1. West Virginia Bureau for Medical Services (BMS)
Health Homes Programs
Richard D. Ernest, Jr., MSW, Special Programs Manager, BMS
Caroline Duckworth MSW LCSW, Socially Necessary Services Director, KEPRO

2. What is a Health Home?
Health Homes were created by the Centers for Medicare and Medicaid Services (CMS) as a part of the Affordable Care Act (ACA) of 2010.
The Health Homes Program consists of a team of people who assist Medicaid members with managing their healthcare needs. The goal of West Virginia Medicaid Health Homes is to help members be their healthiest and be in control of their lives.
The Health Homes Program coordinates physical and behavioral health (both mental health and substance abuse) and long-term services, social services and supports for Medicaid members with chronic health conditions.

3. Why become a Health Homes Provider?
Becoming a Health Homes provider allows you, the premium lead local entity responsible for care coordination, to serve as the bridge to integrate care across existing health delivery systems.
This is a unique opportunity to focus on those with the greatest need, improving health outcomes and cost savings.
The Health Homes Program is based on the principles of patient activation, engagement and support for enrollees to take steps to improve their own health.
Integrating care for enrollees across primary care, behavioral health and community delivery systems care coordinators are charged with engaging enrollees to set health action goals, and increase self-management skills to achieve optimal physical and cognitive health.

4. Required Core Team Members
Provider/Team Lead – MD, DO or Advanced Practice Nurse licensed in West Virginia.
Behavioral Health Specialist – Masters or doctoral prepared individual licensed in West Virginia in counseling, psychology or social work.
Nurse – Registered Nurse (RN) licensed in West Virginia.
Care Manager – RN or behavioral health specialist licensed in West Virginia. Completed an internal credentialing process through a provider designated as a Health Home.
Care Coordinator – Bachelor’s degree in a social science with some applicable patient care or counseling experience. Completion of a care coordination training program through a provider designated as a Health Home.

5. Health Homes Provider Expectations
Health Homes providers are expected to address several functions including but not limited to:
Providing quality-driven, cost-effective, culturally appropriate and person and family-centered Health Homes services.
Coordinating and providing access to high-quality healthcare services informed by evidence-based guidelines.
Coordinating and providing access to preventive and health promotion services.
Coordinating and providing access to mental health and substance abuse services.
Coordinating and providing access to long-term care supports and services.
Developing a person-centered care plan for each individual that coordinates and integrates all of his or her clinical and non-clinical healthcare-related needs and services.

6. CMS Quality Measures Core Set Measures
Initiation and engagement of alcohol and other drug-dependence treatment
Controlling high blood pressure
Screening for clinical depression and follow-up plan
Follow-up after hospitalization for mental illness
Timely transmission of transition record (discharges from an inpatient facility to home/self care or any other site of care)
Plan all-cause acute admission and readmission rate
Adult body mass index assessment
Prevention quality indicator (PQI92): chronic conditions composite (PQI92)
Medication adherence to antipsychotics, antidepressants and mood stabilizers

7. CMS Quality Measures (Cont.)
Percent of Health Homes enrollees completing a risk assessment for Hepatitis B and/or C
Medical assistance with smoking and tobacco use cessation
Percent of care transitions and referrals for which Health Homes provides a summary of care record or continuity of care document (CCD)
Utilization Measures
Ambulatory care – emergency department visits
Inpatient utilization
Nursing facility utilization
CMS’ Health Homes website:

8. Health Homes Services
Health Homes services require documentation monthly of at least one of the following listed services per member per month:
Comprehensive care management
Care coordination
Health promotion
Comprehensive transitional care and follow-up
Patient and family support services
Referral to community and social support services

9. New Health Homes 3 Effective April 1, 2017
A new Health Homes pilot has been launched for Medicaid members having:
Two or more of the following chronic conditions:
Pre-Diabetes
Diabetes
Body Mass Index (BMI) > 25 (Obesity), or:
One chronic condition and the risk of one of following:
Anxiety
Depression
Geographic limitations to the following 14 counties: Boone, Cabell, Fayette, Kanawha, Lincoln, Logan, Mason, McDowell, Mercer, Mingo, Putnam, Raleigh, Wayne and Wyoming

10. New Health Homes 3

11. Health Homes 3 – Service Level
Level I
The basic Level I Health Homes service code is intended to cover the provision of all of the six Health Homes services, as determined to be appropriate to meet the members needs. Reimbursement is $51.00 per member per month (PMPM).

12. Questions

13. Additional Information
Please refer to the BMS website for additional information about the Health Homes Program: The BMS website below will take you directly to the Health Homes Provider Application:

14. Contacts
Richard D. Ernest, Jr., MSW Programs Manager, BMS, Beverly Turpin Review Assistant – West Virginia Health Homes Program, KEPRO Caroline Duckworth, MSW LCSW Director – Socially Necessary Services, KEPRO KEPRO staff can be contacted by calling: or