Health Care Homes
Spotlighting clinics who have taken innovative steps in advancing the Health Care Homes model of patient-centered, team-based care.
Click on clinic name to show detailed information.
301 Highway 65 South
Mora, MN 55051
1425 Main Street North
Pine City, MN 55063
620 Sandy Lane
Hinckley, MN 55037
Information: FirstLight Health System has primary care clinics located in Mora, Pine City and Hinckley, Minnesota. FirstLight with its county owned critical access hospital has provided care in the region for greater than 70 years. A team based care model began in 2011 through a palliative care program which became the template of the care coordination model; partnering a social worker with a registered nurse and resulting in effective patient and family centered care transitions.
Accomplishment: FirstLight Health Systems serves as a powerful success story of care delivery transformation advanced through the State Innovation Model (SIM- grant and guided by strong internal leadership. The grant goals aligned with those of FirstLight culminating in the achievement of Minnesota Department of Health (MDH) Health Care Homes Certification June 23, 2016 and addressed the grant’s goal to provide integrated, accountable care using an innovative model, responsive to local health needs. The grant’s project team met consistently with their leadership team and their committed and engaged patient advisory council. This work is supported by registries which proactively track and manage care. At the MDH Certification site visit the CEO shared, “HCH formalizes the work and brings about system integration. We lived out the integration process and overcame perceived barriers of this transformation through continual conversations." The grant and HCH certification fostered alignment of competing quality metrics. This work helped the clinics and organization to realize a measurable impact through rapid cycle process improvement. FirstLight clinics credit the SIM Practice Transformation Grant with quality improvements specific to patient experience in their care transitions.
Information: HealthEast is an integrated health system that includes four hospitals, specialty care, hospice/home care services, and 14 primary care clinics. The clinics serve approximately 135,000 patients in the east metro area. At HealthEast, our patients are our neighbors and we are dedicated to their, and our, optimal health and well-being. We are guided by our faith-based heritage, a call to healing that respects the dignity and culture of every person. We empower our patients with user-friendly access to their health information, dependable service, and affordable, high-quality care.
Accomplishment: The organization continues to enhance their community health worker (CHW) model for care coordination, embedding certified CHWs (referred to as care guides) into their care teams at each clinic site. Administrative and clinic staff state this is a "great model of team work that balances the clinical needs and social determinants of health for our patients." For care coordinated patients with more complex needs, the care guides are supported by a centralized clinical care coordination team consisting of RNs, LPN, social workers, and financial resource guides who rotate across the clinic sites to meet with patients and the care teams. Pharmacists are also available to provide direct care for patient education and medication reconciliation, providing feedback and recommendations to the provider and care team as appropriate. The inclusion of a pharmacist on the care team has allowed the primary care provider more time to focus on other needs during the visit and spend less time on medications issues/reconciliation. This has been made possible through a partnership with the University of Minnesota pharmacy residency program.
815 2nd St.
Little Falls, MN 56345
Morrison County Community Based Care Coordination website
Information: CHI St. Gabriel’s Family Medical Center is a family practice and multi-specialty health care clinic with three locations: Little Falls, Pierz and Randall, Minnesota. We are a team of 110 doctors, nurses and health professionals who emphasize wellness and lifestyle changes that result in long-term improvement to your health.
Accomplishment: The Morrison County Community Based Care Coordination ACH initiative has created a care coordination model to facilitate excellence in controlled substance care. The partnership includes CHI St. Gabriel’s Health (ACH lead agency), South Country Health Alliance (the insurance plan for Medicaid in Morrison County), and Morrison County Public Health and Social Services. The partnership formed to address the concern about narcotics use in the community, as evidenced by the number of Emergency Room (ER) visits for therapeutic drug monitoring and high numbers of Medicaid patients with eight or more narcotic prescriptions.
The partnership has evolved to include law enforcement, local pharmacies, the school district, and a substance use prevention coalition. A Prescription Drug Task Force of stakeholders meets monthly to facilitate further collaboration beyond the walls of health care. Early indications are showing positive outcomes, including reductions in Medicaid claims paid for narcotics.Link to ACH/SIM Paper
2042 Juniper Avenue
Slayton, MN 56712
Murray County Medical website
Information: Murray County Medical Center, located in the southwestern part of the state, is a county owned organization that has been serving Murray County since 1951. The hospital and multi-specialty medical clinic is staffed by Providers highly trained in a number of specialty fields. One Internal Medicine Doctor, two Family Medicine Doctors, and two Physician Assistants comprise the current Murray County Clinic's medical provider staff. Murray County Medical Center also has an Orthopedic Surgeon and General Surgeon on staff. Murray County Medical Center offers a multitude of visiting specialty services to provide convenient and accessible healthcare for their patients. They are committed to improving the health of the individuals and communities they serve, providing a comprehensive range of health services and education. In addition to the basic scope of primary care services offered, ambulatory care, acute hospital care, diagnostics, laboratory, wellness, pharmaceutical services, emergency ground and air transportation are provided through this clinic and in partnership with a network of providers and community programs. The clinic is governed as a not-for-profit community organization, serving local and regional needs with superior quality, value and patient satisfaction, providing care to all.Accomplishment: The clinic began Health Care Home (HCH) implementation in 2014 with one nurse practitioner initially seeking HCH certification and quickly spread certification to the entire group of primary care providers. They take the health of their population seriously and embrace ways to partner with community resources to enhance health outcomes. An innovative approach to health improvement is their "Big Blue Bus" program that travels to outlying communities, providing health education and support for the remote populations. Visitors of the bus were recipients of blood pressure readings, blood glucose monitoring and diabetic foot assessments. Each month different health spotlights were offered such as diabetic education, heart healthy snacks, pulmonary assessments, reviewing of medications by a pharmacist and seasonal flu vaccinations.
Link to tour of clinic
Nobles County, Community Health Services with Sanford Health-Worthington and Avera Medical
1680 Diagonal Rd.
Worthington, MN 56187
Nobles County Sanford Health
Information: The clinics and CHS are members of the Nobles County Care Coordination Team which partners in programs and services for the clients they mutually serve to provide their region with integrated services. This team has a broad representation from: education, mental health, social services, community health workers and others. Demographically Nobles County has 22,000 residents with over 35 cultures, speaking 55 language dialects. The team meets monthly to determine which entity will lead the care management for unique clients and develop a coordinated plan of care. Additionally WIC Public Health program, and interpreter staff are present in the clinic on high patient volume days (well child visit days).
Accomplishment: An example of integration of public health with primary care occurs at the Sanford Worthington site includes their “Oral Health of Children and Adolescents Program” which addresses high rates of dental disease in vulnerable and underserved populations. Early childhood caries (ECC) is identified as a significant public health problem with 40 percent of children having dental caries by kindergarten. Interventions include: Fluoride vanish at every well child visit and at every opportunity for high risk children; those with caries according to risk stratification.
Elements of the program include:
- A community wide effort to promote oral health.
- Elimination of candy from clinic shelves; replaced with toothbrushes.
- Sugary treats are discouraged in the community. Grocery stores offer a free piece of fresh fruit for children as they enter the store instead of candy at the check-out.
- Referrals made to dentist by all providers and services.
- Examples of education include: less juice/milk in Sippy cups, less sugary snacks and more fluoride prescriptions.
1313 N. Penn Avenue
Minneapolis, MN 55411
NorthPoint Health & Wellness Center
Information: NorthPoint Health & Wellness Center is a multi-specialty medical, dental and mental health center and human service agency located in North Minneapolis. The clinic is administered through a partnership between Hennepin County and a Community Board of Directors comprising NorthPoint’s patients and people who live and/or work in the community. NorthPoint strives to improve the physical and socio-economic health of the North Minneapolis community through an integrated model of health and human services. Their mission is “to reduce health disparities, improve health outcomes, and enhance the overall quality of life for all residents of North Minneapolis by providing high quality social services, with respect, dignity and sensitivity to a culturally rich and ethnically diverse community.”
Northpoint provides patients/families many services such as transportation, culturally knowledgeable and multilingual staff, translation, assistance in applying for public programs, a sliding fee scale as well as an onsite food shelf, and employment – housing assistance and more.
Accomplishment: Northpoint is spotlighted for their experience with nearly two years of using scribes for team documentation. They conducted a pilot test (PDSA) of four provider-scribe teams, asking how scribe use affects provider efficiency and stress, patient care, and the financial bottom line. The scribe is utilized during and after the clinic visit and they shared how providers experienced this change – the positive effects and challenges as well as recommendations for other clinics considering scribes. They developed the role of scribes in their organization and identified three key adjustments to patient flow, documentation and follow up that resulted from adding scribes to the clinical staff. Additionally, the use of scribes led to positive effects of care team satisfaction, patient experience and cost of care.
324 East 35th Street
Minneapolis, MN 55408
Southside Community Health Services website
Information: Southside Community Health Services is a Federally Qualified Health Center (FQHC) was founded in 1971 to provide accessible primary care to the community. Southside Community Health Services exists to serve the community by offering patient focused, friendly, high quality and comprehensive medical care. We strive to provide fiscally responsible health services in an environment that fosters learning and respect, and inspires excellence in our staff. It does this through collaboration, empowerment, and communication with patients with the goal of improving their health.
Accomplishment: Aligned with Southside Community Health Services vision to be an exceptional community health care model that sets the standards for wellness, they recently implemented a new “Garden Produce Share Program.” This program provides fresh produce and targeted health education through the clinic to help patients/families improve overall health and decrease the effects of diabetes, obesity and hypertension. Participants receive a weekly box of fresh produce and track their health progress through the growing season. At the end of the season they will measure health results of those enrolled in the program through clinical health screenings and survey data, and measure costs to establish a future business case.
1239 Payne Ave
St. Paul, MN 55130
Clinic Hours: M-F 9:00 AM - 5:00 PM
Information: St. Paul Family Medical Center was founded in June 2002 by one of the first Hmong woman physicians in the United States, Dr. Phua Xiong, with its primary vision and mission to serve the Hmong community and other low income communities in the Saint Paul and Minneapolis metro area. St. Paul Family Medical Center staff provides health care services that are culturally responsive and respectful of patient’s cultural-religious values.
Accomplishment: St. Paul Family Medical Center has been working towards HCH certification since 2010 and achieved this status early 2016. “We used to get side tracked and go backwards when key staff would leave. Now that we have overcome that challenge and embedded medical home in the day to day activities of our clinic, we won’t have such setbacks.” The provider has seen positive changes at her practice since HCH implementation, noting that they always wanted to do all these things for patients, but now have the structures in place to make it happen: “We used to make recommendations, talk about things in the visit, have a good sense of direction for the patient to go, but never really ended up knowing what happened after the visit. Until they came back and we’d start all over. That doesn’t happen anymore.”