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Health Homes and Neighborhoods

Also known as the patient-centered medical home, the Person-Centered Healthcare Home is a relatively new model gaining momentum throughout the country for its potential to advance both quality health care and cost-effectiveness. Many states are implementing health homes for persons with complex chronic conditions, including serious mental illness and behavioral health issues, as a strategy to improve the patient experience and health care outcomes as well as reduce costs.  By wrapping health and social services around medically complex Medicaid/Medicaid beneficiaries and improving care coordination, states, health plans and provider systems intend to demonstrate reduced hospitalizations, emergency room use and avoidable admissions.

In 2007, several medical associations issued the Joint Principles of Patient-Centered Medical Homes which set forth standards governing these new organizations, including: on-going client relationship with a personal physician; physician-directed multi-disciplinary team to provide services; whole person orientation; coordinated care; outcomes-oriented and evidenced-based treatment; enhanced access to treatment; and reimbursement commensurate with the services offered. In 2008, The Commonwealth Fund, in concert with other organizations, initiated a five-year demonstration project to help primary care safety net sites become high-performing patient-centered medical homes.

Additional information can be found at the NCQA Patient-Centered Medical Home and the Patient Centered Medical Home Resource Center websites. Missouri’s Primary Care Practice Health Homes website provides descriptions, flow charts, MOU’s and other valuable information. The Integrated Care Resource Center provides technical assistance to state Medicaid agencies that seek to amend their Medicaid plan to implement Health Homes for chronic conditions. Their resource library contains much useful information health home design and implementation.

As the 2013 IBHP paper “Health Reform and Transformation of the Delivery of Care” points out, while there is considerable information available on the subject of health reform, widespread transmission of it is vitally needed.  IBHP’s survey of 590 physical and behavioral health providers and students found that over half had “limited” or “no knowledge” of important aspects of health reform such as patient eligibility, population health management and performance incentives.

The State of California has submitted an application to CMH to develop a 2703 Health Home pilot, an innovation of the Affordable Care Act.  California seeks to tie the health home pilot initiative together with its Center for Medicaid and Medicare-funded State Innovation Plan.  Click here to access the Califiornia Department of Health Care Services planning documents.  Other documents related to the State’s application can be found here.

Health Neighborhoods

Systems integration is being achieved in some localities by focusing on health neighborhoods.  Communities are defining and implementing health neighborhoods differently around the country.   They can be defined by geography, population or a virtual approach using data systems to aggregate information.  In seeking to address whole health needs, public systems are particularly seeking new approaches for individuals and communities with high incidence of co-occurring medical, mental health and/or substance abuse issues. Addressing adverse social factors is critical to improving outcomes for these high need individuals, and thus the integration of social services, housing and health is very important.

Agency for Healthcare Research and Quality’s (AHRQ) paper on “Coordinating Care in the Medical Neighborhood”  describes the concept, key features, desired outcomes, operations, barriers to overcome and tools for planning a health neighborhood.  The California Endowment launched its statewide “Building Healthy Communities Initiative” to address the social determinants of health in 14 communities throughout California.  This initiative is committed to achieving “4 Big Results”:  creating health homes for all children; reversing the childhood obesity epidemic; increasing school attendance; and reducing youth violence.

Los Angeles County has become a hot bed of health neighborhood planning.  The County is pursuing a Health Neighborhood pilot to develop health neighborhoods in 5-7 locations in 2015.  The Blue Shield Foundation has awarded LA Care Health Plan a planning grant to develop a Health Neighborhood Joint Planning Collaborative that will complement Los Angeles County’s pilots.  IBHP, this website’s host, has been selected as the facilitator for this planning project.

Listed below are just a few of the myriad papers and reports centering on healthcare homes:

Integrating Mental Health Into The Healthcare Home / Behavioral Health Organizations