Health Home CCCCO

COMMUNITY CARE COORDINATION

Health Home CCCCO

COMMUNITY CARE COORDINATION > HEALTH HOME PROGRAM LEAD | HEALTH HOME CCCCO

Community Choice Care Coordination Organization (CCCCO) contracts with Action Health Partners (AHP) to provide care coordination services in Chelan, Douglas, Grant and Okanogan counties. Through the Health Homes program, we help our most at-risk Medicaid and Medicaid-Medicare, or dual eligible, residents connect to long-term, supportive care coordination.

What is the Health Home Program?

The Health Home Program is a community-based care coordination program that sets out to support participants who have serious chronic conditions, behavioral health conditions, and have social service needs.

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

What are the Core Services provided?

Clients who join the Health Home program are assigned a care coordinator that works one-on-one with the client and members of their care team to connect them to health care and social services they identify as needed. A key focus of the Health Home program is to provide the participant with a key advocate to help guide the participant to better health and quality of life.

The Health Home program provides access to six core services:
Comprehensive Care Management

Develop and maintain a Health Action Plan to help clients meet their health care goals and stay healthy.

Care Coordination

Keep all providers coordinated and up-to-date about client’s health care needs and the services they receive

Health Promotion

Provide information and tools to inform clients and their family members on the best ways to manage health conditions.

Comprehensive Transitional Care/Follow-Up

Help clients move safely and easily between different care settings, such as entering or leaving a hospital or nursing facility and returning to their own home.

Patient & Family Support

Include family or friends on the care team if the client chooses, so they have up-to-date information on their conditions and ways to support them.

Referral to Community & Social Support Services

Help clients find and apply for needed community and social services needed, including housing, food, employment, etc.

Who qualifies for the program?

Eligibility:
To be eligible for the Health Home program, Apple Health clients of all ages, including Medicaid/Medicare dual eligible clients, must:

Have at least one chronic condition and
Be at risk of poor health outcomes in the future based on age, gender and diagnoses
The State enrolls eligible clients with a Health Home lead organization and informs the client’s health plan that (s)he is eligible for Health Home services.

General Qualifications:

All ages, across all settings
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
Are a Medicaid and/or Medicare client
Have a serious health issue that typically requires more than one service provider

A risk score of 1.5 or greater predicting 50% higher healthcare costs than the average Medicaid disabled client in the next 12 months

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