Health Homes

A health home provides extra support for people who need a greater level of care coordination or who face particular difficulty navigating the health care system. That includes people with developmental disabilities, people with mental health needs and those living in long term care facilities, for whom ordinary arrangements often fall short.

What a health home is for

The aim is high-quality care, a better patient experience and more efficient use of resources for people whose needs are complex. A health home works because someone takes responsibility for seeing that the different parts of a person's care fit together, rather than leaving that coordination to the patient or the family.

Providers taking part are responsible for considering their patients' needs proactively, whether or not the patient is currently seeking care. That is a deliberate shift away from reacting only when a problem is presented, and it is why the model suits people whose needs can go unnoticed between episodes of illness.

A hub rather than a gate

A health home is not a gatekeeper for medical care. It is described instead as a hub from which the patient can connect with the full array of providers who together make up that person's health services team, so that access to specialist and other care is supported rather than restricted.

That framing matters for behavioural health, developmental disability and long term services and supports, where care often involves several organisations. A hub that keeps the parts connected can make the difference between a coherent plan and a series of disconnected encounters.

Incentives for wellness

Providers receive incentives for promoting wellness and for achieving health outcomes, which ties the model to results rather than to the volume of care delivered. The incentives are intended to reward the proactive work that good coordination requires but that ordinary payment arrangements often ignore.

Because the incentives depend on outcomes, a health home has a reason to keep track of whether its patients are actually doing better, and to adjust its approach when they are not. That is the same logic that runs through the rest of the payment improvement initiative.

Where health homes fit

Health homes sit alongside episodes of care and patient centered medical homes as part of the state's wider effort to change how care is organised and paid for. They address a group of patients whose needs the other models do not fully reach on their own.

The programme has developed its approach to behavioural health, developmental disabilities and long term services and supports through workgroups and public documents, and the details continue to be set out in the programme's official materials.

Coordination is the heart of the model. For a patient who moves between behavioural health, developmental disability and long term care services, the risk is that no single organisation sees the whole picture. A health home is intended to hold that picture, so that a change in one part of a person's care is known to the others and a plan is followed rather than repeated. The incentives for wellness and outcomes give the health home a reason to keep that picture current rather than treating each contact as a separate transaction.

What a health home offers

• Extra support for people needing more care coordination.
• A single point from which the patient's care team connects.
• Proactive attention to needs between episodes of care.
• Incentives for promoting wellness and achieving outcomes.
• A route to care for behavioural health and developmental disability needs.
• A model suited to people in long term services and supports.

Health home focus areas

Health home arrangements are set and updated by the programme, and eligibility and payment details can change. Providers and families should confirm current arrangements in the official programme materials and with the responsible state agency.