The My Health GPS (MHGPS) initiative, a Health Homes program, was launched by the District of Columbia, Department of Health Care Finance (DHCF) to deliver care coordination services to Medicaid beneficiaries with multiple chronic conditions. The MHGPS program was led by multi-disciplinary teams within the primary care setting to coordinate care across medical, behavioral, and social service systems.

The initiative was designed to improve MHGPS enrollees’ health outcomes and reduce avoidable and preventable hospital admissions and emergency room visits.

Download to read the approach and results.