September 2020 HCH Newsletter
The Connection
In this newsletter:
- Director's Message
- Live Online: State of the HCH Program
- Community Health and Wellness: PCCS & CUHCC
- Encounter Alert Service
- Stratis Health Recruiting for New CMS Improvement Initiative
- Collaborative Learning for the Future of Health
- HIT Ambulatory Survey Open
- New Benchmarking Report on the Horizon
- Congratulations to Certified Health Care Homes!
- HCH Staff Changes
- Noteworthy
Director's Message
Hello Health Care Homes,
2020 has presented many professional and personal challenges for all of us and I hope you are doing well. The Health Care Homes (HCH) team is here to support you as needed.
The HCH program is continuing to move forward with advancement of the HCH rule, implementing a new benchmarking process, making quality improvements to the certification and recertification processes, advancing investment in primary care and participating in the Minnesota Care Coordination Effectiveness Study (MNCARES).
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 introduce the new MNCARES study and outline the important questions it will help the community answer.
Invitations for Certified Health Care Home clinics to participate in the study could be distributed as early as October 2020. Participating clinics will have an opportunity to request some financial reimbursement for expenses, receive reports on overall study outcomes, receive individual reports that can help understand how the clinic compares to its peers and forego one recertification cycle through an experimental variance. Please check the MNCARES webpage, hosted by MDH, for more information.
~ Bonnie
Live Online: State of the HCH Program
We’ve missed you! Please join the HCH team and your colleagues online October 13 from 11:00 am to 12:30 pm to share information about our experiences during COVID-19 and learn more about what to expect in the coming months. We’ll cover program changes, policy initiatives, learning opportunities and provide lots of opportunities for you to weigh in with comments and questions.
Invitations went out via e-mail in mid-September or you can access the meeting link from the HCH News & Announcements webpage. Do you have a burning question you want to make sure we’ll address? Send it along in advance to Health.HealthCareHomes@state.mn.us.
Community Health and Wellness: PCCS & CUHCC
The coronavirus (COVID-19) pandemic reveals deep-seated inequities in health care for communities of color and amplifies social and economic factors that contribute to poor health outcomes. Recent news reports indicate that the pandemic disproportionately impacts communities of color, compounding longstanding racial disparities. Clinical staff from both People’s Center Clinics & Services (PCCS), along with Community University Health Care Center (CUHCC) had concerns about the potential for the virus to spread in the Minneapolis Cedar-Riverside neighborhood, home to a large immigrant and refugee population. Many residents of the Cedar-Riverside area live in multigenerational households, making social distancing and isolation a challenge.
With demand to create new lines of service quickly, PCCS and CUHCC worked collaboratively to meet testing and patient education needs for the Cedar Riverside and South Minneapolis neighborhoods. This collaboration included patient and community voices in its development, showing how FQHCs within the same area can work together across agencies and with the community to more fully provide quality care. In a time when it is challenging for many healthcare institutions to adapt quickly in a culturally responsive way, our agencies demonstrated an ability to be nimble and meet the needs by working together.
Besides offering well-received COVID-19 testing at each of their clinics, PCCS and CUHCC are partnering to host mobile testing events at community centers and public housing buildings bringing this vital service to the community. Regular testing at the Brian Coyle Center is starting mid-September and a rotating schedule of testing in public housing is being developed. Information on these testing events will be widely disseminated within the community.
PCCS and CUHCC have long been committed to the health and wellness of their communities and this partnership will strengthen that resolve long past the COVID-19 pandemic. The trust of the community is essential in combating the spread of COVID-19, and in addressing underlying chronic health issues that affect the course of the virus. With the long-term health of this diverse community in mind, the clinics continue to work with other community providers, leaders and organizations to make sure testing is sustainable and distributed fairly throughout the area. Input on the cultural norms and specific health needs of distinct populations is sought on a regular basis. It is hoped that these coordination efforts can be leveraged into the fall and winter vaccination season and beyond, to improve healthcare access in this vibrant community.
Encounter Alert Service
Fragmented care is expensive; the sooner a provider who is accountable for coordinating a person’s care can be informed of a health event, the more effectively they can support recovery, transitions between care settings, and avoid re-hospitalization. Not all health systems are able to easily communicate to the appropriate providers when an adverse health event occurs, leading to unnecessary hospital readmissions and lower quality care for patients. In response to this problem, in the spring of 2017, the Minnesota Department of Human Services (DHS), issued a Request for Proposal (RFP) to provide admission, discharge and transfer (ADTs) notification services for Medicaid beneficiaries. In partnership with DHS’ vendor, Audacious Inquiry (Ai), the Encounter Alert Service (EAS) was launched in 2018 and initially focused implementation efforts to providers participating as an Integrated Health Partnership (IHP), the state’s Medicaid ACO program. When a patient is admitted, discharged or transferred (typically from a hospital or emergency department), notifications are sent from the Electronic Health Record (EHR) to care coordinators and providers. The EAS uses provider-beneficiary panels to push the alert to the right care team so that they can engage immediately in care planning needs.
Since its launch the service has grown rapidly and now includes large integrated health systems, smaller independent providers, community mental health providers, and skilled nursing facilities in every region of the state. In the spring of 2020, in an effort to combat the COVID-19 crisis, the EAS partnered with the Minnesota Department of Health (MDH) to leverage the ADT feed and send de-identified information on patients presenting to the hospital with COVID-like illness. This supports MDH epidemiologists in monitoring the spread of the disease, while at the same time accelerating the onboarding of many large health systems in greater MN who had not yet joined the service. It also expanded the service to include event notifications for all patients (it had previously been limited to Medicaid). Presently, the EAS receives notifications from 171 sources and delivers over 100,000 alerts per month. DHS contributes attributed patient panels for Integrated Health Partnerships (IHPs), and providers who perform care coordination can upload additional consenting panels. Over the next year, the EAS will focus implementation efforts on expanding the number of providers subscribed to receive alerts, especially smaller, independent providers and community mental health providers. For more information visit www.mneas.org.
The HCH program thanks Jackie Sias, DHS, for her work on this article.
Stratis Health Recruiting for New CMS Improvement Initiative
Stratis Health as part of the Superior Health Quality Alliance (Superior Health) is currently enrolling organizations to participate in a new Community Coalitions for Improving Care initiative sponsored by the Centers for Medicare & Medicaid Services (CMS). Superior Health Community Coalitions are designed to connect health care organizations with the shared goal of improving health and health care throughout the communities they serve. This work runs through November 2024.
The enrollment period ends October 31, 2020.
An online form is available to join a Community Coalition for Improving Care or to request more information.
Collaborative Learning for the Future of Health
The global pandemic has magnified longstanding issues of health care access, quality, cost and inequity within the health care delivery system, and is challenging us all to innovate with our community partners. Now, more than ever, we are all teachers and we are all learners. In 2021, the Health Care Homes learning agenda will focus on harvesting the lessons and opportunities of COVID. We’ll take a closer look at social determinants of health, new telehealth strategies, community partnerships, and how we can hit the reset button on prevention and routine care. We’ll rely on you to share your experiences with others so we can all learn together.
Until it is safe to convene in person, all learning will be virtual, including our annual Learning Days conference in the spring of 2021. E-Learning will continue throughout the year, as well as online interactive learning sessions.
Take advantage of two new e-learning courses coming your way in the coming months. Integrating Primary care and Behavioral Health will open for registration in late September. Developed in collaboration with DHS and Stratis Health, this course will highlight the importance of behavioral health as a component of primary care, and showcase several innovative partnerships. Later in the year, watch for two courses on Arthritis Management developed in partnership with the Office of Health Prevention and Chronic Disease Management.
Watch for more information in the LEARN e-bulletin, on the Learning Collaborative MDH Learning Center webpage, or the MDH Learning Center website.
MDH - MNCM Biennial Health Information Technology Ambulatory Survey Open
MDH and MN Community Measurement’s biennial Health Information Technology (HIT) Ambulatory Survey opened on September 15, 2020. This survey was sent to all medical group primary contacts registered with MN Community Measurement. If your group did not receive a survey link, you have questions, or you need assistance, please contact MN Community Measurement at support@mncm.org. The survey will close on October 15, 2020.
New Benchmarking Report on the Horizon
The HCH program is collaborating with MNCM, with input and guidance from the HCH Measurement and Evaluation Workgroup and members of the HCH Advisory Committee, on developing a new HCH benchmarking process.
Guided by stakeholder recommendations, the new report allows clinics to compare themselves to other clinics with similar patient populations and be a useful tool for networking and sharing best practices. Listening sessions demonstrating the new report have been held with a number of clinics. The feedback has been positive and informative. The HCH program continues to work with MNCM to shape and finalize the new benchmarking process to better meet clinics' needs.
Congratulations to Certified Health Care Homes!
Clinics certifying July - September 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
- CHI St. Gabriel’s Health – Family Medical Center Pierz (1 clinic)
- Tri-County Health Care – Bertha, Henning, Ottertail, and Sebeka Clinics (4 clinics)
- Sanford – Mayville and Perham Health New York Mills Clinics (2 clinics)
- Allina Health - Apple Valley, Bloomington, Buffalo, Burnsville, Edina, Fridley, Inver Grove Heights, Isanti, Jordan, Lakeville, Maplewood, Minneapolis, Oakdale, Savage, St. Paul, Vadnais Heights, River Falls (WI) (20 clinics)
HCH Staff Changes
Chris Dobbe retired from her position as the System Development Supervisor of the Health Care Homes program effective July 21, 2020. Chris has been an integral part of our team for the last 6+years. Her contributions will always be valued and remembered. Her thoughtful style of leadership has promoted team work, HCH strategy, day to day activity and advancement of the HCH rule to name just a few of her accomplishments. We wish Chris all the best, and hope she enjoys a happy retirement.
Noteworthy
- The MDH Center for Health Equity released a new report “Cultivating a Health Equity Ecosystem: Lessons Learned from the Eliminating Health Disparities Initiative". Find more information on the MDH Eliminating Health Disparities Initiative webpage.
- The Quarter 4 Webinar for the Minnesota statewide Pediatric Care Coordination: Community of Practice will be held on Tuesday, October 20th from noon – 1:00pm. For more information visit the PCC CoP webpage.
- The de Beaumont Foundation has a new mental health action guide "Supporting a Nation in Crisis: Solutions for Local Leaders to Improve Mental Health and Well-Being During and Post-COVID-19" (PDF). For more information, visit the de Beaumont Foundation website.
- Individuals with behavioral health conditions in addition to physical health conditions drive high total healthcare costs. Yet among these patients, spending for behavioral health treatment is a small portion of total healthcare spending, while over 95% of spending is for physical treatment. These are among the findings of a new analysis of claims data for 21 million commercially insured individuals conducted by Milliman, Inc. The study was commissioned by The Path Forward for Mental Health and Substance Use and funded by the Mental Health Treatment and Research Institute LLC, a tax-exempt subsidiary of The Bowman Family Foundation.
- The American Psychiatric Association Foundation’s Center for Workplace Mental Health is developing and collecting an array of resources addressing mental health and well-being during and beyond the COVID-19 pandemic.