Care that meets you where you are.

Connected care, centered on you

We provide longitudinal primary care for ongoing health needs, short-term bridge care between providers or after a hospital stay, and behavioral health care to support your emotional and mental well-being.

Our home-based services support adults and older adults who are homebound or face significant mobility, functional, or medical challenges due to frailty, chronic illness, or disability.

Contact us to discuss care at home
01

In-home primary care

Ongoing, preventive, sick-visit, and chronic care for adults at home.

Routine and preventive care

  • Annual wellness visits and physicals
  • Preventive screenings
  • Functional assessments
  • Medication review and refills
  • Lab orders and follow-up
  • Advance care planning when appropriate

Chronic disease management

  • Heart and lung conditions
  • Diabetes and kidney disease
  • Memory, pain, and mobility concerns
  • Medication and symptom monitoring

Sick visits and new concerns

  • Fever, urinary symptoms, and sudden illness
  • Pain, headache, dizziness, and vision changes
  • Wounds and minor injuries
  • Medication concerns or reactions
  • Follow-up after an emergency department visit

Care coordination

  • Specialist and mobile testing referrals
  • Therapy and equipment coordination
  • Care plans and home-service guidance
  • After-hours guidance for established patients

Learn more about Home-Based Primary Care.

02

Behavioral health services

Assessment, treatment planning, medication management, and follow-up, in person or by telehealth.

  • Mood and anxiety concerns
  • ADHD, PTSD, and sleep concerns
  • Thought and behavior changes
  • Medication management and follow-up
  • Cognitive and behavioral complexity support
  • Statewide telehealth for Massachusetts residents

Telehealth visits are booked online through Headway.

Learn more about Behavioral Health Services.

03

Transitional & bridge care

Short-term care after a hospital stay, or while you are between primary care providers.

Transition of Care program

A 30-day program starting on your discharge date from a hospital, rehab, or nursing facility, when avoidable readmissions are most likely. We follow you with in-home provider visits and regular phone check-ins, coordinate what you need to recover safely at home, then hand your care back to your regular primary care provider.

  • In-home medical visits and discharge summary review
  • Medication reconciliation and adherence support
  • Prescriptions, orders, and refills
  • Lab work and diagnostic testing
  • Communication with your primary care provider, specialists, and the discharging hospital
  • Coordination of skilled nursing, PT/OT, and medical equipment and supplies
  • Referrals to specialists, home health aides, and visiting nurse services
  • Patient, family, and caregiver education and support

Bridge Care

Short-term home-based primary care while you are between providers or waiting to establish ongoing care. It generally lasts 30–60 days, depending on clinical needs. Eligibility is reviewed before enrollment.

Medicare Part B may cover transitional care management if you’re eligible. After you meet the Part B deductible, coinsurance applies. See Medicare coverage details.

Learn more about Transition of Care and Bridge Care.

04

Residential & facility support

Primary, chronic, and bridge care for residents of group homes and senior living.

  • Group homes and supportive housing
  • Assisted living and rest homes
  • Chronic disease management for residents
  • Follow-up visits after a hospital stay
  • Staff and caregiver communication
  • Family updates when appropriate

Learn more about Residential Care Partnerships.

Also part of your care

Available alongside any of the services above.

Health navigation

Help making sense of a diagnosis, discharge summary, test results, or a specialist’s instructions, and preparing questions before appointments.

Senior & family care coaching

One-on-one support for families navigating a loved one’s aging, illness, or care transitions, and weighing the options ahead.

Not sure where your situation fits? Call us. We can help you choose the right next step.

Service Areas

Where care is available

In-person and remote telehealth options depend on the type of care needed.

In-person visits

In-person visits are available within 50 miles of our Worcester office, generally within a one-hour drive. Please call to confirm coverage for your address.

Remote telehealth behavioral healthcare

Remote telehealth by video or phone is available across Massachusetts when appropriate.

Not sure which service you need?

Call us and tell us what is going on. We will help you choose the right visit type and explain the next step.