Like many of Hennepin County’s poorest residents, Alfred McClary suffers from multiple chronic health problems that require lots of attention to manage.

“I’ve got so many medications here,” the 60-year-old Minneapolis resident said recently. He takes as many as 10 a day. He’s had gout surgery in the past month, and peripheral artery disease causes excruciating pain in his legs. The pain cost him his longtime job in purchasing at a hotel a few years ago, he said.

It’s patients like McClary that Hennepin County is working with to hold down costs through Hennepin Health. The nation-leading effort, launched a year ago with federal approval in conjunction with the state Department of Human Services, gave Hennepin Health control of Medicaid dollars, allowing it to integrate medical and behavioral health care with social services.

The state often will contract with a managed-care company to run Medicaid for a county, but Hennepin County already had an HMO infrastructure to try innovating on its own.

“Everybody’s watching us,” said health care lawyer and analyst Keith Halleland. “We may be crazy, but there are good signs. I’m a believer myself.”

The project is making inroads in improving coordination of medical care for the indigent and in controlling costs. “From the information we’ve seen so far, it is working,” said Scott Leitz, assistant commissioner of the state Department of Human Services. Now other counties are considering similar efforts, he said.

One of Hennepin Health’s first moves was to put a dental clinic at Hennepin County Medical Center in downtown Minneapolis. That was crucial, because the poor often have troubles with their teeth that grow into bigger health problems. Other initiatives focused on medication management and chemical dependency.

“What we liked about it was that they were really focused on upstream and primary care … rather than on the emergency-room care,” Leitz said.

Service up, costs down

The program, which started with almost 5,000 enrollees, is now at 6,200 with recent Medicaid expansion. That number is growing by about 200 per month, according to program director Jennifer DeCubellis.

Hennepin Health patients come with a cluster of needs and minimal medical literacy and little to no preventive care, she said. For example, almost half are chemically dependent. A third have chronic pain-management problems, more than one chronic disease and unstable housing. The target group is adults ages 21 to 64 with no dependent children at home and income at or below 75 percent of the federal poverty guideline ($8,124 a year for one person) who qualify for Medical Assistance.

In its first year, Hennepin Health reduced hospital admissions for that group by more than 20 percent and cut emergency room use by a similar percentage. DeCubellis said patients have been redirected to an expanded urgent care center where they also are strongly encouraged to link up with primary care providers.

Sometimes a simple fix is all that’s needed. For example, De­Cubellis said, delivering medications to the homeless shelter has cut down on the number of indigent patients showing up in the emergency room for prescription refills.

As a result, the county has been able to reinvest more than $1 million in savings toward filling service gaps.

Hennepin County Board Chairman Mike Opat calls it “heads-up health care” to the chronically sick with “bad teeth, bad feet and often uncontrolled diabetes.”

“They’re just people we’re going to have to take care of,” he said. “We interact with them more, but they don’t end up in a hospital bed at the end of it.”

More improvements to come

McClary is among them. In the past couple of years, he moved from a homeless shelter to an apartment. He needs to move again, he said, because he cannot navigate the 15 stairs to his apartment. “I’m a mess,” he said. “I can walk a block, but then I have to sit down.”

To further help patients like him, Hennepin Health next will improve care coordination and data analysis. Other plans: a sobering center to staunch the overflow of detox patients to the emergency room, interim housing for medically complex patients, vocational support, and behavioral health and psychiatric counseling.

The dearth of psychiatrists to serve these patients has been a major concern. On a first visit, a patient might get a 30-day supply of meds, but then have to wait six weeks to see a psychiatrist. DeCubellis said “real-time consulting” is a goal to quickly diagnose and stabilize patients.

The Hennepin Health model can be replicated, Leitz said. For instance, 12 southwestern Minnesota counties have banded together to administer Medicaid. “We’re very interested in supporting those types of models,” he said. “What works in Hennepin might not necessarily work in southwestern Minnesota.”

Meanwhile, McClary is hanging on, and credits the county with doing the best it can for him. “I’m not complaining,” he said.