December 2023 HCH Newsletter
The Connection
In this newsletter:
- Program Highlights
- Advancing Health Equity at Richfield Medical Group
- HCH Sustainability Roadmap
- HCH Patient Information webpage
- MNCARES Update
- Learning Update
- Congratulations to Certified and Recertified HCH!
- Do you have a Health Equity Story?
- Noteworthy
Program Highlights
As we look back on 2023, it was an eventful year for the Health Care Homes program, with a number of important developments and improvements that we hope you have found helpful.
- Since the implementation of the HCH Rule changes in October 2022, processes were developed for progression to Levels 2 and 3. The past year saw numerous clinics certifying and recertifying at the advanced levels. These organizations demonstrated a focus on building community partnerships, addressing social determinants of health, and enhancing population health. Those certifying at the Foundational Level made use of a streamlined and updated application process. At the end of 2023 we have 12 clinics at Level 2 and 73 clinics at Level 3.
- Further expansion of use of the new HCH Portal. 2023 was the first full year in which Health Care Homes’ new online Portal was used by HCH staff and partners. This included utilizing the system’s dynamic new reporting function to generate reports looking at numerous aspects of HCH implementation.
- Major changes to the HCH benchmarking process. In the past, HCH benchmarking has been based solely on Statewide Quality Reporting and Measurement System (SQRMS) measures. The new process still takes SQRMS measures into account, but also asks organizations to identify their own measurement priorities and use these to track quality improvement.
- Learning opportunities were offered as in-person events for the first time since 2019. Learning Days took place in April 2023 with 200 attendees. HCH also offered Motivational Interviewing training this year in St. Cloud and Mankato, and Intercultural Awareness Training in St. Paul.
We look forward to working with you in 2024!
Advancing Health Equity at Richfield Medical Group
The following is an excerpt of an article which originally appeared in the StarTribune on October 30, 2023.
It doesn't matter if you are Black, white, or other at the Richfield Medical Clinic — you'll get screened for colorectal cancer when it's your time. More than 70% of the clinic's eligible patients were screened in 2022, according to a new report (PDF) on health care disparities by MN Community Measurement, including 73% of its Black patients. Statewide, only 52% of Black patients were screened as recommended last year through colonoscopies or mail-in tests, compared with 70% of white patients.
The disparity is troubling because Black Minnesotans are more likely to suffer from colon cancer and die from it, but the Richfield center's performance shows that a clinic can break through race barriers and help patients overcome discomfort with the screening. HealthPartners was the only other provider with a Black colorectal cancer screening rate at or above 60% last year.
Dr. Kevin Nelson said he has used humor with hesitant patients at his Richfield clinic, calling the screening a "colostomy bag prevention tactic" that can catch or prevent cancer before it requires invasive treatment. Personal relationships with patients go a long way, but he said his suburban clinic's results are boosted by its more affluent patient population. "Socioeconomics is probably as important as anything," he said.
Appendix tables are available for each measure that MN Community Measurement publicly reports. These tables provide medical group and/or clinic level performance rates for each measure, including a comparison to the statewide average (i.e., rating).
HCH Sustainability Roadmap
The Health Care Homes (HCH) Sustainability Roadmap is a framework for action that provides strategies, resources and stories of success to support certified HCH organizations and clinics. Launched as a project of the Sustainability Workgroup, this dynamic tool was created for leaders, providers, and team members for use in policy development, process improvement, and innovative action.
While funding for and reimbursement to primary care practices is a primary objective to sustainability, the Roadmap's scope extends beyond the financial to include five essential elements: Care Coordination, Finance, Learning, Partnerships and Workforce.
Care Coordination
Care coordination is a team approach that engages the patient, the clinician, and other members of the HCH team to enhance the patient’s well-being. It does so by organizing timely access to resources and necessary care that results in continuity of care that builds trust. Example strategies within the Roadmap include implementing and maintaining evidence-based workflows, providing designated time to perform care coordination activities, and ensuring perspectives of diverse populations in policy, workflows and strategic plans.
Finance
Financial reimbursement and value-based arrangements are important to sustaining the HCH model. Roadmap strategies include participation in Merit Based Incentive Payment Systems, Integrated Health Partnerships and other methods of reimbursement for care coordination services. Referenced resources range from the Centers for Medicare and Medicaid Services (CMS) Innovation Center to the Patient-Centered Primary Care Collaborative to the American Journal of Managed Care.
Learning
A third element, Learning, is essential for all clinic partners. The HCH Learning Collaborative provides team members from certified organizations structured and collaborative strategies to improve the quality of their services by learning and sharing experiences. Jennifer Jerde, Lead RN Health Navigator at Ridgeview Clinics and Sustainability Workgroup member remarked: “Learning from other organizations has helped our own organization improve the care that we provide. Healthcare is ever-changing, and the education resources provided by the Health Care Home Learning Collaborative enable us to learn, adapt and grow.”
Partnerships
Traditional and non-traditional partnerships between certified HCH, other health care providers, payers, and community entities improves the ability to connect patients with needed services and resources. Strong and effective community partnerships improve health, wellbeing, and safety for patients and community members. Success stories included in the Roadmap feature the innovative partnerships Gillette Children’s, St. Luke’s, and Children’s Minnesota have created in the communities they serve.
Workforce
The final essential element of the Sustainability Roadmap is Workforce. Sustainability of the model requires that organizations recruit and retain highly qualified team members. Strategies include aligning roles and responsibilities, supporting shadowing, internships and other hand-on experiences, and promoting appreciation, fairness, safety and shared responsibility.
These and other strategies, resources and success stories are embedded throughout the Sustainability Roadmap. Organizations can access the roadmap at regular intervals to evaluate their strengths and opportunities, or they can choose to refer to a specific element when needed.
The Roadmap is now available as a tool to help guide your organization’s Health Care Homes journey!
HCH Patient Information webpage
HCH has a new webpage just for patients! The Patient Information page was created to help patients understand what a Health Care Home is and why they might want to select a certified Health Care Home for their primary care. Although a patient page has been on the back burner for a few years, it became a priority in 2023 when the State Employee Group Insurance Plan (SEGIP) began flagging HCH-certified clinics during fall open enrollment. Employees could link from the open enrollment information to the HCH patient page to learn more and read some patient stories. It is hoped that other large employers will follow suit in the coming years.
MNCARES Update
Season's Greetings from the Minnesota Care Coordination Effectiveness Study (MNCARES) team! As we reflect on all we have to be grateful for, we want to extend a heartfelt thanks to all who have supported the MNCARES study. Together, we have the opportunity to answer important questions about care coordination and how to achieve the best outcomes for the most medically and socially vulnerable patients. Our partnership with Health Care Homes is vital to making this possible.
We are also grateful to our funding agency, the Patient-Centered Outcomes Research Institute (PCORI), which holds a special interest in care coordination. PCORI recently featured our study as one of three mentioned in a blog post from the Director, Nakela Cook, MD MPH.
As we wrap up another year, we are busy looking at a wide range of data, including care quality, utilization, and patient-reported outcomes in our two large patient cohorts. You can expect to begin hearing about preliminary findings in 2024, both through this newsletter and other communications with study-participating care systems.
Sending our best wishes during this season!
Leif Solberg, MD
Principal Investigator, HealthPartners Institute
Steven Dehmer, PhD
Principal Investigator, HealthPartners Institute
Learning Update
Learning Survey
Thanks to the 55 HCH partners who took time to complete the Learning Survey that was distributed this fall. The purpose of the survey was to assess current need and preferences and identify opportunities for innovation.
What You Said
- Learning Needs: Community partnerships was mentioned twice as often as any other topic. Other commonly mentioned topics include chronic disease management, motivational interviewing, care coordination and patient engagement.
- Learning Preferences: Most people prefer to receive learning through Webinars or e-Learning, followed by Learning Days, In-Person Workshops and Peer to Peer Networking.
- Innovation: Several respondents would like to see a hybrid option for Learning Days, and HCH partners never seem to get enough networking.
What's Next?
The HCH team is in the process of creating the learning plan for 2024. Your responses will inform our decisions and hopefully provide you with tools and resources to enhance your practice and path to certification and recertification. We’ll be back soon with more information!
Congratulations to Certified and Recertified HCH!
Clinics certifying and recertifying October - December 2023 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 go to the Level Progression webpage.
For a complete list of HCH certified clinics, please go to the Find Certified Health Care Homes webpage.
Certification
Red Lake Indian Health Services
- Foundational Level - one clinic
- Level 2 - one clinic
Recertification
Riverwood Healthcare Center
- Level 3 - three clinics
Spread Clinic
Avera Medical Group
- Foundational Level - one clinic
Do you have a Health Equity Story?
Certified Health Care Homes -
Do you have a Health Equity Story that you would like highlighted in the HCH newsletter?
Download the Health Equity Story Form (PDF) and follow instructions for submission.
Noteworthy
- Riverwood Healthcare Center, Aitkin, received the 2023 Minnesota Rural Health Team Award for its work in identifying the social determinants of health among their patients, and creating community partnerships to address those needs.
- Watch HealthFinders Success Story - YouTube about HealthFinders Collaborative’s successful use of Community Health Workers.
- Membership applications for the Minnesota e-Health Advisory Committee are currently being accepted. A list of specific positions, along with the application, is available on the Board/Commission: Minnesota e-Health Advisory Committee webpage under the "Details" section.
- View the 2023 Rural Health Care in Minnesota: Data Highlights | MN Rural Health Care Chartbook on the MDH website! The data paints a picture of the rural health care system in Minnesota and is a valuable resource for policy makers and others.
- Not everyone has the same opportunity to be healthy. Minnesota’s Action Plan to Address Cardiovascular Disease, Stroke, and Diabetes 2035 is a road map and call to action for communities. Read the MN 2035 Plan (PDF) and the associated MDH press release.
- The annual Betty Hubbard Maternal and Child Health Leadership Award honorees for 2023 are Faith Kidder, Minneapolis; Connie Hagen, Plummer; and Angela Watts, Plymouth. The award recognizes people or organizations in Minnesota making significant contributions to maternal and child health. More information about the award winners can be found on the Minnesota Department of Health website, Betty Hubbard Award.
- Stratis Health’s Culture Care Connection is an online learning and resource center. This platform serves as a comprehensive hub for clinical and non-clinical health care professionals, offering information and tools to support their efforts in reducing health disparities and promoting health equity. Culture Care Connection provides culturally relevant resources and suggested strategies to support users in recognizing and addressing biases and providing culturally responsive care to improve patient outcomes.
- Read the 2023 Health Is Primary: Charting a Path to Equity and Sustainability Report from Primary Care Collaborative.