Health Homes for Professionals

Health Homes for Professionals

Have a patient struggling to follow up with their care? Refer them to our Health Homes program today!

What is Health Homes?

Health Homes is a free, voluntary care coordination program that helps promote and facilitate communication among all health care professionals involved in a patient’s care. Health Homes helps to make sure that all of a patient’s health, mental, and social services needs are met.

How do providers refer patients to Health Homes?

Health Homes clients must be:

  • on Medicaid
  • have at least two chronic conditions; or one serious mental illness; or HIV

How can Health Homes help patients? We will:

  • Assess and assist with psychosocial needs. This includes helping a patient find housing, entitlements, legal, education and community support services.
  • Give patients appointment reminders
  • Have staff accompany patients to appointments
  • Link patients to mental health and drug abuse services
  • Reach out to patient’s providers to discuss treatment plans
  • Help patients with hospital discharge and planning
  • Set up transportation to appointments if needed
  • Help patients avoid emergency room visits
  • Provide crisis intervention
  • Help patients navigate health and social services and link patients to providers
  • Include providers in a patient’s care plan goals
  • Give providers updates on a patient’s progress by phone and at appointments

A patient must have documentation of illness when they are referred to Health Homes.

If you want to refer a patient, call us at 1 (855) 246-4422.