from 2019. The Area Deprivation Index (ADI) is based on a measure created by the Health Resources and Services Administration over three decades ago, and has since been refined, adapted, and validated to the census block group neighborhood level by Amy Kind, MD, PhD, and her research team at the University of Wisconsin - Madison. Health Trends Across Communities in Minnesota (HTAC) uses information from electronic health records to help fill gaps in the information available to health professionals, organizations, policymakers, and community members to promote health in Minnesota. HTAC is a collaboration among health systems, public health departments, health organizations, and health plans in Minnesota. HTAC uses summary reports from electronic health records on a range of chronic, behavioral, and mental health conditions. The information comes from 11 health systems that make up the Minnesota Electronic Health Record Consortium (MNEHRC). Information from the MNEHRC represents approximately 90% of healthcare for Minnesotans, which makes HTAC a powerful tool to describe the health of many communities. Minnesota Department of Health, County Health Tables were used to look at 2020 county-level top causes of death and premature death.
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Facility , 1 - Fairview Southdale Hospital. The Community Health Needs Assessment Report for Fairview Southdale Hospital are located at: https://www.fairview.org/-/media/Files/Local-Health-Needs-Final/2024-CHNA-Report_Southdale-Hospital_Final.ashx The Community Health Needs Assessment and Implementation Strategy for Fairview Southdale Hospital are located at: https://www.fairview.org/-/media/Files/Local-Health-Needs/CHNA-Implementation-Strategy-Reports-2025/CHNA-Implementation-Strategy-Report-20252027Southdale.ashx
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Facility , 1 - Fairview Southdale Hospital. Our triennial Community Health Needs Assessment (CHNA) process provides an important opportunity to engage with and understand our community, analyze what has changed since the last assessment, and prioritize together with the community the issues we must urgently address to improve wellbeing and resilience. As part of the 2021 CHNA process, we reexamined and built upon the extensive community insights shared during our 2018 CHNA, while also surveying the community for current and emerging needs . This work continued in 2024 as we conducted our triennial assessment, further exploring the barriers experienced by community that tie to priority needs. Our 2021 CHNA used social determinants of health (SDOH) as a lens through which we frame our understanding of our community's most significant health needs. A social determinants of health lens enables us to identify inequitable distribution of resources and access that negatively impacts health. Through this lens we looked at both qualitative and quantitative data. Quantitative data included data points related to demographics, physical environment, socioeconomic factors, healthcare, and health outcomes. We collected additional community voice data by convening a broad array of stakeholders, with special focus on the priority populations - racial or ethnic populations experiencing health disparities and persons experiencing poverty. Southdale Hospital has a community advisory committee (CAC) that is involved in the CHNA process. The committee is comprised of local community and organizational leaders, such as local public health entities, social services organizations, higher education institutions, school districts, and local businesses. The assessment process also included discussions with our community advisory council, listening and learning sessions, and key stakeholder interviews. Throughout this process, community members, local business leaders, government representatives, nonprofit and community organizations, and content experts shared their voices and perspectives about their community's health needs. By bringing together both the qualitative and quantitative data, we established a prioritization process through which we could identify the community health needs that, if effectively addressed, would have the greatest positive impact on our communities and particularly on our priority populations. We prioritized areas of need based on four broad criteria: 1) Has this need been voiced by the community? Has this need been vetted by the community? 2) Does this need align with Fairview's strategies and priorities? 3) Does this need align with existing public health strategies and community health assessments? 4) Does this need build upon Fairview's 2018 CHNA priority needs? Southdale Hospital identified three system-wide priority need areas, and will collaborate with other Fairview hospitals, medical centers, and shared business and clinical services to address these priorities. Our specific response varies by hospital based on the ways the priority needs manifest across a given community, as well as the partnerships-both ongoing and new-that we have developed to address those needs. The three identified needs are: 1) Navigating and accessing care and resources, 2) Addressing structural racism and barriers to equity, and 3) Healing, connectedness, and mental health. Development of 2022-2024 CHNA Implementation Strategies As a healthcare organization that works closely with our community advisory committees and community partners, we have listened to community and learned valuable lessons over the past few decades. This has guided us in the development of the Fairview Health Services 2022-2024 implementation strategies. In particular, we learned that: 1) Despite best efforts, health needs and health inequities continue to grow and deepen, 2) Collective action is critical, and 3) Transformational change requires a sustained and focused commitment. In response to our 2021 Community Health Needs Assessment, Fairview hospitals and medical centers worked collaboratively with local and statewide organizations to address our communities' most pressing needs. In addition, Fairview put forth a 2032 vision of increased community health equity. This vision is supported by three strategies designed to address the priority need areas in distinct ways while collectively moving us closer to achieving our goals. The three strategies are: Strategy 1: Addressing Social Determinants of Health (SDOH) - Addressing the SDOH, individual social risks, and social needs through the creation and expansion of programs, initiatives, collaborations, and research, as well as policy, system, and environmental work. Strategy 2: Community engagement infrastructure - Creating a community engagement infrastructure that builds trusting partnerships and enables community voice to inform and influence our health system. Strategy 3: Inclusive institution - Transforming internal structures to create an antiracist and inclusive environment and to build community health by building community wealth. For this three-year cycle, we are implementing strategies to work toward distinct, anticipated impacts for each priority need and to build upon our 10-year vision of increased community health equity by 2032. For more information, the Southdale Hospital CHNA Implementation Strategy Report outlines the major strategies and actions we will deploy throughout the 2022-2024 assessment cycle as well as the ties between the Southdale Hospital CHNA implementation strategies, anticipated impacts, and key responses. Fairview's mission and vision extend beyond traditional healthcare settings, driving a healthier future for the communities we serve. Significant efforts towards Strategy 1 (Addressing SDOH) occurred over the first three years of our 10-year vision. These efforts are demonstrated through three social determinants of health initiatives: 1) Food is Medicine: Using the healing power of food to nourish our patients, enrich our communities, and transform our systems, 2) Housing is Health: Using the protective power of housing to support patient health and build thriving communities, and 3) Connection is Cure: Strengthening the connection between patients and the healthcare system to address social isolation and improve community mental health and wellbeing. These initiatives are key responses that intersect all three priority needs and are also synergistic. Relationship with our partners. Fairview has a long partnership with the University of Minnesota and University of Minnesota Physicians, now represented in the M Health Fairview brand. Together, we offer access to breakthrough medical research and specialty expertise as part of a continuum of care that reaches all ages and health needs. Policy, systems, and environmental change initiatives are implemented across the health system (hospitals, clinics, specialty care) and in some instances, across the M Health Fairview partners, to create sustainable and lasting change to advance health equity and community wellbeing. Where indicated, community responses as a part of Strategy 2 (Community engagement infrastructure) and Strategy 3 (Inclusive institution) represent the work of Fairview in collaboration with the other M Health Fairview partners. Community action plan. Southdale Hospital has an annual CHNA action plan that supports our vision of increased community health equity, rolls up to our system CHNA implementation strategies, and addresses priority needs. The Fairview Health Services Community Action Plan details the specific and measurable steps we will take during the year to drive change. Program lists by hospital can be found in the appendix. The System Community Action Plan is updated annually and includes impacts from previous years.
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Facility , 2 - Fairview Southdale Hospital. Evaluation of impact. To best evaluate our impact and track progress towards our anticipated impacts, we use a multi-tiered and tailored evaluation approach. Our work is grounded in understanding core information about our communities. This includes identifying and understanding the community needs being addressed, the population or community being affected, current and/or potential partners to work with to address the need, and the impacts we anticipate. Community needs are determined in several ways. In addition to being determined through our formal CHNA process, we respond to emerging needs brought to us by community partners or public health, or those discovered through patient or community data showing significant health disparities. We have standardized several key measures to assess whether we are meeting the needs of the CHNA priority populations, focusing our efforts on equity and participant satisfaction. A subset of established programs and initiatives are set up and supported for deeper evaluation. We have found that one-size-fits-all, evidence-based approaches may not be a good fit for some of our diverse communities. In response to the unique and differing needs of our community members, our programs are co-developed with community, center on the needs of specific populations, and often incorporate unique local tactics. We approach evaluation from a similar perspective by building evaluation approaches informed by our partners and considering strategies that are culturally and linguistically appropriate, allowing us to determine if the programs reflect the values we set out to embody. Fairview is guided by the Centers for Disease Control and Prevention (CDC) model for program evaluation, establishing primary outcomes, process measures, and demographics. We evaluate program impact and success from a variety of approaches using both qualitative and quantitative data. For many of the programs described here, we are reporting our reach or outputs through counts on a variety of levels that meet the rigor required for grant and contract reporting. In addition, we offer a diverse set of programs that vary on the spectrum of "low touch and high count" to "high touch and lower count." More generally put, the effort and impacts of the programs are not the same. This is a purposeful approach as we want a variety of programs that are appropriate to address the community and population-specific needs. We provide outcomes for programs here when we are able, acknowledging not all programs run on a calendar year, and analysis may not be complete for some of the programs on which we do deeper evaluation. Fairview is currently in the process of building an evaluative approach and capacity for our 10-year vision, increasing community health equity, and our three social determinants of health initiatives: Housing is Health, Food is Medicine, and Connection is Cure. Part of this evaluative approach is a monthly social determinants of health dashboard. Southdale Hospital 2024 Implementation Strategy Progress Highlights. The following highlights our implementation strategy work for each of our three priority needs. In this first three-year CHNA cycle working towards our 10-year vision of increased community health equity, the primary way we are directly addressing the three priority needs is through Strategy 1 (Addressing SDOH). Through this strategy, we create programs and partner with community organizations to address social risk factors, social needs, and social determinants of health. Strategy 2 (Engagement infrastructure) and Strategy 3 (Inclusive institution) focus on building infrastructure and creating system changes so that we can more effectively respond to these priority needs in the future, as well as any emerging needs. Strategy 1 - Addressing Social Determinants of Health (SDOH) Priority Need: Navigating and accessing care and resources. Southdale Hospital has a variety of programs that work as a part of Strategy 1 (Addressing SDOH) to address barriers related to navigating and accessing care and resources. Through this strategy, the Southdale Hospital Action Plan programs work towards two anticipated impacts to address this priority need: 1) Remove barriers to care by providing community-placed care, co-located services, and navigation supports that address cultural and language barriers and 2) Increase awareness of, knowledge about, and access to healthcare and community-based resources that support opportunities for health and wellbeing. The following is more information on a selection of programs from the system community action plan that are working to meet the two anticipated impacts. Fairview System Key Initiative Highlights. The Community Clinical Care initiative involves multiple community-based clinical programs, including Fairview's Minnesota Immunization Networking Initiative (MINI), blood pressure checks, and oral health services. All services are multi-sector, community collaborations that provide care and education to the uninsured, under-served, and communities facing health disparities in the greater Twin Cities area. The Community Clinical Care team provides clinical care in trusted community settings at no cost and improves equitable access to vaccines and other services across various populations. The programs ensure a culturally and linguistically appropriate experience in a safe and trusted environment in partnership with over 250 faith-based and grassroots community partners, serving clients at local churches, mosques, temples, schools, community centers, food pantries, and homeless shelters. Across the system in 2024, the community clinical care team provided blood pressure and oral health services at 241 events, including 4 events in the Southdale Hospital community, providing 418 blood pressure checks, and 696 dental fluoride applications. The team also hosted 443 vaccination clinics across the system in 2024. There were 5,525 free COVID-19 vaccine doses and 6,190 free flu shots administered. Of those participants who shared their identity, 72% of people who received a COVID-19 vaccine identified as a person of color and 35% indicated a language other than English as their preferred language. In the Southdale Hospital community specifically, there were 11 MINI clinics at which 126 COVID-19 shots and 418 flu shots were administered. In August 2024, MINI received an invitation to publish an article in the special Public Health issue of the New England Journal of Medicine discussing their cross-sectoral, equity-based approach to COVID-19 response. Later in the year, they published a similar article in the Journal of Public Health Management & Practice, this time focusing specifically on reducing vaccination barriers for refugee, immigrant, and migrant communities during the COVID-19 pandemic. MINI also presented at the 2024 North American Refugee Health Conference. The Colon Cancer Prevention program provides community education on colon cancer prevention, outreach, and recruitment of uninsured individuals to have colonoscopy procedures. Communities served are identified based on disparate colorectal cancer screening rates compared to the state rate. Education and outreach are provided by a Community Health Worker (CHW) across multiple community locations. CHW assesses people who indicate interest in having a colonoscopy procedure at no cost based on program criteria: Age 45-75 or in a group at higher risk for colon cancer, do not have medical insurance, and live anywhere in Minnesota. In 2024, there were 30 colonoscopies provided to uninsured community members in the Southdale Hospital community. The Culturally Tailored Education and Outreach Program provides health education sessions on a variety of health topics including COVID-19 vaccines, COVID-19 virus, colorectal cancer prevention, cancer prevention, diabetes prevention, heart disease prevention, mental health, Alzheimer's disease, heat-related illness, and other health topics. Education provided to the general Latine community. In partnership with community organizations. In 2024 in the Southdale Community, there were four education sessions with 585 people attending.
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Facility , 3 - Fairview Southdale Hospital. The Fairview Community Health and Wellness Hub (The Hub) opened in 2022. The Hub is a first-of-its-kind center that addresses health disparities while providing a range of critical healthcare services and community resources alongside trusted local partners. The Hub provides a variety of services to the community, including primary care, mental healthcare, enrichment options for seniors, food access programs, and community gathering spaces. We bring our own services together with local organizations to make it easier for people to access what they need to thrive. Throughout the year, 7,090 individuals attended 176 events or meetings at the Hub. Eighty-three of the events were public and partner events, reaching 3,263 individuals. Ninety-three events were internal Fairview events. Additionally, we hosted nine Hub Partnership Coordination Meetings, as well as one-on-one check-ins with each of the partners. These meetings serve to deepen our understanding of the diverse missions, visions, and impacts of each Hub partner, fostering better alignment and collaboration. In 2025, we plan to transition to quarterly in-person partnership meetings. This strategic move aims to enhance our collaborative efforts and drive impactful initiatives. The Cultural broker program was co-developed in 2016 in partnership with Fairview's East Side Health and Well-being Collaborative. Cultural brokers help bridge cultural gaps through supporting individuals and families as they navigate schools, healthcare, and other mainstream systems to ultimately build self-sufficiency. The cultural brokers identify with the racial and/or ethnic communities they serve, so they can more easily build trust and have a greater impact on the communities' health. The program comprises six cultural brokers who are Fairview employees located at five respective partner organizations representing different cultural communities: African American, American Indian, Hispanic/Latino, Hmong, and Karen. Across the system, cultural brokers served 510 new clients total, resulting in 4,431 encounters. In the Southdale community they served 17 new clients . In 2024, we continued to expand our work relating to opioid overdose prevention in partnership with the Steve Rummler Hope Network. Fairview's Community Clinical Care team trained several staff members to become naloxone educators, who can then train others. Educators train community members on how to recognize an opioid overdose, what naloxone (Narcan) is and how it works, how to administer naloxone to someone experiencing an overdose, and information about Steve's Law/MN's Good Samaritan and Naloxone Law. In total, there were 39 naloxone trainings where 944 individuals were trained in 2024. In addition, Fairview opened a fourth naloxone access point (NAP) site that provides free kits, extending this important resource to Greater Minnesota. NAP sites are stocked with nasal Narcan and intramuscular naloxone kits, many of which are packed at Fairview volunteer events. In 2024, 12,995 such kits were packed and distributed across our hospital communities. The Community Clinical Care team plans on opening several additional NAP sites in 2025. Fairview hired two Food Resource Navigators in 2024, exemplifying the intersection of Strategy 1 (Addressing SDOH) and navigating and accessing care and resources. Food Resource Navigators serve as experts both in Fairview's Food is Medicine programs, as well as community food resources and government programs such as SNAP and Market Bucks. Rolled out in select clinics across the system, Food Resource Navigators receive clinical referrals when a patient screens positive for food insecurity and expresses interest in being connected with additional support or resources. In 2024, our Food Resource Navigators received 561 referrals across the system, including 35 from the Southdale Hospital service area. Of those referrals, 84% of individuals were connected with internal and/or external resources. Over the next several years, this role will be expanded to additional clinics. In this way, we can support patients in navigating the complex landscape of healthcare and social services. Priority Need: Addressing Structural Racism and Barriers to Equity. Southdale Hospital, in alignment with Strategy 1 (Addressing SDOH), has a variety of programs, events, and community education as a part of the Community Action Plan that work toward the anticipated impact: Develop, grow, and sustain programs, educational offerings, partnerships, and initiatives to address structural racism and barriers to equity. Fairview System Key Initiative Highlights. One of the Fairview social determinants of health initiatives, Food is Medicine, utilizes the knowledge and resources of a large healthcare institution to work towards meeting the immediate needs of our patients, while also transforming the food system into something just, equitable, and sustainable. The initiative aims to 1) Nourish our patients: Advance food security to reduce health disparities and diet-related health conditions. 2) Enrich our communities: Cultivate trusting and engaged partnerships to build and share resources, assets, and capacity. 3) Transform our systems: Nurture just and equitable food systems to ensure health equity. These approaches are framed to increase health equity through focused efforts to serve patients who have been historically marginalized by providing culturally appropriate food options and reducing food insecurity in a manner that upholds dignity and empowers the local food system. Clinically, it enables providers to serve patients experiencing food insecurity through a menu of distinct programs comprising an innovative wrap-around approach. One or more of the Food is Medicine programs-a selection of which are described below-are available to patients in 52+ clinics and 8 acute sites across the health system. One of the Food is Medicine initiative programmatic responses is the fresh food prescription program, which distributes fresh, locally grown produce from three farm partners (Hmong American Farmers Association, Naima's Farm, and Women's Environmental Institute) via a weekly food box. The boxes also contain proteins, whole grains, and pantry staples, as well as a newsletter with community resources and tips for healthy cooking and eating. Crucially, the program offers home delivery to address transportation barriers. In 2024, 31 clinics participated in the fresh food prescription program across Fairview hospital and medical center communities, three being in the Southdale Hospital community. Almost one third (31%) of program participants identified as Asian, 17% as Black, and 2% as Hispanic/Latino. While just 70% of participants speak English as a preferred language, 7% had a preferred language of Hmong, 14% Karen, and 1% Spanish. Most participants had public insurance (79%) or were uninsured (2%). Fairview's food voucher program provides patients with vouchers to redeem at either the Twin Cities Mobile Market or Fare for All program. The program runs year-round and offers rolling enrollment. Throughout the year, 443 patients redeemed vouchers for groceries, including 21 from the Southdale Hospital community. Additionally, we provide shelf-stable food resources for those with an immediate need. The shelf-stable food bags were incorporated into Southdale Hospital for the first time in 2024. The bags come in six different varieties tailored to meet the preferences of diverse cuisines and circumstances. In 2024 there were 6042 shelf-stable bags distributed at 37 sites across the system. There were also 258 food resource packets distributed that contained information about local food resources along with immediate food support. In November 2024, Fairview and local partners hosted the third annual Harvest at the Hub, welcoming 312 households to the Fairview Community Health and Wellness Hub. The event consisted of a food giveaway with turkeys, fresh produce, and other holiday staples, a community resource fair, a vaccine clinic, and other health and wellbeing services. Another of the Fairview social determinants of health initiatives, Housing is Health also responds to the priority need of structural racism and barriers to equity . The Housing is Health initiative aims to use the protective power of housing to support patient health and build thriving communities. We approach this initiative with clinically connected programs, supportive community partnerships, contribution of time and expertise to collaboratives, and efforts to impact policy.
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Facility , 4 - Fairview Southdale Hospital. For example, Fairview partners with Our Saviour's Community Services to provide critical follow-up care and temporary housing for people who are unsheltered after a hospital stay. Patients are referred by staff at a hospital or medical center and sheltered at Our Saviour's. Additionally, a nurse provides care, and patients receive wrap-around services and social work support. In 2024, 50 patients were provided support through this program. As a part of Housing is Health, we are also proud to have helped launch Healthcare for Housing (HC4H). HC4H grew out of the Housing and Health Equity Fellowship and consists of seven health providers and payers. We also strengthened our housing advocacy activities in 2024; we chaired the policy workgroup for HC4H, participated in Homeless Day on the Hill at the Minnesota State Capitol, and submitted letters of support for multiple housing initiatives. In September and October 2024, teams from across the system participated in two Twin Cities Habitat for Humanity builds. Volunteers contributed 300 hours for the Carter Work Project build. During our annual build week with Twin Cities Habitat for Humanity, staff contributed 560 volunteer hours. Priority Need: Healing, Connectedness, and Mental Health. Southdale Hospital works toward the anticipated impact: develop, grow, and sustain programs, educational offerings, partnerships, and initiatives, address barriers to healing, connectedness and mental health through Strategy 1 (Addressing SDOH) and the Community Action Plan. Fairview System Key Initiative Highlights. In response to the priority need of healing, connectedness, and mental health, we have a body of work that makes up the Connection is Cure initiative. Connection is Cure aims to build trust through social connections, center linguistic and cultural diversity, and bridge silos across our hospital system and communities to transform medical practice. As a part of Connection is Cure, we hosted virtual conversations in 2024 around how we can improve mental health services for specific populations: Native patients, youth, and older adults. Three conversations were held-one for each respective population-reaching a total of 108 community members. Other gatherings fostering healing, connectedness, and mental health were held in 2024 as well, including a Heal the Healers event. Exemplifying the integration of traditional healthcare with ancestral and cultural practices, the Heal the Healers event united local healers and caregiving professionals for a transformative day of self-care, learning, and the revival of ancestral practices. Our goal was to empower practitioners and community workers with activities that foster self-care, ensuring they remain strong and resilient for the communities they serve. This and other healing events laid the groundwork for the Community Health and Healing Summit, convened as part of our innovative approach to the Community Health Needs Assessment. Over 100 participants gathered for a day of learning about the health conditions in their local communities, seeking to understand the efforts of the system and collective community in addressing these issues. For many attendees, the event also served as a welcoming introduction to cultural and non-traditional healing practices; individuals had the opportunity to experience these practices firsthand while learning about their application within the community and our health system. As part of our commitment to addressing barriers to healing, connectedness, and mental health, we also launched our Birth Justice Initiative, a cross-departmental effort to advance equity and inclusion in birthing experiences. Focused on eliminating racial bias in maternal healthcare and improving patient outcomes, the Birth Justice Initiative is making systemic changes to improve the quality of healthcare for all pregnant persons. Their research and advocacy led to the removal of race-based maternal health screening tools, which have the potential to unintentionally introduce bias into medical decision-making. Additionally, part of the design of a new prenatal and postpartum clinical care map includes screening all pregnant patients for social determinants of health and lead exposure, empowering healthcare providers to act early to address these concerns. In 2024, departments participating in the Birth Justice Initiative interviewed 649 people who gave birth in the Fairview health system and gathered input from doulas. Based on their feedback, we plan to rewrite policies to enhance culturally congruent care, tailoring maternal healthcare to the specific cultural values of each patient. Additionally, we are responding to the need for healing, connectedness, and mental health with a variety of evidence-based programs, as well as trainings and education sessions. Feeding Hope is a series of virtual one-hour learning sessions focused on positive, hopeful topics that support wellbeing in the general community. This series is offered in partnership with all of Fairview's hospitals and medical centers and is open to anyone across all of Fairview's communities. In 2024, across Fairview hospitals and medical centers there were two sessions held with 60 attendees total. The Faith Community Nursing program makes programs and services available to faith community nurses to hold in their congregation . Additionally, $750 mini grants are provided from Fairview Foundation to faith community nurses, as well as resources such as health education materials and resources, and networking opportunities. In 2024 across the system there were 20 mini grants awarded. In the Southdale Hospital community, 4 mini grants were awarded to faith community nurses. Psychological First Aid is an evidence-informed training for the broader community as well as professionals. Trainees learn how to support healthy recovery for individuals following a traumatic event, public health emergency, natural disaster, or personal crisis. The curriculum integrates public health, community health, and individual psychology by drawing upon skills the trainees probably already have. Psychological First Aid is a two-hour training. In 2024, in the Southdale Hospital community, there were three classes offered with 111 participants attending. A Creative Look at Self-Care (formerly Refresh and Reset your Resiliency) promotes resiliency skills, offers wellness-care tools for mind, body, and spirit, and encourages the development of a personal plan for self-care. In 2024, in the Southdale Hospital community, there was 1 class offered with 17 participants attending. Together, Fairview's Strategy 1 (Addressing SDOH) initiatives and the programs outlined within our action plans comprise a strategic, innovative, and equity-minded approach to community health. We take great care to co-design programmatic responses with the communities impacted by them and collaborate with a broad range of community organizations and other multisectoral partners to address the social determinants of health. In recognition of our commitment to this work, Fairview advanced as a finalist for the American Hospital Association's Foster G. McGaw Prize. Five programs were profiled in Fairview's award submission: Minnesota Immunization Networking Initiative; East Side Health and Well-being Collaborative; Fair Table, Fairview's Food is Medicine initiative; Health Commons; and our Cultural Broker program. It is a great honor to be considered for this award; it serves as motivation to work harder than ever to advance health equity, and to intentionally do so in authentic partnership with the communities we serve. In addition to Strategy 1 (Addressing SDOH) and the programmatic work included on our Action Plans, we strive to reduce health disparities and increase community health equity through two additional system strategies. While Strategy 1 (Addressing SDOH) allows us to directly respond to the three prioritized needs from our community health needs assessment, Strategy 2 (Engagement infrastructure) and Strategy 3 (Inclusive institution) focus on building the structures and systems for us to do the work more capably.
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Facility , 5 - Fairview Southdale Hospital. Strategy 2 - Engagement Infrastructure Addressing our three priority needs while also responding to emerging needs requires an infrastructure that supports building and sustaining strong community partnerships and allows for ongoing, trusting exchanges between Fairview and community members. The importance of this is manifest in Strategy 2 (Engagement infrastructure): Creating community engagement infrastructure that builds trusting partnerships and enables community voice to inform and influence the institution. The anticipated impacts for this strategy are: 1) Build and expand feedback systems for patients and community members; embed process improvement in the health system's response to community voice and 2) Create sustainable structures to convene and engage community voice around addressing social determinants of health. While Fairview boasts an extensive engagement infrastructure already, we continued to bolster the work we do to expand feedback systems and sustainable convening structures. Core to this is building and sustaining trusting partnerships. Our Southdale Hospital Community Advisory Committee (CAC) met through the year to offer input and provide local insight and expertise. Notably, 2024 marks the first year since the COVID-19 pandemic in which we convened our CACs in-person, celebrating the joy of being together in the same room and the spirit of collaboration that it fosters. To enhance the work of each hospital CAC, in 2024 we revitalized our System Community Advisory Council. Spanning the entire health system, the System CAC incorporates the need for internal representation, local representation, and representation from organizations that represent our priority populations. While it plays a large role in advising the CHNA process and implementation, it also ensures the voice of priority populations remain at the center of all discussions and decisions. The System CAC met five times in 2024, providing guidance and insights throughout the Community Health Needs Assessment process. A central part of our community voice work and philosophy, the M Health Fairview Center for Community Health Equity (the Center) was launched in August 2022. The Center guides our efforts to gather community voice and tie the learnings back into the organization. Throughout 2024, we hosted three Center Community Health Equity Work Group meetings to hold strategic discussions on issues of relevance to the center. The Center for Community Health Equity also presented a session at the 2024 American Hospital Association's annual conference . This session focused on the lessons we learned from conducting community input sessions for community members with limited English proficiency, giving us the opportunity to socialize best practices and learn from the experiences of other healthcare systems. Over the course of the year, the Center continued to build out its SDOH platform and community engagement framework, guiding the implementation of the 2024 Community Health Needs Assessment approach. Enabling community voice, particularly the voices of priority populations, to influence and inform the health system is integral to Strategy 2 (Engagement infrastructure). In 2024, the Center for Community Health Equity and Fairview's Quality Improvement team began a joint enterprise to incorporate community voice into the way in which we define, implement, and measure healthcare quality. Members of the East Side Health and Well-being Collaborative and the System Community Advisory Committee gave input regarding what "quality "quality care" means to them, informing the development of the system's ambulatory care composite (high priority quality measures). The priorities yielded by their insights will drive organizational work for the next several years as we work to deliver the highest quality of care to our patients and community. Building our engagement infrastructure involves connecting broadly with community as well as building our capacity to engage with complex and intersectional groups. We are building a set of population health equity initiatives, one of which is the Native Health Equity Initiative (NHEI). As part of this body of work, in 2024 Fairview staff stood up the Indigenous Healing Circle Employee Resource Group to create sacred space for Native employees and patients and reconcile disparities unique to our Native relatives. Fairview also developed a system-wide land acknowledgement to raise awareness of how inequities have impacted the geographies and people we serve and guide us in our work to advance equity and inclusion. The land acknowledgement was published in our 2024 Community Health Needs Assessment report. Throughout our Native health equity efforts, we also hosted a Healing in Four Directions Powwow for more than 350 community members from across the state with partners including St. Paul Public Schools Indian Education, South St. Paul Public Schools Indian Education, Minnesota Indian Affairs Council, and the American Indian Family Center. Later in the year, we participated in the 2024 American Indian Day on the Hill and sponsored Indigenous Peoples Night with the Minnesota Aurora soccer team in collaboration with Northern Indigenous Games and Twin Cities Native Lacrosse. Community outreach in 2024 included providing mobile nursing services at four local powwows and events, including the Indigenous People's Health Fair. As part of the effort to incorporate Native health equity into systems and processes, Fairview reviewed its smudging policy and updated educational tools, providing training at acute care sites about the ritual and how it can be practiced in a clinical setting. Strategy 3 - Inclusive Institution To successfully address our three priority needs and improve the health and wellbeing of our priority populations, it is imperative that we are guided by Strategy 3 (Inclusive institution): Transforming internal structures to create an antiracist and inclusive environment and to build community health by building community wealth. The anticipated impacts tied to Strategy 3 (Inclusive institution) are: 1) Build internal and external processes and structures to provide spaces that are safe and welcoming to all, responsive to community needs, and based on a culture of inclusion, 2) Use an antiracist approach and work to identify and eliminate racism by changing systems, organizational structures, policies, practices, and attitudes, and 3) Leverage everyday business practices to build community wealth, promoting economic and racial equity and justice. Key achievements in alignment with Strategy 3 include the launch of standardized social determinants of health patient screenings (e.g., food security, housing stability) at all ambulatory care sites. In 2024, 414,359 primary care patients across the system completed social determinants of health screenings. We also implemented targeted interventions to improve healthcare disparities, resulting in marked improvement in breast cancer and colon cancer screening rates. In particular, breast cancer screening rates improved among Karen, Hmong, and Somali patients because of six mobile mammography events. Additionally, we are building capacity across the system for more individuals and teams to participate in the Intercultural Development Inventory. Operational improvements driven by the Equity Strategy Office identify and address experience and outcome gaps for employee sub-groups and within patient care and outcomes. Improvements include related dashboarding and reporting across all organizational performance dimensions. This reporting informs the creation of actions plans to mitigate and address identified gaps and create line of sight to progress being made. In 2024, pathways were created to collate and incorporate voices and insights from the patients, employees, and community members Fairview serves. These pathways are being piloted and operationalized in 2025. Robust and strategic efforts across Patient Safety, Human Resources, and Customer Experience to identify and address multiple forms of harm were also supported. In addition, during 2024, units across the organization operationalized systems to identify and prevent potential gaps in care and outcomes across patient populations.
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Facility , 6 - Fairview Southdale Hospital. Our anchor strategy works to advance health equity by investing in the social and economic wellbeing of the communities we serve through our everyday business practices. The strategy focuses on local and diverse hiring, purchasing and investing, and serving and leading with trusted community partners. Fairview's Workforce Partnerships team addresses the social determinants of health by helping people secure employment with family-sustaining wages and benefits, achieve success in their jobs, and learn new skills. The team also focuses on inclusive, local hiring, resulting in a healthcare team that represents the communities we serve. Supply Chain leaders launched a Supplier Diversity program, including updating request for proposal language, creating a new webpage, and identifying potential diverse vendors. Fairview also has a robust social corporate responsibility program including employee volunteerism, memberships, affiliations, and sponsorships. In 2024, there were 13 systemwide employee volunteerism events hosted, including Habitat for Humanity and Twin Cities Pride. Additionally, Fairview staff sit on boards and are members of a diverse set of community organizations. Fairview's sponsorship program is aligned with our commitment to advancing health equity. Our organization provides sponsorships to support local community organizations aligned with our system's priorities. To increase diversity and trust in clinical trials, the Center for Community Health Equity partnered with Fairview Frontiers to develop a community engagement strategy and improve representation in clinical trials. Together, they presented "Integrating Cultural Considerations for Research Participants" to the University of Minnesota research managers, providing education on the importance of diverse participation in research and how to do so thoughtfully and equitably. Fairview Frontiers also appeared at four different community events for "Research 101," informing community members about the process, benefits, and challenges of participating in a research study. Together, Fairview Frontiers and the Center for Community Health Equity are working to engage the community more directly in clinical research with the aim of improving both the process and the outcome of such studies. Significant needs not addressed. Prioritizing needs identified by our communities allows us to develop upstream strategies that will have a large and lasting impact in our communities. The priority needs we have identified will ultimately be positively impacted by addressing their root causes. The following needs were not directly addressed because these issues are outside the scope at this time: cost of care, insurance and medications, childcare, and employment benefits. The following needs were not directly addressed because they fall outside of the scope of the Community Health Needs Assessment Implementation Strategy: clinic/hospital hours, limited time spent with provider, and limited specialty care. This feedback was shared with the appropriate teams to address as part of clinical care.
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Facility , 1 - Fairview Southdale Hospital. The Minnesota Attorney General agreement was used in the determination of the eligibility for financial assistance.
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Facility , 1 - Fairview Southdale Hospital. A summary of the Financial Assistance Policy is posted in various locations in the hospital.
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Facility , 1 - Fairview Southdale Hospital. Pursuant to Treas. Reg. Section 1.501(r)-6(c), Fairview Southdale Hospital made reasonable efforts to determine whether an individual was FAP-eligible for care by satisfying the requirements of Section 1.501(r)-6(c)(3).
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We continue to believe that to have the greatest impact on our communities, we need to take a targeted approach. By focusing on specific issues and communities, we can understand and begin to address the root causes of health inequity in a more meaningful way. Our 2024 CHNA resulted in a reaffirmation, and better understanding, of the significant barriers that make our three priority need areas so difficult to address. We used these barriers to refine and better define the priority needs. Based on our improved understanding of the needs and conversations with advisory groups, we have adjusted the title of one of our priority needs from 2021. Healing, connectedness, and mental health is now Cultivating trust, belonging and healing. Although this change removed Mental Health from the title of this priority, we will lean into accessing mental health services as a part of the priority need "Navigating and accessing care and resources". We recently completed our 2024-2026 Community Health Needs Assessment (CHNA). Three key areas have been identified as the greatest needs in our community - and the greatest opportunities to make a real difference through collaboration and connection: * Accessing and navigating care and resources * Addressing structural racism and barriers to equity * Cultivating trust, belonging and healing Importantly, one thing we heard from the community and saw in the data is that the social determinants of health impact some populations more than others. Based on what we learned during our assessment process, we are prioritizing two populations: racial and ethnic populations experiencing health disparities and people experiencing poverty. The people in these groups are all ages, and they live everywhere from the countryside to the city. We will intentionally seek out the needs and perspectives of these populations that experience greater health inequities, in order to partner with them on building solutions and removing barriers. Many specific concerns fall under each of these areas of need. We used barriers identified in the local communities to help guide us in creating and expanding relevant programs and focused services.
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Facility , 1 - Fairview Ridges Hospital. As Fairview conducts our required CHNA process, led by Fairview's Community Advancement department, we are guided by the approaches and principles developed by the Center for Community Health Equity, which was launched in August 2022. As part of the center, we are building on our existing community engagement by creating an infrastructure that builds trusting partnerships and enables community voice to inform and influence our organization. For example: Fairview developed a Center for Community Health Equity Model of Community Engagement. The model articulates our approach to community engagement, community voice, and community partnerships as we work to advance community health equity. The center is developing a set of standard practices for collecting community voice to influence our social determinants of health initiatives without adding undue burden to the communities we seek to serve. The center's role as a convener and developer of community-informed best practices helps us keep equity at the center of our thinking as we study and evaluate our processes and engagement approaches. The M Health Fairview Center for Community Health Equity is an extension of the work being done in community by of our Community Advancement team. The center creates space for M Health Fairview and community partners to work alongside one another toward a shared goal of improving the health of the communities we serve and to which we belong. Together, we can apply equity-centered, culturally responsive approaches as we identify challenges and opportunities, create or expand programs and partnerships, and then scale or deepen learnings and successes across our system and the communities we serve. Located within the Fairview Community Health and Wellness Hub, the center formalizes the system's efforts to innovate and work with the community in reducing racial and other disparities in community health outcomes. The following strategies are helping us achieve this vision: 1. Addressing the social determinants of health (health behaviors and economic and social conditions that impact overall health) as well as individual social risks and social needs through the creation and expansion of programs; initiatives; collaborations; research; and policy, system, and environmental work. 2. Strengthening a community engagement infrastructure that builds trusting partnerships and enables community voice to inform and influence both inside and outside of our health system walls. 3. Transforming internal structures to create an antiracist and inclusive environment and to build community health by building wealth, knowledge, and capacity. This work would not be possible without the support of trusted community partners and our neighbors. The M Health Fairview Center for Community Health Equity's work is grounded in key principles that guide the ways in which we work with community, including: * Focus on community voice and trust - lifting up especially those who have historically been underrepresented and marginalized. * Commitment to collaboration - bringing community insights and priorities into our health system to address social determinants of health and advance health equity. * Transformation through action - transforming communities, health systems, and the broader ecosystem through innovation and continuous improvement. * Thank you to the experts from across our health system who give of their time and talents on the Center for Community Health Equity Work Group. This leadership group is helping shape and guide our work. * Michele Allen, MD, MS Associate Professor, Department of Family Medicine and Community Health Endowed Chair of Health Equity Research Director, Program in Health Disparities Research MPI, Center for Chronic Disease Reduction and Equity Promotion Across Minnesota (C2DREAM) Director, Community Engagement to Advance Research and Community Health (CEARCH), CTSI * Damien Fair, PA-C, PhD Co-Director, Masonic Institute for the Developing Brain Professor, Division of Clinical Behavioral Neuroscience, University of Minnesota Medical School Faculty, Department of Pediatrics Professor, Institute of Child Development * David Haynes, PhD Assistant Professor, Institute for Health Informatics at the University of Minnesota * Abe Jacob, MD Chief Quality Officer, M Health Fairview Associate Professor, Division of Pediatric Hospital Medicine, University of Minnesota Medical School Faculty, Department of Pediatrics Pediatrician, Internal Medicine, and Pediatric Hospitalist * Jim Letts, MD Family Medicine Provider, M Health Fairview Clinic - Roselawn * Katie Lingras, PhD, LP Director for Inclusive Excellence and Well-Being, Associate Professor, University of Minnesota Medical School * Will Nicholson, MD Vice President of Medical Affairs, M Health Fairview * Ana Nunez, MD, FACP Vice Dean, Diversity, Equity and Inclusion, University of Minnesota Medical School Professor of Medicine, Division of General Internal Medicine Integration Strategist, Clinical and Translational Science Institute * Chris Warlick, MD, PhD Department Head for the Department of Urology, University of Minnesota Medical School The programs and partnerships we have built and co-developed to respond to these needs are deeply embedded in our local communities. Our current assessment and implementation cycle gives us the opportunity to: Continue to build momentum, expanding our networks and collaborations to better understand one another's needs and assets. More deeply integrate the voices of those who are disproportionately impacted by the social determinants of health and the voices of historically marginalized communities in articulating barriers and building solutions. Lean into our unique culturally and linguistically relevant programs and initiatives. As we conduct our 2024 CHNA, we are taking a series of steps to improve our assessment process, keeping in mind the impact of the data collection process itself on the communities we serve. As we engage in bidirectional conversation and partnerships with community organizations that represent our priority populations and others, we are sensitive to the burden that incorporating the community's perspectives places on members of those communities and the organizations that serve them. In response, we are implementing several practices: We are offering grants to community-based organizations that are representing a priority population in our system community advisory council and stipends to the community-based organizations that are cohosting the health systemwide virtual community conversations with us. We are reviewing our outreach strategies, carefully planning, and partnering with others to avoid over surveying, over relying on the same voices or representatives, and asking the same questions assessment cycle after assessment cycle. Fairview has invested in subscriptions to tools, such as Spark Maps, which enable our health system to utilize and respond more effectively to requests for community data. Fairview has taken a leadership role in the Center for Community Health (CCH), a collaborative with health plans, hospitals, and public health agencies in Minnesota's seven-county metropolitan area. The CCH's member organizations will share data and processes to identify health needs and implement innovative approaches to advance community health, wellbeing, and equity. We are among the community partners supporting the Minnesota Homeless Study, a point-in-time study by Wilder Research that collects single-night counts of people experiencing homelessness across the state. Fairview also works with Wilder on the triennial Minnesota Reservation Homelessness Study. The study is conducted in partnership with six American Indian reservations in Minnesota. Fairview has had representation on the planning team and provided financial sponsorship for the Bridge to Health Survey. The survey has been an important source of data on the health status of adults in northeastern Minnesota and Douglas County, Wisconsin, for more than two decades. We have been involved in and supported collaborations particularly related to data and assessment in the medical center and children's hospital community. For example, Fairview staff participate on the Highrise Health Alliance housing team convened by the Minneapolis Health Department and the Minneapolis Public Housing Authority (MPHA). Staff are also a part of the Hennepin County Community Health Improvement Partnership (CHIP) is a coalition of partners from across the community using a collaborative approach to improving people's health. CHIP is committed to equity and informed by data and is focused on community mental well-being and housing stability.
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Facility , 2 - Fairview Ridges Hospital. Our overall engagement approach is guided by four key considerations: 1. Fairview is focusing on building and deepening our engagement infrastructure, putting structures in place that will guide our long-term community engagement efforts. 2. We must implement tactics that gather both breadth and depth of engagement, bringing as many community members as possible into the conversation and yet also seeking to develop a deep understanding of nuances within each need. 3. Our priority needs are systemwide, and we approach our assessment process from a system level. However, each local community Fairview serves is unique, and we recognize, honor, and prioritize local nuances - in context, in populations, and in our understanding of both - so we can respond most appropriately within each locality. This dual system/local approach enables us to maximize our efforts' impact across the region we serve. 4. As we look to our local communities and seek to meet them where they are, we benefit from engaging with multiple perspectives: those of our community members, our patients, and our employees. To do this, we must take into consideration a variety of approaches, modes, and preferences to best fit the needs of these three groups. As we build our multiyear assessment engagement approach, having a single guiding model of community engagement helps us maintain alignment across the organization as we plan and conduct our work. The Center for Community Health Equity engagement spectrum, based on the International Association for Public Participation's Spectrum of Public Participation, was collaboratively developed through interviews with local organizations, community members, Fairview employees, and other stakeholders. Our engagement spectrum depicts five progressively more intensive levels of community engagement: inform, consult, involve, collaborate, and community led. The model includes examples of each level of community engagement, to clarify what each level could look like in practice. It is important to recognize that no level is inherently better than another level - a more intensive engagement is not appropriate in all situations. Rather, each level is equally valid and appropriate for certain activities and at certain times. During our current assessment process, we used the Center for Community Health Equity engagement spectrum to help ensure that we are using strategies and tactics across the spectrum. Our intent is to build the capacity of stakeholders, community organizations, and other influencers to partner with our health system most effectively, enabling them to promote their community's interests to improve the broader community's health and wellbeing. Using the engagement spectrum as a model goes beyond merely incorporating community voice into Fairview's priority need areas. Its goal is to guide and frame co-development of community engagement activities and guide our implementation planning. The phrase "engagement infrastructure" refers to the mechanisms through which we are sharing and receiving bidirectional feedback on an ongoing basis. Like our hospital's physical infrastructure, our engagement infrastructure is composed of enduring, permanent parts of our health system. We are continuing to build a community engagement infrastructure that supports trusting partnerships and enables community voice to inform and influence the organization. Each hospital community has a Local Community Advisory Committee. We have been committed to and honored with a bidirectional, long-term commitment from our local community advisory committees, which have existed in various iterations for over 30 years. The local community advisory committee's role is to: Advise and inform health improvement plans and collaborative programs. Guide local insight and voice for CHNAs and action plans. Monitor progress toward the goals outlined in the CHNA implementation strategy. Review the local CHNA report. Each committee comprises members from, or representatives of, groups such as public health departments, medically underserved communities. communities experiencing poverty, populations experiencing health and/or racial disparities, community-based organizations, and schools. The System Community Advisory Council spans the entire health system and incorporates the need for internal representation, local representation, and representation from organizations that represent our priority populations. Its role is to: Advise the health system on the CHNA process and prioritization model from a systemwide perspective. Guide health system insight and ensure the voice of priority populations remains at the center of all discussions. Provide guidance and expertise in development of implementation strategy plans. Employee Resource Groups (ERGs), are voluntary, employee-led groups that aim to foster a diverse, inclusive workplace. They focus on impacting four important areas: community connection, organizational impact, meaningful change, and people development. ERGs supported the CHNA process by providing feedback and suggestions and supporting dissemination and recruitment of the data and engagement approaches. There are currently nine ERGs representing different affinities. Patient Family Advisory Councils bring together patient and family advisors along with staff to share insights and experiences to help Fairview improve. These committees help validate the current state, understand existing obstacles, and test ideas to overcome those barriers. During this CHNA cycle, our Patient Family Advisory Committees consulted on ways to approach community conversations, specifically our Town Halls. The process of centering community voice enables us to use the CHNA process to bring the perspectives of the communities we serve back to the organization in an actionable format. By using various data gathering methodologies, we gain a better understanding of the top barriers and concerns among the people we serve. This process is also a crucial avenue for adding nuance, understanding how our communities' needs shift among different geographical areas, generations, and cultural communities. Listening and learning sessions: Fairview has held community listening and learning sessions through the HOPE Commission since 2020. These sessions hold a mirror to Fairview, assessing where we are today and helping us understand how we can make lasting change. Sessions were held in 2020 to hear from employees, in 2021 and 2022 to hear from patients, and in 2023 and 2024 to hear from community members. In June 2022, after identifying a gap in participants from previous listening and learning sessions, we expanded these listening and learning sessions to include patients with limited English proficiency. Sessions were held in Somali, Spanish, Hmong, Karen, and American Sign Language. Prior to these sessions, there were limited mechanisms for patients with limited English proficiency to provide feedback about the care they were receiving. This series was an effort to bring more voices to the table and create inclusive opportunities for patients to express their needs and concerns.
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Facility , 3 - Fairview Ridges Hospital. Systemwide virtual conversations: We held a series of systemwide virtual conversations focused on the priority need healing, connectedness, and mental health and what that specifically looks like for youth (April 2024), aging adults (March 2024), and Indigenous populations (June 2024). These conversations were open to all, and their goal was to collect and share learnings and resources with participants. The conversations included presentations from community partners about their work, followed by small group discussions that provided valuable perspectives informing our understanding of population-specific needs, strengths, and future state visioning tied to healing, connectedness, and mental health. CHNA surveys To gather input from a broad set of stakeholders on local strengths and the top needs of communities each of the respective stakeholders serves, we developed two aligned, but distinct, surveys. The surveys gathered feedback about: Patient and community members' top barriers to care, social determinants of health needs, and social needs. The unique barriers and assets for patients in one of our priority populations (racial or ethnic populations experiencing health disparities and people experiencing poverty). Barriers that providers and community partners face in responding to the social determinants of health-related needs of patients as well as existing assets and resources available. The surveys were distributed to care team members and partner organizations, including faith leaders. Surveys were administered from mid-February to the end of March. We heard from 472 individuals across our hospital communities and our health system, with 296 responses from care team members and 176 responses from community organizations. Community Health and Healing Summit: Celebrating Culture, Building Connections, Guiding Action - The Community Health and Healing Summit, held in July 2024, aimed to propel our 10-year vision for a healthier Minnesota forward. The summit was a collaborative event bringing stakeholders together to work collectively on prioritizing needs and barriers to health in our communities. It blended the power of community and cultural healing with activities designed to collect participants' insights to not only shape our priorities but to actively drive positive change in our communities. Stakeholder interviews: From May to July 2024, we conducted stakeholder interviews with various Fairview care team members in both acute sites and clinics, including nurses, physicians, schedulers, social workers, care coordinators, and clinic managers. The interviews were guided by the results of our CHNA survey and aimed to gather more in-depth information and stories about the top barriers that had showed up most frequently during the survey. Facilitated conversations: We conducted a variety of facilitated conversations across the health system, a few examples of which are summarized in this section. The goal of these activities is to gain a fuller, more nuanced picture of topic-specific or population-specific perspectives over time. By holding these conversations on an ongoing basis, we ensure that our assessment process and our aligned programmatic or initiative-related work is responding to and engaging with communities in real time. Food is Medicine community conversations: As a part of our Food is Medicine initiative, we partnered with community-based organizations to host a community conversation in each hospital's service area. The goal was to learn more about the community's needs and strengths related to access to healthy food and the role of Fairview as a healthcare provider. In the fall 2023, we held eight Food is Medicine community conversations across different hospital geographies that were attended by 75 organizations representing sectors across the food scape including food shelves, farmers, social services organizations, schools, and municipalities. Town halls: In November and December 2023, we hosted five town hall sessions that were open to the public and geared toward local government relations offices, the business community, community-based organizations, trade groups, civic groups, and rotaries. Each town hall provided an opportunity for community members to receive updates from Fairview, participate in a question-and-answer session with Fairview leaders, and engage in discussions regarding barriers to health and trust in healthcare organizations. East Side Health and Well-being Collaborative: In February 2024, we joined the East Side Health and Well-being Collaborative's meeting as well as the collaborative's mental health and stress resilience work group meeting. In both meetings, we held facilitated conversations about the CHNA process and priority need areas in the community. During the meeting with the mental health and stress resilience work group, we focused on the healing, connectedness, and mental health priority area. Through ongoing partnership and programmatic conversations, we are vetting and refining our understanding of the identified priorities and the responses that would best address them. As a foundational part of program planning and evaluation, Community Advancement staff members are continuously soliciting feedback from community partners and program participants. We capture this information on an ongoing basis and use it to provide valuable context, driving insights into the needs of the communities we serve. Primary data methods: Fairview staff developed standardized tools, processes, instructions, protocols, and training for facilitators, interviewers, and note takers. We compiled, cleaned, and analyzed all primary data. A note taker captured all community input, and when possible, conversations were also recorded. Secondary community data: Claritas is a widely used national demographic estimation tool. Estimates and projections are provided at a zip code level including, but not limited to, population based on age, sex, ethnicity, and income. Spark Maps is a paid subscription that provides mapping and assessment tools that include a large database of indicators, data cleaning, benchmarking, and contextual information. The Bridge to Health Survey has been an important source of data on the health status of adults in northeastern Minnesota and Douglas County, Wisconsin, for more than two decades. The survey is conducted every five years, with the last survey administered in 2020. The Minnesota Student Survey is one of the longest-running youth surveys in the nation. It is a triennial survey that began in 1989. The data used in this report is from 2019. The Area Deprivation Index (ADI) is based on a measure created by the Health Resources and Services Administration over three decades ago, and has since been refined, adapted, and validated to the census block group neighborhood level by Amy Kind, MD, PhD, and her research team at the University of Wisconsin - Madison. Health Trends Across Communities in Minnesota (HTAC) uses information from electronic health records to help fill gaps in the information available to health professionals, organizations, policymakers, and community members to promote health in Minnesota. HTAC is a collaboration among health systems, public health departments, health organizations, and health plans in Minnesota. HTAC uses summary reports from electronic health records on a range of chronic, behavioral, and mental health conditions. The information comes from 11 health systems that make up the Minnesota Electronic Health Record Consortium (MNEHRC). Information from the MNEHRC represents approximately 90% of healthcare for Minnesotans, which makes HTAC a powerful tool to describe the health of many communities. Minnesota Department of Health, County Health Tables were used to look at 2020 county-level top causes of death and premature death.
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Facility , 1 - Fairview Ridges Hospital. The Community Health Needs Assessment Report for Fairview Ridges Hospital are located at: https://www.fairview.org/-/media/Files/Local-Health-Needs-Final/2024-CHNA-Report_Ridges-Hospital_Final.ashx The Community Health Needs Assessment and Implementation Strategy for Fairview Ridges Hospital are located at: https://www.fairview.org/-/media/Files/Local-Health-Needs/CHNA-Implementation-Strategy-Reports-2025/CHNA-Implementation-Strategy-Report-20252027Ridges.ashx
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Facility , 1 - Fairview Ridges Hospital. . Our triennial Community Health Needs Assessment (CHNA) process provides an important opportunity to engage with and understand our community, analyze what has changed since the last assessment, and prioritize together with the community the issues we must urgently address to improve wellbeing and resilience. As part of the 2021 CHNA process, we reexamined and built upon the extensive community insights shared during our 2018 CHNA, while also surveying the community for current and emerging needs . This work continued in 2024 as we conducted our triennial assessment, further exploring the barriers experienced by community that tie to priority needs. Our 2021 CHNA used social determinants of health (SDOH) as a lens through which we frame our understanding of our community's most significant health needs. A social determinants of health lens enables us to identify inequitable distribution of resources and access that negatively impacts health. Through this lens we looked at both qualitative and quantitative data. Quantitative data included data points related to demographics, physical environment, socioeconomic factors, healthcare, and health outcomes. We collected additional community voice data by convening a broad array of stakeholders, with special focus on the priority populations - racial or ethnic populations experiencing health disparities and persons experiencing poverty. Ridges Hospital has a community advisory committee (CAC) that is involved in the CHNA process. The committee is comprised of local community and organizational leaders, such as local public health entities, social services organizations, higher education institutions, school districts, and local businesses. The assessment process also included discussions with our community advisory council, listening and learning sessions, and key stakeholder interviews. Throughout this process, community members, local business leaders, government representatives, nonprofit and community organizations, and content experts shared their voices and perspectives about their community's health needs. By bringing together both the qualitative and quantitative data, we established a prioritization process through which we could identify the community health needs that, if effectively addressed, would have the greatest positive impact on our communities and particularly on our priority populations. We prioritized areas of need based on four broad criteria: 1) Has this need been voiced by the community? Has this need been vetted by the community? 2) Does this need align with Fairview's strategies and priorities? 3) Does this need align with existing public health strategies and community health assessments? 4) Does this need build upon Fairview's 2018 CHNA priority needs? Ridges Hospital identified three system-wide priority need areas, and will collaborate with other Fairview hospitals, medical centers, and shared business and clinical services to address these priorities. Our specific response varies by hospital based on the ways the priority needs manifest across a given community, as well as the partnerships-both ongoing and new-that we have developed to address those needs. The three identified needs are: 1) Navigating and accessing care and resources, 2) Addressing structural racism and barriers to equity, and 3) Healing, connectedness, and mental health. Development of 2022-2024 CHNA Implementation Strategies As a healthcare organization that works closely with our community advisory committees and community partners, we have listened to community and learned valuable lessons over the past few decades. This has guided us in the development of the Fairview Health Services 2022-2024 implementation strategies. In particular, we learned that: 1) Despite best efforts, health needs and health inequities continue to grow and deepen, 2) Collective action is critical, and 3) Transformational change requires a sustained and focused commitment. In response to our 2021 Community Health Needs Assessment, Fairview hospitals and medical centers worked collaboratively with local and statewide organizations to address our communities' most pressing needs. In addition, Fairview put forth a 2032 vision of increased community health equity. This vision is supported by three strategies designed to address the priority need areas in distinct ways while collectively moving us closer to achieving our goals. The three strategies are: Strategy 1: Addressing Social Determinants of Health (SDOH) - Addressing the SDOH, individual social risks, and social needs through the creation and expansion of programs, initiatives, collaborations, and research, as well as policy, system, and environmental work. Strategy 2: Community engagement infrastructure - Creating a community engagement infrastructure that builds trusting partnerships and enables community voice to inform and influence our health system. Strategy 3: Inclusive institution - Transforming internal structures to create an antiracist and inclusive environment and to build community health by building community wealth. For this three-year cycle, we are implementing strategies to work toward distinct, anticipated impacts for each priority need and to build upon our 10-year vision of increased community health equity by 2032. For more information, the Ridges Hospital CHNA Implementation Strategy Report outlines the major strategies and actions we will deploy throughout the 2022-2024 assessment cycle as well as the ties between the Ridges Hospital CHNA implementation strategies, anticipated impacts, and key responses. Fairview's mission and vision extend beyond traditional healthcare settings, driving a healthier future for the communities we serve. Significant efforts towards Strategy 1 (Addressing SDOH) occurred over the first three years of our 10-year vision. These efforts are demonstrated through three social determinants of health initiatives: 1) Food is Medicine: Using the healing power of food to nourish our patients, enrich our communities, and transform our systems, 2) Housing is Health: Using the protective power of housing to support patient health and build thriving communities, and 3) Connection is Cure: Strengthening the connection between patients and the healthcare system to address social isolation and improve community mental health and wellbeing. These initiatives are key responses that intersect all three priority needs and are also synergistic. Relationship with our partners. Fairview has a long partnership with the University of Minnesota and University of Minnesota Physicians, now represented in the M Health Fairview brand. Together, we offer access to breakthrough medical research and specialty expertise as part of a continuum of care that reaches all ages and health needs. Policy, systems, and environmental change initiatives are implemented across the health system (hospitals, clinics, specialty care) and in some instances, across the M Health Fairview partners, to create sustainable and lasting change to advance health equity and community wellbeing. Where indicated, community responses as a part of Strategy 2 (Community engagement infrastructure) and Strategy 3 (Inclusive institution) represent the work of Fairview in collaboration with the other M Health Fairview partners. Community action plan. Ridges Hospital has an annual CHNA action plan that supports our vision of increased community health equity, rolls up to our system CHNA implementation strategies, and addresses priority needs. The Fairview Health Services Community Action Plan details the specific and measurable steps we will take during the year to drive change. Program lists by hospital can be found in the appendix. The System Community Action Plan is updated annually and includes impacts from previous years.
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Facility , 2 - Fairview Ridges Hospital. Evaluation of impact. To best evaluate our impact and track progress towards our anticipated impacts, we use a multi-tiered and tailored evaluation approach. Our work is grounded in understanding core information about our communities. This includes identifying and understanding the community needs being addressed, the population or community being affected, current and/or potential partners to work with to address the need, and the impacts we anticipate. Community needs are determined in several ways. In addition to being determined through our formal CHNA process, we respond to emerging needs brought to us by community partners or public health, or those discovered through patient or community data showing significant health disparities. We have standardized several key measures to assess whether we are meeting the needs of the CHNA priority populations, focusing our efforts on equity and participant satisfaction. A subset of established programs and initiatives are set up and supported for deeper evaluation. We have found that one-size-fits-all, evidence-based approaches may not be a good fit for some of our diverse communities. In response to the unique and differing needs of our community members, our programs are co-developed with community, center on the needs of specific populations, and often incorporate unique local tactics. We approach evaluation from a similar perspective by building evaluation approaches informed by our partners and considering strategies that are culturally and linguistically appropriate, allowing us to determine if the programs reflect the values we set out to embody. Fairview is guided by the Centers for Disease Control and Prevention (CDC) model for program evaluation, establishing primary outcomes, process measures, and demographics. We evaluate program impact and success from a variety of approaches using both qualitative and quantitative data. For many of the programs described here, we are reporting our reach or outputs through counts on a variety of levels that meet the rigor required for grant and contract reporting. In addition, we offer a diverse set of programs that vary on the spectrum of "low touch and high count" to "high touch and lower count." More generally put, the effort and impacts of the programs are not the same. This is a purposeful approach as we want a variety of programs that are appropriate to address the community and population-specific needs. We provide outcomes for programs here when we are able, acknowledging not all programs run on a calendar year, and analysis may not be complete for some of the programs on which we do deeper evaluation. Fairview is currently in the process of building an evaluative approach and capacity for our 10-year vision, increasing community health equity, and our three social determinants of health initiatives: Housing is Health, Food is Medicine, and Connection is Cure. Part of this evaluative approach is a monthly social determinants of health dashboard. Ridges Hospital 2024 Implementation Strategy Progress Highlights. The following highlights our implementation strategy work for each of our three priority needs. In this first three-year CHNA cycle working towards our 10-year vision of increased community health equity, the primary way we are directly addressing the three priority needs is through Strategy 1 (Addressing SDOH). Through this strategy, we create programs and partner with community organizations to address social risk factors, social needs, and social determinants of health. Strategy 2 (Engagement infrastructure) and Strategy 3 (Inclusive institution) focus on building infrastructure and creating system changes so that we can more effectively respond to these priority needs in the future, as well as any emerging needs. Strategy 1 - Addressing Social Determinants of Health (SDOH) Priority Need: Navigating and accessing care and resources. Ridges Hospital has a variety of programs that work as a part of Strategy 1 (Addressing SDOH) to address barriers related to navigating and accessing care and resources. Through this strategy, the Ridges Hospital Action Plan programs work towards two anticipated impacts to address this priority need: 1) Remove barriers to care by providing community-placed care, co-located services, and navigation supports that address cultural and language barriers and 2) Increase awareness of, knowledge about, and access to healthcare and community-based resources that support opportunities for health and wellbeing. The following is more information on a selection of programs from the system community action plan that are working to meet the two anticipated impacts. Fairview s System Key Initiative Highlights. The Community Clinical Care initiative involves multiple community-based clinical programs, including Fairview's Minnesota Immunization Networking Initiative (MINI), blood pressure checks, and oral health services. All services are multi-sector, community collaborations that provide care and education to the uninsured, under-served, and communities facing health disparities in the greater Twin Cities area. The Community Clinical Care team provides clinical care in trusted community settings at no cost and improves equitable access to vaccines and other services across various populations. The programs ensure a culturally and linguistically appropriate experience in a safe and trusted environment in partnership with over 250 faith-based and grassroots community partners, serving clients at local churches, mosques, temples, schools, community centers, food pantries, and homeless shelters. Across the system in 2024, the community clinical care team provided blood pressure and oral health services at 241 events, including 1 event in the Ridges Hospital community, providing 418 blood pressure checks, and 696 dental fluoride applications. The team also hosted 443 vaccination clinics across the system in 2024. There were 5,525 free COVID-19 vaccine doses and 6,190 free flu shots administered. Of those participants who shared their identity, 72% of people who received a COVID-19 vaccine identified as a person of color and 35% indicated a language other than English as their preferred language. In the Ridges Hospital community specifically, there were 7 MINI clinics at which 36 COVID-19 shots and 185 flu shots were administered. In August 2024, MINI received an invitation to publish an article in the special Public Health issue of the New England Journal of Medicine discussing their cross-sectoral, equity-based approach to COVID-19 response. Later in the year, they published a similar article in the Journal of Public Health Management & Practice, this time focusing specifically on reducing vaccination barriers for refugee, immigrant, and migrant communities during the COVID-19 pandemic. MINI also presented at the 2024 North American Refugee Health Conference. To fill the large gap in the South Metro, our Apple Valley Clinic provides free clinical space, supplies, and lab services one day per week to St. Mary's Health Clinic to provide clinical services to uninsured community members. Fairview's financial, logistical, and infrastructure support allows St. Mary's Health Clinic to successfully provide services in the South Metro area. The Colon Cancer Prevention program provides community education on colon cancer prevention, outreach, and recruitment of uninsured individuals to have colonoscopy procedures. Communities served are identified based on disparate colorectal cancer screening rates compared to the state rate. Education and outreach are provided by a Community Health Worker (CHW) across multiple community locations. CHW assesses people who indicate interest in having a colonoscopy procedure at no cost based on program criteria: Age 45-75 or in a group at higher risk for colon cancer, do not have medical insurance, and live anywhere in Minnesota. In 2024 there were 35 colonoscopies provided to uninsured community members in the Ridges Hospital community. The Culturally Tailored Education and Outreach Program provides health education sessions on a variety of health topics including COVID-19 vaccines, COVID-19 virus, colorectal cancer prevention, cancer prevention, diabetes prevention, heart disease prevention, mental health, Alzheimer's disease, heat-related illness, and other health topics. Education provided to the general Latine community. In partnership with community organizations. In 2024 in the Ridges Community, there were 17 education sessions with 468 people attending.
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Facility , 3 - Fairview Ridges Hospital. The Fairview Community Health and Wellness Hub (The Hub) opened in 2022. The Hub is a first-of-its-kind center that addresses health disparities while providing a range of critical healthcare services and community resources alongside trusted local partners. The Hub provides a variety of services to the community, including primary care, mental healthcare, enrichment options for seniors, food access programs, and community gathering spaces. We bring our own services together with local organizations to make it easier for people to access what they need to thrive. Throughout the year, 7,090 individuals attended 176 events or meetings at the Hub. Eighty-three of the events were public and partner events, reaching 3,263 individuals. Ninety-three events were internal Fairview events. Additionally, we hosted nine Hub Partnership Coordination Meetings, as well as one-on-one check-ins with each of the partners. These meetings serve to deepen our understanding of the diverse missions, visions, and impacts of each Hub partner, fostering better alignment and collaboration. In 2025, we plan to transition to quarterly in-person partnership meetings. This strategic move aims to enhance our collaborative efforts and drive impactful initiatives. The Cultural broker program was co-developed in 2016 in partnership with Fairview's East Side Health and Well-being Collaborative. Cultural brokers help bridge cultural gaps through supporting individuals and families as they navigate schools, healthcare, and other mainstream systems to ultimately build self-sufficiency. The cultural brokers identify with the racial and/or ethnic communities they serve, so they can more easily build trust and have a greater impact on the communities' health. The program comprises six cultural brokers who are Fairview employees located at five respective partner organizations representing different cultural communities: African American, American Indian, Hispanic/Latino, Hmong, and Karen. Across the system, cultural brokers served 510 new clients total, resulting in 4,431 encounters. In the Ridges Hospital community, they served 8 new clients. In 2024, we continued to expand our work relating to opioid overdose prevention in partnership with the Steve Rummler Hope Network. Fairview's Community Clinical Care team trained several staff members to become naloxone educators, who can then train others. Educators train community members on how to recognize an opioid overdose, what naloxone (Narcan) is and how it works, how to administer naloxone to someone experiencing an overdose, and information about Steve's Law/MN's Good Samaritan and Naloxone Law. In total, there were 39 naloxone trainings where 944 individuals were trained in 2024. In addition, Fairview opened a fourth naloxone access point (NAP) site that provides free kits, extending this important resource to Greater Minnesota. NAP sites are stocked with nasal Narcan and intramuscular naloxone kits, many of which are packed at Fairview volunteer events. In 2024, 12,995 such kits were packed and distributed across our hospital communities. The Community Clinical Care team plans on opening several additional NAP sites in 2025. Fairview hired two Food Resource Navigators in 2024, exemplifying the intersection of Strategy 1 (Addressing SDOH) and navigating and accessing care and resources. Food Resource Navigators serve as experts both in Fairview's Food is Medicine programs, as well as community food resources and government programs such as SNAP and Market Bucks. Rolled out in select clinics across the system, Food Resource Navigators receive clinical referrals when a patient screens positive for food insecurity and expresses interest in being connected with additional support or resources. In 2024, our Food Resource Navigators received 561 referrals across the system, including six from the Ridges Hospital service area. Of those referrals, 84% of individuals were connected with internal and/or external resources. Over the next several years, this role will be expanded to additional clinics. In this way, we can support patients in navigating the complex landscape of healthcare and social services. Priority Need: Addressing Structural Racism and Barriers to Equity. Ridges Hospital, in alignment with Strategy 1 (Addressing SDOH), has a variety of programs, events, and community education as a part of the Community Action Plan that work toward the anticipated impact: Develop, grow, and sustain programs, educational offerings, partnerships, and initiatives to address structural racism and barriers to equity. Fairview System Key Initiative Highlights. One of the Fairview social determinants of health initiatives, Food is Medicine, utilizes the knowledge and resources of a large healthcare institution to work towards meeting the immediate needs of our patients, while also transforming the food system into something just, equitable, and sustainable. The initiative aims to 1) Nourish our patients: Advance food security to reduce health disparities and diet-related health conditions. 2) Enrich our communities: Cultivate trusting and engaged partnerships to build and share resources, assets, and capacity. 3) Transform our systems: Nurture just and equitable food systems to ensure health equity. These approaches are framed to increase health equity through focused efforts to serve patients who have been historically marginalized by providing culturally appropriate food options and reducing food insecurity in a manner that upholds dignity and empowers the local food system. Clinically, it enables providers to serve patients experiencing food insecurity through a menu of distinct programs comprising an innovative wrap-around approach. One or more of the Food is Medicine programs-a selection of which are described below-are available to patients in 52+ clinics and 8 acute sites across the health system. One of the Food is Medicine initiative programmatic responses is the fresh food prescription program, which distributes fresh, locally grown produce from three farm partners (Hmong American Farmers Association, Naima's Farm, and Women's Environmental Institute) via a weekly food box. The boxes also contain proteins, whole grains, and pantry staples, as well as a newsletter with community resources and tips for healthy cooking and eating. Crucially, the program offers home delivery to address transportation barriers. In 2024, 31 clinics participated in the fresh food prescription program across Fairview hospital and medical center communities, five being in the Ridges Hospital community. Almost one third (31%) of program participants identified as Asian, 17% as Black, and 2% as Hispanic/Latino. While just 70% of participants speak English as a preferred language, 7% had a preferred language of Hmong, 14% Karen, and 1% Spanish. Most participants had public insurance (79%) or were uninsured (2%). Fairview's food voucher program provides patients with vouchers to redeem at either the Twin Cities Mobile Market or Fare for All program. The program runs year-round and offers rolling enrollment. Throughout the year, 443 patients redeemed vouchers for groceries, including 91 from the Ridges Hospital community. Additionally, we provide shelf-stable food resources for those with an immediate need. The shelf-stable food bags were incorporated into Ridges Hospital for the first time in 2024. The bags come in six different varieties tailored to meet the preferences of diverse cuisines and circumstances. In 2024, there were 6042 shelf-stable bags distributed at 37 sites across the system. There were also 258 food resource packets distributed that contained information about local food resources along with immediate food support.
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Facility , 4 - Fairview Ridges Hospital. In November 2024, Fairview and local partners hosted the third annual Harvest at the Hub, welcoming 312 households to the Fairview Community Health and Wellness Hub. The event consisted of a food giveaway with turkeys, fresh produce, and other holiday staples, a community resource fair, a vaccine clinic, and other health and wellbeing services. Another of the Fairview social determinants of health initiatives, Housing is Health also responds to the priority need of structural racism and barriers to equity . The Housing is Health initiative aims to use the protective power of housing to support patient health and build thriving communities. We approach this initiative with clinically connected programs, supportive community partnerships, contribution of time and expertise to collaboratives, and efforts to impact policy. For example, Fairview partners with Our Saviour's Community Services to provide critical follow-up care and temporary housing for people who are unsheltered after a hospital stay. Patients are referred by staff at a hospital or medical center and sheltered at Our Saviour's. Additionally, a nurse provides care, and patients receive wrap-around services and social work support. In 2024, 50 patients were provided support through this program. As a part of Housing is Health, we are also proud to have helped launch Healthcare for Housing (HC4H). HC4H grew out of the Housing and Health Equity Fellowship and consists of seven health providers and payers. We also strengthened our housing advocacy activities in 2024; we chaired the policy workgroup for HC4H, participated in Homeless Day on the Hill at the Minnesota State Capitol, and submitted letters of support for multiple housing initiatives. In September and October 2024, teams from across the system participated in two Twin Cities Habitat for Humanity builds. Volunteers contributed 300 hours for the Carter Work Project build. During our annual build week with Twin Cities Habitat for Humanity, staff contributed 560 volunteer hours. Priority Need: Healing, Connectedness, and Mental Health. Ridges Hospital works toward the anticipated impact: develop, grow, and sustain programs, educational offerings, partnerships, and initiatives, address barriers to healing, connectedness and mental health through Strategy 1 (Addressing SDOH) and the Community Action Plan. Fairview System Key Initiative Highlights. In response to the priority need of healing, connectedness, and mental health, we have a body of work that makes up the Connection is Cure initiative. Connection is Cure aims to build trust through social connections, center linguistic and cultural diversity, and bridge silos across our hospital system and communities to transform medical practice. As a part of Connection is Cure, we hosted virtual conversations in 2024 around how we can improve mental health services for specific populations: Native patients, youth, and older adults. Three conversations were held-one for each respective population-reaching a total of 108 community members. Other gatherings fostering healing, connectedness, and mental health were held in 2024 as well, including a Heal the Healers event. Exemplifying the integration of traditional healthcare with ancestral and cultural practices, the Heal the Healers event united local healers and caregiving professionals for a transformative day of self-care, learning, and the revival of ancestral practices. Our goal was to empower practitioners and community workers with activities that foster self-care, ensuring they remain strong and resilient for the communities they serve. This and other healing events laid the groundwork for the Community Health and Healing Summit, convened as part of our innovative approach to the Community Health Needs Assessment. Over 100 participants gathered for a day of learning about the health conditions in their local communities, seeking to understand the efforts of the system and collective community in addressing these issues. For many attendees, the event also served as a welcoming introduction to cultural and non-traditional healing practices; individuals had the opportunity to experience these practices firsthand while learning about their application within the community and our health system. As part of our commitment to addressing barriers to healing, connectedness, and mental health, we also launched our Birth Justice Initiative, a cross-departmental effort to advance equity and inclusion in birthing experiences. Focused on eliminating racial bias in maternal healthcare and improving patient outcomes, the Birth Justice Initiative is making systemic changes to improve the quality of healthcare for all pregnant persons. Their research and advocacy led to the removal of race-based maternal health screening tools, which have the potential tounintentionally introduce bias into medical decision-making. Additionally, part of the design of a new prenatal and postpartum clinical care map includes screening all pregnant patients for social determinants of health and lead exposure, empowering healthcare providers to act early to address these concerns. In 2024, departments participating in the Birth Justice Initiative interviewed 649 people who gave birth in the Fairview health system and gathered input from doulas. Based on their feedback, we plan to rewrite policies to enhance culturally congruent care, tailoring maternal healthcare to the specific cultural values of each patient. Additionally, we are responding to the need for healing, connectedness, and mental health with a variety of evidence-based programs, as well as trainings and education sessions. Feeding Hope is a series of virtual one-hour learning sessions focused on positive, hopeful topics that support wellbeing in the general community. This series is offered in partnership with all of Fairview's hospitals and medical centers and is open to anyone across all of Fairview's communities. In 2024, across Fairview hospitals and medical centers there were two sessions held with 60 attendees total. Psychological First Aid is an evidence-informed training for the broader community as well as professionals. Trainees learn how to support healthy recovery for individuals following a traumatic event, public health emergency, natural disaster, or personal crisis. The curriculum integrates public health, community health, and individual psychology by drawing upon skills the trainees probably already have. Psychological First Aid is a two-hour training. In 2024, in the Ridges Hospital community, there were 4 classes offered with 104 participants attending. A Creative Look at Self-Care (formerly Refresh and Reset your Resiliency) promotes resiliency skills, offers wellness-care tools for mind, body, and spirit, and encourages the development of a personal plan for self-care. In 2024, in the Ridges Hospital community, there was one class offered with 9 participants attending. Together, Fairview's Strategy 1 (Addressing SDOH) initiatives and the programs outlined within our action plans comprise a strategic, innovative, and equity-minded approach to community health. We take great care to co-design programmatic responses with the communities impacted by them and collaborate with a broad range of community organizations and other multisectoral partners to address the social determinants of health. In recognition of our commitment to this work, Fairview advanced as a finalist for the American Hospital Association's Foster G. McGaw Prize. Five programs were profiled in Fairview's award submission: Minnesota Immunization Networking Initiative; East Side Health and Well-being Collaborative; Fair Table, Fairview's Food is Medicine initiative; Health Commons; and our Cultural Broker program. It is a great honor to be considered for this award; it serves as motivation to work harder than ever to advance health equity, and to intentionally do so in authentic partnership with the communities we serve. In addition to Strategy 1 (Addressing SDOH) and the programmatic work included on our Action Plans, we strive to reduce health disparities and increase community health equity through two additional system strategies. While Strategy 1 (Addressing SDOH) allows us to directly respond to the three prioritized needs from our community health needs assessment, Strategy 2 (Engagement infrastructure) and Strategy 3 (Inclusive institution) focus on building the structures and systems for us to do the work more capably.
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Schedule H, Part V, Section B, Line 11 Facility , 5
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Facility , 5 - Fairview Ridges Hospital. Strategy 2 - Engagement Infrastructure Addressing our three priority needs while also responding to emerging needs requires an infrastructure that supports building and sustaining strong community partnerships and allows for ongoing, trusting exchanges between Fairview and community members. The importance of this is manifest in Strategy 2 (Engagement infrastructure): Creating community engagement infrastructure that builds trusting partnerships and enables community voice to inform and influence the institution. The anticipated impacts for this strategy are: 1) Build and expand feedback systems for patients and community members; embed process improvement in the health system's response to community voice and 2) Create sustainable structures to convene and engage community voice around addressing social determinants of health. While Fairview boasts an extensive engagement infrastructure already, we continued to bolster the work we do to expand feedback systems and sustainable convening structures. Core to this is building and sustaining trusting partnerships. Our Ridges Hospital Community Advisory Committee (CAC) met through the year to offer input and provide local insight and expertise. Notably, 2024 marks the first year since the COVID-19 pandemic in which we convened our CACs in-person, celebrating the joy of being together in the same room and the spirit of collaboration that it fosters. To enhance the work of each hospital CAC, in 2024 we revitalized our System Community Advisory Council. Spanning the entire health system, the System CAC incorporates the need for internal representation, local representation, and representation from organizations that represent our priority populations. While it plays a large role in advising the CHNA process and implementation, it also ensures the voice of priority populations remain at the center of all discussions and decisions. The System CAC met five times in 2024, providing guidance and insights throughout the Community Health Needs Assessment process. A central part of our community voice work and philosophy, the M Health Fairview Center for Community Health Equity (the Center) was launched in August 2022. The Center guides our efforts to gather community voice and tie the learnings back into the organization. Throughout 2024, we hosted three Center Community Health Equity Work Group meetings to hold strategic discussions on issues of relevance to the center. The Center for Community Health Equity also presented a session at the 2024 American Hospital Association's annual conference . This session focused on the lessons we learned from conducting community input sessions for community members with limited English proficiency, giving us the opportunity to socialize best practices and learn from the experiences of other healthcare systems. Over the course of the year, the Center continued to build out its SDOH platform and community engagement framework, guiding the implementation of the 2024 Community Health Needs Assessment approach. Community Health Needs Assessments - 2024 Enabling community voice, particularly the voices of priority populations, to influence and inform the health system is integral to Strategy 2 (Engagement infrastructure). In 2024, the Center for Community Health Equity and Fairview's Quality Improvement team began a joint enterprise to incorporate community voice into the way in which we define, implement, and measure healthcare quality. Members of the East Side Health and Well-being Collaborative and the System Community Advisory Committee gave input regarding what "quality "quality care" means to them, informing the development of the system's ambulatory care composite (high priority quality measures). The priorities yielded by their insights will drive organizational work for the next several years as we work to deliver the highest quality of care to our patients and community. Building our engagement infrastructure involves connecting broadly with community as well as building our capacity to engage with complex and intersectional groups. We are building a set of population health equity initiatives, one of which is the Native Health Equity Initiative (NHEI). As part of this body of work, in 2024 Fairview staff stood up the Indigenous Healing Circle Employee Resource Group to create sacred space for Native employees and patients and reconcile disparities unique to our Native relatives. Fairview also developed a system-wide land acknowledgement to raise awareness of how inequities have impacted the geographies and people we serve and guide us in our work to advance equity and inclusion. The land acknowledgement was published in our 2024 Community Health Needs Assessment report. Throughout our Native health equity efforts, we also hosted a Healing in Four Directions Powwow for more than 350 community members from across the state with partners including St. Paul Public Schools Indian Education, South St. Paul Public Schools Indian Education, Minnesota Indian Affairs Council, and the American Indian Family Center. Later in the year, we participated in the 2024 American Indian Day on the Hill and sponsored Indigenous Peoples Night with the Minnesota Aurora soccer team in collaboration with Northern Indigenous Games and Twin Cities Native Lacrosse. Community outreach in 2024 included providing mobile nursing services at four local powwows and events, including the Indigenous People's Health Fair. As part of the effort to incorporate Native health equity into systems and processes, Fairview reviewed its smudging policy and updated educational tools, providing training at acute care sites about the ritual and how it can be practiced in a clinical setting. Strategy 3 - Inclusive Institution To successfully address our three priority needs and improve the health and wellbeing of our priority populations, it is imperative that we are guided by Strategy 3 (Inclusive institution): Transforming internal structures to create an antiracist and inclusive environment and to build community health by building community wealth. The anticipated impacts tied to Strategy 3 (Inclusive institution) are: 1) Build internal and external processes and structures to provide spaces that are safe and welcoming to all, responsive to community needs, and based on a culture of inclusion, 2) Use an antiracist approach and work to identify and eliminate racism by changing systems, organizational structures, policies, practices, and attitudes, and 3) Leverage everyday business practices to build community wealth, promoting economic and racial equity and justice. Key achievements in alignment with Strategy 3 include the launch of standardized social determinants of health patient screenings (e.g., food security, housing stability) at all ambulatory care sites. In 2024, 414,359 primary care patients across the system completed social determinants of health screenings. We also implemented targeted interventions to improve healthcare disparities, resulting in marked improvement in breast cancer and colon cancer screening rates. In particular, breast cancer screening rates improved among Karen, Hmong, and Somali patients because of six mobile mammography events. Additionally, we are building capacity across the system for more individuals and teams to participate in the Intercultural Development Inventory. Operational improvements driven by the Equity Strategy Office identify and address experience and outcome gaps for employee sub-groups and within patient care and outcomes. Improvements include related dashboarding and reporting across all organizational performance dimensions. This reporting informs the creation of actions plans to mitigate and address identified gaps and create line of sight to progress being made. In 2024, pathways were created to collate and incorporate voices and insights from the patients, employees, and community members Fairview serves. These pathways are being piloted and operationalized in 2025. Robust and strategic efforts across Patient Safety, Human Resources, and Customer Experience to identify and address multiple forms of harm were also supported. In addition, during 2024, units across the organization operationalized systems to identify and prevent potential gaps in care and outcomes across patient populations. Our anchor strategy works to advance health equity by investing in the social and economic wellbeing of the communities we serve through our everyday business practices. The strategy focuses on local and diverse hiring, purchasing and investing, and serving and leading with trusted community partners. Fairview's Workforce Partnerships team addresses the social determinants of health by helping people secure employment with family-sustaining
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Facility , 6 - Fairview Ridges Hospital. Fairview also has a robust social corporate responsibility program including employee volunteerism, memberships, affiliations, and sponsorships. In 2024, there were 13 systemwide employee volunteerism events hosted, including Habitat for Humanity and Twin Cities Pride. Additionally, Fairview staff sit on boards and are members of a diverse set of community organizations. Fairview's sponsorship program is aligned with our commitment to advancing health equity. Our organization provides sponsorships to support local community organizations aligned with our system's priorities. To increase diversity and trust in clinical trials, the Center for Community Health Equity partnered with Fairview Frontiers to develop a community engagement strategy and improve representation in clinical trials. Together, they presented "Integrating Cultural Considerations for Research Participants" to the University of Minnesota research managers, providing education on the importance of diverse participation in research and how to do so thoughtfully and equitably. Fairview Frontiers also appeared at four different community events for "Research 101," informing community members about the process, benefits, and challenges of participating in a research study. Together, Fairview Frontiers and the Center for Community Health Equity are working to engage the community more directly in clinical research with the aim of improving both the process and the outcome of such studies. Significant needs not addressed. Prioritizing needs identified by our communities allows us to develop upstream strategies that will have a large and lasting impact in our communities. The priority needs we have identified will ultimately be positively impacted by addressing their root causes. The following needs were not directly addressed because these issues are outside the scope at this time: cost of care, insurance and medications, childcare, and employment benefits. The following needs were not directly addressed because they fall outside of the scope of the Community Health Needs Assessment Implementation Strategy: clinic/hospital hours, limited time spent with provider, and limited specialty care. This feedback was shared with the appropriate teams to address as part of clinical care.
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Facility , 1 - Fairview Ridges Hospital. The Minnesota Attorney General agreement was used in the determination of the eligibility for financial assistance.
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Facility , 1 - Fairview Ridges Hospital. A summary of the Financial Assistance Policy is posted in various locations in the hospital.
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Facility , 1 - Fairview Ridges Hospital. Pursuant to Treas. Reg. Section 1.501(r)-6(c), Fairview Ridges Hospital made reasonable efforts to determine whether an individual was FAP-eligible for care by satisfying the requirements of Section 1.501(r)-6(c)(3).
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We continue to believe that to have the greatest impact on our communities, we need to take a targeted approach. By focusing on specific issues and communities, we can understand and begin to address the root causes of health inequity in a more meaningful way. Our 2024 CHNA resulted in a reaffirmation, and better understanding, of the significant barriers that make our three priority need areas so difficult to address. We used these barriers to refine and better define the priority needs. Based on our improved understanding of the needs and conversations with advisory groups, we have adjusted the title of one of our priority needs from 2021. Healing, connectedness, and mental health is now Cultivating trust, belonging and healing. Although this change removed Mental Health from the title of this priority, we will lean into accessing mental health services as a part of the priority need "Navigating and accessing care and resources". We recently completed our 2024-2026 Community Health Needs Assessment (CHNA). Three key areas have been identified as the greatest needs in our community - and the greatest opportunities to make a real difference through collaboration and connection: * Accessing and navigating care and resources * Addressing structural racism and barriers to equity * Cultivating trust, belonging and healing Importantly, one thing we heard from the community and saw in the data is that the social determinants of health impact some populations more than others. Based on what we learned during our assessment process, we are prioritizing two populations: racial and ethnic populations experiencing health disparities and people experiencing poverty. The people in these groups are all ages, and they live everywhere from the countryside to the city. We will intentionally seek out the needs and perspectives of these populations that experience greater health inequities, in order to partner with them on building solutions and removing barriers. Many specific concerns fall under each of these areas of need. We used barriers identified in the local communities to help guide us in creating and expanding relevant programs and focused services.
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Facility , 1 - Fairview Lakes Regional Medical Ctr. As Fairview conducts our required CHNA process, led by Fairview's Community Advancement department, we are guided by the approaches and principles developed by the Center for Community Health Equity, which was launched in August 2022. As part of the center, we are building on our existing community engagement by creating an infrastructure that builds trusting partnerships and enables community voice to inform and influence our organization. For example: Fairview developed a Center for Community Health Equity Model of Community Engagement. The model articulates our approach to community engagement, community voice, and community partnerships as we work to advance community health equity. The center is developing a set of standard practices for collecting community voice to influence our social determinants of health initiatives without adding undue burden to the communities we seek to serve. The center's role as a convener and developer of community-informed best practices helps us keep equity at the center of our thinking as we study and evaluate our processes and engagement approaches. The M Health Fairview Center for Community Health Equity is an extension of the work being done in community by of our Community Advancement team. The center creates space for M Health Fairview and community partners to work alongside one another toward a shared goal of improving the health of the communities we serve and to which we belong. Together, we can apply equity-centered, culturally responsive approaches as we identify challenges and opportunities, create or expand programs and partnerships, and then scale or deepen learnings and successes across our system and the communities we serve. Located within the Fairview Community Health and Wellness Hub, the center formalizes the system's efforts to innovate and work with the community in reducing racial and other disparities in community health outcomes. The following strategies are helping us achieve this vision: 1. Addressing the social determinants of health (health behaviors and economic and social conditions that impact overall health) as well as individual social risks and social needs through the creation and expansion of programs; initiatives; collaborations; research; and policy, system, and environmental work. 2. Strengthening a community engagement infrastructure that builds trusting partnerships and enables community voice to inform and influence both inside and outside of our health system walls. 3. Transforming internal structures to create an antiracist and inclusive environment and to build community health by building wealth, knowledge, and capacity. This work would not be possible without the support of trusted community partners and our neighbors. The M Health Fairview Center for Community Health Equity's work is grounded in key principles that guide the ways in which we work with community, including: * Focus on community voice and trust - lifting up especially those who have historically been underrepresented and marginalized. * Commitment to collaboration - bringing community insights and priorities into our health system to address social determinants of health and advance health equity. * Transformation through action - transforming communities, health systems, and the broader ecosystem through innovation and continuous improvement. * Thank you to the experts from across our health system who give of their time and talents on the Center for Community Health Equity Work Group. This leadership group is helping shape and guide our work. * Michele Allen, MD, MS Associate Professor, Department of Family Medicine and Community Health Endowed Chair of Health Equity Research Director, Program in Health Disparities Research MPI, Center for Chronic Disease Reduction and Equity Promotion Across Minnesota (C2DREAM) Director, Community Engagement to Advance Research and Community Health (CEARCH), CTSI * Damien Fair, PA-C, PhD Co-Director, Masonic Institute for the Developing Brain Professor, Division of Clinical Behavioral Neuroscience, University of Minnesota Medical School Faculty, Department of Pediatrics Professor, Institute of Child Development * David Haynes, PhD Assistant Professor, Institute for Health Informatics at the University of Minnesota * Abe Jacob, MD Chief Quality Officer, M Health Fairview Associate Professor, Division of Pediatric Hospital Medicine, University of Minnesota Medical School Faculty, Department of Pediatrics Pediatrician, Internal Medicine, and Pediatric Hospitalist * Jim Letts, MD Family Medicine Provider, M Health Fairview Clinic - Roselawn * Katie Lingras, PhD, LP Director for Inclusive Excellence and Well-Being, Associate Professor, University of Minnesota Medical School * Will Nicholson, MD Vice President of Medical Affairs, M Health Fairview * Ana Nunez, MD, FACP Vice Dean, Diversity, Equity and Inclusion, University of Minnesota Medical School Professor of Medicine, Division of General Internal Medicine Integration Strategist, Clinical and Translational Science Institute * Chris Warlick, MD, PhD Department Head for the Department of Urology, University of Minnesota Medical School The programs and partnerships we have built and co-developed to respond to these needs are deeply embedded in our local communities. Our current assessment and implementation cycle gives us the opportunity to: Continue to build momentum, expanding our networks and collaborations to better understand one another's needs and assets. More deeply integrate the voices of those who are disproportionately impacted by the social determinants of health and the voices of historically marginalized communities in articulating barriers and building solutions. Lean into our unique culturally and linguistically relevant programs and initiatives. As we conduct our 2024 CHNA, we are taking a series of steps to improve our assessment process, keeping in mind the impact of the data collection process itself on the communities we serve. As we engage in bidirectional conversation and partnerships with community organizations that represent our priority populations and others, we are sensitive to the burden that incorporating the community's perspectives places on members of those communities and the organizations that serve them. In response, we are implementing several practices: We are offering grants to community-based organizations that are representing a priority population in our system community advisory council and stipends to the community-based organizations that are cohosting the health systemwide virtual community conversations with us. We are reviewing our outreach strategies, carefully planning, and partnering with others to avoid over surveying, over relying on the same voices or representatives, and asking the same questions assessment cycle after assessment cycle. Fairview has invested in subscriptions to tools, such as Spark Maps, which enable our health system to utilize and respond more effectively to requests for community data. Fairview has taken a leadership role in the Center for Community Health (CCH), a collaborative with health plans, hospitals, and public health agencies in Minnesota's seven-county metropolitan area. The CCH's member organizations will share data and processes to identify health needs and implement innovative approaches to advance community health, wellbeing, and equity. We are among the community partners supporting the Minnesota Homeless Study, a point-in-time study by Wilder Research that collects single-night counts of people experiencing homelessness across the state. Fairview also works with Wilder on the triennial Minnesota Reservation Homelessness Study. The study is conducted in partnership with six American Indian reservations in Minnesota. Fairview has had representation on the planning team and provided financial sponsorship for the Bridge to Health Survey. The survey has been an important source of data on the health status of adults in northeastern Minnesota and Douglas County, Wisconsin, for more than two decades. We have been involved in and supported collaborations particularly related to data and assessment in the medical center and children's hospital community. For example, Fairview staff participate on the Highrise Health Alliance housing team convened by the Minneapolis Health Department and the Minneapolis Public Housing Authority (MPHA). Staff are also a part of the Hennepin County Community Health Improvement Partnership (CHIP) is a coalition of partners from across the community using a collaborative approach to improving people's health. CHIP is committed to equity and informed by data and is focused on community mental well-being and housing stability.
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Facility , 2 - Fairview Lakes Regional Medical Ctr. Our overall engagement approach is guided by four key considerations: 1. Fairview is focusing on building and deepening our engagement infrastructure, putting structures in place that will guide our long-term community engagement efforts. 2. We must implement tactics that gather both breadth and depth of engagement, bringing as many community members as possible into the conversation and yet also seeking to develop a deep understanding of nuances within each need. 3. Our priority needs are systemwide, and we approach our assessment process from a system level. However, each local community Fairview serves is unique, and we recognize, honor, and prioritize local nuances - in context, in populations, and in our understanding of both - so we can respond most appropriately within each locality. This dual system/local approach enables us to maximize our efforts' impact across the region we serve. 4. As we look to our local communities and seek to meet them where they are, we benefit from engaging with multiple perspectives: those of our community members, our patients, and our employees. To do this, we must take into consideration a variety of approaches, modes, and preferences to best fit the needs of these three groups. As we build our multiyear assessment engagement approach, having a single guiding model of community engagement helps us maintain alignment across the organization as we plan and conduct our work. The Center for Community Health Equity engagement spectrum, based on the International Association for Public Participation's Spectrum of Public Participation, was collaboratively developed through interviews with local organizations, community members, Fairview employees, and other stakeholders. Our engagement spectrum depicts five progressively more intensive levels of community engagement: inform, consult, involve, collaborate, and community led. The model includes examples of each level of community engagement, to clarify what each level could look like in practice. It is important to recognize that no level is inherently better than another level - a more intensive engagement is not appropriate in all situations. Rather, each level is equally valid and appropriate for certain activities and at certain times. During our current assessment process, we used the Center for Community Health Equity engagement spectrum to help ensure that we are using strategies and tactics across the spectrum. Our intent is to build the capacity of stakeholders, community organizations, and other influencers to partner with our health system most effectively, enabling them to promote their community's interests to improve the broader community's health and wellbeing. Using the engagement spectrum as a model goes beyond merely incorporating community voice into Fairview's priority need areas. Its goal is to guide and frame co-development of community engagement activities and guide our implementation planning. The phrase "engagement infrastructure" refers to the mechanisms through which we are sharing and receiving bidirectional feedback on an ongoing basis. Like our hospital's physical infrastructure, our engagement infrastructure is composed of enduring, permanent parts of our health system. We are continuing to build a community engagement infrastructure that supports trusting partnerships and enables community voice to inform and influence the organization. Each hospital community has a Local Community Advisory Committee. We have been committed to and honored with a bidirectional, long-term commitment from our local community advisory committees, which have existed in various iterations for over 30 years. The local community advisory committee's role is to: Advise and inform health improvement plans and collaborative programs. Guide local insight and voice for CHNAs and action plans. Monitor progress toward the goals outlined in the CHNA implementation strategy. Review the local CHNA report. Each committee comprises members from, or representatives of, groups such as public health departments, medically underserved communities. communities experiencing poverty, populations experiencing health and/or racial disparities, community-based organizations, and schools. The System Community Advisory Council spans the entire health system and incorporates the need for internal representation, local representation, and representation from organizations that represent our priority populations. Its role is to: Advise the health system on the CHNA process and prioritization model from a systemwide perspective. Guide health system insight and ensure the voice of priority populations remains at the center of all discussions. Provide guidance and expertise in development of implementation strategy plans. Employee Resource Groups (ERGs), are voluntary, employee-led groups that aim to foster a diverse, inclusive workplace. They focus on impacting four important areas: community connection, organizational impact, meaningful change, and people development. ERGs supported the CHNA process by providing feedback and suggestions and supporting dissemination and recruitment of the data and engagement approaches. There are currently nine ERGs representing different affinities. Patient Family Advisory Councils bring together patient and family advisors along with staff to share insights and experiences to help Fairview improve. These committees help validate the current state, understand existing obstacles, and test ideas to overcome those barriers. During this CHNA cycle, our Patient Family Advisory Committees consulted on ways to approach community conversations, specifically our Town Halls. The process of centering community voice enables us to use the CHNA process to bring the perspectives of the communities we serve back to the organization in an actionable format. By using various data gathering methodologies, we gain a better understanding of the top barriers and concerns among the people we serve. This process is also a crucial avenue for adding nuance, understanding how our communities' needs shift among different geographical areas, generations, and cultural communities. Listening and learning sessions: Fairview has held community listening and learning sessions through the HOPE Commission since 2020. These sessions hold a mirror to Fairview, assessing where we are today and helping us understand how we can make lasting change. Sessions were held in 2020 to hear from employees, in 2021 and 2022 to hear from patients, and in 2023 and 2024 to hear from community members. In June 2022, after identifying a gap in participants from previous listening and learning sessions, we expanded these listening and learning sessions to include patients with limited English proficiency. Sessions were held in Somali, Spanish, Hmong, Karen, and American Sign Language. Prior to these sessions, there were limited mechanisms for patients with limited English proficiency to provide feedback about the care they were receiving. This series was an effort to bring more voices to the table and create inclusive opportunities for patients to express their needs and concerns.
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Facility , 3 - Fairview Lakes Regional Medical Ctr. Systemwide virtual conversations: We held a series of systemwide virtual conversations focused on the priority need healing, connectedness, and mental health and what that specifically looks like for youth (April 2024), aging adults (March 2024), and Indigenous populations (June 2024). These conversations were open to all, and their goal was to collect and share learnings and resources with participants. The conversations included presentations from community partners about their work, followed by small group discussions that provided valuable perspectives informing our understanding of population-specific needs, strengths, and future state visioning tied to healing, connectedness, and mental health. CHNA surveys To gather input from a broad set of stakeholders on local strengths and the top needs of communities each of the respective stakeholders serves, we developed two aligned, but distinct, surveys. The surveys gathered feedback about: Patient and community members' top barriers to care, social determinants of health needs, and social needs. The unique barriers and assets for patients in one of our priority populations (racial or ethnic populations experiencing health disparities and people experiencing poverty). Barriers that providers and community partners face in responding to the social determinants of health-related needs of patients as well as existing assets and resources available. The surveys were distributed to care team members and partner organizations, including faith leaders. Surveys were administered from mid-February to the end of March. We heard from 472 individuals across our hospital communities and our health system, with 296 responses from care team members and 176 responses from community organizations. Community Health and Healing Summit: Celebrating Culture, Building Connections, Guiding Action - The Community Health and Healing Summit, held in July 2024, aimed to propel our 10-year vision for a healthier Minnesota forward. The summit was a collaborative event bringing stakeholders together to work collectively on prioritizing needs and barriers to health in our communities. It blended the power of community and cultural healing with activities designed to collect participants' insights to not only shape our priorities but to actively drive positive change in our communities. Stakeholder interviews: From May to July 2024, we conducted stakeholder interviews with various Fairview care team members in both acute sites and clinics, including nurses, physicians, schedulers, social workers, care coordinators, and clinic managers. The interviews were guided by the results of our CHNA survey and aimed to gather more in-depth information and stories about the top barriers that had showed up most frequently during the survey. Facilitated conversations: We conducted a variety of facilitated conversations across the health system, a few examples of which are summarized in this section. The goal of these activities is to gain a fuller, more nuanced picture of topic-specific or population-specific perspectives over time. By holding these conversations on an ongoing basis, we ensure that our assessment process and our aligned programmatic or initiative-related work is responding to and engaging with communities in real time. Food is Medicine community conversations: As a part of our Food is Medicine initiative, we partnered with community-based organizations to host a community conversation in each hospital's service area. The goal was to learn more about the community's needs and strengths related to access to healthy food and the role of Fairview as a healthcare provider. In the fall 2023, we held eight Food is Medicine community conversations across different hospital geographies that were attended by 75 organizations representing sectors across the food scape including food shelves, farmers, social services organizations, schools, and municipalities. Town halls: In November and December 2023, we hosted five town hall sessions that were open to the public and geared toward local government relations offices, the business community, community-based organizations, trade groups, civic groups, and rotaries. Each town hall provided an opportunity for community members to receive updates from Fairview, participate in a question-and-answer session with Fairview leaders, and engage in discussions regarding barriers to health and trust in healthcare organizations. East Side Health and Well-being Collaborative: In February 2024, we joined the East Side Health and Well-being Collaborative's meeting as well as the collaborative's mental health and stress resilience work group meeting. In both meetings, we held facilitated conversations about the CHNA process and priority need areas in the community. During the meeting with the mental health and stress resilience work group, we focused on the healing, connectedness, and mental health priority area. Through ongoing partnership and programmatic conversations, we are vetting and refining our understanding of the identified priorities and the responses that would best address them. As a foundational part of program planning and evaluation, Community Advancement staff members are continuously soliciting feedback from community partners and program participants. We capture this information on an ongoing basis and use it to provide valuable context, driving insights into the needs of the communities we serve. Primary data methods: Fairview staff developed standardized tools, processes, instructions, protocols, and training for facilitators, interviewers, and note takers. We compiled, cleaned, and analyzed all primary data. A note taker captured all community input, and when possible, conversations were also recorded. Secondary community data: Claritas is a widely used national demographic estimation tool. Estimates and projections are provided at a zip code level including, but not limited to, population based on age, sex, ethnicity, and income. Spark Maps is a paid subscription that provides mapping and assessment tools that include a large database of indicators, data cleaning, benchmarking, and contextual information. The Bridge to Health Survey has been an important source of data on the health status of adults in northeastern Minnesota and Douglas County, Wisconsin, for more than two decades. The survey is conducted every five years, with the last survey administered in 2020. The Minnesota Student Survey is one of the longest-running youth surveys in the nation. It is a triennial survey that began in 1989. The data used in this report is from 2019. The Area Deprivation Index (ADI) is based on a measure created by the Health Resources and Services Administration over three decades ago, and has since been refined, adapted, and validated to the census block group neighborhood level by Amy Kind, MD, PhD, and her research team at the University of Wisconsin - Madison. Health Trends Across Communities in Minnesota (HTAC) uses information from electronic health records to help fill gaps in the information available to health professionals, organizations, policymakers, and community members to promote health in Minnesota. HTAC is a collaboration among health systems, public health departments, health organizations, and health plans in Minnesota. HTAC uses summary reports from electronic health records on a range of chronic, behavioral, and mental health conditions. The information comes from 11 health systems that make up the Minnesota Electronic Health Record Consortium (MNEHRC). Information from the MNEHRC represents approximately 90% of healthcare for Minnesotans, which makes HTAC a powerful tool to describe the health of many communities. Minnesota Department of Health, County Health Tables were used to look at 2020 county-level top causes of death and premature death.
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Facility , 1 - Fairview Lakes Medical Center. The Community Health Needs Assessment Report for Fairview Lakes Medical Center are located at: https://www.fairview.org/-/media/Files/Local-Health-Needs-Final/2024-CHNA-Report_Lakes-Medical-Center_Final.ashx The Community Health Needs Assessment and Implementation Strategy for Fairview Lakes Medical Center are located at: https://www.fairview.org/-/media/Files/Local-Health-Needs/CHNA-Implementation-Strategy-Reports-2025/CHNA-Implementation-Strategy-Report-20252027Lakes.ashx
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Facility , 1 - Fairview Lakes Regional Medical Ctr. Our triennial Community Health Needs Assessment (CHNA) process provides an important opportunity to engage with and understand our community, analyze what has changed since the last assessment, and prioritize together with the community the issues we must urgently address to improve wellbeing and resilience. As part of the 2021 CHNA process, we reexamined and built upon the extensive community insights shared during our 2018 CHNA, while also surveying the community for current and emerging needs . This work continued in 2024 as we conducted our triennial assessment, further exploring the barriers experienced by community that tie to priority needs. Our 2021 CHNA used social determinants of health (SDOH) as a lens through which we frame our understanding of our community's most significant health needs. A social determinants of health lens enables us to identify inequitable distribution of resources and access that negatively impacts health. Through this lens we looked at both qualitative and quantitative data. Quantitative data included data points related to demographics, physical environment, socioeconomic factors, healthcare, and health outcomes. We collected additional community voice data by convening a broad array of stakeholders, with special focus on the priority populations - racial or ethnic populations experiencing health disparities and persons experiencing poverty. Lakes Medical Center has a community advisory committee (CAC) that is involved in the CHNA process. The committee is comprised of local community and organizational leaders, such as local public health entities, social services organizations, higher education institutions, school districts, and local businesses. The assessment process also included discussions with our community advisory council, listening and learning sessions, and key stakeholder interviews. Throughout this process, community members, local business leaders, government representatives, nonprofit and community organizations, and content experts shared their voices and perspectives about their community's health needs. By bringing together both the qualitative and quantitative data, we established a prioritization process through which we could identify the community health needs that, if effectively addressed, would have the greatest positive impact on our communities and particularly on our priority populations. We prioritized areas of need based on four broad criteria: 1) Has this need been voiced by the community? Has this need been vetted by the community? 2) Does this need align with Fairview's strategies and priorities? 3) Does this need align with existing public health strategies and community health assessments? 4) Does this need build upon Fairview's 2018 CHNA priority needs? Lakes Medical Center identified three system-wide priority need areas, and will collaborate with other Fairview hospitals, medical centers, and shared business and clinical services to address these priorities. Our specific response varies by hospital based on the ways the priority needs manifest across a given community, as well as the partnerships-both ongoing and new-that we have developed to address those needs. The three identified needs are: 1) Navigating and accessing care and resources, 2) Addressing structural racism and barriers to equity, and 3) Healing, connectedness, and mental health. Development of 2022-2024 CHNA Implementation Strategies As a healthcare organization that works closely with our community advisory committees and community partners, we have listened to community and learned valuable lessons over the past few decades. This has guided us in the development of the Fairview Health Services 2022-2024 implementation strategies. In particular, we learned that: 1) Despite best efforts, health needs and health inequities continue to grow and deepen, 2) Collective action is critical, and 3) Transformational change requires a sustained and focused commitment. In response to our 2021 Community Health Needs Assessment, Fairview hospitals and medical centers worked collaboratively with local and statewide organizations to address our communities' most pressing needs. In addition, Fairview put forth a 2032 vision of increased community health equity. This vision is supported by three strategies designed to address the priority need areas in distinct ways while collectively moving us closer to achieving our goals. The three strategies are: Strategy 1: Addressing Social Determinants of Health (SDOH) - Addressing the SDOH, individual social risks, and social needs through the creation and expansion of programs, initiatives, collaborations, and research, as well as policy, system, and environmental work. Strategy 2: Community engagement infrastructure - Creating a community engagement infrastructure that builds trusting partnerships and enables community voice to inform and influence our health system. Strategy 3: Inclusive institution - Transforming internal structures to create an antiracist and inclusive environment and to build community health by building community wealth. For this three-year cycle, we are implementing strategies to work toward distinct, anticipated impacts for each priority need and to build upon our 10-year vision of increased community health equity by 2032. For more information, the Lakes Medical Center CHNA Implementation Strategy Report outlines the major strategies and actions we will deploy throughout the 2022-2024 assessment cycle as well as the ties between the Lakes Medical Center CHNA implementation strategies, anticipated impacts, and key responses. Fairview's mission and vision extend beyond traditional healthcare settings, driving a healthier future for the communities we serve. Significant efforts towards Strategy 1 (Addressing SDOH) occurred over the first three years of our 10-year vision. These efforts are demonstrated through three social determinants of health initiatives: 1) Food is Medicine: Using the healing power of food to nourish our patients, enrich our communities, and transform our systems, 2) Housing is Health: Using the protective power of housing to support patient health and build thriving communities, and 3) Connection is Cure: Strengthening the connection between patients and the healthcare system to address social isolation and improve community mental health and wellbeing. These initiatives are key responses that intersect all three priority needs and are also synergistic. Relationship with our partners. Fairview has a long partnership with the University of Minnesota and University of Minnesota Physicians, now represented in the M Health Fairview brand. Together, we offer access to breakthrough medical research and specialty expertise as part of a continuum of care that reaches all ages and health needs. Policy, systems, and environmental change initiatives are implemented across the health system (hospitals, clinics, specialty care) and in some instances, across the M Health Fairview partners, to create sustainable and lasting change to advance health equity and community wellbeing. Where indicated, community responses as a part of Strategy 2 (Community engagement infrastructure) and Strategy 3 (Inclusive institution) represent the work of Fairview in collaboration with the other M Health Fairview partners. Community action plan. Lakes Medical Center has an annual CHNA action plan that supports our vision of increased community health equity, rolls up to our system CHNA implementation strategies, and addresses priority needs. The Fairview Health Services Community Action Plan details the specific and measurable steps we will take during the year to drive change. Program lists by hospital can be found in the appendix. The System Community Action Plan is updated annually and includes impacts from previous years. Evaluation of impact. To best evaluate our impact and track progress towards our anticipated impacts, we use a multi-tiered and tailored evaluation approach. Our work is grounded in understanding core information about our communities. This includes identifying and understanding the community needs being addressed, the population or community being affected, current and/or potential partners to work with to address the need, and the impacts we anticipate. Community needs are determined in several ways. In addition to being determined through our formal CHNA process, we respond to emerging needs brought to us by community partners or public health, or those discovered through patient or community data showing significant health disparities. We have standardized several key measures to assess whether we are meeting the needs of the CHNA priority populations, focusing our efforts on equity and participant satisfaction.
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Facility , 2 - Fairview Lakes Regional Medical Ctr. A subset of established programs and initiatives are set up and supported for deeper evaluation. We have found that one-size-fits-all, evidence-based approaches may not be a good fit for some of our diverse communities. In response to the unique and differing needs of our community members, our programs are co-developed with community, center on the needs of specific populations, and often incorporate unique local tactics. We approach evaluation from a similar perspective by building evaluation approaches informed by our partners and considering strategies that are culturally and linguistically appropriate, allowing us to determine if the programs reflect the values we set out to embody. Fairview is guided by the Centers for Disease Control and Prevention (CDC) model for program evaluation, establishing primary outcomes, process measures, and demographics. We evaluate program impact and success from a variety of approaches using both qualitative and quantitative data. For many of the programs described here, we are reporting our reach or outputs through counts on a variety of levels that meet the rigor required for grant and contract reporting. In addition, we offer a diverse set of programs that vary on the spectrum of "low touch and high count" to "high touch and lower count." More generally put, the effort and impacts of the programs are not the same. This is a purposeful approach as we want a variety of programs that are appropriate to address the community and population-specific needs. We provide outcomes for programs here when we are able, acknowledging not all programs run on a calendar year, and analysis may not be complete for some of the programs on which we do deeper evaluation. Fairview is currently in the process of building an evaluative approach and capacity for our 10-year vision, increasing community health equity, and our three social determinants of health initiatives: Housing is Health, Food is Medicine, and Connection is Cure. Part of this evaluative approach is a monthly social determinants of health dashboard. Lakes Medical Center 2024 Implementation Strategy Progress Highlights. The following highlights our implementation strategy work for each of our three priority needs. In this first three-year CHNA cycle working towards our 10-year vision of increased community health equity, the primary way we are directly addressing the three priority needs is through Strategy 1 (Addressing SDOH). Through this strategy, we create programs and partner with community organizations to address social risk factors, social needs, and social determinants of health. Strategy 2 (Engagement infrastructure) and Strategy 3 (Inclusive institution) focus on building infrastructure and creating system changes so that we can more effectively respond to these priority needs in the future, as well as any emerging needs. Strategy 1 - Addressing Social Determinants of Health (SDOH) Priority Need: Navigating and accessing care and resources. Lakes Medical Center has a variety of programs that work as a part of Strategy 1 (Addressing SDOH) to address barriers related to navigating and accessing care and resources. Through this strategy, the Lakes Medical Center Action Plan programs work towards two anticipated impacts to address this priority need: 1) Remove barriers to care by providing community-placed care, co-located services, and navigation supports that address cultural and language barriers and 2) Increase awareness of, knowledge about, and access to healthcare and community-based resources that support opportunities for health and wellbeing. The following is more information on a selection of programs from the system community action plan that are working to meet the two anticipated impacts. Fairview System Key Initiative Highlights. The Community Clinical Care initiative involves multiple community-based clinical programs, including Fairview's Minnesota Immunization Networking Initiative (MINI), blood pressure checks, and oral health services. All services are multi-sector, community collaborations that provide care and education to the uninsured, under-served, and communities facing health disparities in the greater Twin Cities area. The Community Clinical Care team provides clinical care in trusted community settings at no cost and improves equitable access to vaccines and other services across various populations. The programs ensure a culturally and linguistically appropriate experience in a safe and trusted environment in partnership with over 250 faith-based and grassroots community partners, serving clients at local churches, mosques, temples, schools, community centers, food pantries, and homeless shelters. Across the system in 2024, the community clinical care team provided blood pressure and oral health services at 241 events, including 2 events in the Lakes Medical Center community, providing 418 blood pressure checks, and 696 dental fluoride applications. The team also hosted 443 vaccination clinics across the system in 2024. There were 5,525 free COVID-19 vaccine doses and 6,190 free flu shots administered. Of those participants who shared their identity, 72% of people who received a COVID-19 vaccine identified as a person of color and 35% indicated a language other than English as their preferred language. In the Lakes Medical Center community specifically, there was 1 MINI clinic at which 34 Mpox shots were administered. In August 2024, MINI received an invitation to publish an article in the special Public Health issue of the New England Journal of Medicine discussing their cross-sectoral, equity-based approach to COVID-19 response. Later in the year, they published a similar article in the Journal of Public Health Management & Practice, this time focusing specifically on reducing vaccination barriers for refugee, immigrant, and migrant communities during the COVID-19 pandemic. MINI also presented at the 2024 North American Refugee Health Conference. Health Up's mission is to promote a community where all citizens value, have access to, and engage in opportunities that support active and healthy living and a sense of wellbeing. In 2024, as a part of the Health Up collaboration, Fairview and partners hosted one Health Huddle on mental health resources. The Fairview Community Health and Wellness Hub (The Hub) opened in 2022. The Hub is a first-of-its-kind center that addresses health disparities while providing a range of critical healthcare services and community resources alongside trusted local partners. The Hub provides a variety of services to the community, including primary care, mental healthcare, enrichment options for seniors, food access programs, and community gathering spaces. We bring our own services together with local organizations to make it easier for people to access what they need to thrive. Throughout the year, 7,090 individuals attended 176 events or meetings at the Hub. Eighty-three of the events were public and partner events, reaching 3,263 individuals. Ninety-three events were internal Fairview events. Additionally, we hosted nine Hub Partnership Coordination Meetings, as well as one-on-one check-ins with each of the partners. These meetings serve to deepen our understanding of the diverse missions, visions, and impacts of each Hub partner, fostering better alignment and collaboration. In 2025, we plan to transition to quarterly in-person partnership meetings. This strategic move aims to enhance our collaborative efforts and drive impactful initiatives. In 2024, we continued to expand our work relating to opioid overdose prevention in partnership with the Steve Rummler Hope Network. Fairview's Community Clinical Care team trained several staff members to become naloxone educators, who can then train others. Educators train community members on how to recognize an opioid overdose, what naloxone (Narcan) is and how it works, how to administer naloxone to someone experiencing an overdose, and information about Steve's Law/MN's Good Samaritan and Naloxone Law. In total, there were 39 naloxone trainings where 944 individuals were trained in 2024. In addition, Fairview opened a fourth naloxone access point (NAP) site that provides free kits in the Lakes Medical Center community, extending this important resource to Greater Minnesota. NAP sites are stocked with nasal Narcan and intramuscular naloxone kits, many of which are packed at Fairview volunteer events. In 2024, 12,995 such kits were packed and distributed across our hospital communities. The Community Clinical Care team plans on opening several additional NAP sites in 2025.
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Facility , 3 - Fairview Lakes Regional Medical Ctr. Fairview hired two Food Resource Navigators in 2024, exemplifying the intersection of Strategy 1 (Addressing SDOH) and navigating and accessing care and resources. Food Resource Navigators serve as experts both in Fairview's Food is Medicine programs, as well as community food resources and government programs such as SNAP and Market Bucks. Rolled out in select clinics across the system, Food Resource Navigators receive clinical referrals when a patient screens positive for food insecurity and expresses interest in being connected with additional support or resources. In 2024, our Food Resource Navigators received 561 referrals across the system. Of those referrals, 84% of individuals were connected with internal and/or external resources. Over the next several years, this role will be expanded to additional clinics. In this way, we can support patients in navigating the complex landscape of healthcare and social services. Priority Need: Addressing Structural Racism and Barriers to Equity. Lakes Medical Center, in alignment with Strategy 1 (Addressing SDOH), has a variety of programs, events, and community education as a part of the Community Action Plan that work toward the anticipated impact: Develop, grow, and sustain programs, educational offerings, partnerships, and initiatives to address structural racism and barriers to equity. Fairview System Key Initiative Highlights. One of the Fairview social determinants of health initiatives, Food is Medicine, utilizes the knowledge and resources of a large healthcare institution to work towards meeting the immediate needs of our patients, while also transforming the food system into something just, equitable, and sustainable. The initiative aims to 1) Nourish our patients: Advance food security to reduce health disparities and diet-related health conditions. 2) Enrich our communities: Cultivate trusting and engaged partnerships to build and share resources, assets, and capacity. 3) Transform our systems: Nurture just and equitable food systems to ensure health equity. These approaches are framed to increase health equity through focused efforts to serve patients who have been historically marginalized by providing culturally appropriate food options and reducing food insecurity in a manner that upholds dignity and empowers the local food system. Clinically, it enables providers to serve patients experiencing food insecurity through a menu of distinct programs comprising an innovative wrap-around approach. One or more of the Food is Medicine programs-a selection of which are described below-are available to patients in 52+ clinics and 8 acute sites across the health system. One of the Food is Medicine initiative programmatic responses is the fresh food prescription program, which distributes fresh, locally grown produce from three farm partners (Hmong American Farmers Association, Naima's Farm, and Women's Environmental Institute) via a weekly food box. The boxes also contain proteins, whole grains, and pantry staples, as well as a newsletter with community resources and tips for healthy cooking and eating. Crucially, the program offers home delivery to address transportation barriers. In 2024, 31 clinics participated in the fresh food prescription program across Fairview hospital and medical center communities, three being in the Lakes Medical Center community. Almost one third (31%) of program participants identified as Asian, 17% as Black, and 2% as Hispanic/Latino. While just 70% of participants speak English as a preferred language, 7% had a preferred language of Hmong, 14% Karen, and 1% Spanish. Most participants had public insurance (79%) or were uninsured (2%). Fairview's food voucher program provides patients with vouchers to redeem at either the Twin Cities Mobile Market or Fare for All program. The program runs year-round and offers rolling enrollment. Throughout the year, 443 patients redeemed vouchers for groceries, including 45 from the Lakes Medical Center community. Additionally, we provide shelf-stable food resources for those with an immediate need. The shelf-stable food bags were incorporated into Lakes Medical Center for the first time in 2024. The bags come in six different varieties tailored to meet the preferences of diverse cuisines and circumstances. In 2024 there were 6042 shelf-stable bags distributed at 37 sites across the system. There were also 258 food resource packets distributed that contained information about local food resources along with immediate food support. Lakes Medical Center has a community garden that are available for twenty-five dollars to community members. They are located near the East side of the hospital near the parking lot in locked fenced areas. In 2024 there were 19 garden plots, each taken care of by a community member. Gardeners are harvesting their produce for themselves, their families, and their neighbors. Additionally, through a partnership with Ebenezer (Meadows) 2 plots were provided for Ebenezer residents. In November 2024, Fairview and local partners hosted the third annual Harvest at the Hub, welcoming 312 households to the Fairview Community Health and Wellness Hub. The event consisted of a food giveaway with turkeys, fresh produce, and other holiday staples, a community resource fair, a vaccine clinic, and other health and wellbeing services. Another of the Fairview social determinants of health initiatives, Housing is Health also responds to the priority need of structural racism and barriers to equity . The Housing is Health initiative aims to use the protective power of housing to support patient health and build thriving communities. We approach this initiative with clinically connected programs, supportive community partnerships, contribution of time and expertise to collaboratives, and efforts to impact policy. For example, Fairview partners with Our Savior's Community Services to provide critical follow-up care and temporary housing for people who are unsheltered after a hospital stay. Patients are referred by staff at a hospital or medical center and sheltered at Our Saviors. Additionally, a nurse provides care, and patients receive wrap-around services and social work support. In 2024, 50 patients were provided support through this program. As a part of Housing is Health, we are also proud to have helped launch Healthcare for Housing (HC4H). HC4H grew out of the Housing and Health Equity Fellowship and consists of seven health providers and payers. We also strengthened our housing advocacy activities in 2024; we chair the policy workgroup for HC4H, participated in Homeless Day on the Hill at the Minnesota State Capitol, and submitted letters of support for multiple housing initiatives. In September and October 2024, teams from across the system participated in two Twin Cities Habitat for Humanity builds. Volunteers contributed 300 hours for the Carter Work Project build. During our annual build week with Twin Cities Habitat for Humanity, staff contributed 560 volunteer hours. Priority Need: Healing, Connectedness, and Mental Health. Lakes Medical Center works toward the anticipated impact: develop, grow, and sustain programs, educational offerings, partnerships, and initiatives, address barriers to healing, connectedness and mental health through Strategy 1 (Addressing SDOH) and the Community Action Plan. Fairview System Key Initiative Highlights. In response to the priority need of healing, connectedness, and mental health, we have a body of work that makes up the Connection is Cure initiative. Connection is Cure aims to build trust through social connections, center linguistic and cultural diversity, and bridge silos across our hospital system and communities to transform medical practice. As a part of Connection is Cure, we hosted virtual conversations in 2024 around how we can improve mental health services for specific populations: Native patients, youth, and older adults. Three conversations were held-one for each respective population-reaching a total of 108 community members. Other gatherings fostering healing, connectedness, and mental health were held in 2024 as well, including a Heal the Healers event. Exemplifying the integration of traditional healthcare with ancestral and cultural practices, the Heal the Healers event united local healers and caregiving professionals for a transformative day of self-care, learning, and the revival of ancestral practices. Our goal was to empower practitioners and community workers with activities that foster self-care, ensuring they remain strong and resilient for the communities they serve. This and other healing events laid the groundwork for the Community Health and Healing Summit, convened as part of our innovative approach to the Community Heal
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Facility , 4 - Fairview Lakes Regional Medical Ctr. As part of our commitment to addressing barriers to healing, connectedness, and mental health, we also launched our Birth Justice Initiative, a cross-departmental effort to advance equity and inclusion in birthing experiences. Focused on eliminating racial bias in maternal healthcare and improving patient outcomes, the Birth Justice Initiative is making systemic changes to improve the quality of healthcare for all pregnant persons. Their research and advocacy led to the removal of race-based maternal health screening tools, which can accidentally introduce bias into medical decision-making. Additionally, part of the design of a new prenatal and postpartum clinical care map includes screening all pregnant patients for social determinants of health and lead exposure, empowering healthcare providers to act early to address these concerns. In 2024, departments participating in the Birth Justice Initiative interviewed 649 people who gave birth in the Fairview health system and gathered input from doulas. Based on their feedback, we plan to rewrite policies to enhance culturally congruent care, tailoring maternal healthcare to the specific cultural values of each patient. Additionally, we are responding to the need for healing, connectedness, and mental health with a variety of evidence-based programs, as well as trainings and education sessions. Feeding Hope is a series of virtual one-hour learning sessions focused on positive, hopeful topics that support wellbeing in the general community. This series is offered in partnership with all Fairview's hospitals and medical centers and is open to anyone across all of Fairview's communities. In 2024, across Fairview hospitals and medical centers there were two sessions held with 60 attendees total. SPEAC (Substance Prevention Education & Action Coalition) is an organized coalition created to assist Forest Lake and the surrounding community in increasing positive life choices as it relates to alcohol or substance use in the Forest Lake School District. The coalition is designed to highlight scientifically proven, positive narratives through campaigns, events, and community involvement. Fairview provides infrastructure support through staff time serving as the grant director. In 2024 SPEAC was an active coalition with 15 sectors represented & meeting monthly. Eleven community conversations were held to provide additional insights to the community and increase SPEAC awareness and finally a student group called RISE student group at FLSD. Lifelines is a comprehensive suicide prevention program that targets the entire school community, providing suicide awareness material for administrators, faculty, staff, parents, and students. Basic information about youth suicide is provided and is primarily directed at helping everyone in the school community recognize when a student is at potential risk of suicide and understand how and where to access help. This research-based program is included in the Substance Abuse and Mental Health Services Administration's (SAMHSA) National Registry of Evidence-Based Programs and Practices. The curriculum is provided by Hazelden-Betty Ford Publishing. In 2024 in the Lakes Medical Center Community there were 6 active school districts. The Faith Community Nursing program makes programs and services available to faith community nurses to hold in their congregation . Additionally, $750 mini grants are provided from Fairview Foundation to faith community nurses, as well as resources such as health education materials and resources, and networking opportunities. In 2024 across the system there were 20 mini grants awarded. In the Lakes Medical Center community, 2 mini grants were awarded to faith community nurses. Psychological First Aid is an evidence-informed training for the broader community as well as professionals. Trainees learn how to support healthy recovery for individuals following a traumatic event, public health emergency, natural disaster, or personal crisis. The curriculum integrates public health, community health, and individual psychology by drawing upon skills the trainees probably already have. Psychological First Aid is a two-hour training. In 2024, in the Lakes Medical Center community, there were four classes offered with 155 participants attending. A Creative Look at Self-Care (formerly Refresh and Reset your Resiliency) promotes resiliency skills, offers wellness-care tools for mind, body, and spirit, and encourages the development of a personal plan for self-care. In 2024, in the Lakes Medical Center community, there was one class offered with 22 participants attending. Together, Fairview's Strategy 1 (Addressing SDOH) initiatives and the programs outlined within our action plans comprise a strategic, innovative, and equity-minded approach to community health. We take great care to co-design programmatic responses with the communities impacted by them and collaborate with a broad range of community organizations and other multisectoral partners to address the social determinants of health. In recognition of our commitment to this work, Fairview advanced as a finalist for the American Hospital Association's Foster G. McGaw Prize. Five programs were profiled in Fairview's award submission: Minnesota Immunization Networking Initiative; East Side Health and Well-being Collaborative; Fair Table, Fairview's Food is Medicine initiative; Health Commons; and our Cultural Broker program. It is a great honor to be considered for this award; it serves as motivation to work harder than ever to advance health equity, and to intentionally do so in authentic partnership with the communities we serve. In addition to Strategy 1 (Addressing SDOH) and the programmatic work included on our Action Plans, we strive to reduce health disparities and increase community health equity through two additional system strategies. While Strategy 1 (Addressing SDOH) allows us to directly respond to the three prioritized needs from our community health needs assessment, Strategy 2 (Engagement infrastructure) and Strategy 3 (Inclusive institution) focus on building the structures and systems for us to do the work more capably. Strategy 2 - Engagement Infrastructure Addressing our three priority needs while also responding to emerging needs requires an infrastructure that supports building and sustaining strong community partnerships and allows for ongoing, trusting exchanges between Fairview and community members. The importance of this is manifest in Strategy 2 (Engagement infrastructure): Creating community engagement infrastructure that builds trusting partnerships and enables community voice to inform and influence the institution. The anticipated impacts for this strategy are: 1) Build and expand feedback systems for patients and community members; embed process improvement in the health system's response to community voice and 2) Create sustainable structures to convene and engage community voice around addressing social determinants of health. While Fairview boasts an extensive engagement infrastructure already, we continued to bolster the work we do to expand feedback systems and sustainable convening structures. Core to this is building and sustaining trusting partnerships. The Lakes Medical Center Community Advisory Committee (CAC) met through the year to offer input and provide local insight and expertise. Notably, 2024 marks the first year since the COVID-19 pandemic in which we convened our CACs in-person, celebrating the joy of being together in the same room and the spirit of collaboration that it fosters. To enhance the work of each hospital CAC, in 2024 we revitalized our System Community Advisory Council. Spanning the entire health system, the System CAC incorporates the need for internal representation, local representation, and representation from organizations that represent our priority populations. While it plays a large role in advising the CHNA process and implementation, it also ensures the voice of priority populations remain at the center of all discussions and decisions. The System CAC met five times in 2024, providing guidance and insights throughout the Community Health Needs Assessment process.
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Facility , 5 - Fairview Lakes Regional Medical Ctr. A central part of our community voice work and philosophy, the M Health Fairview Center for Community Health Equity (the Center) was launched in August 2022. The Center guides our efforts to gather community voice and tie the learnings back into the organization. Throughout 2024, we hosted three Center Community Health Equity Work Group meetings to hold strategic discussions on issues of relevance to the center. The Center for Community Health Equity also presented a session at the 2024 American Hospital Association's annual conference . This session focused on the lessons we learned from conducting community input sessions for community members with limited English proficiency, giving us the opportunity to socialize best practices and learn from the experiences of other healthcare systems. Over the course of the year, the Center continued to build out its SDOH platform and community engagement framework, guiding the implementation of the 2024 Community Health Needs Assessment approach. Enabling community voice, particularly the voices of priority populations, to influence and inform the health system is integral to Strategy 2 (Engagement infrastructure). In 2024, the Center for Community Health Equity and Fairview's Quality Improvement team began a joint enterprise to incorporate community voice into the way in which we define, implement, and measure healthcare quality. Members of the East Side Health and Well-being Collaborative and the System Community Advisory Committee gave input regarding what "quality "quality care" means to them, informing the development of the system's ambulatory care composite (high priority quality measures). The priorities yielded by their insights will drive organizational work for the next several years as we work to deliver the highest quality of care to our patients and community. Building our engagement infrastructure involves connecting broadly with community as well as building our capacity to engage with complex and intersectional groups. We are building a set of population health equity initiatives, one of which is the Native Health Equity Initiative (NHEI). As part of this body of work, in 2024 Fairview staff stood up the Indigenous Healing Circle Employee Resource Group to create sacred space for Native employees and patients and reconcile disparities unique to our Native relatives. Fairview also developed a system-wide land acknowledgement to raise awareness of how inequities have impacted the geographies and people we serve and guide us in our work to advance equity and inclusion. The land acknowledgement was published in our 2024 Community Health Needs Assessment report. Throughout our Native health equity efforts, we also hosted a Healing in Four Directions Powwow for more than 350 community members from across the state with partners including St. Paul Public Schools Indian Education, South St. Paul Public Schools Indian Education, Minnesota Indian Affairs Council, and the American Indian Family Center. Later in the year, we participated in the 2024 American Indian Day on the Hill and sponsored Indigenous Peoples Night with the Minnesota Aurora soccer team in collaboration with Northern Indigenous Games and Twin Cities Native Lacrosse. Community outreach in 2024 included providing mobile nursing services at four local powwows and events, including the Indigenous People's Health Fair. As part of the effort to incorporate Native health equity into systems and processes, Fairview reviewed its smudging policy and updated educational tools, providing training at acute care sites about the ritual and how it can be practiced in a clinical setting. In the Lakes Medical Center community, we participate in and have leadership roles in collaboratives such as , CONNECT Washington County, Chisago Age Well Coalition, Chisago County MAPP (Mobilizing for Action through Planning and Partnerships) Committee, Health Up and Substance Prevention Education and Action (SPEAC), Interfaith Health Collaborative and the Center for Community Health. These are spaces where we do ongoing listening and relationship building with community partners and community members. Strategy 3 - Inclusive Institution To successfully address our three priority needs and improve the health and wellbeing of our priority populations, it is imperative that we are guided by Strategy 3 (Inclusive institution): Transforming internal structures to create an antiracist and inclusive environment and to build community health by building community wealth. The anticipated impacts tied to Strategy 3 (Inclusive institution) are: 1) Build internal and external processes and structures to provide spaces that are safe and welcoming to all, responsive to community needs, and based on a culture of inclusion, 2) Use an antiracist approach and work to identify and eliminate racism by changing systems, organizational structures, policies, practices, and attitudes, and 3) Leverage everyday business practices to build community wealth, promoting economic and racial equity and justice. Key achievements in alignment with Strategy 3 include the launch of standardized social determinants of health patient screenings (e.g., food security, housing stability) at all ambulatory care sites. In 2024, 414,359 primary care patients across the system completed social determinants of health screenings. We also implemented targeted interventions to improve healthcare disparities, resulting in marked improvement in breast cancer and colon cancer screening rates. In particular, breast cancer screening rates improved among Karen, Hmong, and Somali patients because of six mobile mammography events. Additionally, we are building capacity across the system for more individuals and teams to participate in the Intercultural Development Inventory. Operational improvements driven by the Equity Strategy Office identify and address experience and outcome gaps for employee sub-groups and within patient care and outcomes. Improvements include related dashboarding and reporting across all organizational performance dimensions. This reporting informs the creation of actions plans to mitigate and address identified gaps and create line of sight to progress being made. In 2024, pathways were created to collate and incorporate voices and insights from the patients, employees, and community members Fairview serves. These pathways are being piloted and operationalized in 2025. Robust and strategic efforts across Patient Safety, Human Resources, and Customer Experience to identify and address multiple forms of harm were also supported. In addition, during 2024, units across the organization operationalized systems to identify and prevent potential gaps in care and outcomes across patient populations. Our anchor strategy works to advance health equity by investing in the social and economic wellbeing of the communities we serve through our everyday business practices. The strategy focuses on local and diverse hiring, purchasing and investing, and serving and leading with trusted community partners. Fairview's Workforce Partnerships team addresses the social determinants of health by helping people secure employment with family-sustaining wages and benefits, achieve success in their jobs, and learn new skills. The team also focuses on inclusive, local hiring, resulting in a healthcare team that represents the communities we serve. Supply Chain leaders launched a Supplier Diversity program, including updating request for proposal language, creating a new webpage, and identifying potential diverse vendors. Fairview also has a robust social corporate responsibility program including employee volunteerism, memberships, affiliations, and sponsorships. In 2024, there were 13 systemwide employee volunteerism events hosted, including Habitat for Humanity and Twin Cities Pride. Additionally, Fairview staff sit on boards and are members of a diverse set of community organizations. Fairview's sponsorship program is aligned with our commitment to advancing health equity. Our organization provides sponsorships to support local community organizations aligned with our system's priorities.
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Facility , 6 - Fairview Lakes Regional Medical Ctr. To increase diversity and trust in clinical trials, the Center for Community Health Equity partnered with Fairview Frontiers to develop a community engagement strategy and improve representation in clinical trials. Together, they presented "Integrating Cultural Considerations for Research Participants" to the University of Minnesota research managers, providing education on the importance of diverse participation in research and how to do so thoughtfully and equitably. Fairview Frontiers also appeared at four different community events for "Research 101," informing community members about the process, benefits, and challenges of participating in a research study. Together, Fairview Frontiers and the Center for Community Health Equity are working to engage the community more directly in clinical research with the aim of improving both the process and the outcome of such studies. Significant needs not addressed. Prioritizing needs identified by our communities allows us to develop upstream strategies that will have a large and lasting impact in our communities. The priority needs we have identified will ultimately be positively impacted by addressing their root causes. The following needs were not directly addressed because these issues are outside the scope at this time: cost of care, insurance and medications, childcare, and employment benefits. The following needs were not directly addressed because they fall outside of the scope of the Community Health Needs Assessment Implementation Strategy: clinic/hospital hours, limited time spent with provider, and limited specialty care. This feedback was shared with the appropriate teams to address as part of clinical care.
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Facility , 1 - Fairview Lakes Regional Medical Ctr. The Minnesota Attorney General agreement was used in the determination of the eligibility for financial assistance.
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Facility , 1 - Fairview Lakes Regional Medical Ctr. A summary of the Financial Assistance Policy is posted in various locations in the hospital.
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Facility , 1 - Fairview Lakes Regional Medical Center. Pursuant to Treas. Reg. Section 1.501(r)-6(c), Fairview Lakes Regional Medical Center made reasonable efforts to determine whether an individual was FAP-eligible for care by satisfying the requirements of Section 1.501(r)-6(c)(3).
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We continue to believe that to have the greatest impact on our communities, we need to take a targeted approach. By focusing on specific issues and communities, we can understand and begin to address the root causes of health inequity in a more meaningful way. Our 2024 CHNA resulted in a reaffirmation, and better understanding, of the significant barriers that make our three priority need areas so difficult to address. We used these barriers to refine and better define the priority needs. Based on our improved understanding of the needs and conversations with advisory groups, we have adjusted the title of one of our priority needs from 2021. Healing, connectedness, and mental health is now Cultivating trust, belonging and healing. Although this change removed Mental Health from the title of this priority, we will lean into accessing mental health services as a part of the priority need "Navigating and accessing care and resources". We recently completed our 2024-2026 Community Health Needs Assessment (CHNA). Three key areas have been identified as the greatest needs in our community - and the greatest opportunities to make a real difference through collaboration and connection: * Accessing and navigating care and resources * Addressing structural racism and barriers to equity * Cultivating trust, belonging and healing Importantly, one thing we heard from the community and saw in the data is that the social determinants of health impact some populations more than others. Based on what we learned during our assessment process, we are prioritizing two populations: racial and ethnic populations experiencing health disparities and people experiencing poverty. The people in these groups are all ages, and they live everywhere from the countryside to the city. We will intentionally seek out the needs and perspectives of these populations that experience greater health inequities, in order to partner with them on building solutions and removing barriers. Many specific concerns fall under each of these areas of need. We used barriers identified in the local communities to help guide us in creating and expanding relevant programs and focused services.
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Schedule H, Part V, Section B, Line 5 Facility , 1
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Facility , 1 - Fairview Northland Regional Hosp. As Fairview conducts our required CHNA process, led by Fairview's Community Advancement department, we are guided by the approaches and principles developed by the Center for Community Health Equity, which was launched in August 2022. As part of the center, we are building on our existing community engagement by creating an infrastructure that builds trusting partnerships and enables community voice to inform and influence our organization. For example: Fairview developed a Center for Community Health Equity Model of Community Engagement. The model articulates our approach to community engagement, community voice, and community partnerships as we work to advance community health equity. The center is developing a set of standard practices for collecting community voice to influence our social determinants of health initiatives without adding undue burden to the communities we seek to serve. The center's role as a convener and developer of community-informed best practices helps us keep equity at the center of our thinking as we study and evaluate our processes and engagement approaches. The M Health Fairview Center for Community Health Equity is an extension of the work being done in community by of our Community Advancement team. The center creates space for M Health Fairview and community partners to work alongside one another toward a shared goal of improving the health of the communities we serve and to which we belong. Together, we can apply equity-centered, culturally responsive approaches as we identify challenges and opportunities, create or expand programs and partnerships, and then scale or deepen learnings and successes across our system and the communities we serve. Located within the Fairview Community Health and Wellness Hub, the center formalizes the system's efforts to innovate and work with the community in reducing racial and other disparities in community health outcomes. The following strategies are helping us achieve this vision: 1. Addressing the social determinants of health (health behaviors and economic and social conditions that impact overall health) as well as individual social risks and social needs through the creation and expansion of programs; initiatives; collaborations; research; and policy, system, and environmental work. 2. Strengthening a community engagement infrastructure that builds trusting partnerships and enables community voice to inform and influence both inside and outside of our health system walls. 3. Transforming internal structures to create an antiracist and inclusive environment and to build community health by building wealth, knowledge, and capacity. This work would not be possible without the support of trusted community partners and our neighbors. The M Health Fairview Center for Community Health Equity's work is grounded in key principles that guide the ways in which we work with community, including: * Focus on community voice and trust - lifting up especially those who have historically been underrepresented and marginalized. * Commitment to collaboration - bringing community insights and priorities into our health system to address social determinants of health and advance health equity. * Transformation through action - transforming communities, health systems, and the broader ecosystem through innovation and continuous improvement. * Thank you to the experts from across our health system who give of their time and talents on the Center for Community Health Equity Work Group. This leadership group is helping shape and guide our work. * Michele Allen, MD, MS Associate Professor, Department of Family Medicine and Community Health Endowed Chair of Health Equity Research Director, Program in Health Disparities Research MPI, Center for Chronic Disease Reduction and Equity Promotion Across Minnesota (C2DREAM) Director, Community Engagement to Advance Research and Community Health (CEARCH), CTSI * Damien Fair, PA-C, PhD Co-Director, Masonic Institute for the Developing Brain Professor, Division of Clinical Behavioral Neuroscience, University of Minnesota Medical School Faculty, Department of Pediatrics Professor, Institute of Child Development * David Haynes, PhD Assistant Professor, Institute for Health Informatics at the University of Minnesota * Abe Jacob, MD Chief Quality Officer, M Health Fairview Associate Professor, Division of Pediatric Hospital Medicine, University of Minnesota Medical School Faculty, Department of Pediatrics Pediatrician, Internal Medicine, and Pediatric Hospitalist * Jim Letts, MD Family Medicine Provider, M Health Fairview Clinic - Roselawn * Katie Lingras, PhD, LP Director for Inclusive Excellence and Well-Being, Associate Professor, University of Minnesota Medical School * Will Nicholson, MD Vice President of Medical Affairs, M Health Fairview * Ana Nunez, MD, FACP Vice Dean, Diversity, Equity and Inclusion, University of Minnesota Medical School Professor of Medicine, Division of General Internal Medicine Integration Strategist, Clinical and Translational Science Institute * Chris Warlick, MD, PhD Department Head for the Department of Urology, University of Minnesota Medical School The programs and partnerships we have built and co-developed to respond to these needs are deeply embedded in our local communities. Our current assessment and implementation cycle gives us the opportunity to: Continue to build momentum, expanding our networks and collaborations to better understand one another's needs and assets. More deeply integrate the voices of those who are disproportionately impacted by the social determinants of health and the voices of historically marginalized communities in articulating barriers and building solutions. Lean into our unique culturally and linguistically relevant programs and initiatives. As we conduct our 2024 CHNA, we are taking a series of steps to improve our assessment process, keeping in mind the impact of the data collection process itself on the communities we serve. As we engage in bidirectional conversation and partnerships with community organizations that represent our priority populations and others, we are sensitive to the burden that incorporating the community's perspectives places on members of those communities and the organizations that serve them. In response, we are implementing several practices: We are offering grants to community-based organizations that are representing a priority population in our system community advisory council and stipends to the community-based organizations that are cohosting the health systemwide virtual community conversations with us. We are reviewing our outreach strategies, carefully planning, and partnering with others to avoid over surveying, over relying on the same voices or representatives, and asking the same questions assessment cycle after assessment cycle. Fairview has invested in subscriptions to tools, such as Spark Maps, which enable our health system to utilize and respond more effectively to requests for community data. Fairview has taken a leadership role in the Center for Community Health (CCH), a collaborative with health plans, hospitals, and public health agencies in Minnesota's seven-county metropolitan area. The CCH's member organizations will share data and processes to identify health needs and implement innovative approaches to advance community health, wellbeing, and equity. We are among the community partners supporting the Minnesota Homeless Study, a point-in-time study by Wilder Research that collects single-night counts of people experiencing homelessness across the state. Fairview also works with Wilder on the triennial Minnesota Reservation Homelessness Study. The study is conducted in partnership with six American Indian reservations in Minnesota. Fairview has had representation on the planning team and provided financial sponsorship for the Bridge to Health Survey. The survey has been an important source of data on the health status of adults in northeastern Minnesota and Douglas County, Wisconsin, for more than two decades. We have been involved in and supported collaborations particularly related to data and assessment in the medical center and children's hospital community. For example, Fairview staff participate on the Highrise Health Alliance housing team convened by the Minneapolis Health Department and the Minneapolis Public Housing Authority (MPHA). Staff are also a part of the Hennepin County Community Health Improvement Partnership (CHIP) is a coalition of partners from across the community using a collaborative approach to improving people's health. CHIP is committed to equity and informed by data and is focused on community mental well-being and housing stability.
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Schedule H, Part V, Section B, Line 5 Facility , 2
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Facility , 2 - Fairview Northland Regional Hosp. Our overall engagement approach is guided by four key considerations: 1. Fairview is focusing on building and deepening our engagement infrastructure, putting structures in place that will guide our long-term community engagement efforts. 2. We must implement tactics that gather both breadth and depth of engagement, bringing as many community members as possible into the conversation and yet also seeking to develop a deep understanding of nuances within each need. 3. Our priority needs are systemwide, and we approach our assessment process from a system level. However, each local community Fairview serves is unique, and we recognize, honor, and prioritize local nuances - in context, in populations, and in our understanding of both - so we can respond most appropriately within each locality. This dual system/local approach enables us to maximize our efforts' impact across the region we serve. 4. As we look to our local communities and seek to meet them where they are, we benefit from engaging with multiple perspectives: those of our community members, our patients, and our employees. To do this, we must take into consideration a variety of approaches, modes, and preferences to best fit the needs of these three groups. As we build our multiyear assessment engagement approach, having a single guiding model of community engagement helps us maintain alignment across the organization as we plan and conduct our work. The Center for Community Health Equity engagement spectrum, based on the International Association for Public Participation's Spectrum of Public Participation, was collaboratively developed through interviews with local organizations, community members, Fairview employees, and other stakeholders. Our engagement spectrum depicts five progressively more intensive levels of community engagement: inform, consult, involve, collaborate, and community led. The model includes examples of each level of community engagement, to clarify what each level could look like in practice. It is important to recognize that no level is inherently better than another level - a more intensive engagement is not appropriate in all situations. Rather, each level is equally valid and appropriate for certain activities and at certain times. During our current assessment process, we used the Center for Community Health Equity engagement spectrum to help ensure that we are using strategies and tactics across the spectrum. Our intent is to build the capacity of stakeholders, community organizations, and other influencers to partner with our health system most effectively, enabling them to promote their community's interests to improve the broader community's health and wellbeing. Using the engagement spectrum as a model goes beyond merely incorporating community voice into Fairview's priority need areas. Its goal is to guide and frame co-development of community engagement activities and guide our implementation planning. The phrase "engagement infrastructure" refers to the mechanisms through which we are sharing and receiving bidirectional feedback on an ongoing basis. Like our hospital's physical infrastructure, our engagement infrastructure is composed of enduring, permanent parts of our health system. We are continuing to build a community engagement infrastructure that supports trusting partnerships and enables community voice to inform and influence the organization. Each hospital community has a Local Community Advisory Committee. We have been committed to and honored with a bidirectional, long-term commitment from our local community advisory committees, which have existed in various iterations for over 30 years. The local community advisory committee's role is to: Advise and inform health improvement plans and collaborative programs. Guide local insight and voice for CHNAs and action plans. Monitor progress toward the goals outlined in the CHNA implementation strategy. Review the local CHNA report. Each committee comprises members from, or representatives of, groups such as public health departments, medically underserved communities. communities experiencing poverty, populations experiencing health and/or racial disparities, community-based organizations, and schools. The System Community Advisory Council spans the entire health system and incorporates the need for internal representation, local representation, and representation from organizations that represent our priority populations. Its role is to: Advise the health system on the CHNA process and prioritization model from a systemwide perspective. Guide health system insight and ensure the voice of priority populations remains at the center of all discussions. Provide guidance and expertise in development of implementation strategy plans. Employee Resource Groups (ERGs), are voluntary, employee-led groups that aim to foster a diverse, inclusive workplace. They focus on impacting four important areas: community connection, organizational impact, meaningful change, and people development. ERGs supported the CHNA process by providing feedback and suggestions and supporting dissemination and recruitment of the data and engagement approaches. There are currently nine ERGs representing different affinities. Patient Family Advisory Councils bring together patient and family advisors along with staff to share insights and experiences to help Fairview improve. These committees help validate the current state, understand existing obstacles, and test ideas to overcome those barriers. During this CHNA cycle, our Patient Family Advisory Committees consulted on ways to approach community conversations, specifically our Town Halls. The process of centering community voice enables us to use the CHNA process to bring the perspectives of the communities we serve back to the organization in an actionable format. By using various data gathering methodologies, we gain a better understanding of the top barriers and concerns among the people we serve. This process is also a crucial avenue for adding nuance, understanding how our communities' needs shift among different geographical areas, generations, and cultural communities. Listening and learning sessions: Fairview has held community listening and learning sessions through the HOPE Commission since 2020. These sessions hold a mirror to Fairview, assessing where we are today and helping us understand how we can make lasting change. Sessions were held in 2020 to hear from employees, in 2021 and 2022 to hear from patients, and in 2023 and 2024 to hear from community members. In June 2022, after identifying a gap in participants from previous listening and learning sessions, we expanded these listening and learning sessions to include patients with limited English proficiency. Sessions were held in Somali, Spanish, Hmong, Karen, and American Sign Language. Prior to these sessions, there were limited mechanisms for patients with limited English proficiency to provide feedback about the care they were receiving. This series was an effort to bring more voices to the table and create inclusive opportunities for patients to express their needs and concerns.
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Schedule H, Part V, Section B, Line 5 Facility , 3
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Facility , 3 - Fairview Northland Regional Hosp. Systemwide virtual conversations: We held a series of systemwide virtual conversations focused on the priority need healing, connectedness, and mental health and what that specifically looks like for youth (April 2024), aging adults (March 2024), and Indigenous populations (June 2024). These conversations were open to all, and their goal was to collect and share learnings and resources with participants. The conversations included presentations from community partners about their work, followed by small group discussions that provided valuable perspectives informing our understanding of population-specific needs, strengths, and future state visioning tied to healing, connectedness, and mental health. CHNA surveys To gather input from a broad set of stakeholders on local strengths and the top needs of communities each of the respective stakeholders serves, we developed two aligned, but distinct, surveys. The surveys gathered feedback about: Patient and community members' top barriers to care, social determinants of health needs, and social needs. The unique barriers and assets for patients in one of our priority populations (racial or ethnic populations experiencing health disparities and people experiencing poverty). Barriers that providers and community partners face in responding to the social determinants of health-related needs of patients as well as existing assets and resources available. The surveys were distributed to care team members and partner organizations, including faith leaders. Surveys were administered from mid-February to the end of March. We heard from 472 individuals across our hospital communities and our health system, with 296 responses from care team members and 176 responses from community organizations. Community Health and Healing Summit: Celebrating Culture, Building Connections, Guiding Action - The Community Health and Healing Summit, held in July 2024, aimed to propel our 10-year vision for a healthier Minnesota forward. The summit was a collaborative event bringing stakeholders together to work collectively on prioritizing needs and barriers to health in our communities. It blended the power of community and cultural healing with activities designed to collect participants' insights to not only shape our priorities but to actively drive positive change in our communities. Stakeholder interviews: From May to July 2024, we conducted stakeholder interviews with various Fairview care team members in both acute sites and clinics, including nurses, physicians, schedulers, social workers, care coordinators, and clinic managers. The interviews were guided by the results of our CHNA survey and aimed to gather more in-depth information and stories about the top barriers that had showed up most frequently during the survey. Facilitated conversations: We conducted a variety of facilitated conversations across the health system, a few examples of which are summarized in this section. The goal of these activities is to gain a fuller, more nuanced picture of topic-specific or population-specific perspectives over time. By holding these conversations on an ongoing basis, we ensure that our assessment process and our aligned programmatic or initiative-related work is responding to and engaging with communities in real time. Food is Medicine community conversations: As a part of our Food is Medicine initiative, we partnered with community-based organizations to host a community conversation in each hospital's service area. The goal was to learn more about the community's needs and strengths related to access to healthy food and the role of Fairview as a healthcare provider. In the fall 2023, we held eight Food is Medicine community conversations across different hospital geographies that were attended by 75 organizations representing sectors across the food scape including food shelves, farmers, social services organizations, schools, and municipalities. Town halls: In November and December 2023, we hosted five town hall sessions that were open to the public and geared toward local government relations offices, the business community, community-based organizations, trade groups, civic groups, and rotaries. Each town hall provided an opportunity for community members to receive updates from Fairview, participate in a question-and-answer session with Fairview leaders, and engage in discussions regarding barriers to health and trust in healthcare organizations. East Side Health and Well-being Collaborative: In February 2024, we joined the East Side Health and Well-being Collaborative's meeting as well as the collaborative's mental health and stress resilience work group meeting. In both meetings, we held facilitated conversations about the CHNA process and priority need areas in the community. During the meeting with the mental health and stress resilience work group, we focused on the healing, connectedness, and mental health priority area. Through ongoing partnership and programmatic conversations, we are vetting and refining our understanding of the identified priorities and the responses that would best address them. As a foundational part of program planning and evaluation, Community Advancement staff members are continuously soliciting feedback from community partners and program participants. We capture this information on an ongoing basis and use it to provide valuable context, driving insights into the needs of the communities we serve. Primary data methods: Fairview staff developed standardized tools, processes, instructions, protocols, and training for facilitators, interviewers, and note takers. We compiled, cleaned, and analyzed all primary data. A note taker captured all community input, and when possible, conversations were also recorded. Secondary community data: Claritas is a widely used national demographic estimation tool. Estimates and projections are provided at a zip code level including, but not limited to, population based on age, sex, ethnicity, and income. Spark Maps is a paid subscription that provides mapping and assessment tools that include a large database of indicators, data cleaning, benchmarking, and contextual information. The Bridge to Health Survey has been an important source of data on the health status of adults in northeastern Minnesota and Douglas County, Wisconsin, for more than two decades. The survey is conducted every five years, with the last survey administered in 2020. The Minnesota Student Survey is one of the longest-running youth surveys in the nation. It is a triennial survey that began in 1989. The data used in this report is from 2019. The Area Deprivation Index (ADI) is based on a measure created by the Health Resources and Services Administration over three decades ago, and has since been refined, adapted, and validated to the census block group neighborhood level by Amy Kind, MD, PhD, and her research team at the University of Wisconsin - Madison. Health Trends Across Communities in Minnesota (HTAC) uses information from electronic health records to help fill gaps in the information available to health professionals, organizations, policymakers, and community members to promote health in Minnesota. HTAC is a collaboration among health systems, public health departments, health organizations, and health plans in Minnesota. HTAC uses summary reports from electronic health records on a range of chronic, behavioral, and mental health conditions. The information comes from 11 health systems that make up the Minnesota Electronic Health Record Consortium (MNEHRC). Information from the MNEHRC represents approximately 90% of healthcare for Minnesotans, which makes HTAC a powerful tool to describe the health of many communities. Minnesota Department of Health, County Health Tables were used to look at 2020 county-level top causes of death and premature death.
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Schedule H, Part V, Section B, Line 7 Facility , 1
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Facility , 1 - Fairview Northland Regional Hosp. The Community Health Needs Assessment Report for Fairview Northland Regional Hosp are located at: https://www.fairview.org/-/media/Files/Local-Health-Needs-Final/2024-CHNA-Report_Northland-Medical-Center_Final.ashx The Community Health Needs Assessment and Implementation Strategy for Fairview Northland Regional Hosp are located at: https://www.fairview.org/-/media/Files/Local-Health-Needs/CHNA-Implementation-Strategy-Reports-2025/CHNA-Implementation-Strategy-Report-20252027Northland.ashx
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Schedule H, Part V, Section B, Line 11 Facility , 1
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Facility , 1 - Fairview Northland Regional Hosp. Our triennial Community Health Needs Assessment (CHNA) process provides an important opportunity to engage with and understand our community, analyze what has changed since the last assessment, and prioritize together with the community the issues we must urgently address to improve wellbeing and resilience. As part of the 2021 CHNA process, we reexamined and built upon the extensive community insights shared during our 2018 CHNA, while also surveying the community for current and emerging needs . This work continued in 2024 as we conducted our triennial assessment, further exploring the barriers experienced by community that tie to priority needs. Our 2021 CHNA used social determinants of health (SDOH) as a lens through which we frame our understanding of our community's most significant health needs. A social determinants of health lens enables us to identify inequitable distribution of resources and access that negatively impacts health. Through this lens we looked at both qualitative and quantitative data. Quantitative data included data points related to demographics, physical environment, socioeconomic factors, healthcare, and health outcomes. We collected additional community voice data by convening a broad array of stakeholders, with special focus on the priority populations - racial or ethnic populations experiencing health disparities and persons experiencing poverty. Northland Medical Center has a community advisory committee (CAC) that is involved in the CHNA process. The committee is comprised of local community and organizational leaders, such as local public health entities, social services organizations, higher education institutions, school districts, and local businesses. The assessment process also included discussions with our community advisory council, listening and learning sessions, and key stakeholder interviews. Throughout this process, community members, local business leaders, government representatives, nonprofit and community organizations, and content experts shared their voices and perspectives about their community's health needs. By bringing together both the qualitative and quantitative data, we established a prioritization process through which we could identify the community health needs that, if effectively addressed, would have the greatest positive impact on our communities and particularly on our priority populations. We prioritized areas of need based on four broad criteria: 1) Has this need been voiced by the community? Has this need been vetted by the community? 2) Does this need align with Fairview's strategies and priorities? 3) Does this need align with existing public health strategies and community health assessments? 4) Does this need build upon Fairview's 2018 CHNA priority needs? Northland Medical Center identified three system-wide priority need areas, and will collaborate with other Fairview hospitals, medical centers, and shared business and clinical services to address these priorities. Our specific response varies by hospital based on the ways the priority needs manifest across a given community, as well as the partnerships-both ongoing and new-that we have developed to address those needs. The three identified needs are: 1) Navigating and accessing care and resources, 2) Addressing structural racism and barriers to equity, and 3) Healing, connectedness, and mental health. Development of 2022-2024 CHNA Implementation Strategies As a healthcare organization that works closely with our community advisory committees and community partners, we have listened to community and learned valuable lessons over the past few decades. This has guided us in the development of the Fairview Health Services 2022-2024 implementation strategies. In particular, we learned that: 1) Despite best efforts, health needs and health inequities continue to grow and deepen, 2) Collective action is critical, and 3) Transformational change requires a sustained and focused commitment. In response to our 2021 Community Health Needs Assessment, Fairview hospitals and medical centers worked collaboratively with local and statewide organizations to address our communities' most pressing needs. In addition, Fairview put forth a 2032 vision of increased community health equity. This vision is supported by three strategies designed to address the priority need areas in distinct ways while collectively moving us closer to achieving our goals. The three strategies are: Strategy 1: Addressing Social Determinants of Health (SDOH) - Addressing the SDOH, individual social risks, and social needs through the creation and expansion of programs, initiatives, collaborations, and research, as well as policy, system, and environmental work. Strategy 2: Community engagement infrastructure - Creating a community engagement infrastructure that builds trusting partnerships and enables community voice to inform and influence our health system. Strategy 3: Inclusive institution - Transforming internal structures to create an antiracist and inclusive environment and to build community health by building community wealth. For this three-year cycle, we are implementing strategies to work toward distinct, anticipated impacts for each priority need and to build upon our 10-year vision of increased community health equity by 2032. For more information, the Northland Medical Center CHNA Implementation Strategy Report outlines the major strategies and actions we will deploy throughout the 2022-2024 assessment cycle as well as the ties between the Northland Medical Center CHNA implementation strategies, anticipated impacts, and key responses. Fairview's mission and vision extend beyond traditional healthcare settings, driving a healthier future for the communities we serve. Significant efforts towards Strategy 1 (Addressing SDOH) occurred over the first three years of our 10-year vision. These efforts are demonstrated through three social determinants of health initiatives: 1) Food is Medicine: Using the healing power of food to nourish our patients, enrich our communities, and transform our systems, 2) Housing is Health: Using the protective power of housing to support patient health and build thriving communities, and 3) Connection is Cure: Strengthening the connection between patients and the healthcare system to address social isolation and improve community mental health and wellbeing. These initiatives are key responses that intersect all three priority needs and are also synergistic. Relationship with our partners. Fairview has a long partnership with the University of Minnesota and University of Minnesota Physicians, now represented in the M Health Fairview brand. Together, we offer access to breakthrough medical research and specialty expertise as part of a continuum of care that reaches all ages and health needs. Policy, systems, and environmental change initiatives are implemented across the health system (hospitals, clinics, specialty care) and in some instances, across the M Health Fairview partners, to create sustainable and lasting change to advance health equity and community wellbeing. Where indicated, community responses as a part of Strategy 2 (Community engagement infrastructure) and Strategy 3 (Inclusive institution) represent the work of Fairview in collaboration with the other M Health Fairview partners. Community action plan. Northland Medical Center has an annual CHNA action plan that supports our vision of increased community health equity, rolls up to our system CHNA implementation strategies, and addresses priority needs. The Fairview Health Services Community Action Plan details the specific and measurable steps we will take during the year to drive change. Evaluation of impact. To best evaluate our impact and track progress towards our anticipated impacts, we use a multi-tiered and tailored evaluation approach. Our work is grounded in understanding core information about our communities. This includes identifying and understanding the community needs being addressed, the population or community being affected, current and/or potential partners to work with to address the need, and the impacts we anticipate. Community needs are determined in several ways. In addition to being determined through our formal CHNA process, we respond to emerging needs brought to us by community partners or public health, or those discovered through patient or community data showing significant health disparities. We have standardized several key measures to assess whether we are meeting the needs of the CHNA priority populations, focusing our efforts on equity and participant satisfaction. A subset of established programs and initiatives are set up and supported for deeper evaluation.
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Schedule H, Part V, Section B, Line 11 Facility , 2
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Facility , 2 - Fairview Northland Regional Hosp. We have found that one-size-fits-all, evidence-based approaches may not be a good fit for some of our diverse communities. In response to the unique and differing needs of our community members, our programs are co-developed with community, center on the needs of specific populations, and often incorporate unique local tactics. We approach evaluation from a similar perspective by building evaluation approaches informed by our partners and considering strategies that are culturally and linguistically appropriate, allowing us to determine if the programs reflect the values we set out to embody. Fairview is guided by the Centers for Disease Control and Prevention (CDC) model for program evaluation, establishing primary outcomes, process measures, and demographics. We evaluate program impact and success from a variety of approaches using both qualitative and quantitative data. For many of the programs described here, we are reporting our reach or outputs through counts on a variety of levels that meet the rigor required for grant and contract reporting. In addition, we offer a diverse set of programs that vary on the spectrum of "low touch and high count" to "high touch and lower count." More generally put, the effort and impacts of the programs are not the same. This is a purposeful approach as we want a variety of programs that are appropriate to address the community and population-specific needs. We provide outcomes for programs here when we are able, acknowledging not all programs run on a calendar year, and analysis may not be complete for some of the programs on which we do deeper evaluation. Fairview is currently in the process of building an evaluative approach and capacity for our 10-year vision, increasing community health equity, and our three social determinants of health initiatives: Housing is Health, Food is Medicine, and Connection is Cure. Part of this evaluative approach is a monthly social determinants of health dashboard. In this first three-year CHNA cycle working towards our 10-year vision of increased community health equity, the primary way we are directly addressing the three priority needs is through Strategy 1 (Addressing SDOH). Through this strategy, we create programs and partner with community organizations to address social risk factors, social needs, and social determinants of health. Strategy 2 (Engagement infrastructure) and Strategy 3 (Inclusive institution) focus on building infrastructure and creating system changes so that we can more effectively respond to these priority needs in the future, as well as any emerging needs. Strategy 1 - Addressing Social Determinants of Health (SDOH) Priority Need: Navigating and accessing care and resources. Northland Medical Center has a variety of programs that work as a part of Strategy 1 (Addressing SDOH) to address barriers related to navigating and accessing care and resources. Through this strategy, the Northland Medical Center Action Plan programs work towards two anticipated impacts to address this priority need: 1) Remove barriers to care by providing community-placed care, co-located services, and navigation supports that address cultural and language barriers and 2) Increase awareness of, knowledge about, and access to healthcare and community-based resources that support opportunities for health and wellbeing. The following is more information on a selection of programs from the system community action plan that are working to meet the two anticipated impacts. Fairview System Key Initiative Highlights. The Community Clinical Care initiative involves multiple community-based clinical programs, including Fairview's Minnesota Immunization Networking Initiative (MINI), blood pressure checks, and oral health services. All services are multi-sector, community collaborations that provide care and education to the uninsured, under-served, and communities facing health disparities in the greater Twin Cities area. The Community Clinical Care team provides clinical care in trusted community settings at no cost and improves equitable access to vaccines and other services across various populations. The programs ensure a culturally and linguistically appropriate experience in a safe and trusted environment in partnership with over 250 faith-based and grassroots community partners, serving clients at local churches, mosques, temples, schools, community centers, food pantries, and homeless shelters. Across the system in 2024, the community clinical care team provided blood pressure and oral health services at 241 events, including 1 event in the Northland Medical Center community, providing 418 blood pressure checks, and 696 dental fluoride applications. The team also hosted 443 vaccination clinics across the system in 2024. There were 5,525 free COVID-19 vaccine doses and 6,190 free flu shots administered. Of those participants who shared their identity, 72% of people who received a COVID-19 vaccine identified as a person of color and 35% indicated a language other than English as their preferred language. In the Northland Medical Center community specifically, there were 2 MINI clinics at which 103 flu shots were administered. In August 2024, MINI received an invitation to publish an article in the special Public Health issue of the New England Journal of Medicine discussing their cross-sectoral, equity-based approach to COVID-19 response. Later in the year, they published a similar article in the Journal of Public Health Management & Practice, this time focusing specifically on reducing vaccination barriers for refugee, immigrant, and migrant communities during the COVID-19 pandemic. MINI also presented at the 2024 North American Refugee Health Conference. The Youth Education Partnerships Programs collaborates with local high schools to host events where students are exposed to healthcare career opportunities including learning new skills, hands-on experiences, and hearing from health care providers. In 2024 Northland Medical Center hosted 9 events reaching 295 students. The Fairview Community Health and Wellness Hub (The Hub) opened in 2022. The Hub is a first-of-its-kind center that addresses health disparities while providing a range of critical healthcare services and community resources alongside trusted local partners. The Hub provides a variety of services to the community, including primary care, mental healthcare, enrichment options for seniors, food access programs, and community gathering spaces. We bring our own services together with local organizations to make it easier for people to access what they need to thrive. Throughout the year, 7,090 individuals attended 176 events or meetings at the Hub. Eighty-three of the events were public and partner events, reaching 3,263 individuals. Ninety-three events were internal Fairview events. Additionally, we hosted nine Hub Partnership Coordination Meetings, as well as one-on-one check-ins with each of the partners. These meetings serve to deepen our understanding of the diverse missions, visions, and impacts of each Hub partner, fostering better alignment and collaboration. In 2025, we plan to transition to quarterly in-person partnership meetings. This strategic move aims to enhance our collaborative efforts and drive impactful initiatives. In 2024, we continued to expand our work relating to opioid overdose prevention in partnership with the Steve Rummler Hope Network. Fairview's Community Clinical Care team trained several staff members to become naloxone educators, who can then train others. Educators train community members on how to recognize an opioid overdose, what naloxone (Narcan) is and how it works, how to administer naloxone to someone experiencing an overdose, and information about Steve's Law/MN's Good Samaritan and Naloxone Law. In total, there were 39 naloxone trainings where 944 individuals were trained in 2024. In addition, Fairview opened a fourth naloxone access point (NAP) site that provides free kits, extending this important resource to Greater Minnesota. NAP sites are stocked with nasal Narcan and intramuscular naloxone kits, many of which are packed at Fairview volunteer events. In 2024, 12,995 such kits were packed and distributed across our hospital communities. The Community Clinical Care team plans on opening several additional NAP sites in 2025.
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Facility , 3 - Fairview Northland Regional Hosp. Fairview hired two Food Resource Navigators in 2024, exemplifying the intersection of Strategy 1 (Addressing SDOH) and navigating and accessing care and resources. Food Resource Navigators serve as experts both in Fairview's Food is Medicine programs, as well as community food resources and government programs such as SNAP and Market Bucks. Rolled out in select clinics across the system, Food Resource Navigators receive clinical referrals when a patient screens positive for food insecurity and expresses interest in being connected with additional support or resources. In 2024, our Food Resource Navigators received 561 referrals across the system. Of those referrals, 84% of individuals were connected with internal and/or external resources. Over the next several years, this role will be expanded to additional clinics. In this way, we can support patients in navigating the complex landscape of healthcare and social services. Priority Need: Addressing Structural Racism and Barriers to Equity. Northland Medical Center, in alignment with Strategy 1 (Addressing SDOH), has a variety of programs, events, and community education as a part of the Community Action Plan that work toward the anticipated impact: Develop, grow, and sustain programs, educational offerings, partnerships, and initiatives to address structural racism and barriers to equity. Fairview System Key Initiative Highlights. One of the Fairview social determinants of health initiatives, Food is Medicine, utilizes the knowledge and resources of a large healthcare institution to work towards meeting the immediate needs of our patients, while also transforming the food system into something just, equitable, and sustainable. The initiative aims to 1) Nourish our patients: Advance food security to reduce health disparities and diet-related health conditions. 2) Enrich our communities: Cultivate trusting and engaged partnerships to build and share resources, assets, and capacity. 3) Transform our systems: Nurture just and equitable food systems to ensure health equity. These approaches are framed to increase health equity through focused efforts to serve patients who have been historically marginalized by providing culturally appropriate food options and reducing food insecurity in a manner that upholds dignity and empowers the local food system. Clinically, it enables providers to serve patients experiencing food insecurity through a menu of distinct programs comprising an innovative wrap-around approach. One or more of the Food is Medicine programs-a selection of which are described below-are available to patients in 52+ clinics and 8 acute sites across the health system. One of the Food is Medicine initiative programmatic responses is the fresh food prescription program, which distributes fresh, locally grown produce from three farm partners (Hmong American Farmers Association, Naima's Farm, and Women's Environmental Institute) via a weekly food box. The boxes also contain proteins, whole grains, and pantry staples, as well as a newsletter with community resources and tips for healthy cooking and eating. Crucially, the program offers home delivery to address transportation barriers. In 2024, 31 clinics participated in the fresh food prescription program across Fairview hospital and medical center communities, one being in the Northland Medical Center community. Almost one third (31%) of program participants identified as Asian, 17% as Black, and 2% as Hispanic/Latino. While just 70% of participants speak English as a preferred language, 7% had a preferred language of Hmong, 14% Karen, and 1% Spanish. Most participants had public insurance (79%) or were uninsured (2%). Fairview's food voucher program provides patients with vouchers to redeem at either the Twin Cities Mobile Market or Fare for All program. The program runs year-round and offers rolling enrollment. Throughout the year, 443 patients redeemed vouchers for groceries, including 12 from the Northland Medical Center community. Additionally, we provide shelf-stable food resources for those with an immediate need. The shelf-stable food bags were incorporated into Northland Medical Center for the first time in 2024. The bags come in six different varieties tailored to meet the preferences of diverse cuisines and circumstances. In 2024 there were 6042 shelf-stable bags distributed at 37 sites across the system. There were also 258 food resource packets distributed that contained information about local food resources along with immediate food support. In coordination with seven local churches, Fairview Northland Medical Center nutrition services offers a program called Meals a la Car. Northland Medical Center prepares healthy meals in the kitchen at Northland, and volunteers deliver those meals to the City of Princeton recipients, targeting senior citizens. The person-to person delivery model provides a social connection to people who might otherwise be isolated, as well as an opportunity for the delivery driver to do a welfare check. In 2024 there were 1,457 meals provided to seniors. In November 2024, Fairview and local partners hosted the third annual Harvest at the Hub, welcoming 312 households to the Fairview Community Health and Wellness Hub. The event consisted of a food giveaway with turkeys, fresh produce, and other holiday staples, a community resource fair, a vaccine clinic, and other health and wellbeing services. Another of the Fairview social determinants of health initiatives, Housing is Health also responds to the priority need of structural racism and barriers to equity . The Housing is Health initiative aims to use the protective power of housing to support patient health and build thriving communities. We approach this initiative with clinically connected programs, supportive community partnerships, contribution of time and expertise to collaboratives, and efforts to impact policy. For example, Fairview partners with Our Savior's Community Services to provide critical follow-up care and temporary housing for people who are unsheltered after a hospital stay. Patients are referred by staff at a hospital or medical center and sheltered at Our Saviors. Additionally, a nurse provides care, and patients receive wrap-around services and social work support. In 2024, 50 patients were provided support through this program. As a part of Housing is Health, we are also proud to have helped launch Healthcare for Housing (HC4H). HC4H grew out of the Housing and Health Equity Fellowship and consists of seven health providers and payers. We also strengthened our housing advocacy activities in 2024; we chair the policy workgroup for HC4H, participated in Homeless Day on the Hill at the Minnesota State Capitol, and submitted letters of support for multiple housing initiatives. In September and October 2024, teams from across the system participated in two Twin Cities Habitat for Humanity builds. Volunteers contributed 300 hours for the Carter Work Project build. During our annual build week with Twin Cities Habitat for Humanity, staff contributed 560 volunteer hours.
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Facility , 4 - Fairview Northland Regional Hosp. Priority Need: Healing, Connectedness, and Mental Health. Northland Medical Center works toward the anticipated impact: develop, grow, and sustain programs, educational offerings, partnerships, and initiatives, address barriers to healing, connectedness and mental health through Strategy 1 (Addressing SDOH) and the Community Action Plan. Fairview System Key Initiative Highlights. In response to the priority need of healing, connectedness, and mental health, we have a body of work that makes up the Connection is Cure initiative. Connection is Cure aims to build trust through social connections, center linguistic and cultural diversity, and bridge silos across our hospital system and communities to transform medical practice. As a part of Connection is Cure, we hosted virtual conversations in 2024 around how we can improve mental health services for specific populations: Native patients, youth, and older adults. Three conversations were held-one for each respective population-reaching a total of 108 community members. Other gatherings fostering healing, connectedness, and mental health were held in 2024 as well, including a Heal the Healers event. Exemplifying the integration of traditional healthcare with ancestral and cultural practices, the Heal the Healers event united local healers and caregiving professionals for a transformative day of self-care, learning, and the revival of ancestral practices. Our goal was to empower practitioners and community workers with activities that foster self-care, ensuring they remain strong and resilient for the communities they serve. This and other healing events laid the groundwork for the Community Health and Healing Summit, convened as part of our innovative approach to the Community Health Needs Assessment. Over 100 participants gathered for a day of learning about the health conditions in their local communities, seeking to understand the efforts of the system and collective community in addressing these issues. For many attendees, the event also served as a welcoming introduction to cultural and non-traditional healing practices; individuals had the opportunity to experience these practices firsthand while learning about their application within the community and our health system. As part of our commitment to addressing barriers to healing, connectedness, and mental health, we also launched our Birth Justice Initiative, a cross-departmental effort to advance equity and inclusion in birthing experiences. Focused on eliminating racial bias in maternal healthcare and improving patient outcomes, the Birth Justice Initiative is making systemic changes to improve the quality of healthcare for all pregnant persons. Their research and advocacy led to the removal of race-based maternal health screening tools, which can accidentally introduce bias into medical decision-making. Additionally, part of the design of a new prenatal and postpartum clinical care map includes screening all pregnant patients for social determinants of health and lead exposure, empowering healthcare providers to act early to address these concerns. In 2024, departments participating in the Birth Justice Initiative interviewed 649 people who gave birth in the Fairview health system and gathered input from doulas. Based on their feedback, we plan to rewrite policies to enhance culturally congruent care, tailoring maternal healthcare to the specific cultural values of each patient. Additionally, we are responding to the need for healing, connectedness, and mental health with a variety of evidence-based programs, as well as trainings and education sessions. Feeding Hope is a series of virtual one-hour learning sessions focused on positive, hopeful topics that support wellbeing in the general community. This series is offered in partnership with all Fairview's hospitals and medical centers and is open to anyone across all of Fairview's communities. In 2024, across Fairview hospitals and medical centers there were two sessions held with 60 attendees total. Lifelines is a comprehensive suicide prevention program that targets the entire school community, providing suicide awareness material for administrators, faculty, staff, parents, and students. Basic information about youth suicide is provided and is primarily directed at helping everyone in the school community recognize when a student is at potential risk of suicide and understand how and where to access help. This research-based program is included in the Substance Abuse and Mental Health Services Administration's (SAMHSA) National Registry of Evidence-Based Programs and Practices. The curriculum is provided by Hazelden-Betty Ford Publishing. In 2024 in the Northland Medical Center Community there were two active school districts. Psychological First Aid is an evidence-informed training for the broader community as well as professionals. Trainees learn how to support healthy recovery for individuals following a traumatic event, public health emergency, natural disaster, or personal crisis. The curriculum integrates public health, community health, and individual psychology by drawing upon skills the trainees probably already have. Psychological First Aid is a two-hour training. In 2024, in the Northland Medical Center community, there were three classes offered with 50 participants attending. A Creative Look at Self-Care (formerly Refresh and Reset your Resiliency) promotes resiliency skills, offers wellness-care tools for mind, body, and spirit, and encourages the development of a personal plan for self-care. In 2024, in the Northland Medical Center community, there was one class offered with 17 participants attending. Together, Fairview's Strategy 1 (Addressing SDOH) initiatives and the programs outlined within our action plans comprise a strategic, innovative, and equity-minded approach to community health. We take great care to co-design programmatic responses with the communities impacted by them and collaborate with a broad range of community organizations and other multisectoral partners to address the social determinants of health. In recognition of our commitment to this work, Fairview advanced as a finalist for the American Hospital Association's Foster G. McGaw Prize. Five programs were profiled in Fairview's award submission: Minnesota Immunization Networking Initiative; East Side Health and Well-being Collaborative; Fair Table, Fairview's Food is Medicine initiative; Health Commons; and our Cultural Broker program. It is a great honor to be considered for this award; it serves as motivation to work harder than ever to advance health equity, and to intentionally do so in authentic partnership with the communities we serve. In addition to Strategy 1 (Addressing SDOH) and the programmatic work included on our Action Plans, we strive to reduce health disparities and increase community health equity through two additional system strategies. While Strategy 1 (Addressing SDOH) allows us to directly respond to the three prioritized needs from our community health needs assessment, Strategy 2 (Engagement infrastructure) and Strategy 3 (Inclusive institution) focus on building the structures and systems for us to do the work more capably.
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Facility , 5 - Fairview Northland Regional Hosp. Strategy 2 - Engagement Infrastructure Addressing our three priority needs while also responding to emerging needs requires an infrastructure that supports building and sustaining strong community partnerships and allows for ongoing, trusting exchanges between Fairview and community members. The importance of this is manifest in Strategy 2 (Engagement infrastructure): Creating community engagement infrastructure that builds trusting partnerships and enables community voice to inform and influence the institution. The anticipated impacts for this strategy are: 1) Build and expand feedback systems for patients and community members; embed process improvement in the health system's response to community voice and 2) Create sustainable structures to convene and engage community voice around addressing social determinants of health. While Fairview boasts an extensive engagement infrastructure already, we continued to bolster the work we do to expand feedback systems and sustainable convening structures. Core to this is building and sustaining trusting partnerships. Our Northland Medical Center Community Advisory Committee (CAC) met through the year to offer input and provide local insight and expertise. Notably, 2024 marks the first year since the COVID-19 pandemic in which we convened our CACs in-person, celebrating the joy of being together in the same room and the spirit of collaboration that it fosters. To enhance the work of each hospital CAC, in 2024 we revitalized our System Community Advisory Council. Spanning the entire health system, the System CAC incorporates the need for internal representation, local representation, and representation from organizations that represent our priority populations. While it plays a large role in advising the CHNA process and implementation, it also ensures the voice of priority populations remain at the center of all discussions and decisions. The System CAC met five times in 2024, providing guidance and insights throughout the Community Health Needs Assessment process. A central part of our community voice work and philosophy, the M Health Fairview Center for Community Health Equity (the Center) was launched in August 2022. The Center guides our efforts to gather community voice and tie the learnings back into the organization. Throughout 2024, we hosted three Center Community Health Equity Work Group meetings to hold strategic discussions on issues of relevance to the center. The Center for Community Health Equity also presented a session at the 2024 American Hospital Association's annual conference . This session focused on the lessons we learned from conducting community input sessions for community members with limited English proficiency, giving us the opportunity to socialize best practices and learn from the experiences of other healthcare systems. Over the course of the year, the Center continued to build out its SDOH platform and community engagement framework, guiding the implementation of the 2024 Community Health Needs Assessment approach. For a detailed explanation of how we integrate community voice into our Community Health Needs Assessment process, please view our 2024 CHNA reports: Community Health Needs Assessments - 2024 Enabling community voice, particularly the voices of priority populations, to influence and inform the health system is integral to Strategy 2 (Engagement infrastructure). In 2024, the Center for Community Health Equity and Fairview's Quality Improvement team began a joint enterprise to incorporate community voice into the way in which we define, implement, and measure healthcare quality. Members of the East Side Health and Well-being Collaborative and the System Community Advisory Committee gave input regarding what "quality "quality care" means to them, informing the development of the system's ambulatory care composite (high priority quality measures). The priorities yielded by their insights will drive organizational work for the next several years as we work to deliver the highest quality of care to our patients and community. Building our engagement infrastructure involves connecting broadly with community as well as building our capacity to engage with complex and intersectional groups. We are building a set of population health equity initiatives, one of which is the Native Health Equity Initiative (NHEI). As part of this body of work, in 2024 Fairview staff stood up the Indigenous Healing Circle Employee Resource Group to create sacred space for Native employees and patients and reconcile disparities unique to our Native relatives. Fairview also developed a system-wide land acknowledgement to raise awareness of how inequities have impacted the geographies and people we serve and guide us in our work to advance equity and inclusion. The land acknowledgement was published in our 2024 Community Health Needs Assessment report. Throughout our Native health equity efforts, we also hosted a Healing in Four Directions Powwow for more than 350 community members from across the state with partners including St. Paul Public Schools Indian Education, South St. Paul Public Schools Indian Education, Minnesota Indian Affairs Council, and the American Indian Family Center. Later in the year, we participated in the 2024 American Indian Day on the Hill and sponsored Indigenous Peoples Night with the Minnesota Aurora soccer team in collaboration with Northern Indigenous Games and Twin Cities Native Lacrosse. Community outreach in 2024 included providing mobile nursing services at four local powwows and events, including the Indigenous People's Health Fair. As part of the effort to incorporate Native health equity into systems and processes, Fairview reviewed its smudging policy and updated educational tools, providing training at acute care sites about the ritual and how it can be practiced in a clinical setting. In the Northland Medical Center, we participate and are active members on collaborations such as Age Friendly Princeton, Princeton Chamber of Commerce, Tiger Community Connections, East Central Regional Transportation Coordinating Council, and Rum River Housing and Homelessness Coalition. These are spaces where we do ongoing listening and relationship building with community partners and community members. Strategy 3 - Inclusive Institution To successfully address our three priority needs and improve the health and wellbeing of our priority populations, it is imperative that we are guided by Strategy 3 (Inclusive institution): Transforming internal structures to create an antiracist and inclusive environment and to build community health by building community wealth. The anticipated impacts tied to Strategy 3 (Inclusive institution) are: 1) Build internal and external processes and structures to provide spaces that are safe and welcoming to all, responsive to community needs, and based on a culture of inclusion, 2) Use an antiracist approach and work to identify and eliminate racism by changing systems, organizational structures, policies, practices, and attitudes, and 3) Leverage everyday business practices to build community wealth, promoting economic and racial equity and justice. Key achievements in alignment with Strategy 3 include the launch of standardized social determinants of health patient screenings (e.g., food security, housing stability) at all ambulatory care sites. In 2024, 414,359 primary care patients across the system completed social determinants of health screenings. We also implemented targeted interventions to improve healthcare disparities, resulting in marked improvement in breast cancer and colon cancer screening rates. In particular, breast cancer screening rates improved among Karen, Hmong, and Somali patients because of six mobile mammography events. Additionally, we are building capacity across the system for more individuals and teams to participate in the Intercultural Development Inventory.
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Schedule H, Part V, Section B, Line 11 Facility , 6
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Facility , 6 - Fairview Northland Regional Hosp. Operational improvements driven by the Equity Strategy Office identify and address experience and outcome gaps for employee sub-groups and within patient care and outcomes. Improvements include related dashboarding and reporting across all organizational performance dimensions. This reporting informs the creation of actions plans to mitigate and address identified gaps and create line of sight to progress being made. In 2024, pathways were created to collate and incorporate voices and insights from the patients, employees, and community members Fairview serves. These pathways are being piloted and operationalized in 2025. Robust and strategic efforts across Patient Safety, Human Resources, and Customer Experience to identify and address multiple forms of harm were also supported. In addition, during 2024, units across the organization operationalized systems to identify and prevent potential gaps in care and outcomes across patient populations. Our anchor strategy works to advance health equity by investing in the social and economic wellbeing of the communities we serve through our everyday business practices. The strategy focuses on local and diverse hiring, purchasing and investing, and serving and leading with trusted community partners. Fairview's Workforce Partnerships team addresses the social determinants of health by helping people secure employment with family-sustaining wages and benefits, achieve success in their jobs, and learn new skills. The team also focuses on inclusive, local hiring, resulting in a healthcare team that represents the communities we serve. Supply Chain leaders launched a Supplier Diversity program, including updating request for proposal language, creating a new webpage, and identifying potential diverse vendors. Fairview also has a robust social corporate responsibility program including employee volunteerism, memberships, affiliations, and sponsorships. In 2024, there were 13 systemwide employee volunteerism events hosted, including Habitat for Humanity and Twin Cities Pride. Additionally, Fairview staff sit on boards and are members of a diverse set of community organizations. Fairview's sponsorship program is aligned with our commitment to advancing health equity. Our organization provides sponsorships to support local community organizations aligned with our system's priorities. To increase diversity and trust in clinical trials, the Center for Community Health Equity partnered with Fairview Frontiers to develop a community engagement strategy and improve representation in clinical trials. Together, they presented "Integrating Cultural Considerations for Research Participants" to the University of Minnesota research managers, providing education on the importance of diverse participation in research and how to do so thoughtfully and equitably. Fairview Frontiers also appeared at four different community events for "Research 101," informing community members about the process, benefits, and challenges of participating in a research study. Together, Fairview Frontiers and the Center for Community Health Equity are working to engage the community more directly in clinical research with the aim of improving both the process and the outcome of such studies. Significant needs not addressed. Prioritizing needs identified by our communities allows us to develop upstream strategies that will have a large and lasting impact in our communities. The priority needs we have identified will ultimately be positively impacted by addressing their root causes. The following needs were not directly addressed because these issues are outside the scope at this time: cost of care, insurance and medications, childcare, and employment benefits. The following needs were not directly addressed because they fall outside of the scope of the Community Health Needs Assessment Implementation Strategy: clinic/hospital hours, limited time spent with provider, and limited specialty care. This feedback was shared with the appropriate teams to address as part of clinical care.
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Facility , 1 - Fairview Northland Regional Hosp. The Minnesota Attorney General agreement was used in the determination of the eligibility for financial assistance.
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Facility , 1 - Fairview Northland Regional Hosp. A summary of the Financial Assistance Policy is posted in various locations in the hospital.
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Facility , 1 - Fairview Northland Regional Hospital. Pursuant to Treas. Reg. Section 1.501(r)-6(c), Northland Regional Hospital made reasonable efforts to determine whether an individual was FAP-eligible for care by satisfying the requirements of Section 1.501(r)-6(c)(3).
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Attach to Form 990 or Form 990-EZ.