Physician Home Care Services:

HIGHLIGHTS OF PHYSICIAN HOME CARE SERVICES

This programs is designed to care for the frail, chronically ill, high ER and hospital utilizing patients.

Program eligibility and visits:

• Each patient with 3 or more chronic conditions can be admitted to the home care services.
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• Any patient that is determined to be frail by the PCP can be admitted to the program. 
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• All patients discharged from the hospital or the nursing home with high risk of readmissions are admitted
• to the home care program within 48 hours of the discharge or sooner if the condition warrants based on their re hospitalization risk. 
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• The hospitalization risk tool is used to screen every patient for the risk of hospitalization.
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• Each patient is visited monthly by a member of the team and a visit report sent to the PCP.
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• All management changes are coordinated with the PCP.
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• Each admitted patient is called by the call center to administer the weekly screening that will trigger a home
• visit before any problem arises.
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• Each patient is assigned to a particular home care team and shall be encouraged to access the team after hours
• for any condition that needs attention. They shall be required to call the PCP during the regular hours. Home care
• teams shall serve as back ups during this time.

  The home care team works closely with the home care agency to coordinate the case and avoid unnecessary

  ER visit or hospital admission

Ancillary services to be provided at home includes:

• Plain radiography
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• Sonography
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• Doppler studies
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• Electrocardiogram
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• Intramuscular and intravenous medications.
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• Laboratory services
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• Echocardiogram

 Hospital at home program

• Patients with exacerbation of their chronic conditions or simple conditions that does not require hospitalization shall be admitted to “hospital at home program”.
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• Patient will be visited daily by the home care team and discharged when appropriate to chronic management.