NYC Health + Hospitals Launches Health Systems First Home-Based Primary Care Program

December 5, 2019

NYC Health + Hospitals today announced the launch of the health system’s first home-based primary care program designed to improve health outcomes, quality of life, and reduce hospitalization for frail, homebound New Yorkers from Harlem to the Hudson. The pilot program will support a new team of visiting doctors and nurse practitioners who will make house calls to home-limited patients served by NYC Health + Hospitals/Kings County in Brooklyn. The program will offer primary care services in the home and use telehealth video visits to connect patients to specialty care, mental health services and help from social workers. Unlike traditional home care services that focus on short-term nursing assistance and physical therapy, this home-based service will expand access to primary care, preventive care, chronic disease management and mental health services to a population that faces obstacles to care due to their limited mobility. The new home-based primary care pilot program is expected to serve 200 patients.

The new program will be funded in part by grants from the Altman Foundation, the New York Community Trust, and the Fan Fox and Leslie R. Samuels Foundation, Inc., as well as investments by NYC Health + Hospitals, totaling $900,000 over the next two years to cover the cost of new staff, transportation, equipment and supplies. The new at-home primary care model builds on the NYC Health + Hospitals’ transformation goals to expand access to primary care to New York’s most vulnerable populations. Based on the results of the pilot, health system officials expect to expand the at-home primary care service model to other communities served by NYC Health + Hospitals.

“Too many people with debilitating chronic conditions that limit their mobility find it very challenging to leave the home and travel to visit their primary care physician. They are more likely to be disconnected to care, skip regular preventive care, and end up with additional health complications,” said Mitchell Katz, MD, NYC Health + Hospitals President and Chief Executive Officer. “This first home-based primary care pilot program will break down barriers and help improve health outcomes for some of the City’s most vulnerable populations.”

“Our home-based primary care program shows the depth of our commitment to make sure all New Yorkers have the access to the care they deserve and need,” said Dave Chokshi, MD, NYC Health + Hospitals Vice President and Chief Population Health Officer. “We must meet people where they are, particularly our most vulnerable and underserved patients. With our elderly population continuing to grow, investments into accessible health care are critical.”

“Someday, our society’s institutions may be structured to serve more than the temporarily able-bodied among us. We’re proud to be the first in our health system to adopt this new model of care in the home which will better position us to serve the patients of the future,” said Scott McGarvey, MD, program lead at NYC Health + Hospitals/Kings County.

At-home primary care has been shown to produce better health outcomes. According to the CMS Independence at Home Medicare Demonstration Project, 15 physician practices providing home-based primary care to 10,000 Medicare beneficiaries saw major improvements in quality of care and health outcomes, including 50 percent fewer hospitalizations, emergency department visits, and senior nursing facility days.

Those eligible for the NYC Health + Hospitals home-based primary care services will include patients over 50 years of age who are homebound or find it too physically taxing to leave the home and have at least one chronic condition. Patients will be referred to the program by primary care physicians at NYC Health + Hospitals/Kings County. Each at-home primary care patient will get house calls by a primary care physician and follow up visits by a nurse practitioner who will bring an “at-home kit” tailored to a patient’s previous diagnosis and care, including necessary medical devices and medications. The home-based primary care providers will be part of an extended care team that may include a social worker, home health aide, other specialists, and palliative care, professionals. Most of a patient’s care will be arranged by a care coordinator.

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“I am delighted that our City’s public hospital system has initiated yet another innovative program. Homebound New Yorkers will have access to home-based primary care and wraparound support that will improve health outcomes while reducing barriers and expenses,” said State Senator Gustavo Rivera, Chair of the Senate Health Committee. “Forward-thinking services like these make me proud of our public system’s commitment to convenient and reliable connections to care.”

“I want to commend the leadership of NYC Health + Hospitals/Kings County and our valued local foundations for their commitment to improving the quality of life of homebound patients,” said Councilmember Mathieu Eugene. “The launch of the home-based primary care program will have a substantial benefit to the quality of healthcare that we are able to provide our frail and underserved adult patients. As a community, it is important that we continue to expand the resources available to those who are infirm and have difficulty traveling. I am confident that by working together, we will increase the level of efficient and cost-effective medical care available to current and future generations of New Yorkers.”

“In today’s world, access to even necessary but basic health services too-often requires travel to a health care facility. For frail, homebound, low-income older adults, this can be an insurmountable barrier to care,” said Rachael N. Pine, Senior Program Officer at the Altman Foundation. “We applaud and are pleased to support NYC Health + Hospitals’ effort to pilot and initiate a program to bring primary health care into the homes of its most vulnerable and mobility-challenged patients. This program has the potential to reduce unnecessary hospitalization use and promote health, independent living, and quality of life for patients that might otherwise fall through the cracks in the City’s health care safety net.”

“Home-based primary care – a modern day house call – is a viable option for homebound patients to get quality and compassionate care,” said Irfan Hasan, Program Director at the New York Community Trust. “NYC Health + Hospitals is uniquely positioned to use the Trust’s support to deploy interdisciplinary clinical teams to serve the City’s most isolated homebound older adults. This effort fits with the Trust’s goal to advance efficient, patient-focused, equitable, and cost-effective health and behavioral health services to all New Yorkers.”

“The Fan Fox and Leslie R. Samuels Foundation, Inc. supports NYC Health + Hospitals’ priority of breaking down barriers to primary health care access, despite challenges with mobility,” said Julio Urbina, PhD, Vice President and Director, Healthy Aging of the Samuels Foundation, Inc.. “As our aging population grows in New York City, we have to continue to create innovative methods to make sure these patients receive the comprehensive, high-quality, and convenient health care they require.”

The NYC Health + Hospitals new home-based primary care program will complement existing home-based care services offered through NYC Health + Hospitals/Community Care, which offers short-term nursing assistance, physical therapy and social work.

NYC Health + Hospitals/Kings County is a 639-bed acute care teaching hospital located in Central Brooklyn. Among our highly specialized programs are a Level I Trauma Center, Pediatric Emergency Room, Level 3 Perinatal Center, Heart Health Center, Stroke Center, Sickle Cell Program, Behavioral Health Center, and Diabetes Education Center of Excellence. Many of our programs have received national recognition, including our cardiac, stroke and diabetes services. The hospital offers a broad array of primary and specialty care, including practices in neuroscience, orthopedics, urology and cardiology. Annually, our ambulatory care clinics see well over 500,000 visits, and more than 150,000 visits in the Behavioral Health outpatient program, in addition to close to 23,000 inpatient discharges. NYC Health + Hospitals/Kings County has played a major role in providing health care to vulnerable populations in Brooklyn since 1831, and is part of NYC Health + Hospitals, the largest public health care system in the nation. For more information visit, and stay connected on Facebook at or Twitter at @KingsCountyHosp.

NYC Health + Hospitals is the largest public health care system in the nation serving more than a million New Yorkers annually in more than 70 patient care locations across the city’s five boroughs. A robust network of outpatient, neighborhood-based primary and specialty care centers anchors care coordination with the system’s trauma centers, nursing homes, post-acute care centers, home care agency, and MetroPlus health plan—all supported by 11 essential hospitals. Its diverse workforce of more than 42,000 employees is uniquely focused on empowering New Yorkers, without exception, to live the healthiest life possible. For more information, visit

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