Health Care Homes (aka Medical Homes)



A "health care home," also called a "medical home," is an approach to primary care in which primary care providers, families and patients work in partnership to improve health outcomes and quality of life for individuals with chronic health conditions and disabilities.

The development of health care homes in Minnesota is part of the ground-breaking health reform legislation passed in May 2008. The legislation includes payment to primary care providers for partnering with patients and families to provide coordination of care.

What's new?

  • December Webinar:

    Intensive Behavioral Therapy: Medicare's Obesity Counseling Benefit

    Presented by Lisa Bartholomay, Sanford Clinics
    Date:  December 11, 2014
    Time: 12:00 - 1:00 p.m.

    It’s been almost two years since Sanford Health implemented obesity counseling for a population of 120 unique patients using the Medicare intensive behavioral therapy benefit. Lisa Bartholomay, LD, RLD, and Manager of Diabetes Education and Nutrition Therapy, will share Sanford’s experience with implementing a model of care, including the ins and outs of coding, billing, documentation and care coordination.

    Register for this webinar.

  • Requests for Proposals for Learning Community Grants

    New opportunities are now available. The Minnesota Department of Health (MDH) is seeking proposals from qualified professionals or organizations to plan, implement, facilitate, and evaluate four Learning Communities visit the Health Reform Minnesota Learning Communities Page.

  • Medicare Intensive Behavioral Therapy for Obesity

    The goal of this course is to educate healthcare providers about causes and consequences of obesity and provide them with the tools necessary to implement a Medicare-compliant program for Intensive Behavioral Therapy for Obesity.

    For more information visit our Education Page.

  • American Academy of Pediatrics: Pediatric Obesity Services: What's Covered Friday January 30, 2015, 12:00 p.m. to 1:30 p.m.

    The goal of this course is to educate healthcare providers about causes and consequences of obesity and provide them with the tools necessary to implement a Medicare-compliant program for Intensive Behavioral Therapy for Obesity.

    For more information visit our Education Page.

  • Newly Certified Health Care Homes

    The Minnesota Department of Health announces the following two clinics as newly certified health care homes:
  • Mayo Clinic - Employee and Community Health (Baldwin Bldg. Internal Medicine) Rochester, MN
    Mayo Clinic - Employee and Community Health (Baldwin Bldg. Pediatrics) Rochester, MN

We now have certified a total of 356 clinics.

Interactive map of all certified health care homes.

  • Haven't Heard From Us Lately?

    It is important that your contact information in the Health Care Home Data Base Portal are up to date. Please take a moment to make sure the most current person we can contact at your organization is listed in the Portal. Thank you.

  • Learn More about our Learning Communities

    Health Care Homes funded four learning community opportunities during the last year. They focused on Community Care Coordination, Pediatric Obesity, Data Analytics and Prevention and Patient and Family Involvement. Learning Communities are intended to provide learning for primary care teams in a focused environment to improve specific aspects of care. Visit our Learning Communities page to learn more.

  • Minnesota Community Health Worker Alliance - Upcoming Webinar

    • Webinar: Community Health Worker Enrollment, Coverage and Payment under Minnesota Health Care Programs
      Wednesday, Dec. 3, 10:00-11:00 a.m. CST


      This free webinar will provide an informative overview of Community Health Worker (CHW) coverage and rates under Minnesota Health Care Programs (MHCP). The session will include step-by-step guidance on the CHW enrollment process and billing procedures. Requirements related to CHW supervision and documentation of CHW services will also be addressed. Q & A will be part of the session.

      Whether you are new to the CHW role or an experienced CHW employer, this webinar will help you better understand this funding stream for CHW services available to Medicaid-eligible providers. Registration is now open.


    • The Community Health Worker Role and Mental Health: Current Practice and Future Opportunities
      A Learning Session for Mental Health and Primary Care Providers
      Thursday, Dec. 4, 8:30-11:30 a.m. CST
      Wellstone Center/Neighborhood House, St. Paul

      Wilder Center, St. Paul

      This workshop is intended for professionals from multiple disciplines who work in the areas of mental health and substance abuse prevention and treatment in a variety of settings including mental health, primary care and community-based organizations; disparities, diversity and equity; health policy; and health care design and delivery.

      Clinic representatives who attend will be eligible to apply for a planning mini-grant to help introduce CHW approaches within their organizations utilizing an online tool kit available in 2015. Registration is now open.

      More details are listed on our Education Page.

  • MAPCP Demonstration ending soon.

    In August the ending of the MAPCP Demonstration with CMS was announced. We are providing some preliminary information on the care management codes that may be used. The CMS website has information relating to the use of the final rule and care management codes.

  • Care Coordination Toolkit:

    As a part of Minnesota's Medicare Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration Project, a toolkit has been developed to assist health care homes and primary care clinics in serving the complex population of seniors and persons with disabilities. For more information, please visit the Care Coordination Toolkit webpage.


  • Introduction to Health Care Homes Webinar Series

    The Health Care Homes Learning Collaborative is hosting a webinar series designed to increase knowledge of standards and help equip clinics to transform their practice into patient-centered medical homes. For more information please visit the Introduction to Health Care Homes webpage.
Updated Tuesday, November 25, 2014 at 02:50PM