Homebase at the DOC: using collaborative care to strengthen the medical home

Saturday, February 24, 2018

The Duke Outpatient Clinic (DOC) is invested in targeting high utilizers of emergency and inpatient care, or “superutilizers”. These clinicians started the "Homebase" program to help decrease the need for Emergency Department (ED) and inpatient care among the superutilizers. 

How it works:

Inclusion criteria for the Homebase intervention were 6 or more ED visits or hospitalizations in the past 6 months with a pattern of ongoing ED utilization. Patients were identified through North Carolina Medicaid and Duke Hospital data quantifying ED use for all DOC patients and through direct referral by providers. 

After patients are identified for enrollment, the care manager performs a retrospective chart review identifying patterns of utilization and potential areas for intervention. The team then develops an individual care plan and places it in the patient’s electronic medical record. The care manager proactively reaches out to the patient to cooperatively address barriers to medical care and drivers of ED utilization. Interaction with the patient is broken down into two 6-month phases:

> an “engagement” phase when patient driven goals are identified and addressed and focus is given to improved relationship and connection with clinic medical providers

> a 6-month “action” phase during which explicit focus is placed on improved medical health and decreased ED dependence.

The team receives real-time electronic notification when enrolled patients arrive in the ED and then can coordinate care with ED providers. Enrolled patients are provided enhanced walk-in access to the clinic, and are frequently co-managed by a resident primary care provider and the nurse practitioner. The team holds 2 weekly meetings to discuss new patients and those with acute needs or increased utilization. Patients are reviewed every 6 months following enrollment to assess response to the intervention and the effectiveness of engagement strategies.


The institution of the Homebase program and related redesign changes has resulted already in dramatic reductions in hospitalizations and ED visits by DOC primary care patients, particularly at Duke University Hospital (DUH).  Year-on-year reductions in hospitalizations have averaged 11.6% over the period from July 2013 through June 2016 (the end of the last completed fiscal year), for a net decline of 41.5% in admissions to DUH.  Year-on-year reductions in ED visits have averaged 16.9% over the same period.

What's next:

Since the Homebase program has been so successful, DUH is supporting an expansion (HomeBASE Plus) of clinic-based care management and increased walk-in capacity.  The idea is to provide on-site acute illness and other care for high-need patients with chronic illnesses who experience frequent exacerbations, and then position the clinic to be a capable alternative to the ED for some of the most common presenting complaints.  Other future plans include better using empanelment and visualization to identify high-need patients more systematically.

Read more about the Homebase program in our previous story (from March 2016) and in this research article (Mental Health and Addiction Research, August 2016).