Elder at Home

Seniors can stay in their homes, and be healthier


The U.S. population is aging, and communities everywhere are looking for ways to help seniors have better access to health care and other vital services.

Providence Health Plan and the delivery system caregivers in Oregon partnered to create the Elder at Home program to care for the mind, body and spirit of the elderly. By providing frail elders the care they need, where and when they need it, the program aims to improve their overall health, reduce emergency department visits and give the elders and their loved ones more peace of mind.

The program launched in August 2015 and is available to a group of Providence Health Plan Medicare Advantage members in the three-county Portland metropolitan area. To qualify, members must have six or more specific chronic medical conditions which put them at potential risk for future injury or escalating care needs. These multiple conditions often put the elders in constant need of a variety of health services which have historically been delivered in an uncoordinated fashion at inconvenient locations.

Elder at Home cares for the patients in their homes – wherever they call home. The members are charged their regular co-payments when seen by a physician, nurse practitioner or physician assistant. There is no cost to join the program and no cost when the member is seen by a nurse or social worker. When a senior joins the program, an interdisciplinary care plan is created to address all of the patient’s needs on a regular schedule.

Group members receive routine in-home care visits and have access to 24/7 nursing support for urgent issues. When needed, the program provides in-home triage assessments and treatment by registered nurses, physicians, nurse practitioners or physician assistants, even on weekends or outside business hours.

The Elder at Home care teams include physicians, nurse practitioners, physician assistants, registered nurses and clinical social workers. The direct care team is augmented by chaplains, pharmacists, dietitians, licensed practical nurses, medical assistants and rehabilitation specialists.

The program’s caregivers work closely with patients’ primary care providers and use the common medical record (Epic) to ensure continuity of care. If a patient receives treatment at a hospital, one of the program’s nurses or providers participates in the discharge planning to ensure the plan is followed.

The commitment of the care team is to support the patients and their families through their health care journey and to honor and know the whole person, physically, emotionally and spiritually.

This program truly fulfills the Providence promise of “know me, care for me, ease my way.”