House calls are back with team health care

Some of us of a certain age remember the days when doctors used to make house calls with their black bags. Well, things have come full circle.

In this high-tech age, when health care seems more complicated, some local Medicare Advantage plans have arranged to provide home-based services to those with multiple chronic conditions. What health providers have discovered is that those persons with the greatest needs will do much better if given this kind of intensive attention at home and it will avoid the need to go to a hospital or use more expensive services.

The home-based team often includes physicians, nurse practitioners, nurses, pharmacists, dietitians, and social workers. The team is not meant to replace the patient’s primary-care doctor but rather to provide follow-up care and to implement a plan of care coordination.

Other efforts are underway to provide better care coordination even if home visits are not involved. Many providers are calling their patients when they return home to make sure they are connected to the follow-up care needed for them to remain at home and improve their health condition.

Some hospitals are also considering adding community-services providers in the hospital to help coordinate care for the person when he or she returns home.

The services of Community Caregivers, of course, also help people remain living at home. We are working more closely with medical providers, giving our advice on the best ways for the coordination of medical and community services for those persons returning home from the hospital.

In the coming year, we are hoping to work with them on developing and training volunteer patient navigators who could be available to provide assistance with the follow-up and coaching to make progress with a care plan.

Community Caregivers Inc. is a not-for-profit organization that provides non-medical services, including transportation and caregiver support at no charge to residents of Guilderland, Bethlehem, Altamont, New  Scotland, Berne, Knox, and the city of Albany through a strong volunteer pool of dedicated individuals with a desire to assist their neighbors.

Our funding is derived in part from the Albany County Department for Aging, the New York State Office for the Aging, and the United States Administration on Aging. To find out more about our services, as well as volunteer opportunities, please visit or call us at (518) 456-2898.

Editor’s note: Michael Burgess is a health policy consultant for Community Caregivers Inc.