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
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Member of your staff (care manager)
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Physicians, nurse care coordinators, nutritionists, social workers, behavioral health professionals, or any professionals that the state deems appropriate for its model.
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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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