Medicine HOME Program


H - High Needs, High Caring: Home, Community, and Ambulatory Focus

O - Optimally managed: Comprehensive Interdisciplinary Patient-Centered Care

M - Maintains Seamless Quality

E - Empowerment through Education and Advanced Care Planning

Complex care is a growing field that seeks to improve health and well-being for people with complex health and social needs. This includes those who have multiple chronic medical and behavioral health conditions, combined with social barriers such as homelessness and unstable housing, food insecurity, lack of transportation, and more, which are exacerbated by systemic problems such as racism and poverty. 

The Medicine HOME Program was piloted in 2017 by a dedicated group of individuals to reduce hospital utilization and 30-day readmissions for a small cohort of patients (n=10) with sickle cell disease. The program consists of the multidisciplinary development of an individualized care plan (ICP) and intensive care coordination to address barriers to care. Based on its initial success in decreasing utilization (>65% reduction in 30-day readmissions, 40% reduction in hospital bed days), the program was funded and expanded. The program’s rolling active census is 25-30 individuals with approximately 45 lifetime enrollees. Most are among the top 1% of utilizers of inpatient care.

The HOME Program is driven by the following guiding principles:

  • Person-Centered – Individual’s goals and preferences guide all aspects of care
  • Equitable – Seeks to improve health equity by addressing the consequences of systemic issues
  • Cross-Sector – Works at the systems level to break down the silos dividing fields, sectors, and specialties
  • Team-Based – Delivered through inter-professional, non-traditional, and inclusive teams. Teams incorporate the individuals themselves and their family members
  • Data-Driven – Timely, cross-sector data freely shared across all care team members

Team members include Medical Director, Amber Inofuentes, MD, Lead Hospitalist for Diabetes Subgroup (Ian Crane, MD), Clinical Programs Coordinator, Teresa Radford, RN, and Social Worker, Guy Lushin, LCSW. The team joined the Population Health Department in 2021.

In 2019, the program received the Charles L. Brown Award for Excellence in Patient Care quality and has presented its work at national meetings including the Society of Hospital Medicine and the National Center for Complex Care.