Behavioral Health Home (BHH) services - quarterly newsletter

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Behavioral Health Home (BHH) services

Quarterly newsletter

April 2018

In this issue:

New Year check-ins

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Providers share feedback on BHH services

In January and February, Minnesota Department of Human Services (DHS) staff contacted BHH services providers to ask for their thoughts on the program. Below are common themes that surfaced from those discussions. DHS staff hope to use future newsletters to explore these areas in more detail, providing further discussion points around these topics.

What is working well with BHH services

  • Team work: supporting each other’s work on the BHH services team as well as being able to better serve individuals and families receiving BHH services.
  • BHH services teams are given the flexibility to engage individuals in a way that makes the most sense for them, creating a meaningful service delivery approach that is truly person centered.
  • Emphasis placed on integration with primary care is helpful in addressing physical health needs as part of a whole person care approach. BHH services teams have been helpful in re-engaging individuals into the physical health care system.


  • BHH services are not yet widely known as a potentially valuable service to qualifying individuals – there is limited understanding about what the service is, as well as misunderstandings about the gaps it can fill.
  • Upfront work required by BHH services providers to address the above points requires extensive outreach and relationship building with other providers serving this shared population.
  • Related to the first two bullet points, referrals into the service have been slower than anticipated.
  • The need for flexibility with staffing regarding qualifications of staff.
  • The financial feasibility of having the required staff for the program.
  • The need to provide higher levels of care to individuals with complex needs is not supported by the current rate.
  • The diagnostic assessment (DA) can act as a barrier to getting individuals engaged in BHH services. 

Partner Portal

  • Claims data limitations:  not real-time, features/methodology not always useful.
  • Partner Portal is user friendly, easy to access.
  • Additional support in how to use the reports in the Partner Portal is requested by most providers.
  • Patient registries are a useful tool; many providers have added data elements to their patient registry to assist them in tracking other individual and population level needs and used this information to inform strategies, educational needs and more.
  • Electronic Health Record (EHR) capacity varies and most providers continue to work to build capabilities/functions that support tracking and the collection of data in their EHR.

Thank you for your feedback!

We want to thank you again for participating in the New Year check-ins. The feedback you provided will help inform policy and future learning events, as well as develop referral partnerships and guide content for the quarterly BHH services newsletters.

Successful spring learning event

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Thank you to everyone who attended the BHH services spring 2018 learning event!

We were so happy to have that time with you. We hope that our team at DHS, along with the amazing Anne Gomez, were able to facilitate a meaningful and engaging learning event for you.

For those who were unable to join us, the learning event provided a peer-to-peer learning opportunity where BHH services providers could discuss what they find most important in relation to promoting and providing the service. We hope the peer-to-peer discussions fostered your developing partnerships with one another and encouraged providers to continue learning and networking outside of the event. We also hoped that those discussions would help you start to identify what specific support is needed from us at DHS in order to help your model, as well as the people you serve, begin to flourish.

Anne will be creating a harvest document of all the discussion points that noted at the tables, as well as the comments provided at the end of the day. We will send that document to the authorized representatives for each team so everyone can review what was discussed and learn from the event, even if they weren’t there in person.

Thank you again for joining us. We hope that you found it helpful and that you enjoyed yourselves during the process. We look forward to supporting you and providing additional opportunities to help you connect with one another and keep those “seeds” growing.

Open Space Workshop
The "topics" wall where attendees suggested dialogues for the peer-to-peer discussions.

BHH services provider spotlight


Highlights from the front lines

People Incorporated’s BHH Services:

People Incorporated is one of three Minnesota mental health organizations that aim to implement a tobacco-free policy on their respective campuses via a partnership with the American Lung Association. The commercial tobacco-free grounds policy is slated to be deployed across the organization throughout 2018. Click here to read more about the three Minnesota mental health organizations implementing a tobacco-free policy.

People Incorporated is also moving toward a standardized screening for tobacco use, as well as a standardized referral process for tobacco treatment, across their entire organization. People Incorporated offers both individual and group tobacco treatment as well as access to Nicotine Replacement Therapies. In line with their current efforts to address tobacco use in the people they serve, People Incorporated has developed a robust tobacco treatment training plan for registered nurses. The tobacco treatment training at People Incorporated utilizes elements of the Mayo Clinic Tobacco Treatment Specialist training, Tobacco and Behavioral Health trainings from Dr. Jill Williams and training on internal processes and procedures related to providing, documenting, and billing for the service.

People Incorporated’s BHH services Integration Specialist, Amy Glubka, is one of approximately five employees at People Incorporated who have completed the internal tobacco treatment training. Amy, and the rest of her BHH services team members, are currently planning to brainstorm new ways to increase referrals for tobacco treatment within BHH services as well as across all People Incorporated programs. Within the BHH services they are also working toward a continuous quality improvement project. The BHH services team will identify people new to receiving BHH services (since Feb. 1st, 2018) with diabetes, tobacco use, heart disease, and/or hypertension (self-reported by the person on the health wellness assessment) and will offer relevant services within 90 days.

For more information about the tobacco treatment training plan at People Incorporated or how their BHH services team is working to refer people for tobacco treatment, please contact Jamie Andycha at

Information about tobacco use & treatment

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Statistics and strategies

According to the American Lung Association, tobacco use is the number one cause of death in people with mental illness. Not only that, but it affects people with mental illness at alarmingly disparate rates compared to the general population. This will be a continuing section in the BHH services quarterly newsletter in order to provide you with information about the effects of tobacco use and how you may support people in their efforts to reduce their use or quit altogether.

Did you know?

44% of the US tobacco market is consumed by people with mental illness and substance use disorders, even though people with mental illness and substance use conditions only account for 25% of the US adult population.

75% of people who smoke have a past or present problem with mental illness or addiction.

People who give up drinking and smoking at the same time have a 25% greater chance at success with both.

Smoking can make medications less effective. Needing more medications can lead to more side effects.

American Lung Association in Minnesota

The information on this American Lung Association page will provide resources to trainings, cessation materials, and other lines to integrating tobacco treatment services in organizations that serve people with mental illness and substance use disorders.

For information on how you can partner with ALAMN to decrease smoking among people with mental illness and substance abuse disorders, contact Janelle Koscinski at or 651-268-7612.

ClearWay MinnesotaSM

The ClearWay Minnesota website is a rich source of information about reducing commercial tobacco use and exposure to secondhand smoke. Please consider starting with the following resources from their site.

For more information about any of these services please visit or contact Randi Lachter at

Learning and Resources

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Information on upcoming learning opportunities, available resources, and important dates to remember.

eLearning modules

DHS has developed eleven eLearning modules for BHH services providers. These modules are intended to introduce the guiding principles of BHH services in Minnesota and to train BHH services provider team members on BHH services policy. All staff on certified BHH services teams are expected to view the eLearning modules.

The eLearning modules are available online and can be accessed by BHH services teams at any time by logging into TrainLink. Directions on how to access the training portal (TrainLink) are available on the MN BHH services website under the additional materials heading.

Population health management webinar series

On March 20th, 2018, DHS hosted the first in a series of webinars related to Population Health Management (PHM). The first webinar focused on the principles of PHM, defined how PHM supports the delivery of BHH services and highlighted how the DHS partner portal may support PHM. We will be sending out an invitation to the next webinar in the series to BHH authorized representatives. Please contact with questions or comments about the webinar series.

ICSI quality improvement workshop

Thursday, May 3 in Brooklyn Park OR Thursday, May 10 in Redwood Falls:  The Institute for Clinical Systems Improvement (ICSI) is hosting “Free Workshops for Health Systems Doing Quality Improvement.” Click here for more information.

Save the Date: Free upcoming regional meeting

The MN Department of Health is convening a Central Minnesota Regional Meeting for Health Care Homes (HCH), Behavioral Health Home (BHH) Services Providers, and Certified Community Behavioral Health Clinics (CCBHC) and their partners to network and connect with other Minnesota providers as well as learn skills in collaborative communication and quality improvement from the Institute for Clinical Systems Improvement (ICSI). The event will be held May 31, 2018 from 9:00 – 3:00 at the River’s Edge Convention Center in St. Cloud, MN. Lunch will be provided. Registration for the event will open April 23, 2018 and more information will go out to the BHH services authorized representatives via email when it is available. Please note that although this meeting is being convened as a regional meeting in Central MN, it is not limited to providers within specific geographical borders.  It is free to any and all BHH services providers who wish to attend.

Partnering to better coordinate care & increase referrals

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This section is a space for BHH services providers to learn about and suggest ideas for building relationships with other providers involved in a person’s life as a means to better coordinate care. This section will also provide information and updates about relational strategies to increase awareness about BHH services and increase external referral opportunities for BHH services providers. In the meantime, please read about a metro area BHH services cohort that was formed to address topics such as coordination and referrals. Please submit content and/or ideas for content to Sophie Burnevik at

Metro area BHH services cohort

BHH services providers Guild Incorporated, Natalis Outcomes, People Incorporated, and Touchstone Mental Health formed a BHH services cohort in August 2017 as a means of growing and learning about this new service line. The cohort began meeting officially in November 2017. The cohort meets quarterly and engages in conversation around enrollment, engagement, service provision, barriers, success stories and more. The benefits from this cohort include collaboration, brainstorming strategies, sharing ideas and resources and general support and camaraderie. The cohort is a supportive group of like agencies working together to support the mission of delivering high quality services to our communities.

This cohort came to fruition after leaders from the founding organizations connected to discuss programming, standards, referrals, etc. and it became clear that having a platform for all of them to come together regularly would be of great benefit, and they report it has been! The members of this particular cohort encourage other BHH services providers throughout the state to reach out to their local BHH services providers to develop a cohort as well.

Networking opportunities

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Connect with your community partners

MN Coordination of Care Communities 

Stratis Health facilitates health care organizations to develop care coordination processes and serves as a neutral conveyor, bringing together over 367 organizations and 940 individuals within nine coordination of care communities across Minnesota.  The goal of this collaboration is to improve transitions of care.  For information about the care community regions, a schedule of meetings and how to join, please visit their website or email Janelle Shearer at

Mental Well-Being and Resilience Learning Community

The Minnesota Department of Health (MDH) leads a monthly, interactive statewide webinar and local discussion – at multiple locations -for anyone who is interested in promoting mental well-being.  Following the webinar, local discussions occur to identify area needs, share resources, and contribute to community planning.  This brochure provides further details and information about how to participate and join the conversation. 

Care Coordination for the Pediatric Population Community of Practice

MDH is launching a networking and learning opportunity for care coordinators serving children and youth.  If you are interested in learning more, please contact Wendy Berghorst at    

Submit a networking opportunity

Please send any networking opportunities you wish to share to Sophie Burnevik at

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