The first thing people see when they enter the small clinic inside the Hennepin County Medical Center is Sarah Bruemmer's smile.

And that's by design.

"I know their stories, and they know mine," said Bruemmer, the receptionist and "patient care guide" at HCMC's Coordinated Care Center in downtown Minneapolis.

It seems obvious, having a receptionist who recognizes patients and greets them by name. But Bruemmer is part of a trailblazing effort taking shape across Hennepin County, in which clinics are using an intensely personal approach to keep the poorest and neediest patients from bouncing in and out of the hospital.

Teams of social workers and case managers have set up shop at places like HCMC's Coordinated Care Clinic to focus on getting patients the social services they need -- such as housing, transportation or mental health care.

The new approach comes at a time when federal health care efforts are pushing hospitals to put prevention ahead of costly treatments. But Hennepin County will move forward on its own, with or without government prompting, said Jennifer DeCubellis, the county's director for Human Services and Public Health.

That's because tapping into county services at the front end has proven to be a cost-effective way to keep people healthier and out of the emergency room. Among the 150 patients the Coordinated Care Clinic sees, emergency room visits were cut in half in the first year. Hospital visits, which can cost $20,000 to $40,000, have declined from an average of five to three.

"If you want to look at the future of health care, look at what they're doing at Hennepin County," said former Republican U.S. Sen. Dave Durenberger, senior health policy fellow at the University of St. Thomas. "You've got the biggest hospital in the state, it happens to be a public hospital, and it happens to be quasi-owned by the county. Who else is going to see the impact of failed programs and failed health care than the county?"

In January, Hennepin County will expand its front-loaded approach into a formal demonstration project with the state to see if it will work on a larger scale. By August, it could include as many as 12,000 low-income adults, a group that tends to use a disproportionate share of county medical and social services.

The bedrock idea is that people can't take care of their health until their basic needs are met. Under the demonstration project, more than two dozen clinics will be set up as hubs, and people who aren't necessarily medical experts will work with patients to tap into the county's vast resources -- including public housing, food shelves and services for mental health, addiction, domestic violence, corrections and immigration.

"Hennepin County is truly the place of last resort," said DeCubellis, director of the program, formally known as Hennepin Health. "If something doesn't change, the taxpayers of Hennepin County will pay, not to mention the lives that are thrown into chaos. Nothing in our toolbox fits, so we need a new set of tools."

Simple changes, big results

Stories of early success include that of a diabetes patient who kept showing up in the hospital with an upset stomach. A case worker discovered his refrigerator didn't work and he wasn't taking his medicine with food. She helped him get financial assistance.

Or the case of Clarence Anthony, 55, who has congestive heart failure. He wound up in the hospital three times in February and two times in March. Once connected with the HCMC clinic in March, case workers arranged for the nurse at the homeless shelter to weigh him daily to catch a sudden change. The clinic also gave him a pillbox that helped him take his pills regularly, and a bus token when he needed one.

He hasn't been to the hospital since.

"It seems like something so simple," said Anthony, now living with a friend and on a waiting list for public housing. "But they've done good by me and I appreciate it."

New financial model

The county was pushed into the new approach in 2010 after former Gov. Tim Pawlenty and the Legislature changed the reimbursement payments for low-income adults. Instead of the traditional fee-for-service, health systems were given a reduced block of money to manage.

Gov. Mark Dayton restored some of the federal funding when he took office, but the county was on its way to making fundamental changes.

Ten percent of total costs were racked up by 60 patients in intensive care units, much of them "preventable admissions," according to the county. That's the equivalent cost of nearly 25,000 outpatient visits or 16,000 emergency room visits.

Under the demonstration project, an estimated $120 million in Medicaid dollars will go directly to Hennepin County and its health plan to manage, rather than having private health insurers reimburse the hospital and clinics based on the number of medical services.

The hope is that giving the county the flexibility to funnel money where it's needed, whether for addiction treatment or to hire more crisis outreach workers, will lead to system-wide savings in law enforcement, corrections and other community agencies, DeCubellis said.

Expansion challenges

Dr. Paul Johnson, director of the HCMC Coordinated Care Center, said he is energized by the results of the clinic's first year. But he isn't shy about laying out the challenges of expanding the model.

Johnson is one of two part-time family physicians, working with a small full-time staff that includes a nurse practitioner and social worker. Each case manager handles 40 to 45 patients, compared with a more typical ratio of one for every 300 patients. That level of attention "just isn't sustainable," he said.

Expanding to care for 10,000 people would require up to five full time primary care doctors, who are in short supply at HCMC, as they are across the state.

But Johnson is also hopeful.

He gives patient Chris Choice a fist bump when Choice announces he's been sober for about seven months. Because of that, Johnson can dial back the blood pressure medication even further, and give more attention to helping Choice, 54, cope with shortness of breath and other lung problems.

"The exciting thing to me is that many of the things we treat here as medical illnesses are really more properly addressed in other realms," Johnson said. "They're really social service problems that need to be more adequately cared for. To bring all of that together, so we're all working to solve the needs of our patients, is really exciting."

Jackie Crosby • 612-673-7335