Providing Primary Care to Homebound Patients: UCSF Health's Care at Home Program (Case Study)

Providing Primary Care to Homebound Patients: UCSF Health's Care at Home Program (Case Study)

Learning Systems for Accountable Care Organizations
Published: Aug 30, 2020
Publisher: Baltimore, MD: U.S. Centers for Medicare & Medicaid Services
Clients
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Associated Project

Learning Systems for Accountable Care Organizations

Time frame: 2013-2020

Prepared for:

U.S. Department of Health and Human Services, Center for Medicare & Medicaid Innovation

Authors

Julia Embry

Key Findings
  • Preliminary internal analyses show decreased inpatient and emergency department utilization for patients enrolled in Care at Home, and nearly 95 percent of patients surveyed expressed satisfaction with the program.

This case study describes how University of California San Francisco (UCSF) Health delivers primary care to homebound patients through its Care at Home program. Care at Home providers use a multifaceted approach when conducting home visits to address clinical needs, environmental factors, and social determinants of health. The Care at Home team has a three-step process: (1) identify patients eligible and well-suited for the program,(2) complete an initial home visit to assess patient needs and fit for the program, and (3) deliver on-going primary care through home visits. UCSF Health’s experience may be useful for ACOs or health care organizations interested in offering home-based primary care to their beneficiaries.

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