Health Homes

What is a Health Home?
A Health Home is not a place. It is a set of care coordination services.

What is the Health Homes Program?
The Health Homes Program provides a skilled care coordinator to help individuals who face challenges related to chronic and complicated health problems be less overwhelmed and receive better and more effective care.

Click link to view Health Homes PowerPoint presentation.

Who is eligible to receive Health Home services?
Eligible individuals are those with chronic illnesses who are eligible for Medicaid or both Medicare and Medicaid who are also at significant risk for health problems that can lead to unnecessary use of hospitals, emergency rooms, and other expensive institutional settings such as psychiatric hospitals and nursing homes. Washington uses a predictive risk modeling system called PRISM to identify individuals who are at significant risk.

What kinds of supports are provided to individuals receiving Health Home services?
Individuals receiving Health Home services are assigned a Health Home care coordinator who will partner with eligible individuals, their families, doctors, mental health providers, chemical dependency services, long-term services and supports and other agencies to ensure coordination across these systems of care. In addition, the health home coordinator will make in-person visits and be available by telephone to help the individual, their families, and service providers to:

  • Conduct screenings to identify health risks and referral needs
  • Set goals that will improve beneficiaries’ health and service access
  • Improve management of health conditions through education and coaching
  • Make changes to improve beneficiaries’ ability to function in their home and community and their self-care abilities
  • Access the right care, at the right time and place
  • Successfully transition from hospital to other settings and get necessary follow-up care
  • Reduce avoidable health care costs

How do people access Health Home services?
Referrals for individuals who meet the risk modeling criteria (PRISM) are generated by the Health Care Authority (HCA) and sent to local Care Coordination Organizations (CCOs). The CCOs then reach out to the individuals to offer Health Home services.

To inquire about eligibility please contact Community Programs at 360-738-2500 or 800-585-6749 or e-mail inquiries to

For more information about Health Homes please visit: