learning days 2018 - health.state.mn.us improve community health and health equity. ... a case study...

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Minnesota Department of Health – Health Care Homes is proud to host

April 3-4, 2018University of Minnesota Continuing Education and Conference Center

1890 Buford Avenue | St. Paul, MN 55108

LEARNING DAYS 2018

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WELCOMEWelcome to Learning Days! We are so pleased to have you with us for this annual event where health care homes, and behavioral health providers, public health and community partners come together to share best practice, learn from each other, and form collaborative relationships. This year’s theme, Coming Together: Cultivating Health for All, reflects our continuing commitment to work together across the care continuum to improve community health and health equity. Thank you for being with us. Have a great Learning Days!

CONFERENCE HIGHLIGHTSNew Location: The Continuing Education and Conference Center on the University of Minnesota’s St. Paul campus is conveniently located, and features free reserved parking in lot 104 ONLY. Stay nearby at the

Radisson Minneapolis/St. Paul North, and take advantage of a full amenity hotel with free parking, free hot breakfast, and free shuttle to and from the conference site.

Health Care Homes Innovation Awards: Don’t miss this opportunity honor the first award recipients for the Health Care Home Innovation Awards at the closing session on April 3. Hear their stories and find inspiration for your own transformation!

Peer to Peer Networking and Wall of Fame: Connect with colleagues from around the state at this informal networking reception. Have a snack, chat with HCH Award winners, presenters and exhibitors, visit (and help us build) the Wall of Fame, and provide us with friendly feedback to help shape the HCH program and future learning opportunities.

REGISTERRegister on the new Health Care Homes Learning Management System and receive conference updates through the Health Care Homes LEARN e-news bulletin. Visit the Health Care Homes website for registration and subscription information.

LEARNING OBJECTIVESLearning Days attendees will enhance knowledge and skills for:

1. Providing whole-person care that addresses patients’ physical, behavioral and social needs

2. Delivering team-based care in partnership with internal and external care providers

3. Implementing quality improvement methods and data analysis to improve patient/provider experience,health outcomes, cost and health equity

4. Preparing for the future of value-based payment

EVALUATIONA survey will be sent to all registered participants after the conference. Please take time to provide feedback so we can continually improve this learning opportunity for you.

CONTINUING EDUCATION CREDITSCertificates of attendance will be available upon completion of the online evaluation following the conference and accrued to your Learning Management System transcript. Please submit the certificate to your licensing board to obtain CEU credits. CME is not available for this event.

http://www.health.state.mn.us/healthreform/homes/

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PRESENTATIONS AVAILABLE ONLINE Conference presentations and handouts may be found online after the conference on the Health Care Homes Learning Management System.

THANK YOU LEARNING DAYS PLANNING TEAMGeorgia Anderson, Minnesota Department of Health, Health Care Homes

Carol Bauer, Minnesota Department of Health, Health Care Homes

Wendy Berghorst, Minnesota Department of Health, Children and Youth with Special Health Needs

Alex Dahlquist, Minnesota Department of Health, Office of Statewide Health Improvement Initiatives

Chris Dobbe, Minnesota Department of Health, Health Care Homes

David Kurtzon, Minnesota Department of Health, Health Care Homes

Bonnie LaPlante, Minnesota Department of Health, Health Care Homes

Amy Michael, Minnesota Department of Health, Office of Statewide Health Improvement Initiatives

Tina Peters, Minnesota Department of Health, Health Care Homes

Rosemarie Rodriguez-Hager, Minnesota Department of Health, Health Care Homes

Cherylee Sherry, Minnesota Department of Health, Office of Statewide Health Improvement Initiatives

Traci Warnberg-Lemm, Minnesota Department of Human Services, State Innovation Model

LEARNING AND TECHNICAL ASSISTANCE WORK GROUPSunny Ainley, Normandale Community College

Michelle Barclay, The Barclay Group, LLC

Carol Bauer, Minnesota Department of Health, Health Care Homes

Peter Carlson, North Memorial Medical Center

Chris Dobbe, Minnesota Department of Health, Health Care Homes

Mary Kautto, Gillette Children’s Specialty Healthcare

David Kurtzon, Minnesota Department of Health, Health Care Homes

Bonnie LaPlante, Minnesota Department of Health, Health Care Homes

Rosemarie Rodriguez-Hager, Minnesota Department of Health, Health Care Homes

Jill Swenson, CentraCare Health

Cally Vinz, Institute for Clinical Systems Improvement

Traci Warnberg-Lemm, Minnesota Department of Human Services, State Innovation Model

SCHEDULE-AT-A-GLANCETUESDAY, APRIL 3TIME/LOCATION SESSION

7:00 AMRegistration Area

REGISTRATION OPENS

7:30 AM - 4:00 PMUpper Lobby

BREAKFAST AND EXHIBITS

8:00 – 9:30 AM135

OPENING SESSION AND PANEL Coming Together: Addressing Social Determinants of Health

9:45 - 10:45 AM BREAKOUTS A1-A5

155 A1- Well Together: Generating Health Through Community Collaboration

42 A2- Allina Health - Accountable Health Communities Model

83 A3- Carrying Out Shared Decision Making in a Changing World of Measurement

156 A4- Connecting Primary Care and Community Services

166 A5 - Group Visits for Hypertension: A Team Approach

11:00 a.m. - Noon BREAKOUTS B1-B5

155 B1 - Bridging the Health Disparities Gap Through the Use of CHWs

156 B2 - Planting the Seeds for an Effective Asthma Home Visiting Program

83 B3 - Creating a Culture of Team Based Care for Improved Patient Experience

42 B4 - Minnesota Collaborates: Opioids and Mental Health

166 B5 - Leverage Your Team’s Leadership Skills To Impact Your Quality Measures

Noon - 1:30 p.m.Upper Lobby

LUNCH AND EXHIBITS

1:30 - 2:30 PM BREAKOUTS C1-C5

156 C1- Costs and Benefits of Care Coordination: A Case Study Approach

83 C2 - Whole Person Care: A Behavioral Health Home Services Approach

42 C3 - Communicating Effectively to Enhance Quality: A Team-Based Approach

155 C4 - Partnering to Pilot Community Health Worker Services

166 C5 - Using Information to Support Care Coordination and Population Health

2:30 - 3:00 PMUpper Lobby

BREAK AND EXHIBITS

3:00 - 4:00 PM135

HEALTH CARE HOMES INNOVATION AWARDS

4:00 - 5:00 PM Upper Lobby

PEER TO PEER NETWORKING AND WALL OF FAME

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WEDNESDAY, APRIL 4TIME/LOCATION WORKSHOPS

8:00 AM Registration Area

REGISTRATION OPENS

8:00 - 9:00 AM Upper Lobby

COFFEE

9:00 AM - Noon W1 - W4 (BREAK 10:15 AM in Upper Lobby)

135AC W1 - Coming Together: Health Care Homes and Integrated Health Partnerships

52 W2 - Community Wellness Grant Learning Session (Invitation only)

42 W3 - Cultivating a Community of Practice: Pediatric Care Coordination

83 W4 - Behavioral Health Home (BHH) Services Providers Learning Workshop (invitation only)

SCHEDULE-AT-A-GLANCE

PHOTOGRAPHSMDH will take photographs throughout the conference to use for promotional materials. If you do not want MDH to use your photo, please sign a Photo Opt-out form, available at the conference registration desk.

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TUESDAY, APRIL 3Opening Session8:00 – 9:30 am

Welcome Bonnie LaPlante, Director, Health Care Homes Program, Minnesota Department of Health, St. Paul, MN

Panel Discussion: Partnering to Address Social Determinants of Health. Learn how several Minnesota communities are coming together to address social determinants of health and improve population health.

Moderator Christine Smith, Health Program Representative, Health Equity & Tribal Grants, Office of Statewide Health Improvement Initiatives, Minnesota Department of Health, St. Paul, MN

Panelists: Peter Carlson, Community Paramedic Manager, North Memorial Health Care and team member, North Market community collaborative, Minneapolis, MN

Carole Stiles, Director of Social Work, Mayo Clinic and team member, Olmstead County Care Collaborative, Rochester, MN

Ursula Reynoso, Program Coordinator, Aqui Para Ti, Whittier Clinic, Hennepin County Medical Center, Minneapolis, MN

Lisa Brodsky, Public Health Director, Scott County Public Health and team member Scott County Healthy Communities Initiative, Shakopee, MN

Breakout Sessions A1 - A59:45 – 10:45 am

A1 Well Together: Generating Health Through Community Collaboration PresentersKathy Bystrom, Community Health Outreach Manager – Fairview North Region

Kirk Erickson (YMCA) or Derek Otto, YMCA – Forest Lake, MN

Christine Gove-Berg, M.D. Fairview Medical Group, Fairview Clinics-Hugo, MN

Kellie Kershisnik, M.D, Fairview Medical Group, Fairview Clinics-Hugo, MN

Carmen Parrotta, Fairview Medical Group, Fairview Clinics-Hugo, MN

DescriptionAn aging population, increasing prevalence of chronic disease, and a greater demand for quality outcomes have led to a dynamic shift toward value-based care and population health approaches that are focused on prevention, disease management, and wellness. Leveraging the strengths and resources of healthcare systems and key community partners is critical to improving health outcomes. Learn how two organizations, Fairview and the YMCA, came together to develop a comprehensive and innovative program model that provides participants the tools, guidance and support they need to reach their health improvement goals.

Learning Objectives By the end of this session, participants will be able to:

1. Share the key components necessary for a successfulcollaborative with a community partner

2. Describe how the intervention leveraged each partner’sstrengths and core services

3. Describe key metrics in assessing the impact ofwellness collaborative focused on prevention

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A2 Allina Health - Accountable Health Communities Model PresentersEllie Zuehlke, MPH, Director Community Benefit and Engagement, Allina Health, Minneapolis, MN

DescriptionThis session provides an overview of Allina Health’s Accountable Health Communities model, how it is being implemented through the Allina Health system, the technology being used to support the model, and what we’ve learned. Please join us for a presentation and interactive discussion with ample time for questions and answers.

Learning ObjectivesBy the end of this session, participants will be able to:

1. Describe how the CMS Accountable HealthCommunities model is being implemented inMinnesota

2. Explain how to screen for health related social needsin a clinical setting

3. Identify how new technology is being implementedto connecting patients to community resources

A3 Carrying Out Shared Decision Making in a Changing World of MeasurementPresentersCandy Hanson, BSN, PHN, LHIT-HP, Program Manager, Stratis Health, Minneapolis, MN

DescriptionShared decision making (SDM) is an important tool in supporting the patient and care team relationship, and is specifically called out in the Minnesota Health Care Home model. How do you know if your team is effectively using SDM? Members of the Minnesota Shared Decision Making Collaborative have assembled real examples that can support a successful Health Care Home, and which also fulfill measure specifications from CMS’ Quality Payment Program. Learn from these examples how to apply principles to all the measurement and improvement programs you participate in.


1. Explain shared decision making and its potential for ourhealth systems in a rapidly changing care delivery andpayment environment

2. List questions you should ask to analyze and improveyour shared decision making efforts

3. Identify how to apply these principles to yourmeasurement and improvement priorities

A4 Connecting Primary Care and Community ServicesPresenters Mona Walden-Frey, MA, Program Manager, Caregiver Services/Health and Wellness, Amherst H. Wilder Foundation Community Services for Aging, St. Paul, MN

Wynee O’Neil, Care Coordinator, Entira Family Clinics, St. Paul, MN

Jayshree Patel, Care Coordinator, Entira Family Clinics, St. Paul, MN

Catherine Engstrom, LICSW, Amherst H. Wilder Foundation, St. Paul, MN

DescriptionThe Caregiver Support Referral Pilot Project between Wilder Foundation Community Services for Aging and Entira Clinics was launched in 2013. This project introduced a model for service delivery which integrates medical services with community-based supports. Four years later, this partnership continues. A panel of participants from Entira and Wilder will discuss the evolution of their partnership and how sustaining this relationship adds value to care delivery and patient experience. Following the panel presentation, attendees will participate in table discussions, using case studies to better understand how a clinic system and community based organization can work together successfully to meet caregiver needs.

Learning Objectives:By the end of this session, participants will be able to:

1. Describe the types of services and supports available tocaregivers through community based organizations

2. Explain how healthcare and community basedorganizations can collaborate to support the goalof providing whole person care

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A5 Group Visits for Hypertension: A Team ApproachPresentersPaul Erickson, MDH, MPH, Physician, NorthPoint Health and Wellness Center, Hennepin County Medical Center, Minneapolis, MN

Solange Monono, Health Coach, NorthPoint Health and Wellness Center, Hennepin County Medical Center, Minneapolis, MN

Kevin Gilliam, Physician, NorthPoint Health and Wellness Center, Hennepin County Medical Center, Minneapolis, MN

Description We will describe our path in developing group visits for our patients with hypertension. These shared medical visits are led by a clinician and health coach along with our teammates from nursing, pharmacy and nutrition. There is some “magic” that happens in a group with the sharing of information and strategies. Through presentation and dialogue we will share our learnings along this path.

Learning Objectives

By the end of this session, participants will be able to:

1. Describe the process of developing and recruiting

2.

a shared medical-group visit for hypertension

Explain the agenda, content and flow for these group visits for hypertension

Breakout Sessions B1-B5 11:00 am – Noon

B1 Bridging the Health Disparities Gap Through the Use of CHWs PresentersDr. Jokho Farah, MBBS, Director of Quality Improvement/Population Health, People’s Center and Services, Minneapolis, MN

Kelly Coughlin, RD, CDE, Certified Diabetes Educator, People’s Center and Services, Minneapolis, MN

Hayu Abdulle, Community Health Worker, People’s Center and Services, Minneapolis, MN

Asha Farah, BS Candidate 2018, Intern, People’s Center and Services, Minneapolis, MN

DescriptionNew immigrants and refugees face many challenges in accessing health care due to language, trauma, lack of understanding of preventive care, and stigmas stemming from differences in ethnicity, culture and religious practices. People’s Center Clinics and Services aims to reduce the disparities gap by implementing a model of practice utilizing bilingual Community Health Workers, providing culturally specific education and clinical services, and linking to community-based resources. A key goal of this work is to improve overall heart health by focusing on patients with prediabetes, diabetes and/or hypertension.


1. Describe the Community Health Worker modeldeveloped with the East African population in theCedar-Riverside neighborhood of Minneapolis

2. Compare and contrast various Community HealthWorker models of practice

3. Explain the barriers that had to be overcomeand the factors that led to success inapplying the People’s Center CommunityHealth Worker model of practice

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B3 Creating a Culture of Team Based Care for Improved Patient Experience PresentersKylee Funk, Doctor of Pharmacy, Board Certified Pharmacotherapy Specialist, Assistant Professor, University of Minnesota College of Pharmacy, Minneapolis, MN

Jane Anderson, DNP, ANP-C, FNP-C, RN, Clinical Assistant Professor, University of Minnesota School of Nursing, Minneapolis, MN, and University of Minnesota Health Nurse Practitioners Clinic, Minneapolis, MN

DescriptionLearn how to increase joy in practice and provide better patient care by creating a culture of team based care. This session will begin with a discussion of how team-based care affects the quadruple aim followed by a case study based on a nurse practitioner-pharmacy collaborative care partnership. During the session, participants will have an opportunity to evaluate and reflect on how to improve team culture in their own clinics.

Learning Objectives:By the end of this session, participants will be able to:

1. Identify an example and impact on patients of nurse practitioners and pharmacists partnering to provide care

2. Explain the role of teams in meeting the quadruple aim

3. Describe a method to measure team culture

B2 Planting the Seeds for an Effective Asthma Home Visiting Program PresentersLisa Konicek, BSN, PHN, Public Health Nurse, St. Louis County Public Health Department, Duluth MN

Laura Greensmith, BSN, PHN, Public Health Nurse, St. Louis County Public Health Department, Duluth MN

Seiquayia Morris, CHW, Community Health Worker, St. Louis County Public Health Department, Duluth MN

Carrie Gertsema, BSN, PHN, Public Health Supervisor, St. Louis County Public Health Department, Duluth MN

DescriptionThis interactive presentation will illustrate the challenges and successes of initiating a public health asthma home visiting program from the ground up, with support from the MN Department of Health. We will highlight how we established a referral process with local health care homes and integrated a Community Health Worker for outreach and client support to address social determinants of health impacting asthma outcomes. Participants will leave with sample assessment tools for asthma management, outreach suggestions, and other asthma education resources.


1. Describe the ways in which public health andcommunity partners and providers can collaborateto achieve the triple aim for asthma patient care

2. List best practices in asthma education to promotepatient self-management

3. Describe ways in which a Community Health Workercan help achieve optimal asthma care

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B4 Minnesota Collaborates: Opioids and Mental HealthPresentersDana Slade, CHMM, Director Sustainability, HealthPartners, Bloomington, MN

John Pastor, PharmD, FASHP, System Director, Acute Care Pharmacy Services, Fairview Health, Minneapolis, MN

DescriptionIn a momentous collaborative effort, 15 of our region’s health system and health plan CEOs committed to work together on pressing health care issues that cannot be solved without broad collaboration. This collaborative began in January 2017 focusing on addressing the opioid crisis and improving mental health care. How can such an ambitious effort be designed, built, and supported? In addition to initial results, we will share strategies, lessons learned, and recommendations for success.


1. Identify challenges health systems face with the opioid crisis and/or mental health care

2. Describe the framework of a collaborative effort

3. Discuss early successes in the work

4. Explain barriers to the collaborative effort and methods to overcome them

B5 Leverage Your Team’s Leadership Skills To Impact Your Quality MeasuresPresenterSandy Zutz-Wiczek, MBA, Chief Operating Officer, FirstLight Health System, Mora, MN

DescriptionIn this session, you will learn the actionable framework for your leadership team to create focus, clarity and consistent communication to improve your clinic quality measures. Learn how to run an effective quality forum with exercises to engage, problem solve and dissolve the friction that is slowing your organization from improving its measures.


1. Identify six essential leadership skills to increasecollaboration among care team members to impactyour results

2. Explain why a participant-centered approach is the bestway for your care team to learn and improve your clinicquality measures

3. Describe how to develop trust, align your care team andincrease peer-to-peer learning through regular qualityforums

LUNCH AND EXHIBITSNoon – 1:30 pm

BREAKOUT SESSIONS C1 – C51:30 – 2:30 pm

C1 Costs and Benefits of Care Coordination: A Case Study ApproachPresentersChristina Worrall, MPP, Senior Research Fellow, State Health Access Data Assistance Center (SHADAC), University of Minnesota, Minneapolis, MN

Lacey Hartman, MPP, Senior Research Fellow, State Health Access Data Assistance Center (SHADAC), University of Minnesota, Minneapolis, MN

Description Care coordination is central to several care delivery and payment reforms in Minnesota, including Minnesota’s State Innovation Model (SIM) efforts. In order to inform future programming, payer engagement, and reimbursement policy, the state conducted a study quantifying the cost of care coordination in a sample of primary care clinics certified as Health Care Homes. Study researchers will present their methods and framework for cataloguing care coordination activities, informed by recent literature. Researchers will also share average costs of care coordination per individual in a typical month and the range and value of care coordination approaches employed by clinics.

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Learning Objectives By the end of this session, participants will be able to:

1. Cite recent evidence to quantify care coordinationcosts or advance primary care interventions

2. Describe a framework for measuring the costs of carecoordination associated with Minnesota Health CareHome certification

3. Explain the variation in care coordination approachesand costs for adults across six clinics studied and havean opportunity to discuss these findings

C2 Whole Person Care: A Behavioral Health Home Services Approach PresentersVimbai Madzura, MA, LGSW, Care Integration Liaison, State of Minnesota Department of Human Services, St. Paul, MN

Sophie Burnevik, MA, LMFT, Care Integration Liaison, State of Minnesota Department of Human Services, St. Paul, MN

Additional Presenter TBD

DescriptionThis session will introduce the behavioral health home (BHH) services model and how it uses Ecological Systems Theory to provide integrated and coordinated care to individuals with serious mental illness or emotional disturbance. A panel of BHH services providers, and primary care and community partners will dive deeper into how Ecological Systems Theory informs “whole person” care and ensures access to a coordinated delivery of primary care, behavioral health and social services.


1. Define the behavioral health home (BHH) servicesmodel

2. Explain how the Ecological Systems Theory frameworkallows for the BHH services model to operate under a“whole person” philosophy of care

3. Describe examples of how the BHH services modelallows for “whole person” care and ensures access to acoordinated delivery of primary care, behavioral healthand social services

C3 Communicating Effectively to Enhance Quality: A Team-Based ApproachPresentersNate Hunkins, MPH, Director of Population Health, Bluestone Physician Services, Stillwater, MN

Annette Fagerlee, RN, Director of Care Coordination. Bluestone Physician Services, Stillwater, MN

DescriptionBluestone Physician Services specializes in caring for elderly and disabled patients. These populations have unique needs and complex conditions which makes communication challenging. For this presentation, Bluestone will share strategies and tools used by care team members to improve communication across the spectrum of care for complex patients. Through round table discussions, participants will work with case studies to practice techniques for asking the right questions to the right provider to help deliver the right services at the right time and utilizing the right data—all of which increase the quality of care for the patient.


1. Identify strategies for communicating with all membersof the patient’s care team to benefit the whole personand increase the quality of care

2. Describe how to use data to help understand and betterserve complex patients.

3. Explain how to use interdisciplinary care teams tocollaborate and make positive change in people’s lives

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C4 Partnering to Pilot Community Health Worker ServicesPresentersKristin Erickson, MS, APHN-BC, RN, Healthcare Initiatives Coordinator, PartnerSHIP 4 Health, Otter Tail County Public Health, Fergus Falls, MN

Jody Lien, BSN, RN, PHN, Assistant Public Health Director, Otter Tail County Public Health, Fergus Falls, MN

Megan Nieto, CHW, President, CHW Services, CHW Solutions, Minneapolis, MN

DescriptionThis presentation includes a PowerPoint, Q&A session, and the opportunity to complete the American Diabetes Association (ADA) Type II Diabetes Risk Test. The presentation highlights a Community Health Worker Services pilot achieved through partnership between PartnerSHIP 4 Health (local public health and community partners in Becker, Clay, Otter Tail, and Wilkin counties), CHW Solutions, and Otter Tail County Public Health (OTCPH). The pilot project, funded by Community Wellness Grant (CWG) dollars, engaged Community Health Workers (CHWs) to promote linkages between health systems and community resources for adults with high blood pressure or prediabetes or at high risk for type 2 diabetes.


1. Detail how the partnership emerged and developedthe CHW Pilot

2. Identify the successes of the CHW Pilot at OTCPH

3. Recall lessons learned during the CHW Pilot at OTCPH

C5 Using Information to Support Care Coordination and Population HealthPresentersKaren Soderberg, MS, Research Scientist, Minnesota Department of Health, Office of Health Information Technology, St. Paul, MN

Anne Schloegel, MPH, e-Health Program Lead, Minnesota Department of Health, Office of Health Information Technology, St. Paul, MN

DescriptionClinics participating in health care homes and/or accountable care arrangements have a growing need for better patient information. Health information exchange (HIE) is a key tool for moving health information across the continuum in a timely and efficient way. This session will provide an update on Minnesota’s HIE approach and latest developments, including recommendations from a recent study, lessons learned from grant projects, and a toolkit to help communities understand how to use clinical data to support their health improvement efforts. Hear how your organization can participate in HIE to support patient care, improve care coordination and patient engagement.


1. Describe Minnesota’s health information exchange (HIE)landscape and activities

2. Incorporate lessons learned from communitycollaboratives implementing HIE

3. Access a toolkit describing how communitycollaborations share clinical and other data to improvehealth in their communities

HEALTH CARE HOMES INNOVATION AWARDS3:00 – 4:00 pm

Don’t miss this opportunity to honor the first recipients of the new Health Care Home Innovation Awards! Learn about the exciting work they are doing and find inspiration to continue your own transformation.

PEER TO PEER NETWORKING AND WALL OF FAME4:00 – 5:00 pm

Take advantage of this opportunity to connect with colleagues from around the state at this informal networking reception. Have a snack, chat with HCH Award winners, presenters and exhibitors, visit (and help us build) the Wall of Fame, and provide us with friendly feedback to help shape the HCH program and future learning opportunities.

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WEDNESDAY, APRIL 4Workshops9:00 am – Noon

W1 Coming Together: Health Care Homes and Integrated Health PartnershipsPresentersMathew Spaan, Manager, Care Delivery and Payment Reform, Minnesota Department of Human Services Health Care Administration – Office of the Assistant Commissioner, St. Paul, MN

Danette Holznagel, RN, BAN, PHN, CDE, FCN. Senior Nurse

Planner, Health Care Homes Program, Minnesota Department of Health, St. Paul, MN

DescriptionFind out what’s next for the Health Care Home and Integrated Health Partnership programs in their shared focus on care coordination and community linkages, population health, health equity and value-based payment. See where the programs intersect and hear from your peers how health care home certification can be an asset in seeking certification as integrated health partnerships. Take advantage of this unique opportunity to interact with program staff and clinical peers who are shaping the future of health care.

Objectives By the end of this session, participants will be able to:

1. Explain how health care homes and integrated healthpartnerships are shaping the future of health

2. Identify intersections between health care homes andintegrated health partnership programs

3. Describe some ways in which the health care homeprogram could serve as a foundation for becomingan integrated health partnership

W2 Community Wellness Grant Learning Session (Invitation only)PresentersAlex Dahlquist, Community Health Systems Coordinator, Office of Statewide Health Improvement Initiatives, Minnesota Department of Health, St. Paul, MN

Amy Michael, Community Health Systems Coordinator, Office of Statewide Health Improvement Initiatives, Minnesota Department of Health, St. Paul, MN

Reid Haase, Program Manager, Stratis Health, Minneapolis, MN

Emily Styles, Epidemiologist, Office of Statewide Health Improvement Initiatives, Minnesota Department of Health, St. Paul, MN

DescriptionThis learning session brings staff together from clinics, local public health, and the MN Department of Health to share resources and experiences in the work happening around prediabetes and hypertension in CDC-funded Community Wellness Grant (CWG) regions.

ObjectivesBy the end of this session, participants will be able to:

1. Recall efforts to implement change and achievements made possible through this work

2. Detail how system and protocol changes will be sustained beyond the end of the grant cycle

3. Identify plans for continuation and potential expansion into work that still needs to be done

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W3 Cultivating a Community of Practice: Care Coordination for the Pediatric Population

PresentersStacy Ward, RN, PHN, Clinical Care Coordination Supervisor, Park Nicollet, Minneapolis, MN

Mary Kautto, MA, BSN, RN, Clinical and Marketing Outreach, Gillette Children's Specialty Healthcare, St. Paul, MN

Tara Mahin, Pediatric Care Coordinator, South Lake Pediatrics, Minnetonka, MN

Tanya Bruns, RN, Health Coach, Sanford Clinic, Worthington, MN

DescriptionProviding pediatric care coordination is both challenging and rewarding. It is time to build a community of practice for all who provide care coordination for the pediatric population. This kick–off session is for staff that are actively working in this area and are interested in learning with and from each other! We will share information, processes and experiences to promote our professional and personal development. The session includes a panel presentation with care coordinators representing various sectors in our state, time for discussion, networking, and planning for future networking and information exchange.

ObjectivesBy the end of this session, participants will be able to:

1. Explain the benefits of participating in a Communityof Practice for pediatric care coordination

2. Describe the different roles and responsibilities of patients and their coordinating care for pediatric

families

3. Discuss current care coordination challenges andidentify options to address

W4 Behavioral Health Home (BHH) Services Providers Learning Workshop (Invitation only)PresentersSophie Burnevik, MA, LMFT, Care Integration Liaison, Community & Care Integration Reform Team, Health Care Administration, Minnesota Department of Human Services, St. Paul, MN

Vimbai Madzura, MA, LGSW, Care Integration Liaison, Health Care Administration, Minnesota Department of Human Services, St, Paul, MN

Tina Peters, RN, PHN, MPH, Nurse Planner, Behavioral Health Integration Nurse Coordinator, Health Care Homes, Minnesota Department of Health, St. Paul, MN

DescriptionThis three-hour workshop will be divided to allow time for DHS state staff to provide updates to BHH services providers, while also providing ample time for providers to connect and network with each other. These interactions will occur through rounds of small group conversations designed around themes and questions that are relevant to the work of BHH services providers. Topic examples include: Partner Portal, patient registries, quality improvement and using feedback from individuals/families on experiences of care, whole person care and development of a person centered action plan, assessing and addressing tobacco use, and integration of a trauma informed approach.

Objectives By the end of this session, participants will be able to:

1. Describe current state policy work relevant to BHHservices

2. Explain processes utilized in the provision of BHH services across different settings and populations

3. Share experiences, challenges, and solutions inthe provision of BHH services

4. Develop peer relationships

The Minnesota Department of Health – Health Care Homes and the Minnesota Department of Human Services would like to thank members of the Learning and Technical Assistance Work Group, Learning Days planning team, presenters, exhibitors and sponsors who contributed time and resources to make this event possible. Together, we are working together to improve health and health equity for all Minnesotans!

2018 Minnesota Department of Health – Health Care HomesLearning Days Event

learning days 2018 - health.state.mn.us improve community health and health equity. ... a case study...

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