New At-Home Care Program Focuses on Underserved Patients

New Equality Health at Home Helps Complex Patients Navigate Healthcare System, Address SDoH and Reconnect to Primary Care Provider

Equality Health, a leader in value-based care, unveiled its Equality Health at Home care program – an innovative initiative whereby on-staff community health workers, nurse practitioners, and chaplains deliver in-person and virtual care at home to patients facing complex medical issues and experiencing significant barriers to managing their health. The program aims to overcome a range of challenges and reconnect patients to their primary care provider in the Equality Health Network, driving better health outcomes through timely and appropriate delivery of care.

Equality Health at Home is the latest in Equality Health’s comprehensive offering focused on helping independent primary care practices (PCPs) be successful in value-based care contracting and care delivery. PCPs in its network gain access to value-based care contracts, risk-bearing financial incentives, an advanced practice technology platform, training, hands-on practice support with dedicated practice performance managers, and now staff for in-home care.

“We’ve seen the major impact in-home care can have on health outcomes, especially among the most complex patients in underserved communities.  We are committed to expanding these key functions to meet this growing community need,” says Mark Stephan, M.D., Chief Medical Officer Equality Health.

Equality Health’s value-based care technology platform, CareEmpower, identifies high-risk candidates for the 12-week program. The platform enables critical patient health alerts, including those concerning chronic conditions, co-morbidities, recent hospital stays, ED visits, and missed PCP appointments. PCPs can also send a message through CareEmpower, email or phone to Equality Health to refer high-risk or very high-risk patients to the program.

An Equality Health community health worker or nurse practitioner is assigned to the patient and conducts outreach via phone for the initial engagement. Through in-person and virtual care, the Equality Health staff provides a customized care plan and support to help patients navigate the often-complex healthcare delivery system, payer programs and local resources. Support includes general home care such as wellness exams and screenings; lab results review; equipment such as walkers, oxygen machines, and shower chairs; disease and chronic care education; SDoH support, such as access to affordable, healthy food and transportation; transportation to PCP appointments; spiritual support; and more.

Equality Health is initially launching the program in Arizona. Eligible patients are Equality Health members 18 years of age or older and assigned to a primary care provider within the Equality Health Network. Providers interested in joining the Equality Health Network in Arizona, Texas, or Tennessee can find more information here.

Read real-world patient stories about how Equality Health directly impacts lives, including Becky’s story: a Collaboration of Care.