Health Care Homes

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Contact Info
Health Care Homes
651-201-5421
health.healthcarehomes@state.mn.us

Contact Info

Health Care Homes
651-201-5421
health.healthcarehomes@state.mn.us

Health Care Homes
Learning for Certified Health Care Homes

Free on-demand, CEU eligible e-learning on a variety of primary care topics.

Registration information

Register as follows for Health Care Homes e-learning courses listed below:

  1. Log in to the MDH Learning Center. If you do not have an account, you must create one. There is no cost for creating an account. Leave your browser open once you have logged in.
  2. From the courses listed below, click on the registration link for the course in which you want to enroll.
  3. When the enrollment key appears, click on the Click to Enroll button.
  4. When the enrollment success message appears, click on the title of the course link to go directly to the course.
  5. You will receive an email confirming your registration.
  6. Complete the course. If you do not complete the course right away, you can return to it later.
  7. After completing the course, you will receive a certificate of completion via email. Submit this to your licensing board for CEU credit. Your completion certificate can be found in the Transcript section of your MDH Learning Center account.

How to Register for Health Care Homes E-Learning Courses (PDF)

MDH Learning Center e-learning courses

Analyzing Healthcare Data with Excel: A Practice Guide for Quality Improvement

This course teaches practical Excel skills for working with healthcare quality data, including that from Minnesota Community Measurement (MNCM) and other sources. Learners will learn how to prepare data files, use pivot tables, calculate clinic rates, stratify data by demographics, and create charts to better understand and share results.

The course is organized into short, focused modules and was developed in partnership with MNCM. It is intended for anyone looking to improve their ability to analyze and use healthcare data for reporting and quality improvement.

Registration

Beyond the Clinic Walls: Recognizing and Addressing the Social Determinants of Health

Course Overview

This course explores the social determinants of health, including the resulting social needs. Participants will learn about the screening tools used to identify social needs as well as strategies to address them. This includes real-world examples of Minnesota health care homes.

Learning objectives

After completing this course, participants will be able to:

  1. Describe social determinants of health and the resulting social needs of a clinic’s patient population.
  2. Describe social determinants of health screening tools available to identify social needs.
  3. Identify strategies to address social needs.
  4. Discuss real world examples of screening for and addressing social needs.

Registration

Resources

Strategies
Tools
Community Resources
Privacy and Data Sharing

Care Coordinator - Bridging Care for Diabetes Management

This course explores diabetes and the role care coordinator's play in managing diabetes and addressing social determinants of health that can lead to poor health outcomes for people with diabetes.

Learning objectives:

  1. Define the care coordinator’s role in diabetes management.
  2. Identify the tools and resources available for diabetes management.
  3. Describe how to bridge care for patients with diabetes.

Course details

  • Cost: Free
  • Format: On demand 
  • Certificate: A completion certificate is available for CEUs

Registration

Resources

Diabetes Management
Tools and Resources

Check Up from the Neck Up

A course for clinicians and care team members focusing on best practices and tools for diagnosing cognitive impairment in older adults. Created in partnership with Act on Alzheimer’s, this free course includes video demonstrations, webinars, and practice exercises.

Learning objectives:

  1. Describe the value of timely detection of cognitive impairment and dementia.
  2. Administer, score, and interpret at least one objective cognitive assessment tool.
  3. Discuss cognitive assessment results and next steps with patients and other providers.

This online course was developed in partnership with ACT on Alzheimer's.

Course details

  • Cost: Free
  • Format: On demand 
  • Certificate: A completion certificate is available for CEUs

Registration

Resources

Alzheimer's Information
Cognitive Screening
Communicating Results of Cognitive Assessment

Emerging Professions

Emerging Professions was developed in partnership with the MDH Office of Rural Health and Primary Care. In this course, you will learn how community health workers, community paramedics and dental therapists can enhance your practice and better serve your patients. You will also learn where to find qualified candidates, how to write job descriptions, and how to build them into your practice.

Registration

Resources

Community Health Worker
Community Paramedics
Dental Therapist

Foundations of Health Care Homes Certification

An updated version of the Foundations of Health Care Homes Certification e-learning course is now available from the MDH Learning Center. The course covers the health care homes progression model and the standards and requirements for certification and recertification as a health care home. The course is designed for primary care providers considering health care home certification, as a resource for clinical staff in the certification or recertification process, and as an orientation for care team members who would benefit from learning about the health care home model.

Registration

Visit Foundations of Health Care Homes Certification - Resources.

Fundamentals of Care Coordination

Health Care Homes is excited to introduce Fundamentals of Care Coordination, a multi-lesson foundations course that covers the principles and practices of effective care coordination. Like its other e-learning courses, the care coordination course is free and consists of short lessons, so you can select topics of interest and complete lessons in manageable chunks of time. Health Care Homes practice improvement specialists provided subject matter expertise and resources for the course.

Registration

Resources

Introduction to Care Coordination
Quadruple Aim
Treat High-need, High-cost Patients
Triple Aim
The Care Coordinator
Assessing Your Needs
Quality Improvement and the Care Coordinator
Recognizing and Preventing Care Coordinator Burnout
TeleHealth
What is a Care Coordinator?
Where to Find a Care Coordinator
Defining Care Coordination
Managing Care Transitions
Patient Centered Care
Patient Engagement and Activation
Team Based Workflows
Resources for Care Coordination
Behavioral Health, Tools and Strategies for Care Coordinators
Community Partnerships
Cultural Competence
Literacy Learning
Motivational Interviewing and Coaching
Shared Decision Making and SMART Goals
Social Determinants of Health
Trauma Informed Care

Health Care Homes Webinar Recordings 2026

Registration

Implementing a Clinic-based Self-Measured Blood Pressure Program

This course introduces basic components of clinic-based self-measured blood pressure programs, profiles three Minnesota clinics that have implemented self-measured blood pressure programs and explores their similarities and differences. Produced in partnership with the Office of Statewide Health Improvement Initiatives.

Learners who complete this course will be able to:

  • Explore options for clinic-based self-measured blood pressure programs.
  • Identify similarities and differences between example programs.
  • Consider how to structure a program in a participant clinic.

Registration

Resources

Clinics - Self-Measured Blood Pressure (SMBP) Resources
Patients - Self-Measured Blood Pressure (SMBP) Resources
Clinic Tools to Support a Healthy Lifestyle
Patient Resources to Support a Healthy Lifestyle

Implicit Bias in Health Care

Learn about the difference between implicit and explicit bias, the various lenses through which we view our environment, and how implicit bias affects quality of care and patient health. Additional tools and resources provided. Created by Health Care Homes in partnership with Stratis Health.

Participants in this course will be able to:

  • Recognize that everyone holds implicit bias.
  • Describe how implicit bias impacts care quality.
  • Provide one example of how implicit bias impacts patients.
  • Identify strategies to increase awareness of implicit bias to minimize impacts.

Registration

Resources

Integrating Primary Care and Behavioral Health: Approaches and Strategies

This course was created through a collaboration between two MDH sections, Health Care Homes and the Office of Statewide Health Improvement Initiatives. Topics covered include best practices in integrated care as well as Minnesota-based examples of work being done by both primary care and behavioral health providers. Learners who complete this course will be able to:

  • Define bidirectional integration and the need for this approach.
  • Identify three key components of integrated care and how they can be implemented in primary care or behavioral health settings.
  • Describe the experiences, challenges, and solutions of Hennepin County Mental Health Center and their integrated care delivery model.

Registration

Resources

The Juniper Solution: Referring Patients to Evidence Based Disease Prevention and Self-Management Programs

This course provides an overview of the Juniper network of Minnesota community-based resources for individuals with chronic diseases. The course is designed for providers who are interested in referring their patients to Juniper's evidence-based disease prevention and self-management courses.

Learning objectives

After completing this course, you will be able to:

  • Describe Juniper evidence-based self-management and disease prevention resources.
  • Explain how to promote and refer patients to Juniper self-management education programs.

This online course was developed in partnership with the Diabetes and Health Behavior Unit of the Health Promotion and Chronic Disease Division and is worth .5 credit hours.

Registration

The Juniper Solution - Resources

Juniper, Network Programs and Providers
Implementing Health Care Provider Referrals to SME
Minnesota Evidence-Based Self-Management Education Providers University of Minnesota Extension Programs
Self-Management and Support Research
Self-Management Resource Center Self-Management Programs
  • Fidelity Manual is used to guide fidelity for any self-management program. Self-Management Program Resource Center (SMRC)
Self-Management Program Impact and Outcomes

Medication Therapy Management

This course explores pharmacy-led medication therapy management and the opportunities, challenges and requirements for partnering with an embedded pharmacist or community pharmacist. Produced in partnership with the Office of Statewide Health Improvement Initiatives.

Learners who complete this course will be able to:

  • Understand pharmacy-led medication therapy management.
  • Describe current reimbursement sources for medication therapy management.
  • Discuss the opportunities, challenges, and requirements for partnering with an embedded clinical pharmacist or a community pharmacist.
  • Identify key steps to embedding pharmacist-led medication therapy management into a clinic setting.

Registration

Resources

Medication Therapy Management (MTM)
Reimbursement for Pharmacist led MTM
Clinic - Pharmacist Partnership Models

Prediabetes: A Time to Act

One in three American adults has undiagnosed prediabetes. Left unchecked, prediabetes can lead to heart attack, stroke and Type 2 diabetes. The good news is that lifestyle changes can stop or slow prediabetes. This course looks at prediabetes through the lens of population health, including screening, identifying risk factors, and ways that community partnerships can aid prediabetes management. Developed by the MDH Health Care Homes Program in collaboration with the MDH Office of Statewide Health Improvement Initiatives.

Participants who complete this course will be able to:

  • Explain the significance of prediabetes to population health.
  • Identify risk factors and symptoms of prediabetes.
  • Describe screening tools and diagnostic tests for prediabetes.
  • List key action steps for developing care plans for individuals living with prediabetes.
  • Refer or recommend a community or online diabetes prevention program or other lifestyle change resource.
  • Identify opportunities for partnering with the community to address prediabetes.

Registration

Prediabetes: A Time to Act Resources 

Understanding Prediabetes
Incorporating Prediabetes Prevention into Clinical Practice
Community Partnerships

Introduction to Risk Stratification - Learning about Your Population

Learn about risk stratification and how to use it to manage population health in these two related courses.

Describes risk stratification and its link to health care homes, explains why it is important and provides examples of processes and tools.

Participants who complete this course will be able to:

  • Define risk stratification and describe why it is important.
  • Recognize how risk stratification is connected to health care homes standards.
  • Describe the benefits of knowing the complexity of your population.
  • Identify levels of risk, processes, and examples of risk stratification tools.

Registration

Resources

Risk Stratifying Your Population: Strategies and Examples

This course explores models of risk stratification, highlights work being done by health care homes clinics to assess and manage patient populations and looks at the link between risk stratification and care coordination.

Participants who complete this course will be able to:

  • Describe multiple risk stratification models for the care coordination of a population.
  • Identify how using data sources can create levels of risk in your patient population.
  • Describe real world examples of assessing and managing patients from a data driven perspective.
  • Recognize how care coordination interventions are tailored to risk levels

Registration

Resources

Sailing Toward Success with Telehealth

For many organizations, COVID-19 has been a catalyst in adoption of telehealth. Whether your organization is just starting or on its way, this course will help you chart your voyage with information, tools, and resources to advance your telehealth practice. All aboard! Developed by the MDH Health Care Homes program in collaboration with the MDH Office of Statewide Health Improvement Initiatives.

Participants who complete this course will be able to:

  • Relate one example of telehealth to clinical practice experience.
  • Measure current readiness to change telehealth practices.
  • Identify and prioritize one area for improvement in the use of telehealth solutions.
  • Describe the value and impact of making a change to telehealth practices.
  • Select at least one resource to assist in making the identified telehealth practice improvement.

Registration

Sailing Towards Success with Telehealth - Resources

Shared Decision-Making

Learners will explore shared decision-making, a model of patient-centered care. Topics include defining and describing the shared decision-making approach, when and how to make use of shared decision-making, and what steps should be taken when implementing this model in your organizational setting.

Learning objectives:

  • Describe shared decision-making and its potential for our health system in a rapidly changing care delivery and payment environment.
  • Identify the questions you should ask to analyze and improve your shared decision-making efforts.
  • List the steps needed to apply these principles to your measurement and improvement priorities.

This online course was developed in partnership with Stratis Health. 

Registration

Shared Decision-Making - Resources

General Information
Decision Aids
Share Approach (Agency for Healthcare Research and Quality)

Strategies for Hypertension Management

Explores strategies to support management of hypertension, including prevention, patient self-management, and partnerships between clinics, local public health, and community organizations.

Learning objectives:

  • Explain the importance of self-measuring blood pressure for hypertension management.
  • Identify strategies to coordinate hypertension management through partnerships between clinics, community organizations, and local public health.
  • Help clinics and communities partner to promote healthy lifestyles to reduce and manage hypertension.

Registration

Resources

  • See resources under the course "Implementing a Clinic-based Self-Measured Blood Pressure Program".

Health Care Homes, in partnership with the MDH Office of Statewide Health Improvement Initiatives, has created two e-learning courses focusing on arthritis management:

Clinic-Community Linkage for Arthritis Management

This course takes learners through best practices for supporting patients in managing arthritis. This includes a focus on the Walk With Ease program.

Learners who complete this course will be able to:

  • Review how arthritis disease affects people’s lives.
  • Describe the framework of screen, counsel, referral and follow up in a system workflow process, and the importance of using patient registries.
  • Recognize using the 5 A’s for individual counseling with arthritis patients: ask, advise, assess, assist, and arrange within the screen, counsel, referral and follow-up workflow.
  • Identify referral process to evidence-based lifestyle management programs and physical activity interventions.
  • Select communication tools to promote physical activity.

Registration

Resources

Clinic-Community Linkage for Arthritis Management
Walk With Ease

Supporting Arthritis Management - The Role of Community Health Workers

This course explores the role of community health workers in supporting patient arthritis management.

Learners who complete this course will be able to:

  • Understand the community health workers role with people who have arthritis.
  • Recognize risk factors for and describe the management and treatment of arthritis.
  • Recognize how community health workers can use the 5 A’s with arthritis patients.
  • Identify a referral process to evidence-based lifestyle management programs and physical activity interventions.
  • Select communication tools to promote physical activity.

Registration

Supporting Arthritis Management - The Role of CHW Resources

Laying the Foundation
Understanding and Managing Arthritis
Using the 5 A’s
Referral to Community Programs and Interventions

Using the Collaborative Care Model to Integrate Behavioral Health into Primary Care

Learn how organizations in Minnesota and nationally are integrating behavioral health and primary care through the Collaborative Care Model. Explore how this evidence-based model is improving outcomes for primary care patients with behavioral health needs and consider action steps for implementing the model in your organization.

Learners who complete this course will be able to:

  • Describe the Collaborative Care Model and how it works
  • Explain how the model is being used nationally and in Minnesota.
  • Identify action steps and resources to start implementing the Collaborative Care Model.

Registration

Resources

Resources available for health providers interested in setting up Collaborative Care Model (CoCM) programs

Return to Learning Collaborative Main Page

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Last Updated: 02/26/2026

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