In Iowa, many individuals with chronic health conditions no longer dread going to the doctor's office despite having serious problems like mental health conditions or substance use disorders, heart disease, asthma, hypertension, overweight, and diabetes. That's because they're part of Iowa's health home program and have access to a health coach.
"[One] doctor was talking about the difference he's seen in individual cases—people dropping eight pounds between each visit because their health coach is calling and asking how they can help, for example," said Project Director Marni Bussell, P.M.P., of Iowa Medicaid Enterprise.
Typically housed in primary care settings, Iowa's health home program focuses on Medicaid beneficiaries with two chronic conditions or one chronic condition and high risk of developing another. The state is hoping to receive approval of a second health home focused on adults with serious, persistent mental illness and children with serious emotional disturbances.
Before the program started, care was fragmented. "Behavioral health providers didn't talk to medical doctors, so each didn't know what medications the other was prescribing," Ms. Bussell explained. "The behavioral health office wouldn't realize someone had been to the emergency room for a diabetic episode." Plus, clients often had trouble getting appointments or understanding their treatment regimens.
Health homes remove such barriers. Each health home features a practitioner, care coordinator, and health coach who build ongoing relationships with individuals. Together they ensure that all of an individual's needs—whether physical, behavioral, or oral health—are met.
Convinced that data help staff focus their attention most effectively, the state uses disease registries to identify gaps in care. A care coordinator or health coach can check the diabetes registry, for instance, to see who still needs help controlling the disease and invite them to come in for care.
"Having the data in front of you ... is really the key to transforming how you deliver care," said Ms. Bussell. "You can't wait for the member to come to the door. You have to know which members need to get to the door."
For more information, visit Iowa Medicaid Enterprise's health home website .
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