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Health Homes is a program where care coordinators provide long-term support for seriously ill individuals, ones with broad and complex medical and other needs.

Refer an individual to Health Homes


Wraparound Care for High-Risk Individuals

Health Homes helps vulnerable adults and children navigate and access the larger ecosystem of care more efficiently. As a result, hospitals can focus their resources on patients who need hospital-level services the most.

Individuals meet the following criteria:

  • Be a hospital readmission risk because of a chronic illness and/or a mental health challenge
  • Received a high score on PRISM (Predictive Risk Intelligence System), a tool used by the Washington State Health Care Authority

Health Homes are not physical spaces but rather a program initially designed to help qualified recipients access the spectrum of services they need to achieve and maintain whole person health. Our goal is to provide access to a broader ecosystem of medical and social services for at-risk individuals who may face hospital readmission.

Health Homes care coordinators assess and help address not only an individual’s medical and behavioral needs—such as diabetes check-ups or substance-use counseling—but also social determinants of health: the conditions in which people live, work and play. Coordinators and individuals work together to create a goal-driven plan meeting an individual’s medical, behavioral and social needs.


Meet the Team

At Elevate Health, we work with our partners to provide Medicaid and Medicare beneficiaries in Pierce County with Health Homes support. This team includes:

The Washington State Health Care Authority (HCA)
The Washington State Health Care Authority (HCA) gathers data on potential clients, assesses their need for the Health Homes program, and shares their contact information with Elevate Health. The HCA also reimburses care coordination organizations (CCOs) for services provided to clients.

Care Coordination Organizations (CCO)
CCOs contract with Elevate Health to administer Health Homes care coordination services. In collaboration with Elevate Health, our partners, hire, train and supervise care coordinators within their respective organizations. Our contracted CCOs include health systems, clinics, providers and community-based organizations, among others.

Care Coordinators
The coordinators — possessing either strong cultural competencies or a degree in social work, health or public health — provide clients with comprehensive care management, coordination and support. They serve as a navigator between the worlds of medical and social services, and help individuals develop and follow a health action plan.

Elevate Health
As a lead Health Homes organization, we receive client eligibility lists from the HCA, distribute these lists to our CCOs for client outreach and service engagement, help process billing and reimbursement for our CCOs, provide quality control and assurance to compliance, and manage state reporting requirements. We also input Health Homes’ data into the Community Data Trust, using secure, HIPAA-compliant and HITRUST processes to monitor and guide member enrollment, needs, and engagement. The community-governed data collective ingests and encrypts data from multiple sources – such as criminal justice, tribal, education and human services agencies – thus serving as a central resource to assess whole-person health and address community health challenges.


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

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

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