A Day in the Life of Nurse Planner Joan Kindt in the Minnesota Health Care Home Program

Health care reform goals established by the Minnesota Legislature call for all Minnesotans to have access to patient-centered care, accessible, comprehensive, and coordinated primary care. The HCH program is the path to these goals.
Becoming a health care home (HCH) in Minnesota means adopting “an approach to primary care in which primary care providers, families, and patients work in partnership to improve health outcomes and quality of life for individuals with chronic health conditions and disabilities.”9
Certifying that clinics are meeting standards that align with this definition is a priority for the state of Minnesota and it is the job of nurse planner, Joan Kindt, RN. Of the 171 clinics in Joan Kindt’s 38-county region, 139 have yet to become a HCH.

Preparing Practices for Certification

At her home in Rock County, Joan Kindt is preparing for a HCH certification visit. During today’s visit, she will lead a team to certify whether or not a health system that provides primary care services onsite at assisted living and long-term care facilities meets HCH standards. She is concerned about the readiness of the health system, and therefore has asked Marie Maes-Voreis, Director of the Health Care Homes for the Minnesota Department of Health to accompany the team.
The role of the nurse planner starts with reaching out to clinics in his or her region of the state. Making the case to prospective HCH clinics is something that Joan does both on- and off-site. From home, she checks her list of clinics, provided by the Minnesota Department of Health, that have not gone through the HCH certification process and those that have expressed interest to become certified through a letter of intent.
For the former group of clinics, she often “cold calls” them aiming to arrange a time to go on-site to meet with the clinic staff, including the lead primary care provider, to answer questions and discuss the benefits of becoming a HCH. Joan and the other nurse planners provide free on- and off-site coaching about how to become more patientcentered and how becoming more efficient will save the clinic money and improve quality. In addition, certified HCHs are eligible to receive monthly payments from both commercial and public payers for their patients receiving care coordination. Joan often organizes webinars and invites local certified HCH clinics to speak so that prospective clinics have an opportunity to learn first hand from their peers.
When a clinic decides that it wants to pursue HCH certification, Joan walks its staff through the certification process. The clinic sends a letter of intent to apply for certification, which prompts the Minnesota Department of Health to send an application and a self-assessment tool. The clinic uses the self-assessment tool to determine its readiness to apply. Joan then functions as a “coach” and guides each clinic through the certification process. Coaching requires both remote and face-toface time to talk about the certification process, what the clinic needs to do to meet the standards, and what kind of documentation is necessary to demonstrate that it is meeting the standards.
Before the certification site visit today, Joan spent a fair amount of time providing technical assistance to the health system, especially on the care planning process— one of the core tenets of a HCH—because its model of integrating primary care services into assisted living facilities is quite different than the typical primary care clinic. Joan has found that many clinics have faced challenges in becoming more patient-centered, especially in developing processes that increase consumer and family engagement in the care planning process.
All HCH clinics need to design quality improvement projects in order to gain certification. The health system undergoing certification today chose to focus on advanced care planning and care coordination. Joan encouraged the health system to apply for a grant to help with those projects. Like other clinics, the health system also needed to develop a registry to help report data to the state and use the registry to better track care. Joan ensured that the facility attended a two-day learning collaborative that she also helps to organize and teach.

Leading the On-Site Certification

Joan briefed the certification team three weeks ago, sharing the data, and her concern about the health system’s readiness. The certification team consists of Joan, a consumer representative, and a clinician “peer” consultant—typically a nurse or a physician—and for today’s visit, Marie Maes-Voreis. Joan has developed the agenda, dividing the interviews among the certification team. These interviews typically include providers, nursing staff, care coordinators, and front-office staff. The interviews always include patients and often, family members. Today, family members both in-person and via conference line accompany the patients.
Joan arrives at the clinic and huddles with her site visit team before they fan out to begin the interviews. Joan first meets with the quality improvement coordinator. She sits down with the coordinator in front of the computer to review the health system’s use of a registry for reporting quality and utilization measures. Site visits ensure that what the facility reports on paper is actually occurring at the clinic. She asks the coordinator, “tell me how you are tracking preventive care, and assigning risk scores to identify patients for care planning,” and the coordinator walks her through how the registry is used.
Next Joan meets with the reception staff and asks about their HCH vision and goals. The receptionist responds by describing facility policy for answering calls— an important aspect for meeting HCH access standards.
She also talks with the medical director of the facility and discusses how care delivery has changed since starting the HCH process. He describes transformational changes about embedding a nurse practitioner on-site and how the facility is better meeting the patients’ primary care needs. He explains that the facility is just beginning to put in place population-based panel management and Joan offers advice about how to help the facility advance to the next stage.
Meanwhile another member of the certification team meets with a nurse practitioner at the health system to discuss after-hours access to primary care. She requests that the nurse practitioner describe the processes in place to ensure that care coordination and referrals are being effectively made.
Joan also meets with the nurse supervisor at the facility who talks about newly formed care processes that include daily huddles with the primary care team. The nurse supervisor remarked, “we worked really hard with our care teams… we’ve had live lunch meetings to prepare. Every week was focused on one of the standards, such as access.”

Measuring Performance

At the end of the afternoon, the certification team reserves an hour to huddle to discuss what it observed. The consumer representative discusses how she interviewed two patients and their family members. Both families knew the names of their primary care provider, described strong communication between the primary care provider and the family, and were generally satisfied with their care. At the end of the day the certification team met with the health system seeking certification and reviewed examples of their positive work and areas for improvement.
Following the huddle, the certification team meets with the health system staff. Together, they review the positives from the site visit—strong team culture, commitment to patient-centered care, use of shared decision-making tools, and other innovative work. They discuss areas to improve, including the care planning process, after-hours care, communication, and focus on goals. The health system staff expresses appreciation for the feedback and its commitment to transforming care delivery.