Preliminary Analysis of an Advanced Health Care Practitioner-Led Home-Visit Primary Care Program for High-Risk Patients Reduced Health Care Costs and Utilization

Parag Bharadwaj
Nathan Dyjack
Gagandeep Gill
Adam Solomon
Mark Schafer
Elizabeth Simpson
Roseann DeVito
Gwyn Merz
Lysa Switzer
Marshall Gillette
Lindsay Fahnestock
Chintan K. Somaiya
Manjit Randhawa
Peer-Reviewed Article
October 2023


A home-based primary care program for homebound older adults leads to reductions in health care utilization and overall cost savings.


Approximately seven million adults in the United States face the challenge of either being homebound or experiencing significant difficulty leaving their house. This population is more likely to encounter barriers in accessing care as well as demonstrate additional complex health and social needs. Home-based primary care (HBPC) models have emerged as a promising practice to improve care for this population.

In response to these challenges, MemorialCare Medical Group (MCMG) in Long Beach, California, launched the Wellness Healing Optimization of Health Life Planning and Education (WHOLE Life) program. This initiative provided Medicare Advantage patients with home visits conducted by a nurse practitioner working in coordination with a primary care provider. Additionally, a social worker offered counselling and care coordination services. Eligibility for the WHOLE Life program was extended to patients who were over the age of 75, classified as high clinical risk, homebound, and had no primary care visits for the past 12 months.


This study evaluated the effects of the WHOLE Life program on both total cost of care and health service utilization. Analyzing a sample of 135 enrolled patients, the study found a 29 percent decrease in the total cost of care in the year following the program’s launch. Utilization, measured by inpatient visits, emergency department visits, and 30-day readmission rates, also decreased by 36, 39, and 54 percent, respectively, among the sampled patients.


This study adds substantially to the growing evidence base indicating the efficacy of home-based primary care programs. The inclusion of a total cost of care calculation in these findings provides valuable insights into the potential return on investment for similar programs. Additionally, the authors note that increased utilization of home-based palliative care and hospice care was also observed among the study's sample. The program’s emphasis on in-person connections with various providers offered may have increased patients’ awareness and comfort with these services.  

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