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Beginning January 1, 2012, Missouri began providing “Health Homes” to Missourians who are Medicaid eligible participants with chronic illnesses. With the assistance of consultants funded by Missouri Foundation for Health, the State has collaborated with the Missouri Primary Care Association (PCA), the Missouri Coalition of Community Mental Health Centers (CMHC) and various stakeholders to develop a Health Home model for Missouri.


Dr. Joe Parks, medical director for Missouri’s Department of Mental Health, notes that the mentally ill have particular difficulty in obtaining integrated care. “Persons with serious mental illness and multiple chronic medical conditions often have many, many different healthcare providers and take many, different medications,” notes Parks. “Without care managers using data analytic tracking to find and address care gaps, there is no way to assure that they get high-quality health care that keeps them out of the ER and hospital and in their communities.”

What is a Health Home?


The Health Home is an alternative approach to the delivery of health care services that promises better patient experiences and better results than traditional care. The Health Home has many characteristics of the Patient-Centered Medical Home, but is customized to meet the specific needs of low-income patients with chronic medical conditions.

What are the components of Health Homes?


  • Comprehensive care management

  • Care coordination and health promotion

  • Comprehensive transitional care including follow-up from inpatient and other settings

  • Patient and family support

  • Referral to community and support services

  • Use of health information technology to link services

What are the goals of the Health Home Initiative?


  • Implement and evaluate the Health Home model as a way to achieve accessible, high-quality primary health care and behavioral health care.

  • Demonstrate cost-effectiveness in order to justify and support the sustainability and spread of the model.

  • Support primary care and behavioral care practice sites by increasing available resources and improving care coordination to result in improved quality of clinician work life and patient outcomes.

  • Missouri will use this initiative to reduce inpatient hospitalization and emergency room visits, enhance the amount of primary care nurse liaison staffing available at community mental health centers, add primary care physician consultation, and enhance the State’s ability to provide transitional care between institutions in the community.

Who is eligible to be served in by a Health Home?


  • Persons covered by MO HealthNet, including those covered through MO HealthNet’s managed care plans

  • Persons with 2 chronic conditions

  • Persons with 1 chronic condition who are also at risk for a 2nd chronic condition, and/or

  • Persons who have 1 serious and persistent mental health condition

What chronic conditions qualify?


  • Serious Mental Health Condition

  • Asthma

  • Substance Abuse Disorders

  • Diabetes

  • Cardiovascular Disease – including hypertension

  • Overweight (BMI>25)

  • Developmental Disabilities

  • Smoking or Diabetes*


*Qualifies a person for being at risk of having a second chronic condition

For more information on Healthcare Homes, please visit the Department of Mental Health's Website at

Healthcare Home Documents

CMHC Healthcare Home Contacts​

Paving the Way for Healthcare Homes


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