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Health Homes Program

Kern Health Systems (KHS) will cover Health Homes Program (HHP) services for Kern Family Health Care (KFHC) Members with certain chronic health conditions starting July 1, 2019. These services help coordinate physical health services, behavioral health services, and community-based long term services and supports (LTSS) for Members with chronic conditions.

You or the KFHC Member may call KHS to see if they qualify. KHS or our contracted Health Homes Program providers may also outreach to your assigned KFHC Members that may quality for this program to see if they are interested in enrolling into a Health Homes Program. Contracted Health Homes Program providers currently include: Kern Medical, Omni Family Health (Oildale and Shafter), Premier and Dignity Health.


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.

What services does HHP cover?

HHP will give them a care coordinator and care team. HHP treatment team will work with the Member and their health care providers. The health care providers including doctors, specialists, pharmacists, case managers, and others, will coordinate the Members’ care. KHS HHP services include:

  • Comprehensive Care Management.
  • Care Coordination.
  • Health Promotion.
  • Comprehensive Transitional Care.
  • Individual and Family Support Services.
  • Referral to Community and Social Support.

Is there a cost?

There is no cost to the Member for HHP services.