Medicine HOME

For people with complex health and social needs, there is a need for comprehensive individualized care. The Medicine HOME program follows a complex care model to improve health and well-being. This program is for patients with multiple chronic medical and behavioral health concerns, combined with significant health-related social needs concerns.

What Does HOME Stand For?

High Needs, High Caring: Home, Community, & Ambulatory Focus

Optimally Managed: Comprehensive Interdisciplinary Patient-Centered Care

Maintains Seamless Quality: Care Team Collaboration

Empowerment: Education & Advanced Care Planning

What Principles Guide Care?

The HOME team focuses their care on these principles

Patient-Centered

An individual's goals and preferences guide all aspects of care.

Healthy Outcomes for All

Addressing healthcare challenges improves health outcomes.

Cross-Sector

Breaking down silos that divide fields, sectors, and specialties leads to better care.

Team-Based

Teams should include interprofessional and non-traditional partners. That includes people in the community, the individual being cared for, and their support network.

Data-Driven

Important information is shared freely between all care team members to support care plan goals.

Who Facilitates Care?

The Medicine HOME program includes physicians, registered nurses, a social worker, and a population health specialist. The Medicine HOME team works collaboratively with each patient's care team to develop and follow individualized care plans.

History of Medicine Home

The Medicine HOME program was piloted in 2017. Their initial patient group saw significantly better health outcomes. This has led to the program expanding, and they now routinely care for 40-50 patients. In 2019, the program received the Charles L. Brown award for Excellence in Patient Care Quality. Program team members have been awarded Leonard W. Sandridge Outstanding Contribution Awards, DAISY Awards, and UTeam recognition.