PHYSICIAN-LED CARE AT HOME
More support for patients with complex health needs.
Available to qualifying patients
Complex Care brings physicians, nursing support, diagnostics, caregiver education, and care coordination together for qualifying patients across Oʻahu.
The program is designed for patients whose medical needs, recent health history, mobility, or difficulty accessing care require more support than routine clinic visits can provide.
WHO IT'S FOR
Who Complex Care is designed for.
Multiple serious conditions
Several diagnoses, medications, specialists, and treatment plans that are becoming difficult to coordinate.
Recent or repeated hospital care
Repeated hospitalizations, emergency department visits, or a difficult transition after hospital or skilled nursing care.
Difficulty reaching a clinic
Mobility, frailty, cognition, transportation, or caregiver needs make office visits difficult.
Caregiver or equipment needs at home
Daily care depends on family support, home health, oxygen, mobility equipment, catheters, feeding support, or other services.
These are common indicators, not automatic qualification. Our team considers the patient's overall medical needs, location, insurance coverage, and current program availability.
Evidence behind the model
Dedicated care can change what happens next.
In 2024, CMS High Needs ACOs cared for Medicare beneficiaries with an average of twelve chronic conditions. Compared with similar beneficiaries, these programs reported meaningful improvements in hospital use, skilled nursing care, and time spent at home.
13.2%
Fewer acute care hospitalizations
16.3%
Fewer days in acute care
13.6%
Fewer skilled nursing facility days
6.4%
Fewer emergency and observation visits
High Needs ACOs also helped patients spend more days at home.
Results reflect national CMS ACO REACH High Needs ACOs and are not health2me outcomes. Individual results vary.
CMS Perspective: ACO REACH Model PY 2023 Evaluation Report and Preliminary Results for PY 2024
Referral fit
What makes a strong Complex Care referral?
A diagnosis alone does not determine whether a patient is a good fit. Strong referrals usually involve a combination of medical complexity, recent utilization, functional limitations, caregiver needs, and difficulty carrying out the care plan at home.
Recent utilization
Repeated hospitalizations, emergency department visits, or a prolonged skilled nursing facility stay.
Mobility or frailty
Leaving home requires substantial effort, another person’s help, or medical equipment.
An unstable care plan
Frequent medication changes, unresolved orders, or several specialists without a clear central plan.
Caregiver strain
Family members or paid caregivers need more education, direction, or clinical support.
Medical care occurring at home
The patient relies on oxygen, catheters, wound supplies, feeding support, mobility equipment, or home health.
Caregiver strain
Family members or paid caregivers need more education, direction, or clinical support.
What we bring to you
A full care team,
brought to your door.
For qualifying patients, we deliver real medical care in the place it actually happens every day, your home.
Physician care at home
Ongoing physician care at home, including timely assessment when an enrolled patient’s condition changes. Provider visits in your home when getting to the office is the barrier, with the same continuity you’d get in the clinic.
In-home nursing, labs, and imaging
Depending on your needs, our team provides or coordinates in-home nursing care, laboratory collection, mobile imaging, and other support in your home.
Care education that sticks
We teach you and your loved ones how to deliver care in the setting where it happens, so the plan holds up between visits.
Coordination & close follow-up
We help coordinate appropriate appointments and keep specialists, pharmacies, and other members of your care team informed.
Between visits
Complex Care continues after the physician leaves.
The work between visits can be as important as the visit itself. Our team follows the care plan, identifies unresolved needs, and helps keep everyone involved working from the same information.
Medication and record review
We review hospital records, medication changes, specialist recommendations, and conflicting instructions.
Orders and referrals
We follow laboratory orders, imaging, equipment, home services, and specialist referrals through the next step.
Care team communication
We help keep specialists, pharmacies, home health agencies, caregivers, and other providers informed.
Changes in condition
When the patient’s condition changes, the team can reassess the plan and determine the appropriate next step.
In the home
The home can reveal what the clinic cannot.
Seeing where daily care happens helps us understand whether medications, equipment, routines, caregiver support, and the home environment are helping the care plan work.
Medication organization
Old prescriptions, conflicting instructions, or practical barriers may become clearer in the home.
Safety and equipment
The physician can see fall risks, bathroom safety needs, medical equipment, and whether supplies are being used safely.
Caregiver teaching
Education can happen using the exact equipment, supplies, and routines caregivers use every day.
Getting started
From referral to a coordinated care plan.
1
Contact or referral
A patient, family member, provider, hospital, health plan, or care manager contacts health2me.
2
Eligibility review
We review medical needs, recent utilization, mobility, caregiver support, location, insurance, and program availability.
3
Initial assessment
The team gathers records, identifies immediate priorities, and completes the initial medical assessment.
4
Ongoing care
The patient receives physician care, support between visits, coordination, and additional services based on the care plan.
What we work toward
Better coordinated care, measured in practical outcomes.
CMS measures complex care programs using outcomes that include hospital use, readmissions, days at home, timely follow up, and patient and caregiver experience. These same priorities help guide how we design and evaluate our program.
More days safely at home
Timely follow up when health changes
Fewer avoidable gaps in care
A clearer plan for patients and caregivers
Questions
Frequently asked questions.
Not sure whether Complex Care is the right fit?
Tell us about the patient's medical needs, recent hospital or skilled nursing care, mobility, caregivers, and the barriers making care difficult. Our team will review the situation and explain what options may be available.