HCH Recertification
Year Two, Three and Beyond
Presented by:
MDH Health Care Homes
Regional Nurse Planners
Capacity Building, Certification and Recertification
Kathleen Conboy, RN, BSN
Tina Peters, RN, BSN, PHN
Joan Kindt, RN-C, BSN, PHN
Danette Holznagel, RN, BAN, CDE, PHN, FCN
Health Care Homes
HCH Certification Updates
___ Certified HCH Clinics

Applicants are from all over
the state.

Variety of practice types
such as solo, rural, urban,
independent, community,
FQHC and large
organizations.

All types of primary care
providers are certified,
family medicine, pediatrics,
internal medicine,
med/peds and geriatrics.
HCH Recertification Process
Learning Objectives
1. Describe the Health Care Home legislative rule subpart
criteria required at recertification year two, three and
beyond.
2. Review the progression of recertification as it addresses
improvement to population health.
3. Describe the requirements for statewide quality
improvement reporting and measurement for certified HCH
clinics.
Recertification Process

Begins at previous year’s certification

Reflects the progression of the clinic’s HCH journey

Validates existing processes

Reflects improvement through outcomes
Recertification Steps for the Applicant
STEP 1:
Letter of intent, the clinic will receive an
automated notification from MDH one
year from initial certification.
STEP 2:
Application and Certification assessment
STEP 3:
Team Meeting with MDH
STEP 4:
MDH Review and Notification
STEP 5:
Optional: Variance requests
STEP 6:
Recertification
Recertification Site
Team Meetings

The team meeting is an opportunity for the
clinic or organization to “share the story” of
progression of the Health Care Home.

Applicants should include care team
representation, care coordinator(s), leadership,
and patient partners.
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Recertification Year Two
Requirements

Continue to meet all initial certification and recertification
requirements (.0040 Subparts 1,2,3,4,5,6,7,8,9,10). Submit
documentation by exception.

Address any variances and/or recommendations made at initial
certification (if applicable).

Updates to specific subparts are required (1A; 2; 5A; 6A,B,D; 8;
9A; 9D; 10A; 10B.

At year two recertification Subpart 11, HCH Benchmark Report
is added.
Recertification Year Two, Three and Beyond
.0040 Subpart 1A, 1
Subp. 1A, 1: Services to Patients with
Complex and Chronic Conditions

Submit documentation of progress in
identifying patients who would benefit
from care coordination services.

Describe new population-based screening
methods for risk stratification, registries,
and predictive modeling tools.
Recertification Year Two
.0040 Subpart 2 Patient Participation
Submit strategies used to encourage patients to take an
active role in managing their care.
Describe the clinic’s progress since recertification year one:
• Participant’s readiness for change
• Literacy level
• Barriers to learning
Recertification Year Two, Three and Beyond
.0040 Subpart 5A
Subpart 5A Care Coordination Program Expansion:
•
•
•
Submit the number of patients receiving care
coordination services and care plans.
Update if there are changes to care
coordination or goal setting processes.
HCH audit as prescribed by MDH. The audit
reflects an evaluation and an action plan.
Recertification Year Two
.0040 Subpart 6A Shared Decision-Making
Examples:
• Workflows to solicit patient participation &
shared decision-making
• Policies—patient and family-centered principles
• Job descriptions
• Education programs
• Tools: Patient Activation Measure(PAM),
Ottawa Shared Decision Making tools,
questionnaires or other tools
• TruthPoint
• Measurement of patient /family centered care
• Patient stories/chart documentation
Recertification Year Two
.0040 Subpart 6B Community Partnerships
Demonstration of on-going partnership with at least one
community resource.
• Meeting Minutes
• Communication or education plan
• Formal referral agreements
• Work plan
Examples of community resources
• Waiver or Senior services
• Local public health
• Home Health
• Assisted living
• Schools
• Behavioral Health
Recertification Year Two
.0040 Subpart 6D Planning for Transitions in Care
Anticipatory planning care transitions:
• Pediatric to adult care
• Transition assisted living, skilled nursing or
memory care facility
• Transition to temporary rehabilitation
• Transition to palliative care or hospice
Recertification Year Two, Three and Beyond
.0040 Subpart 8 External Care Plans

All clinics must provide documentation of the
number and type of care plans (comprehensive
or action plans).

Submit two care plans per certified clinic or a
maximum of 20 care plans demonstrating
integration of external care plans; OR complete
an audit of 20 integrated care plans and submit
a summary of findings and next steps.
Recertification Year Two
.0040 Subpart 9A
Subpart 9A The Quality Team

Submit documentation that the quality
improvement team is in place with meeting
dates, names, roles of participants, and patient
partnership activity.
.0040 Subpart 9D
Learning Collaborative Participation
•
•
•
Submit names, roles and dates of those who attended the
HCH Learning Collaborative.
• Suggested attendees:
• One or more clinicians
• One or more care coordinators
• One or more representatives from the clinic
leadership
Describe how patients were encouraged to participate.
Submit how learning collaborative information is shared with
the rest of the HCH team.
Recertification Year Two, Three and Beyond
.0040 Subpart 10 A
Reporting & Quality Improvement
Statewide Quality Reporting
Patient level data:
Pursuant to Minnesota Rules, chapter 4764.0040, and Minnesota
Statutes, section 256B.0752, the applicant will submit health care
homes data in the manner prescribed by the commissioner to
fulfill evaluation requirements. To meet this requirement, the
applicant will submit patient level data to MDH, in the manner
prescribed by the commissioner. The applicant will submit data
through the MDH contracted data collection vendor; the data
collection vendor will provide de-identified patient-level data
from the applicant to MDH for the purposes of evaluation.
Recertification Year Two, Three and Beyond
.0040 Subpart 10 A
Reporting & Quality Improvement 2
Statewide Quality Reporting
Required Measures:
•Diabetes
•Vascular
•Pediatric and Adult Asthma,
•Colorectal Cancer screening
•Depression Remission at 6 months
•Patient Experience measured through the CG-CAPHS with the
PCMH additional questions
New: Pediatric Preventive Care – Adolescent Mental Health
and/or Depression
Pediatric Preventive Care – Obesity/BMI and Counseling
Recertification Year Two
.0040 Subpart 10 B Quality Improvement Planning
Submit a quality improvement plan that addresses
the “Triple Aim” of health improvement:
• Clinical Improvement
• Patient Experience Improvement
• Cost effectiveness of services
Health Reform in Minnesota
Minnesota’s Three Reform Goals

Improve the health of the population

Improve patient experience

Improve the affordability of health care
Institute of Medicine’s Triple Aim
Recertification Year Two
.0040 Subpart 10B Quality Measures
Examples of Triple Aim Indicators :
Reduced duplication of services
Hospital readmissions, ER usage
Poly pharmacy
Patient satisfaction surveys
Immunization rates
Advanced directives, physician orders for life sustaining
treatment (POLST)
• Optimal care scores
•
•
•
•
•
•
Health Care Homes Recertification
Quality Plan Document
Standard 10A: The applicant must participate in the statewide quality reporting system by submitting data on quality indicators approved by the
Commissioner of Health. Annually benchmarking results are reviewed at recertification.
Standard 10B: At Recertification the HCH selects at least one quality indicator from each of the following categories below (“triple aim”) and
measures, analyzes and tracks those indicators throughout the year. To meet this standard the HCH submits its annual quality plan and quality
reports with data that has been measured, analyzed and tracked. The quality plan may include the quality measures that are submitted to the
Statewide Quality Reporting System or they may be based on other quality needs.
The following is an example template of how the clinic might organize their quality plan. PDSA (Plan, Do, Study, Act) planning cycles also work well
to meet this standard by demonstrating the quality work in the quality plan, or other structured QI methods.
Clinic Name:
Quality Plan
Clinical improvement in
patient health
Patient Experience
Cost Effectiveness
Quality Goals in Each Category.
Data Collection Methods
(Measures / Tools / Methods)
Action Plan (Timeline,
responsible person, PDSA.)
Recertification Year Two, Three, and Beyond
.0040 Subpart 11 A, B

Shows internal improvement over time

Reflects comparison of MN HCH certified clinics

Follow established state or federal standards

Use best practices, outcome-based measures

Assures accountability at recertification

Reflects the framework for statewide quality improvement
Recertification Requirements
Year Three

Continue to meet all initial certification and
recertification requirements (.0040 Subparts
1,2,3,4,5,6,7,8,9,10). Submit documentation by
exception.

Address all variances and recommendations made
from the previous year.

Updates to specific subparts are required (1A; 5A; 8;
9D; 10A; 11).
Recertification Year Three and Beyond
.0040 Subpart 11 A,B
Benchmark Reporting
Review and discuss HCH benchmarking data at the
team meeting. Based on results the certified clinic
may:

Submit a variance for superior outcomes and
continued progress on standards if eligible, or

Continue with present improvement plan, or

Submit a variance with action plan for justifiable
failure to show measureable improvement.
HCH Benchmark Report
Access to Benchmarking Reports
https://hch-data.org/login
HCH Benchmarks
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Benchmarking Approach
Internal and external benchmarking using a hierarchy approach:
•
•
•


A performance (comparison) benchmark, and
An internal improvement benchmark
Benchmarks are established at the clinic level.
Statewide averages are the aggregate of all the optimal patients
eligible to be in the measure.
Health Care Home averages are the aggregate of all the
optimal patients eligible for the certified health care home.
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Statewide and HCH Averages
The statewide average is calculated by taking the total
number of optimal patients in the state (numerator)
divided by the total number of eligible patients in the
state (denominator).
The health care home average is calculated by taking the
total number of optimal patients at the HCH clinic sites
(numerator) divided by the total number of eligible
patients at the HCH clinic sites (denominator).
Improvement Benchmark

If a clinic’s rate is less than the statewide average then MDH will
review the relative percent change from the previous year.

Factors to consider when reviewing the relative percent change
from the previous year are:
• High improvement can be considered a 10 % change or greater
from the previous year.
• Stable performance can be considered a change in performance
between (-9.9% to 9.9%) from the previous year.
• Reduced performance can be considered a change greater than
10 % from the previous year.
Performance Benchmarks
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Improvement Benchmark
If a clinic’s rate falls into the “low
performance” range then MDH will
review the change in performance from
the previous year and work directly with
the clinic to determine if an action plan
and variance is needed to meet the
standard.
Benchmarking Baseline and Beyond

Year one recertification benchmarking results serve as
the baseline comparison.

Year two recertification benchmarking results are a
major component of the recertification process.

Year three and beyond recertification benchmark
results become the measure of clinical quality.
Thank you!
For more information visit the Minnesota
Department of Health, Health Care Home website
at:
http://www.health.state.mn.us/healthreform/homes/index.ht
ml
651-201-5421
HCH Nurse Planners’ Contact Information

Bonnie LaPlante, Supervisor
651-201-3744
[email protected]



Tina Peters– Metro Area
651 201-3934
[email protected]



Kathleen Conboy – Metro Area

•

Joan Kindt- Southern Region



651-201-3753
[email protected]
507-272-4486
[email protected]
Danette Holznagel – Northern Region


218-206-3239
[email protected]