The Health Homes Program is Happening Across California

Originally published by Harbage Consulting (July 7, 2018)


On July 1, 2018, the California Medicaid program launched its Health Homes Program, which provides a new set of health care services at no cost to beneficiaries with certain chronic health conditions and/or a serious mental illness. San Francisco County is the first county to roll-out the program, with 28 other counties implementing in two phases over the next year. California joins 22 states and the District of Columbia in operating health home initiatives – in total there are 34 initiatives underway, as some states have designed health homes for more than one target population.


The goal of the California Health Homes Program is to coordinate and promote access to the full range of physical health, behavioral health, and social services for Medi-Cal (California’s Medicaid program) beneficiaries with complex needs and empower them to play an active role in their own care.


Medi-Cal managed care plans are leading the development and implementation of the Health Homes Program. The plans contract with community health care providers, known as Community Based Care Management Entities (CB-CMEs), to engage eligible Medi-Cal patients and provide health homes services.


Target Populations


To qualify for the Health Homes Program, Medi-Cal beneficiaries must:

  • Be enrolled in a Medi-Cal managed care plan;

  • Have certain chronic health conditions (e.g. asthma, diabetes, kidney or liver disease, heart failure, etc.); and

  • Meet certain acuity criteria (e.g. have had emergency room visits, hospital stays, or be chronically homeless).

In January 2019, the program will expand to include Medi-Cal beneficiaries with a serious mental illness.


Medi-Cal health plans contact the members who qualify for the Health Homes Program and connect them with a community provider to deliver the services. Health care providers can also refer patients to the health plan to see if they qualify. Joining the program does not take away or change any of the person’s Medi-Cal benefits.


Core Services


People who join the Health Homes Program are assigned a care team – including a care coordinator – that works together to help them get the health care and social services they need. The care team is composed of the person’s current and new health care providers, as well as case managers or others from community organization that serve the patient. A key focus of the HHP is connecting people who are experiencing homelessness with housing supports.


The Health Homes Program provides access to six core services:

  • Develop and maintain a Health Action Plan to help them meet their health care goals and stay healthy;

  • Keep all providers coordinated and up-to-date about members’ health care needs and the services they receive;

  • Provide information and tools to inform people and their family members on the best ways to manage health conditions;

  • Help people move safely and easily between different care settings, such as entering or leaving a hospital or nursing facility and returning to their own home;

  • Include family or friends on the care team if the person chooses, so they have up-to-date information on their conditions and ways to support them; and

  • Help people find and apply for needed community and social services, including housing.

My Role


On behalf of Harbage Consulting, Bethany Snyder worked with the California Department of Health Care Services (DHCS) to design and execute a comprehensive engagement, education, and communications strategy to support implementation of the HHP. Bethany led the Harbage Health Homes team as they developed strategies, materials, and messages for a range of stakeholders including managed care plans, health care providers, Medi-Cal beneficiaries, and community-based organizations.


These materials include a Member Toolkit, a Provider Guide, and a fact sheet for health plans to use to educate their members and community providers on the program. We also have outreach staff on the ground in the counties that are connecting directly with participating providers, beneficiaries, and community-based organizations. Additionally, we supported the development of a Program Guide, which identifies the HHP requirements.


I will continue to follow DHCS' implementation of the Health Homes Program and its transformation of how medical and social service providers work together to ensure that the most vulnerable Medicaid beneficiaries have access to the care and support they need.

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