DD Health Home

• A team of healthcare professionals who take time to understand your health.
• Support to set goals that reflect what matters to you. 
• Easy-to-understand information about your health and medications.
• Support in getting information and resources that can help connect you with health providers, such as doctors and specialists. This information may also be shared with your support team to ensure care needs are addressed. 
• Receiving information about community resources that will help you manage health and wellness needs. 
• Support after a hospital stay. This includes checking medications to make sure they are correct and safe. 

Better care. Better support. Better health.

• Asthma
• Autism
• Diabetes
• Cardiovascular Disease or Hypertension
• Chronic Obstructive Pulmonary Disease (COPD)
• Dementia
• Dependence on a Ventilator
• Overweight (BMI>25)
• Tobacco Use
• One of the Fatal Five Plus Conditions
  • Pulmonary Aspiration
  • Bowel Obstruction
  • Gastroesophageal Reflux Disease (GERD)
  • Seizures
  • Dehydration
• Healthcare Level of 3 or Greater - per the Health Rist Screening Tool (HRST)

There are three ways to join the DD Health Home Program: 

1. Auto-Enrollment
   • Some people receiving services through the Division may be automatically enrolled into the program. If you are automatically enrolled, a letter will be sent in the mail.
2. Referral 
   • Anyone may submit a DD Health Home Referral to find out if a person is eligible for the program. A referral may also be submitted by another person on someone else's behalf.
3. Enrollment through a DD Health Home Provider
   • A DD Health Home Provider may enroll a person directly if program eligibility is met.

If you are enrolled, you may choose to opt out of the program at any time. 

Program Information

• DD Health Home Referral Form: Use this form to determine eligibility for the program.
• Find a DD Health Home Provider: Find a provider in a specific area.
• Frequently Asked Questions

For Individuals Auto-Enrolled in the Program

• Sample Enrollment Letter: A letter a person receives when they are auto enrolled into the program by the Division of DD. 

DD Health Home Providers 

These organizations provide DD Health Home services in Missouri

• Abilities First 
• Compass Health Network 
• Easterseals Midwest 
• Skillset
• Supported Living and Employment Services (also known as Firefly) 

Find a DD Health Home Provider

DD Health Home State Plan & Regulations 

Health Homes are guided by federal and state rules that help states provide better, more coordinated care for people with chronic health conditions

• CMS – Approved DD Health Home State Plan Amendment: Federal approval for Missouri’s DD Health Home program (effective 7/1/2024).
• CMS DD Health Home State Plan Amendment Approval Letter: Confirmation from Centers for Medicare & Medicaid Services approving Missouri’s State Plan changes.
• State Code of Regulations (9 CSR 45-7.010) for DD Health Home: State regulation outlining DD Health Home requirement. 

Operations & Rates

• DD Health Home Provider Operations Manual: A guide for daily program operations 
  • Latest version can be requested at DDHealthHome@dmh.mo.gov 
• Per Member Per Month (PMPM) Rate Chart: Shows the monthly rates for DD Health Home services 

Forms & Additional Resources

Enrollment, Transfers, and Discharges

Submit completed forms to DDHHEnrollTransferDischarge@dmh.mo.gov

• Enrollment, Transfers, & Discharge Worksheets can be requested from DDHHEnrollTransferDischarge@dmh.mo.gov
• Enrollment, Transfers, & Discharge Worksheet Instructions 
• Enrollment Error Attestation Form: Used to correct enrollment mistakes.
• Recoupment Form: Used to correct payment mistakes if an enrollee was attested to in error.

Reporting Staff Changes 

Submit completed form to DDHealthHome@dmh.mo.gov within 7 business days.

• Contact Profile Form: Used to report new staff, position changes, or resignations. 

Enrollee Notifications 

• Physician Notification Letter: Notifies a person’s doctor about their DD Health Home enrollment.
• Hospital Introduction Letter: Introduces DD Health Home services to hospitals involved in the person’s care.

Additional Forms & Tools

• MO Health Risk Screening Tool (HRST) Webpage: For more information on the tool used to provide early detection of health risks and destabilization.
• New Director Checklist: Helps new directors complete required onboarding steps. 
• Missouri’s Proofpoint System for Encrypted Email: For sending secure, protected messages.

Becoming a DD Health Home Provider

• DD Health Home Application Memo: Provides guidance for completing the application.
• Initial Provider Application: First step to apply as a DD Health Home provider.

• Centers for Medicare & Medicaid Services Health Homes: National information on Health Home programs. 
• Missouri’s Behavioral Health Healthcare Homes: Health Home services for individuals facing mental health or substance use disorders along with chronic health conditions. 
• Missouri’s Primary Care Health Home: Health Home services for individuals with two or more chronic health conditions.