For Healthcare Organizations

We Offer Flexible And Reliable Care Solutions

We help healthplans, medical groups, and other at-risk organizations improve patient access, clinical care, patient satisfaction, quality, and avoidable costs.

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The Problem

  • 10% of the Senior population accounts for 70% of Medicare costs. 5% of this population is access-challenged with a high incidence of inpatient and SNF care.
  • Readmissions among high risk and frail populations average more than 30%, and in some diagnosis categories can be 10x the rate of the average Medicare Advantage population. Many of these episodes are avoidable.

Our Solution

  • A free-standing, outsourced solution that can function in multiple diverse markets, driving high ROI for clients. Positioned for additional care cycle collaboration options, closely integrating hospital and skilled nursing care with Residentialist services in a single coordinated platform.
  • Committed to transforming care for homebound, high-risk and elderly patients, improving access, continuity, quality of life, and outcomes. We bring care to where it is needed most.
  • Tech-enabled/high-touch, in-home clinical care provided by trained residentialist clinicians. We enhance case management, communication, engagement, compliance, patient satisfaction, and outcomes.
  • Multiple client-centric service lines include post-acute care transitions, chronic/palliative care services, and HCC/Star rating enhancements.
Our Approach

Taking Care Of The Whole Patient

We take a whole patient/population health approach that addresses both clinical issues and social determinants of health. These include living environment, safety, nutrition, mobility, cognitive status and caregiver support.

We have a team of over 30 board-certified clinicians: physicians, nurse practitioners, and physicians assistants, who have been trained in the unique challenges of providing efficient, effective, high-quality care in the home.

Helping A Senior Out of Bed - Housecall Doctors

When possible, we discharge the patient back to the care of their ambulatory physician.

We share information among key stakeholders including case managers and other physicians.

We orchestrate additional care resources on behalf of the patient and facilitate coordination of care.

We risk stratify all patients to delineate medical complexity and needed resources to minimize risk of acute admissions.

Our Services

Why Choose Us?

Customized Platform

Our proprietary data-driven platform identifies and stratifies high-risk/high-value patients to maximize ROI on services. It continually matches care resources to individual patient needs, yielding positive utilization, cost, quality measures, coding accuracy and patient satisfaction.

Expertise

As dedicated residentialists, we are the leaders in accountable, cost-effective, home-based care. We have deep experience in managed care models, ACO services, CMMI pilots, and traditional Medicare FFS.

Flexibility

Our turnkey solutions can be customized to meet patient and client needs. If your population is growing, we have proven ability to scale.

Both Clinical & Wellness Services

We are one of the few free-standing local home care groups that offers clients high-quality in-home clinical care and HCC Coding/Star Ratings support.

For High-risk/homebound populations

Resource Management and Continuity of Care

It is well documented that a small percentage of the senior population is responsible for the majority of costs. Additionally, many frail elders suffer because of poor mobility and/or their homebound status limits access to ongoing continuity of care.

Many of these excessive costs are avoidable through effective deployment of residentialist care resources. Residentialists are clinicians who specialize in the unique challenges of delivering care within the walls of the patient’s home.

Housecall Doctors Medical Group features a widely-deployed network of highly-trained residentialist clinicians who can improve access, quality of care, continuity of care, and patient satisfaction while concurrently reducing unnecessary costs.

We offer a “plug-and-play” solution for at-risk payers and medical groups, providing core competencies and efficiencies of delivery that are challenging and costly to develop and operate within an existing delivery system.

Our core services for residentialist care management include:

Ongoing Continuity of Care services for chronically homebound/access-challenged frail elderly patients

Care Transition Management services for post-discharge patients who are at high risk for readmission

Increase Your ROI

Revenue Enhancement Opportunities​

Organizations at-risk for costs of care face significant challenges in the effective management of high-costs seniors. Within the revenues and quality incentive arenas, many senior populations do not receive optimal penetration for HCC coding evaluation/reconfirmation, and Wellness Screening. This may occur through lack of access, lack of patient compliance, or insufficient documentation and coding within the ambulatory environment.

We have extensive background and expertise in providing HCC documentation and wellness services to senior populations. Utilizing a fully-trained field-based staff, supported by in-office coding review and quality-control systems, we provide clients with a comprehensive, fully-compliant documentation to support HCC reporting requirements and Star Ratings criteria. Additionally, the assessment tool is structured to be of high-value for case management and care coordination.