1. Shurson, Lauren DNP, FNP-BC
  2. Pilon, Bonnie PhD, RN, NEA-BC, FAAN
  3. Ketel, Christian DNP, RN
  4. Anthamatten, Angelina DNP, FNP-BC


In response to the need for increased access to primary care services for a low-income, at-risk community, two local universities partnered with a nonprofit Housing and Urban Development affiliated provider of affordable housing to launch a primary care clinic within an urban public housing community. Although the establishment of this clinic represented progress in meeting many healthcare needs of the target population, an interprofessional team also identified a need for the initiation of a new home-based service line. The goal of this project was to establish an innovative, sustainable, and cost-effective healthcare delivery method that would improve the health of this population. The project focused on a literature review, needs-assessment, and development of a comprehensive medical home visit program to serve the homebound, frail elderly, and other at-risk adults with complex medical conditions who reside in this community. The medical needs of potential recipients were assessed by conducting interviews with key support staff including a health service coordinator, health advocates, and housing provider service coordinators. Residents were also interviewed using a newly developed health perception and information survey. The data derived from the needs-assessment and pertinent literature were used to draft an initial program guideline. Because the needs-assessment indicated this population would not derive maximum benefit from a traditional house calls program, the project team developed a Home Healthcare Management service with an expanded scope to provide enhanced care coordination, house visits (medical and nonmedical), and community outreach.