A patient-centered, multidisciplinary team approach to home-based primary care: A new care model at the Mount Sinai Visiting Doctors Program

Mount Sinai Visiting Doctors Program, the largest academic home-based primary care program in the U.S., cares for over 1000 homebound patients in Manhattan annually. Despite the program's growth, there continues to be a greater need in the community for primary care services for the homebound than the program is able to meet at its current capacity and structure. We launched a project in September 2009 designed to extend care for the most vulnerable homebound patients. Utilizing a patient-centered care team consisting of physician, social worker, nurse practitioner, and administrative assistant, the restructure has enabled the program to extend primary care services to 50% more homebound individuals per primary care provider. The addition of a nurse practitioner, working in tandem with the physician, allows the physician to refocus on patient care, increasing panel size as well as proportion of high-level home visits. In addition, the project targets patients at greatest risk of repeat hospitalizations through extensive use of proactive social work care management. Rigorous project evaluation will enable us to develop the most effective home-based care model for serving the growing and underserved homebound community. Preliminary project evaluation of the cost-effectiveness of this new approach as compared to our existing care model includes a comparison of frequency of patient hospitalizations and hospital length of stay. Project evaluation also includes assessing provider level of satisfaction for those working as part of care team and for those patients being served by the team.