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  • Health Home (HH)

    A health home is a healthcare delivery approach that focuses on the whole person and integrates and coordinates primary care, behavioral health, other healthcare, and community and social support services. A health home allows for individual choice and is capable of assessing the various physical and behavioral health needs of persons served. The program demonstrates the capacity to address, either directly or through linkage with or referral to external resources, behavioral health conditions, such as mental illness and substance use disorders, and physical health conditions. Programs may also serve persons who have intellectual or other developmental disabilities and physical health needs or those who are at risk for or exhibiting behavioral disorders. Care is coordinated over time across providers, functions, activities, and sites to maximize the value and effectiveness of services delivered to persons served.

    A health home provides comprehensive care management, care coordination, health promotion, comprehensive transitional care, individual and family/support services, and linkage and referral to community and social support services. Services are designed to support overall health and wellness and:

    • Embody a recovery-focused model of care that respects and promotes independence and responsibility.
    • Promote healthy lifestyles and provide prevention and education services that focus on wellness and self-care.
    • Ensure access to and coordination of care across prevention, primary care (including ensuring that persons served have a primary care physician), and specialty healthcare services.
    • Monitor critical health indicators.
    • Support individuals in the self-management of chronic health conditions.
    • Coordinate/monitor emergency room visits and hospitalizations, including participation in transition/discharge planning and follow up.

    A health home collects, aggregates, and analyzes individual healthcare data across the population of persons served by the program and uses that data and analysis to manage and improve outcomes for the persons served. If the health home is not the actual provider of a particular healthcare service, it remains responsible for supporting and facilitating improved outcomes by providing disease management supports and care coordination with other providers.

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