I. Executive Summary
Care at Home Solutions is an innovative, community-based program designed by COPE Health Solutions to support high-risk, medically complex patients where they feel safest, at home. Through a physician-led, multidisciplinary care team, we aim to improve outcomes, reduce avoidable utilization, and restore connections to ongoing care.
II. The Problem: Gaps in Post-Acute and Chronic Care Management
Rising medical costs and worsening health disparities signal a need for new approaches to care. Research shows:
- Patients over age 65 are 3x more likely to be readmitted if they lack follow-up care post-discharge
- For patients with multiple chronic conditions, outreach within 14 days post-discharge can lead to a 19.1% reduction in readmissions2
For Medicare and Dual Eligible Special Needs Plans (D-SNPs) populations, social determinants like food insecurity, housing instability, and lack of transportation further impede access to preventive care and care coordination.
III. Our Solution: Care at Home Solutions
What We Do: Care at Home Solutions provides, high-touch, wraparound care to stabilize high risk patients whether they are at home or facility (e.g. hospital, skilled nursing facility, etc.). Services include:
- In-person and telehealth visits with a physician led multidisciplinary team
- 90-day engagement model tailored to the patient’s goals
- Care coordination with PCPs and IPAs to realign patients with in-network care
- Behavioral and social support addressing SDoH, HRSN needs and more
Who We Serve: High-risk patients with multiple chronic conditions, high ED/inpatient utilization and lack of established PCP relationship.
What Makes Us Different?
Care at Home Solutions prioritizes face-to-face care and direct community resource linkage, building trust and improving adherence.
IV. Measurable Impact
Care at Home Solutions is designed to improve outcomes and reduce cost through:
- Optimized Medical Cost Savings
- Reduction in Avoidable Utilization
- Improved Quality Metrics
- Improved Access to Care
- Increased Patient and Provider Satisfaction
Case Study
What We Did: COPE Health Solutions implemented Care at Home Solutions for a large IPA client in New York, delivering on the model through in-person, multidisciplinary care to high-risk, complex members.
Outcomes:
- 46% reduction in hospital readmissions
- 66% reduction in hospital admissions
- Demonstrated strong improvement in member outcomes and positive ROI
V. Why COPE Health Solutions?
With decades of experience in care delivery innovation, COPE Health Solutions brings a proven approach:
- In-home focus: Prioritizing physical presence to build trust and identify home-based barriers
- Physician-led teams: Ensuring clinical quality and integration with existing care networks
- Scalable model: Designed for health plans, IPAs, and providers aiming to manage risk and improve outcomes
VI. Let’s Partner
Care at Home Solutions offers a scalable, results-driven model that enhances the value of your network. Contact info@copehealthsolutions.com today to talk about how this program can work for your population.