People with Chronic Conditions

  • New Mexico

    In 2009, New Mexico unanimously enacted Chapter 143 of the 2009 Laws, intended to provide medical homes for members of the state's Medicaid, Children's Health Insurance Program (CHIP), and State Coverage Initiative (SCI) program. SCI is a public-private managed care program in New Mexico that targets low-income adults without insurance working for small employers. The statute directs the New Mexico Human Services Department to apply for a waiver or state plan amendment to implement a medical home program, and to work with managed care contractors to "promote, and if practicable, develop” a medical home program.
    Participating SALUD! managed care organizations (MCOs) are providing grants to a small number of primary care practices in the state with the goal of achieving NCQA PCMH certification. Initial estimates indicate that over 45,000 members are participating in PCMH delivery models through the SALUD! medical home pilots.
    New Mexico Medicaid is focusing on four main objectives:
  • Transforming the Workforce to Provide Better Chronic Care: The Role of Registered Nurses

    Check for NEW briefs below.

    Susan Reinhard, AARP Public Policy Institute
    Mary Takach, Senior Program Director
    Rachel Yalowich, Policy Analyst

    This series explores the evolution of primary care systems to better meet the needs of consumers with complex health conditions. It demonstrates that changes in the workforce are required to empower consumers to better manage their health.

    The series is a collaboration of the National Academy for State Health Policy and the AARP Public Policy Institute. We recognize that it takes a team of skilled professionals to deliver improved chronic care. In this series, we focus on how registered nurses—who make up the largest segment of the health care workforce—are being deployed in ambulatory delivery systems to take on new roles. Future series will focus on other members of the health care team.

  • Michigan

    Michigan’s medical home activity began with a 2008-2010 Improving Performance in Practice (IPIP) program sponsored by the Michigan Primary Care Consortium (MPCC), which combined learning sessions with coaching to implement components of PCMH and chronic illness care. MPCC has also created a patient-centered medical home toolkit.
  • Louisiana

    Act 243 of the 2007 Regular Legislative Session, known as the Health Care Reform Act of 2007, directed the state to develop and implement a medical home system of care called Louisiana Health First. The law further stipulated that the medical home system incorporate health information technology (HIT) and quality measures to increase access, improve quality, and provide sustainability in medical care for the Medicaid and low-income uninsured populations.  However, the Centers for Medicare & Medicaid Services (CMS) did not approve the Louisiana Health First Section 1115 waiver required to implement the program. Act 243 of the 2007 Regular Legislative Session required the Louisiana Department of Health and Hospitals (DHH) to implement the legislation as feasible if CMS did not approve the waiver.
  • Hawaii

    In May 2011, Hawaii Governor Neil Abercrombie announced his administration’s intent to secure medical homes for Hawaii’s 270,000 Med-QUEST (Medicaid) beneficiaries. Integrating behavioral health and social services with primary care will be a major goal of the state’s medical home efforts. 
    Hawaii is currently working to develop and obtain approval for a health homes state plan amendment (SPA). A State Plan Option Collaborative has been meeting to select chronic conditions to focus on, define what “health home” will mean in Hawaii, reach consensus on culturally competent health home service definitions, agree on a payment methodology, and identify key measures to track. The state is now carrying out a workplan for developing the health homes SPA.
  • Connecticut

    In January 2012, Connecticut introduced a person-centered medical home (PCMH) initiative within their redesigned HUSKY Health program. Under this initiative, Connecticut Medicaid provides new payment incentives to practices and clinics that demonstrate a higher standard of person-centered medical care. In order to receive enhanced payments for medical home services, providers must be an active licensed physician, nurse practitioner or physician’s assistant specializing in general internal medicine, geriatrics, family medicine or general pediatrics that functions as a primary care provider for a set panel of patients. Furthermore, primary care must account for 60 percent of the practitioner’s time across all payers.  
  • Tennessee

    We have no information on medical home activity that meets the following criteria: (1) program implementation (or major expansion or improvement) in 2006 or later; (2) Medicaid or CHIP agency participation (not necessarily leadership); (3) explicitly intended to advance medical homes for Medicaid or CHIP participants; and (4) evidence of commitment, such as workgroups, legislation, executive orders, or dedicated staff.
    Federal Support: Tennessee has received a duals demonstration grant from the Centers for Medicare & Medicaid Services (CMS) to “coordinate care across primary, acute, behavioral health and long-term supports and services for dual eligible individuals.”
    Last updated: June 2013
  • Washington

    Washington State has pursued multiple efforts to advance medical homes:
  • Colorado

    Colorado’s medical home efforts began in 2001 with the Colorado Medical Home Initiative (CMHI). This program, administered by the state’s Department of Public Health and Environment (CDPHE), was charged with ensuring that all children receive comprehensive coordinated care within a Medical Home. Chapter 346 of the 2007 Session Laws of Colorado required the Department of Health Care Policy & Financing (HCPF), the state agency that administers the Medicaid and SCHIP programs, to work with CDPHE to maximize the number of children served by medical homes in Medicaid and SCHIP. A non-profit organization known as the Colorado Children's Healthcare Access Program (CCHAP) also works collaboratively with state agencies in the Medical Homes for Children Program
  • Georgia

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