Health Homes

Our Health Homes program in coordination with the "whole-person" philosophy is dedicated to providing integrated and coordinated care for individuals with chronic conditions. As a Health Homes provider, our primary goal is to address the comprehensive needs of each individual by integrating and coordinating all primary, acute, behavioral health, and long-term services and supports.

Eligibility for our Health Homes program is open to individuals with Medicaid who meet the following criteria:

• Have two or more chronic conditions.
• Have one chronic condition and are at risk of developing a second.
• Have one serious and persistent mental health condition.

The chronic conditions covered under the program encompass mental health, substance abuse, asthma, diabetes, heart disease, and being overweight. Furthermore, the program may consider additional chronic conditions such as HIV/AIDS for approval. In some cases, health home services may be targeted geographically based on state guidelines.

Our comprehensive range of services includes:

• Comprehensive care management: We provide personalized care management services to ensure holistic and individualized care plans for each participant.

• Care coordination: We facilitate seamless coordination of care across various healthcare providers and settings, ensuring optimal health outcomes.

• Health promotion: We actively promote health and well-being through education, preventive measures, and lifestyle interventions.

• Comprehensive transitional care/follow-up: We offer support during transitions between healthcare settings, ensuring continuity of care and minimizing disruptions.

• Patient and family support: We recognize the importance of involving patients and their families as active participants in the care process, providing them with the necessary support and resources.

• Referral to community and social support services: We assist individuals in accessing community and social support services that can enhance their overall well-being and address social determinants of health.

By integrating and coordinating these services, our Health Homes program strives to provide comprehensive care, improve health outcomes, and enhance the overall quality of life for individuals with chronic conditions.