CHPW is one of several Medicaid Qualified Health Home Lead Entities (QHHL) selected by the state for the Health Home program in all Washington counties.

Medicaid Health Home Services

Our Health Home services will be provided by an established and growing network of care coordination organizations under CHPW for eligible members throughout Washington.

Health home services can be provided in primary care settings and through community-based organizations, depending on the particular care needs of an enrollee. Medicaid enrollees must meet certain clinical and cost criteria to qualify to receive for health home services. Criteria include having a cost profile in Medicaid that is around 50% higher than the average enrollee (i.e., PRISM score of 1.5 or greater).

The Health Home program, as outlined by Section 2703 of the 2010 Affordable Care Act, establishes “health home services” for Medicaid enrollees with complex conditions and high service needs. As defined by the Centers for Medicare and Medicaid Services (CMS), health home services include six specific services beyond usual clinical care, including:

  • Comprehensive care management
  • Care coordination and health promotion
  • Comprehensive transitional care and follow-up
  • Patient and family support
  • Referral to community and social support services
  • Use of information technology to link services

CHPW provides Health Home services for all Washington counties. See the Health Home area map for details on coverage areas.

Network of care coordination organizations deliver Health Home services statewide

Our care coordination organizations deliver Health Home services and include both community health centers and community-based organizations. Community-based organizations include but are not limited to the Area Agencies on Aging, behavioral health providers in the Behavioral Health Northwest statewide network, and the Washington Care Coordination Services Group. See link below to a list of CHPW’s community health centers and community-based organizations for each Health Home area.

Training and support for care coordination organizations

We provide online training and technical assistance to care coordination organizations statewide. Additionally, Care Coordinators who will provide Health Home services are required to take a two-day training developed by the Washington Health Care Authority (HCA) and Department of Social and Health Services (DSHS). These standardized trainings are offered across the state. Sign up now as sessions fill up quickly!

Please contact, to discuss training needs and opportunities. 

We partner with WSHA to provide training for comprehensive transitional care and follow-up

Care coordination and follow-up after hospitalization is one of the key Health Home services in reducing costs and assuring a safe and effective hospital discharge. Current research shows that around 20 percent of patients in the U.S. are re-hospitalized within 30 days of discharge, and many researchers believe that this percentage is even higher for Medicaid patients. 

CHPW partners with the Washington State Hospital Association and other organizations to support implementation of WSHA’s toolkit to reduce readmissions through effective transitional care. WSHA offers tools for both hospitals and primary care providers, many of which are being used in Washington State’s health homes strategies.

Health Homes Questions

If you have any questions specific to the CHPW Health Homes program, or would like to request more information please contact the CHPW Health Homes Team at