June 2025 HCH Newsletter
The Connection
In this newsletter:
- Director's Message
- Herself Health: HCH Certification Supports Value-Based Care
- Physicians can receive board MOC credits for practicing within a HCH
- Learning Days 2025: A Resounding Success!
- 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!
Of late, Health Care Homes (HCH) staff have been pouring energy into strategic planning as we move to complete the process by mid-summer. This has involved looking long and deep at the program’s present and future, determining how best to continue our work supporting advanced primary care. In service to this goal, three members of the HCH team, myself, Tina Peters, and Jennifer Strickland, recently attended the Primary Care Collaborative (PCC) conference in Washington DC.
Held on June 4 and 5, this national conference brought together leaders in care delivery, health policy, health research and other expertise necessary to advance primary care. Ann Greiner, PCC President and CEO shared, “Years of underinvestment in primary care and a broken approach to payment has left Americans with a system that is far too focused on advanced treatment rather than prevention or management. The result is sky-high costs, lower life expectancy, and a surge in the number of people with chronic conditions. But there are bright spots. Innovators are working to improve the way we deliver and pay for high-quality, whole-person primary care.”
Our staff were proud to represent Minnesota, MDH, and Health Care Homes. We took this opportunity to learn more about groundbreaking approaches to tackling industry challenges, hear from leaders on the front lines of promoting public health and primary care, and to network with professionals from around the country. The conference was also a chance to share some of the great work we’re doing in our own state, and it was gratifying to hear from a number of individuals that Minnesota is held in high esteem when it comes to health care innovation.
I and my colleagues returned home with a number of insights and ideas that will contribute to setting the strategic direction and future plans of HCH. Plus, new connections were made that planted the seeds of what will hopefully be fruitful partnerships down the road.
To bring things back to strategic planning, stay tuned for additional opportunities to provide feedback (and a huge thanks to the many contributions that have been made by friends and partners; they are truly appreciated!) as well as the release of the new strategic plan itself. We will be in touch in the near future.
Take care and best wishes,
~David
Herself Health: HCH Certification Supports Value-Based Care
What opportunity to improve health equity did you discover and how did you recognize it?
Herself Health is a primary care practice dedicated specifically to women 65 and older, providing whole-person, compassionate care designed around their unique needs. We saw that this population, often managing multiple conditions and navigating life transitions, was often underserved by traditional models that emphasized volume over value, leading to fragmented care and unmet health needs. The momentum around value-based care (VBC) gave us a clear opportunity to rethink delivery and center it around prevention, personalization, and equity.
What actions did you take to improve health for this diverse population?
We developed tailored care pathways designed specifically for older women, focusing on areas such as post-menopausal care, bone and pelvic floor health, and chronic disease management. Our coordinated care teams collaborated to deliver longer, more frequent visits, deprescribing strategies, and advanced screenings. Each patient’s care team, consisting of a Primary Care Provider, Medical Assistant, Nurse, and Care Coordinator if needed, work together closely to ensure a seamless patient experience that provides continuity of care, ongoing support, specialist management, and a deep understanding of the unique needs of the women we serve. We also prioritized trust-building and deep patient engagement to help women take a more active role in their health.
What were your challenges, successes, and what did you learn?
Adopting a value-based care model required significant operational shifts and posed financial risks. One key challenge was maintaining a high-touch, personalized care model while ensuring scalability. We addressed this through focused metrics such as hospital admissions, medication adherence, and patient satisfaction. These measures showed consistent improvement, reinforcing that starting with a framework for delivering organized, coordinated care and a well-defined population enables both impact and learning. We’re especially proud of how this work aligned with the Health Care Home (HCH) care delivery model and helped us earn our HCH certification—a milestone that validates our commitment to team-based, coordinated, and patient-centered care. We’re thrilled to be recognized for this achievement as it affirms the foundation we’ve built for better outcomes.
What improved as a result? Please share a patient story that highlights this impact, if available.
We’ve seen measurable improvements across key areas, including more consistent chronic disease management, fewer emergency visits, and stronger engagement in preventive care. But the most powerful outcomes often come through our patients’ voices. One woman shared that, for the first time, she feels like her provider truly knows her—not just her conditions, but her goals—and has a complete picture of her health. Her experience highlights the impact of personalized, coordinated care and why we’re so energized by what’s ahead.
The HCH Program thanks Herself Health for sharing their story and for the work they continue to do to improve the health and wellbeing of Minnesotans.
Physicians can receive board maintenance of certification (MOC) credits for practicing within a Health Care Home
Did you know about this benefit of HCH certification? There are numerous benefits to HCH certification, many of which are outlined in the recently updated Business Case for Clinics (PDF). One in particular has caught recent attention: the ability for physicians to use HCH certification to meet maintenance of certification (MOC) credits (specifically, the Performance Improvement requirement) for the American Board of Family Medicine (PDF) and the American Board of Pediatrics. We have heard firsthand from family medicine physicians that using HCH certification to meet the MOC Performance Improvement Requirement is “efficient and quick” - and another perk of HCH certification! Spread the word about this at your clinics and feel free to reach out to the HCH program or your assigned Practice Improvement Specialist with any questions.
Check out the recent blog post Health Care Homes Certification: Advancing Primary Care in MN - MAFP highlighting this benefit written by the Minnesota Academy of Family Physicians (MAFP). MDH Health Care Homes thanks MAFP for their continued partnership and the work they do to support and advocate for primary care in Minnesota!
Learning Days 2025: A Resounding Success!
Health Care Homes Learning Days 2025 brought together over 170 health care professionals from across Minnesota at the Heritage Center of Brooklyn Center for a day of learning, networking, and collaboration.
Attendees engaged in valuable discussions about advancing health equity, integrating behavioral health, supporting adolescent health, and implementing innovative care models. Dr. David Satin delivered an engaging keynote address and afternoon session that resonated with participants and provided practical insights for health care transformation. Our new EventMobi conference app enhanced the experience, allowing attendees to connect with colleagues seamlessly and access conference handouts.
Thank You to Our Community
- To our attendees: Your enthusiasm and willingness to share experiences created the collaborative atmosphere that makes this conference special.
- To our presenters: Thank you for sharing your expertise. Your sessions provided practical, actionable content that will improve health care delivery across Minnesota.
- To our exhibitors and sponsors: Your support enriched the conference experience and demonstrates your commitment to advancing health care in Minnesota.
Looking Ahead
We're already planning for 2026, incorporating your feedback to develop next year's program. Thank you for being part of the Health Care Homes community. Together, we're making a real difference in health care delivery across Minnesota.
We look forward to seeing you at Learning Days 2026!
Health Care Homes Staff on the Road
The first half of 2025 has been among the busiest ever in Health Care Homes (HCH)! MDH HCH staff have supported three initial certification Site Visits and 13 recertification Team Meetings. HCH Practice Improvement Specialists (PIS) have also connected with numerous organizations through Patient and Family Advisory Council (PFAC) engagement opportunities, technical assistance requests, Learning Days 2025, and 18-month check-ins.
Recently, PIS Jen Strickland partnered with Mary Meyer, MDH Asthma Program, and Bridget Ideker, MDH Diabetes Unit, for check-ins at Cass Lake Indian Health Services and Red Lake Indian Health Services. Both organizations graciously welcomed the MDH team members to their clinics for conversations involving their respective HCH programs and the latest approaches to caring for individuals diagnosed with asthma and diabetes. During the check-in, individuals exchanged stories, ideas, best-practices, and resources available to care teams. HCH would like to thank all organizations who have allowed us to see their teams in action and witness the difference they make!
Congratulations to Certified and Recertified HCH!
Clinics recently certified and 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.
Certified
Community Health Service Inc
- Foundational Level - four clinics
Herself Health MN PC
- Foundational Level - five clinics
Integracare Clinics
- Level 2 - three clinics
Recertified
Astera Health
- Level 3 - six clinics
HealthPartners
- Level 3 - 51 clinics
Lake Superior Community Health Center
- Level 3 - two clinics
Lakewood Health System
- Level 3 - five clinics
M Health Fairview
- Level 2 - 38 clinics
Olmsted Medical Center
- Level 3 - 15 clinics
Sawtooth Mountain Clinic, Inc
- Level 2 - one clinic
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
- Stratis Health and the Minnesota Department of Health Long COVID Program have released three new evidence-informed tools to support providers in caring for patients with Long COVID and related conditions. More information can be found at MDH: For Health Care Providers: Post-COVID Conditions.
- The Healthy Minnesota Partnership, a group of cross-sectoral organizations led by MDH, released an action plan in response to the Minnesota Statewide Health Assessment. The Minnesota Statewide Health Improvement Framework highlights three health priorities with objectives and strategies the Healthy Minnesota Partnership will work on between 2025 and 2029:
- Belonging, wellbeing, and substance use prevention
- Health and housing
- Equitable access and care
- The Minnesota Northstar Geriatrics Workforce Enhancement Program (MN GWEP) is a five-year project funded by the Health Resources and Services Administration (HRSA), the primary federal agency for improving health care for people who are geographically isolated and economically or medically vulnerable. The purpose of MN GWEP is to improve the health care and health of older adults across the entire state of Minnesota. Visit their website for geriatric education resources and toolkits.
- Save the date for the Many Faces of Community Health conference on October 1-2.
- The 2025 MN HIMSS and MN e-Health Initiative Virtual Conference Series dates have been set. Mark your calendars for Oct. 23, 30, Nov 6 and 13. Each 90-minute session will take place from noon-1:30 p.m. and is free to attend. Participants can attend any or all sessions. Follow the event page 2024 HIMSS MN Chapter and Minnesota e-Health Initiative Virtual Series - Stratis Health for updates and to view presentations from the previous conference series.
- The Toxic Free Kids program and the Biomonitoring program at the Minnesota Department of Health are offering health care provider trainings on mercury exposure in skin lightening products. This presentation is offered both in person or virtually and health care providers are being offered one continuing medical education (CME) credit. The primary goal of the training is to raise awareness about this topic and give providers guidance and next steps for identifying patients at risk for elevated mercury exposure. As the issue of skin lightening is tied closely to colorism, we know anecdotally that these products are used more frequently in communities of color and newer immigrant communities. Our data and work to date, which involve urine screenings for mercury and public health interventions for cases with elevated mercury levels, have confirmed this. If your clinic is interested, please email health.risk@state.mn.us with a training request.