Community Mental Health Center (CMHC) Healthcare Home
What is a CMHC Healthcare Home?
Missouri's CMHC Healthcare Homes are designed to integrate care for chronic health conditions into the CMHC setting. They assist individuals in accessing needed health services and supports, and learning to manage their health conditions, and improve their general health, by monitoring health conditions and healthcare needs of enrollees and intervening with clients whose health conditions are not properly controlled or managed. HCHs promote and encourage wellness, healthy lifestyles and preventative care, educate and teach persons how to better manage their chronic health conditions, educate agency staff about chronic health conditions and how to manage them, and encourage a population health approach to help improve chronic health conditions for persons served by CMHCs.
Individuals covered by MO HealthNet are eligible to be served by a CMHC Healthcare Home if they have:
- A serious mental illness (including children and adults receiving psychiatric rehabilitation services under the Medicaid Rehabilitation Option), or
- A mental health condition and a substance use disorder, or
- A mental health condition or a substance use disorder, and one of the following chronic conditions or risk factors:
- Cardiovascular Disease
- Developmental Disability
- Overweight (BM >25)
- Use Tobacco
This website provides information regarding the development, and current status, of Missouri’s CMHC Healthcare Homes. Information regarding Missouri’s Primary Care Health Homes can be accessed at the following website: dss.mo.gov/mhd/cs/health-homes/
Introduction to Missouri’s CMHC Healthcare Homes
This section contains general information, achievements, and reports regarding MO CMHC Healthcare Homes (HCH).
State Plan Amendment for Missouri's Healthcare Homes
Awards and Recognition
HCH Annual Reports
- Missouri Community Mental Health Center Healthcare Home: Six Month Review
- Missouri Community Mental Health Center Healthcare Home: 18 Month Review
- Missouri Community Mental Health Center Healthcare Home Progress Report 2012-2015
- Missouri Community Mental Health Center Healthcare Home Progress Report 2016
- Missouri Community Mental Health Center Healthcare Home Progress Report 2017
HCH Policy Memos and Clinical Bulletins
This section contains the policy memos, clinical bulletins, and guidelines regarding the operations of HCHs.
CMHC HCH General Memos and Bulletins
Nurse Care Manager (NCM) Policy Memos and Tools
- Billing Policies for NCMs
- Addressing Physical Health Needs of Assertive Community Treatment (ACT) Clients
- Healthcare Home Health Screenings
Primary Care Physician Consultants
Metabolic Syndrome Screening
HCH Forms and Tools
This section contains the forms and tools needed to complete the daily operations of a HCH.
- Healthcare Home Contact Profile Form
- CMHC HCH Enrollment Form
- CMHC HCH Transfer Form
- CMHC HCH Discharge Form
Please encrypt all emails containing PHI, if you have any questions please email Jessica.Bounds@dmh.mo.gov
This section contains educational information for training new staff and provides other HCH training materials.
HCH General Training Tools
- HCH 101 PowerPoint
- HCH Q&A
- CMHC Healthcare Home Flyer
- CMHC Introductory Script
- HCH Letter to MO HealthNet Providers
- HCH Introductory Letter to Hospitals
- The Howard Narrative
- Healthcare Home and CPRC Integration
HCH Director Training Tools
- HCH Director Roles and Responsibilities - coming soon
- HCH New Director Training Power Point
HCH Nurse Care Manager (NCM) Training Tools
- HCH Nurse Care Manager Roles and Responsibilities - coming soon
HCH Primary Care Physician Consultant Training Tools
- HCH PCPC Roles and Responsibilities - coming soon
- Advanced Practice Nurse (APN) Specialties for APNs Substituting for PCPC Time
HCH Care Coordinator Training Tools
- HCH Care Coordinator - coming soon
Metabolic Syndrome Screening Training Tools
Medication Reconciliation Tools
- Guidelines for Medication Reconciliation
- Medication Reconciliation Post Hospital Discharge Guidelines
HCH Training Links
The Missouri Coalition for Community Behavioral Healthcare and the Missouri Department of Mental Health are sponsoring this website for champions of health and wellness. On this website you will find health and wellness articles, news, videos, and webinars. You can find documents from trainings, meeting minutes, activities, PowerPoints, etc. https://www.wellmissouri.com/
HCH Health Information Technology (HIT)
This section contains information regarding the HIT tools that is utilized by the HCHs.
CareManager - Under Construction
CyberAccess - Under Construction
Risk Stratification Tools - Under ConstructionMO Outcome Measures Catalog - Under Construction
This section contains a brief introduction to the Disease Management (DM) programs in MO, as well as a link to the DM home pages.
The Disease Management (DM) projects are a collaborative effort among the Department of Mental Health’s (DMH) Division of Behavioral Health (DBH), the Department of Social Services’ (DSS) MO HealthNet Division (MHD), and the Coalition for Community Behavioral Healthcare. The project targets Medicaid-eligible adults with high medical costs who have a serious mental illness or substance use disorder and who are not currently receiving behavioral health services. The goal is to locate and enroll these individuals in services, who frequently have impactful chronic medical conditions, in order to improve health outcomes and reduce related medical costs. The DMH has adopted a whole person approach regarding treatment and services. To make any impact in reducing premature mortality and costs and to increase individual outcomes, services can no longer be delivered in silos. An integrated approach must be embraced. Services should be delivered based on a chronic care model rather than an acute care model. This model enables providers to assist consumers with their overall health care needs and gain an understanding of their strengths and barriers which may impact their recovery and quality of life. Disease management is a philosophy that embraces the above models and involves coordinating complex care with multiple providers. For individuals with chronic health conditions, high quality care truly requires integrated, person centered, and coordinated care. Many individuals with a mental illness or a substance use disorder also have chronic physical health conditions resulting in premature mortality. Despite this fact, behavioral and physical health services have historically been delivered through separate systems with little cross-system coordination. This results in poor individual outcomes and excessive costs to the healthcare system.