Specialized Primary Care and Senior Wellness

Managing your chronic or complex health condition can sometimes feel daunting. That’s why we have designed specialized primary care services and senior wellness programs that bring coordinated, personalized care into your home—all to ease that burden.

Our providers bring deep expertise in advanced, specialized care for your complex health condition. We do this through the primary care medical home (PCMH) concept, which is centered on providing you care that’s:

• Accessible
• Comprehensive
• Coordinated
• Patient-centered
• Rooted in quality and safety

Home Based Primary Care

Home Based Primary Care is a multidisciplinary, mobile and in-home primary care program for seniors or adults of any age facing barriers to care and health. Think of your care team as “a doctor’s office on wheels” if you’re too sick or otherwise unable to come to the clinic. They make home visits to provide primary and urgent care.

We’re also proud to collaborate with the Richmond Health and Wellness Program on improving health outcomes of the Richmond community through education, reducing health care costs and enhancing the lives of our senior patients.

Learn more about Senior Services and Continuum Integration.

Am I Eligible for Home Based Primary Care?

You may benefit from these services if you:

• Are 18 years old or older
• Are a patient of VCU Health’s primary care network
• Are in stable condition
• Are unable to leave home to receive care in a clinic
• Have complex care needs or co-occurring diseases
• Live within 15 miles of VCU Medical Center in Richmond, Virginia

Conditions We Treat with Home Based Primary Care

Our care team treats conditions you would normally see a primary care physician for, including managing:

• Allergies
• Diabetes
• High blood pressure
• Joint pain
• Upper respiratory infections
• Urinary tract infections

Coordinating Your Care at Home

VCU Health’s care team can connect you and coordinate additional in-home services to support your needs, including:

• Behavioral health services
• Medication management
• Physical and occupational therapy
• Skilled nursing services
• Social work
• Well-patient visits

What are the Benefits of Primary Care at Home?

With Home Based Primary Care, you and your loved ones benefit from a team of expert providers that bring healthcare into your home. They will be your PCP for life. The best part? You can get care in the comfort and privacy of your own home.

Advanced Health Homes

Advanced Health Homes are VCU Health’s unique approach to treating patients with complex care needs in a centralized place for advanced, comprehensive care. These Advanced Health Homes provide comprehensive adult and geriatric care for patients no matter where they are.

Am I Eligible for care at an Advanced Health Home?

You may benefit from becoming a patient of an Advanced Health Home if you:

• Are 18 years old or older
• Are in stable condition
• Have complex care needs or co-occurring diseases
• Live within 25 miles of VCU Medical Center in Richmond, Virginia

Conditions We Treat with Advanced Health Homes

We treat stable, high-risk patients with several conditions. Some of these conditions include:

• Cancer
• Dementia
• Sickle cell anemia

Advanced Health Home Services

VCU Health provides Advanced Health Home services to support your needs, including:

• Behavioral health services
• Care management with nursing, social work and counseling services
• House calls for patients who cannot get to clinics for appointments
• Medication management
• Nursing home care with 24/7 coverage
• Palliative care and hospice care
• Telehealth services including home monitoring, video visits and specialist consultations
• Transitional care from nurse practitioners for post-acute and post-ambulatory care needs

What are the Benefits of Advanced Health Homes?

Wherever you are, you can expect a seamless experience of advanced, comprehensive care. VCU Health’s Advanced Health Homes are here to provide a full range of support. Your care team brings a continuum of care that gives you appropriate services from the hospital to outpatient clinics to nursing homes and to your own home. This tailored care means timely support when you need it most.

Contact the VCU Health at Home Team

To learn more about our program, call our care coordinator at (804) 628-HOME.