Lynne A. Valenti
Cabinet Secretary

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Health Home Data Dashboard

South Dakota Medicaid’s Health Homes are a person centered system of care focused on transforming care for high cost, high need Medicaid recipients to improve the patient experience, increase preventive and primary care services while improving outcomes for Medicaid recipients and adding value to the Medicaid program.

Transforming Care

South Dakota Medicaid’s Health Homes is changing the way Medicaid recipients receive care by creating a person-centered care team to meet the needs of the patient. The following measures show how the Health Home program is changing the way individuals receives care.

Increasing Preventive and Primary Care

Health Home participants have high-cost chronic and/or behavioral health conditions. The goal of Health Homes is to provide care in primary care settings and help participants effectively manage their conditions by increasing preventive care. Overall, primary care has increased by 6%. The measures below show health homes success in increasing preventive screenings.

Improving Clinical Outcomes

By transforming care, increasing preventive services and improving the patient experience, Health Homes are able to improve clinical outcomes for patients. The following measures show how clinical outcomes have improved for individuals the longer the individual participates in the program.

CY2016 Behavioral Health Outcome Goals and Results


CY2016 Diabetes and Skeletal and Connective Disorders Goals and Results

CY2016 Cardiovascular and Obesity Goals and Results

Rounded Rectangle: Health Home Recipient Success Story  Recipient began Health Homes in 2014 and at that time, weight was 220 pounds with a BMI of 36.  Labs from 2014 show that cholesterol was in the borderline high range at 207 and triglycerides were also in that same range at 239.  This recipient has been following up regularly with a case manager, began seeing a therapist about one year ago, and sees a psychiatrist as scheduled.  Recipient identified a goal to be healthy both physically and mentally.  In 2016, the recipient’s cholesterol was within the desirable range at 148 and triglycerides were down to 46.  The recipient has lost over 60 pounds.  The recipient and the therapist have discussed termination of therapy due to meeting therapeutic needs.   

Cost Effectiveness of the Health Home Program

DSS matched Health Home participants and individuals eligible but not participating before and after program implementation.  Prior to Health Homes both groups PMPM costs increased.  After Health Homes PMPM costs for Health Home participants decreased relative to those not participating.  Costs for individuals not participating continued to rise. 

In CY 2016 HH recipients cost $141 less per month that recipients who looked  like them  DSS estimates $7.7 million was cost avoided in CY 2016 after payment of the PMPM.  Without Health Homes, DSS would have expended approximately 7.7 million more.

DSS found that 68% of costs avoided are due to decrease inpatient admissions and emergency room use.

We can also see how this impacts our expenditure categories below. 

As anticipated, recipients in higher tiers produced the largest amount of savings.  Eighty two percent of the $7.7 million in cost avoidance is attributed to Tiers 3 and 4 as shown in Figure 5 below.

CY2016 Percentage of cost avoidance by Tier

A summary of the methodology used to calculate the cost avoidance of Health Homes can be found in written format.

Improving Patient Experience

Health Homes are tasked with focusing care on the person, including establishing a relationship with health home participants. A positive patient experience helps support the health home model, leading to better continuity of care and better health outcomes.  Outcomes in this area are split between primary care clinics and community mental health centers.

View the full set of Outcome Measures here. Information about how outcome measures are collected and defined is available here.