FUHN doubled screening of health-related needs from 2023 to 2025

A dedicated FUHN workgroup staffed by Mark Sonneborn, FUHN's Data Analytics Consultant, meets every other month to consider the best way to approach health-related needs across member clinics and the network. To make screening routine across different clinics that vary by size, location, patient populations, and more, the Health-related Needs Workgroup focused on three things: sharing best practices among members, adopting minimum standards for how often patients are screened, and streamlining screening to four core areas—housing, food, transportation, and finances—that most directly affect patients' health and ability to access care. The results followed. The share of patients screened for health-related needs across FUHN clinics increased from 14 percent in 2023 to 29 percent in 2024, and to more than 33 percent in 2025.

For this work, FUHN looks to leaders like Native American Community Clinic Clinical Manager Chris Singer, DNP, RN, CPHQ, whose health-related needs screening work anchored her doctoral work, a 2022 peer-reviewed article, and the most recent FUHN blog, Strengthening the Foundation for Health-Related Needs Screening to Better Support Patients.

NETWORK DATA STRATEGY: Behind every data point in a community health center is a person. Each screening completed, each blood pressure brought under control, each diabetes check represents a patient getting the care they need and deserve. FUHN's network data strategy starts there. Quality is more than hitting targets: it’s about making sure our patients—many of whom face the steepest barriers to care—get what they need. Our clinics do this work every day. Too often, however, data have been scattered across reports, systems, and spreadsheets. 

That’s why FUHN’s data strategy—led by Mark Sonneborn, FUHN's Data Analytics Consultant—centers on a scaled, network-wide rollout of Azara, a population health platform. Azara will improve several focus areas of FUHN’s data strategy, including Electronic Health Records use, data reporting and analysis, best-practice implementation, and more to increase quality and reduce costs. At the clinic level, providers will see open care gaps as patients arrive and close them during the visit. At the network level, questions that once required every clinic to run its own report will take a couple of clicks.

Another core of FUHN’s data strategy is a partnership with the University of Minnesota's Best Practices Integrated Informatics Core, which houses FUHN data in a secure, HIPAA-compliant environment offering a clearer, network-wide view of how we are serving patients and supporting advanced analytics. 

FUHN's data strategy also reaches statewide. MNSHINE, Minnesota's emerging health data utility, is poised to become how the state measures health care quality. Today, the patients FUHN serves are largely missing from that picture; claims-based reporting often undercounts the care our clinics deliver. FUHN's participation helps make sure they are seen and that our clinics' work is fully recognized.

Native American Community Clinic Moves Into New Building

The NACC team moved into its new facility in September, celebrating the opening of its new clinic and welcoming patients to its beautiful new space. The $55 million project brings together medical care, behavioral health, dental services, addiction treatment, and traditional healing, with four additional floors dedicated to affordable housing (the 83-unit Wihinaphe Apartments, which means “New Beginnings”). To learn more about the project, watch the Fox 9 story, Native American clinic and housing project set to open in Mpls, or the Minnesota Native News story, The Native American Community Clinic Moves into a New Building, and Native Running Clubs Are Growing Fast, to hear from NACC President and CEO Antony Stately. 

Data analysis is a critical piece of FUHN's work—and Hunter Doyle is playing an important role in making it happen

Hunter Doyle, MPH, is part of Dr. Joel Farley's team at the University of Minnesota College of Pharmacy, which provides the data and analysis behind FUHN's value-based care work. With a bachelor's degree in health education and a Master of Public Health, Hunter began his career in quality improvement analytics and has spent the past year and a half turning claims and lab data into information clinics can act on—work that sits at the center of FUHN's Network Data Strategy and value-based care efforts.

As part of his role with FUHN, Hunter produces recurring reports that give each clinic a clear picture of its patient population, including attribution trends, chronic condition prevalence, substance use disorder, homelessness, and high-frequency emergency department use. He also draws on Quest lab data to help clinics find tests patients completed elsewhere, closing gaps in quality measures such as diabetes control. Hunter is also key in FUHN's efforts to connect patients who are seen in an Emergency Department back to their primary care clinic, if they have one, or to a clinic if they don't, given the importance of reducing non-emergency ED visits to control health care costs and improve patient care.