About Us

Transition of Care (TOC) Visits

During an in-home TOC visit, HouseCalls staff will:

Address post-discharge medication reconciliation issues
Provide additional education to patients and families about how to manage the patient’s health
Identify other psychosocial factors for the primary care team to address

These visits help to bridge care between the hospital, the primary care team, and specialists during a period of time when patients are vulnerable. The TOC visit will be scheduled within 7-14 days of hospital discharge based on the patient’s complexity.

Patient criteria for in-home TOC Visit

Age 18 and older
Has a Michigan Medicine PCP
Live in Washtenaw County or Belleville
Were in the hospital for something that impacts mobility (I.e. Fracture, hip replacement, increased dementia, new stroke, increase in dementia, etc.)
Are likely to have increased debilitation (I.e. the patient been in the hospital for several weeks)
Has a history of multiple appointment no-shows
Does not have access to transportation to make it to the appointment

Referral Assessments

HouseCalls provide focused assessments that can help to augment understanding of factors in the patient’s home environment that impact health, well-being, treatment compliance and acute care utilization. The HouseCalls Program will determine whether the patient requires either a onetime assessment or enrollment in the Care Management Model. The referrer and PCP will be notified within 3 business days if referral has been accepted or denied.

Patient criteria for Referral Assessment

Age 18 and older
Has a Michigan Medicine PCP
Lives in Washtenaw County and Belleville
PCP believes an in-home assessment may reveal barriers to care that patient may not otherwise disclose.

Care Management

Through care management, HouseCalls staff complete a comprehensive in-home assessment to evaluate medication issues, along with functional, psychosocial, and financial barriers that may impede a patient’s health. HouseCalls staff can also assist in resource finding, and overall care coordination.

By providing in-home care coordination and assistance with accessing local resources, we help patients stay healthy at home and minimize unnecessary calls to the primary care office and utilization of the emergency department and hospital.

The referrer and PCP will be notified within 3 business days if referral has been accepted or denied. HouseCalls will attempt to schedule initial assessment within 7 business days.

We provide urgent visits for established patients who are unable to see their PCP in a timely manner. Per PCP request, these urgent visits will be provided within 24 hours during the business week.

Patient criteria for Care Management

Age 55 and older
Has a Michigan Medicine PCP
Lives in Washtenaw County or Belleville
Has had at least 1 admission in past year AND one of the following:

6 or more PCP visits, OR
2 ED visits

2 or more chronic illnesses
Has difficulty with at least one Activity of Daily Living (ADL) and has at least one Geriatric Condition

Visit Standards

The patient’s insurance is billed similarly to an office visit. If a patient incurs a co-pay or deductible for office visit, the same would apply.
HouseCalls will notify PCP/referrer whether the referral has been accepted or denied within 3 business days.
Patient PCP retains primary care responsibility across all service lines.

Documentation of immediate concerns will be sent to the PCP and other members of care team within 24 hours of visit through MiChart. The completed assessment will be routed to the provider and patient’s care team within 2 business days.