Home-Based Care

Advanced Care for Your Most Vulnerable Seniors and Adults

A small percentage of your population is fueling runaway costs and placing an enormous burden on your bottom line. Meanwhile, your overall membership is aging and developing multiple chronic diseases along the way.

We can help improve outcomes for your members in ways that go beyond what traditional care management strategies can accomplish. We’re a mobile medical provider group focused on supporting meaningful clinical outcomes and effectively managing medical expenses.

  • Improve quality of life for medically complex or frail members
  • Close quality care gaps
  • Reduce unneeded utilization
  • Reduce overall medical expenses
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40% reduction in total cost of care
11% readmission rate
42% reduction in inpatient admission rates
net promoter score
22 STARS/HEDIS measures directly influenced
additional STARS/HEDIS measures influenced
/year HCC capture (MA population)

We offer physician-led, in-home, medical care that improves the lives of your most vulnerable seniors and adults by preventing unnecessary utilization and lowering overall healthcare costs. We are confident in our ability to drive positive change and will place our fees at risk to prove it.

You have made significant investments in health management across your organization. Let us help you increase your impact.

We offer a configurable approach to home-based advanced primary care, built upon our proven CareSight delivery model. Our approach:

  • Pinpoints members who are both consistently high cost and can be positively impacted through additional home-based care and treatment.
  • Leverages interdisciplinary medical care teams to deliver an average of 18 in-home visits per member while spending over 11 hours per year with each participant.
  • Integrates a comprehensive range of medical services, including primary and urgent care, medication therapeutic management and adherence support, disease management, kidney and palliative care.
  • Connects, augments and enhances your current care management efforts, filling gaps where they exist.
  • Provides 24/7/365 availability for routine scheduled visits and urgent after-hours care.
  • Quarterbacks the overall management of complex members to deliver a holistic and integrated experience.



We focus on your members who:

  • Drive 50% of all hospital admissions
  • Account for 40% of total cost
  • Cost an average of $38k/year
  • Have 4+ chronic conditions
  • Are on 6+ medications



We provide a flexible care delivery model, adjusting for your plan goals and unique market needs. We can operate in an attributed model where our physicians and APPs become the assigned PCP for the patient, or we can serve as home visiting specialists, providing an added layer of targeted and proactive care to complement an established PCP. We can also deploy a hybrid model that is customized for various subsets of your member population.

In all of these scenarios, we deliver a host of comprehensive and fully integrated in-home and virtual care solutions 24/7/365, including

  • Primary care designed for older adults
  • Advance care planning, palliative care, and caregiver collaboration
  • Geriatricized care model
  • Mobile and virtual urgent care 24/7/365
  • Quality gap closure and HCC documentation
  • MTM, medication reconciliation, and adherence support
  • Behavioral health assessment and therapy
  • In-home bloodwork, point-of-care testing, imaging, and vaccinations
  • Self-management of chronic disease education
  • SDoH screening, intervention, and community resource coordination


My provider takes the time to listen to me and go over all of my medications with me. I have COPD, diabetes, and arthritis, so it’s not easy to get to my appointments. By coming to my home, she makes it convenient for me.

Robert M., Member



Using a comprehensive group of data sets over multiple years, we tailor our model to the clinical and behavioral trends within your population. Our predictive models pinpoint the best opportunities within your population, those high-cost but addressable members who need more help. We align with you to set specific goals based on your data and your plan’s imperatives.


To encourage your members to enroll in the program, we develop a 12-month communications plan incorporating the best practices of behavioral economics across multiple channels that is consistent with your brand voice. In collaboration with your member engagement teams, we establish campaign goals, develop materials using simple and purposeful language, and track the results of our shared efforts.

Assess & Plan

We partner with you to deeply understand your current provider network and existing resources so that we can effectively embed our team and extend your impact. We become a credentialed medical practice in your network as a specialty medical group and staff a market-based care team based on geographic concentrations of your addressable high-cost members. Remote patient monitoring and other technology enable our care teams to reach rural populations, bridging the access challenges they commonly face.

We integrate and coordinate care to address medical costs, quality, and revenue challenges associated with high risk populations. Participants average 18 encounters annually with our providers spending over 11 hours a year with them. The national average for physician face-to-face time with a patient is only nine minutes annually*.


Our physician-led medical group provides high-touch clinical support via our in-home and virtual care model. This multi-disciplinary team includes nurse practitioners, RNs, master’s level social workers, community health workers and care coordination specialists. We increase the quality and frequency of information sharing with each patient’s care team, close clinical gaps and help prevent unnecessary utilization. Our in-home evaluations assess lifestyle and living environment (medical, behavioral, and SDoH). We coordinate home visits with additional fully employed social and behavioral support that overcomes common access bottlenecks in the traditional delivery system.


Based on your specific goals (MLR, quality, retention), we hold ourselves accountable for delivering credible and meaningful outcomes. We offer a number of validated measurement methodologies, including total population, identified population, full or partial risk, and shared savings. Our rigorous approach to measurement ensures you can trust the progress we make together, and that real value is being created.

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The current environment is creating unprecedented demand for virtual and remote care services, while placing specific strain on primary care delivery. This is particularly true for medically complex and frail individuals. Our in-home delivery model is led by physicians and advance practice providers. This is a powerful approach because it:

  • Increases engagement and trust with members, which in turn drives adherence and compliance
  • Creates better access to healthcare services
  • Is often a more convenient and safe way to deliver support to medically complex and frail individuals
  • Provides a 360-degree view of health and lifestyle for a more holistic assessment of needs, including social determinants of health
  • Established medical practice with 7+ years of successful experience delivery care to complex vulnerable patients.
  • Deep experience in serving and achieving outcomes across all lines of business, including Medicare Advantage (MA), Managed Medicaid including Long-Term Services and Supports (LTSS), Dual Eligible, Institutional Special Needs Plans (ISNP) & Dual Special Needs Plan (DSNP).
  • Our national medical group is licensed and credentialed. We offer holistic, multi-disciplinary support.
  • Integration is a core competency, bringing together a range of in-home medical care capabilities without duplication of costs and interventions.
  • Proven success managing risk-based contracts.
  • Superior Member Experience: 82 NPS.
  • Reconciled, validated outcomes with our clients demonstrates ability to significantly reduce total cost of care.
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After getting a call about a lower blood pressure reading from a home-bound patient, PopHealthCare’s nurse practitioner visited my patient in her home, took her blood pressure, and reviewed her medications. Having another set of eyes on my patients in between their visits with me helps me provide the best level of care.

Dr. Zachary Suter, UR Medicine Primary CarePulsifer Medical Associates

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