An Innovative Health System Employs House Calls to Serve its Most Vulnerable Patients

October 31, 2019

Dody Fisher, MD

Today’s article in the Harvard Business Review featuring Geisinger’s Home Care program is a great example of how one health system is embracing an old model in a new way to drive better outcomes at a lower cost for its managed populations. Geisinger has incorporated a “house calls” model that brings comprehensive care teams into the homes of its most vulnerable patients, typically older individuals with complex care needs. For the more than 5,000 patients they’ve enrolled in the program, the results have been dramatic: 35% reduction in ER visits, 40% reduction in hospitalizations, and an average $8,000 PPPY reduction in spend.  

So why aren’t more health systems following suit? The challenges are inherent in the model itself which requires money, time and scalability – three factors that not all health systems are able or willing to absorb. The reason this works for Geisinger is that they are an integrated health system with a robust health plan, which means they are also at risk for a large number of patients they serve. Therefore, they have more incentive to spend money on programs that require additional resources to deploy if they ultimately drive healthier populations in the long run. 

A few other integrated care delivery systems, such as the Cleveland Clinic and Christiana Care, have established home-based primary care programs. But until we as a country have fully embraced value-based care, it is unlikely that traditional healthcare provider groups, who don’t have the necessary infrastructure and scale, will be able to justify the cost required to build out a house calls model. That’s where we come in. 

Vively Health partners with health plans and their provider networks to bring our house calls program to members at scale across a market. We take all the risk so health plans can justify the cost of our program by carving out their most complex members, those with multiple chronic conditions, to our medical group to manage. Our program uses predictive analytics to identify rising risk patients in addition to the highest utilizers. Like Geisinger, we have experienced exceptional results. Our house calls program, which served more than 7,000 members at one of the nation’s largest regional health plans, realized a 40% reduction in hospitalizations and 20% reduction in total cost of care. 

As the former Medical Director of Provider Network Management and Strategic Partnerships at Geisinger and the current National Medical Officer at Vively Health, I remain extremely bullish on value-based care delivery models that meet patients where they are when they need it most. Our health care system is moving in the right direction, but if we are truly going to move the needle on quality and cost of care, we must get it right for our nation’s Most Vulnerable Patients.  

To learn more about our house calls program or our full-risk partnerships with health plans, contact us directly.


Dorothy "Dody" Fisher
National Medical Director, Vively Health