June 2021 HCH Newsletter
The Connection
In this newsletter:
- Director's Message
- Learning Days 2021 Recap
- Mental Health Awareness Month webinar
- Dakota Child and Family Clinic
- MDH Learning Center: New HCH course
- Congratulations to Certified Health Care Homes!
- Noteworthy
Director's Message
Hello Health Care Homes,
Thank you for all you have done throughout the COVID-19 pandemic to serve and care for Minnesotans!
This past year has been challenging to say the least, but some exciting initiatives are occurring in the HCH program with the support of many partners. Click on topic to show detailed information.
Minnesota Care Coordination Effectiveness Study (MNCARES) is moving forward with a recent approval of the study’s adaptation plan by Patient Centered Outcomes Research Institute (PCORI). The submission period opened June 14th and closes August 15th, 2021.
To get started, below are the preparations and next steps to submitting data for the Historical Cohort:
- Please download and review the data field specifications and file templates from the MNCARES Information Page for Clinics. The specifications provide details about all data elements that will be submitted for the clinic demographic and problem list data files.
- Please also complete the pre-submission questionnaire to provide additional information about your clinic's/care system's ability to identify patients meeting criteria for the Historical Cohort. This will help the study team understand any challenges your clinic(s) may have in identifying this group of patients in your data system(s) for historical patient records.
- Login credentials for the MNCARES data portal will be sent to your organization’s data submission contact for this project on the day that the portal opens. Once logged in, you will have access to upload data files for the study. Until then, we encourage you to view the recorded instructional video.
The webinar, "Welcome to MNCARES! A Study to Inform Care Coordination Strategies" was presented on April 14, 2021 to provide more detail on the study activities and timeline and an opportunity for questions and suggestions. The webinar was recorded for those who were unable to attend. The link to view the webinar, review the slides and a list questions and answers can be found under the MNCARES UPDATE tab at: Health Care Homes - Minnesota Care Coordination Effectiveness Study (state.mn.us).
We appreciate your participation in this study! Please email HCH with questions: Health.HealthCareHomes@state.mn.us.
The Minnesota Academy of Family Physicians, along with the Minnesota Department of Health’s Health Care Homes Program and Office of Rural Health and Primary Care, convened a group of primary care stakeholders in January 2020 focused on increasing investment in primary care in Minnesota. The COVID-19 pandemic reinforced our goal of increasing primary care investment in Minnesota but constrained our capacity to move on a proposal in 2021. Investing in Primary Care: The Path Forward, a Report of the Minnesota Primary Care Stakeholders Group, captures the key primary care focus areas identified by the group and will serve as a basis for continued discussion of a legislative proposal and primary care recommendations. Areas of strategic focus include improve population health, rethink health infrastructure, expand payment, and strengthen the primary care work force. The report can be found at: Health Care Homes - Primary Care Stakeholder Group Resources (state.mn.us).
The HCH Rulemaking process to advance the current HCH rule is still underway but delayed due to MDH’s COVID response activities. The Health Care Homes proposed new framework builds on the current HCH certification and adds levels of progression. Certified clinics can choose to remain in their current level if they continue to meet required criteria and would not have to advance beyond the foundational standards and certification structure. A certified health care home could elect to change levels within the 3-year recertification period if they met requirements.
As a reminder:
- HCH Foundational - (Current Standards) The foundational level of certification focuses on building team-based patient-centered care that helps individuals achieve coordinated care within the clinic and among specialty providers.
- HCH Level 2 - Broadens the focus for individuals and attributed clinic populations to improve processes that affect whole person care such as addressing social determinants of health, wellness, and early prevention; and strengthening partnerships across the medical neighborhood and community support system.
- HCH Level 3 - Further broadens the focus to include population health with emphasis on integrating community health efforts, developing shared responsibility for health, using data, and sharing care management.
Collaboration with certified HCH partners to improve tools, resources and the new online application process is ongoing currently. Based on clinic feedback and recommendations to alleviate duplication and burden in the current application process, the health care homes team has been designing a new way for clinics to apply for certification and recertification. It is expected to take some time to configure new software and to develop new tools and resources to use in conjunction with the new application process. Please stay tuned for the roll out later this year.
Best,
~ Bonnie
Learning Days 2021 Recap
Learning Days 2021 broke attendance records with 454 participants registered for this free, one-day, virtual learning opportunity featuring innovation and lessons learning during the COVID-19 pandemic.
The conference kicked off with livestreamed program updates from Health Care Homes director, Bonnie LaPlante, followed by a greeting from Minnesota Department of Health Commissioner, Jan Malcolm. Kelly Robinson, founder of Black Nurses Rock Twin Cities Chapter, delivered the opening keynote address. A special noon presentation featured Gunnar Nelson from Minnesota Community Measurement, who reviewed a new benchmarking tool for Health Care Home clinics.
Breakout sessions were held throughout the day featuring knowledge, skills and resources presented by Health Care Home stakeholders. Breakouts covered a broad range of topics, including care coordination, behavioral health integration, community partnership, social determinants of health, and more. The agenda included a balance of rural and urban perspectives as well as a variety of specialized population health topics.
Conference participants received certificates of attendance that can be submitted to licensing boards for CEU credit. All breakout sessions were recorded and uploaded to the Learning Days Event webpage so those who were unable to attend can still participate and receive credit for attending recorded learning sessions. Post event evaluation is under way and will help to shape our 2022 event.
Mental Health Awareness Month webinar
MN Community Measurement hosted a special webinar during May 2021 as part of Mental Health Awareness Month, Improving Together: Advancing Mental Health Outcomes in Minnesota. During the webinar, Dr. Angeline Carlson and Deb Krause shared highlights from a project funded by a prestigious Eugene B. Washington Community Engagement Award from the Patient Centered Outcomes Research Institute (PCORI). The project used a Mixed Methods approach to engage diverse stakeholders, including MDH, employers, health plans, providers, and nonprofit organizations. The presenters highlighted key findings regarding clinical practices, community perspectives, and opportunities for collective action. In addition, resources were shared to educate stakeholders and empower action.
Live polling revealed a shared sense of priority and urgency to improve mental health outcomes, coupled with the willingness to act personally, and a sense of optimism regarding the ability to make progress together. Specific findings included:
- Stakeholders believe that helping clinics advance the identified enablers of success and address the identified challenges in providing mental health care to patients should be a high priority (89% - top priority or one of top three priorities).
- Stakeholders believe that helping clinics advance the identified enablers of success and address the identified challenges in providing mental health care to patients should be urgent (33% highly urgent/immediate, and 65% urgent/in the next 1-2 years).
- Stakeholders are committed to taking action, within their own sphere of influence, to improve mental health care (97%).
- Stakeholders are optimistic that, working together, the community will be able to advance mental health care and outcomes in Minnesota and our local areas (92%).
- Stakeholders have a variety of ideas for maintaining momentum of this project. The most frequent suggestion regarding "What can Minnesota communities do to maintain the momentum of this project to improve mental health care and outcomes?" was continued education regarding best practices (45%), followed by continued community discussions and collaborations (18%). A variety of other suggestions were also offered, including the need for new funding and additional resources.
The webinar recording and slides can be accessed at mncm past events webinars.
As Deb Krause, PCORI Project Leader noted, "It is inspiring to see the shared sense of priority and urgency to improve mental health outcomes. Health Care Homes play a unique role in providing Minnesotans with accessible mental health care that compassionately helps patients take the first step, or the next step, in getting where they want to be, feeling better.”
Dakota Child and Family Clinic
Dakota Child & Family Clinic (DCFC) is a non-profit primary care clinic located in Burnsville, serving families in Dakota County and surrounding areas. While a smaller clinic in size, our heart and passion is immeasurable. Founded by a nurse practitioner, our clinic provides care to approximately 5,000 patients of all ages. DCFC knows that health and wellness requires us to look at the whole person. If patients and families are experiencing hunger, homelessness, or a lack of access to mental health resources, it’s harder for them to be well.
In 2020, DCFC switched patient care from in-person to telehealth ensuring the safety of patients and staff with the onset of the COVID-19 global pandemic. Less than 2 weeks after discovering increased need in Dakota County, we pivoted again to set up a barrier free COVID-19 testing site. We have since provided COVID-19 testing to nearly 10,000 community members in partnership with local public health. With a focus on making sure everyone –especially BIPOC (Black, Indigenous, People of Color) patients who are disproportionately affected by the pandemic– has access to testing. Because of additional community partnerships and our mighty staff we were even able to do outreach in multiple languages. Additionally, with support from Dakota County, we have built connections with people who tested positive for COVID-19, to offer mental health support and other resources while they grappled with the challenges of quarantining and recovery. DCFC has recently been working with Dakota County and other non-profits to provide COVID-19 vaccinations, continuing to focus on communities that are so often forgotten or overlooked in our healthcare ecosystem.
Dakota County non-profits have a history of working together to address issues multilaterally. DCFC has been working with The Open Door over the past year to address hunger while simultaneously providing healthcare for underserved communities. Before the pandemic, The Open Door stocked the food pantry at DCFC, making it possible to send home groceries with families experiencing food insecurity. In August, when the Drive-up COVID testing site began, The Open Door asked to collaborate to ensure that any individual getting tested for COVID-19 could go home with food. During testing, the medical staff asked if families needed groceries and loaded them into their car if requested. The partnership between The Open Door and Dakota Child and Family Clinic has once again addressed a gap in the health and wellness of our community.
DCFC offers many free support and resource groups for members of the community, these include; Indigenizing Love (support for Two Spirit and Native LGBTQIA+ youth), It’s Complicated (support for Black/African American youth). We regularly partner with other organizations to provide support for: grandparents raising grandchildren, caregivers of those with disabilities, and transgender, non binary, and gender creative youth and their families. In the days following the murder of George Floyd, DCFC staff attended rallies to offer resources through a 24/7 text line, deliver diapers, formula, food, toiletries, masks, sanitizer and more to folks that were in need. All of us, staff and board members of DCFC believe that health care should be for people, not for profit, and we work daily towards that goal.
The HCH program thanks Heather Tidd, DCFC Clinic Director, for her work on this article.
MDH Learning Center: New HCH course
The Health Care Homes program has created a new e-learning course:
Beyond the Clinic Walls: Recognizing and Addressing the Social Determinants of Health
Participants will learn about social determinants of health screening tools used to identify social needs, as well as strategies to address them. This includes real-world examples of Minnesota Health Care Homes.
Register now on the MDH Learning Center website.
After completing a course, you will receive an e-mail confirming course completion that you may submit to your licensing board for CEU credit.
Visit the Health Care Homes Learning Collaborative MDH Learning Center webpage for more information.
Congratulations to Certified Health Care Homes!
Clinics recertifying April - June 2021 are listed below. Congratulations to these and other certified clinics working every day to provide better health and better care at lower cost!
Recertification
- U of M Academic Health Center (1 clinic)
Noteworthy
- The National Rural Health Resource Center has created a podcast series on the ‘why’ and ‘how’ of value–based care and population health. Series have been created for both hospital staff and for mid-level leaders. Explore this free and informative podcast series.
- The report, Blood Pressure Medication Non-Adherence in Minnesota: 2015 (PDF) , provides a state and local overview of blood pressure medication adherence in Minnesota, utilizing the Minnesota All Payer Claims Database (MN APCD), a large repository of health insurance claims, enrollment information, and costs for services provided to Minnesota residents. This report is the first-of-its-kind on medication adherence for Minnesota and highlights the variation in blood pressure medication adherence across our state with maps and data tables.