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Health Homes Program

Kern Family Health Care (KFHC) covers Health Homes Program (HHP) services for members with certain chronic health conditions. These services are to help coordinate physical health services, like behavioral health services and community-based long-term services and supports, for members with chronic conditions.

You may be contacted if you qualify for the program. You can also call KFHC or speak to your doctor or clinic staff to see if you qualify.

Covered HHP services

HHP will give you a care coordinator and care team that will work with you and your health care providers, such as your doctors, specialists, pharmacists, case managers and others, to coordinate your care. Kern Family Health Care provides HHP services, which include:

  • Comprehensive care management.
  • Care coordination.
  • Health promotion.
  • Comprehensive transitional care.
  • Individual and family support services.
  • Referral to community and social supports.

Cost to member

There is no cost to the member for HHP services.


KFHC members qualify for HHP if they meet the following criteria in both sections A and B

A: HHP Chronic Conditions—the member must have one of the following

  • At least two of the following: chronic obstructive pulmonary disease (COPD), diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease (CAD), chronic liver disease, dementia, substance use disorder.
  • Hypertension and one of the following: COPD, diabetes, CAD, chronic or congestive heart failure.
  • One of the following: major depression disorder, bipolar disorder, psychotic disorders (including schizophrenia).
  • Asthma.

B) In addition, the member must also have one of the following

  • Has at least 3 or more of the HHP chronic conditions.
  • At least one inpatient stay in the last year.
  • At least 3 ER visits in the past 12 months.
  • Chronic homelessness.

Members do not qualify to receive HHP services if they meet one of the following:

  • Members receiving hospice services.
  • Members residing in a skilled nursing facility for longer than the month of admission and the following month.