Current through Register Vol. 49, No. 13, September 23, 2024
Subpart
1.
Access and communication standard; certification
requirements.
The health care home must have a system in place to support
effective communication among the members of the health care home team, the
patient and family, other providers, and care team members. The health care
home must do the following:
A. offer
health care home services to all of the primary care services population that
includes:
(1) identifying patients who have or
are at risk of developing complex or chronic conditions;
(2) offering varying levels of coordinated
care to meet the needs of the patient; and
(3) offering more intensive care coordination
for patients with complex needs;
B. establish a system designed to ensure
that:
(1) the health care home informs the
patient that they have continuous access to designated clinic staff, an on-call
provider, or a phone triage system;
(2) the designated clinic staff, on-call
provider, or phone triage system representative has continuous access to
patients medical record information, which must include the following for each
patient:
(a) the patients contact information,
personal clinicians or local trade area clinicians name and contact
information, and designated enrollment in intensive care coordination
services;
(b) the patients racial
or ethnic background, primary language, and preferred means of
communication;
(c) the patients
consents and restrictions for releasing medical information; and
(d) the patients diagnoses, allergies,
medications, and whether a care plan has been created for the patient;
and
(3) the designated
clinic staff, on-call provider, or phone triage system representative who has
continuous access to the patients medical record information will determine
when scheduling an appointment for the patient is appropriate based on:
(a) the acuity of the patients condition;
and
(b) application of a protocol
that addresses whether to schedule an appointment within one business day to
avoid unnecessary emergency room visits and hospitalizations;
C. collect information
about patients cultural background, racial heritage, and primary language and
describe how the health care home will apply this information to improve
care;
D. document that the health
care home is using the patients preferred means of communication, if that means
of communication is available within the health care homes
capability;
E. inform patients that
the patient may choose a specialty care resource without regard to whether a
specialist is a member of the same provider group or network as the patients
health care home, and that the patient is then responsible for determining
whether specialty care resources are covered by the patients insurance;
and
F. maintain policies and
procedures that establish privacy and security protections of health
information and comply with applicable privacy and confidentiality
laws.
Subp. 2.
Access and communication standard; recertification requirements.
The health care home must demonstrate that the health care
home encourages patients to take an active role in managing their health care,
and must demonstrate patient involvement and communication by identifying and
responding to one of the following: the patients readiness for change, literacy
level, or other barriers to learning.
Subp. 2a.
Access and communication
standard; level 2 certification requirements.
The health care home must demonstrate:
A. incorporating screening processes to
assess whole person care needs and use this information to determine risk and
manage patient care;
B. offering
options beyond the traditional in-person office visit such as expanded hours of
operation, electronic virtual visits, delivery of services in locations other
than the clinic setting, and other efforts that increase patient access to the
health care home team and that enhance the health care homes ability to meet
the patients preventative, acute, and chronic care needs;
C. implementing care delivery strategies
responsive to the patients social, cultural, and linguistic needs;
and
D. implementing enhanced
strategies to encourage patient engagement through interventions that support
health literacy and help the patient manage chronic diseases, reduce risk
factors, and address overall health and wellness.
Subp. 3.
Patient registry and tracking
patient care activity standard; certification requirements.
The health care home must use a searchable, electronic registry
to record patient information and track patient care.
A. The registry must enable the health care
home team to conduct systematic reviews of the health care homes patient
population to manage health care services, provide appropriate follow-up, and
identify any gaps in care.
B. The
registry must contain:
(1) for each patient,
the name, age, gender identity, contact information, and identification number
assigned by the health care provider, if any; and
(2) sufficient data elements to issue a
report that shows any gaps in care.
C. The health care home must use the registry
to identify gaps in care and implement remedies to prevent gaps in
care.
Subp. 3a.
Registry and tracking standard; level 2 certification
requirements.
The health care home must demonstrate:
A. expanding registry criteria to identify
needs related to social determinants of health and other whole person care data
elements in the clinic population; and
B. planning and implementing interventions to
address unmet needs identified by the expanded registry.
Subp. 5.
Care coordination standard;
certification requirements.
The health care home must adopt a system of care coordination
that promotes patient and family-centered care through the following
steps:
A. collaboration within the
health care home, including the patient, care coordinator, and personal
clinician or local trade area clinician as follows:
(1) one or more members of the health care
home team, usually including the care coordinator, and the patient set goals
and identify resources to achieve the goals;
(2) the personal clinician or local trade
area clinician and the care coordinator ensure consistency and continuity of
care; and
(3) the health care home
team and patient determine whether and how often the patient will have contact
with the care team, other providers involved in the patients care, or other
community resources involved in the patients care;
B. uses health care home teams to provide and
coordinate patient care, including communication and collaboration with
specialists. If a health care home team includes more than one personal
clinician or local trade area clinician, or more than one care coordinator, the
health care home must identify one personal clinician or local trade area
clinician and one care coordinator as the primary contact for each patient and
inform the patient of this designation;
C. provides for direct communication in which
routine, face-to-face discussions take place between the personal clinician or
local trade area clinician and the care coordinator;
D. provides the care coordinator with
dedicated time to perform care coordination responsibilities; and
E. documents the following elements of care
coordination in the patients chart or care plan:
(1) referrals for specialty care, whether and
when the patient has been seen by a provider to whom a referral was made, and
the result of the referral;
(2)
tests ordered, and when test results have been received and communicated to the
patient;
(3) admissions to hospitals
or skilled nursing facilities, and the result of the admission;
(4) timely postdischarge planning according
to a protocol for patients discharged from hospitals, skilled nursing
facilities, or other health care institutions;
(5) communication with the patients pharmacy
regarding use of medication and medication reconciliation; and
(6) other information, such as links to
external care plans, as determined by the care team to be beneficial to
coordination of the patients care.
Subp. 6.
Care coordination standard;
recertification requirements.
The health care home must enhance the health care homes care
coordination system by adopting and implementing the following additional
patient and family-centered principles:
A. ensure that patients are given the
opportunity to fully engage in care planning and shared decision-making
regarding the patients care, and that the health care home solicits and
documents the patients feedback regarding the patients role in the patients
care;
B. identify and work with
community-based organizations and public health resources such as disability
and aging services, social services, transportation services, school-based
services, and home health care services to facilitate the availability of
appropriate resources for patients;
C. permit and encourage professionals within
the health care home team to practice at a level that fully uses the
professionals' training and skills; and
D. engage patients in planning for
transitions among providers, and between life stages such as the transition
from childhood to adulthood.
Subp.
6a.
Care coordination standard; level 2 certification
requirements.
For the primary care services patient population, the health
care home must demonstrate:
A.
providing and coordinating care using an integrated care team;
B. supporting ongoing coordination of care
and follow-up with partners by sharing information; and
C. implementing processes to improve care
transitions that reduce readmission, adverse events, and unnecessary emergency
department utilization.
Subp.
7.
Care plan standard; certification requirements.
The health care home must establish and implement policies and
procedures to guide the health care home in the identification and use of care
plan strategies to engage patients in their care and to support
self-management. These strategies must include:
A. providing patients with information from
their personal clinician or local trade area clinician visit that includes
relevant clinical details, health maintenance and preventative care
instructions, and chronic condition monitoring instructions, including
indicated early intervention steps and plans for managing exacerbations, as
applicable;
B. offering
documentation of any collaboratively developed patient-centered goals and
action steps, including resources and supports needed to achieve these goals,
when applicable. Include pertinent information related to whole person care
needs or other determinants of health;
C. using advanced care planning processes to
discuss palliative care, end-of-life care, and complete health care directives,
when applicable. This includes providing the care team with information about
the presence of a health care directive and providing a copy for the patient
and family; and
D. informing
strategies with evidence-based practice guidelines when available.
Subp. 8.
Care plan standard;
recertification requirements.
The health care home must integrate pertinent medical, medical
specialty, quality of life, behavioral health, social services, community-based
services, and other external care plans into care planning strategies to meet
unique needs and circumstances of the patient.
Subp. 9.
Performance reporting and
quality improvement standard; certification requirements.
The health care home must measure the health care homes
performance and engage in a quality improvement process, focusing on patient
experience, patient health, and measuring the cost-effectiveness of services,
by doing the following:
A.
establishing a health care home quality improvement team that reflects the
structure of the clinic and includes, at a minimum, the following persons at
the clinic level:
(1) one or more personal
clinicians or local trade area clinicians who deliver services within the
health care home;
(2) one or more
care coordinators;
(3) two or more
patient representatives who were provided the opportunity and encouraged to
participate; and
(4) if the health
care home is a clinic, one or more representatives from clinic administration
or management;
B.
establishing procedures for the health care home quality improvement team to
share their work and elicit feedback from health care home team members and
other staff regarding quality improvement activities;
C. demonstrating capability in performance
measurement by showing that the health care home has measured, analyzed, and
tracked changes in at least one quality indicator selected by the health care
home based upon the opportunity for improvement;
D. participating in The health care home
learning collaborative through care team members that reflect the structure of
the clinic and may include the following:
(1)
clinicians or local trade area clinicians who deliver services in the health
care home;
(2) care
coordinators;
(3) other care team
members;
(4) representatives from
clinic administration or management; and
(5) patient representatives who were provided
the opportunity and encouraged to participate with the goal of having patients
of the health care home take part; and
E. establishing procedures for
representatives of the health care home to share information learned through
the collaborative and elicit feedback from health care home team members and
other staff regarding information.
Subp. 10.
Performance reporting and
quality improvement standard; recertification requirements.
The health care home must:
A. participate in the Minnesota statewide
quality reporting and measurement system by submitting outcomes for the quality
indicators identified and in the manner prescribed by the
commissioner;
B. show that the
health care home has selected at least one quality indicator from each of the
following categories and has measured, analyzed, and tracked those indicators
during the previous year:
(1) improvement in
patient health;
(2) quality of
patient experience; and
(3)
measures related to cost-effectiveness of services;
C. 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;
and
D. achieve the benchmarks for
patient health, patient experience, and cost-effectiveness established under
part 4764.0030, subpart 6, for the health care homes outcomes in its primary
care services patient population.
Subp. 11. [See repealer.]
Subp. 12.
Performance reporting and
quality improvement standard; level 2 certification requirements.
The health care home must demonstrate:
A. using information and population health
data about the community served to inform organizational strategies and quality
improvement plans;
B. measuring,
analyzing, tracking, and addressing health disparities within the clinic
population through continuous improvement processes;
C. establishing procedures for sharing work
on health equity and eliciting feedback from the health care home team and
other staff regarding these activities; and
D. recruiting, promoting, and supporting
patient representation to the health care home quality improvement team that
reflects the diversity of the patient population.
Subp. 13.
Performance reporting and
quality improvement standard; level 3 certification requirements.
The health care home must contribute to a coordinated
community health needs assessment and population health improvement planning
process by:
A. sharing aggregated
information or de-identified data that describes health issues and
inequities;
B. prioritizing
population health issues in the community and planning for population health
improvement, in collaboration with community stakeholders;
C. implementing and monitoring progress of
the population health improvement plan using shared goals and responsibility;
and
D. sharing in the communication
and dissemination of work on population health improvement and eliciting
feedback from the community members and health care home staff regarding these
activities.
Statutory Authority: MS s
256B.0751;
256B.0752;
256B.0753
