Community Health Plan of Washington Medicare Advantage Plans Community Health Plan of Washington Medicare Advantage Plans

Health Homes

CHPW is a Qualified Health Home Lead Entity

Community Health Plan of Washington (CHPW) is one of several Qualified Health Home Lead Entities (QHHL) selected by the state for the Health Home program.

Health Home services CHPW provides

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

The Health Home program, as outlined by Section 2703 of the 2010 Affordable Care Act, establishes “Health Home services” for enrollees with complex conditions and high service needs. These conditions include asthma, diabetes, cancer, and depression.

As defined by the Centers for Medicare and Medicaid Services (CMS), health home services include six specific services beyond usual clinical care:

  • Comprehensive care management
  • Care coordination
  • Transitional care and follow-up
  • Patient and family support
  • Referral to community support services
  • Health promotion

Health Home services can be provided in primary care settings and through community-based organizations, depending on the particular care needs of an enrollee.

CHPW provides Health Home services in many regions throughout Washington. Refer to the coverage map to find out if we offer the service in your county.

Health Home services are an additional benefit that enrollees are eligible for on top of D-SNP Case Management services.

Who qualifies?

The program is for people with Medicare D-SNP coverage who are already active in the program when they enroll in a Medicare Dual Special Needs Plan.

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.


CHPW Clinic-Based Health Homes
Care Coordination Organizations Counties Served Health Home Regions Served
Community Health of Central Washington Yakima, Kittitas 7
HealthPoint King 3
International Community Health Services King 3
NeighborCare Health King 3
Sea Mar Community Health Centers Clark, Skagit, Whatcom, King, Snohomish 2, 3, 5
Yakima Neighborhood Health Services Yakima 7
CHPW Community-Based Health Homes
Care Coordination Organizations Counties Served Health Home Regions Served
Aging & Adult Care of Central WA Chelan, Douglas, Grant, Okanogan, Adams 6
Aging & Long-Term Care of Eastern WA Spokane 6
Behavioral Health Northwest Snohomish, Skagit, Whatcom, Island, San Juan, Benton, Franklin, Yakima, Walla Walla, Spokane 2, 6, 7
Columbia River Mental Health Services Clark 5
Community Health Plan of Washington King 3
King County Behavioral Health and Recovery Division King 3
Lifeline Connections Clark 5
Northwest Regional Council Skagit, Whatcom, Island, San Juan 2
Rural Resources Community Action Stevens, Ferry, Pend Oreille, Whitman, Lincoln 6
Southeast Washington Aging and Long Term Care Asotin, Benton, Columbia, Franklin, Garfield, Kittitas, Yakima, Walla Walla 7
Southwest Washington Agency on Aging and Disabilities Clark, Klickitat, Skamania, Wahkiakum 5
Sunrise Services Inc Snohomish, Skagit, Whatcom, Island 2
You Grow Girl! King 3

Training and support for care coordination organizations

We provide online training and technical assistance to care coordination organizations statewide.

Additionally, Care Coordinators who provide health home services are required to take a two-day training developed by the Washington State Health Care Authority (HCA) and Department of Social and Health Services (DSHS). These standardized trainings are offered across the state.

Please contact [email protected], to discuss training needs and opportunities.

Training for comprehensive transitional care and follow-up

Current research shows that around 20 percent of patients in the U.S. are re-hospitalized within 30 days of discharge. Care coordination and follow-up after hospitalization are key health home services that reduce costs and assure a safe, effective hospital discharge.

CHPW partners with the Washington State Hospital Association (WSHA) 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.

Questions about Health Homes

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 [email protected] or contact CHPW Customer Service at 1-800-924-0247.


Stay on Top of Your Prescriptions

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