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. The program was funded and expanded based on its initial success in decreasing utilization (>65% reduction in 30-day readmissions, 40% reduction in hospital bed days). The program’s rolling active census is 30-40 individuals with approximately 85-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

Our team comprises a physician medical director, a lead hospitalist, a family nurse practitioner, a licensed clinical social worker, registered nurses, a case manager, and a program coordinator.  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. Program team members have been recognized for their dedication to patients through the Leonard W. Sandridge Outstanding Contribution Award, Daisy Award, and UTeam. This program’s work has been presented at national meetings, including the Society of Hospital Medicine, the National Center for Complex Care, and a Becker’s Webinar.

For more information, please call the Medicine HOME team at 434.982.2045.

    Amber Inofuentes, MD

    Medical Director

    Teresa Radford, BSN, CMSRN

    Clinical Program Coordinator

    Mary Wade, RN, BSN

    RN Clinician 3

    Guy Lushin, LCSW


    Jack Hooppaw, MSW

    Population Health Case Manager
    Social Worker, Medicine HOME Program

    Amy Luu, MPH

    Population Health Specialist
    Medicine HOME Liaison
    Tel: 434.982.2045