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.