We want our healthcare community to provide equitable care for complex patients.

Hennepin County Medical Center

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    Our process began with patients. We met them in their homes, accompanied them to clinic visits, and learned about their lived experiences of health, both within and outside the healthcare setting.

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    Research also included observations at community partners, including homeless shelters, mental health drop-in centers and chemical dependency treatment programs. We needed to learn how these professionals worked with the same people that HCMC serves.

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    We also learned about HCMC’s many innovative programs serving complex patients, such as when we rode along with community paramedics.

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    The client team traveled to Chicago for a synthesis workshop, to parse through thousands of data points and identify patterns and opportunities for design.

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    We summarized our research in four key principles for building a new, journey-based model of care. Each had actionable opportunity spaces as well as “How might we…” prompts to support the creation of innovative programs and services.

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    We facilitated a concept workshop with the extended HCMC team, community partners and stakeholders, and generated over 300 ideas that would change how healthcare is delivered.

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    After the client team helped us narrow to the 20 most impactful concepts, we surveyed the local healthcare community to help us narrow to 10. We created storyboards of each concept to illustrate the patient experience.

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    We shared storyboards with a wide range of stakeholders, including patients, health care providers and social service leaders. Each feedback session not only narrowed our set of concepts, but helped us identify how to make each idea stronger.

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Project Outputs

Within the healthcare system, health had primarily been approached as a destination, an end goal for patients to achieve. Yet successful community partners saw their interactions as moving someone along in their journey. This project introduced a strategic shift towards a journey-based model of care.


One concept we designed, called Priorities Conversation, was a protocol of questions to aid medical assistants in engaging patients during the intake process. Its purpose was to help the care team understand a patient’s “big picture,” rather than only addressing their specific medical complaint. We worked with a primary care team to prototype and test this tool in a clinical setting. HCMC is continuing to iterate on the concept.


One program we developed, called Members Give Back, was meant to connect complex patients with work and volunteer opportunities. This concept was built off the insight that many patients desire to do more than take from society – they want to give back. We worked with a team at the HCMC day treatment center to prototype the program, in partnership with a local workforce development provider. The group built a curriculum and worked closely with 10 patients to help them build skills and find jobs. One year after the pilot, 100% of participants still had their jobs and/or were volunteering. The results have also shown a reduction in Emergency Department utilization and a decrease in inpatient stays.

The GGS team opened my eyes to the truth that there’s more than one way to solve a problem. Their research reframed longstanding problems as opportunities.”

William Walsh, Upstream Health Innovations Team at HCMC

Client & Community Outcomes

By the end of the project, HCMC staff cultivated a deeper understanding of complex patients’ experiences and how to better support their needs on their journey towards healthier lives. After watching video of a patient traveling to and from her appointment, Patient Experience Officer Sheila Moroney shared, “This is the most I’ve learned about our patients in all the years I’ve worked at HCMC.”

Many concepts developed through this engagement were fast-tracked to implementation by HCMC’s team. One concept, Hitch Health, has already been spun out as a separate C Corporation, and is being offered to other safety net health systems. It’s a software product that seamlessly removes transportation barriers to and from the appointment, yielding powerful behavior change by decreasing clinic no-shows.


Our work coincided with the beginning of a culture shift at HCMC. The newly formed Upstream Health Innovations team had a mandate to shift the health system conversation towards a more proactive and holistic approach to health. Our work increased the organization’s understanding of the social determinants of health in communities, and opened the door to further collaboration with local community partners.