Norfolk, Va.-based Sentara Health said its home-based primary care program is cutting unnecessary emergency department visits, and improving patient experience and access to care for vulnerable patients.
The program first launched in 2023 when Christopher Nein, MD, noticed some patients had trouble getting to his office. To meet the need, Dr. Nein started visiting patients on his drive home.
“There are a lot of high-complexity patients who don’t see a doctor as often as they need to because they’re not able to leave the house,” Dr. Nein, who leads the program, said in an April 14 system article. “The solution was to bring a Sentara provider into the home.”
In 2024, only one home-based NP served patients, now there are five, with a sixth NP joining the team this July.
Home visits are conducted by nurse practitioners who often add same- or next-day visits for patients. They also provide hospital discharge visits within two to four days of discharge, which has helped prevent ED readmissions among complex and vulnerable patients.
“Our home-based nurse practitioners often will arrive to a home visit to find the patient experiencing acute symptoms,” Dr. Nein told Becker’s. “At the time of the visit, the NP is able to assess the patient, diagnose the issue, order treatment and arrange for close follow up. Most often, these acute symptoms are related to [chronic obstructive pulmonary disease] exacerbation, [congestive heart failure] exacerbation, sinusitis/bronchitis or acute pain.”
In 2025, the program provided more than 3,500 home visits and over 75 hospital discharge home visits. The home-based primary care nurse practitioners performed over 300 virtual video visits and 382 Medicare annual wellness visits.
To participate, patients need to have Medicare and be referred by their primary care physician. Most of the program participants are older patients, but there are many younger patients with disabilities that use it as well. Currently, more than 1,000 patients are enrolled in the program, with eight to 12 referrals coming in each week.
The system has also launched a medical assistant home visit program in 2025, where medical assistants provide one-on-one education to patients who are not familiar with virtual technology. These MAs help patients log on and complete virtual video visits, which expands their access to specialty care. They also draw necessary labs, administer vaccinations and perform clinical tasks within their scope of practice and licensure.
“Our mission is to provide them top-quality care that keeps them happy, healthy and thriving at home as long as possible,” Dr. Nein said.
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