Health Care Home
Beginning 1/1/2012 Missouri will be providing “Health Homes” to Missourians who are Medicaid eligible participants with chronic illnesses. With the assistance of consultants funded by Missouri Foundation for Health, the State has collaborated with the Missouri Primary Care Association (PCA), the Missouri Coalition of Community Mental Health Centers (CMHC) and various stakeholders to develop a Health Home model for Missouri.
Dr. Joe Parks, Medical Director for Missouri’s Department of Mental Health, notes that the mentally ill have particular difficulty in obtaining integrated care. “Persons with serious mental illness and multiple chronic medical conditions often have many, many different healthcare providers and take many, different medications,” notes Parks. “Without care managers using data analytic tracking to find and address care gaps there is no way to assure that they get high quality health care that keeps them out of the ER and hospital and in their communities.”
What is a Health Home?
The Health Home is an alternative approach to the delivery of health care services that promises better patient experience and better results than traditional care. The Health Home has many characteristics of the Patient-Centered Medical Home but is customized to meet the specific needs of low-income patients with chronic medical conditions.
What are the components of Health Homes?
- Comprehensive care management;
- Care coordination and health promotion;
- Comprehensive transitional care including follow-up from inpatient and other settings;
- Patient and family support;
- Referral to community and support services; and
- Use of health information technology to link services.
What are the Goals of Health Home Initiative?
- Implement and evaluate the Health Home model as a way to achieve accessible, high quality primary health care and behavioral health care;
- Demonstrate cost-effectiveness in order to justify and support the sustainability and spread of the model; and
- Support primary care and behavioral care practice sites by increasing available resources and improving care coordination to result in improved quality of clinician work life and patient outcomes.
Missouri will use this initiative to reduce inpatient hospitalization and emergency room visits, enhance the amount of primary care nurse liaison staffing available at community mental health centers, add primary care physician consultation, and enhance the State’s ability to provide transitional care between institutions in the community.
Who is eligible to be served in by a Health Home?
- Persons covered by Mo HealthNet including those covered through Mo HealthNet’s Managed Care Plans;
- Persons with 2 chronic conditions;
- Persons with 1 chronic condition who are also at risk for a 2nd chronic condition; and/or
- Persons who have 1 serious and persistent mental health condition
What chronic conditions qualify?
- Serious Mental Health Condition
- Substance Abuse Disorders
- Cardiovascular Disease – including hypertension
- Overweight (BMI>25)
- Developmental Disabilities
- *Smoking or Diabetes
*qualifies a person for being at risk of having a second chronic condition
Who will be the providers of these services?
Selected CMHC's, FQHC's and public entity primary care clinics. Applications were disseminated for primary health care and behavioral health care providers to complete and return to the State for consideration to be a Health Home. Review of applications was performed by MO HealthNet and Department of Mental Health to make the final determination of selected practice sites. Specific practice selection was based upon the merits of each individual application and upon the CMS requirement that there be statewide geographic representation. Each application was reviewed and carefully considered.
Applicants qualifyng to be Health Homes will work to transform their practices over a two-year period by participating in ongoing training sessions or “learning collaboratives.” CMHCs will be required to obtain Health Home certification through nationally recognized Health Home accrediting organizations, and primary care practices will be required to obtain NCQA (National Committee for Quality Assurance) Health Home certification. At least 25% of a provider’s patient base must consist of Medicaid patients and/or uninsured patients.
Community Mental Health Center Health Homes (CMHC-HH)
- MO SPA 11-11 10-21-11
- CMHC HH CMS Approval of SPA 10-20-11
- Draft CMHC Health Home Regulation 10/11/11
- CMHC Healthcare Homes Contacts 10/25/11
- Paving the Way for Healthcare Home Final
- Healthcare Home 101 Leadership Training 11/1/11
- Missouri Show Me How to Build a Health Home Part 1 5/1/12
- Missouri Show Me How to Build a Health Home Part 2 5/1/12
- Missouri Show Me How to Build a Health Home Part 3 5/1/12
- Missouri Show Me How to Build a Health Home Part 4 5/1/12
- Missouri Show Me How to Build a Health Home Part 5 5/1/12
- Missouri Show Me How to Build a Health Home Part 6 5/1/12
Implementation - CMHC
- CMHC Participant Offer Letter 10/25/11
- Hypothetical Health Care Home Patient Scenario 7/18/11
- CMHC Health Home Flow Chart 07/22/11
- HCH Client Flyer 10/25/11
- CMHC HCH Client Opt-Out Letter 10/25/11
- Paving the Way Sign-In Sheet 07/22/11
- Memorandum of Understanding - Hospital and Health Homes 1/23/12
- SAMHSA Health Homes Report_Final_092412
Primary Care Practice Health Homes (PCP-HH)
- Primary Care Health Home Bulletin 7/5/11
- Primary Care Health Home Application 07/22/11
- MO Primary Care Health Home SPA 12/14/11
- Memorandum of Understanding - Hospital and Health Homes1/23/12
- Primary Care Health Homes - Site List 1/23/12
- PCHH Paving the Way Presentation 1/23/12
Implementation - Primary Care
- Health Home Letter 1/12/12
- Primary Care Health Home Flow Chart 07/22/11
- PCHH Patient Flyer without Nurse Care Management information 1/13/12
- PCHH Patient Flyer with Nurse Care Management information 1/13/12
- PCHH Contact Profile final 1/12/12
- PC discharge request Form Final 1/12/12
- PC Transfer Request Form Final 1/12/12
- PC Health Home Discharge Protocol Final 1/12/12
- PC Health Home Transfer Protocol Final 1/12/12
Partners in Developing Missouri Health Homes
- Michael Bailit of Bailit Health Purchasing
- Alicia Smith of Health Management Associates
- Missouri Coalition of Community Mental Health Centers
- Missouri Primary Care Association
- Care Management Technologies “CMT”
- Missouri Foundation for Health
Source Documents from CMS
- Health Home SPA Template 11/16/10
- Health Home SMD Final 11/16/10
- CMS Responses to Questions 2/3/11
- Edwards Home Health Response 2/16/11
- Missouri Response to CMS Feedback 3/10/11
- Attachment 1 to Response to CMS Feedback 3/10/11
- Attachment 2 to Response to CMS Feedback 3/10/11
- MO HH-PC Feedback 4/4/11
- Edwards 5/6/11
- Edwards encl CMHC SPA Template 5/6/11
- Edwards encl HCH Payment Methodology 5/6/11
- Edwards encl HCH Stakeholders 5/6/11
- CMHC - Six Month Review 11/05/12
- Metabolic Screening Database Training Video 1/13/12 ............NOTE: This is a large file. Please download file to your computer to view.
- Insulin Associated Weight Gain Article 07/22/11
- Relationship Between Smoking and Cardiovascular Disease 07/22/11
- Epidemiologic Study of Bronchial Asthma and Smoking 07/11/11