Minnesota Department of Health
Health Care Homes
Application for Certification
I. Applicant Demographic Information
(The information in this section of the online application will pre-populate from the demographic information submitted as part
of the letter of intent.)
II. Additional Clinic Information
To help us get to know you and your clinic better, please provide the following information regarding
health care homes at your clinic.
1.
Please list the number of people who are direct members of the health care home team.
# of full time staff/
partners
Team Members
# of part time staff/
partners
1. Clinicians- Primary Care Medical Doctors
(MDs)/ Doctors of Osteopathy (DOs)
2. Clinicians- Primary Care Nurse Practitioners
(NPs)
3. Clinicians- Physician Assistants (PAs)
4. Certified Medical Assistants (CMAs)/ Medical
Assistants (MAs)
5. Registered Nurses (RNs)
6. Licensed Practical Nurses (LPNs)
7. Participants (patient or family members
participating on the clinic’s quality team or
learning collaborative)
8. Clerical Staff
9. Interpreters
10. Others (specify)
11. Please explain how your clinic or organization defines full time or part time as used above
(example: full time is equal to 80 hours per pay period for staff and 9 clinic sessions for MDs)
12. How many Full Time Equivalents (FTE’s) of the above staff work as the Care Coordinator (may be
fractions of time)?
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2. Providers and services available to your clinic site (check all that apply):
Family Medicine
Pediatrics
General Internal Medicine
Med/Peds
Obstetrics/Gynecology
Geriatrics
Pharmacists
Therapists (PT, OT, or Speech)
Patient Educators (diabetes, health, asthma)
Mental Health Professionals
Surgical Services
Dieticians
Specialties
Community Health Workers
Medical Interpreters
Triage system
Other (specify):
3. Clinic Days and Hours of Operation
Please enter in each box the days and hours of operation. Example: “M, W, F 8:00 a.m. - 6:00 p.m.,
T,Th 9:00 a.m. - 7:00 p.m.” If your clinic does not offer those hours, please enter “None”.
Clinic Hours
Urgent Care Hours
On-call Clinician Hours
Monday – Friday
Daytime Hours
Monday- Friday
After Hours
Saturday - Sunday
Holidays
4. Clinic Information Systems (please check the appropriate box)
Note: The electronic medical record (EMR)
and the electronic health record (EHR) are
not required for health care home
certification.
Yes
1. Do you have an EMR/EHR at the clinic
site? (If no, skip to # 10 in this table)
2. Does your EMR/EHR have the ability
to generate a patient registry for
preventive disease management?
3. Does your EMR/EHR have the ability
to generate a patient registry for
reporting that can be used to identify
patients by severity and complex or
chronic conditions?
2
No
Yes, paper
version
only
Working to
Implement
(Continued) Clinic Information Systems (please check the appropriate box)
Note: The electronic medical record (EMR) and
the electronic health record (EHR) are not
required for health care home certification.
Yes
4. Does your EMR/EHR have functions that
trigger follow-up with patients (ex. lab
results, annual exam reminders, etc.?)
5. Can the EMR generate a care plan?
6. Can the clinic’s EMR produce a clinical
summary of a visit?
7. Does the clinic use the EMR to identify
opportunities to improve care delivery?
8. Can the clinic’s EMR electronically track
referrals?
9. Does the clinic in any way exchange
electronic health record information?
10. Can patients use the clinic information
systems to directly:
a. access their health information;
b. access medications;
c. make appointments through the same
web portal;
d.use secure email communication with
clinic;
e. receive electronic communication of
test results;
f. receive electronic visit reminders?
g. access and print their care plan?
11. Does the clinic have a plan to acquire and
implement an EMR if not already using
one?
12. Does the clinic have a website?
13. Does the clinic have an electronic system
for clinical decision making support?
14. Is the function of electronic tracking of
diagnostic tests and test results currently
in use?
15. Do you e-prescribe?
16. What is the name of your EMR/HER Software?
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No
Yes, paper
version only
Working to
Implement
5. How many years have you been working on clinic system redesign on the following aspects to meet
health care home requirements (please enter in years or portions of years):
Standards
Years
A. Access and communication
B. Participant registry and tracking participant care activity
C. Care coordination
D. Care plan
E. Performance reporting and quality improvement
F. Patient- and family- centered care
G. Team-based care delivery
H. Submission of quality data to Minnesota Community Measurement
III. Clinic’s Patient Panel
To help us get to know you and your clinic better, please provide the following information regarding
your clinic’s patient profile. (The following questions and categories are based on those used by
MDH, NCQA, Healthcare Effectiveness Data and Information Set (HEDIS), HHS, CMS, and others):
1. Number of your patients (unique patients, not visits) by
gender:
Female
Male
Unknown
2. Number of your patients by age:
0-5 years
6-17 years
18-35 years
36-64 years
65 +
Unknown
3. Number of your patients by ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Unknown
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4. Number of your patients by race:
American Indian or Alaska Native
Asian
Black / African American
Native Hawaiian or Other Pacific Islander
White
More than one race
Unreported/ Refused to Report
Other
Unknown
5. Percentage of your patients whose Primary language is:
English
%
Non-English
%
• Specify language
%
• Specify language
%
• Specify language
%
6. Percentage of patients by payer
mix: Public
Medicare
Medical Assistance
Minnesota Care
%
%
%
Private
Fully Insured
Self-Insured
%
%
Other
Uninsured
Unknown
%
%
7. Does the Applicant’s patient panel differ significantly from above, or are there additional
characteristics that could describe the applicant’s patient panel (example: a large number
of geriatric patients or a large number of patients with significant special health care
needs)? Explain:
D
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IV.
Representations and Signature
I apply on behalf of the clinician(s), department(s)/ practice(s), or clinic(s) named above to be
certified as a health care home based on the following representations:
1.
2.
The applicant recognizes that application for certification is voluntary.
The applicant qualifies as a personal clinician or a clinic as defined in 4764.0020 Subp.28
and Subp.8 and each personal clinician meets the requirements for health care homes.
3. The applicant has read and agrees to meet or exceed the standards and criteria in the health
care home rule 4764.0010-0070, or seeks a variance by subpart under 4764.0500.
4. The applicant will implement the health care home certification and recertification procedures
per 4764.0300.
5. The applicant has a system in place to offer the applicant's health care home services to all of
the applicant's patients who:(1) have or are at risk of developing complex or chronic
conditions; and
(2) are interested in participation, per 4764.0040, Subp.1.A.
6. The applicant will participate in a health care home learning collaborative, per
4764.0040 Subp.9.D.
7. The applicant will participate in the statewide quality reporting system by submitting outcomes
for the quality indicators identified in the manner prescribed by the commissioner, per
4764.0040 Subp.10A and Subp. 11 A.
8. The applicant will submit health care homes data in the manner prescribed by the commissioner
to fulfill the health care homes evaluation requirements in Minnesota Statutes, section
256B.0752, subdivision 2, per 4764.0040 Subp.10.C.
9. Representatives of the Commissioner of Health may perform on-site reviews of the
applicant’s practice to verify these representations and determine whether the applicant
complies with certification or recertification requirements, per 4764.0030 Subp.3.
10. The applicant will notify the Commissioner of the Minnesota Department of Health and the
health care home participants by written notice 90 days in advance if he or she wishes to
voluntarily surrender health care home certification, per 4764.0070 Subp.3.
11. All information that I have provided in this application is complete, true, and accurate to the
best of my knowledge.
12. Under the applicant’s articles of incorporation, bylaws, or resolution of the board of directors,
I am authorized to submit this application on behalf of the organization and bind it.
If the applicant needs to qualify any of the above representations please explain here:
e
Name of Authorizing Person
Name
Job Title
Please allow one to two weeks for MDH to respond and indicate the next steps. If you have questions, please contact
MDH by phone (651) 201-5421, or by email: [email protected].
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