Special Projects Fund

Project Title

The Medical House Call Model: Caring for Homebound, Chronically Ill Patients

Grant Amount


Priority Area

Special Projects Fund

Date Awarded

November 2, 2012


Capital Region






By 2030, the number of permanently homebound individuals in the U.S. will increase by 50% to reach 2 million.

These highest-need and sickest patients are also the ones who bear the greatest financial burden on the health care system. In 2011, Samaritan Hospital privately launched a small home-based care pilot program to determine whether a medical house call service could help patients with frequent hospital readmissions. The results were promising—the majority of patients were not re-hospitalized, and the conclusion was that the medical house call model warrants further study on a larger scale. With support from NYHealth, Eddy Visiting Nurse Association (Eddy VNA) and its affiliate St. Peter’s Health Partners set out to test the medical house call model in four upstate New York counties: Albany, Rensselaer, Schenectady, and Saratoga.

The target population included homebound patients residing in the four-county service area who can benefit from in-home primary care, either long-term or transitional. Patients were identified by hospital staff, home care staff, Eddy VNA Care Transition Coach RNs, community physicians, and health plan case managers. Selection criteria focused on patients with a history of repeated emergency room use and hospitalization. This model recruited two physician/nurse practitioner teams through an income guarantee model and the provision of a formal training program. By the end of the grant, the two teams served more than 600 patients annually. A consultant from Rensselaer Institute of Technology oversaw the project’s evaluation and dissemination of its findings.