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Health Homes   



Oklahoma Behavioral Health Homes Initiative 

Health Homes is an optional Medicaid State Plan benefit that provides an opportunity to build a person-centered system of care that achieves improved outcomes and better services and value for the Oklahoma SoonerCare program for individuals with complex needs.The Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) has partnered with OHCA to expand upon the patient-centered medical home model to provide coordinated primary and behavioral health integration.  

Implementation began January 5, 2015. 


Health Home Links: 

-Admin Letter Template       


Target Populations 

  • Adults with Serious Mental Illness (SMI)  
  • Children with Serious Emotional Disturbance (SED)      

Because of the different physical and behavioral needs and social complexities across these two target population age groups, as well as potential differences in the providers who serve them, it is the States’ intent to tailor health homes to meet each population’s unique needs.  


Health Home Services 

A health home must provide all six of the following services, based on members’ changing needs, linked as appropriate and feasible by Health Information Technology (HIT): 

  • Comprehensive care management 
  • Care coordination  
  • Health promotion  
  • Comprehensive transitional care from inpatient to other settings, includingappropriate follow-up, and transition from pediatric to adult settings   
  • Individual and family support 
  • Referral to community and social support services 

The expectation is that behavioral health homes will result in improved quality of care and more cost efficiencies; improved experience with care on the part of members; and reductions in the use of hospitals, emergency departments, and other expensive facility-based care, such as Psychiatric Residential treatment for children. 


Health Home Providers 

Health Home services will be provided by designated behavioral health organizations (BHO) with multi-disciplinary teams of medical, mental health and chemical dependency professionals for integrated service delivery in the behavioral health setting.The behavioral health professionals will be responsible for the overall provision of health home services.  

Each BHO approved as a Health Home must be: 

  • enrolled as a SoonerCare provider in good standing; and 
  • able to meet minimum Health Home staffing requirements; and 
  • able to provide Health Home services and meet specified reporting requirements. 

ReportingRequirements and Supports 

Health homes will be provided with ongoing training and support from the State and will have access to a Health Home patient registry.The registry will aid in enrollment, reporting and tracking, identifying gaps in care and best treatment practices for their members. Health Home providers will receive per member, per month reimbursement contingent upon minimum service delivery and adherence to all requirements. 



Last Modified on Dec 02, 2020
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