OneCare Kansas Partners must provide the following services:

• Comprehensive care management
• Care coordination and health promotion
• Comprehensive transitional care, including appropriate follow-up, from inpatient to other settings
• Patient and family support (including authorized representative)
• Referral to community and social support services, if relevant
• Use of health information technology (HIT) to link services

States must specifically describe how each of these services will be provided when they submit their health homes (called OneCare Kansas in our state) Medicaid state plan amendment (SPA) to the Centers for Medicare and Medicaid Services (CMS).