In a fee-for-service health system, Medicare beneficiaries who qualify for home care services often receive inadequate, uncoordinated care for their chronic conditions, resulting in more visits to the emergency room, more hospital admissions, and/or more placements in a skilled nursing facility. We advocate on behalf of patients to ensure that their needs and preferences are considered in the care planning process. Collaborating with healthcare and home care providers to address barriers to effective care and transitions decreases unnecessary healthcare costs. 

We are a team of medical providers devoted to treating patients in the comfort of their homes, group homes, boarding homes, and assisted living facilities. We evaluate and review their medications, order labs, adjust medications based on the results, and refill prescriptions as needed to reduce duplication of services, minimize polypharmacy, and streamline care delivery. We also assess the social determinates of health in the home and the surrounding community. We are the bridge between the home care      organizations, families, patients, and their PCP.    We also provide a warm handoff to the patient's   PCP upon discharge from home care.