Behavioral Health Home (BHH) services - July 2020 newsletter

Minnesota Department of Human Services logo

Behavioral Health Home (BHH) services

Quarterly newsletter

July 2020

In this issue:

This newsletter has been sent to all authorized representatives on each BHH services team. Please forward to other BHH services staff at your organization.

Quarterly updates

check mark icon

News, programmatic updates, and useful information.

As part of DHS’ ongoing efforts to support BHH services providers during the COVID-19 pandemic, the following changes have been made:

  • The notification of eligibility form no longer requires the individual’s signature.
    • Regarding the consent form, you can obtain verbal consent and document this information in the client’s chart, form, progress note, or similar document.
  • The BHH services intake, initial assessment, and health action plan do not need to be completed face-to-face. The BHH services standards have been updated to reflect this change.
  • For the six-month face-to-face requirement, BHH services team professionals that can provide telemedicine and that have a telemedicine agreement on file can complete the six-month face-to-face via telemedicine (which can include a telephone call).

We will seek approval to waive the state plan amendment face-to-face contact requirement; however, we hope the provision regarding telemedicine will provide flexibility until we receive approval for the waiver. You can review the all the changes in the MHCP provider manual - BHH services section.

Building Systems for Culturally Responsive Integrated Care

The Minnesota Department of Health (MDH) and the Department of Human Services (DHS) wrapped up the free six-month learning series “Building Systems for Culturally Responsive Integrated Care” in June 2020. The series provided team-based learning experience for providers to learn about and take collaborative action to strengthen integrated care and reduce Minnesota’s health disparities. Visit the MDH YouTube page to view past sessions. The Minnesota Medical Association designates these videos as live and enduring learning activities, and participants are eligible for a maximum of 19.75 AMA PRA Category 1 Credit(s)™ through December 2020.

Assessing quality measures and ongoing certification

The DHS BHH services team is working with a consultant to review BHH service outcomes to date, and offer recommendations on how to best track outcomes. We are taking into account:

  • current efforts in quality measurement at DHS;
  • understanding what outcomes are most meaningful for providers and individuals’ served in assessing improvement in health and addressing health disparities;
  • how individuals receiving BHH services have articulated the value of the care they receive; and
  • the cost and quality data the State collects as part of its reporting requirements across BHH services, IHPs, CCBHCs, and Health Care Homes.

A final report to be released in Spring 2021 will share lessons learned through the launch of BHH services on population health management and quality improvement initiatives. In addition, we will use this work to inform an ongoing certification process for BHH services providers.

Population Health Management Spotlight

light bulb

Connecting with High-Risk Patients When In-Person Visits are Not Possible

The following excerpt provides an example of how a primary care practice is using data to inform a population health management (PHM) strategy that proactively identifies high-risk patients for outreach during COVID-19 stay-at-home orders.

Norm Ward, MD, a family practitioner and chief medical officer for OneCare Vermont — an all-payer accountable care organization serving roughly 250,000 individuals — was concerned that he had seen very few patients in his office since COVID-19 stay-at-home orders were issued. Many of his patients were older and suffered with chronic conditions, and he knew that people were likely not seeking care due to the pandemic and that many were at high-risk for COVID-19.

To support practices like Dr. Ward’s in identifying high-risk individuals for outreach amid the pandemic, OneCare Vermont’s analytics team created the COVID-19 Care Coordination Tool. The tool combines medical and pharmacy claims information with data indicating medical and social complexity to create lists of high-risk patients. Practices have used this information to conduct outreach and assessment calls for their high-risk patients.

This profile, part of the Center for Health Care Strategies’ Innovations Amid COVID-19 series, highlights the successes and lessons learned from implementing OneCare’s COVID-19 Care Coordination Tool. The tool is assisting OneCare providers in: (1) identifying patients who may have slipped through the cracks in the stay-at-home environment; (2) organizing remote care delivery; and (3) adopting a population health approach to care. Moving forward, OneCare is seeking to standardize this tool and care process to deliver better care for those at high-risk even after the COVID-19 pandemic subsides.

Did you know? BHH services providers tip:  You have access to much of the data and information used in this example through reports accessed from the DHS Partner Portal and information in your patient registry!  Here are a few examples:

  • Risk factor: Number (or type) of chronic conditions
    • DHS Partner Portal Report and Column Name: Care Management Report > Chronic Condition Count
    • Patient Registry Data Element: Filter your patient registry by type of physical health diagnosis to identify those individuals you serve who also have diabetes, heart disease, hypertension, lung disease, etc.
  • Risk Factor: Number of providers seen in the last year, indicating a care coordination issue
    • DHS Partner Portal Report and Column Name: Care Management Report > Coordination of Risk Indicator (A marker used to stratify the likelihood of coordination issues by unlikely, possibly, and likely to experience coordination issues.)
    • Patient Registry Data Element: N/A
  • Risk Factor: High or low health care utilization
    • DHS Partner Portal Report and Column Name: CMR Resource Utilization Band (RUB) Sub Report > Resource Utilization Band (RUB) (The RUB is an estimate of concurrent resource use associated with the recipient’s current ACG score and can be indicated as healthy user, low user, moderate user, high user, or very high user). CMR Resource Utilization Band (RUB) Sub Report > Utilization: provides outpatient counts, ED counts, and inpatient counts of the person
    • Patient Registry Data Element: Use Date of last visit with primary care and Dental exam within the past 12 months to understand appropriate utilization of these services for those you serve
  • Risk Factor: High social complexity groups
    • Patient Registry Data Element: Use housing status and highest education level completed (adjusted for age) to understand rates of housing insecurity and high school graduation (or equivalency)

For more information on the partner portal and patient registry please visit one or more of the following resources:

Additionally, the DHS BHH services policy team is always willing to discuss other individualized support to promote the implementation of population health management (such as one-to-one discussions, technical assistance, or other ideas). Please email if you are interested in individualized support for your team.

BHH services provider spotlight



Highlights from the front lines


For this newsletter we asked for your help to highlight you amazing and tireless efforts during these unsettled times. We asked you to send us information on any of the following:

  • Examples of what you have done to continue meeting the needs of people during the COVID-19 pandemic
  • Examples of what your team or organization has done in response to the murder of George Floyd — whether that be how you have:
    • supported the people you serve,
    • supported your staff, or
    • begun to develop and implement efforts and/or bolster already existing efforts to address systemic racism at your organization.  
  • Information about any unique referral or care coordination relationships

We received so many amazing responses that we decided to highlight them all. Please see the Q2 2020 Newsletter Addendum to view the separate spotlight publication. Thank you for time and thank you for everything you do! We are in awe of you all.

Incorporating tobacco treatment

"no" icon


Information related to the use of commercial tobacco products, and how to help people address their use of them.


Did you know that, 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 section will provide ongoing information related to commercial tobacco products and how to help people address their use of them.

Free one-hour tobacco brief intervention training for healthcare professionals

The Ask, Advise, Refer to Quit Don’t Switch training is based on the CDC’s Ask-Advise-Refer model, and utilizes updated tools and strategies for conducting an effective brief tobacco intervention with patients identified as tobacco users, including e-cigarettes. Its development was in response to the 2020 Surgeon General’s Report highlighting that four out of every nine adult smokers who saw a health professional in the last year did not receive advice to quit. It is our hope that this course will further support the United States Public Health Service clinical guidelines recommending all healthcare providers offer smoking-cessation interventions. The training reviews evidence-based, proven-effective cessation strategies to support an individual’s quit and reviews the seven FDA-approved quit medications currently available. The Ask, Advise, Refer to Quit Don’t Switch training is accredited for continuing education and contact hours from select organizations through December 31, 2020. A complete agenda and FAQ are available on the American Lung Association training site.

Creating and Enhancing Tobacco Free Facilities and Treatment Services National Virtual Training

Are you interested in supporting your behavioral health organization in going tobacco-free, or enhancing your current policy and cessation supports? Need assistance in how to engage leadership, staff and clients around next steps?

The National Council’s National Behavioral Health Network (NBHN) and SAMHSA’s National Center of Excellence for Tobacco Free Recovery (SAMHSA-CTFR), operated by UCSF’s Smoking Cessation Leadership Center funded by the Centers for Disease Control and Prevention, are pleased to offer two free virtual trainings this summer on creating and enhancing tobacco-free facilities to address the needs of individuals with behavioral health conditions. 4.75 units of FREE credit can be earned through UCSF for participants who join either live session on August 6, 2020, or August 12, 2020. (See registration pages for specific guidance.) Register at the registration website for the Creating and Enhancing Tobacco Free Facilities and Treatment Services.

Reducing Vaping Among Youth and Young Adults

This guide supports health care providers, systems and communities seeking to prevent vaping. It describes relevant research findings, examines emerging and best practices, identifies knowledge gaps and implementation challenges, and offers useful resources. You may download this publication and other resources related to commercial tobacco use on the Substance Abuse and Mental Health Services website.

Mark your calendars

calendar icon

Important dates specific to BHH services


Housing Stabilization Services

Housing Stabilization Services, a new state Medicaid benefit beginning in mid-July 2020 for people with disabilities and seniors, is designed to help people with disabilities and seniors find and keep housing. Email with general questions. You may also visit the Housing Stabilization Services website for more information about the benefit.

 2020 Learning Days Canceled

Protecting the health, safety and well-being of the participants at Learning Days is our first priority. Due to the uncertainties related to the COVID-19 pandemic, we canceled Learning Days 2020. Read more about the cancelation on the HCH website.

Learning and resources

resources icon


Information on upcoming learning opportunities and available resources that may be helpful for BHH services providers.

Cultural, Faith, and Disability Communities COVID-19 Update

The Cultural, Faith, and Disability Communities COVID-19 Update includes links to a variety of resources including grants, funding and student support opportunities. Please visit the most recent Cultural, Faith, and Disability Communities COVID-19 Update communication for more information.

New E-Learning: Prediabetes: A Time to Act

One in three American adults has undiagnosed prediabetes. Left unchecked, prediabetes can lead to heart attack, stroke and Type 2 diabetes. The good news is that lifestyle changes can stop or slow prediabetes. This course looks at prediabetes through the lens of population health, including screening, identifying risk factors and how community partnerships can aid prediabetes management. Register now on the MDH Learning Center website.

New E-Learning: Sailing Toward Success with Telehealth

For many organizations, COVID-19 has been a catalyst in adopting telehealth. Whether your organization is just starting or on your way, this course will help you chart your voyage with information, tools and resources to advance your telehealth practice. All aboard! Register now on the MDH Learning Center.

Partnering to better coordinate care & increase referrals

shaking hands


Building collaborative relationships with other providers to address whole-person care & promote service sustainability


Transition Coalition

The mission of the coalition is “to provide spaces and forums for stakeholders to build innovative and sustainable supports for people impacted by the criminal justice system.” The vision of the coalition is “a community where all stakeholders work together to effectively provide transitional support to justice involved individuals.” BHH services policy lead Sophie Burnevik participated in a Twin Cities Coalition meeting on July 10, 2020, to raise awareness of BHH services.

Julia McCarthy from Portico Healthnet also presented during the meeting. Per Portico’s website, their “multi-lingual and culturally competent staff help low-income people, people of color, and immigrants navigate a complicated health system. Clients receive assistance applying for qualifying programs including MNsure, health system charity care, or reduced-fee clinics. Portico’s enrollment experts help clients understand critical health care resources available within the community, connecting them via referrals and providing advocacy with county and state agencies. They also educate clients about effective health care utilization.” Please visit the Portico Healthnet website for more information about how Portico connects uninsured Minnesotans with health coverage and care. You many also contact Julia McCarthy directly with general questions at

There are five transitional coalition communities in the state. A list of all the regional coalition communities is in the following table. Please consider connection and/or presenting about your BHH services program during an upcoming meeting. Contact Christen Donley at for additional information about the coalition.

Coalition Communities Schedule*
Central MN – Nystrom & Associates - Baxter

3rd Friday of every other month

Twin Cities – DOC Central Office - St. Paul

2nd Friday of every month

Southeast – Olmsted County Government Center Rochester

2nd Wednesday of every other month

Duluth – SOAR Career Solutions, Duluth

Quarterly – 1st Wednesday of every three months

Mid MN – Great River Regional Library St. Cloud

3rd Thursday of every month

*All locations & times are subject to change

Contact us

state of mn logo