March 2021 HCH Newsletter
The Connection
In this newsletter:
- Director's Message
- HCH Benchmarking Tool
- MNCARES Study
- Mental Health Summit follow-up
- Lakewood Health System: Lakewood Engage
- Save the Date for Learning Days: June 10, 2021
- HCH program team changes
- MDH Learning Center: New HCH courses
- Noteworthy
Director's Message
Hello Health Care Homes,
Thank you for all your hard work and service in battling COVID-19 and caring for all Minnesotans! It has been a long and trying year and hopefully we are beginning to see the light at the end of the tunnel.
I am happy to highlight two significant HCH updates:
Please see the following articles for further information on these two updates.
~ Bonnie
HCH Benchmarking Tool
The HCH program, in partnership with MN Community Measurement (MNCM), has launched a new HCH benchmarking tool based on certified HCH recommendations. The benchmarking tool data supports certified organizations in telling their story of achieving improved patient outcomes and has the following functions:
- Measure Comparison – shows how a selected clinic compares to other HCH clinics for each MNCM quality measure
- Peer Comparison – finds the 8 HCH clinics that have the closest match for patient risk and displays the results for each selected clinic and measure
- Navigation instructions within the new tool to assist with using the tool’s functions
In 2021, additional features will be added to the HCH Benchmarking Tool:
- Data for 2020 dates-of-service
- Tools to convert charts to PDF, EXCEL, and PowerPoint
- Trending over time analysis
- Ability to choose a peer group for comparison
If you have not received a username and password to the benchmarking tool, please contact: support@mncm.org.
MNCARES Study
Thank you to all clinics who have agreed to participate in the Minnesota Care Coordination Effectiveness Study (MNCARES). MNCARES is funded by PCORI and is a collaboration among HealthPartners Institute, Minnesota Department of Health, Minnesota Community Measurement, four payors (MN Department of Human Services, Blue Cross Blue Shield of Minnesota, Ucare, and HealthPartners), and the participating care systems. The goal of this study is to learn what approaches to care coordination in primary care settings produce the best care quality, utilization, and patient-centered outcomes.
Study Updates:
- We have had a great response from eligible clinics and care systems, with 45 care systems and 319 clinics agreeing to participate (84% of those eligible). This response rate is terrific. Thank you!
- We are currently negotiating study adaptations with the funder due to the Covid-19 disruptions in care, which is causing some delay in our timeline.
- At the earliest, data submissions on care coordination patients could start in Quarter 2 of 2021 (May-June). When data submissions are ready to begin, we plan to have several months available to complete the process for added flexibility. Our partners at MN Community Measurement will offer training materials and assistance with the process of data submission.
We invite you to attend a free webinar hosted by MN Community Measurement on Wednesday, April 14th at 9:00am that will provide more detail on the study activities and timeline and an opportunity for questions and suggestions. The webinar will be recorded for those who are unable to attend. This free webinar will:
- Highlight progress made in preparation for the official launch of the study activities this spring.
- Share how Minnesota Health Care Home Clinics, health plans, and patients will be engaged with the study.
- Outline the key questions the study will help us to answer to inform improvement efforts.
- Provide an opportunity for questions and for input on what information you hope we can provide.
- Provide information on how you can learn more and stay up to date with the study’s progress.
On behalf of the MNCARES partners, we greatly value and appreciate your participation in this study and look forward to working with you. Please email HCH with questions: Health.HealthCareHomes@state.mn.us .
Mental Health Summit follow-up
MN Community Measurement's 2021 Annual Conference, Building Bridges to Better Health, was held virtually in February. For the first time ever, this premier event included a special Pre-Conference Summit on Mental Health, designed to fuel the conversation regarding community collaboration to improve mental health care and outcomes.
One of the featured sessions was Strategies for Success: Minnesota Providers’ Experiences in Improving Depression Care. Dr. Angeline Carlson and Deb Krause shared 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 project was modeled after a study of diabetes care done 10 years ago and guided by a multi-stakeholder coalition, including MDH, employers, health plans, providers, and nonprofit organizations. At the Summit, the presenters highlighted key findings regarding clinical practices, enablers of success, challenges to address, and opportunities for collective action. Quotes from clinic representatives brought the concepts to life and sparked robust conversation among Summit attendees. The session recording and slides can be accessed at mncm past events and webinars.
MNCM is hosting a free follow-up webinar on May 11, as part of Mental Health Awareness Month. This webinar will expand on topics highlighted during the Mental Health Summit, weaving in perspectives shared in the recent Community Dialogues and bringing forward new information gathered through the 2021 Clinic Practices in Depression Care Survey. Attendees will learn about clinic practices that contribute to higher rates of performance on the depression suite of measures publicly reported by MNCM. The webinar will identify actions to support improved outcomes for patients. In addition, the webinar will recognize high-performing clinics for their excellent work in supporting patients with depression on their journey to remission. Health care homes are invited to register at: mncm events.
As Deb Krause, Regional Strategic Advisor to the MN Health Leadership Council noted, "It was an honor for Dr. Carlson and me to engage with clinics, learn from them, and synthesize the insights. The realities of our world today… the coronavirus pandemic, the increasing prevalence of depression, recent performance on the MN Community Measurement depression suite of measures, and heart-breaking health disparities… make the focus on working together to improve depression care and outcomes even more important and even more urgent.”
Lakewood Health System: Lakewood Engage
Health equity exists when every individual has the opportunity and resources to achieve their best health. Unfortunately, factors such as poverty, racial or ethnic discrimination, lack of access to quality education, or inadequate housing can prevent this.
Lakewood Health System, based in Staples, MN, identified disparities for families living in extreme poverty and the senior population through their 2013 Community Health Needs Assessment. Lakewood also recognized individuals needed the engagement and support of community organizations to overcome these barriers to health equity.
In response, Lakewood Engage was developed to partner with schools, communities, and public health organizations. Engage’s goal: To develop food access initiatives to increase access to safe, nutritious, and affordable food for positive health outcomes.
The results of their tremendous work are as follows:
- Food Farmacy is an onsite ‘pharmacy’ that dispenses healthy foods. Food insecurity screenings - approximately 30,000 annually- are included with primary care visits. Clinics are equipped with Acute Care Packs filled with non-perishable food items that are sent home with patients identified through the screening as being food insecure. Providers place a referral connecting patients with healthy food options, educational opportunities, goal setting, and support. Food Farmacy serves 130 families, dispensing nearly 4,000 pounds of fresh vegetables, fruit, and meat each month.
- An expansion of Food Farmacy, Fresh Delivered connects local seniors with the same fresh, healthy food in their home. The delivery option removes the barrier of transportation and serves 200 seniors annually.
- Cardinal PAX is a weekend backpack program providing nutritious, non-perishable food for school-aged children. Named after the Staple-Motley School mascot, Cardinal PAX provides nearly 1,000 packs of food to students each year.
- Engage hosts the Staples Area Farmers Market throughout the local growing season and provides market vouchers to participants who cannot afford the regular market price.
- Meals at COVID+, a collaboration with Lakewood clinics, is the latest Engage initiative. Clinic staff screen patients for program participation when they call to share positive COVID-19 test results. Fresh, frozen meals are then delivered to the family allowing them to begin quarantine immediately. The meals are free, designed by a licensed dietician, and prepared by Hilltop Regional Kitchen in Eagle Bend, MN. All meals are made with fresh ingredients and frozen right after preparation, giving them higher nutritional value that requires less food processing than typical frozen dinners. The program has served 15,000 meals to 1,000 individuals.
For more information visit Lakewood Engage.
Save the Date for Learning Days: June 10, 2021
After a year’s hiatus, Learning Days will return as a one day virtual event on June 10, 2021. This year’s event will focus on capturing primary care innovation and lessons learned during the COVID-19 pandemic. Unlike previous years, we will not be issuing a call for proposals. All presentations will be curated by the Learning Days planning team with strong input from our HCH practice improvement and integration specialists. Since we believe all our HCH certified clinics deserve an award for innovation during this challenging time, we are suspending the Health Care Home Innovation Awards for one year.
Stay tuned for more Learning Days details in the coming weeks. We are looking forward to being with you again - this year virtually, next year in person!
HCH program team changes
The HCH program is pleased to announcement the following team updates. Welcome David and Jennifer!
David Kurtzon is stepping into the role of System Development Supervisor. David has been a member of the HCH team for the last five years. His focus has been on developing and delivering learning for HCH stakeholders. David has been a leader in the creation of e-learning modules and the management of the MDH Learning Center. David has also helped lead efforts to promote sustainability for HCH certified clinics. This included facilitating an interdisciplinary workgroup, building partnerships with other state agencies, and participating in the development of strategies to support successful implementation of the HCH model. David is excited about transitioning to a new position, while continuing to work with his amazing colleagues at HCH.
Jennifer Strickland, RN, recently joined the HCH team as a Practice Improvement Specialist. After graduating from Concordia College in Moorhead, MN, with a degree in Nursing, Jennifer had the opportunity to work for health care systems in North Carolina and Alabama. Returning to Minnesota 16 years ago, Jennifer began working at Lakewood Health System where she developed a passion for improving healthcare in the rural setting. Before coming to HCH, Jennifer was the Director of Clinics and Clinic Nursing at Lakewood, and prior to that served in a variety of roles including Director of Customer Experience, Joint Connection Program Coordinator, and Staff Development and Education Coordinator. Jennifer brings to HCH nearly 30 years of nursing and leadership experience in acute and primary care. She enjoys working with teams and individuals to find sustainable solutions to improve the health of patients and communities. Jennifer is looking forward to collaborating with primary care clinicians and clinics in Northern MN to pursue and maintain their HCH certification.
MDH Learning Center: New HCH courses
Health Care Homes, in partnership with the MDH Office of Statewide Health Improvement Initiatives (OSHII), has created two e-learning courses focusing on arthritis management. They are:
- Clinic-Community Linkage for Arthritis Management : Provides information, tools, and resources for health care professionals to support patient arthritis management. An emphasis is placed on the role of partnering with community organizations and local public health.
- Supporting Arthritis Management – The Role of Community Health Workers (CHWs) : Focuses on how CHWs can engage with patients to manage arthritis. The course includes both information and practical tools to support the work of CHWs.
Register now on the MDH Learning Center website.
Visit the Health Care Homes Learning Collaborative MDH Learning Center webpage for more information.
Noteworthy
- Read a Mayo Clinic article , highlighting Open Cities Health Center, which describes the process of setting up a drive-thru COVID-19 test collection site.
- Watch a video of nurses in Minnesota, as they share their experiences working during the COVID-19 pandemic.
- Free webinar: Understanding Fetal Alcohol Spectrum Disorders (FASD): What Care Coordinators Need to Know, Tuesday, April 20, 2021; 12:00pm - 1:00pm. Hosted by Pediatric Care Coordination: Community of Practice (PCC CoP).
- The Primary Care Collaborative (PCC) has transformation tools for improvements in clinical practice. The Clinical Practice and Transformation Quick Start Guide provides resources to boost patient and family engagement. The PCC website also includes a Transforming Clinical Practice Initiative Guide.
- The National Center for Complex Health & Social Needs has released Core competencies for frontline complex care providers , which is designed for the complex care field.
- Read the Accountable Care Organization Care Transformation Toolkit , fourth in a series from the Centers for Medicare & Medicaid Services, which provides practical steps for Medicare accountable care organizations to transform the delivery of care.