A Health Home Program or "HHP" is a program designed to serve Medi-Cal beneficiaries with complex medical needs and chronic conditions who may benefit from enhanced care management and coordination. The HHP coordinates the full range of physical health, behavioral health, and community-based long-term services and supports (LTSS) needed by eligible beneficiaries.

The HHP provides six core services:

• Comprehensive care management
• Care coordination (physical health, behavioral health, community-based long-term services and supports "LTSS")
• Health promotion
• Comprehensive transitional care
• Individual and family support
• Referral to community and social support services, including housing

What will you gain as a member of the HHP?

You will have a personalized care team – including a Care Coordinator – that works together to help you get the care you need. 

Your care team and Care Coordinator will work with you to develop an individualized Health Action Plan (HAP). A HAP will help you to meet your goals and objectives in hopes of better overall health and wellness. 

You receive extra services at no cost as part of your Medi-Cal benefits, including help with:

• Making and following-through with appointments
• Transportation to-and-from doctors appointments
• Understanding your prescription medications
• Medication reminders
• Getting follow-up services after you leave the hospital
• Connecting to and applying for community programs and services, including food benefits and housing

Who qualifies for the HHP? 

To be eligible for HHP services, patients must meet the following requirements

• Be enrolled in a Medi-Cal health plan
• Have certain chronic conditions that are determined by ICD-10 codes. Including at least 1 of the boxes below:
  
• At least 2 of the following: Chronic obstructive pulmonary disease (COPD), diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver disease, chronic kidney disease, dementia, or substance use disorders
  
• Hypertension (high blood pressure) and 1 of the following: COPD, diabetes, coronary artery disease, or chronic or congestive heart failure
  
• 1 of the following: Major depression disorders, bipolar disorder, or psychotic disorders (including schizophrenia)
  
• Asthma

• Meets at least one acuity or complexity criteria. The member can check at least 1 box below: 
  
• Has 3 or more of the HHP-eligible chronic conditions
• Had at least 1 inpatient hospital stay in the last year
  
• Had 3 or more emergency department visits in the last year
  
• Is experiencing chronic homelessness 
  

For more general information regarding the Health Home Program, please view the following documents:

1. English: HHP Member Toolkit
2. Spanish: Caja De Herramientas Para El Miembro

For more information regarding CNCHC's Health Home Program, please contact Amanda Granados: (213)-610-5131. Thank you!