PRIMARY CARE
Clinicians who stay with patients between visits
Guided by daily readings from the patient’s home, we provide continuous care alongside the patient’s physician or as their primary care provider.
Primary care designed around the patient’s daily life
Continuous primary care means patients have a care team that knows how they are doing at home, and clinicians see changes earlier and can act on them.
Visits and treatment
Our clinicians see patients, prescribe, and adjust treatment as their conditions change.
Orders and referrals
Labs, tests, and referrals are ordered and followed through to a result, so nothing is left open.
One shared record
Every visit, order, and prescription is documented and written back to the patient’s record.
Two decades of better control and fewer hospital stays
Reduced Risk of 30-Day Readmissions
Lower Odds of Hospital Admission
Blood Pressure Control Sustained at 18 Months
Lower HbA1c on Average
You choose the role our clinicians play
The care is the same whether we extend an established relationship or serve as the patient’s primary care provider.
| Comparison | Extended Primary Care |
Accountable Primary Care |
|---|---|---|
| Primary care provider | The patient’s own physician | Our clinicians |
| Our role | Care between the physician’s visits | The full primary care relationship |
| Accountability | The physician’s plan governs when the two differ | We are accountable for the patient’s outcomes |
| Best for | Patients with an active primary care relationship | Patients without an active primary care relationship |
| Comparison | Extended Primary Care |
Accountable Primary Care |
|---|---|---|
| Primary care provider | The patient’s own physician | Our clinicians |
| Our role | Care between the physician’s visits | The full primary care relationship |
| Accountability | The physician’s plan governs when the two differ | We are accountable for the patient’s outcomes |
| Best for | Patients with an active primary care relationship | Patients without an active primary care relationship |
You choose the role our clinicians play
The care is the same whether we extend an established relationship or serve as the patient’s primary care provider.
| Comparison | Extended Primary Care |
Accountable Primary Care |
|---|---|---|
| Primary care provider | The patient’s own physician | Our clinicians |
| Our role | Care between the physician’s visits | The full primary care relationship |
| Accountability | The physician’s plan governs when the two differ | We are accountable for the patient’s outcomes |
| Best for | Patients with an active primary care relationship | Patients without an active primary care relationship |
| Comparison | Extended Primary Care |
Accountable Primary Care |
|---|---|---|
| Primary care provider | The patient’s own physician | Our clinicians |
| Our role | Care between the physician’s visits | The full primary care relationship |
| Accountability | The physician’s plan governs when the two differ | We are accountable for the patient’s outcomes |
| Best for | Patients with an active primary care relationship | Patients without an active primary care relationship |
Built for conditions that need continuous care
Our largest programs focus on major chronic diseases, but we provide the same level of care for a wide range of other conditions.
Daily weight and blood pressure readings catch fluid changes early, so treatment is adjusted before a flare-up becomes a hospital stay.
Oxygen readings and reported symptoms show when breathing is getting harder, so clinicians can step in as a flare-up develops.
Glucose readings from home guide medication changes, so treatment keeps pace with how a patient’s numbers are actually moving.
Home readings show how blood pressure behaves day to day, so clinicians can adjust medication and keep control over time.
One care team treats the whole patient, coordinating medications, orders, and referrals across the conditions they live with.
One clinical team, from visit to follow-through
Patients are cared for by one licensed, multidisciplinary team. Prescribing clinicians see patients and adjust treatment, while care managers make sure every order, referral, and test is completed. Our physicians are licensed in the states where patients live.
Care at home, in person when needed
Our clinicians care for patients remotely, wherever they live, so access doesn’t depend on how far they live from a clinic. When a patient needs an in-person visit, their own physician or an in-network physician provides it, and the results return to the shared record.
RANDOMIZED TRIAL
Blood pressure controlled from home, results that held, in a randomized trial
HealthPartners, an integrated health system in Minnesota, gave adults with uncontrolled hypertension, half of them still working, AMC Health home blood pressure monitors and had clinical pharmacists adjust their medications from the readings by phone. Within six months most patients had their blood pressure under control, compared with fewer than half in usual care, and the gap was still there six months after the program ended. Published in JAMA.
