Reduced Emergency Room and Hospital Utilization in Persons with Multiple Chronic Conditions and Disability Receiving Home-Based Primary Care

Andrew Schamess
Randi Foraker
Matthew Kretovics
Kelli Barnes
Stuart Beatty
Seuli Bose-Brill
Neeraj Tayal
Peer-Reviewed Article
October 2016


People with multiple chronic conditions and disabilities enrolled in home-based primary care experienced persistent reduced acute care utilization.


In traditional office-based primary care, adults with multiple chronic conditions and disabilities often face barriers to accessing care resulting in lower rates of preventive care and higher emergency department use. This population also reports high unmet health care needs and often lacks a usual source of care. Home-based primary care (HBPC) models can be designed to address these needs and structural barriers. The Division of General Internal Medicine at the Ohio State University (OSU) Wexner Medical Center developed OSU Healthy at Home for chronically ill patients with one or more disabling conditions. The program provides coordinated in-home care from a team that includes a licensed social worker and pharmacist. This study compared rates of utilization from three years prior to enrollment to one and three years after first home visits.


Patients in OSU’s Healthy at Home program (mean age 63) experienced reduced admissions, 30-day readmissions, and inpatient days as measured at both one year and three years following enrollment. Program interventions focused on managing symptoms and anticipating health crises, which allowed for more preventive care coordination.


These findings demonstrate that HBPC can reduce barriers to primary care access and support reduced acute care utilization for a non-geriatric population with multiple chronic conditions and disabilities.

Posted to The Playbook on