March 2025 HCH Newsletter
The Connection
In this newsletter:
- Director's Message
- North Memorial Health: Black Women's Breast Health Initiative
- MNCARES Update
- Learning Update
- Health Care Homes Staff on the Road
- Congratulations to Certified and Recertified HCH!
- Do you have a Health Equity Story?
- Noteworthy
Director's Message
Greetings!
I want to say “thank you” to our many partners for your support as Health Care Homes continues with strategic planning. While HCH has undergone strategic planning in the past, major changes to the program such as the addition of advanced certification levels prompted the launch of a new process in the Fall of 2024. Since then, we’ve benefited from great feedback provided by certified clinics, patients, community organizations, and many others. Your engagement has already made this a successful experience and we hope that you will continue to partner with us. For the latest news, please visit the HCH strategic planning webpage.
I’d also like to take a moment to recognize the amazing work of the HCH staff as we wrap up the first quarter of 2025. Practice improvement specialists have been working particularly hard, completing a higher than usual number of initial certifications and recertifications while continuing to provide support and technical assistance. Our learning team has overseen the roll out of several webinars per month over the last few months, including a three-part health coaching series; all while planning for the annual Learning Days conference on May 14. I don’t say it enough, but it’s a real honor to work with such a great group of professionals!
Take care and best wishes,
~David
North Memorial Health: Black Women's Breast Health Initiative
In early 2023, North Memorial Health discovered a concerning health disparity: only 60.2% of non-white patients at their clinics were up to date on breast cancer screenings, compared to 72.2% of white women. In response, a multidisciplinary workgroup was established to address and eliminate these disparities in breast cancer screenings using a comprehensive approach.
Community conversations, including dinner, were held with approximately 100 Black women in 2024. Sessions identified principals for ongoing interventions:
- Educate everyone about the disparities in health outcomes for African American women, with a focus on breast health.
- Design screening spaces with empathy and intention to ensure they meet the needs of the community.
- Create scripts based on the concept of “narrating care” to train team members across all levels of patient care.
- Identify events that shape attitudes toward breast exams and breast health engagement, and measure women’s responses to current marketing materials and communications related to breast health.
To address the disparity in the West Metro, North Memorial, with funding from United Health Care, hired community health worker Angela Bowen from CHW Solutions. Angela diligently reached out to over 400 women who were overdue for appointments. Her efforts resulted in 177 completed mammograms, just three short of their goal of 180. Patients trusted Angela to help them overcome barriers related to transportation, language, and trust by listening to their concerns and meeting them where they were at. “I’m making a difference in my community. For myself, for my children, and for everybody else,” Bowen said.
Another effective tool used by North staff in clinics and at community education events was a brown breast self-exam model. Each model includes palpable lumps to help individuals learn how to detect potential abnormalities through touch, as well as non-palpable lumps that are visible only with a penlight, highlighting the critical role of mammography.
North Memorial Health was recognized at the 2024 Minnesota Hospital Association’s Annual Meeting for their excellence in innovation, advocacy, and leadership, specifically in the Community Benefit category, for their work on the Black Women’s Breast Health Initiative.
The HCH Program thanks North Memorial Health for sharing their story and for the work they continue to do to improve health equity in Minnesota.
MNCARES Update
The Minnesota Care Coordination Effectiveness Study (MNCARES) has been completed, and the Health Care Homes team would like to extend our heartfelt thanks to the 317 clinics (83% of eligible clinics) that participated. Minnesota's success in securing funding for a study on care coordination was made possible by the commitment of our Health Care Homes certified clinics. Their involvement enabled the essential observational study that helped deepen our understanding of care coordination.
The insights and data shared by participating clinics were vital to generating valuable findings that significantly contributed to the success of our research. This was made possible by thoughtful and detailed responses from organization leadership and care coordinators to survey questions, along with the additional input provided by staff during interviews. We deeply appreciate the time and effort invested by participating organizations and sincerely thank them for their invaluable contribution to this important research.
MNCARES sought to answer three key questions about care coordination:
- What care coordination model produces the best outcomes for patients: a traditional medical-nursing model or one that incorporates a social worker on the team?
- What additional components of either model are important for achieving the best outcomes?
- What other aspects of the community, care system, or patients help explain differences in outcomes?
The final research article is now available in the January 2025 issue of the Journal of the American Board of Family Medicine, titled "Care Coordination: How Is It Implemented and Is It Different If a Social Worker Is on the Team?". Links to this and other MNCARES publications are found in the Health Care Homes MNCARES webpage.
The application to continue this research study has been declined, so there will be no continuation of the Minnesota Care Coordination Effectiveness Study.
Learning Update
We've kicked off the year with an exciting lineup of webinars! Our webinars kicked off with a strong start, featuring engaging sessions on health coaching strategies, an "Exercise is Medicine" webinar, and a co-hosted session with the Diabetes and Health Behavior Unit. These sessions provided valuable insights and practical techniques for practitioners across the field. We're also pleased to share that after a several-month hiatus, we're gradually uploading webinars from last year to MDH's YouTube channel. Keep checking back as more content will be available in the coming weeks — these resources are perfect for reviewing key concepts or catching up on sessions you might have missed.
The response to our call for presenter submissions for the upcoming Learning Days Conference has been truly overwhelming! The quality and diversity of proposals received promise to make this year's event one of our most valuable yet. We're excited to showcase innovative approaches, research findings, and best practices from leaders across our community. We warmly invite you to join us for the Learning Days Conference on May 14th at the Heritage Center of Brooklyn Center. Registration details will be available in late March, and we encourage you to secure your spot early as we anticipate high attendance based on the exceptional program we're assembling.
Health Care Homes Staff on the Road
Red Lake Indian Health Services HCH check-in
This photo was captured during a routine check-in with Tiffany Schouten and Deonna Patch from Red Lake Indian Health Services. A check-in is an informal conversation which provides organizations the chance to share what is going well, challenges being faced, changes to the organization’s HCH program, and any other updates.
Do I spy a Practice Improvement Specialist as well? Why yes I do - it is Jen Strickland!
Mankato Clinic Patient Advisory Council
As part of Health Care Homes’ strategic planning process, staff traveled across the state to attend Patient and Family Advisory Council meetings. During these meetings, they gathered input on ways to improve the dissemination of information about health care homes.
These photos are of the Mankato Clinic Patient Advisory Council, where HCH topics were being discussed with Practice Improvement Specialist Joan Kindt.
Congratulations to Certified and 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.
Recertification
Alomere Health
- Level 3 - two clinics
Avera Medical Group
- Foundational Level - twelve clinics
CentraCare Health System
- Level 3 - 26 clinics
CHI St. Gabriel's Health
- Foundational Level - three clinics
HealthFinders Collaborative
- Level 3 - three clinics
Lake Region Healthcare Clinic Services
- Level 3 - nine clinics
NorthPoint Health & Wellness
- Level 3 - one clinic
Ridgeview Medical Center
- Level 3 - thirteen clinics
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
- Read the 2024 HCH Year End Report (PDF), which highlights the great work done by the HCH program and partners.
- Make plans now to attend the June 9-10 2025 Minnesota Rural Health Conference in Duluth MN.
- The Asthma Program developed printable asthma education sheets for adults and youth. They are culturally tailored and beautifully designed for health care providers and Tribal communities to support American Indians who have been diagnosed with asthma. The education sheets are found at: Asthma Education Resources for American Indian Communities. If you have questions about these materials or seek technical assistance from the program Clinical Advisor, please email: health.asthma@state.mn.us
- The Minnesota Office of Rural Health and Primary Care (ORHPC) launched a new and improved Minnesota Health Care Workforce Dashboard in January. The Health Care Workforce Dashboard features data on licensed providers in a wide range of health care fields, including physicians, nurses, mental health professionals, dentists, respiratory therapists and many others.
- The 2024 MDH Community Health Worker (CHW) Statewide Environmental Scan report (PDF) and summary findings (PDF) have been posted on the MDH Community Health Worker Initiatives website! The scan highlights how CHWs are currently integrated into the workforce across Minnesota, including the implementation and financing models, as well as barriers and facilitators of CHW initiatives in Minnesota.
- The Centers for Medicare & Medicaid Services (CMS) announced in January that Minnesota was selected as one of 15 states to participate in the Transforming Maternal Health (TMaH) Model. TMaH aims to improve health outcomes and foster a safe and supportive environment for mothers and infants enrolled in Medicaid and the Children’s Health Insurance Program (CHIP).