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NYC Health + Hospitals Launches Health System’s 1st Home Based Program for Homebound Patients

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NYC Health + Hospitals recently announced the launch of the health system’s first home-based primary care program designed to improve health outcomes, quality of life, and reduce hospitalization for frail, homebound New Yorkers

Pilot program will feature new teams of visiting doctors and nurse practitioners who will make house calls to frail, homebound New Yorkers served by NYC Health + Hospitals/Kings County in Brooklyn

Edited by: TJV News

NYC Health + Hospitals recently announced the launch of the health system’s first home-based primary care program designed to improve health outcomes, quality of life, and reduce hospitalization for frail, homebound New Yorkers. The pilot program will support a new team of visiting doctors and nurse practitioners who will make house calls to home-limited patients served by NYC Health + Hospitals/Kings County in Brooklyn. The program will offer primary care services in the home and use telehealth video visits to connect patients to specialty care, mental health services and help from social workers. Unlike traditional home care services that focus on short-term nursing assistance and physical therapy, this home-based service will expand access to primary care, preventive care, chronic disease management and mental health services to a population that faces obstacles to care due to their limited mobility. The new home-based primary care pilot program is expected to serve 200 patients.

The new program will be funded in part by grants from the Altman Foundation, the New York Community Trust, and the Fan Fox and Leslie R. Samuels Foundation, Inc., as well as investments by NYC Health + Hospitals, totaling $900,000 over the next two years to cover the cost of new staff, transportation, equipment and supplies. The new at-home primary care model builds on the NYC Health + Hospitals’ transformation goals to expand access to primary care to New York’s most vulnerable populations. Based on the results of the pilot, health system officials expect to expand the at-home primary care service model to other communities served by NYC Health + Hospitals.

“Too many people with debilitating chronic conditions that limit their mobility find it very challenging to leave the home and travel to visit their primary care physician. They are more likely to be disconnected to care, skip regular preventive care, and end up with additional health complications,” said Mitchell Katz, MD, NYC Health + Hospitals President and Chief Executive Officer. “This first home-based primary care pilot program will break down barriers and help improve health outcomes for some of the City’s most vulnerable population.”

“Our home-based primary care program shows the depth of our commitment to make sure all New Yorkers have the access to the care they deserve and need,” said Dave Chokshi, MD, NYC Health + Hospitals Vice President and Chief Population Health Officer. “We must meet people where they are, particularly our most vulnerable and underserved patients. With our elderly population continuing to grow, investments into accessible health care are critical.”

“Someday, our society’s institutions may be structured to serve more than the temporarily able- bodied among us. We’re proud to be the first in our health system to adopt this new model of care in the home which will better position us to serve the patients of the future,” said Scott McGarvey, MD, program lead at NYC Health + Hospitals/Kings County.

At-home primary care has been shown to produce better health outcomes. According to the CMS Independence at Home Medicare Demonstration Project, 15 physician practices providing home-based primary care to 10,000 Medicare beneficiaries saw major improvements in quality of care and health outcomes, including 50 percent fewer hospitalizations, emergency department visits, and senior nursing facility days.

Those eligible for the NYC Health + Hospitals home-based primary care services will include patients over 50 years of age who are homebound or find it too physically taxing to leave the home, and have at least one chronic condition. Patients will be referred to the program by primary care physicians at NYC Health + Hospitals/Kings County. Each at-home primary care patient will get house calls by a primary care physician and follow up visits by a nurse practitioner who will bring an “at-home kit” tailored to a patient’s previous diagnosis and care, including necessary medical devices and medications. The home-based primary care providers will be part of an extensive care team that may include a social worker, home health aide, other specialists, and palliative care professionals. Most of a patient’s care will be arranged by a care coordinator.

“I am delighted that our City’s public hospital system has initiated yet another innovative program. Homebound New Yorkers will have access to home-based primary care and wraparound support that will improve health outcomes while reducing barriers and expenses,” said State Senator Gustavo Rivera, Chair of the Senate Health Committee. “Forward-thinking services like these make me proud of our public system’s commitment to convenient and reliable connections to care.”

“I want to commend the leadership of NYC Health + Hospitals/Kings County and our valued local foundations for their commitment to improving the quality of life of homebound patients,” said Councilmember Mathieu Eugene. “The launch of the home-based primary care program will have a substantial benefit to the quality of healthcare that we are able to provide our frail and underserved adult patients. As a community, it is important that we continue to expand the resources available to those who are infirm and have difficulty traveling. I am confident that by working together, we will increase the level of efficient and cost-effective medical care available to current and future generations of New Yorkers.”

“The Fan Fox and Leslie R. Samuels Foundation, Inc. supports NYC Health + Hospitals’ priority of breaking down barriers to primary health care access, despite challenges with mobility,” said Julio Urbina, PhD, Vice President and Director, Healthy Aging of the Samuels Foundation, Inc.. “As our aging population grows in New York City, we have to continue to create innovative methods to make sure these patients receive the comprehensive, high-quality, and convenient health care they require.”

The NYC Health + Hospitals new home-based primary care program will complement existing home-based care services offered through NYC Health + Hospitals/Community Care, which offers short-term nursing assistance, physical therapy and social work.

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