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Medical Home at Home Program Provides Comprehensive Care to Patients with Chronic Diseases

Evara Health provides care to more than 60,000 patients in Pinellas County, Florida, including many people who have multiple chronic diseases and need recurring appointments to monitor their health and help them follow their care plans. Many of these patients, however, lack transportation, have lower incomes, and do not want to risk COVID-19 exposure through in-person medical appointments, which creates challenges for them with maintaining in-person appointments. To address these barriers and increase access to care, Evara Health launched an innovative telehealth delivery program supported by HRSA’s Optimizing Virtual Care (OVC) grant. The new Medical Home at Home program brings the coordinated, comprehensive approach of the medical home model of care to the patient’s home. Since the program began in March 2022, Evara Health is already seeing the impact in their community. 

The Medical Home at Home program aims to increase equitable access to primary care and wraparound services for patients with limited accessibility and multiple chronic conditions. Two mobile teams visit patients’ homes, complete screenings and assessments, and set patients up for telehealth visits with providers. Each mobile team is equipped with clinical and virtual care tools, including connected devices and a Wi-Fi hot spot to facilitate telehealth visits. Staff on the mobile team also provide and offer instruction on remote patient monitoring (RPM) devices that allow nurse case managers to monitor a patient’s health from an Evara Health site. A patient recently shared, “I appreciate knowing that you’re monitoring my vitals and reaching out when something is off.” Through this initiative, Evara Health aims to improve digital health literacy, diabetes, and hypertension care management.


Already, results of the program are encouraging. Evara Health enrolled 128 patients in Medical Home at Home through June 2022, and statin compliance increased by 21% during the first quarter of 2022. In addition, human immunodeficiency viruses (HIV) screening rates for patients with chronic conditions increased by 12%. Medical Home at Home is helping patients stay connected with their medical providers and remain on track with their health care goals from home.