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 Betty Jean Kerr Peoples Health Center Family Care Health Center St. Louis, MO St. Louis, MO Citizens Memorial Healthcare, dba Cox Health, Family Medical Care Center Butterfield Park Pediatrics Springfield, MO Boliver, MO John Fitzgibbon Hospital Southeast MO Health Network, dba Marshall, MO Sikeston Medical Clinic Sikeston, MO Truman Medical Centers Hospital Hill Primary Care Clinic Grace Hill Health Center Kansas City, MO St. Louis, MO University of MO Health Care Ozark Tri-County Health Care Consortium, dba Internal Medicine Clinic Access Family Care at Joplin Columbia, MO Joplin, MO Fordland Clinic, Inc. Samuel U. Rodgers Health Center – Fordland, MO Downtown Campus Kansas City, MO Northwest Health Services St. Joseph, MO Jordan Valley Community Health Ctr. Springfield, MO

Participating Primary Care Health Homes Family Health Center of Boone County Regional Health Care Clinic, dba Columbia, MO Katy Trail Community Health Sedalia, MO Community Health Center of Central Missouri Jefferson City, MO Crider Health Center Wentzville, MO Myrtle Hilliard Davis Comp. Health Centers St. Louis, MO University of MO Health Care Green Meadows Pediatric Clinic Skaggs Family Health Clinic Columbia, MO Branson, MO Kneibert Clinic Swope Health Services Poplar Bluff, MO Kansas City, MO Big Springs Medical Association, dba University of MO Health Care Missouri Highlands Medical Clinic Dept. of Family and Community Medicine Poplar Bluff, MO Columbia, MO Northeast Missouri Health Council Rural Alliance for Better Family Health, dba Kirksville, MO Southern Missouri Community Health Center West Plains, MO Cross Trails Medical Center Cape Girardeau, 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. •

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

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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

Oregon Health Authority Patient-Centered Primary Care Home Initiative School-Based Health Center

Transitions and the Primary Care Home Stacy Moritz, RN, MBA Acumentra Health October 8, 2013

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Enhanced Home Health Care Enhanced Home Health Care Available for Rex and UNC UNC Home Health and

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Introduction to the Community Health Sector Tom Manning Primary Care Development Corporation

Information Sharing Strategy for Primary Care Home and Across the Continuum of Care Betty Da

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Collaborative Integrated Medical-Behavioral Care David R. Rosenberg, M.D., Alireza Amirsadri,

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Primary Care Home Mr. Nick Sutton Programme Manager Wakefield Integrated Care Partnership &

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