September 2025 HCH Newsletter
The Connection
In this newsletter:
- Director's Message
- Closing the Gap: Advancing Equity in Colorectal Cancer Screening at M Health Fairview
- Physicians can receive board MOC credits for practicing within a HCH
- Spotlight on Innovation: MDH Health Care Homes Visits the Fairview Community Health and Wellness Hub
- New HCH staff
- Learning Update
- Congratulations to Certified and Recertified HCH!
- Do you have a Health Equity Story?
- Noteworthy
Director's Message
Greetings and Happy Fall!
Health Care Homes (HCH) is excited to be entering the home stretch in our strategic planning process. Over the past year we have been gathering feedback from stakeholders and meeting as a team to map out the future of the program. It’s been an amazing process, one that’s yielded many insights into where we’ve been, where we are, and where we’d like to be. One really energizing aspect of this particular strategic planning effort is the way in which we are setting the new plan up to be a living document. Rather than wrapping up a year long planning process and putting the finished project on a shelf, the new HCH strategic plan will be an evolving blueprint, a standard to which we will hold ourselves accountable, and an ongoing guide to building a stronger and more effective Health Care Homes. We look forward to sharing the results of our work in the not-too-distant future, so please stay tuned for updates.
Take care and best wishes,
~David Kurtzon
Closing the Gap: Advancing Equity in Colorectal Cancer Screening at M Health Fairview
To ensure quality in primary care, M Health Fairview uses the Ambulatory Care Composite (ACC) to track performance across acute and chronic conditions. In 2025, recognizing persistent disparities, the organization introduced a disparity-specific measure focused on increasing colorectal cancer (CRC) screening rates in BIPOC communities. The goal: reduce the disparity gap by 1% by year’s end.
A cross-functional team—including primary care providers, leadership, cultural brokers, community engagement staff, quality consultants, communications, and front-line staff—collaborated to shape an approach centered on health literacy, shared decision-making, accessibility, and sustainability.
The result was a set of patient education tools developed in 10 languages. These include printed materials and QR codes linking to videos that walk patients through CRC screening options. Narrated by M Health Fairview staff, the videos offer clear, culturally sensitive guidance on colonoscopy preparation and FIT (fecal immunochemical test) sample collection.
Dr. Thor, a family physician at Rice Street Clinic, played a key role. Serving large Hmong and Karen populations, she expressed frustration over the lack of accessible visual aids. Feedback from early Hmong-language materials revealed the need for simplification, which informed improvements later applied across other languages. Six months into implementation, staff report that the materials are easy to use, support shared decision-making, and help normalize conversations about screening.
Despite these successes, challenges remain: inconsistent use of tools by staff, cultural resistance to invasive procedures, financial and transportation barriers, and the complexity of the multi-step CRC screening process.
M Health Fairview is addressing these hurdles by designating front-line staff champions, aligning efforts with the Colorectal Cancer Prevention Program, and deepening community engagement. Francisco Ramirez, Supervisor of Community Education and Outreach, exemplifies this approach. He meets with patients before their screenings to explain the process, answer questions, and provide support. His culturally tailored outreach has led to a 96% completion rate for 81 scheduled CRC screenings last year. Ramirez credits this success to trust-building, accessibility, and strong partnerships across the care team.
“Identify champions in the community,” he advises. “Be authentic, respectful, and listen—communities will open up.”
Looking ahead, M Health Fairview aims to embed language-specific QR codes in After Visit Summaries, expand the role of CRC nurse navigators, and strengthen the presence of cultural brokers and community health workers. As Dr. Thor notes, trust takes time: “This is a long game. I teach you now, I teach you again—and sometimes after the fifth time, you agree to the screening.”
The HCH Program thanks Dr. Stephen Robinson, Dr. Mai Thor, Francisco Ramirez, Matt Wilkie, and Jill Fischer 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. While there is not an equivalent benefit for nurse practitioners and physician assistants, HCH is networking with professional organizations to research.
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!
This article is reprinted from the HCH June newsletter with modification.
Spotlight on Innovation: MDH Health Care Homes Visits the Fairview Community Health and Wellness Hub
The MDH Health Care Homes team recently had the opportunity to tour Fairview’s groundbreaking Community Health and Wellness Hub — a first-of-its-kind facility designed to address health disparities by delivering comprehensive healthcare services and community resources in partnership with local organizations.
Fairview’s vision was ambitious: to create a collaborative space where Fairview and community partners could work side by side to focus on addressing the needs of the community. After two years of in-depth research and multilingual community engagement — including input from employees, patients, civic leaders, and St. Paul residents — the hub officially opened its doors in August 2022. In just three years, the impact has been substantial.
Designed with Equity at the Center
Key takeaways from the community assessment were the need to access affordable, patient-centered, and culturally relevant care, to address food insecurity and other social needs, and to invest in the neighborhood. In response, the hub includes:
- A Federally Qualified Health Center (FQHC) primary care clinic
- A retail pharmacy in downtown St. Paul
- Mental health, addiction, and harm reduction services
- Senior care programs and senior living
- A mobile health services depot bringing clinical services, including immunizations and opioid response programs, into neighborhoods to expand access.
- A fresh food packaging and distribution space to support nutrition and food access
“So much important work happens within the hub, but its impact extends far beyond these walls — reaching individual clinics and the broader community. As an anchor institution, our goal is to address the social determinants of health and advance health equity, creating a healthier community for all,” said John Swanholm, Vice President, Community Advancement, Fairview.
Center for Community Health Equity
Also located within the hub is the Center for Community Health Equity — dedicated to advancing equity and addressing social determinants of health across the M Health Fairview system in collaboration with community partners.
“Although the center is headquartered here, the vision is to make equity and community engagement actionable in everyday clinical care — and to spread that culture throughout the organization,” said Diane Tran, System Executive Director, Community Health Equity and Engagement, Fairview.
Health Care Homes in Action
It was inspiring to see this level of community-clinic integration — identifying community health priorities, engaging in collaborative planning for population health improvement, and sharing responsibility in that work — brought to life through the work at the Community Health and Wellness Hub.
We extend our sincere thanks to the Fairview team for hosting us, for their continued leadership in community-centered care, and for their ongoing commitment to providing high-quality primary care through HCH certification:
- John Swanholm, Vice President, Community Advancement
- Nate Mussell, Vice President, Public Policy
- Diane Tran, System Executive Director, Community Health Equity and Engagement
- Ingrid Johansen, Director, Community Clinical Care
New HCH Staff
Xp Lee - Communications and Learning Planner
Xp Lee has joined the HCH team as the Communications and Learning Planner. He comes from a health equity strategy and programming background with the MDH Health Equity Bureau but has a degree in marketing and graphic design from the University of South Carolina Upstate. A community and socially minded creative spirit, Xp has worked and gained skills in the nonprofit, philanthropic, business, political, and government sectors. This broad experience allows Xp to see patterns and make connections across various systems, helping him communicate clearly and concisely through a variety of mediums. Xp looks forward to bringing his style and approach to HCH in helping to support our external and internal communications structure and ultimately raising our industry profile and desirability. He’s married to See Vue Lee, they have a mini poodle named Nkauj Hli (“Gao-li”) and just recently had their first child, Arkin, a roly-poly boy. Xp also likes comic book superheroes, sriracha sauce, and philosophical quotes about life and nature.
Welcome Xp!
Learning Update
A Busy Summer and Exciting Changes Ahead
It’s been a busy and productive summer for Health Care Homes! Our team has been hard at work delivering educational opportunities and supporting clinics across the state. We’ve hosted a range of webinars that sparked great discussions and shared valuable tools for advancing care.
Looking ahead, we’re excited to share several upcoming webinars designed to strengthen care delivery and support Health Care Homes across Minnesota:
- Health Literacy Foundations – October 15
- Patients as Partners: A New Model for Care Delivery Innovation – December 4
- Building a Sustainable, Empowering Pediatric to Adult Healthcare Transition Program – December 11
We invite you to join us for these sessions as we continue to explore new strategies, share best practices, and grow together as a community. For more information and registration links, be sure to check out the Health Care Homes Learning Collaborative Webinars webpage.
Finally, we are delighted to welcome a new staff member, Xp Lee, to the Health Care Homes Learning team. Xp brings fresh perspective and energy, and we’re excited for the contributions he will make in supporting our mission.
Stay tuned for more updates and thank you for being part of our Health Care Homes community!
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.
Recertified
Ortonville Area Health Services
- Level 3 - three clinics
People's Center Clinics & Services
- Level 3 - one clinic
University of Minnesota Physicians
- Level 2 - four clinics
Welia Health
- Level 3 - three 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
- Congratulations to Fairview Health Services for being awarded the 2025 Foster G. McGaw Prize by the American Hospital Association (AHA). The prize is awarded to one hospital or health system each year. This prestigious award recognizes a health care organization not only for its clinical care but for its efforts to create a healthier community for all. This is the first time in nearly 30 years a Minnesota Health System has won the award.
- New Funding Opportunity - The MDH Stroke Program is requesting proposals from qualified organizations for innovative solutions to enhance the use of team-based care to improve communication, coordination, and collaboration in the care of stroke survivors and individuals at risk for stroke. Learn more: Stroke Team-Based Care: Request for Proposals. Applicants will be asked to share how their project aligns with key strategies and objectives outlined in Minnesota's Action Plan to Address Cardiovascular Disease, Stroke, and Diabetes 2035. Two selected organizations will be awarded $15,000 for one year, with the possibility to extend two years based on funding availability. Applications are due Wednesday, Oct. 15, 2025 at 4:30 p.m. CT. Questions: Contact health.stroke@state.mn.us.
- The Minnesota Community Health Worker Alliance is conducting a survey to learn more about the work experiences of Community Health Workers (CHWs), including those working in Minnesota as Community Health Representatives (CHRs), Promotores(as), or in similar roles across clinics, schools, community organizations, and public health programs. Please complete the Statewide CHW Survey 2025 by October 31. Your voice matters — and it can help shape the future of the CHW field. If you have any questions, please email rachel@mnchwalliance.org.
- Registration is open for the upcoming e-Health Initiative conference sessions on October 23 and 30, and November 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. For more information and to register, visit MN HIMSS and Minnesota e-Health Initiative Virtual Series.
- The Minnesota Health Care Transition (MN HCT) Learning Collaborative is hosting four FREE hour-long ECHO sessions aimed at advancing pediatric to adult health care transition for children and youth with special health needs. Session dates: Oct. 6, Dec. 1, Jan. 26, and Mar. 23. Learn more and register at 2025 Gillette Children's Health Care Transition Learning Collaborative ECHO Series. After attending the entire series, participants should be able to:
- Examine evidence-informed pediatric to adult health care transition practices and case presentations.
- Translate pediatric to adult health transition learning and peer-to-peer support to clinical practice.
- Save the date for National Rural Health Day - Thursday November 20!
- Find detailed information about the 988 Suicide & Crisis Lifeline on the Minnesota Department of Health 988 Lifeline System and Services webpage. This resource explains how to access mental and emotional support via call, text, or online chat, along with 988 frequently asked questions.
- Watch the new Public Health is Community Health YouTube video created by the Minnesota Local Public Health Association! The video showcases the power and importance of public health across Minnesota.
- Tune into the American Hospital Association's (AHA) Advancing Health podcast for insightful episodes on geriatric care, including:
- "Mobilizing the 4Ms: How El Camino Health is Transforming Age-Friendly Care"
- "What Matters Most: Inside Froedtert’s Mission to Transform Geriatric Care."
- As the CMS Quality Innovation Network – Quality Improvement Organization (QIN-QIO) for the Great Lakes Region, Superior Health will provide no-cost technical assistance to eligible providers in Illinois, Indiana, Michigan, Minnesota, Ohio and Wisconsin. This includes support for chronic disease management, behavioral health integration, patient safety, care coordination and health care quality — all aligned with CMS national goals. To access this assistance, Enroll With Superior Health Quality Alliance to begin enrollment process or reach out to info@superiorhealthqa.org for more information.