Chronic Condition Health Home (for Providers)

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.

Health Home Happenings- Quarterly Newsletter [1]

Chronic Condition Health Home Brochure [2]

Iowa Medicaid Chronic Condition Health Home Provider List [3]

Chronic Condition Health Home Program Executive Summary [4]

Map of Chronic Condition Health Home Participating Counties [5]

Chronic Condition Health Home Learning Collaborative
Date:	September 13, 2022
Time:	(to come)
Location:	(to come)
Meeting Agenda:	Agenda (to come)
Meeting Materials:	Materials (to come)

Benefits for Providers

Providers can practice more proactive, coordinated care, because of a new reimbursement structure.
More opportunities to track and engage with patients.
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 the program manager at Healthhomes@dhs.state.ia.us [6] or call 515-974-3050. To enroll complete the forms below and email them to Healthhomes@dhs.state.ia.us [6]. 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 [7]. This agreement outlines the expectations of the health home.
Complete the Provider Application [8]
If you have not already achieved Health Home recognition or accreditation, complete the TransforMED Self-Assessment [9]to identify at a high level where you are at in medical home transformation.

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:

Tools were created by MCOs and IME.

Chronic Condition Health Home Billing Guidance [11] (Effective January 1, 2022)

Chronic Condition Health Home Billing Guidance [12]

Chronic Condition Health Home State Plan Amendment (SPA) [13]

Chronic Condition Health Homes July 2020 [14]

Guide for Chronic Condition Health Home Services [15]

Chronic Condition Health Home Program Toolkit [16]

Health Home Learning Collaborative: PTAT and Enrollment [17]

Health Homes Managed Care Organizations Notification [18]

Patient Tier Assignment Tool (PTAT)

PTAT Guide [19]
PTAT Tool [20]

Expanded Diagnosis Clusters [21] (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 [22]
IMPA [23]
IMPA Training [24]
Eligibility and Verification Information System (ELVS) [25]

Learning Collaborative Webinars:

Webinars were created by MCOs and IME.

CCHH Workgroup Learning Activities and Topics 2022 [26]

February 2022:

Health Home Learning Collaborative: Transitional Care
- Recording [27]
- Presentation [28]

December 2021:

Health Home Learning Collaborative: Member Benefits and Community Resources
- Recording [29]
- Presentation [30]
- Mom's Meals Referral Form [31]

November 2021:

Health Home Learning Collaborative: Grievance, Appeals, Member Rights, and Guardianship
- Recording [32]
- Presentation [33]

Health Home Learning Collaborative: Person-Centered Planning Philosophy
- Recording [34]
- Presentation [35]
Health Home Learning Collaborative: Incorporating Specialist's Plan of Care
- Recording [36]
- Presentation [37]
Health Home Learning Collaborative: Assessment Process
- Recording [38]
- Presentation [39]
Health Home Learning Collaborative: Transitions in Care
- Recording [40]
- Presentation [41]
- Fillable Transition Guidebook [42]
Health Home Learning Collaborative: Benefits of Health Homes/Interventions for members with SMI/SED
- Recording [43]
- Presentation [44]
Health Home Learning Collaborative: Health Home Core Services and Roles
- Recording [45]
- Presentation [46]
Health Home Learning Collaborative: How to collect your own data/measure your own performance
- Recording [47]
- Presentation [48]
Health Home Learning Collaborative: Creating & Maintaining Relationships with Guardians & Providers
- Recording [49]
- Presentation [50]
- 2021 Brochure [51]
- 2021 Guardians Schedule of Fees [52]
- Guardianship Application [53]
- Presentation [54]
- Info Sheet-OPG Application Process [55]
Health Home Learning Collaborative: NCQA PCMH: Care Management
- Recording [56]
- Presentation [57]
Health Home Learning Collaborative: Substance Use Disorder
- Recording [58]
- Presentation [59]
- Methamphetamine Studies [60]
Health Home Learning Collaborative: Understanding Health Coach Training
- Recording [61]
- Presentation [62]
CCHH Person-Centered Planning Annual Review of Requirements [63]
Health Home Learning Collaborative: Population Health Risk Stratification [64]
Health Home Learning Collaborative: Value Added Benefits [65]
Health Home Learning Collaborative: Quality Improvement Final [66]
Health Home Learning Collaborative: Member Employment Resources [67]
Making the Behavioral and Physical Healthcare Marriage Work [68]
Enroll Disenroll Change in Status Matrix [69]
Change in Status and Disenrollment [70]

Provider Services Contact Information

800-338-7909 Toll Free

515-256-4609 (Des Moines area)

(Monday to Friday from 8:00 a.m. to 5:00 p.m. Central Time)

Healthhomes@dhs.state.ia.us [6]

515-725-1155 (Fax)

Provider Services

P.O. Box 36450

Des Moines, IA IA 50315

MCO Provider-Specific Contact Information [71]

Managed Care Organization	Provider-Specific Contact Information
Amerigroup Iowa, Inc.	Email: iowamedicaid@amerigroup.com [72] Phone: 1-800-454-3730 Website: https://providers.amerigroup.com/ia [73]
Iowa Total Care	Phone: 1-833-404-1061 Website: https://www.iowatotalcare.com [74]

To view member-specific contact information, please go to MCO Member-Specific Contact Information [75].

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