The team at Prospect Medical Holdings - Coordinated Regional Care (CRC), RI launched its Care@Home program in July 2020 to address social isolation, system access issues, and an above-average readmission rate for their Medicare population. The Care@Home program primarily focuses on delegated Medicare Advantage patients and traditional Medicare patients who would benefit from in-person home visits by a team of providers, nurses, and social workers. The goal: to prevent disease exacerbations, improve symptom management, and reduce unnecessary utilization—all while working closely with the patient's primary care providers.

Serving as an extension of the primary care physician in the home setting, the Care@Home team provides patients with 24/7 access to the team, including after-hours visits. Prior to patients having access to the program, emergency department (ED), hospital, and skilled nursing admissions were the only options for patients outside of normal business hours. The results have been striking. Care@Home program utilization metrics for 2022 showed a readmission rate of only 3%, along with a 63% reduction in inpatient admissions, 81% reduction in ED visits, 89% reduction in urgent care visits, and a 17% reduction in skilled nursing admissions.

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Project Team

Monica Walston Kucks, RN, BS, CCM,
VP Care Integration & Transformation

Lidia Vognar, MD
Care@Home Medical Director

Matthew Brazier
PharmD, Director of Pharmacy

Mark Mazzye, PA-C, CAH

Krystal Coutcher, PA-C BS MHS, CAH

Jen Landi, BSN, RN HIHC-CSp, CAH
Lead Nurse Care Manager

Diane Cocroft, RN, CAH
Nurse Care Manager

Jaimie Chomka, LCSW
Lead Social Worker

Liz Camara, SW

Katelyn Russo
Post Discharge Coordinator

Carmen Bobadilla
Outreach Coordinator

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