December 2020 HCH Newsletter
The Connection
In this newsletter:
- Director's Message
- MNCARES recruitment
- South Lake Pediatrics: Care Coordination's Response to COVID-19
- Mental Health Summit
- Update: Learning Days 2021
- Recap: State of the HCH Program
- MDH Learning Center: Updates
- Congratulations to Certified Health Care Homes!
- Hope for Better Days Ahead
- Noteworthy
Director's Message
Season's greetings!
As 2020 ends, the Health Care Homes team would like to thank you for all you have done to care for Minnesotans during this difficult year.
You have faced unprecedented challenges with strength, creativity, perseverance and compassion. The next year will bring new challenges, but we are hopeful that the COVID-19 vaccine will provide some relief and improve workplace safety for our front line health care workers and their families.
In 2021, the Health Care Homes team will continue our collaborative work to:
- Advance health equity
- Revise the Health Care Home rule to reflect advances in the program
- Engage in research to further our understanding of the effect of care coordination on patient outcomes
- Pursue policy recommendations to increase investment in primary care
- Implement a new benchmarking process with improved analytical capabilities
- Continually improve our service to HCH stakeholders and partners
As we reach to establish a new normal, the Health Care Home team is here to help, and we wish you the very best as we work together to serve our patients and communities. Be safe, and be well.
~ Bonnie
MNCARES Recruitment
HealthPartners Institute, in collaboration with the Minnesota Department of Health and MN Community Measurement, has been awarded $4 Million of funding from the Patient Centered Outcomes Research Institute (PCORI) to study the effect of care coordination on patient outcomes. The partners are pleased to present the Minnesota Care Coordination Effectiveness Study (MNCARES) and outline the important questions it will help the community answer – and encourage you to bookmark the MNCARES web page hosted by MDH for ongoing updates at: Health Care Homes Minnesota Care Coordination Effectiveness Study (MNCARES).
The purpose of MNCARES is to compare two approaches to care coordination for patients with high health care costs and multiple morbidities. The goal is to learn what approaches to care coordination in primary care settings produce the best care quality, utilization, and patient-centered outcomes. The first model includes care coordination performed by a nurse or other clinical staff. The second model includes a social worker as part of the care team.
MNCARES is currently recruiting clinics across the state that are certified as health care homes through MDH. As of December 15th, 75% of eligible clinics have agreed to participate. Later in 2021, participating clinics will complete a survey about care coordination and securely provide data about adult care coordination patients.
Recruitment of clinics will be open through January 31, 2021.
South Lake Pediatrics: Care Coordination's Response to COVID-19
South Lake Pediatrics is an independent pediatric practice with five clinics in the west metro area of Minneapolis. We have a robust care coordination team with diverse experience and expertise. Our team consists of two nurse coordinators, a social worker, and a Somali community health worker and an educator.
Our team utilizes patient registries to prevent gaps in care and to help patients maintain their optimal health and wellness. We never imagined that our registries would be helpful in addressing the unexpected challenges families would face beginning in March of this year.
When the state of Minnesota implemented the stay at home orders in March, parents all but stopped bringing their children to the doctor’s office. There were so many unknowns about the coronavirus and the anxiety throughout the community was high. Our pediatric practice, like all others, made rapid adjustments to clinic protocols and procedures. Our point of care services also expanded to include; telehealth appointments, well clinics, extended weekend hours, and curbside COVID clinics.
Our Care Coordination team’s first response was to turn to their registries. Their first calls were to families with children and youth who have special health care needs. Even though we did not have a lot of information about the virus in the early stages of the pandemic, we did know that families were anxious and facing unprecedented challenges. Care Coordinators initiated calls to families to see how they were managing. Care Coordinators supported families by actively listening, providing community resources and information about how to access medical and mental health care.
Care Coordinators next focused on their patients who suffered from anxiety and depression. They checked in with patients and families to be sure they had the mental health support they needed. They provided community resources and connected patients to care.
The stay at home orders placed additional stress on families who were struggling with food insecurity, housing and financial needs. Care Coordinators reviewed the social determinants of health screens for the previous three months and reached out to families to offer support and community resources as needed.
Our registries proved to be helpful in ways we couldn’t have imagined a few months ago. Even though the pandemic is not over, and our challenges and anxieties have not diminished, our Care Coordinators continue to work hard at helping families access resources and coordinate care.
The HCH program thanks Tara Mahin, South Lake Pediatrics, for her work on this article.
Mental Health Summit
The Minnesota Department of Health (MDH) is continuing to work closely with providers, employers, policymakers, and non-profit organizations across the state to drive improvement in Statewide Depression Remission at 6-months as reported by MN Community Measurement (MNCM). This collaborative work has increased visibility and relevance now, given the COVID-19 pandemic's profoundly negative impact on communities.
The theme of MNCM's 2021 Annual Conference is Building Bridges to Better Health, and the virtual event will include a special Pre-Conference Summit on Mental Health on the afternoon of February 17. MDH's Health Care Homes are encouraged to attend the Mental Health Summit which will feature engaging content, designed to fuel the conversation regarding community collaboration to improve mental health care and outcomes.
The agenda includes:
- Keynote address by Daniel H. Gillison, Jr., CEO of the National Alliance of Mental Health (NAMI). An accomplished non-profit and corporate executive, Mr. Gillison will provide critical context on the state of mental health and mental health care in the United States and the region, highlight the reasons why now is the time for the community to take action, and provide key insights on how stakeholders can leverage data to inform action and achieve better outcomes.
- New information gathered through a best practices study of Minnesota clinics and care systems funded by a prestigious Eugene B. Washington Community Engagement award from the Patient Centered Outcomes Research Institute (PCORI). The session will highlight best clinical practices, as well as gaps and opportunities in care management for persons diagnosed with depression.
- Community dialogues. Regional breakout sessions will provide the opportunity for community stakeholders to reflect on the information presented and discuss how it relates to the nuances that exist within their local areas.
- Closing Session focused on Moving Forward Together – From Ideas to Action, facilitated by Darcy Gruttadaro, J.D., Director for the Center for Workplace Mental Health American Psychiatric Association Foundation. Ms. Gruttadaro will synthesize the major themes and strategies that emerged throughout the summit with a focus on empowering all stakeholders – health care providers, payers, purchasers, and community members – in doing their part to drive more rapid change.
As Bonnie LaPlante, MDH's Director of Health Care Homes, noted, "It is wonderful to see MN Community Measurement using this special Summit on Mental Health to engage stakeholders in improving mental health care and outcomes, one of the top public health issues of this time." Attendees can register for the Summit on Mental Health at MNCM Events.
The HCH program thanks Deb Krause, Minnesota Health Leadership Council, for her work on this article.
Update: Learning Days 2021
After a year off, Learning Days will return in 2021 in a virtual format in late May. With limited staff resources and participant availability, HCH is scaling Learning Days to a one-day event and scheduling later in the spring to allow more time to plan. The 2021 agenda will feature COVID-19 related lessons and innovations, and will take place on a virtual platform with general sessions, breakout rooms and online engagement opportunities. Speaker recruitment will begin soon and all presentations will take place remotely.
Because we all deserve an award for the innovation in the face of COVID-19 during 2020, there will be no Health Care Home Innovation Awards made at the 2021 Learning Days. We hope to return to a live, in person event to facilitate opportunities for networking and building new relationships when we can be safe. Stay tuned for more information!
Recap: State of the HCH Program
Nearly 200 health care home stakeholders and friends tuned in on October 13, 2020 for a State of the Health Care Homes Program update delivered by the HCH staff via MS Teams. Over the course of an hour, the staff provided updates on newly certified clinics, important new program initiatives, changes coming to the HCH benchmarking process, educational opportunities and more. A recording of the meeting may be accessed on YouTube: Health Care Homes - State of the Program.
MDH Learning Center: Updates
The MDH Learning Center has undergone several recent changes. We think you’ll like the new look and other updates! To view the revised navigation directions and new login page link, visit the Health Care Homes Learning Collaborative MDH Learning Center webpage.
New E-Learning: Integrating Primary Care and Behavioral Health: Approaches and Strategies
Putting the patient at the center of care means providing whole person care. Learn about the best practices in integrated care and see how Minnesota-based primary care and behavioral health providers are building them into their practices. Register now on the MDH Learning Center website.
Congratulations to Certified Health Care Homes!
Clinics certifying October - December 2020 are listed below. Congratulations to these and other certified clinics working every day to provide better health and better care at lower cost!
Certification
- Scenic Rivers Health Services - Big Falls, Floodwood, and Northome (3 clinics)
- Lake Crystal Clinic is now part of Madelia Community (1 clinic)
- Cuyuna Regional Medical Center - Crosby (1 clinic)
- CCM Health - Clara City, Clarkfield, Milan, and Montevideo (4 clinics)
Hope for Better Days Ahead
In closing, we would like to leave you with this lovely video produced by TPT2 as part of Hippocrates Café: Reflections on the Pandemic. Hold each other close. Better days are coming!
Cabin of Love performs "Slowly Exploding" alongside Scott Streble’s "Porch Portraits".
Noteworthy
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30 Minnesota companies sign a Commitment to Diversity, Equity and Inclusion. Read the September 18, 2020 news release on the ICSI website.
- MDH has resources and guidance for community members, healthcare providers and more on the MDH Coronavirus webpage . For our health care providers, including long-term care and nursing homes, visit the Health Care: Coronavirus Disease 2019 (COVID-19) webpage for guidance. There is a Minnesota Helpline for questions related to the COVID-19 pandemic: 651-297-1304 or 1-800-657-3504 . This hotline is staffed Monday - Friday 9 a.m. to 4 p.m. Subscribe to MDH COVID-19 updates to get emails when the daily situation update is posted and other Minnesota news updates.