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Health Home

Home-based, patient-centered care coordination services

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

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.

What is the Health Home Program?

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

Who is eligible for Health Home services?

Project Access Northwest has partnered with Coordinated Care to launch our pilot program in King and Snohomish counties. We are reaching out to Medicaid patients of all ages who are eligible for Health Home services. 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.

What are the goals of the program?

  • Bridge systems of care to improve the quality and coordination of care across systems
  • Reduce expenditures in the rising costs of health care
  • Increase patient engagement and confidence in self-management of health goals
  • Slow the progression of disease and disability

How does the program work?

  • Patients will receive a care coordinator who will partner with them, their families, doctors and other agencies to ensure that everyone is on the same treatment plan.
  • Care coordinators will assist in developing a patient-centered Health Action Plan to support each individual in achieving personal goals.
  • Patients will receive core services, including: comprehensive care management; care coordination so all providers are aware of the patient goals; health promotion, education and coaching; comprehensive transitional care and follow up; patient and family support; and referrals to community and social supports.
  • There is no specific end date for the program. Patients will receive services for as long as they remain engaged and maintain the same insurance coverage.

Where will services take place?

The Health Home care coordinators will provide in-person visits at the patient’s home or another convenient setting. They can meet patients in hospitals and clinics to ensure consistent care. Providing care coordination at the location where patients need it the most can help reduce barriers to services.

Why is Health Homes so valuable?

Patients who have participated in the Health Home Program in other parts of the state1 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.

While the program is new to Snohomish and King counties as of April 2017, Health Home programs have been operating in other counties throughout Washington state since 2013.


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