Innovative program brings primary care into the homes of high-need patients

Frances Brooks, 87, was dealing with worsening eyesight, in addition to chronic kidney disease, hypothyroidism, and a number of other health issues. A year ago, she decided to stop driving. In June, when she saw her physician, he realized she needed more support. He enrolled her in a program that offers in-home primary care visits.

Since then, Amanda Coyle, a nurse practitioner, has visited Brooks at her home in Virginia Beach, Virginia, to ensure she gets the care she needs.

“I look forward to seeing her,” said Brooks. “You always feel better when you’ve been to the doctor and he says everything’s OK. That’s the way Amanda makes me feel, too.”

Coyle is one of six advanced practice providers who bring primary care into the homes of high-need patients in Virginia’s Hampton Roads region as part of Sentara’s home-based primary care initiative. The innovative program serves patients who face transportation, cognitive, or other barriers to care.

Coyle has been a nurse practitioner for 20 years, and her career has included providing humanitarian relief in Haiti after the 2010 earthquake, as well as supporting the Ebola response in Sierra Leone in 2015. The work she does now is among the most satisfying of her career, she said.

“We have a rapidly aging population,” said Coyle. “Being able to meet them where they’re at, and give them the best care for their acute and chronic conditions, is a really important thing to me.”

Frances Brooks (left) with Nurse Practitioner Amanda Coyle in Brooks’ home in Virginia Beach, Virginia.

Additional support for patients who face barriers to care

Brooks’ physician, Bradley Cotrina, M.D., sees a number of older patients who have difficulty getting to his office. Some are bedbound, while others have trouble finding a ride.

"When I know transportation is a big issue, I say, hey, we have a service available,” Dr. Cotrina said. “I let them know it’s not replacing their care with me. It’s just additional support.”

Patients have been very enthusiastic about the program, he said. During home visits, primary care team members treat conditions like diabetes or heart disease, provide acute care for infections and injuries, and review medications. They also identify issues that may otherwise go unreported.

"My patients are all really happy with it,” said Dr. Cotrina, adding that older patients, in particular, appreciate the person-to-person interaction.

A unique program in today’s healthcare landscape

In 2023, Christopher Nein, M.D., noticed that some of his patients had trouble coming to his office. He started visiting those patients on his drive home. They were very appreciative.

That led to the home-based primary care program, which launched that year.

“We are an extension of the patient’s primary care physician,” said Dr. Nein, who leads the program.

“There are a lot of high-complexity patients who don't see a doctor as often as they need to because they’re not able to leave the house. The solution was to bring a Sentara provider into the home.”

As part of the program, licensed providers show up with a collapsible stool, laptop, stethoscope, and other medical equipment. They can do everything from an annual wellness visit to chronic disease management.

“You get the same type of visit in the comfort of your house that you would get in a Sentara exam room,” said Dr. Nein.

In 2025, the program provided more than 3,500 home visits.

To participate in the home-based primary care program, patients need to have Medicare and be referred by their primary care physician. Most patients in the program are elderly, but there are also younger patients eligible for Medicare due to disability.

In addition to easing access to care, the home-based primary care program reduces unnecessary visits to the emergency department, said Dr. Nein.

“If we weren’t there, our patients would be using the emergency room a lot more,” he said.

He added that the program is unusual in today’s healthcare landscape.

“This is a unique initiative,” he said. “When I present on this to other health systems, they say we have nothing like this.”

To meet patient health goals, home-based primary care team members partner with Sentara Home Care, a separate program whose services are typically provided by nurses, physical therapists, or other healthcare providers.

‘It’s been wonderful’

Brooks lives alone in her house, though her grandson is in a separate structure on her property.

“I think it’s important to older people to stay in their home,” she said. “I know I feel that way, and I hope I can stay here.”

She sees Dr. Cotrina twice a year and receives home visits from Coyle every two or three months.

“To have Amanda come in-between makes me feel like I’m being more looked after,” she said. “So far, it’s been wonderful. I enjoy every minute.”

She added, laughing, “And if I have any problems that I don’t want to talk to a man about, I can talk to her.”

Coyle highlighted the range of challenges faced by older patients, from health to financial to mobility issues.

“My older patients have taught me that aging is not for the faint of heart,” she said. “If we can meet them where they’re at, appreciate their journeys, and help manage some of their acute and chronic conditions, that’s a good day for me.”