Health Home Program Lead

COMMUNITY CARE COORDINATION

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

The Health Home program is a Medicaid benefit available at no cost to help promote person-centered health action planning to empower clients to take charge of their own health. This is accomplished through better coordination between the client and members of their care team and encourages involvement and independence. The Health Home program is designed to ensure clients receive the right care, at the right time with the right provider.

Health Homes Provide:

• Comprehensive care management.
•   Care coordination and health promotion.
•   Transition planning.
•   Individual family support.
•   Referral to relevant community and social support services

Health Home Program Goals:

HEALTH HOME LEAD ENTITIES

The Health Care Authority contracts with designated “Health Home Lead Entities” to provide Health Home services directly, or through contracted Care Coordination Organizations. The Health Home program emphasizes person-centered care with the development of the Health Action Plan (HAP). The HAP includes routine screenings such as the Patient Activation Measure (PAM).

The PAM is an assessment that gauges the knowledge, skills and confidence essential to managing one’s own health and healthcare. The HAP also includes screenings for body mass index, depression, level of independence in accomplishing activities of daily living, risk of falls, anxiety, chemical dependency, and pain.

The HAP and assessment screens are updated on a 4-month cycle. The centerpiece of the HAP is the client’s self-identified short and long-term health related goals, including what action steps the client and others will do to help improve his or her health. With client consent the HAP can be shared with care providers in order to foster open communication, support, and encouragement to reach their health goals.

HEALTH HOME CARE COORDINATORS

Health Home Care Coordinators will help clients manage their chronic conditions and assist them in meeting their health goals. The Health Home Program reduces gaps in services and increases coordination between all types of service providers (medical, behavioral health, long term services and supports and other social services).

A Health Home Care Coordinator is an individual who works with eligible clients, their families, and providers to:

Coordinate services for clients with chronic and complex medical and social needs
Identify gaps in care and help remove barriers
Connect clients to a broad range of benefits and community resources
Support successful transitions from inpatient facilities to other levels of care
Help establish primary and specialty care relationships
Help manage multiple providers
Communicate and coordinate with the client’s providers
Provide appointment assistance
Support and assist clients to reach their identified health goals and improve quality of life.

Eligibility Criteria

Identified chronic condition
All ages, across all settings
A risk score of 1.5 or greater predicting 50% higher healthcare costs than the average Medicaid disabled client in the next 12 months
Have at least one chronic condition and are at risk for a second one
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.

Health Home services support individuals in their health journey. Participation is voluntary. It does not impact eligibility for other services or complaint and appeal rights.

ABOUT THE CARE COORDINATION NETWORK PROGRAM

Care coordination services provided through the Health Home Program include:

Comprehensive care management for the development of individualized health goals and action steps
Care coordination and health promotion to integrate services
Transition planning (e.g. from nursing facility/hospital to home)
Individual and family support services (e.g. identifying and recognizing the role families, informal supports, and caregivers provide in supporting their health goals)
Referral to community and social support services (e.g. transportation, food, housing)