Physicians Follow Patients into Home Care Under New Model

The Affordable Care Act has long-emphasized the concept of coordinated care among healthcare providers, now giving way to a new care model currently being tested where physicians follow patients throughout their hospital stay and into home-based care settings, reports Modern Healthcare via Crain’s Detroit Business.

A clinical trial funded by the Centers for Medicare & Medicaid Services Innovation Center and tested by the University of Chicago is giving a new take to a somewhat old-fashioned concept—one that targets patients at high-risk for hospitalization via “comprehensive care physicians.”

Under the program, physicians are each assigned panels of 200 patients who are expected to average about 10 hospital days per year. Physicians are assisted by a clinical coordinator, a registered nurse, nurse practitioner and a social worker. 


The program’s key outcomes are measured across several categories, including self-rated health status, limitations on activities of daily living and mortality. The program’s economic success will be judged by the cost of care to Medicare, the article notes.

“Providing these physicians with a high volume of inpatients and locating their clinics in or near the hospital can allow them to offer many of the same benefits that hospitalists provide in terms of inpatient experience and physical presence and to offer the additional benefit of continuity across settings and over time,” said researchers behind the project, David Meltzer, M.D., and Gregory Ruhnke, M.D. in an article from Health Affairs cited by Modern Healthcare.

Read more at Crain’s Detroit Business.


Written by Jason Oliva

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