Chronic Condition Health Home Overview:

Chronic Condition Health Home is an Iowa Medicaid program. The goal is to target members with chronic conditions, engage them in their health, coordinate their care and show improved health outcomes. The Chronic Condition Health Home program provides primary care delivered through a patient-centered medical home (PCMH) model.   

Benefits for Providers

• Providers can practice more proactive, coordinated care that they want to provide, because of a new reimbursement structure.
• More opportunities to track, coach and engage the patient’s.
• Improved communication and coordination for better patient outcomes
• Improved utilization of health information technology

Benefits for Patients

• Better coordination and management of their often complicated and complex care.
• Help navigating multiple systems
• More engagement in their own care
• Access to a wider range of services 

The medical home approach to the delivery of primary care is:

• Patient-centered: A partnership among practitioners, patients, and their families ensures that decisions respect patients’ wants, needs, and preferences, and that patients have the education and support they need to make decisions and participate in their own care.
• Comprehensive: A team of care providers is wholly accountable for a patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care.
• Coordinated: Care is organized across all elements of the broader health care system, including specialty care, hospitals, home health care, community services and supports.
• Accessible: Patients are able to access services with shorter waiting times, "after hours" care, 24/7 electronic or telephone access and strong communication through health IT innovations.
• Committed to quality and safety: Clinicians and staff enhance quality improvement through the use of health IT and other tools to ensure that patients and families make informed decisions about their health.

Enroll as a Chronic Condition Health Home Provider

We are excited to have you as part of our Health Home Program. A potential participation call is available for clinics that are interested. Contact Joyce Vance at Healthhomes@dhs.state.ia.us [1] or call 515-974-3050. To enroll complete the forms below and email them to Healthhomes@dhs.state.ia.us [1]. Once the forms are processed there will be a call with your team to assist with the success of the program.

• Read and understand the Health Home Provider Agreement [6]. This agreement outlines the expectations of the health home. 
• Complete the Provider Application [7]
• If you have not already achieved Health Home recognition or accreditation, complete the TransforMed Self-Assessment  [8]to identify at a high level where you are at in medical home transformation. 
• Identify your EMR, Health Home locations and practitioners on form # 470-5131 [9].

Providers must meet standards outlined by the State and seek patient centered medical home (PCMH) Recognition or Accreditation within 12 months of enrolling in the program. To facilitate a team-based, community focused approach, providers participating as a Health Home must connect to the Iowa Health Information Network (IHIN). 

Chronic Condition Health Home Standards:

There are requirements to be met, called Health Home Standards [10], to be able to participate in the Health Home Program. Minimum requirements listed below:

• Use some form of a Patient Registry
• Electronic Health Record (EHR)
• Agree to participate in the Iowa Health Information Network
• Dedicated care coordinators
• Expanded hours for access
• Alternative means to communicate with patients and get them engaged, such as email, personal health records, reminders, etc.
• On the path to PCMH recognition or certification

Chronic Condition Health Home Tools for Providers: 

Patient Tier Assessment Tool (PTAT)

• PTAT Guide [13]
• PTAT Tool [14]

Expanded Diagnosis Clusters [15] (EDCs) are groupings of diagnostic codes that describe the same or related condition. This payment methodology from John Hopkins is used as a disease/condition marker to identify patients that are in need of health home services and the severity based on a tiering system. 

Iowa Medicaid Portal Access (IMPA)

• IMPA Access Form [16]
• IMPA  [17]
• I-MERS [18]
• Per Member Per Month (PMPM) Fee Schedule [19]

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