December 2025 HCH Newsletter
The Connection
In this newsletter:
- Director's Message
- Minnesota Health Care Homes' New Tagline
- Supporting New Clinics on the Path to Health Care Homes Certification
- A HCH Advantage: Unlock the Power of Your Practice Improvement Specialist
- Health Care Homes Staff on the Road
- Learning Update
- Congratulations to Recertified HCH!
- Health Care Homes' Sustainability Roadmap Updates
- Do you have a Health Equity Story?
- Noteworthy
Director's Message
Hello and Happy Holidays!
2025 has been a busy and productive year for Health Care Homes. As has become my tradition, I’d like to take this opportunity to highlight a few of the year’s many accomplishments:
- The development, with input from numerous key stakeholders, of a new strategic plan that charts a course for HCH in the short and long term. This plan was created with input from numerous key stakeholders, including our advisory committee and workgroups, clinics, state government staff, and patient-family advisory councils.
- A number of new clinic certifications as well as numerous instances of clinics progressing from the Foundational Level to Levels 2 and 3.
- Another highly successful Learning Days conference!
- The delivery of a three-part health coaching series as well as a separate deep dive training for interested clinic partners.
- Multiple collaborations with the Community Health Worker and Diabetes programs at MDH that led to the creation of e-learning courses and webinars.
- The delivery of highly successful webinars, including Refugee health and Building Trust in Culturally Diverse Clinic Environments.
- The dissemination of information to clinics on an important benefit to HCH certification, namely that Family Medicine physicians and Pediatricians can use HCH certification to meet maintenance of certification (MOC) credits (specifically, the Performance Improvement requirement).
- Connecting and collaborating with others around issues important to primary care, both within MDH as well as across the state and nation, and with our Advisory Committee and workgroup partners. This included co-facilitation of the Minnesota Primary Care Stakeholders Group.
I’m extremely proud of the work done by HCH staff and am grateful that I have the opportunity to work with such a talented and dedicated group of individuals. As we head into 2026, I’m excited to continue our present efforts and look forward to exciting new opportunities.
Thanks to all for your commitment to the health and wellbeing of Minnesotans!
~David Kurtzon
Minnesota Health Care Homes' New Tagline: "Primary Care Clinics That Put You First"
Minnesota’s Health Care Homes program is excited to announce that we are adopting a new tagline, “Primary Care Clinics That Put You First.”
This change addresses a longstanding misconception. Many people mistakenly associate Health Care Homes with home healthcare services or nursing home facilities. In reality, Health Care Homes are clinic-based primary care practices that provide coordinated care. These clinics have met Minnesota’s patient-centered standards and are certified by the state.
While the previous tagline spoke to the systems-change work, it did not convey our clinic-based model. The new tagline specifies primary care and emphasizes our patient-centered approach.
We are enthusiastic that this shift in our tagline framing will help people more clearly understand what Health Care Homes are and the valuable work that Health Care Homes do all across our state.
Supporting New Clinics on the Path to Health Care Homes Certification
A core feature of Minnesota’s Health Care Homes (HCH) program is outreach to primary care clinics that are not yet certified. Practice Improvement Specialists (PISs) play an essential role in this work by helping clinics learn about the HCH model, its benefits, and how it can be adapted to diverse primary care settings.
This fall, a PIS connected with Inspire Change Clinic, a new primary care clinic serving South Minneapolis, and visited the clinic ahead of its official launch in October. Prior to this outreach, Inspire Change Clinic had only limited knowledge of the HCH model. As founder Munira Maalimisaq shared, “Before the outreach, our understanding of Health Care Homes was limited. Our meeting with the PIS provided valuable insights into the model, its benefits, and how it could support Inspire Change Clinic in delivering patient-centered, coordinated care to our community.”
Inspire Change Clinic is grounded in culturally responsive, holistic care. The clinic emphasizes prevention, wellness, community education and partnerships, and addressing social determinants of health—an approach that aligns closely with HCH principles. “Certification would formalize our patient-centered approach, enhance care coordination, and provide access to resources that improve outcomes for our patients and the broader community,” Munira noted.
The PIS’s guidance also influenced the clinic’s decision to pursue certification. “Working with the PIS clarified the certification process and gave us the confidence to move forward,” Munira said.
Inspire Change Clinic is now preparing to take its next steps toward HCH certification, demonstrating how PIS support helps clinics leverage HCH to build strong, sustainable models of patient-centered care.
A HCH Advantage: Unlock the Power of Your Practice Improvement Specialist
Each HCH certified organization has a Practice Improvement Specialist assigned to them. This person is a registered nurse (RN) with a clinical background whose primary role is to support clinics in delivering high-quality, coordinated, and patient-centered care.
What this means for you:
- “Our Practice Improvement Specialist made the recertification process so smooth. She was extremely patient and easy to work with.” - Whether you are applying for certification for the first time or completing your fifth recertification, your assigned Practice Improvement Specialist will guide you each step of the way. If it feels overwhelming…reach out!
- “We appreciate being connected to other clinics working through similar issues.” – Practice Improvement Specialists leverage their insight into the successes and challenges of primary care organizations to facilitate peer connections around specific topics. If you are being challenged by something in your clinic, it is likely that others are (or have been) too…reach out!
- “Our Practice Improvement Specialist is a wealth of knowledge and incredibly responsive.” – While Practice Improvement Specialists may not have all the answers, they are very well connected to information and resources. If you have questions or want to elevate an issue…reach out!
- “We truly appreciate the variety of learning topics offered; they provide a comprehensive understanding of current trends, best practices, and new strategies in HCH models.” – By collaborating closely with the HCH Learning Team, Practice Improvement Specialists amplify clinic voices and help shape future learning opportunities. If you want your perspective represented…reach out!
Having personalized support from HCH RNs is one of the many benefits to MDH HCH certification. Reach out – they’re here and ready to help!
Health Care Homes Staff on the Road: PrimeWest Conference
Health Care Homes Practice Improvement Specialists Jen Strickland and Joan Kindt exhibited at PrimeWest Health's Fall 2025 Providers & Partners Conference on Tuesday, October 28, 2025, at The Prairie Event Center in Parkers Prairie, MN.
PrimeWest Health is a partnership of rural counties that have joined together to provide innovative, affordable health care coverage for their residents eligible for Minnesota Health Care Programs (MHCP). The conference brought together primary care providers, local public health professionals, and community partners dedicated to improving the health and wellness of PrimeWest Health's members.
Jen and Joan enjoyed a day of meaningful connections and networking, including the opportunity to connect with Jim Przybilla, PrimeWest Health CEO and Health Care Homes Sustainability Workgroup member. The event provided a valuable platform to strengthen partnerships and share resources with those working on the front lines of rural health care delivery.
Learning Update
Recent Learning Events
This fall, Health Care Homes offered a range of learning opportunities focused on improving communication, strengthening care coordination, and supporting patient-centered practices. Sessions covered topics such as advancing health literacy, supporting patients with opioid use disorder, and integrating patient and family voices into care delivery. Several past webinar recordings—including refugee health, adolescent communication, and culturally responsive care—were also added to the MDH YouTube channel for on-demand viewing.
Upcoming Webinars
In the months ahead, we’re offering additional learning sessions to support clinics in meeting certification standards and implementing evidence-based practices. Upcoming webinars include:
• Building a sustainable pediatric-to-adult healthcare transition program
• Tools for billing Community Health Worker services
• Patients as Partners: A New Model for Care Delivery Innovation
Save the Date: Learning Days 2026
Looking ahead, mark your calendars for Learning Days 2026, taking place May 13, 2026 at the Heritage Center of Brooklyn Center. More details on registration, speakers, and sessions will be shared early next year as we continue to provide high-quality learning resources for certified clinics.
Congratulations to Recertified HCH!
Clinics recently recertified are listed below. Congratulations to these and other certified clinics working every day to provide better health and better care at lower costs!
For more information regarding HCH certification levels, please see Health Care Homes Certification and Recertification Level Progression.
For a complete list of HCH certified clinics, see Find Certified Health Care Homes.
Recertified
Axis Medical Center
- Level 3 - three clinics
Gillette Children’s Specialty Healthcare
- Level 3 - five clinics
Madison Healthcare Services
- Level 3 - one clinic
Minnesota Community Care
- Level 3 - five clinics
South Lake Pediatrics
- Level 2 – four clinics
St. Paul Family Medical Center
- Foundational Level - one clinic
Stellis Health, PA
- Foundational Level - two clinics
Health Care Homes' Sustainability Roadmap Updates
In December 2025, the Health Care Homes (HCH) Sustainability Roadmap will be updated to include new strategies, expanded resources, and success stories from certified HCH programs across Minnesota. Originally designed to give primary care teams concrete steps for implementing and sustaining the HCH model, the Roadmap has grown into a widely trusted guide—one that many organizations rely on to strengthen care coordination, navigate financial change, enhance learning, build partnerships, and support their workforce.
While the Roadmap recognizes that funding and reimbursement are central to sustaining the HCH model of care, its scope reaches far beyond finances. It offers practical guidance across five essential elements of sustainability—Care Coordination, Finance, Learning, Partnerships, and Workforce—helping organizations strengthen policies, improve processes, and implement innovative strategies tailored to their unique needs.
Over the past year, the Roadmap has been accessed more than 580 times, averaging about 50 visits per month. Visitors most often explored resources and success stories in the Finance element—followed by Care Coordination, Partnerships, Workforce, and Learning—underscoring the shifting priorities and challenges faced by primary care teams statewide.
We invite you to visit the Health Care Homes Sustainability Roadmap - MN Dept. of Health to discover practical ways to strengthen and sustain your certified HCH program. Learn how Stellis Health partnered with Stepful to fully staff a strong, community-rooted primary care workforce, and how Open Door Health Center expanded intern and shadowing programs to deepen engagement and build future talent from within.
Whether you’re looking to enhance care coordination, explore new financing options, expand community partnerships, support your workforce, or sharpen your learning culture, the Roadmap is the perfect place to start—and a valuable resource to return to again and again.
Do you have a Health Equity Story?
Certified Health Care Homes
Do you have a Health Equity Story that you would like highlighted here in the HCH Connection newsletter?
Download the Health Equity Story Form (PDF) and follow instructions for submission. Thank you!
Noteworthy
Superior Health Quality Alliance
As the CMS Quality Innovation Network – Quality Improvement Organization (QIN-QIO) for the Great Lakes Region, Superior Health will provide no-cost technical assistance to eligible providers in Illinois, Indiana, Michigan, Minnesota, Ohio and Wisconsin. This includes support for chronic disease management, behavioral health integration, patient safety, care coordination and health care quality — all aligned with CMS national goals. To access this assistance, Enroll With Superior Health Quality Alliance to begin the enrollment process or reach out to info@superiorhealthqa.org for more information.
Rural Health Clinic Billing and Coding Bootcamp
The MN FLEX program is collaborating with Archpro Coding to provide a Rural Health Clinic billing and coding bootcamp on Feb. 24 & 25, 2026 from 9:00-4:00 pm; 9-12:30 p.m. The intended audience for this training is RHC billing/coding staff, billing/coding supervisors, hiring managers, and providers who create clinical documentation. The training is free to attend for staff at MN RHCs and will be presented virtually. The training will also offer up to 11 CEUs and the option to take the Rural Health Clinic Coding and Billing online certification exam. If you are interested in attending you can register at: 2026 Minnesota Rural Health Coding & Billing Bootcamp Feb. 24th - 25th, 2026
Gillette ECHO Series
The Minnesota Health Care Transition Learning Collaborative (HCT LC) is a groundbreaking project aimed at advancing pediatric to adult health care transition for children and youth with special health needs. The leadership team of Gillette Children's Health Care Transition efforts is a collaboration between Gillette's Health Services Research Program, The National Alliance to Advance Adolescent Health, Got Transition®, and the Minnesota Department of Health (MDH)'s Children and Youth with Special Health Needs (CYSHN) section. Our work is funded by the MDH CYSHN section. For upcoming sessions, visit 2025 Gillette Children's Health Care Transition Learning Collaborative ECHO Series.
CHW Billing Toolkit
NEW resources now available to support organizations that integrate Community Health Workers (CHWs) into care teams on the MDH CHW Initiatives website, Community Health Worker Resources for Employers, including:
- Informational grids with CHW service models, supervision requirements and codes
- Workflows and checklists outlining steps to successfully obtain reimbursement
- Tip sheets and example forms for obtaining NPI numbers, enrolling CHWs with the Department of Human Services, and contracting with managed care organizations
- An interactive financial modeling workbook to estimate expenditures and income for providing reimbursable CHW services
A webinar on will be scheduled in January to provide an overview of the new CHW Billing Toolkit and how to use the tools to deliver and bill for CHW services.
For questions or more information on the toolkit, contact: health.chw.MDH@state.mn.us
