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Access Health Louisiana launches home-visit pilot aimed at reconnecting vulnerable patients
Summary
Access Health Louisiana told the Saint Charles Parish Council it is piloting home visits for high-risk patients to improve chronic disease management; staff presented six-month data showing improved blood-pressure control and said the program will expand beyond Medicare patients by summer.
Access Health Louisiana representatives told the Saint Charles Parish Council on March 10 that the health system has launched a pilot home-visit program aimed at reconnecting the parish's most vulnerable patients to primary care.
The presentation, delivered by Robertson, senior vice president for population health at Access Health Louisiana, said the agency operates two primary-care centers in the parish and managed more than 25,000 patient encounters last year. Robertson said the pilot began in October and initially enrolled Medicare patients.
Robertson said, "We're introducing tonight a new service called home visits for those most vulnerable patients." He described the goal as helping patients who have become disconnected from care to reestablish a medical home and receive medication reconciliation, social-needs screening and coordinated care plans.
Nurse care manager Peggy Barrios described the clinical work done during visits. "So, what I do and I feel a very big privilege to be able to go into a patient's home ... and go in with that, for a purpose to shed a light on it with the providers and make a difference in their health," Barrios said.
The presenters shared six-month outcome data showing improvement in hypertension control among home-visit patients. Robertson said the share of home-visit patients with blood pressure in control rose from about 58% to 73% over the pilot period, which the team attributed to medication reconciliation, connection to primary-care providers and coordinated follow-up.
Latina Hunter Grover, clinical case manager for the Luling clinic, explained that case managers connect home-visit patients with community-based services, including organizations such as the Arc and the Council on Aging. Robertson said the pilot team is refining internal workflows and tracking outcomes closely to ensure care-team communication when a patient receives a visit.
The pilot currently enrolls Medicare patients only; Robertson said Access Health hopes to expand the service to Medicaid, commercial and uninsured patients by the summer of 2025.
The presentation included a short testimonial from Dr. Joseph, the clinic's medical director, and closed with an offer to provide additional data to the council if requested. No formal council action was taken; the item was presented as an informational report.
