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.