Primary Care Health Home Eligibility Two chronic conditions One - - PowerPoint PPT Presentation

Primary Care Health Home

Eligibility

• Two chronic conditions
• One chronic condition and the risk of

developing another

– Asthma – Diabetes – Heart Disease – BMI Over 25 – Developmental Disability

Designated providers

• Federally qualified health centers (FQHCs)
• Rural health clinics (RHCs)
• Primary care clinics operated by hospitals

*Not all FQHCs, RHCs or primary care clinics, voluntary and have to apply

Participating Primary Care Health Homes

Family Care Health Center

• St. Louis, MO

Cox Health, Family Medical Care Center Springfield, MO John Fitzgibbon Hospital Marshall, MO Truman Medical Centers Hospital Hill Primary Care Clinic Kansas City, MO University of MO Health Care Internal Medicine Clinic Columbia, MO Fordland Clinic, Inc. Fordland, MO Northwest Health Services

• St. Joseph, MO

Betty Jean Kerr Peoples Health Center

• St. Louis, MO

Citizens Memorial Healthcare, dba Butterfield Park Pediatrics Boliver, MO Southeast MO Health Network, dba Sikeston Medical Clinic Sikeston, MO Grace Hill Health Center

• St. Louis, MO

Ozark Tri-County Health Care Consortium, dba Access Family Care at Joplin Joplin, MO Samuel U. Rodgers Health Center – Downtown Campus Kansas City, MO Jordan Valley Community Health Ctr. Springfield, MO

Participating Primary Care Health Homes

Regional Health Care Clinic, dba Katy Trail Community Health Sedalia, MO Crider Health Center Wentzville, MO University of MO Health Care Green Meadows Pediatric Clinic Columbia, MO Kneibert Clinic Poplar Bluff, MO Big Springs Medical Association, dba Missouri Highlands Medical Clinic Poplar Bluff, MO Northeast Missouri Health Council Kirksville, MO Cross Trails Medical Center Cape Girardeau, MO Family Health Center of Boone County Columbia, MO Community Health Center of Central Missouri Jefferson City, MO Myrtle Hilliard Davis Comp. Health Centers

• St. Louis, MO

Skaggs Family Health Clinic Branson, MO Swope Health Services Kansas City, MO University of MO Health Care

• Dept. of Family and Community Medicine

Columbia, MO Rural Alliance for Better Family Health, dba Southern Missouri Community Health Center West Plains, MO

Health Home Team

• Physician-led
• Primary care physician (i.e., family practice, internal

medicine, or pediatrician) or nurse practitioner,

• Licensed nurse or medical assistant,
• Behavioral health consultant,
• Nurse care manager
• Optional team members may include a nutritionist,

diabetes educator, public school personnel and others as appropriate and available.

Services

• Comprehensive Care Management
• Care Coordination
• Health Promotion
• Comprehensive Transitional Care
• Individual and Family Support Services
• Referral to Community and Social Support

Services

State Outcomes

• Avoidable hospital readmissions
• Cost savings that result from improved chronic

care coordination and management

• Use of health information technology in providing

Health Home services to improve service delivery and coordination across the care continuum

Improve Behavioral Healthcare

• Integration of physical and behavioral health

care

• Screening for and reduction in substance

abuse

• Screening for depression in adults
• Screening through EPSDT for mental health

issues in children

Preventive Care

• Weight, BMI
• Immunizations

Chronic Health Conditions

• Diabetes

– HbA1c – Blood Pressure – Cholesterol (LDL-C) – Adherence to diabetes medication

• Asthma
• Use of and adherence to controller medications
• Cardiovascular

– Blood Pressure – Lipid levels – Medication Adherence

Members Choice for Health Home

• Members may choose their health home
• Members may choose to transfer their health

home

• Members may choose to opt out of health

home services all together without impact on their other health services

For More Information

http://dmh.mo.gov/about/chiefclinicalofficer/healthcarehome.htm

• 573-522-3012
• Monday thru Friday from 9:00 a.m. to 4:00 p.m., excluding holidays.