What is a Health Home Program?
The Health Home Program was created by Affordable Care Act (ACA) section 2703. It allows states to provide Health Home services and care coordination to high cost high risk Medicaid and Medicare/Medicaid (duals) eligible clients. Its purpose is to reduce duplication of services and provide smoother transition and more personalized care to help reduce the progression of chronic disease, reduce inappropriate emergency department utilization and preventable hospital readmissions, and improve health and self-management of conditions.
As defined by the Centers for Medicare and Medicaid (CMS), a Health Home provides six specific services beyond the clinical services offered by a typical provider.
- Comprehensive care management
- Care coordination and health promotion
- Comprehensive transitional care and follow-up
- Patient and family support
- Referral to community and social support services
- Use of information technology to link services, if applicable
The Health Care Authority (HCA) and Department of Social and Health Services (DSHS) approve “Lead” Organizations. These Leads include Managed Care Organizations, as well as Community Based Organizations. The Leads contract with Care Coordination Organizations (CCOs) too and may include mental health clinics, area agencies on aging, chemical dependency providers, HIV/AIDs networks, child social service agencies, and community health centers. The CCO’s provide Health Home services through a Care Coordinator. Care Coordinators assist clients in coordinating medical care, long-term services and supports, and behavioral health as appropriate. The client and Care Coordinator can meet at a location of the client’s choice: a clinic, the patient’s home, or other community location. Washington offers the program in all counties except King and Snohomish.
Care Coordinator Training
- Clinical Eligibility Tool
- Clinical Eligibility Tool Instructions
- Goals Setting Action Plan Worksheet (Revised February 2015)
- Health Action Plan (Revised February 2015)
- Health Action Plan instructions (Revised February 2015)
- Health Action Plan Questions (February 2015)
- Incident Report: Word, PDF
- Information Sharing Consent Form: Word, PDF (Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese)
- Participation (Opt-Out/Decline Services) Form: Word, PDF (Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese)
- Patient Symptoms Checklist (PSC-17): Word, PDF
- Patient Symptoms Checklist (PSC-17) Instructions
- Release of Information (ROI) for Chemical Dependency (CD) Services
- Health Home Letter
- Health Home Booklet: English, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
- Trifold Brochure: English, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese