1. Health Home Program Services
Alabama Community Care – Region C

2. Health Home Program
The Health Home Program is designed to add an additional level of support to Patient 1st Primary Medical Providers by intensively coordinating the care of patients who have or who are at risk of having certain chronic conditions.

3. 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.

4. 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

5. Clinical Care Team Medical Director Quality Care Manager
Clinical Care Supervisors- Nurse and Social Work
Clinical and Network Pharmacists
Licensed Social Workers
Transition of Care Registered Nurses
Behavioral Health Registered Nurses
Community Health Workers

6. Health Home Services Traditional Care Coordination
Licensed Social Workers 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

7. Health Home Services Specialty Services for Recipients
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.

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

9. 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.

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

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

12. Statewide Health Home Initiatives
Alabama Opioid Crisis
Statewide Health Home Initiatives

13. Substance Abuse Screening Adolescents and Adults
Screen patients enrolled in active care coordination services
CRAFFT – Adolescent
CAGE-AID – Adult
Address positive screen with patient
Assist with identifying and linking patient to available resources for treatment
Notify PMP of positive screen (with patient approval) and provide information regarding referral to treatment

14. Report Development
Work with the data to develop a standard report that will identify:
Multiple Prescribers
Opioid daily dosage greater than ninety (90) MME for ninety (90) days or more
Opioid/Benzodiazepine combination for three (3) consecutive months or more
ALCC Clinical and Network Pharmacists will review data reports and follow up when indicated.
*Note: Cancer patients excluded

16. Education and Outreach
Staff education on Substance Abuse Disorder (SUD)/ Screening tools
Motivational Interviewing training for Care Coordination Staff
Patient education on opioids/SUD
Medical Management Meetings focused on Provider Education
Community education via partnering with other organizations and programs to conduct outreach and health fairs

17. Thank you!