Read: Prospero’s Response to COVID-19

The COVID-19 crisis has created barriers to accessing care, particularly for those facing complex conditions. In response, Prospero’s team has innovated quickly by combining our compassionate home-based support with enhanced telemedicine offerings. This comprehensive care model is tailored to people’s needs and meets them where they are most comfortable and better treated – in the home. We are committed to ensuring the safety of those in our care, their families, and our clinicians and will continue to remain in compliance with the Centers for Disease Control and Prevention (CDC) guidelines. We are also closely monitoring directives from state and local health departments.

If you have questions about how we can best support you or your loved one, call our team at 1-888-608-0499, TTY 711.

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Nurse practitioner performing home-based medical check-up for aging female patient.

Is Home-Based Medical Care Right for Your Patients?


As a healthcare provider, you have the honor and responsibility to ensure your patients’ well being. While positive outcomes are routine for many in your care, others – particularly older patients who suffer from serious illness – are challenging to manage if they don’t have access to a dedicated caregiver and if they don’t receive support from a team of healthcare professionals.

In these cases, Prospero’s home-based medical care may be an effective addition to their care plan.

Sick elderly woman laying in bed at home frustrated and upset
Home-based medical care gives providers a closer look into their patients’ lives in a way they may not see in a clinic-based model.

5 Signs a Patient May Need Home-Based Medical Care

The common signs a patient could use more support at home are fairly easy to spot: weight loss, decreased mobility, and difficulty performing basic daily activities. Other red flags include repeated falls, kitchen fires, and a loss of interest in activities or relationships that were once important. Also, be sure to keep an eye on how often patients seek out or require medical attention. 

Here are the top signs a patient could benefit from home-based care, and tips for raising the topic with your patient once you’ve identified a need.

1. Weight Loss

If a patient experiences sudden weight loss, it could be a cause for concern. They may not have the mobility or energy to visit the grocery store or cook their own meals, especially if their issue is increasing in severity.

Patients with chronic illnesses may be at a higher risk of suffering from depression, which is also known to cause weight loss.

Unintentional weight loss occurs in 15 to 20% of older adults and is associated with increased morbidity and mortality.

Home-based medical care can prevent weight loss with regular home screenings. This can include meal planning to ensure patients are receiving adequate nutrition. In-home care can also monitor any early signs of depression and arrange any necessary mental health support.

2. Decreased Patient Mobility

Patients who have a chronic illness affecting their muscles and joints (such as Parkinson’s Disease or Rheumatoid arthritis) will experience a decrease in mobility over time. This is largely due to tremors and inflammation, which can make daily activities including walking, bathing, dressing, and toileting a challenge.

But mobility loss doesn’t just burden a patient – it impacts the caregiver as well.

Obese or severely disabled patients can put caregivers at risk of becoming injured during transferring. Caregivers may also attempt to help their loved one up after a fall and, in turn, injure themselves. 

In-home support can help reduce the risk of falling and prevent caregiver injuries, which increases as patient mobility decreases.

3. Difficulty Performing Basic Daily Activities

Aging patients often experience problems in daily life performing basic activities due to chronic illnesses or health-related disabilities. Self-care may be a challenge, which is just one reason why these patients seek help from loved ones or caregivers or end up moving to an assisted living facility.

According to the CDC, over 20% of seniors over the age of 85 need assistance with these activities of daily living (ADL):

  • Ambulating
  • Continence
  • Dressing
  • Feeding
  • Personal hygiene
  • Toileting

However, some patients who can complete ADLs unassisted will still experience difficulty with cognitive tasks. This is especially common among patients diagnosed with Alzheimer’s or other related dementias.

Struggling to perform these instrumental activities of daily living (IADLs) may indicate the patient needs home-based medical care in order to live independently in their home. 

Some IADLs include:

  • Grocery shopping
  • Housekeeping and laundry
  • Making and receiving phone calls
  • Managing medications
  • Managing personal finances
  • Pet care
  • Preparing meals
  • Transportation

Providing in-home care can help bridge these limitation gaps and support patients where needed in their daily activities.

4. Increased Hospitalizations and Emergency Room Admissions

When a patient is frequently admitted to the hospital, there’s reason to be concerned for their safety. One BMC Geriatrics study found that a high number of prescribed drugs, history of heart disease, and low income can all contribute to frequent hospitalizations and emergency room admissions.

These factors, combined with inadequate support in the home, increase the likelihood of patients ending up in the hospital.

“Lots of studies show that when people are frequently visiting emergency departments and being hospitalized for chronic conditions, the support they have at home isn’t working as well as it could,” says Dr. Dave Moen, President of Prospero Health Partners, P.C. “And often that’s just due to a lack of access to what they need to live independently at home.”

“Lots of studies show that when people are frequently visiting emergency departments and being hospitalized for chronic conditions, the support they have at home isn’t working as well as it could.”

Dr. Dave Moen

Patients who frequent the emergency room often need more support in the home to live safely. This is where medication management and regular physical examinations provided by home-based medical care can help.

5. Caregiver Strain

Caregivers can also be an important resource in understanding unmet patient needs. They are often first to notice changes in their loved one’s mood or demeanor, as well as symptoms of memory loss.

When the duties of caregiving become overwhelming, tension between a patient and caregiver could mean the caregiver is being stretched beyond their limits.

If you notice the dynamic between a patient and their primary caregiver has changed, home-based care may be a worthwhile next step.

Common signs that a primary caregiver is under strain include:

  • Depression and anxiety
  • Exhaustion
  • Outbursts of anger
  • Alcohol or drug abuse
  • Resentment directed at their loved one
  • Tension between a caregiver and their loved one
  • Weight gain or weight loss

To investigate if a primary caregiver is struggling, you may need to speak with them alone. They may not be open or honest to discussing the situation around their loved one.

Social worker talking to elderly male patient at his home.
Albert, a Prospero patient, lives by himself and cherishes the support he receives from his Prospero care team. He describes Heather, his social worker (pictured above), as a “sister I never had.”

Talking to Patients and Caregivers About Home-Based Care

Once you’ve identified the need for home-based care, carefully consider how you want to raise the subject. As you know from experience, older people who live at home are understandably protective of their independence. They may also struggle to accept that their illnesses are progressing and they need more help. To ensure patients don’t feel like they are being pushed in a certain direction, ask questions that gauge how they view their own abilities. 

“It’s important to give patients time to share what it is they want,” says Dr. Moen. “The real art of it is hearing what it is they’re afraid of and worried about and giving them a sense of control over their destiny and choices.” 

“The real art of it is hearing what it is they’re afraid of and worried about and giving them a sense of control over their destiny and choices.” 

Dr. Dave Moen

Patients may also fear losing their healthcare providers. When bringing up home-based care, you want to make it clear you’ll continue seeing the patient no matter what they decide. Feeling supported can help ease some of their anxieties. 

Lastly, spend time understanding the caregiver’s perspective on the situation. Even if the caregiver is desperate for extra support, they may feel guilty, as if they have failed their loved one. Validate those emotions and reassure them that home-based care will ease the burden of caregiving and give the whole family more time to enjoy this chapter, and those to come. 

To learn more about how healthcare providers can partner with Prospero, visit our providers page. If you have any questions or may be interested in partnering, reach out to our team by submitting the form below.

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