Atrius Health’s Medically Home Program Integrates Acute Hospitalization and Post-Discharge Care

By the Playbook staff

A new care delivery model of providing hospital-level services in the home (sometimes referred to as “home hospitalization” or “hospital at home”) has been launching with pilots at a number of health systems nationally. Atrius Health and its subsidiary VNA Care, in clinical collaboration with Medically Home Group, have developed a special version of this program that combines acute and post-acute medical care in the patient’s home called the Medically Home Program. The Medically Home Program seamlessly integrates acute with restorative phases of care, using a single, cohesive care team during an average 30-day episode. By integrating acute hospitalization and post-discharge care into a single episode managed by a single care team, transitions of care and opportunity for error are minimized. In addition to delivering acute hospital-level care in the comfort and security of a patient’s home, Medically Home’s differentiation from other home hospitalization includes: communication tools; safety systems and redundancy; and integration with patients’ primary care physicians. The Medically Home Porgram aims to protect patients’ well-being and prevent avoidable medical errors.

This home hospitalization approach helps to better reveal and address the psycho-social triggers of “where and how” the patient’s medical episode transpired (in the home).  Being in patients’ homes provides the care team the ideal time and site to address preventing (avoidable) future events.

In the following videos, Rob Mechanic*, Executive Director for the Institute for Accountable Care interviews Dr. Pippa Shulman, Director, Center for Healthcare Innovation at Atrius Health about home hospitalization.


Advice for Getting Started with Home Hospitalization 


Pippa Shulman Discusses her Home Care Background


How Do Hospitals Feel About Home Hospitalization? 


How Do You Determine if a Patient is Well-suited for Home Hospitalization?


What are the Necessary Components? 


What Are Some Other Applications? 


What Are Your Home Hospitalization Patients Like? 


What Kind of ROI Have You Seen? 


Why Start Slowly? 


Full-Length Interview:


Atrius Health, an innovative nonprofit healthcare leader, delivers an effective system of connected care for more than 720,000 adult and pediatric patients in eastern and central Massachusetts. Atrius Health’s 32 medical practices, with more than 50 specialties and 825 physicians, work together with the home health and hospice services of its VNA Care subsidiary and in close collaboration with hospital partners, community specialists and skilled nursing facilities.  Learn more about Atrius Health at

Medically Home Group is a technology-enabled services company that provides all the necessary tools to allow medical providers to safely-shift advanced medical care from hospitals to patients’ homes. Through their commitment to creating superior experiences and outcomes for patients, their families and other healthcare stakeholders, Medically Home Group is leading the charge in innovation of healthcare delivery.

*Rob Mechanic serves on the Atrius Health Board of Trustees