Standards for public agencies

2020 Edition

Integrated Care; Health Homes Definition


Adults and children who receive integrated care experience improved health care quality, an improved client care experience, and improved clinical and non-clinical outcomes.


Integrated care is the systematic coordination of behavioral and physical health care in order to improve an individual’s overall health.

Behavioral health providers can offer integrated care by fully integrating primary care into their existing program, establishing written agreements with a primary care provider that is located on-site, or establishing written agreements with a primary care provider that is located in the community.


Viewing: PA-ICHH - Integrated Care; Health Homes


Examples: One specific model for providing integrated care is the Medicaid health home, which was established by the Patient Protection and Affordable Care Act (ACA) to coordinate health care for adults and children with chronic conditions. The health home is a central point of contact responsible for facilitating access to and systematically coordinating an individual’s behavioral, medical, and oral health care, while making linkages to needed community and social support services.

Health home services that are eligible for federal reimbursement as authorized by the ACA include:
  1. comprehensive care management;
  2. care coordination and health promotion;
  3. comprehensive transitional care, including appropriate follow-up from inpatient to other settings;
  4. individual and family support;
  5. referral to community and social support services, as applicable; and
  6. the use of health information technology (HIT) to link services.

Examples: Chronic conditions include, but are not limited to, substance use disorders, mental health conditions, asthma, diabetes, heart disease, and having a Body Mass Index (BMI) over 25.
Note: Throughout the PA-ICHH standards, the involvement of the person’s family has been emphasized due to the significant impact family engagement can have on resilience and recovery. However, the level of family involvement will vary given the age and expressed wishes of the person and as permitted by law.

Due to the importance of family involvement in achieving positive outcomes for children, all aspects of service delivery should be family-driven when working with this population, accounting for the dynamics of the family as well as the needs of the child.

Note: Please see PA-ICHH Reference List for the research that informed the development of these standards.

Note: For information about changes made in the 2020 Edition, please see the ICHH Crosswalk.