With kale and tai chi, Minnesota hospitals try a new way to keep patients healthy

STAPLES, Minn. – The latest medical innovation at Lakewood Health System isn't some high-resolution scanner or micro laser scalpel.

It's a shipping container.

Starting this fall, the hospital and clinic system will use hydroponic irrigation and lighting in the container to grow vegetables — 120 pounds each week — and distribute them to patients whose malnutrition is causing health problems that could result in costly medical procedures.

Whether or not the project produces its ultimate goal — a decline in malnutrition and related diseases — it shows how Minnesota hospitals have moved beyond fun runs and tree plantings to promote health in their communities.

Large or small, broke or flush, almost every hospital in the state has invested in a strategy known as "population health" to identify and address the problems keeping patients from optimal health. The projects range from large-scale investments, such as wellness centers created by Mayo Clinic in Cannon Falls and CentraCare in Long Prairie, to web apps that nudge patients to make healthier choices.

From a crude business perspective, it's a counterproductive approach — the equivalent of McDonald's conditioning customers to hate French fries — because hospitals are still paid mainly to treat patients, not prevent disease.

But hospital executives say they are gradually receiving more "risk-based" contracts from private insurers and government health programs, which give them financial rewards if they can find ways to keep patients healthier and out of the hospital.

"We're at the tipping point," said Debbie Welle-Powell, chief population health officer for Duluth-based Essentia Health. She estimated that 45% of the system's revenue is tied to risk-based contracts with incentives to help patients avoid medical problems.

Essentia launched two community projects this year, including one that connects patients at risk for diabetes with online advice and local exercise and diet programs.

Hospitals vary in their strategies, but the efforts stem from the same source: a requirement in the 2010 federal Affordable Care Act, or Obamacare, to assess their communities' health needs every three years.

Fairview Health focused its Twin Cities-area hospitals and clinics on three issues — mental health, wellness and access to care — and created 19 free programs, including a 12-week Tai Ji Quan class to improve balance and prevent falls in the elderly and a six-week workshop on self-management of chronic pain.

The programs come at Fairview's expense, but its leaders said they hope to prove that they produce healthier — and cheaper — patients so that insurance companies will chip in more.

"Would you rather pay for a meal delivery [to a malnourished patient]?" asked John Swanholm, Fairview's vice president for community advancement, "or whatever the costs are for pre-diabetes … or someone who ends up with diabetes? Those are the conversations we've been starting to have with payers."

Food insecurity might seem an odd problem in rural Staples, but high poverty in the region coexists with high produce prices. Alicia Bauman, Lakewood's community health director, visited a market in nearby Grey Eagle and found a sad $4 head of lettuce. Only lemons and limes were cheap and abundant.

"I would say that reflects more on alcohol consumption," she said of the fruits that often garnish beer and cocktails.

In addition to hydroponic food production, Lakewood started a Food Farmacy last year after finding that 15% of patients struggled with grocery bills. Qualifying patients pick up boxes of healthy food in the winter and vouchers in the summer for the farmers market in the hospital parking lot.

"This allows us to connect with patients in a whole different way," Bauman said.

These efforts continue despite the lack of "return on investment," said Matt Anderson of the Minnesota Hospital Association. "To the extent there is any payoff, it's not to the hospitals. It's to the individuals. It's to the community."

Tina Miesbauer said Essentia's prediabetes program was the nudge she needed to make lasting behavior changes. The health system is paying for her to use Omada, an app that connects her with a support group and a coach who gives her fitness strategies, such as parking as far away as possible in a parking lot or at work.

"It gives you ideas that you didn't think of before," she said.

While anecdotal success is good, hospital leaders said they know they will need to prove they are improving health and reducing patients' medical spending to coax insurers to cover their prevention efforts. Measuring progress can be challenging.

Allina Health's long-running Heart of New Ulm project was unique nationally in proving that a communitywide focus, led by a local hospital, could improve cardiac health. Allina invested $9 million in the 10-year project, which reduced the number of residents with high cholesterol, hypertension and smoking habits in New Ulm — a town known for the beers and brats of its Oktoberfest.

The project encouraged walking to school, moved healthy foods to high-profile spots in stores, and even changed food served at church events. "You think of [a meal with] the old Jell-O dishes and the like, and that wasn't present," said Toby Freier, medical center president.

The hospital also saw a decline over time in admissions for high-dollar cardiac treatments, presumably due to healthier patients not needing those services.

That risk of losing inpatient revenue is why hospital leaders are in a race to prove that insurers should pay for their investments, though Freier stressed that the Heart of New Ulm project was more about proving that such an effort could improve health, regardless of cost.

"You see lasting change," he said. "We still have the Schell's Brewery. We still have the Kaiserhoff German restaurant. It's not like you can't walk into a convenience store and buy a Mountain Dew, but there has been a cultural shift."

Much of the population health movement has centered on "social determinants" of health, such as neighborhoods without playgrounds or housing with lead paint.

Sioux Falls-based Sanford Health is experimenting with health guides who, for example, might meet patients at the bus station and help them get to the doctor's office on time, said Dr. Allison Suttle, Sanford's chief medical officer.

Allina has been testing a similar approach through a federally funded Medicare project that has identified more than 28,700 people with a social barrier to good health.

"We had one gentleman who couldn't get to his second job because his headlights wouldn't work," said Penny Wheeler, Allina's chief executive. That meant he struggled to pay for medications and clinic appointments. "This puts us into a sphere of health that isn't just a response to illness," she added.

The key question over the five years of this experiment will be whether it actually produces better health and reduced medical spending.

Many efforts are too new to provide proof. Lakewood over time hopes to see declines in obesity, blood sugar levels and unnecessary ER visits, but for now welcomes surveys showing improved quality of life for patients in its food programs.

Mashelle Deutsch of Motley was grateful for Lakewood's efforts after she lost her job and struggled to pay for groceries. She picked up tomatoes and green peppers last week for a salad her family couldn't otherwise afford.

"We never ate so many salads," she said, adding that they've also grown fond of grilled sweet potatoes, but haven't gotten into kale.

"We tried making these chips with it," she said. "They were OK, but we're not really big on kale."