North Memorial reaches out to high-risk communities


HealthRise is a collaboration between Pillsbury United Communities (PUC) and North Memorial Medical Center to help address health disparities in Minneapolis’ Camden and Near North neighborhoods. Funded by Medtronic Foundation, the program uses a “Care Team” primarily serving African American participants ages 60-65  — a population segment that is at highest risk for hypertension and diabetes.

“The goal of the project is to reduce pre-mortality and to improve access to quality health care and healthy food,” said Naomi Sadighi, director of PUC’s Oak Park Center.  HealthRise works to achieve that by addressing the whole person. There are approximately 100 people enrolled in the program, who are graduated out when they meet their goals. HealthRise averages 40 home visits per month, including first and follow up visits.

The collaboration is successful because PUC has a firm understanding of the needs of the community, while North Memorial wants to improve their relationship in the neighborhood by improving local family practice clinics with closer connection to the patients. Sadighi posed the question: “Does North Memorial know how to go beyond the conversation of ‘You have to eat better?’”

She pointed out, “It is helpful for North Memorial to have the conversation around a realistic health plan with the patient.” In other words, “This is how you can eat better in your community.”

HealthRise, located in North Market, is the “physical manifestation of the goal of this program,” said Sadighi. The program’s wellness center in North Market includes a pharmacist, nutritionist, and wellness coordinator. It provides access to healthy food and healthcare education.

MSR asked about benefits resulting from the holistic care approach. Sadighi affirmed there were positive quantitative and qualitative improvements. Quantitatively, patients entering the program begin by having their A1C and blood pressure measured to determine the best way to work with the participants. Qualitatively, patients are demonstrating improved attitudes and more confidence in ways to manage their health care.

When a doctor gives a diagnosis to a patient, that patient’s confidence can be pretty low, because the diagnosis can be a little complicated. “Maybe they don’t trust the instructions they are given from the provider, because maybe they don’t trust the provider,” said Sadighi.

A HealthRise community health worker works with patients to slowly instill confidence, help them to better understand the medication, and teach them how to take better care of themselves. “We can lower their numbers tomorrow with medication, but [HealthRise teaches patients] long-term skills to take care of their health,” she said.

Naomi Sadighi, director of Oak Park

Baby steps to better health

One technique with a particular patient was to use “baby steps” to change poor health habits. The person’s physical condition made it difficult to be treated in the clinic, so care was managed in the home.

The patient was severely diabetic, going blind, and a double amputee, having lost both legs. The person was housebound and in denial, blaming the condition on having had to stand long hours working at a grocery store. The community health worker found a fundamental difference between the diagnosis and what the provider was telling the patient.

HealthRise focused on education, building trust, and building a relationship with the patient, who was determined to drink juice that was mostly sugar. Within a month, the watered-down juice was replaced with watered-down Diet Coke. Eventually, the patient demonstrated a willingness to make changes. “We know this is baby steps, but it was a success,” said Sadighi. “The patient’s numbers improved dramatically.”

North Memorial clinic support

HealthRise also partners with North Memorial clinics in Camden and Plymouth. North Memorial requested support with patients who were having trouble with their numbers.

HealthRise does an initial visit with the healthcare worker and with the North Memorial community paramedic. Sadighi said the community paramedic has added training in community work, building long-term relationships, assessing medication, doing blood draws, and other duties typically conducted in a medical clinic.

The community health worker conducts social service evaluations inquiring about basic needs that are barriers to implementing health changes. These needs can be addressed with food stamps, housing, clothing and childcare, for example.

Sadighi said one of the biggest challenges for the program is finding and getting commitments from people in the community. “Just because we know they’re out there doesn’t mean they are available or willing.”

Another challenge is finding community health workers. “You can’t just post an ad for a healthcare worker. It has to be someone [who lives] in the community and understands the community. That’s not someone who would be on looking for a job.”

Sadighi concluded the interview with an appeal: “Everybody cares about their health and everybody wants to be healthy. Oftentimes, people think this population just doesn’t care, and that’s not true. We need to provide the tools so everyone can live a healthy life.”


A grant from the Medtronic Foundation helped make this story possible.