A Burnsville clinic that focused on helping people regardless of their ability to pay has closed its doors after two decades of service in what former workers, board members and volunteers called a sign of a U.S. health care system that fails to adequately care for many of its residents.

Dakota Child and Family Clinic, which started as Mendota Health in 2002 and eventually grew into its current iteration with the formation of a nonprofit organization in 2012, closed permanently on Dec. 30.

The clinic focused on primary care and behavioral health management but grew to include educational services for students in nurse practitioner and physician’s assistant programs, as well as vaccination services in conjunction with local school districts. Many patients were uninsured or underinsured.

It was the first clinic owned and operated by a nurse practitioner in Minnesota when Gretchen Moen began operating it in 2002. Growing up in Nashwauk, Minn., Moen’s father operated a clinic out of part of their home. Community health was ingrained in her at a young age, leading her to pursue a career in health care where she looked to serve the whole patient, she said.

The closure was decided in December by parent company Open Door Health Center. The two groups announced a merger in early 2024, after the Burnsville clinic approached the Mankato based nonprofit about a potential partnership. In October of this year, Open Door and Dakota Child and Family Center officially merged. However, plans to bring DCFC into the Open Door fold never completely took shape.

“I’m not shocked, but I’m devastated. We are all just sick about it,” said Heather Tidd, who served as executive director of Dakota Child and Family Clinic from 2020 to 2022, and is currently a grant specialist at Open Door Health Center. She has worked for the clinic on and off during the past 20 years. “This was the last safety net for a lot of people. I hope people pay attention to this, and take it seriously. If (Dakota Child and Family Clinic is) not there, there’s nothing for many people.”

In the red

Open Door Health Center officials said they tried to adjust operations of Dakota Child and Family Clinic to keep the balance sheet figures from spiraling into the red, but DCFC providers and Open Door officials could never agree on a path forward.

Contentious as those management decisions became at times, many staff members had connections with both Dakota Child and Family Clinic and Open Door Health Center. Rather than blaming one organization or the other, longtime employees conceded that the decision to close was long in the making.

Complicating matters for clinics like Dakota Child and Family, the financial environment for nonprofits in Minnesota has become much more unstable in recent years, according to a 2024 report from the Minnesota Council of Nonprofits. That report cited rising expenses, fluctuations in charitable giving and COVID relief funding drying up for nonprofits.

Meanwhile, the core function of the clinic, primary care, is in crisis nationally, according to a national Primary Care Scoreboard developed by researchers with the American Academy of Family Physicians. That report, co-funded by the Milbank Memorial Fund and The Physicians Foundation, blamed systemic failures in meeting patient demand, retaining physicians and securing adequate funding for clinics.

It has become a common refrain in primary care facilities across the nation: provider-patient time gets squeezed in order to move more patients through the clinic doors, if they even can find enough providers to work.

As one example of the difference in services, Open Door primary care providers spend an average of 30 minutes with each patient, but providers at DCFC were spending up to an hour on each patient.

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As Moen described a typical visit at Dakota Child and Family Clinic, an appointment often went far beyond treating a patient’s stomach ache. Providers tried to connect patients with other needed community services. Providers sometimes attended children’s individualized education plan meetings at area schools. Other times, Moen said, the clinic was a safe place for patients dealing with mental health concerns.

Those “invisible” costs in primary care, like checking online patient messages, talking with insurance companies about prior authorization for prescriptions or services or documenting other patient information, also cut deeply into face-to-face patient time.

“The people who cut our hair get an hour. I’m asking for 45 minutes with people who have complex problems going on that are intertwined with many other things,” said Michelle Christian, a nurse practitioner who had been with Dakota Child and Family Clinic for more than 11 years.

Spending that extra time with patients was what originally brought Christian to the clinic. She was leaving a clinic setting that prioritized shorter patient visits, and realized it was negatively impacting patient care.

“When I was interviewing with Heather Tidd, I asked her, ‘How many patients are you expecting me to see per day? What are our time constraints for your visits?’ She said, ‘That is up to you. Who else could make that decision?’ And I thought, ‘This is where I want to be.”

Christian’s last day was Dec. 30. In giving her three-week notice, she worked to help patients find ways to transition to other care facilities.

“The thing that I know for sure is that we did everything we could to keep this place open,” she said. “It has felt like we tried everything we could, but the system is too broken to sustain it.”

Financial strains for community clinics

Kelly Kenley, Open Door Health Center interim CEO, wrote to stakeholders that this closure highlights significant problems faced by primary care clinics in the American healthcare system. Kenley also previously served as the executive director at Dakota Child and Family Clinic.

“Community Health Centers across the U.S. and here in Minnesota are under extreme financial strain, asked to meet an ever-increasing demand for services while operating small, community-based clinics with tighter and tighter margins,” Kenley wrote. “Coupled with inadequate reimbursement models and a rising number of barriers to access, these issues collectively contribute to poorer patient outcomes, higher healthcare costs and staff burnout.”

As the two sides struggled to reach an agreement on operational changes, four providers at Dakota Child and Family Clinic resigned over a 10-day period at the start of December. That left coverage to one part-time provider who was scheduled less than three hours a week. By Dec. 9, only months after finalizing the merger, Open Door decided to close the doors of Dakota Child and Family Clinic. By Dec. 19, letters were sent to former patients, board members and community members announcing the closure.

“Once the fourth person left, there was no path forward,” Open Door Health Center Marketing and Engagement Director Emily Heinis said. “It’s a really good example of why we need to reform health care so much. We can’t give people what they really need, but we also have to stay open for the people who don’t have anywhere else to go. The fact that Dakota Child and Family Clinic was able to operate with that level of personal care is admirable, but they never operated in the black once that 12 years. It’s not sustainable. We absolutely wish it were.”

The clinic nearly shuttered its doors other times, but usually found a way to keep the lights on. In 2012, the clinic was set to close, but the community rallied and formed the nonprofit organization. The clinic held on for another decade, but by late 2023, the end of the line seemed imminent. The merger with Open Door came as a hopeful lifeline, but eventually, the challenges proved too great.

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As Tidd looked back, she recalled years of painting walls, laying carpet, placing tile and total dedication from any and all involved.

“We had to devote our lives to keep it open,” Tidd said. “I wish we had been more honest about how much work it was to keep it open.”

In the current healthcare system though, all of that work came up against the need to make sure enough patients are scheduled throughout the clinic day, in order to deliver enough revenue to pay for operations.

“The only way to increase our revenue is to see more patients. As a nonprofit, that doesn’t mean we’re putting profit over our patients. We are just trying to pay our staff,” Heinis said. “It is a real statement about the problems with primary care and health care in general in our country.”