News & Events

Creating Health Equity Through Care Coordination

Care Coordinators are good at cold-calling. Most of their work is done by phone. And often they don’t know much about the person they’re calling.

Coordinators call individuals referred by their health plans. The calls begin with a brief introduction, including an explanation that Care Coordination Services are a free health and wellness promotion tool offered by the individual’s insurance plan.

Then the conversation might sound something like this: “I hear you’ve had some hospitalizations.” From there, Care Coordinators work on relationship-building to understand the person’s health status, needs, and overall goals. Common questions are: “What kinds of things could you use help with?” and “How can we help?”

Care Coordinators see clients once a year to complete a full assessment of their health and needs, but mostly they get to know people by phone. “We act as a centralized telephonic delegate on behalf of the insurance company to answer questions, connect people to resources, remind them of appointments, schedule rides, and assure all of their health providers are on the same page,” explains Mel, one of the Coordinators.

To qualify, individuals must have a physical, mental health, or cognitive disability. Services aim to connect them with preventive services that will help them reach their goals in the most efficient, cost-effective way. Individuals receive assistance to develop and use an integrated plan for care, including their physical, mental, and dental health.

Coordinators work with the individual, the health plan, the primary care physician, and others as needed in support of the individual’s goals. “We don’t push our idea of what our goals are on those we work with,” says Melissa Mikkonen, Program Manager. “We really make sure that it’s tied back to their overall goals.”

This level of coordination assures that people are knowledgeable about their health plan and that they know how to access and utilize their benefits. Another Coordinator on the team, Molli, describes the value of Care Coordination Services this way: “We put a human face on what can be a behemoth of an industry. Insurance in general is often confusing, overwhelming and time consuming. When individuals experience this, they don’t access the full benefits available to them. Meaning only their minimal health needs are met, if that. By helping people connect to services and providers consistently to meet their needs, it allows people to more easily attain optimal physical and behavioral health.”

It’s the personal connection that makes a difference. Recent outcomes from the Healthcare Effectiveness Data and Information Set (HEDIS), used by health plans to measure performance on important dimensions of care and service, reflect excellence. The Care Coordination team’s outcomes are exceedingly higher than the national average. “The reason we’re far exceeding national standards,” comments Melissa, Program Manager, “is because we really take the time to build those relationships.”

“The significance of Care Coordination is really health equity,” she says. “It’s really rewarding to get people connected with health services.”


More About Guild’s Care Coordination Services 

  • Provides: Primarily telephonic services with some face-to-face services, including an annual assessment, to help people develop and utilize an integrated plan for care (physical, mental health, and dental) that includes coordination with the health plan and primary care physician, so individuals can meet their goals.
  • Counties served: 7-county metro area
  • Accepts referrals from:  Individuals must be referred to Guild by a health plan we’re contracted with to provide Care Coordination Services.
  • Payment for services: Medical assistance


January 25, 2019

No Caller Turned Away: Helping the Community Get Mental Health Services

Lots of dead ends. Nowhere to turn. Loss of hope. This is how people often describe attempts to get help with mental health. Community Access Services were created to give them somewhere to turn.

“Ultimately, the mental health system tends to be very fragmented, and access is so difficult for so many,” says Melissa Klein, Program Manager. “Ten years ago, Guild recognized this need and responded.” A grant provided start-up funds and a small team began providing 20 free days of service to callers. No caller was turned away. The team received 239 calls in 2009.

As the new Community Access Services moved forward, Melissa noticed that people were still having difficulty getting connected to services. Something was missing: a diagnostic assessment. “You can’t really get access to services without one,” Melissa explains.

Her observation helped services evolve to include completion of a diagnostic assessment. Conducted face-to-face, the assessment helps Guild staff gain a full understanding of an individual’s needs. “We’re not just giving people a diagnosis and then just letting go,” Melissa describes. “We really listen to them and to their family to understand and make recommendations based on needs. We might recommend them to a program that Guild has – Targeted Case Management, Behavioral Health Home Services, or Assertive Community Treatment (ACT). If we don’t have a service that meets their needs, then we recommend them to another provider or resource that does.”

In 2017, the Community Access team:

  • Responded to 1,229 calls (a 32% increase over 2016)
  • Completed over 300 diagnostic assessments (a 98% increase over 2016)
  • Referred 97% of the individuals referred to them for assessment to one of these Guild service teams: Targeted Case Management, Behavioral Health Home, or Assertive Community Treatment

Community Access Services still operate under the same principal they did when they started: no caller is turned away. Eligibility issues are addressed by helping people figure out how to enroll for medical insurance. A private pay option is offered for those who don’t qualify or have private insurance that doesn’t cover services.

“To have a significant number of people getting that comprehensive assessment and getting connected to services is really exciting,” Melissa says of the impact of services. “I get the opportunity to see people that came through Community Access getting service from one of our teams, and I see how far they’ve come. I also think about our private pay clients, and that they might not have services at all if we didn’t provide this.”

More About Community Access Services:

Provides:  Assistance to general inquiries about Guild services and navigating the mental health system; Completion of Diagnostic Assessments for appropriate referral to Guild’s Targeted Case Management, Behavioral Health Home, or Assertive Community Treatment or to a community resource that fits individual needs; and Service directly to individuals and families (through private pay) that want services but aren’t eligible due to insurance or other requirements.

Number of teams: 1

Counties served: All 7 metro counties

Accepts referrals from: Anyone can call the Community Access team for help.




December 20, 2018

Notes on the Ladder of Hope from Our Executive Director | CEO

Photo Credit: Terra Sura Photography

“We do better when we all do better. Together, we fill the gap.”

In total, 1,240 people attended the Ladder of Hope luncheons this year. Looking out into the sea of people, gathered to listen to our stories, is a profound reminder that our community celebrates our work. Understanding that this sea of people is also willing to generously give from their personal resources to financially support our work is the perfect end to an amazing year. We raised over $530,000!

Our featured speakers, Zaheeda and Nick, shared stories of how traumatic experiences led to a loss of hope and how Guild’s services helped them throughout their recovery to move closer to health. It was incredibly moving to hear how each of them navigated very difficult circumstances and are now able to visualize and hope for a future they didn’t dream was possible.

“I like to get out and see what’s happening in the world,” Zaheeda says. “I want to see the light.” A long struggle with mental health symptoms made it difficult for to leave her apartment. Today, she and her significant other, Mike, share the joy of a good adventure, counting trips to Ely, Minnesota and Branson, Missouri among their favorites. Watch Zaheeda’s story.

“In my mind, my future goes something like this: a career, a family; 2 cats and a dog, my own place to live, lots of tattoos, a small family trip every year, and — some day – grandkids,” Nick says with a laugh. At 18, he’s dealt with multiple challenging circumstances, including mental health symptoms and diabetes. With help from our Equilibrium (EQ) Team and his personal support system, he’s excited for the next stop: college…on his way to becoming a music therapist. Read Nick’s story.

Like Nick’s and Zaheeda’s, Guild’s future is bright. We plan to lean in to what we do well and expand our services to more people. During 2019, we will be expanding our Mental Health Crisis and Intensive Residential Treatment program, thanks to the city of Savage and our partnership with Scott and Dakota Counties.

We cannot do our work without you. From the bottom of our hearts, thank you for your support. As T. Mychael Rambo sang at our recent events…maybe you’re still singing it: “We do better when we all do better. Together, we fill the gap.”


Our sincerest thanks also goes out to:

Hilary, Nick, Tom, and Zaheeda for sharing their personal stories, and to Dana, Ellie, and Katherine, Guild staff, for sharing, with permission, stories about individual clients.

The Hubbard Broadcasting Foundation and two anonymous donors for pledging a total of $175,000 in matching funds. Between the two events, we raised all of the matching funds!

Bituminous Roadways, Inc. and Riverland Bank for being our Presenting Sponsors and City National Bank, Nasseff Mechanical Contractors, Region 185 financial advisors of Edward Jones, Team Incorporated, and Wilson Mc-Shane Corporation for being our Title Sponsors.

Our Supporting Sponsors: Alerus FinancialAlerus Mortgage, Bernstein Private Wealth Management, Bremer Bank, Carl Bolander, CBL Floors, Credible Behavioral Health, Dean Schiffler with Guaranteed Rate Affinity, Drake Bank, Genoa Healthcare, Gino Ward Agency of Farmers Insurance, HealthPartners, Hiway Federal Credit Union, Hometown Tire and Service, Lakeview Bank, Leadership Transitions, Maguire Agency, Medica Foundation, Monarch Healthcare Management, Mutual of America, Qualitech, United Science, Valley Staffing, and Wipfli CPAs and Consultants.

The many staff and our 35 volunteers.


See photos from both events here on Facebook. Photos by Terra Sura Photography.


December 20, 2018

We’re Grateful for You!


“Thankfulness is the beginning of gratitude. Gratitude is the completion of thankfulness. Thankfulness may consist merely of words. Gratitude is shown in acts.”

— Henri Frederic Amiel

In this season of thanks, we’re sharing a photo album with you. Take a look to see just some of the things we’re grateful for.

Individuals We Serve: Nellie, Charlie, Tina and many others share their stories with us every year. Whether they choose to talk about their lives publicly or share with their Guild team, we’re honored by the opportunity to partner with them on their journey. And we’re amazed and humbled by their courage and resilience.

Staff:  Tou, Gail, Robbin, Angela, and Mary were among staff members who told us more about the goals of the services they provide, their specific roles on their teams, and the true meaning of their day-to-day work, giving us a behind-the-scenes, in-their-own-words look at why they do what they do. We’re grateful to all staff members, across programs and services, for their passion, knowledge, dedication, and persistence. We continue to feature staff on social media. Follow us on Facebook, Twitter, and LinkedIn to get the latest.

Volunteers and Donors give their time, passion, and resources to help us meet our mission every single day. Addressing and stuffing envelopes, moving furniture, teaching classes, donating goods and services, befriending those who experience isolation, talking about our work at community events, engaging their friends, families, and colleagues in our work; walking to raise funds for advocacy and to beat stigma, and so much more. We couldn’t do our work without them, and it certainly wouldn’t be as much fun!

Partners: We couldn’t do our work without the support and collaboration of numerous partners in the community. Colleague organizations who collaborate with us on initiatives and pilot projects, police officers who come to our office for crisis intervention training, landlords who work with us on housing, hospital and clinic staff…the list goes on and on. This summer, individuals receiving our Intensive Residential Treatment Services (IRTS) enjoyed a day on the river thanks to Let’s Go Fishing, a nonprofit providing opportunity for people who otherwise might not get the chance to go boating and fishing. The Steve Rummler HOPE Network trained Guild staff on how to recognize and reverse opioid overdoses. And 191 clients and their families who are in need will receive a holiday meal from Thanksgiving Meals on Wheels.

Celebrations: We had many moments of celebration this year. Guild board member, Melissa Scanlan-Duncan, participated in the Arthur Murray Minneapolis’ Dancing with Twin Cities Celebrities, and became the 2018 Dance for the Cause Champion! We are grateful that she designated Guild as the recipient for funds raised. As part of Guild for All, our Inclusion, Diversity, and Equity initiative, staff were led through an activity where they were asked to stand under a sign that represented the facet of their personality they most want to be known for. The group under “Compassion” was so large, they filled up an entire wall! And a long-standing tradition – the Delancey Services Picnic – brought staff, individuals served and their families, and even a few pets together for a BBQ, conversation, camaraderie, and fun. Delancey Services works with people who have histories of homelessness.


Thank you for being part of our community, and for making these moments possible. We are grateful for you!


November 13, 2018

Employment Services Expand to Serve Youth

Looking for work is a big job – a job that becomes even bigger when you face barriers, like a lack of self-confidence, lapses in work history, or underdeveloped people skills. Fortunately, big jobs are the perfect fit for Guild’s Employment Services team.

Program Highlight: Employment Services and Team Photo

Resume Writing as Confidence-Builder

Employment Specialists take what can feel like a daunting task and turn it into a confidence-building opportunity. “It’s amazing when we help someone put together a resume,” says Peggy Darmody, Employment Services Manager. “People often say, ‘Wow, I can’t believe that’s me – I’ve never seen my experience written down on paper that way.’” Resume creation is often the first step in breaking down the fear that can easily set in when people have had to leave the workforce to take care of their mental health.

Addressing Employment Gaps

Employment gaps are often a significant stressor because people begin to doubt their abilities and because they’re not sure how to talk about periods of unemployment. By working with both employers and clients, Employment Specialists help to bridge that gap. “Some people don’t have the people skills to connect with employers or figure out how to explain their employment history,” Peggy explains. “Employment Specialists must have a unique skill set: they need to be able to work as effectively with employers as they do with clients.”

Working with Employers and Job Seekers

Weekly meetings with potential employers are a requirement for Employment Specialists, providing an opportunity for them to learn about available jobs and to create partnerships. They also meet with existing employers – those who employ individuals served by Guild –to provide ongoing support with a focus on retention. From Peggy’s perspective, the approach creates a win-win, “All employers have individuals that are dealing with mental health challenges,” she says. “Some of them just don’t know it.” By working together – Employee, Employer, and Employment Specialist – workplace challenges can be discussed, and support needs identified and implemented.

Quote from Ken, individual receiving Employment Services: "Every day that I go to work, I realize that I do get a lot of self-confidence out of it. I do matter. People do enjoy my company."

Value of Ongoing Support, Ken’s Story

Ongoing support is critical in helping people maintain employment in the competitive workforce. This was especially true for Ken who had a job in retail, but found the environment created significant stress, exacerbating his mental health symptoms. Employment Specialist, Ellie, worked with Ken to create an employment plan based on his interests, strengths, and preferences and to find a job that reflected his goals. He works in a group home now and recently celebrated his two-year employment anniversary. ““Every day that I go to work, I realize that I do get a lot of self-confidence out of it,” he says of his life today. “I do matter. People do enjoy my company.”

Expanding Services to More Adults and to Youth!

Ken’s sentiment echoes what Peggy maintains about the value of employment in recovery: “Working gives people the chance to be productive, to create structure and routine, and to make new friends.” It’s one of the reasons she’s excited to see the work expand. Thanks to an Innovation Grant from the Minnesota Department of Human Services, Guild’s Employment team has expanded to bring services to more adults and to start something new – providing services to youth.  Working with youth is a prospect that Peggy finds invigorating: “We’ll have the opportunity to shape future workers and link that – earlier on – with recovery.”


Ways You Can Help:

Help Us Connect with Employers: Are you an employer or do you know an employer who might be interested in partnering with our Employment Services Team? Contact our Employment Services Program Manager.

Help Us Reach $5,000 in Matching Funds for Employment Services: Give to the Max on November 15.

Join Our Team: We have an Employment Specialist position available. Learn more about the job.


More About Guild’s Employment Services:

  • Provides help and support to individuals — using the Individual Placement and Support (IPS) model and a person-centered approach — so they can find, get, and keep jobs in the competitive labor market.
  • Number of teams: 1
  • Counties served: Dakota, Ramsey, and Scott
  • Accepts referrals from: Guild Incorporated’s Targeted Case Management and Delancey Services, Scott County Targeted Case Management, Mental Health Targeted Case Management providers in Dakota County, Youth Innovations – School Districts, Link Drop In Center, and Lincoln Place.



October 25, 2018

You Can Help:

carf Charities Review Guide Star United-Way-Community-Partner