Centerstone Adult Health Home

Using Technology to Keep Medicaid Superutilizers Out of Hospitals

Developed by Centerstone Research Institute, Centerstone Adult Health Home is a short term (3 month) high-touch, hightech intervention providing care for Medicaid superutilizers. The Centerstone Adult Health Home model is designed to serve superutilizers who have co-occurring mental and physical health needs and recent hospitalization and ER utilization. The Centerstone Adult Health Home model was created for providers, health homes, managed care organizations, and ACOs aiming to improve their ability to provide value based care to Medicaid superutilizers. The Centerstone Adult Health Home model partners with the patient and the patient’s loved ones to improve the patient’s mental wellness, physical wellness and enjoyment of life.

Piloted at Centerstone, a five-state mental health provider, the Centerstone Adult Health Home model has been tested with patients with schizophrenia, bipolar disorder, personality disorders, COPD, heart disease, heart failure, end stage renal disease, and diabetes, among many other behavioral and physical health conditions.
The Formation of Centerstone Adult Health Home

Since 2010, the Research Institute has been researching integrated care solutions for persons with serious mental illness and physical health concerns.

After receiving exceptional results from the Be Well Integrated health home project, with 70% of patients losing an average of 11.38 pounds within the first year and the average patient moving from “diabetic” to “pre-diabetic” on their hgbA1cs within six months, the Research Institute decided to take this intervention, add 21st century technology tools, and focus on high utilizing patients with recent, multiple hospitalizations.

In 2014, the Research Institute launched several pilot projects to test this model. The results from the 3 completed pilots are extremely promising, showing a 61% decrease in hospital days and a 32% decrease in ER visits for engaged patients.