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Intensive Home-Based Primary Care

A unique part of the Atrius Health care network is our Intensive Home-Based Primary Care program which provides both short-term intensive care and longitudinal primary care for patients who have advancing illness, are at high risk of hospitalization, or need a multi-disciplinary home-based plan of care.

Home visits by nurse practitioners or physicians for short-term, long-term or a one-time visit include:

  • Geriatric-focused physical exam including assessment of executive and cognitive functions
  • Reconciliation of medications
  • Documentation into the electronic medical record with coordination of care between the patient’s primary care team and other specialists
  • Advance care planning, including completion of health care proxies and advance directives
Coordination of care with our home care partners, elder services, or private homecare services