COMMUNITY CARE COORDINATION

PROGRAMS > COMMUNITY CARE COORDINATION | HEALTH EDUCATION | HEALTH INSURANCE | NETWORK SUPPORT SERVICES

Community Care Coordination

Action Health Partners works to improve regional health outcomes through community-based care coordination. Through community-based care coordination a person-centered approach is utilized by Action Health Partners and contracted partners that work to connect individuals to a full range of services and encourage them to achieve goals to achieve greater wellbeing. Action Health Partners provides the Health Home program as a Lead entity and a Care Coordination Organization.

Health Home Program

The Health Home program is not a place, it is a set of services supporting eligible clients. It is a community-based care coordination program that sets out to support participants who have chronic conditions, behavioral health conditions, and have social service needs.

The program provides care coordination of medical, behavioral health, and long-term services and support for individuals of all ages through a person-centered approach. The program aims to help clients take charge of their own health. Participation is voluntary.

Services Provided

Care Coordinators work one-on-one with clients to achieve goals, reduce gaps in services, and increase coordination between all types of service providers. The program aims to provide the client with an advocate to help guide the client to better health and quality of life through six Health Homes services.

Referral to community and social support services: Connects clients to a broad range of benefits and community resources (e.g. transportation, food, housing, etc.)
Individual and family support: Identifies and recognizes the role families, informal supports, and caregivers provide in supporting client’s health goals
Health promotion: Supports and assists clients to reach their identified health goals and improve quality of life
Care coordination: Coordinates and communicates with providers to identify gaps in care and help remove barriers
Comprehensive care management: Improve self-management of chronic conditions through individualized health goals and action steps
Comprehensive transitional: Supports transitions from inpatient facilities to other levels of care (e.g. from nursing facility/hospital to home)

Eligibility

Apple Health clients of all ages, including Medicaid/Medicare dual eligible clients, may be eligible for the Health Home program if they:

Have at least one chronic condition and are at risk for a second one (e.g. asthma, diabetes, kidney or liver disease, heart failure, mental health conditions, substance abuse, obesity, etc.)
Be at risk of poor health outcomes in the future based on age, gender, and diagnoses

Additional requirements may apply.