Health Home care coordinators help develop patient-centered Health Action Plans to support patients in achieving their goals.

Project Access Northwest has launched its newest care coordination effort, the Health Home Program, which provides intensive, home-based, care coordination services for individuals with one or more chronic conditions. Through in-person visits at patient homes or other convenient settings, Health Home care coordinators help develop patient-centered Health Action Plans to support each individual in achieving personal goals.

Project Access Northwest has launched its newest care coordination effort, the Health Home Program, which provides intensive, home-based, care coordination services for individuals with one or more chronic conditions. Health Home services are covered by Washington state’s Medicaid program and are designed to address complex health issues through a “whole-person” approach.

“It’s a perfect, natural fit for us and our patient-centered approach,” explains Executive Director Sallie Neillie. “The Health Home Program allows us to reach patients at home and meet them where they are — emotionally, spiritually, physically — to help improve their health and their lives based on their personal goals. It’s like putting on steroids everything we’ve always done, continuing our patient-centered approach that supports using the health care system efficiently.”

Our Health Home care coordinators provide in-person visits at our patient’s home or another convenient setting and help develop a patient-centered Health Action Plan to support each individual in achieving personal goals. These goals can be health-related or lifestyle-related, such as being able to cook a meal independently. Patients will receive a wide variety of services to support their goals, including comprehensive care management, care coordination, health education and coaching, transitional care and follow-up, and referrals to community and social supports, so they know where to find services that meet their needs. While one patient may need a wheelchair ramp built at home to increase mobility, another may need help managing medications or understanding a doctor’s instructions. Our Care Coordinators will help identify and eliminate these barriers to care.

Our pilot partner: Coordinated Care

Project Access Northwest has partnered with Coordinated Care to launch our pilot Health Home Program in King and Snohomish counties. While Health Home programs have been operating in other counties throughout Washington state since 2013, the program is new to Snohomish and King counties in April 2017.

Coordinated Care reached out to Project Access Northwest because of its proven track record in care coordination. Together, we will work to identify and contact Coordinated Care patients who qualify for the new Health Home benefit. Typically, patients will have at least one significant chronic medical condition or a serious mental health condition, and be at increased risk for future medical needs. Once identified, these patients will work with a care coordinator who will partner with them, their families, doctors and other agencies to ensure that everyone is on the same treatment plan. Patients will receive services for as long as they need and are moving forward in their goals.

Ambitious goals

The Health Home Program is designed to: improve the quality and coordination of care across systems; increase patient engagement and confidence in self-management of health goals; slow the progression of disease and disability; and reduce expenditures in the rising costs of care.

Encouraging results ​

Patients who have participated in the Health Home Program in other parts of the state report significant improvement in health or quality of life, as well as appreciation for the role of their care coordinator. Initial studies demonstrate significant health care savings as well, as patients receive the right level of care at the right time.