Washington Health Home Program


Addition of King and Snohomish Counties to the Health Homes Program

Beginning in 2017, HCA and DSHS will add Health Home care coordination services to King and Snohomish counties. This will result in statewide coverage, with Health Homes available in all 39 Washington counties. This addition is pending final approval of the State Plan Amendment by the Centers for Medicare and Medicaid Services (CMS).

Recorded information about implementation in the two counties and Health Home Program is available at: https://www.youtube.com/watch?v=HnfY8a_7Mcc

Recorded general information about Pediatric Health Homes can be viewed at:  https://www.youtube.com/watch?v=CMWH8lwB0OA&feature=youtu.be

Achieving Washington State's Vision of Integrated Services

The Department of Social and Health Services and the Health Care authority have been collaborating on the Health Home program with federal partners for over two years, and have received strong support from individuals, local health care providers, and advocates. It provides both intensive care coordination and comprehensive care management and has resulted in improved health outcomes and a reduction in service costs for some of Washington's highest-need individuals.

In Washington State Health Homes are available in all but two counties (King and Snohomish). To be eligible individuals of all ages receiving Medicaid, including those who also receive Medicare must:

  • have one or more chronic conditions such as diabetes, heart disease, or a mental health condition; and
  • be at risk for a second chronic condition, defined as having a predictive risk score of 1.5 or greater.

Health Homes seek to address complex health issues by offering:

  • comprehensive care management;
  • care coordination;
  • health promotion;
  • comprehensive transitional care and follow-up;
  • individual and family support; and
  • referral to community and social services support.

A key component Health Homes is an in depth assessment conducted by a Care Coordinator with the individual, resulting in the joint development of a health action plan.  The health action plan includes an evidence based tool that determines an individuals’ level of activation (knowledge, skill, and confidence for managing one’s health and health care) in addition to several risk assessment tools that evaluate potential health risks and quality of life.  All Care Coordinators receive intensive training on how to develop the health action plan and the six Health Home services.  The Care Coordinators work to reduce gaps in services and increase coordination of all service providers (medical, behavioral health, long-term services and supports and other social services). 

The goal of the health home program is to improve coordination of care, quality, and to increase an individual’s participation in their own care.  Health Homes have reduced Medicare inpatient hospital admission, avoidable emergency room visits, inpatient psychiatric admissions, and the need for nursing home admissions. 

Care Coordinators do not duplicate or replace services provided by Aging & Long-Term Support Administration or other Medicaid programs.    




Memorandum of Understanding with CMS

Complete 10.24.12

Application Requests for Geographical Roll


State Plan Amendment 

Approved - Phase 1

Final CMS Agreement 

Completed 06/28/2013

Geographical implementation and enrollment. See Health Home service area map.



For more information about the Health Homes Project

Karen Fitzharris, Project Director, 360.725.2254 or karen.digre-fitzharris@dshs.wa.gov.