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
Chronic Condition Health Home Brochure
Iowa Medicaid Chronic Condition Health Home Provider List
Chronic Condition Health Home Program Executive Summary
Map of Chronic Condition Health Home Participating Counties
LEARNING COLLABORATIVE TOPICS & ACTIVITIES
A list of 2023 topics for learning collaborative webinars can be found here.
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 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 or call 515-974-3050. To enroll complete the forms below and email them to Healthhomes@dhs.state.ia.us. 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. This agreement outlines the expectations of the health home.
Complete the Provider Application
If you have not already achieved Health Home recognition or accreditation, complete the TransforMED Self-Assessment 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, 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 (Effective January 1, 2022)
Chronic Condition Health Home Billing Guidance
Chronic Condition Health Home State Plan Amendment (SPA)
Chronic Condition Health Homes July 2020
Guide for Chronic Condition Health Home Services
Chronic Condition Health Home Program Toolkit
Health Home Learning Collaborative: PTAT and Enrollment
Health Homes Managed Care Organizations Notification
Health Homes Managed Care Organizations Notification Guide
Patient Tier Assignment Tool (PTAT)
Expanded Diagnosis Clusters (EDCs) are groupings of diagnostic codes that describe the same or related condition. This payment methodology from Johns 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)
Eligibility and Verification Information System (ELVS)
Learning Collaborative Webinar Archive:
Webinars were created by MCOs and IME.
Health Home Learning Collaborative: Transitional Care
Health Home Learning Collaborative: Member Benefits and Community Resources
Mom's Meals Referral Form
Health Home Learning Collaborative: Grievance, Appeals, Member Rights, and Guardianship
Health Home Learning Collaborative: Person-Centered Planning Philosophy
Health Home Learning Collaborative: Incorporating Specialist's Plan of Care
Health Home Learning Collaborative: Assessment Process
Health Home Learning Collaborative: Transitions in Care
Fillable Transition Guidebook
Health Home Learning Collaborative: Benefits of Health Homes/Interventions for members with SMI/SED
Health Home Learning Collaborative: Health Home Core Services and Roles
Health Home Learning Collaborative: How to collect your own data/measure your own performance
Health Home Learning Collaborative: Creating & Maintaining Relationships with Guardians & Providers
2021 Guardians Schedule of Fees
Info Sheet-OPG Application Process
Health Home Learning Collaborative: NCQA PCMH: Care Management
Health Home Learning Collaborative: Substance Use Disorder
Health Home Learning Collaborative: Understanding Health Coach Training
CCHH Person-Centered Planning Annual Review of Requirements
Health Home Learning Collaborative: Population Health Risk Stratification
Health Home Learning Collaborative: Value Added Benefits
Health Home Learning Collaborative: Quality Improvement Final
Health Home Learning Collaborative: Member Employment Resources
Making the Behavioral and Physical Healthcare Marriage Work
Enroll Disenroll Change in Status Matrix
Change in Status and Disenrollment
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)
P.O. Box 36450
Des Moines, IA IA 50315
MCO Provider-Specific Contact Information
Managed Care Organization
Provider-Specific Contact Information
Amerigroup Iowa, Inc.
Iowa Total Care
Molina Healthcare of Iowa
Operating Hours: 7:30 AM to 6:00 PM, Monday to Friday
To view member-specific contact information, please go to MCO Member-Specific Contact Information.