Information for physicians and case managers

Our forté is proactive medical management of frail older adults or those with multiple degenerative diseases such as COPD, CHF, and Alzheimer’s disease, especially in the later stages, when an office visit may be particularly difficult.

Who qualifies for our services

  • Homebound adults (Medicare definition: leaving home requires assistance or considerable and taxing effort);
  • Living in the greater Portland area;
  • Not in need of an emergency first visit;
  • Patient (or family, when appropriate) agrees to have our services, as PCP (or as referral from their HMO PCP).

Places we visit

  • Private homes
  • Adult foster homes
  • Assisted living and residential care facilities

Geographic areas we currently serve

  • Eastern boundary: Gresham/Troutdale
  • Western boundary: Forest Grove
  • Northern boundary: North Portland/St. Johns
  • Southern boundary: Tigard, Gladstone, Clackamas

Insurance we accept

  • Medicare
  • Medicaid (including CareOregon and FamilyCare HMOs);
  • Most secondary (Medigap type) insurances
  • HMOs. We are on most provider panels including:
    • Blue Cross Blue Shield /1st Choice 65
    • Secure Horizons
    • Providence Health Plan
  • For HMO referrals we request approval for a minimum of three visits. Special arrangements need to be made for one-time visits.

Our usual procedure

  • Patient assigned to one of our doctors or nurse practitioners for initial history and physical (H&P) evaluation on Monday morning.
  • Clinician calls, usually on Tuesday, to set up appointment for initial history and physical, which takes 1-2 hours.
  • On following Monday, patient may be transferred to a nurse practitioner or physician assistant who will manage ongoing care.
  • Most patients are visited monthly. We see them more often if need arises.
  • We are like a doctor’s office on wheels. We are not mobile ERs. We do not routinely make after-hours or weekend visits, but a clinician is available by phone 24x7.
  • Clinicians take turns managing weekend calls.

A note about hospital visits
We do not provide in-patient hospital care, but work with the hospitalists at most area hospitals to insure continuity of care.