Research Insights Highlight Challenges & Care Required for High-Risk Patients

October 30, 2019

Dody Fisher, MD

When I think back over my career as a primary care physician, I am grateful that in my first year of residency I had the opportunity to experience caring for patients in their homes. That exposure helped shape my career and I dedicated extensive time providing home care as part of my outpatient practice, as well as during my 6+ years at PACE (Programs of All-Inclusive Care of the Elderly), where house calls were a large part of the model.

Seeing patients in their home environment informed me of aspects of patients’ lives that I would ordinarily not know about, such as safety issues, eating habits, medication storage issues, heating/cooling problems, and family dynamics, all of which can influence care decision making. The top pain points for treating chronically ill populations that are identified in the Primary Care Physician (PCP) Insights research paper is, therefore, not surprising. We are still grappling with the same issue after all this time – a time constrained, one-sided view of high-risk, chronically ill patients. The research paper finds that patients would benefit from a home visit, which for most PCPs is time prohibitive and not adequately compensated.

This is one reason I am so excited to be part of the Vively Health team. We offer a solution for many PCPs – more care for their complex, chronic disease patients and insight into the home and social situations that affect their health. Our house calls team functions as an extension of the care provided by patients’ PCPs. It is a supplement, not a substitute.

But for this house calls model to really work, our Vively care teams and local providers need to effectively work together to ensure their mutual patients benefit. Above all, trust and communication are most important. We are really talking about a true partnership. And each partner in this relationship needs the communication from the other in order to perform their function effectively. Together we can effectively care for high-needs individuals in a world that is generally not set up to do so very well.

Click here to read the Primary Care Physician (PCP) Insights research.


Dorothy "Dody" Fisher
National Medical Director, Vively Health