HCH Recertification Year One
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.
The Health Care Homes
Recertification Process
Learning Objectives
1. Describe the Health Care Home legislative rule subpart
criteria required at recertification year one.
2. Define the progression of quality improvement requirements
3. Identify strategies to implement the standards at
recertification year one.
Recertification Process
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Begins at previous year’s certification
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Reflects the progression of the clinic’s HCH journey
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Validates existing processes

Reflects improvement through outcomes
Timelines:
Recertification
The Recertification Process Window is: 90 Days
On the one year anniversary of your initial certification
date, MDH will send you an email to notify you that you
have 90 days to complete the recertification process:
 LOI
 Application
 Assessment (if changes)
 Site Visit
•
Your clinic will now have a rolling 15 month
recertification due date.
Recertification Time Line: 60 Days
60 days before the end of your recertification:
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Submit a Letter of Intent to indicate your wish to pursue
recertification.
•
Update the application with new clinicians or clinic information.
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MDH Planner will contact via phone or e mail
•
Plan a date for your site visit.
Recertification Time Line: 45 Days
45 days before the end date of your recertification:
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Submit your recertification assessment
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•
•
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Address any recommendations from previous year’s report
Complete the HCH audit tool or your clinic audit
Update number of care coordinated patients and
number of care plans and send to planner
Submit corrective action plans for variance resolution
Apply for extension of variances, if needed
Recertification Timeline: 30 Days

All documents have been submitted for MDH review
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MDH conducts site visit team meeting with clinic
unless the clinic outcomes are “Superior”

MDH reviews information presented and may
request additional information and/or interviews

MDH completes the recertification report
Recertification Timeline: Finish Line
Final Steps:
•
•
•
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MDH sends the recertification final report
to the commissioner/assistant
commissioner for review and signature
MDH sends a signed recertification letter
with the final report to the clinic,
Along with a list of recertified clinicians
MDH updates certified clinicians on the
MDH website
HCH Rolling Recertification Dates


Recertification
by
Spread
As HCH model is implemented in new clinic sites, referred to as
“spread” the new clinicians are certified and the certified status
for the clinic will be declared at annual recertification.
When a previously certified clinician leaves a clinic and goes to
work at a non-certified clinic, the new clinic and clinician/s apply
for their certification. The previous clinic employer identifies an
“end” date for that clinician in the HCH on-line portal.
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 Resources:
Training tools for your reference can be accessed by going to:
http://www.health.state.mn.us/healthreform/homes/certification/index.html
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Recertification Assessment Tool
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Recertification Site Visits
Team Meeting Format
Recertification Site
Team Meeting
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The team meeting is an opportunity for the
clinic or organization to “share the story” of
progression of the Health Care Home.
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Applicants should include care team
representation, care coordinator(s), leadership,
and patient partners.
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Preparing for Site Visit
Be in contact with your planner / common topics:
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Culture change and care team development
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Successes and challenges
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New planned initiatives
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Discuss the required updates to subparts for recertification
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Share how variances and recommendations were addressed.
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Quality improvement activities, committee structure changes, data
collection.
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Recertification
Requirements
Year One
Recertification Requirements
Year One continued

Continue to meet all initial certification (ODD numbered
subparts: .0040 Subparts 1,3,5,7,9). Submit documentation
by exception.
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Address any variances and/or recommendations made at
initial certification (if applicable).
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Updates to specific subparts are required (1A, 5A, 9A, 9D)

At year one recertification the new EVEN numbered
subparts are added to reflect progress (2,4,6,8,10).
Recertification Year One
.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.
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Describe new population-based screening
methods for risk stratification, registries,
and predictive modeling tools.
Recertification Year One
.0040 Subpart 5A
Subpart 5A Care Coordination Program Expansion:
•
•
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Submit the number of patients receiving care
coordination services and the number of 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.
HCH Clinic Audit Tool
Recertification Year One
.0040 Subpart 9A
Subpart 9A 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 One
New Subparts to reflect progress
Subpart 2 Patient Activation
Subpart 4 Registries to Track Gaps in Care
Subpart 6 Shared Decision Making, Community
Partnerships, Teams working to the full
extent of licensure, Transitions in Care
Subpart 8
External Care Plans
Subpart 10 Quality Measurement and Triple Aim
Quality Plan
.0040 Subpart 2
Patient Participation in Managing Their Care
Submit strategies used to encourage patients to take an
active role in managing their care.
Demonstrate one of the following criteria through
procedures/workflows and concrete examples:
• Participant’s readiness for change
• Literacy level
• Barriers to learning
.0040 Subpart 2
Patient Participation
Examples:
Clinic Level Process:
• Measurement of patient and family centered care:
• PCMH-A (questions 9-11)
• Family voices
• The Institute for patient & family centered care
Individual Patient Process:
• Teach-Back Method
• Ask Me 3
• Patient Activation Measure (PAM)
• Literacy Assessment/Questionnaire
.0040 Subpart 4
Registries & Tracking Gaps in Care
• Documented process with identified staff time for:
•
•
•
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Pre-visit planning
Call reminders for preventive care or procedures
Follow-up appointments for chronic conditions
Guidelines to identify patients with gaps in services
• Evidence that the registry is actively worked by the
care team
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•
•
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Internal audit process
Job performance review
Blinded copies of completed work tools
Work assignments
.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
.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
.0040 Subpart 6C
Care Team Practices to the top of licensure
Clinicians & team members working at the top of their
education, licensure, and training.
• Job descriptions/responsibilities
• Workflows
• QI project related to workflow or team
responsibilities
.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
.0040 Subpart 8
External Care Plans
• Identify patients with care plans who also have
external care plans.
• Process used to create a comprehensive care
plan which adds relevant information from the
external care plan.
• Examples: wound care, falls prevention,
behavioral health, asthma action plan.
• Submit three integrated care plans for review.
.0040 Subpart 10 A
Reporting & Quality Improvement 1
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.
.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
.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
Health Care Homes
Recertification
Quality Plan Document
Health Care Homes
Recertification Quality Plan
Document Examples
.0040 Subpart 10
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
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•
•
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•
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HCH Benchmark Reporting
Preparing for Recertification
Years 2, 3 and Beyond
HCH Benchmarks
Benchmarking Continuum for HCH
Low
Average
High
PerformancePerformancePerformance
Variance Low Average
Variance for
Performance Continued
Superior
Corrective
Transformation Performance
Action Plan Action Plan
Recertification Performance Continuum for HCH
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Benchmarking Approach
Internal and external benchmarking using a hierarchy approach:
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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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Access to Benchmarking Reports
https://hch-data.org/login
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]
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Tina Peters– Metro Area
651 201-3934
[email protected]
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Kathleen Conboy – Metro Area
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Joan Kindt- Southern Region
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651-201-3753
[email protected]
507-272-4486
[email protected]
Danette Holznagel – Northern Region
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218-206-3239
[email protected]