Quality improvement

Immunizations are one of the best ways to prevent many serious and deadly diseases. In the past several years, childhood immunization rates have declined leaving children vulnerable. HealthPartners is working to educate parents and the community about the importance of immunizations.

Children’s immune systems are more vulnerable to illness and disease, and vaccination schedules are scientifically designed by top infectious disease experts and doctors with this in mind. The goal is to protect kids from vaccine-preventable diseases as early and as safely as possible. They work with the body’s natural defenses to develop its resistance to illnesses. Far fewer people have become sick or died from diseases like meningitis, polio, rubella and diphtheria since most people began getting regular vaccinations. Vaccines are safe and effective to protect children from getting seriously ill from these preventable illnesses.

It is recommended that children have these immunizations before they turn two years old:

HealthPartners wanted to understand which of our members were up to date on immunizations and who would benefit from reminders about the importance of immunizations. We analyzed our data and saw that Medical Assistance members were significantly less likely to need immunizations compared to commercial members. In addition, Black and Indigenous children are much more likely to need immunizations than other children.

We worked with the other Medical Assistance health plans and the Minnesota Council of Health Plans on a social media campaign to share information about the importance of well-child visits and childhood immunizations with Minnesota parents of children ages 0-2. Parents could visit this site for more detailed information about immunizations. The social media campaign and the educational information was available in English, Spanish, Somali and Hmong, and the educational content is in both written and audio formats.

We worked with health coaches and Community Health Workers (CHWs) to make phone calls to parents of members who need to get immunizations and well-child visits. CHWs are trusted, knowledgeable front line health personnel who typically come from the communities they serve. They were able to reach out to members in their own language and help them make appointments for the care they needed.

We created a campaign to educate parents about immunizations, their importance and their safety. We encouraged them to contact their clinic to talk to their doctor about getting caught up. This information was delivered by email whenever we had the family’s email address; otherwise, it was sent in the mail.

We feel childhood immunizations are so important that we offer a $25 gift card to MHCP members who receive all the recommended immunizations before their second birthday. We promote this in our member materials, on our website and with our county C&TC partners.

We worked with other health plans to hold listening sessions with African American and Spanish-speaking parenting groups to learn about their views of immunizations. We compiled a summary of this information and shared it with our provider network, our communications area and other partners to inform communication outreach with members and the community.

We hold periodic meetings, called Quality Connections, to bring together quality staff from various clinics and share best practices around quality improvement activities. Several clinics have discussed how they have improved their immunization rates for young children so other doctors can do better as well.

Changing recommendations for immunizations and increased public attention to the issue along with mixed messages has created confusion for parents and the community.

Many parents are not fully aware of the immunizations that their child needs, so our messages included information about what is recommended. Mailing addresses and phone numbers can change which means we can’t reach the family.

Families reported that they felt well-child visits and immunizations were not needed because their child is healthy, older or due to mistrust of health care providers. Others report barriers to care such as work schedules, transportation, childcare and immigration-related stress as reasons for not receiving recommended care.

CHWs were able to reach 45% of the identified families by phone and educate them about the importance of immunizations and well-child visits.

The social media campaign appeared in feeds 3.15 million times, and over 28,000 Minnesotans clicked through to the educational information.

• The Spanish version drew almost 4,500 clicks.
• More than 5,000 clicked on the Somali version.
• The Hmong language version received over 6,100 clicks.

In 2025, 1,105 children received the incentive for completing all recommended immunizations by their second birthday.

Despite these efforts, our immunization rate remains stagnant. Our childhood immunization rate (combo 10) rate at the end of 2025 was 31.4% compared to 31.6% in 2024.

HealthPartners is committed to working to increase childhood immunizations. In 2026, we continue to reach out to members who need immunizations. We are working with the clinics who care for our members to help them remind families of the importance of immunizations. And we will continue to provide an incentive to PMAP and MinnesotaCare members.

When someone is discharged after a psychiatric hospitalization, they are at higher risk for suicide – especially children, adolescents and young adults. Receiving outpatient mental health care within seven days of discharge is one of the most effective ways to reduce suicide risk and support continuity of care.

The time immediately after discharge from an inpatient psychiatric hospitalization is one of the highest risk periods for suicide – especially for children, adolescents, and young adults. Research consistently shows that receiving outpatient mental health care within seven days of discharge is one of the most effective ways to reduce suicide risk and support continuity of care.

In 2024, however, only 50.5% of HealthPartners members received timely follow-up after psychiatric hospitalization. This gap points to serious access and safety concerns, particularly for members covered by Medical Assistance who demonstrated lower follow-up care rates than members covered by commercial insurance.

HealthPartners partnered with PrairieCare, the organization’s second largest psychiatric hospital by discharge volume, to pilot a care transition appointment model. The initiative focused on ensuring timely follow-up care after discharge through several key actions:

• Identification of patients who lack an established mental health provider or appointment within 7 days of inpatient discharge from PrairieCare
• For those patients, completion of a care transition appointment conducted by a PrairieCare clinician within 7 days of discharge to review after-care and safety plans, ensure medications are filled, and complete a preliminary risk assessment
• Use of contractual financial incentives from HealthPartners to support PrairieCare’s operational investment in staff time and infrastructure needed to deliver timely care transition appointments

Implementation of the care transition appointment model has surfaced a few key challenges related to measurement and equity. Addressing these issues will be essential for accurately evaluating the model’s effectiveness, improving outcomes across member populations and assessing its readiness for expansion to additional hospital partners.

The absence of a clearly defined baseline or utilization target for care transition appointments limited our ability to accurately measure the effectiveness and overall reach of these appointments for patients without other follow-up behavioral health care.

Notable differences in follow-up rates between commercial and Medial Assistance members highlighted potential disparities and underscored the need for more tailored discharge planning and support for certain populations.

PrairieCare’s combined FUH rate for HealthPartners commercial and Medical Assistance members decreased from 62% in 2024 to 61.4% in 2025, driven by a decline in follow-up care for Medical Assistance members from 59.2% in 2024 to 54.4% in 2025.

While the model is still working to demonstrate improvements in FUH rates, preliminary reviews of inpatient readmission and emergency department visits at PrairieCare revealed a decline in 30-day inpatient readmissions from 9 in 2024 to 5 in 2025, as well as a decline in emergency department visits from 38 in 2024 to 32 in 2025.

Building upon lessons learned, ongoing efforts are focused on strengthening measurement, addressing equity gaps, and positioning the care transition appointment model for long-term sustainability and growth by:

• Engaging further analysis to better understand the use of, effectiveness of and barriers to care transition visits as a feasible strategy to improve follow-up care timeliness and completion
• Setting a baseline and goal for the completion of care transition appointments for members who do not have other established mental health care upon discharge
• Exploring the differences in Medial Assistance members’ discharge plans and needs in comparison to commercial members’ needs. Medial Assistance populations may require additional, targeted strategies to address access and social barriers.
• Considering additional, meaningful measures such as inpatient readmission and emergency department visit rates and further exploring if the patients who are engaging in follow-up care are members who are less likely to engage in subsequent readmissions or emergency department visits (as would be expected)
• Utilizing ongoing financial and operational alignment to sustain quality improvement efforts

Colorectal cancer screening can find cancer early when it is easiest to treat or even prevent it by removing polyps that could develop into cancer. But many people worry about the screening process. We wanted to make it easy for our members to access an easy, at-home option to screen for colon cancer.

Nearly everyone should have a colon cancer screening beginning at age 45. When colon cancer is caught early, it is easier to treat. Screening can also prevent colon cancer from occurring by removing small growths called polyps before they become cancerous. A screening test can find cancer when there are no symptoms. Screening guidelines have recently changed, so not everyone is aware of when they should begin getting screened for colorectal cancer. We looked at our data and saw that people who don’t have a primary care clinic have lower screening rates than those who have a regular health care provider. While there are a few screening tests for colorectal cancer, this project uses fecal immunochemical test kit, also known as a FIT kit, an in-home test kit that screens for the presence of blood in the stool, which can be an early indication of colorectal cancer.

We wanted to create a high-quality program and have real-time access to data, so we worked with HealthPartners Central Lab and our online care provider, Virtuwell, to create an end-to-end process to provide the service and meet the needs of our members. We launched the first iteration of the program in 2021 and continually assess program performance to improve program quality.

Through this program, our members experience three key touchpoints from us:

1. Eligible members will receive an e-mail from Virtuwell inviting them to order a kit.
2. Central Lab mails the kit to the member, and the member completes the kit and mails it back to Central Lab for processing.
3. Once processed, the member receives their results from a Virtuwell clinician.

In 2022, we identified that a lot of members were ordering a FIT kit but not returning it. We conducted one-on-one interviews with members to understand why a member might not return the kit after requesting it. Through these interviews, we learned two primary reasons that people were not returning the FIT kits:

• Members would receive the kit but not recognize that it was the FIT kit because the envelope was generic or they thought it was junk mail.
• The member knew that it was their FIT kit, but they were not in a rush to complete it and return because they did not know that the kit had an expiration date.

Understanding these barriers, language was added on the outside of the kit envelopes to call out that the contents are time sensitive while still maintaining member privacy. With this change, our return rate increased from 53.1% in 2022 to 67.4% in 2023. Return rates dropped to 58.4% in 2024 and as a result, we made additional changes to the 2025 campaign to strengthen the reminder communications we send members. We also made other improvements to the 2025 campaign, including making it easier for members to tell us which address we should use to send them the kit (a helpful option for snowbirds) and adding information about how members can help their family members get screened.

Through in-house automation, we have been able to deliver a sustainable, high-quality and highly reliable colon cancer screening process to our members. Year over year, we have been able to increase our outreach and the number of FIT kits sent, without impacting the resources needed. In 2025, we shipped over 2,100 kits and had over 1,300 of those kits returned to us by members. This resulted in a return rate of 64.4%. Our Central Lab team was able to send out a kit to a member, on average, in less than half a day after receiving the kit request and was then able to process the kit within two days once receiving the completed kit back.

Additionally, we are finding that members are very satisfied with the FIT kit experience, especially as our consumer base moves to wanting a more hybrid approach to care that is still reliable and personable. We have heard from our members numerous times that our program is easy, fast and efficient to participate in. They also feel that FIT kits provide a convenient way to screen for colorectal cancer that results in comprehensive but easy-to-understand test findings and recommended next steps.

HealthPartners is committed to encouraging our members to receive routine colorectal cancer screenings starting at age 45. We will continue to send screening reminders to members when they are due as well as offer the option of a FIT kit for colorectal screening to those members that it is appropriate for.

When an older woman breaks a bone, it could be a warning sign that her bones may be getting weak. A screening can tell her if she has osteoporosis. HealthPartners worked with our clinics to create a process to identify women who needed to be screened for osteoporosis.

Getting screened (checked) is important because:

• A broken bone (fracture) can be the first clue that bones are not as strong as they should be.
• Osteoporosis makes bones break more easily, even from small falls or bumps.
• A screening test can show how strong bones are.
• If osteoporosis is found early, doctors can help with steps to protect bones, like healthy habits or treatments.
• Stronger bones mean fewer future breaks, which helps women stay healthy, active and independent.

HealthPartners did two key things to help women who have had a fracture more easily and quickly get a bone screening test:

1. We created a process to reserve or hold bone screening appointment slots for women who have had a recent fracture.
2. We started providing in-home bone screening tests for women who struggled to get to the clinic.

HealthPartners mainly faced two challenges:

1. We needed to educate women about why it is important to get a bone scan after they have had a fracture.
2. We needed to make it easier to schedule a bone scan.

Between November 2024 and November 2025, we improved our bone screening rate in women who had a fracture from 32% up to 50%. Our rate now exceeds the national average of 44%.

We will continue to work to educate our members about the importance of bone health and monitor access to bone scans to ensure our members and patients get the care they need. We will also continue the in-home bone screening program because we know that some of our members find it difficult to go to the clinic for their scan.