Our Health@Home program delivers comprehensive primary care for high-cost, high-risk patients in their homes.


To improve patient outcomes and reduce health care costs.

Population Served

The program will treat approximately 425 patients with complex, multi-chronic, disabling conditions for whom routine clinic-based care is not effective. Each of these patients average $58,000 in medical costs per year. In a one-year period, they average seven emergency room visits, at least two hospital admissions and primary care provider (PCP) visits, and 22 prescriptions.

Target Population Profile

  • 54 is their average age
  • 58% are female
  • 65% are not a community health center patient
  • 74% have chronic pain or psychiatric prescriptions
  • 22% have not visited their PCP in the last 12 months
  • 10% predicted annual mortality

Services Provided

The program is an extension of a patient’s PCP care, not a replacement. Three nurse practitioner-led teams will provide at-home primary care for patients coupled with telemedicine interactions at regular intervals.

For More Information

The program launch will take place from December 2014 to April 2015. To refer a patient, or for more information, call 1-401-427-6727.