Form CMS-10398 #22 CMS-10398 #22 Health Homes Administrative Component

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OMB Control Number: 0938‐1148
Expiration date: 10/31/2014

Health Homes Administrative Component
Health Homes Administrative Component
Name of Health Homes Program:
Monitoring
Provide an estimate of the number of individuals to be served by the Health Homes program during the first year of operation:

Provide an estimate of the cost-savings that will be achieved from implementation of the Health Homes program during the first
year of operation:
$
Describe how this cost-saving estimate was calculated, whether it accounted for savings associated with dual eligibles, and if
Medicare data was available to the State to utilize in arriving at its cost-savings estimates:

Quality Measurement
CMS Recommended Core Measures
For each Health Homes core measure, indicate the data source, the measure specification, and how HIT will be utilized
in reporting on the measure.

Health Homes Core Measure

Health Homes Administrative Component: Core Measure Detail
Measure

Measure Specification, including a description of the numerator and denominator.

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Data Sources:

Frequency of Data Collection:
Monthly
Quarterly
Annually
Continuously
Other

How Health IT will be utilized

State Goals and Quality Measures
In addition to the CMS recommended core measures, identify the goals and define the measures the State will use to assess its
Health Homes model of service delivery:

Health Home Goal

Health Homes Administrative Component: Goal Detail
Health Home Goal:

Measure

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Health Homes Administrative Component: Measure Detail
Measure

The measure is an Evaluation Measure from the Health Homes State Plan for
purposes of determining the effect of the program on reducing one of the
following:
Hospital Admissions
Emergency Room Visits
Skilled Nursing Facility Admissions
The measure is not included in the Health Homes State Plan
Measure Specification, including a description of the numerator and denominator.

Data Sources:

Frequency of Data Collection:
Monthly
Quarterly
Annually
Continuously
Other

How Health IT will be utilized

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Measure is related to:
Clinical Outcomes
Experience of Care
Quality of Care
Other
Describe:

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-1148. The time required to complete this information collection is estimated to average 80
hours per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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