Grant Partners:

• Arrowhead Area Agency on Aging

• HealthPartners Neuroscience Center

• Minnesota Board on Aging

• Minnesota Department of Health 

• Minnesota River Area Agency on Aging

• North Dakota Department of Health

• Presbyterian Homes & Services

• Sanford Health

Grant Objectives:

1) Integrate programming into at least 3 care 

settings where Juniper will embed community 

health workers to offer SDOH screening, care 

navigation, health promotion programing, and 

referrals for other long-term services and 

supports in a CIHN model. 

2) Provide referrals to HCBS services for at least 

1,000 patients.

3) Provide support, including sharing business 

strategy advice, to at least 4 other NLEs across 

the U.S. 

Expected deliverables include:

1) A report identifying and analyzing key 

considerations when expanding NLEs across 

state lines.

2) Report detailing learnings from collecting ICD10 Z codes related to SDOH and creating 

service provider contract templates and other 

business planning tools. 

Scaling Network Lead Entities Grantee Profile

Network Name: Innovations for Aging, LLC (d.b.a. Trellis)

Grant Contact:

Mark Cullen, Trellis, mcullen@trellisconnects.org

Grant Goal:

Trellis is a network lead entity (NLE) in Minnesota, operating under the Juniper® brand. With this grant, they aim to apply lessons 

learned in their evidence-based health promotion network to an expansion into home and community-based services (HCBS) 

offerings that address social determinants of health (SDOH). They will take on efforts to incorporate HCBS into healthcare through 

the use of ICD 10 Z codes. Trellis will also further integrate network services into health care settings in a community integrated 

health network (CIHN) model that includes providers and health plans, with an emphasis on value-based contracting 

arrangements. Lastly, they will explore the expansion of NLE services to support other networks’ activities in the state.

Target Population:

Older adults and high-risk populations (people of 

color and individuals with disabilities)

Grant Summary:

Since 2016, Juniper, a program of Innovations for Aging (d.b.a. Trellis),

has grown from a foundation formed by Minnesota’s Area Agencies on 

Aging (AAAs) and Older American’s Act providers. Today, they are a NLE 

for 86 Minnesota organizations that serve as program providers and 

many other stakeholders who share the goal of improving Minnesotans’ 

health and well-being. Their services touch all 87 counties and leverage

Minnesota’s NWD System comprised of the Senior LinkAge Line® and 

Disability Hub MN. 

Work under this grant will expand services into healthcare systems across 

the state, particularly in places where health plans and healthcare 

systems have entered into value-based contracts. In January 2021, 

Innovations for Aging launched a pilot placing a community health worker

(CHW) in a clinic setting that follows the CIHN model. This was funded by 

the Minnesota Department of Health and services are provided by 

HealthPartners Neuroscience Center. Two additional pilots are in 

progress with Sanford Health and Presbyterian Homes & Services. This 

grant will allow two additional CHWs in these two clinics.

Trellis currently contracts with 2 health plans serving dually enrolled 

older adults and is negotiating partnerships with 5 health plans to 

continue program models and receiving interest from philanthropic 

organizations, part of their ongoing business plan that will not have to 

rely on grant funding in the future. Their software application lends 

strength in tracking and reporting information related to network 

activities. Illinois, Maine, North Dakota, and Texas license this software 

application that has tools to help them meet their network goals. 

Through this grant, Trellis will build upon this software to translate data 

and services received to medical claims. This will allow Trellis to 

strengthen the return on investment data for building additional 

partnerships and moving toward sustainability. Trellis will also leverage 

this funding to enhance their provider network, build additional financial 

models and business development, continue relationship development 

with healthcare organizations, and provide NLE leadership and expand to 

additional states.

Planned activities for NLE enhancement will focus on:

☒Leadership

☒Finance

☒Business Development

☒Network Development and Support

☒Network Administration

Award: $291,565