Frequently Asked Questions

Health Homes is not a physical space. Rather, Health Homes is a service directed at improving the health care delivery system, and it is available to people of all ages.

Individuals who join the Health Homes program work with a care coordinator to assess and access services to meet their medical needs, behavioral health and substance-use challenges, and social determinants of health challenges (conditions such as employment status, language and access to food and housing) that may negatively affect their pursuit of whole person health, wellness, and quality of life.

Through regular meetings, discussions and planning — and through the development of a health action plan (HAP) — coordinators and individuals work together to address an individual’s medical, emotional and social needs. As a result, individuals receive tailored care with appropriate services, and hospitals are better able to focus on addressing acute medical conditions.

Health Homes is an optional state Medicaid plan benefit, and services are free. The Centers for Medicare and Medicaid Services (CMS) pay the costs for this service. However, individuals (both adults and children) must meet a few criteria:

• They must be eligible for Medicaid or Medicare/Medicaid.

• They must meet HCA risk criteria by means of a PRISM scoring (Predictive Risk Intelligence System), a tool used by the Washington State Health Care Authority to estimate healthcare costs for Medicaid recipients.

AND meet ONE of the following criteria:

• Two or more chronic conditions

• One chronic condition with risk of another

• A serious and persistent mental health condition

Once enrolled, a client may remain in the program as long as needed — their entire life, if they wish, so long as they are eligible for Medicaid or Medicare/Medicaid.

Health Homes partners are care coordination organizations (CCO). Contracted CCOs include health systems, clinics, providers and community-based organizations, among others.

The primary responsibilities of the CCO include hiring, training and supervising care coordinators, following Elevate Health’s billing processes and using a specific data platform for documentation and data collection. (Please note that this is a partial list.) In their turn, care coordinators are responsible for a minimum of one individual contact per month to fulfill any number of six key services:

• Comprehensive care management;

• Care coordination and health promotion;

• Comprehensive transitional care from inpatient to other settings, including appropriate follow-up;

• Individual and family support;

• Referral to community and social support services, if relevant; and

• The use of health information technology to link services, as feasible and appropriate.

To learn more about becoming a CCO, please contact Elevate Health at care@elevatehealth.org for more information.

Please contact care@elevatehealth.org to set up a pre-referral discussion.

If you or someone you know might benefit from non-emergent care coordination services, please contact us at care@elevatehealth.org or call the Care Continuum Network referral line at (253) 331-2380.

If you or someone you know if suffering a life-threatening medical or behavioral health emergency, please call 9-1-1 for immediate assistance.

If you or someone you know is experiencing a non-life-threatening but urgent mental health crisis, call one of these 24/7 crisis lines:

Pierce County Crisis Line: 800-576-7764

National Suicide Prevention Lifeline: 1-800-273-8255