Minnesota's Action Plan to Address Cardiovascular Disease, Stroke, and Diabetes 2035

• Strategy 1-1: Specifically budget time and resources for relationship building.

  Example actions:

  • Budget time at the start of projects for listening and building relationships and trust.
  • Identify realistic expectations about the time commitment needed for group meetings and projects to successfully build relationships.
  • Financially pay community members and community-based organizations for their time and effort.

• Strategy 1-2: Develop relationships around common goals.

  Example actions:

  • Create space to learn about community or organizational goals and needs.
  • Work to identify common goals shared across organizations that can bring organizations together.
  • Partner with community groups or organizations to identify meaningful indicators of success.

• Strategy 1-3: Seek out opportunities to engage and participate in partnership with communities, healthcare networks, and other sectors.

  Example actions:

  • Show up and participate in existing community and other multi-sector efforts to improve community wealth and well-being.
  • Explore partnerships across sectors, disciplines, regions, and geographies that have not traditionally been included or pursued.

Success Story Spotlight - Partners in Prevention Clinic: Using a public health nursing model to foster conversations about health and wellness and to build a strong nursing workforce. Watch the full story here:

• Strategy 2-1: Recognize and address how biases often operate together, in order to build equitable health and social systems.

  Example actions:

  • Assess organizational practices and build a plan with concrete, time-bound actions to improve equity. Create and reinforce work cultures that remove bias from processes.
  • Use a Health in All Policies approach to evaluate potential policies and consider equity before implementation.
  • Implement training programs on bias, racism, and other discriminatory attitudes that incorporate follow-up work.

• Strategy 2-2: Acknowledge and address historical trauma using culturally responsive and holistic approaches.

  Example actions:

  • Educate leaders about historical trauma and how it contributes to health outcomes and mistrust of health care and community health systems.
  • Educate workers about how to be culturally responsive.
  • Train providers to implement trauma-responsive care approaches and how to make referrals to trauma-related resources.

• Strategy 2-3: Recognize the important role of social determinants of health (SDOH) and integrate steps to address them in all work.

  Example actions:

  • Build partnerships between community, political, and health care leaders to address SDOH.
  • Support and expand the use of workers who bridge health care and community to better address social needs. 
  • Gather and share data about SDOH for different groups of people so effective, community-informed interventions can be developed.

Success Story Spotlight - Butterfield Hardware Store: To help address challenges to healthy and affordable foods in the rural community of Butterfield, the local hardware store made a business and community decision to carry healthy food in addition to tools. Watch the full story here:

• Strategy 3-1: Create and sustain authentic partnerships and power sharing.

  Example Actions:

  • Ensure funding supports long-term, dynamic engagement by community members and organizations.
  • Implement effective strategies for power sharing.
    • Use community-based decision making in grant processes and other decisions. 

• Strategy 3-2: Engage community participation and leadership from the beginning.

  Example Actions:

  • Continuously expand community outreach and participation beyond existing partnerships through the inclusion of new communities and community members.
  • Co-create with community members and organizations (e.g., working with communities, not directing communities).

• Strategy 3-3: Recognize that communities have unique insight, therefore they contribute valuable knowledge that should be the basis for any solution.

  Example Actions:

  • Compensate community members and community-based organizations for their participation.
  • View contributing community members and community-based organizations as expert consultants rather than volunteers.

Success Story Spotlight - Bois Forte Band of Chippewa: The impacts of colonialism and other structural and economic barriers lead to high rates of cardiovascular disease and diabetes within Native American and Indigenous communities. Bois Forte has implemented multifaceted health and wellbeing efforts aimed at improving the health of tribal members and reducing rates of cardiovascular disease and diabetes. Watch the full story here:

• Strategy 4-1: Increase collaboration between clinical and community-based organizations to integrate services to improve people's health and well-being. 

  Example Actions: 

  • Develop partnerships and work collectively across health care and community organizations to optimize resources to achieve greater goals and address community needs.
  • Expand and improve coordination efforts among health care providers and across a variety of health care settings to better support patients seeking health care services and community supports. 

• Strategy 4-2: Build or enhance data sharing and coordination systems that respond to community needs for health and social services, prevention, and self-management programs, and supporting activities. 

  Example Actions:

  • Build or enhance health information exchange systems to improve access to patient health records so clinics can refer patients to community-based services and programs, and both clinical and community service providers can follow up on patient care and support. 
  • Coordinate real-time, simplified, and innovative data sharing to meet the needs of communities. 
  • Build partnerships to collaboratively conduct community health and health needs assessments and use them to implement coordinated projects. 

• Strategy 4-3: Increase access to community and clinical resources through improved planning, coordination, and integration of work.

  Example Actions:

  • Identify resources and create or improve methods to connect people and organizations to them. 
  • Use technology and innovative tools to make multi-directional referrals to programs and services and to create opportunities for feedback to make sure that the needs of individuals are being met. 
  • Use incentives to support participation in programming, care coordination, and other supportive services. 

Success Story Spotlight - Native American Community Clinic (NACC): NACC opened its doors in 2003 to address the health disparities within the urban Native American community of the Twin Cities, offering healthcare services that include medical, behavioral health, dental, and substance abuse programs. Notably, NACC supports patients with high blood pressure by offering self-monitoring blood pressure cuffs where patients can monitor their blood pressure on their own, in the comfort of their own home. They participated in creating an instructional video to show patients how it works and what to expect to make them feel more comfortable with the process. Watch the full story here:

• Strategy 5-1: Strengthen and maintain data collection infrastructure for cardiovascular and diabetes-related conditions and outcomes.

  Example actions:

  • Expand and support surveillance data on chronic conditions to meet community and public health goals.
  • Standardize community data measuring cardiovascular- and diabetes-related conditions and outcomes. 

• Strategy 5-2: Establish and maintain data collection standards that support equity goals and reporting that inform community and public health data needs.

  Example Actions: 

  • Establish and maintain data standards that describe communities (e.g., race, ethnicity, disability status, sexual orientation, gender identity, country of origin, preferred language) and allow for breaking data apart so that what is happening for specific groups and communities can be better understood. 
  • Establish and maintain data collection methods that permit reporting data for small geographies. 

• Strategy 5-3: Co-develop and engage in assessment, evaluation, and research using participatory and community-driven approaches.

  Example Actions: 

  • Engage with community to utilize diverse methods of data collection, analysis, and reporting (e.g., community-based participatory research models, Indigenous and non-Western perspectives, mixed qualitative and quantitative strategies, and outcome evaluation methods).
  • Co-develop evaluation processes to measure community health goals with community data. 

• Strategy 5-4: Strengthen approaches and standards to share and use data.

  Example Actions: 

  • Implement data-sharing practices centered on usability and community empowerment. 
  • Implement robust data-sharing practices for community benefit. 
  • Simplify and increase supports to help communities to effectively develop and use data. 

• Strategy 6-1: Train the workforce to understand and appreciate language and cultural differences and apply cultural humility in practices.

  Example Actions: 

  • Create and reinforce cultures in the workplace that emphasize respect and self-reflection from health care providers. 
  • Build opportunities for the health care workforce and the community to learn from each other and co-create solutions. 

• Strategy 6-2: Cultivate a health care workforce that reflects the community's cultural makeup and understands its needs. 

  Example Actions:

  • Use incentives, targeted recruitment and retention strategies, and technology (e.g., telehealth, mobile health) to expand the workforce. 
  • Create a path to train, recruit, support, and retain health care workers from Black and African American, American Indian, Asian, Latino/a, and other communities including rural, disability, and LGBTQIA+ communities. Build mechanisms for people to continue pursuing more advanced degrees. 
  • Hire health care providers who speak the languages of the communities being served. 

• Strategy 6-3: Expand the types of health care workers to reflect the needs of the community and increase their numbers. 

  Example Actions:

  • Increase the number of health care workers in the community to meet community needs and address workforce shortages. 
  • Implement strategies to increase support for community-based health care workers by using train-the-trainer models, engaging community health workers across clinics, etc. 

• Strategy 6-4: Provide appropriate compensation to all health and community care workforce employees.

  Example Actions:

  • Ensure fair pay for community health workers, care coordinators, and others who help to connect health care with community resources, address social needs, and support care coordination. 
  • Pay people for work that benefits the organization even if the people are not employed by the organizations (for example, community knowledge keepers, cultural resources, and translators).

Success Story Spotlight - HealthFinders: HealthFinders helps Faribault, MN community members find primary medical care including chronic disease management, which includes cardiovascular disease and diabetes. Community Health Workers (CHWs) are an integral part of their community health outreach. CHWs meet community members where they're at to provide a compassionate approach to health care. Watch the full story here:

• Strategy 7-1: Expand educational delivery through clinical and community channels by using varied methods, locations, and messengers.

  Example Actions:

  • Increase access to, awareness of, and participation in proven prevention and disease management programs and include telemedicine and culturally and linguistically appropriate formats. 
  • Share messages in fun and engaging ways, such as storytelling, in community locations where gatherings already occur. 

• Strategy 7-2: Co-design education with community, keeping culture, language, and health literacy in mind.

  Example Actions: 

  • Develop toolkits and other resources with community experts that support proven prevention or self-management strategies. 

• Strategy 7-3: Coordinate work within and across organizations with community to support learning and delivery of education. 

  Example Actions

  • Bring people together across regions, sectors, and organizations to collaborate and learn about new and different perspectives on strategies and messaging from diverse communities. 
  • Fund collaborative work between diverse partners, including public health, schools, faith-based organizations, community organizations, etc. 

• Strategy 7-4: Reinforce a culture of health.

  Example Actions

  • Identify and promote stories within communities that acknowledge and affirm the sources of strength and resilience communities hold that lead to improved health. 
  • Promote the fun side of nutrition and exercise that supports well-being, in addition to disease prevention, while creating awareness around the need to employ behaviors that support good health. 
  • Increase education to build awareness and engagement in efforts to change school policies to increase physical activity, healthy eating, and reduce access to commercial tobacco and nicotine. 

• Strategy 7-5: Increase understanding about reducing chronic disease risk, improving self-management, and responding to warning signs of heart disease, stroke, and diabetes-related problems.

  Example Actions: 

  • Promote activities that support good health, including healthy eating through increased access to fruits and vegetables, safe access to physical activity, stopping the use of commercial tobacco products and nicotine, social support, stress management, mental well-being, oral health, and sleep. 
  • Create awareness of the benefits of adopting health-promoting behaviors related to healthy eating, increased physical activity, well-being, and commercial tobacco and nicotine use reduction. 
  • Raise awareness and share resources about the American Heart Association's Life's Essential 8 to lower the risk for heart disease, stroke, and other major health problems. 
  • Increase community knowledge of early warning signs for heart-related problems, stroke, and diabetes and what to do about them. 

• Strategy 7-6: Develop and expand education about policy and advocacy work to impact health. Recognize and uplift existing community policy and advocacy work.

  Example Actions: 

  • Translate policy impacting the community to plain language so people feel empowered to support issues that are relevant to them. 

Success Story Spotlight - Whitney Senior Center + CAIRO: The Whitney Senior Center, an organization that supports the wellbeing of people 55+ in the greater St. Cloud area, is a recognized National Diabetes Prevention Program provider. They teamed up with the Center for African Immigrants and Refugees Organization (CAIRO), a St. Cloud nonprofit that advocates for equitable social, health, and economic opportunities for African refugees and immigrant children, youth, and families in St. Cloud. A member of each organization teamed up to offer the National Diabetes Prevention Program to a Somali cohort that is held on-site at CAIRO. Watch the full story here:

• Strategy 8-1: Create systems and structures to support community members in developing and leading strategies, solutions, and programs. 

  Example Actions:

  • Work with community members to develop programming and strategies that fit community needs (e.g., serving communities of color, refugees, rural communities, people experiencing homelessness, those with chronic diseases, etc.).
  • Use community-based decision making in grant processes and other decisions. 
  • Lead organizations should provide funding to implement a community decision-making model to engage communities in planning and delivering prevention education. 

• Strategy 8-2: Provide services and/or programs in ways that are responsive to community needs in familiar, trusted settings.

  Example Actions: 

  • Develop or adapt health education and programs to be culturally, linguistically, and ability appropriate for different communities and settings. 
  • Encourage participation in screening programs outside of the health care system, such as in grocery stores, libraries, community centers, farmers markets, schools, and other locations. 

Success Story Spotlight - Rise: People with disabilities face many challenges and inequities to obtaining and maintaining good health, including tailored, accessible opportunities for physical activity, health eating, and well-being. Rise, a nonprofit working in the Twin Cities Metro Area and Central Minnesota, has worked to create opportunities for their clients to engage in physical activity and healthy eating programs that are tailored to their client's needs. They partner with local organizations to help facilitate these opportunities. Watch the full story here:

• Strategy 9-1: Increase access to evidence-based preventive care, disease management, specialty care, and rehabilitation that follows guidelines and protocols for those most at risk for cardiovascular disease, stroke, and diabetes. 

  Example Actions: 

  • Offer multiple access points to care/care settings, including non-clinic-based care settings. 
  • Use technology to increase access.
  • Ensure best practices and protocols are applied in a community-informed manner. 
  • Set up systems to screen patients for health-related social needs and make referrals, as needed, to social services and other supports. 

• Strategy 9-2: Provide whole-person care inside and outside the clinic by creating opportunities for patients to practice self-management, advocate for themselves, and shape their own care planning. 

  Example Actions: 

  • Include patient perspectives to help guide care planning. 
  • Teach patients to advocate for themselves. 
  • Explore patient peer-to-peer learning opportunities. 

• Strategy 9-3: Improve and increase patient-provider engagement. 

  Example Actions:

  • Improve provider and health care team communication methods and skills to successfully engage and serve patients. 
  • Allow providers and care team members to bill for communication time to effectively engage and support patients. 

• Strategy 9-4: Use team-based care and provide care coordination that is person-centered.

  Example Actions: 

  • Use health information systems to support team-based care to monitor individual and population health with a focus on health disparities. 
  • Improve community-clinical linkages and information sharing to enhanve services for patients. 
  • Set up clinical-community linkages to screen and refer patients for social needs and supports to advance disease management and treatment that improves patient health and well-being. 

• Strategy 9-5: Use data to inform screening, prevention, and disease management programs.

  Example Actions: 

  • Use data to prioritize individuals for participation in prevention and disease management programs. 
  • Use patient record data to appropriately screen for cardiovascular disease, diabetes, and risk factors. 

Success Story Spotlight - Southside Community Health Services: Southside Community Health Services is a full-service community health center committed to providing exceptional and comprehensive health services in a professional, inclusive, and culturally responsive setting to the South Minneapolis community. The team offers a complete spectrum of holistic care including medical, dental, vision, and behavioral health services. Southside worked hard to turn their internal operation into one that supports employee suggestions, tries new things, and sustains programs. Watch the full story here:

• Strategy 10-1: Increase funding and supports for in-person and telehealth delivery of prevention, disease management, mental health, and other well-being resources. 

  Example Actions: 

  • Improve reimbursement policies and payment structures for allied health services, including telehealth services. 
  • Incorporate stress management or other mental health or well-being content with disease prevention and management programs. 
  • Expand reimbursement for delivery of the National Diabetes Prevention Program (National DPP) to people most at risk for acquiring diabetes and continue to promote and implement cost-effective and culturally appropriate program delivery methods. 

• Strategy 10-2: Develop and advocate for community and systems-driven policy changes that address SDOH, including safe spaces to be physically active, access to healthy and affordable food, and affordable and dignified housing, as well as the reduction of commercial tobacco and nicotine use.

  Example Actions: 

  • Advocate for policies that support health-promoting behaviors in workplaces, schools, childcare facilities, businesses, faith-based and government organizations, and other settings. 
  • Develop programs that cover or subsidize costs associated with making healthy choices readily available (e.g., access to healthy and affordable foods, safe places to exercise, commercial tobacco and nicotine preventions and cessation), particularly in rural and/or under-served communities. 

• Strategy 10-3: Improve funding and reimbursement to increase access to affordable and culturally responsive healthcare and supportive services.

  Example Actions: 

  • Improve reimbursement policies and payment structures by shifting payment away from acute treatment and fee-for-service payment toward prevention, disease management and improve patient outcome (e.g., pay for counseling, care coordination, community health worker support and patient improvements like reduced blood pressure and A1C blood glucose levels).
  • Encourage insurers to cover wider sets of necessary services and build broader provider networks that decrease barriers to accessing health care and medicines. 
  • Improve availability of translation services and work to provide culturally responsive care. 

Success Story Spotlight - Hmong American Farmer's Association (HAFA): HAFA is led by farmers and is dedicated to advancing the prosperity of Hmong farmers in Minnesota. HAFA partnered with HealthEast to connect patients to fresh, culturally relevant produce through their Veggie Rx program. This endeavor lends support in all directions-- local Hmong farmers are supported, doctors build stronger relationships with their patients, and most importantly, patients receive access to foods that will help them feel their best. Watch the HAFA: Veggie Rx video created by BlueCross BlueShield Center for Prevention MN.