Health Home Program Services for Patient 1st Medicaid Recipients Alabama Community Care – Region A

Health Home Program The Health Home Program is designed to add an additional level of support to Primary Medical Providers by intensively coordinating the care of patients who have or who are at risk of having certain chronic conditions.

Who Qualifies for Care Coordination Services? Medicaid Patient 1st Recipients: Assigned to a Patient 1st Primary Medical Provider who is contracted with the Health Home Program; Diagnosed with two (2) chronic conditions; Diagnosed with one (1) chronic condition and the risk of developing another; or Diagnosed with a serious mental health condition with at least one of the targeted diagnoses.

Targeted Chronic Conditions Asthma Organ Transplants Chronic Obstructive Cancer Pulmonary Disease Sickle Cell Anemia Diabetes HIV Heart Disease BMI over 25 Mental Illness Hepatitis C Substance Abuse

Clinical Care Team Medical Director Quality Care Manager RN Clinical Care Supervisor Social Work Supervisor Clinical and Network Pharmacists Licensed Social Workers Transition of Care Registered Nurses Behavioral Health Registered Nurses Registered Dietitians for Consultations Population Management Licensed Practical Nurses Community Health Workers

Health Home Services Traditional Care Coordination Licensed Social Workers with the assistance of Licensed Practical Nurses and Community Health Workers: Conduct home visits Attend Physician appointments Coordinate transportation Link Recipients with needed community resources and other programs Assist with disease education Assist with medication scheduling and reconciliation Communicate with all treating Providers

Health Home Services All components of Health Home Care Coordination contain aspects of Traditional Care Coordination; however, some services are specific to certain populations: Transition of Care RNs assist recipients with transitioning to a community setting or change in level of care. Behavioral Health RNs support the integration of behavioral health services, including both mental health and substance abuse, and medical services for recipients.

Health Home Services Clinical and Network Pharmacy Management and Support Medication reconciliation Pharmacy home visits for high risk patients with multiple diseases and medications Updates on formulary changes and other pertinent information

Health Home Services ALCC maintains a Patient Assistance Fund (PAF) to be utilized for services and items not covered by Medicaid. These include but are not limited to the following: Co-pays Medications Blood pressure cuffs Scales Diabetic shoes The PAF is requested when all other resources have been exhausted.

Referral Sources Primary Medical Providers Specialists Hospitals Emergency Departments Alabama Medicaid Claims-based data Other agencies Patient self-referral

Health Home Resources Claims Data Pharmacy Team Initiative Funding Care Coordination Staff

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