Improve care coordination and engagement of patients with self-management goals and shared-care plans.

About Health Home Programs (HHP)

HHP offers coordinated care and linking people to needed services by integrating physical and behavioral health and long-term services to support high-need, high-cost Medicaid populations.

Care Team Involved

  • Member of your staff (care manager)
  • Physicians, nurse care coordinators, nutritionists, social workers, behavioral health professionals, or any professionals that the state deems appropriate for its model.
  • Trained virtual care coach embedded with access to the care management platform (Powered by Certintell)
  • Medicaid beneficiary must be diagnosed with (according to state-defined criteria): two chronic conditions; one chronic condition and risk for a second; or a serious mental illness.

  • Care Coordinator works with the patient to create a care plan, covering all physical, mental health, and social service needs.

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  • Six core services must be provided to the patient: comprehensive care management; care coordination; health promotion; comprehensive transitional care and follow-up; individual and family support; and referral to community and social services.

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