Health care homes sound like buildings, but actually represent centralized, coordinated care at medical clinics. Conceived to help Minnesota's sickest patients, they are evolving to streamline and personalize care for everyone.

Health care homes are part of a movement that began with state legislation passed in 2007 to improve care coordination for Medicaid patients with the most complex illnesses. Now primary care clinic personnel are working more closely together as well as with complex and ordinary patients and families to improve care and communication and reduce costs. (For information, visit

Taking a different tack
Each Minnesota care system is approaching health care homes a little differently, according to Yeng Yang, M.D., an internist and pediatrician who chairs the health care home committee for Fairview Health Services.

Fairview is taking the "big bang" approach, introducing the health care home model system-wide, Yang said. Where she works at Fairview's Maple Grove Clinic, Yang said health care homes have flattened out the hierarchy of care. "I think it has really empowered our nurses to work on top of their licenses," she said. "We really urge people to use their skills maximally, kind of creating the right work for the right person."

This frees Yang to spend more time talking with patients about things that only she as a physician should be talking about. "To me, it's more satisfying," Yang said. "When we've done surveys, patients feel that they're more cared for and that we know them better and that they are less burdened by their disease."

How it works
Each patient gets a care coordinator, who may be a nurse, medical assistant or trained lay person who keeps in close contact with the patient via phone or online. Clinic staffers work with patients and families as a team to set and track health and social goals for patients, reducing the need for clinic and emergency room visits and hospitalizations, Yang said.

The health care home model has expanded from the original 11 certified clinics to 47 throughout the state. Each needs to meet standards and criteria around improved access, care coordination and care-taking and quality improvement, according to Marie Maes-Voreis, program manager of the health care home program for the Minnesota Department of Health. "Our goal is to get 150 clinics certified by June," she said.

The department is studying patient outcomes and cost containment. "We see this as the beginning of the transformation of primary care," Maes-Voreis added. "We want to provide stronger links with mental health, with home health and with local public health. We really want to continue to expand and engage the whole community in the expansion and development of the health care home."