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Health Care HomeHealth Care Home coordinator

What is a health care home?

A health care home is a respectful partnership between you, your family, your provider, a care coordinator and others such as pharmacists or therapists.

When you have a health care home, you and your family can be certain you are partnering with knowledgeable and caring professionals who are always there to help you receive high-quality health care.

A health care home is:


  • Available to you 24 hours a day, 7 days a week.
  • Your care coordinator is available during office hours.
  • When the clinic is closed, our on-call provider will have access to your care plan.
  • Provides local health care that best serves you.

Patient- and Family-Centered

  • Believes that you and your family are experts in your needs.
  • Offers a safe place for patients, families and professionals to talk about health care issues as partners.


  • Ensures that you see the same doctor or health care provider over time.
  • Provides communication and information exchange between specialists and your health care home team.


  • Cares about you and your family.


  • Provides necessary health care, including preventive services such as physical exams, immunizations and screening tests.
  • Works together with the specialists and therapists of your choice when they are needed.
  • Shares information about insurance and other resources.


  • Cost is considered and discussed as choices are made.

Culturally competent

  • Acknowledges and respects every patient’s customs and religious values.
  • A health care home team includes your doctor, nurse practitioner or physician assistant and other health care members.

In a health care home, you and your family will:


  • Be listened to in a respectful way by your health care home team (or medical care team).  
  • Be the experts in your needs and your care.
  • Be able to see the same provider or health care home team member.
  • Be able to talk with your care team.
  • Name the family and friends who are important to you and your care.
  • Learn about ways you can stay healthy.
  • Be able to contact someone about your care needs 24 hours a day, 7 days a week.

Your care coordinator will:

  • Learn about you.
  • Involve you and your family as partners in your care.
  • Work with you, your family and your care team to develop a care plan.
  • Provide time for your questions.
  • Offer support, education and links to community services.
  • Help you coordinate all of your health care information.

Your provider and health care home team will:

  • Offer a safe and accepting setting to talk about your health concerns.
  • Care about you as a whole person with respect for your cultural and religious values.
  • Give you hope and help you take care of yourself.
  • Help you when you are faced with hard choices.
  • Provide you with information you can understand.
  • Offer choices for care with cost information.

Patient Comments

“I avoided an ER visit twice by contacting my care coordinator first. This saves money.”

“It has significantly decreased my hospital and ER visits.
I had 21 ER visits last year and only one this year.”

“I can talk to one nurse who knows me and my medical issues.”

“This is the best thing doctors have ever done for health care.”

What is a care plan?

A care plan is a document used by families, educators and health care professionals to organize and streamline medical information. A care plan provides efficient and family centered care for your child, whether he is seen in the clinic, emergency room, hospital on vacation or at a specialist’s office. The purpose of a care plan is to improve the quality of care that we provide to children with special health care needs.

How do I get a care plan?

To get a care plan started, contact your clinic and ask for the care coordinator. Once the necessary patient information is gathered, the health care provider will add the pertinent medical needs to the care plan. A final copy will be mailed to you and a copy will remain in our electronic medical record for use at all CentraCare entities.

What is a Chronic Care Visit?

A Chronic Care Visit (or CCV) is an important health care visit for patients with chronic health care needs. This appointment is in addition to an annual physical. At this visit, your provider will update your care plan, as well as:

  • Review current therapies, services, equipment and medical care
  • Problem solve questions or issues
  • Set future health care goals
  • Create a follow-up plan

Chronic care visits are not meant to replace your yearly physical. Most insurance companies cover CCV once yearly in addition to yearly physicals, please confirm with your insurance prior to scheduling.

How do I update my care plan?

  1. If you have an upcoming appointment with your provider, bring the updates with you;
  2. Schedule a CCV (see “What is a CCV”); or
  3. Call your Health Care Home Coordinator with any updates.

How do I get a handicap tag for my vehicle?

Log on to Minnesota Department of Public Safety - Driver and Vehicle Services

  • Click on "Disability Parking"
  • Print the application
  • Give the completed application to your provider to fill in medical section
  • Mail the completed form to the Driver and Vehicle Services office
  • Or, ask your provider for a blank application form when you are at the clinic.

How can I get a copy of my specialist's report?

When you have an appointment with the specialist, ask the front desk staff if you can sign a release of information form so a copy of the specialist’s notes can be sent to you and your primary provider.

Web Resources

Patients may try to diagnose illnesses based on information available on the internet or look for additional information when a new diagnosis is made. Sometimes it’s a place where patients connect with other patients.

While the internet can be a great source of information, it also can be a source of modern-day quackery. Here is an updated list of informational web sites that can be used by patients to find credible medical information.

Health information accessed through web sites is not intended to be a substitute for professional medical advice, diagnosis or treatment.

Health Care Home Videos

Learn more about this program from our patients and health care home coordinators.

Related Locations

Learn how health care home can help you.