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Serving Northern Virginia, Fredericksburg & Winchester 703-662-7500 - Available 24/7
Sister Company. Five Star House Calls

Home-Based Primary Care

For your most complex and homebound patients, we serve as a trusted extension of your care team. providing in-home clinical support, monitoring, and coordination so your patients stay safe, stable, and connected to the care you have planned for them.

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✓ In-home visits aligned with your care plan
✓ Clinical findings shared directly with your team
✓ Coordinated with our nursing & therapy team
A Trusted Model of Care

Care Delivered in the Home. Historically Proven, Clinically Validated

For most of medical history, the house call was the standard of care. Physicians traveled to patients. observing their living conditions, meeting their families, and treating illness in the context of real life. This model produced a depth of clinical insight that a brief office visit cannot replicate.

For the growing population of homebound and medically complex older adults, access to consistent primary care remains a significant challenge. These patients. who make up just 5.6% of Medicare enrollees. are among the most difficult to manage and the most at risk of preventable hospitalizations when routine care is interrupted.

Home-based primary care fills that gap. not by replacing the physician-patient relationship, but by extending it into the home. We bring the clinical presence your patients need between visits, after discharge, and in settings where consistent oversight is otherwise unavailable.

By the Numbers
5.6%
of Medicare enrollees are homebound. yet they represent a disproportionate share of Medicare spending due to gaps in routine care
$49M+
saved by the CMS Independence at Home demonstration in its first three years through proactive, coordinated home-based care
17%
reduction in hospital admissions reported for patients enrolled in structured home-based primary care programs
1 team
House Calls + Home Health Care. one coordinated team working under your care plan
How We Support Your Team

Where We Fill the Gaps

We are not here to replace the physician-patient relationship. we are here to support it. These are the clinical situations where a home-based presence makes the greatest difference for your most complex patients.

When the Patient Cannot Get to You
For patients who are homebound or functionally limited, we serve as your eyes and ears in the home. conducting visits, monitoring changes, and reporting back so you can continue directing their care.
Between Office Visits
Complex patients often deteriorate between scheduled appointments. We provide the in-between touchpoints that keep your most vulnerable patients stable and out of the emergency room.
After Hospital Discharge
We support your patients through the highest-risk window after discharge. ensuring medication adherence, identifying early warning signs, and communicating directly with your team.
In Assisted Living & Community Settings
For patients in ALFs or group homes where access to consistent medical oversight is limited, we provide the clinical presence that keeps their care plan on track.
When Caregivers Need Support
Family caregivers are often the first to notice changes. We educate and support them as an extension of your care instructions. reinforcing your guidance in the home.
For Coordinated Chronic Disease Management
We work alongside your treatment plan for heart failure, COPD, diabetes, dementia, and other complex conditions. adding the home-based layer of monitoring and support your patients need.
What We Provide

Services Delivered

All services are delivered in coordination with the patient's existing care team. Our goal is to execute your care plan in the home. not to redirect it.

Medical House Call
Physician and advanced practice provider visits conducted in the home, ALF, or wherever the patient resides. including full physical exams, medication management, and care plan review aligned with your treatment goals.
Medicare Annual Wellness Screening
Comprehensive preventive health screenings conducted in the home for Medicare beneficiaries. including health risk assessments, cognitive screening, and personalized prevention plans. removing the transportation barrier that prevents many patients from completing this benefit.
Advance Care Planning
Structured, in-home conversations to help patients and families document their goals, values, and wishes for future medical care. We facilitate and record these discussions so your team and the patient's family are aligned when decisions need to be made.
Chronic Disease Management
Ongoing in-home monitoring and management of heart failure, COPD, diabetes, hypertension, and other complex conditions. with clinical findings and any changes communicated directly to the referring physician and specialist team.
Transition Care Management
Intensive support during the highest-risk window after hospital or facility discharge. ensuring medication reconciliation, follow-up compliance, early warning sign identification, and direct communication with your team to prevent readmission.
Principal Illness Navigation
For patients managing a primary serious illness, we serve as a consistent clinical presence in the home. coordinating across specialists, monitoring disease progression, and keeping the care plan on track between your office visits.
Dementia Assessment
In-home cognitive and functional assessments for patients with known or suspected dementia. evaluating safety, behavioral changes, caregiver capacity, and home environment. Findings are shared with the care team to inform diagnosis, staging, and care planning.
Palliative Care
Symptom management, comfort-focused care, and goals-of-care conversations for patients with serious illness. conducted in the home in full coordination with the patient's existing care team, specialists, and family.
Communication & Transparency

You Stay Informed. You Stay in Charge.

Referring a patient to us means gaining a partner, not losing oversight. We keep you informed at every step. sharing clinical findings, flagging concerns, and deferring to your judgment on care decisions.

Our role is to be the clinical presence in the home that you cannot always provide. and to make sure everything we observe and do is visible to you and your team.

What we share with your team
✓Visit summaries and clinical findings after every home visit
✓Medication changes, new diagnoses, or concerns identified in the home
✓Caregiver status and home environment observations relevant to the care plan
✓Coordination notes shared with our nursing and therapy teams
✓Proactive outreach when a patient's condition warrants your attention
Our Sister Company
Five Star House Calls. sister company providing home-based primary care

Five Star House Calls is our primary care arm. bringing physicians and nurse practitioners to patients in their homes and assisted living communities across Northern Virginia, in partnership with referring physicians and care teams.

Visit fivestarhousecalls.com
Who We Serve Together

Patients Who Benefit Most from a Home-Based Partner

These are the patients who are most difficult to manage through office visits alone. and where a coordinated home-based presence makes the greatest clinical difference.

✓Homebound older adults who cannot reliably travel to your office
✓Patients in Assisted Living Facilities (ALFs) needing consistent medical oversight
✓Individuals with two or more complex chronic conditions requiring frequent monitoring
✓Patients recently discharged from hospital in the high-risk post-acute window
✓Patients with dementia or cognitive decline whose behavior is best assessed at home
✓Families managing a loved one's care who need clinical support and guidance

Source: John A. Hartford Foundation. Home-Based Primary Care: Helping Homebound Older Adults

Partner With Us for Your Most Complex Patients

We welcome the opportunity to work alongside you and your team. Contact us to discuss how Five Star House Calls and our home health team can support the patients you are already caring for.

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