Health Care Homes Learning Collaborative
Learning Days Brochure

Conference Highlights 

Live and In Person! You can look forward to a full day of programming, including 12 breakout sessions, and an engaging networking session led by our own Health Care Homes practice improvement specialists. Make sure to stop by the exhibit hall and take advantage of lunch and break times to network with your colleagues.

Date and Time: May 14, 2025, 8:30 a.m. - 4:00 p.m.

Venue: Heritage Center, 6155 Earle Brown Dr, Brooklyn Center, MN 55430

Opening General Session: We’ll kick off the conference with program updates from Health Care Homes program Director, David Kurtzon.

Exhibit Hall: Take time to visit the exhibit hall and learn about products, programs and services that are making a positive difference for our patients.

Register

Register on the MDH Learning Center and receive conference updates through the Health Care Homes website and LEARN e-news bulletin. Visit the Health Care Homes website for registration information.

Learning Objectives

Learning Days attendees will enhance knowledge and skills to:

1. Learn how addressing social determinants including health literacy improves health outcomes.
2. Explore how using data effectively and responsibly can drive patient centered care and health equity.
3. Examine strategies to integrate behavioral health into primary care for individuals of all ages.
4. Identify innovative approaches that leverage the Health Care Homes model to improve patient and team member experiences.
5. Examine evidence-informed methods for empowering patients in chronic disease prevention and management.

Evaluation

All registered participants will receive an online evaluation after the conference. Please take time to provide feedback so we can continually improve this learning opportunity for you.

Continuing Education Credits

A certificate of attendance including credit hours will be available after the conference. Please submit the certificate to your licensing board to obtain CEU credits. CME is not available for this event.

Presentations Available Online

Access conference presentations and handouts online on the Health Care Homes website.

Photographs

MDH will take photographs throughout the conference. If you do not wish to be photographed, please complete a Photo Opt-Out form at registration and avoid being photographed when possible.

Agenda At-A-Glance

Welcome 8:30 - 8:35 a.m.

Director's Message - Location: Carriage Hall A

David Kurtzon
Director,
Health Care Homes Program
Minnesota Department of Health
St. Paul, MN

Keynote Address 8:35 - 9:30 a.m.

Top 10 Evidence-Informed Methods for Empowering Patients

Location: Carriage Hall A

Description

This fast-paced, interactive keynote asks you to consider how many of the top ten methods for empowering patients you use in your everyday life – at work and at home! With plenty of practical resources and take-home tools, we will explore high-yield topics like shared decision-making, motivational interviewing, and the activated patient movement. What can we learn from high reliability industries like nuclear power and aviation? How is healthcare like bungie jumping? By the end of this session we will have answered these questions, practiced “closing the loop” and debated the value of the “value equation” for your patients.

Learning Objectives

Participants will enhance knowledge and skills to:

1. Describe ten evidence-informed methods for empowering patients in chronic disease prevention and management.
2. Explain how you apply these methods at work and at home.
3. Commit to adding one of the top ten to your routine.
4. Pick your favorite to share with colleagues and friends!

Breakout A1 - Location: Captain's Room

Individuals Beyond Their Medical Diagnosis

Description

Individuals Beyond Their Medical Diagnosis is intended for all attendees to discuss the importance and strategies for Health-Related Social Needs (HRSN) in the communities Allina Health serves. The team will share their knowledge gained throughout the years supporting Health Related Social Needs and provide the framework to be able to replicate the process.

Learning Objectives

Participants will enhance knowledge and skills to:

1. Describing a sustainable model for screening and supporting Health Related Social Needs
2. Implementation of opt in individual and community partnership focused navigation
3. Learnings and responsiveness for future HRSN.
4. Discussion for increasing capacity for HRSN.

Breakout A2 - Location: Harvest Room

Community Integrated Health Care: Evidence-based and innovative CHW models to address SDOH and advance HCH levels of progression

Description

This presentation will highlight the pivotal role of CHW models in addressing health related social needs and extending the reach of clinics into the community, aligning with HCH certification levels progression. We will spotlight results from a 2024 statewide scan on the CHW field in MN and include a panel of CHW program clinic-community partnerships. The panel will highlight partnership strategies for screening and addressing SDOH and innovative solutions to structure and finance CHW models. Don’t miss this opportunity to hear from CHW programs as they describe the opportunities and logistics for collaboration across settings to address SDOH needs effectively and improve health.

Learning Objectives

Participants will enhance knowledge and skills to:

1. Understand the current field of the CHW workforce and models in Minnesota.
2. Examine the integration of clinical-community CHW models and their role in advancing HCH certification levels in MN.
3. Identify strategies for screening and addressing Social Determinants of Health (SDOH) through partnerships between health care home clinics and community-based CHW models.
4. Discover strategies for developing and sustaining CHW initiatives to improve health equity and access to care.

Breakout A3 - Location: Tack A Room

The Care Management Provider: Transitional Care Management in Primary Care

Description
Lakewood Health System has implemented a transitional care program specifically designed to assist patients who have recently been hospitalized.  Marissa Baumgartner, Care Management Provider, follows patients throughout their hospitalization and works closely with hospitalists, the discharge planning team, care managers in the hospital and clinic setting, and clinic providers to ensure that patients have a bridge of care coordination from the in-patient setting back to primary care.

Learning Objectives

Participants will enhance knowledge and skills to:

1. Learn about the innovative approach to dedicate access for patients post hospitalization.  The plan works to ensure appointments are scheduled within 7 to 14 days of hospital discharge with a provider that is familiar with the patient’s hospitalization.
2. Recognize the uniquely designed process of engaging patients, providers, care teams, and hospital staff to ensure patients' needs are identified and met throughout discharge process.
3. Identify how teams collaborate to improve care transitions, ultimately reducing readmissions, adverse events, and unnecessary emergency department utilization

Breakout A4 - Location: Tack B Room

Using Learning Health Systems to Implement and Evaluate Care Coordination

Description
This interactive seminar introduces participants to methodology from Learning Health Systems, implementation science, and program evaluation to enable health systems to evaluate and improve their clinical care delivery. Throughout the seminar, we will share learnings from our health system’s evidence-based care coordination programs developed for families of children living with medical complexity. The target audience is researchers and health care professionals interested in continuous improvement of clinical care or those interested in care coordination methods for those living with complex health conditions.

Learning Objectives

Participants will enhance knowledge and skills to:

1. Understand a real-world application of how Learning Health Systems methodology was used to develop and integrate care coordination at Gillette Children’s Specialty Healthcare, primarily highlighting learnings from a cerebral palsy-specific program.
2. Understand the importance of comprehensive implementation and evaluation strategies and how they can drive patient centered care, health equity, and align with national system standards for children and youth with special health care needs.

Breakout B1 - Location: Harvest Room

Nurse-led Care Coordination for Complex Patients to Reduce Readmissions

Description
Hospital readmissions of patients with multiple chronic conditions place a significant burden on healthcare resources. A nurse-led care coordination program, emphasizing self-management and personalized goal setting, achieved remarkable reductions in hospital readmissions and enhanced quality of life. Learn how nurses played a key role in the development and implementation of this program.
 

Learning Objectives
Participants will enhance knowledge and skills to:

1. Describe the effect of nurse-led care coordination on hospital readmissions.
2. Identify nursing interventions that promote self-management of patients with chronic conditions.

Breakout B2 - Location: Tack A Room

Supporting Adolescents and Young Adults in Their Transition to Adult Life

Description
The purpose of this presentation is to share South Lake Pediatrics' experience from development to integration of a Transition to Adulthood process that includes Healthcare Transition (HCT) from pediatric to adult primary care as well other education/support to patients in the transition from adolescence to young adulthood. The intended audience of our presentation is individuals or healthcare teams who serve adolescents and young adults (pediatrics, internal medicine, family practice). The presentation will be interactive and include case discussions. Available resources for take-home will include a Transition Readiness Assessment, Warm Handoff Letter from Pediatrician to Adult Primary Physician, Educational resources for professionals who are interested in developing their own Health Care Transition process and practical, local resources for parents and patients who are in the planning phase of transitioning their special needs child to adult life.

Learning Objectives
Participants will enhance knowledge and skills to:

1. The objective of this presentation is to outline the development and implementation strategies for a healthcare transition process that is centered on improving patient experience.
2. This presentation will address health literacy in the context of the unique learning needs of young people as they move into adult life.
3. The objective of this presentation is to equip participants with practical, actionable resources and strategies to create effective transition to adulthood processes in their clinic and to provide tools that empowers parents and young adults to navigate this critical transition with confidence.

Breakout B3 - Location: Tack B Room

Bridging Care and Community: The Role of SDoH in Health System Transformation

Description
This presentation highlights how Social Drivers of Health (SDoH) influence health outcomes across our patient and communities. The foundation has helped to align our health systems transformation to address needs and wrap around services. This presentation will examine the intersection of care delivery and community engagement, emphasizing the importance of addressing SDoH to achieve health equity, improve population health, and reduce healthcare costs. Attendees will leave with a comprehensive understanding of how addressing SDoH can drive health system transformation, enhance patient outcomes, and create a more equitable healthcare landscape.

Learning Objectives
Participants will enhance knowledge and skills to:

1. Understanding SDoH: Defining and categorizing SDoH, including economic stability, education access, healthcare access, neighborhood environments, and social support networks. Highlights from Community Health Needs Assessments and Community Health Improvement Plans.
2. Health System Transformation: Strategies for integrating SDoH into clinical workflows, care coordination, and community partnerships to address health inequities.
3. Case Studies and Best Practices: Highlighting successful examples of health systems leveraging SDoH data to improve outcomes and guide policy changes.
4. Tools and Technology: Exploring innovative approaches, including data analytics, and community health dashboards, to identify and address SDoH.
5. Actionable Insights: Practical steps for stakeholders to bridge care and community, foster collaboration, and embed SDoH in health system planning.

Breakout B4 - Location: Captain's Room

Building a Population Health Care Management Program

Description
This presentation will describe the process of building a new population health team, including planning on a director level. Implementation included creating registries based on payor, defining scope, and building standard workflows. The team also researched and created patient outreach methods based on evidence-based practice, including motivational interviewing. The team also worked with Epic to create a program-specific version of Compass Rose to manage our patient panels. We will also include outcome data and patient success stories.

Learning Objectives

Participants will enhance knowledge and skills to:

1. Identify innovative approaches that leverage the health Care Homes model to improve patient and team member experience.
2. Examine evidence-informed methods for empowering patients in chronic disease prevention and management.
3. Learn how addressing social determinants including health literacy improves health outcomes.

Lunch Break 12:00 -1:00 p.m.

Lunch is served in Carriage Hall A. Stop by the Exhibitor tables!

Breakout C1 - Location: Tack A Room

Strengthening Colorectal Cancer Screening Underpinnings

Description Community-University Health Care Center (CUHCC) is a Federally Qualified Health Center serving the Phillips Neighborhood in Minneapolis. CUHCC provides whole-person care to patients from more than 10 racial and ethnic communities.

Using 2022 data from Health Resources Services Administration Uniform Data Systems, CUHCC identified colorectal cancer (CRC) screenings as a focus for quality improvement. CUHCC improved its CRC screening rate from 26% in 2023 to 30% (712/2,374) in 2024. We will share our approach, key interventions, and lessons learned to help other primary care clinics.
 

Learning Objectives
Participants will enhance knowledge and skills to:

1. Identify and implement key system improvements to enhance workflows and patient engagement, leading to increased colorectal cancer screening rates.
2. Learn how to set up a team and communication plan to connect with patients who struggle to complete colorectal cancer screening.

Breakout C2 - Location: Harvest Room

Implementation of the Collaborative Care Model (CoCM): Data-Driven Behavioral Health Integration

Description
We will present on Hennepin Healthcare’s implementation of the Collaborative Care Model (cocm), an evidence-based model that integrates psychiatric/addiction medicine consultants and behavioral health clinician (bhcs) into the primary care setting and uses a registry to facilitate monitoring of individual level patients outcome and population level trends. Cocm results in shortened time to remission for depression, anxiety, and common substance use conditions. We will provide the audience with an overview of the landscape of cocm in MN, lessons learned from our program evaluation, and tips and tricks for building a registry and starting a new program.

Learning Objectives
Participants will enhance knowledge and skills to:

1. Explore how using data effectively and responsibly can drive patient-centered care and health equity: We will present on our methods for the collection of data from the electronic health record and patient interviews, as well as how we have used these data to inform changes in the program.
2. Identify strategies to integrate behavioral health into primary care for people of all ages: CoCM is applicable for all ages, and our participants range for 12-82 CoCM is reimbursable through "incident-to" billing under the PCP, and is currently reimbursed by Medicare and several commercial payers. We are working with a broad coalition to make CoCM a Medicaid benefit in MN this legislative session. The reimbursement structure of CoCM makes it a financially viable integrated model for many primary care clinics.

Breakout C3 - Location: Captain's Room

Making an Impact for a Positive Outcome

Description
This session will explore key themes from The Last Lecture by Randy Pausch, applying them to complex care coordination in healthcare. The session will inspire care coordinators to reflect on personal values, resilience, and the power of empathy in patient interactions. Intended for healthcare professionals and leaders, the seminar will engage participants through interactive discussions, reflective exercises, and real-life case studies. Attendees will leave with practical tools for fostering meaningful relationships with patients and creating impactful, positive outcomes, along with resources for ongoing personal and professional growth.

Learning Objectives
Participants will enhance knowledge and skills to:

1. How to embrace obstacles as opportunities.
2. The value of time.
3. Fostering a positive attitude and optimism.
4. Teaching, learning and feedback loops.

Breakout C4 – Location: Tack B Room

Addressing Disparities in Breast Cancer Care for Black Woman

Description
We will share our experiences aimed at increasing the number of Black women who live in the Robbinsdale/North Minneapolis region who get screened for breast cancer. The target population was based on patient and population-based data that revealed large numbers of North’s patients were behind on their mammograms, even though they lived within 8 miles of the Breast Center. It is well documented that Black women die at higher rates of breast cancer compared to white women, some due to being diagnosed at later stages or not getting screened as often. This work has been successful due to the work of a Community Health Worker (CHW) we hired to provide outreach and education specifically to these patients. Our CHW connects with patients, schedules their mammograms, follow-up, etc. We have also increased outreach, using Black breast models and educational materials translated into Somali at community events.

Learning Objectives

Participants will enhance knowledge and skills to:

1. Understand the data and community activity data that led our organization to drive this initiative.
2. Learn about our model and strategies that have been proven effective to increase breast cancer screenings for black woman.
3. Learn how we addressed gaps and barriers identified by patients and community members that prevented timely screenings.

General Session 2:15 - 3:00 p.m.

Reconciling the polarity of population and individual health

Location: Carriage Hall A

Description

Have you ever struggled with quality measures and processes aimed at population health while you try to be patient-centered by caring for the individual needs of your patient? Perhaps you’ve been frustrated by trying to improve your clinic data while providers ignore key metrics? Whichever side of this push-and-pull you find yourself on, this workshop asks you to grapple with the “polarity” of Big Data and Individual Care. By understanding “polarities” in general, and this “polarity” in particular, participants will be able to more effectively engage with population data and individual needs to improve health outcomes for your patients!

Learning Objectives

Participants will enhance knowledge and skills to:

1. Describe the quality measurement landscape and the growing value-based care movement.
2. Define “polarities” and explain the polarity of population health vs. individual health.
3. Reconcile using big data and patient-centered care to improve patient outcomes.
4. Describe ways to reduce your patients’ disparities using your data and the latest evidence.

Meaningful Conversations 3:00-3:55 p.m.

Peer to Peer Networking

Location: Carriage Hall A

Description
This workshop is a structured, self-facilitated interactive networking session on select topics. Conversations will occur through small group discussion, providing an opportunity to meet new people, actively contribute, exchange perspectives, and obtain new insights. We encourage you to send topic ideas to the HCH team at Health.HealthCareHomes@state.mn.us.

Learning Objectives
Participants will enhance knowledge and skills to:

1. Address challenges related to implementing, maintaining, and advancing the Health Care Homes patient and family- centered care model.
2. Identify effective processes and workflows being utilized in different Health Care Homes programs and populations.
3. Apply strategies to enhance the delivery of patient and family centered care within their organization.

Closing Remarks 3:55-4:00 p.m.

Description
Thank you to attendees! See you next year!

Learning Days Planning Team

• Wendy Berghorst, Minnesota Department of Health, Children and Youth with Special Health Needs
• Alex Dahlquist, Minnesota Department of Health, Office of Statewide Health Improvement Initiatives
• Bridget Ideker, Minnesota Department of Health, Health Promotion and Chronic Disease
• Catherine Johnson, Minnesota Department of Health, Health Care Homes
• David Kurtzon, Minnesota Department of Health, Health Care Homes
• Tina Peters, Minnesota Department of Health, Health Care Homes
• Rosemarie Rodriguez-Hager, Minnesota Department of Health, Health Care Homes
• Anne Schloegel, Minnesota Department of Health, Center for Health Information Policy and Transformation
• Cherylee Sherry, Minnesota Department of Health, Office of Statewide Health Improvement Initiatives
• Jen Strickland, Minnesota Department of Health, Health Care Homes

Sponsors and Exhibitors