Enhancing and Scaling a High-Touch Home-based Primary Care Program

The overall goal of the West Health Institute-Northwell PRP is to identify a clinical and economic model that can support scaling the Northwell House Calls program within a four year implementation period, while maintaining the same level of quality, patient/caregiver satisfaction, and "high touch" provider-patient communication that the program is known for. The Clinical Trial portion of this study refers to the secondary endpoint listed below.

Primary Endpoint: Northwell's House Calls program will be effectively scaled to maintain a patient census of 2000 without compromising patient and caregiver satisfaction.

Secondary Endpoint: The telehealth platform, Avizia, effectively improves communication of patient and caregiver needs to House Calls staff, and overall program satisfaction.

In order to achieve the secondary endpoint, a telehealth platform will be implemented that will allow patients and their caregivers to teleconference with their care manager, who is either a nurse or a social worker, replacing a typical visit which is completed telephonically.

Hypotheses to be tested through a home based telehealth intervention :

* Maintain longitudinal non-inferiority of: in-person acute care home visits from a provider, in-person acute care home visits from a care manager, hospitalizations, ED visits, Community Paramedicine deployments, Community Paramedicine transports to hospital, the patient's acuity level, LACE Score, Charelson Co-Morbidity score and the total number of ADLs group compared to usual care group.
* Telehealth acceptability
* decrease caregiver stress
* Improve program satisfaction
* Improve staff satisfaction and engagement

Eligibility Criteria:
Inclusion Criteria:

* Patients from the chronic and complex phone-only acuity level, from House Calls, Advanced Illness Management, Northwell Health Solutions.
* If possible, we will recruit both patient and caregiver dyads.
* The caregiver can be a family member or a paid caregiver.
* If patients are cognitively impaired, then they must have a caregiver who can verbally confirm that they will be present with the patient for the telehealth visit. -Caregiver must be present during Avizia enrollment with the research staff to ensure proper use of the device.
* The eligible patient or the eligible caregiver, must have a mobile phone number or email address listed in Allscripts is the associated chart, in order to participate in an Avizia visit with House Calls.
* Patients will be able to participate in the study regardless of cognitive impairment, if they have a caregiver who is able to consent on their behalf. This caregiver must be their power of attorney or family member, but does not have the be the caregiver present for the Avizia visit.

Exclusion Criteria:

* Patients under 18
* Patients that are cognitively impaired and unable to use the device, who also do not have a present and willing caregiver who can use the device.
* If the patient and willing caregiver do not have an email address or phone number listed on the associated chart on Allscripts.
* Patient or caregiver does not have a smart phone, tablet, laptop or desktop computer able to launch Avizia.