For patients living with multiple chronic conditions, mobility limitations and other complex health needs, getting to a doctor’s office is not always easy. Additionally, traditional primary care alone may not provide the level of access, coordination and support these patients need to remain safely at home.
That’s where the “housepitalist” provider comes in.
Just as a hospitalist specializes in caring for patients in the hospital, a housepitalist provider specializes in improving the quality of life for patients in the home, working with office-based providers to improve access and extend provider care into the patient’s home. Trademarked by HarmonyCares, the housepitalist term reflects the specialized role our clinicians serve, bringing together primary care, pharmacy, social work, care coordination, and other specialty care in the home for the most vulnerable patients across the nation.
More Than a Traditional House Call
Housepitalist providers do much more than bring a traditional primary care office visit into the home. They care for patients who may be managing several chronic conditions, taking numerous medications, or recovering from a recent hospitalization with a multi-disciplinary team.
Seeing patients at home gives clinicians a lens into the context that influences a person’s health and provides a perspective they may never get in an exam room. They can see whether a patient has access to nutritious food, understand how medications are being taken, identify potential fall risks, and recognize when a caregiver may need additional support. This also allows our providers to come alongside the patients’ primary care providers to ensure the best possible care for those who may not be able to travel to the doctor’s office.
Specialized Training for a Different Kind of Primary Care
At HarmonyCares, preparing to become housepitalist providers starts with a rigorous onboarding and mentorship experience. While many providers come from internal medicine, family medicine, hospital medicine, geriatrics, and palliative/hospice backgrounds, caring for medically complex patients in the home requires them to apply that expertise in a very different environment. New providers begin with an immersive orientation where they learn about HarmonyCares’ mission, care model, and patient population; meet company and clinical leaders; and hear directly from experienced providers about the realities of delivering care in the home.
From there, providers are paired with a mentor in their local market and work alongside them until they are prepared to practice independently. The goal is to give providers the clinical, operational and team-based support they need to confidently care for complex patients in the home.
A Care Model and Team Built Around the Patient
Housepitalist providers don’t work alone. At HarmonyCares, our providers are organized into small, closely connected teams – or pods – made up physicians or nurse practitioners that are designed to make coordinated care part of everyday practice.
An embedded care management nurse works alongside the clinical team, while care navigators and community health workers help address socioeconomic health needs.
The broader care team can also include experts in primary care, pharmacy, social work, care coordination, and palliative care. Through interdisciplinary care meetings, these providers bring their expertise to complex patient cases even when they aren’t directly caring for that particular patient.
The result is seamless clinical support for patients as they manage their care rather than a series of disconnected healthcare encounters.
Proactive Care for Patients Who Need It Most
The housepitalist provider model also changes when care happens. Instead of waiting until a patient declines, HarmonyCares identifies patients who are most likely to get sick and brings extra resources to the patient to prevent that next trip to the hospital.
For example, after a hospitalization, the HarmonyCares care management team reaches out, typically within 24-48 hours, to coordinate follow-up, identify problems and marshal resources to reduce the risk of avoidable readmission.
Diligent medication management is equally important. Detailed medication reconciliation helps patients and caregivers understand what medications they are taking, why they are taking them and whether their regimen remains appropriate.
For all patients with complex illness, the HarmonyCares care model emphasizes taking the time to understand what matters most to patients and families so they can make health decisions that are aligned with their goals and values. Housepitalist providers also coordinate with specialty teams to improve quality of life, even as patient approach the final stages of life.
Bringing Complex Primary Care Home
At its core, being a housepitalist provider means meeting patients where they are – literally and figuratively. Housepitalist providers bring the skills needed to care for medically complex patients into the home, where they can integrate the bigger picture of a person’s life into their medical situation.
Supported by a closely connected care team, housepitalist providers anticipate needs, respond when a patient’s condition changes and help coordinate care through some of the most vulnerable moments in a patient’s life. For patients who may struggle with access to traditional care, that means so much more than convenience. It means having a care team built around helping them live healthier and spend more days where they want to be – at home.
