Jeff Lamoreaux

Senior Writer and Editor

The Heart of New Ulm Project

Nestled in rural Minnesota is a small but vibrant town of about 14,000—New Ulm—which was just named best Minnesota city to live in by USA Today, and highly ranked when compared with cities across the country. In New Ulm, the residents predominantly take safe, enjoyable walks (not drives) to restaurants, where they order fresh fruits, vegetables, and whole grains. This is a big shift in residents’ behavior. Merely a decade ago, residents’ heart disease risk factors were high. Back then, the residents of New Ulm described their three major food groups as “beer, brats, and butter,” which made sense, given that the town—which bills itself as “the most German town in the US”—is home to the nation’s second oldest family-owned brewery, as well as a major butter producer.

In the years since, New Ulm’s population, on average, has seen a huge jump in heart health. They’ve had nearly a 7 percent increase in adults testing within normal blood pressure and cholesterol ranges, a 10 percent increase in residents who get the American Heart Association’s recommended 150 minutes of moderate exercise per week, and a 14 percent increase in residents eating the recommended five or more servings of fruit or vegetables a day.

Hearts Beat Back 

It’s probably not a coincidence that this period of change coincides with a program of interventions enacted as part of a research study from the Minneapolis Heart Institute Foundation® (MHIF), in partnership with the New Ulm Medical Center (NUMC), called Hearts Beat Back®: The Heart of New Ulm Project (HONU).

Here on The ReThinkers’ Blog, we often describe how to approach practices considered essential for stewards working to transform health and well-being regionally, such as cultivating a shared vision, sound strategy (including a portfolio of interventions), and resident engagement. HONU is a great example of putting those practices into action.

In February, we sat down with Rebecca Lindberg, Senior Director of MHIF’s population health research, education, and marketing, and Cindy Winters, a former New Ulm resident and MHIF’s project manager for HONU, to learn about their experiences as stewards of New Ulm. Here are some highlights from that conversation:

What Would You Say Made HONU Successful?

REBECCA: Hearts Beat Back: The Heart of New Ulm Project has succeeded because of our pioneering use of health data and electronic health records, our implementation of evidence-based heart-health interventions in so many different facets of the town, and our effectiveness in engaging diverse key stakeholders and helping them align around a common vision.

What are the Highlights from HONU’s Portfolio of Interventions?

REBECCA: We had multiple interventions, all working together toward the same goal: improving heart health. Out of them, I think the food environment work—where we helped businesses increase the healthy foods they offered—was something the community had consistently been asking for. They see it’s easier to make healthier choices. So it was nice to be able to partner across the community with the convenience stores, grocery stores, and restaurants—over 50 percent of them engaged in partnerships with us, because it actually made competitive business sense for them. Not only were we working to change New Ulm’s food environment, but we were messaging to the residents at the same time. As a result, our partners were seeing increased demand—they got more customers, and customers were coming back more often and spending more; people were changing their purchases because of the program.

CINDY: The healthy food intervention is one of the most popular. Everybody talks about it. They recognize the different levels [how much each partner embraces the intervention] and the residents as a whole tend to spend their money at those places that offer the healthier options.

Another intervention, the built environment [e.g., infrastructure, such as roads and bike paths], does speak to me and impact my life personally; I can see how making it easier to walk and bike made it easier for me to manage my weight. The Safe Routes to School initiative didn’t start until later on in the project, because it’s for kids but our target audience was 40–79 year-olds. After the adults understood HONU overall was working, they kept asking “what are you doing for the kids?” So Safe Routes was a perfect fit to address children’s health while also making changes that improved our target population’s ability to get enough exercise, and all the schools got on board with it and really helped move those initiatives forward.

What Makes HONU Unique?

REBECCA: One thing that makes it unique is that it started primarily as a research project, to understand the best ways we could improve heart health in a community.

Another thing that makes it unique is that we use the Electronic Health Record (EHR) as the primary population health monitoring tool. Over 90 percent of New Ulm residents seek care at New Ulm Medical Center, which made it an ideal environment to examine from a research standpoint. We were able to make a map of the town’s health risks. Our community diagnosis started with a voluntary comprehensive resident health screening and an assessment of EHR data. From the data we found at that time the town was 41 percent obese, 35 percent overweight, 38 percent had metabolic syndrome, and from a lifestyle standpoint only 17 percent consumed the minimum recommended fruits and vegetables. We also added a comprehensive random survey of residents to find out what they wanted, too—really considering residents’ perspectives in decision making. We used that type of data to influence the evidence-based programs we brought to the residents.

We also had a very strategic communications plan. We knew it was important to make sure the messages were clear, and that residents could really understand them—and take action on them. It was a very comprehensive plan from the start, to educate the entire public about intent and goals. People got the same messages at the clinic, from their employers, on billboards, in restaurants, and at convenience stores.

How Did You Get Residents Involved?

REBECCA: One thing we’re really proud of is that over 90 percent of residents were aware of the project and we were able to maintain that level of awareness throughout 10 years. Residents were excited about the opportunity of the project coming into their town. From an engagement standpoint, we probably took a nontraditional approach. We did a lot of in-person events at the beginning and really got people engaged in the work we were doing first. That built trust in the community. They understood it and wanted to engage with it. Then we opened dialogue about the more complicated population health ideas like policy, systems, and environment, and they were more open to listening to that after we laid the groundwork—and we needed them to understand and engage with those concepts as part of building their capacity so the residents could participate in, and eventually take leadership of, this work. Cindy was instrumental in making that transition with the community.

CINDY: We worked really hard to understand residents and speak their language. I helped to focus the messages around what motivated the residents to be involved. Instead of opening by talking about health, we’d talk about economic prosperity for residents, how a thriving community is a healthy community—and this is how we can support your work to become a healthy community. We didn’t always approach it as “how can you support us,” but how can our project support work already happening in New Ulm? We really tried to find out who influencers were in the community, and discuss with them what they thought their role could and should be, and then how they could help us get where we want to be in the context of their role.

REBECCA: Cindy attends every city council meeting. Not because we’ve told her she needs to; she attends whether she’s on the agenda or not because she understands that in order to have an impact, she has to know what’s important to residents and the councilmembers at any given time. That way, when she has an opportunity to present to the council she can not only represent the residents well, but also help councilmembers understand how giving residents what they want will also help the councilmembers meet their goals for improving New Ulm.

Advice for Anyone Thinking About Implementing Multiple Interventions

CINDY: Don’t do everything for free! You cannot come back from that, and HONU is the second project I worked on that started everything for free. Once people are used to that, it’s very difficult to get them to pay you for the same services or get them to chip in money to replace or supplement your grant, and that’s very limiting. The question from residents and businesses often is: “If HONU was willing to do this or free, why should I start paying them for the same work?”

REBECCA: Often, we want to see fast results from a program, but this work takes time, and a lot of people. It is really about having passionate champions across the community that really understand what it takes to create change, and that change takes time. We got big results, but it didn’t happen overnight.

CINDY: There are a lot of residents who have that capability and want to be champions for the initiative. Then it becomes about just giving them the info they need and helping them find their voice and where they can be most helpful.
Also, I’ve been following ReThink Health since the first Pulse Check survey of multisector partnerships. I brought that report back to the leadership team back in 2016 and it helped us know we were doing OK. We are normal as these things go, and we are in exactly the space we need to be in. Since then, I pass a lot of ReThink Health resources on to our leadership team members to help us think differently, so we don’t get stuck in a rut while we’re working really hard to do this. It’s really helped us move our work forward.

What’s Next?

REBECCA: The 10-year research phase actually ended in 2018, so MHIF is going to turn to analyzing and understanding the data on a deeper level. We actually spent an hour today looking through some data from residents, and comparing it to another town in Minnesota to see if changes we see are due to HONU’s interventions rather than natural changes across the state or country as a whole.
As far as next steps, we want to take what we’ve learned and help other towns and regions with their work to improve health and well-being. We found that people aren’t asking us to replicate all we did in New Ulm. What they are asking instead is, “Can you help us, we are stuck—we have done A, B, and D, and we want to advance further and faster.” For instance, they may have a leadership team, but are struggling to get the team to own the work.

CINDY: The NUMC Foundation Board agreed to fund HONU for the next three years to continue all of the work. Three years ago we combined MHIF’s New Ulm team with the residents’ HONU leadership team while preserving its nature as a multisector partnership, and now the leadership team has encompassed all the work so we can hand it off to them. They’ve taken ownership, so it’s now fully resident owned and driven. We can still get guidance from MHIF, but now we have the capacity and are excited to do the work. We’re looking forward to using Rethink Health’s sustainable financing workbook for long term sustainable funding, since we know we can’t rely on philanthropy forever.

We’d like to thank Rebecca and Cindy for taking the time for this interview. You can read more about Hearts Beat Back: Heart of New Ulm on its website, and check out its Nine-Year Impact Report here, and other articles with more information on HONU here, as well as a 23-minute documentary film about the project here.

The personal views and opinions expressed in this blog (and in any comments) are those of the original authors only, and do not reflect the opinions of The Rippel Foundation or ReThink Health. Neither The Rippel Foundation nor ReThink Health is responsible for the accuracy or validity of any of the information contained in the blog or any comments. All information is provided on an “as-is” basis.

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