WV Diabetes Health Home

One of the two Medicaid Health Home programs (i.e. Behavioral Health Health Home and Diabetes Health Home) designed to coordinate health care teams to provide the best care possible to patients living with chronic illnesses, with the goal of increasing provider-patient communication, improved patient health, and reducing excess costs within the health care system. The WV Department of Health and Human Resources began implementing the Diabetes Health Home in 2017 within 14 counties in West Virginia.

Eligibility

Eligible Counties

Boone
Cabell
Fayette
Kanawha
Lincoln
Logan
Mason
McDowell
Mercer
Mingo
Putnam
Raleigh
Wayne
Wyoming

Steps to enroll as a Diabetes Health Home

1. Identify core team members

Provider/Team Lead
- MD, DO or Advanced Practice Nurse

Behavioral Health Specialist
- Masters or doctoral level
- Licensed in counseling, psychology or social work

Nurse
- RN

Care Manager
- RN or behavioral health specialist

Care Coordinator
- Bachelor’s level
- Social science with some applicable patient care or counseling experience

1. Identify eligible patients

Medicaid patients who have been diagnosed with pre-diabetes, diabetes or obesity, as well as being at risk for anxiety or depression, who receive services from a provider in an eligible county (see map above).

5. Document patient care coordination.

Document patient care coordination (document in either EHR or KeyPro). See page 7 in the

Health Home Provider Standards PDF.

2. Enroll patients

The Diabetes Health Home is an opt-out consent process meaning that Health Home providers can auto-enroll eligible patients in Health Home. Patients will then have the option to opt out at any point.

6. Invoice for service-$51 per month per patient

3. Provide required Health Home services

For each patient enrolled in Health Home provide:

Comprehensive care management
Care coordination
Health promotion
Comprehensive transitional care and follow-up
Patient and family support
Referral to community and social support services

For more details, see pages 5-7 in the Health Home Provider Standards PDF.

7. Re-certify enrollees/patients in KeyPro every 4 months

Re-enroll patients in KeyPro every 4 months. Patients must still be eligible for Medicaid (as well as still at risk for anxiety/depression) to qualify for re-enrollment.