Minnesota Accountable Health Model

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Accountable Communities for Health Grant Projects

Accountable Communities for Health Grant Program, Round 2

The establishment of 15 Accountable Communities for Health (ACH) in 2015 marked a major milestone of the Minnesota Account Health Model. Collectively, ACH projects coordinate care among 180 clinical and social service providers for over 100,000 people, the vast majority of whom are on Medical Assistance. Much like a laboratory, these projects mix together various elements of health innovation and reform, allowing Minnesota to uncover the best approaches for improving health outcomes and achieving health equity.

ACH projects in Minnesota are a community-led endeavor. A Request for Proposal in September of 2014 solicited applications for up to 12 ACH grants of up to $370,000 over a two-year period. Eligible applicants included tribes, community or consumer organizations, public health boards, health plans, counties, health care providers, or any other non-profit or for profit entity located in the State of Minnesota. The state received applications from 20 organizations.

By early 2015, Minnesota had executed $370,000 grants to 15 organizations, for a total of $5.6 million, to create ACH models of care. Twelve grantees were selected through a competitive application process. Three previously funded community care teams—Ely, HCMC, and Mayo—received sole-source funding. The ACH grant period is scheduled to end on December 31, 2016.

Funded Projects




ACH for People with Disabilities

Metro area

Explore models of health care delivery and improve disability-competency of medical providers with a holistic LifePlan approach for people with intellectual and developmental disabilities who are supported by Altair ACO member organizations.

CentraCare Health

Stearns County

Reduce the incidence of unmanaged diabetes in Latino and East African patient populations

Ely Community Care Team

Ely and surrounding communities

Provide coordinated health and social services for people living in poverty or with behavioral health challenges

Greater Fergus Falls

Becker, Clay and Otter Tail counties

Coordinate health and social services for people on MN Healthcare Plans and uninsured low-income residents

Hennepin Health

Metro area

Improve enrollment in health programs, reduce homelessness, increase employment, and reduce recidivism among correctional facility clients

HCMC Brooklyn Park

Brooklyn Park

Provide mental health-focused care using community interventions that combine social connectedness and healthful lifestyle, improved care transitions, and other support

Mayo Community Care Team


Link chronically ill adults with community services using a wraparound process to support patient self-management

New Ulm Medical Center

New Ulm

Decrease emergency department visits and inpatient admissions, and improve health outcomes in Medical Assistance population

North Country Community Health Services

Clearwater, Hubbard, Beltrami and Lake of the Woods counties; White Earth Tribe

Improve region's capacity to support at-risk youth in crisis

Northwest Metro Health Student Partnership

Hennepin and Anoka counties

Provide high school students with expanded mental health screening, supportive services, and health education

Southern Prairie Community Care

12-county area in southwestern MN

Develop a community-wide initiative to delay and ultimately prevent Type 2 diabetes in those at risk

Together for Health


Meet health and wellness needs of students and family members.

Total Care Collaborative

Metro area

Increase person-centered care for people with serious mental illness living with chemical dependency issues and co-occurring chronic diseases


Metro area

Document and strengthen processes of care for people with MN Healthcare Plans members at FUHN clinics

Unity Family Health Care

Morrison County

Mitigate need, overuse and access to prescription narcotics and illegal drugs among seniors and other individuals

Grant Request Information

  • Request for proposals – September 2, 2014
  • Webinar for applicants – September 10, 2014
  • Applicant questions and answers – October 17, 2014