Key Services provided by Health Home Care Providers

Health Home Care refers to the ongoing professional care provided by licensed personnel in a skilled nursing facility such as nursing homes or other long-term care facilities. A Health Home is no longer a place; rather it is a comprehensive care management service which involves better organization of clinical and medical care, better coordination of medical and social services, and gives better medical and behavioral health management. In fact the term “Health Home” is now used more often than “nursery.” Some communities are now calling this type of care home care, which saves the taxpayers’ money and the communities’ revenue by offering quality health and related services when hospitals are already in use for caregiving. The most common activities include but are not limited to maintenance of competency, assessment, improvement, and training of competence.

Health Promotion/Provision involves improving the health of the patient. This is accomplished by evaluating the current situation and reviewing the health promotion and provision plans/ procedures. They are then integrated with the patient’s needs, expectations and preferences, in the context of the patient’s recovery plan. Health Promotion/ Provision also involves providing education to the general public on nutritional and lifestyle advice to promote good health and well-being. It involves the coordination of community-based programs to promote preventative services as well as casualty care.

Eligibility Criteria. The most common eligibility criteria for entering a health home are Medicaid, Medicare and some private health insurance. However, there are certain conditions that cannot be met by these. For instance, Medicare does not cover chronic conditions. Similarly, private insurance does not cover medically necessary treatments and procedures for medically uninsured individuals.

Chronic Conditions. Health promotion and provision require that the patient be evaluated and treated for chronic conditions. Chronic conditions include Alzheimer’s disease, diabetes, HIV/AIDS, kidney disease, heart disease, cancer, stroke, asthma, chronic obstructive pulmonary disease, Parkinson’s disease, osteoporosis, Raynaud’s syndrome and any other physical or mental disease or impairment that has resulted in progressively disabling the person’s ability to participate in one or more of life’s daily activities. Some such disorders include chronic obstructive pulmonary disease, kidney disease, heart disease, cancer and AIDS. As these conditions cannot be diagnosed or treated, their management requires special considerations.

Comprehensive Care Management. Most health promotion and provision initiatives focus on promoting and maintaining optimal wellness through comprehensive care management. This includes assessment of risk factors and prophylaxis; implementation of treatment plans; maintenance of quality of life; establishment of goals and outcomes; establishment of a system to monitor and measure progress; and referrals to relevant medical professionals. All of these components require a comprehensive care management strategy. Such strategies are generally implemented at the family care coordination unit.

Family Care Management. The primary objective of family care management is to promote optimal well being of all family members, especially children. A family care manager shall facilitate transition from childhood to adulthood and assist with all aspects of transitional care for the patient. A family care manager also provides primary and ongoing medical care and assists families in the process of looking after their respective elders. Certain chronic medical conditions, alcohol and substance abuse, and certain physical conditions may require special consideration under the care of a family care manager.

Care Transition. Care transition involves arranging for consistent access to the various required home health care providers. The providers may come from a variety of sources including the family, friends, public and private organizations and agencies. Care transition facilitates consistent access to care by keeping track of care receipt and use by the various beneficiaries. Care Transition also involves ensuring appropriate use of medical equipment and supplies by the recipients. It also involves coordinating and encouraging changes in lifestyle of the patients.

Coordination. Coordination is an important part of the Health Home Care option. It involves establishing continuity in services between the various service partners. All health plan sponsors play an important role in coordination of care for their participants.

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