Where primary care fits in the shift toward home care

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The future of health care isn’t in hospital wings — it’s in living rooms and bedrooms. Hospital-at-Home (HaH) programs and remote patient monitoring (RPM) are shifting the center of care to where patients feel most comfortable. But their success relies on the combined efforts of physicians, nurses, therapists and specialists — with primary care physicians at the forefront.

Large health systems may have led this shift, but smaller and independent practices bring something important: a tradition of relationship-driven care. From the days of house calls to today’s evolving care models, primary care providers have prioritized meeting patients where they are. Now, with tools like RPM and other tech-enabled solutions, they are uniquely equipped to blend advancements with their hands-on approach.

Opportunities for smaller practices

Jiang Li, PhD
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HaH programs, which bring hospital-level care into patients’ homes, have traditionally been driven by large health systems with the infrastructure to support them. However, independent practices have an opportunity to carve out their place in this shift — especially in caring for elderly patients, those with complex medical needs, or individuals in rural and underserved areas.

A patient’s HaH journey typically begins when a physician — often in an emergency room or outpatient setting — determines whether the patient is stable enough for home-based treatment. Conditions like congestive heart failure, chronic obstructive pulmonary disease and pneumonia, which follow well-defined clinical protocols, are ideal for this model. Once a patient is enrolled, a multidisciplinary team of nurses, social workers and physicians works to ensure the home is a safe and effective environment for care.

Primary care physicians are increasingly taking on roles focused on ongoing monitoring and management in at-home care. Within HaH programs, hospital-based physicians lead care during the acute phase, stabilizing patients and managing immediate needs. Once patients are stable and ready to resume their daily routines, primary care physicians step in to oversee ongoing care — easing the transition from hospital to home. Some practices are also partnering with medical schools to train fellows and develop family physicians who can provide home-based care for patients who need it.

With RPM tools, primary care providers can monitor vital signs, detect early warning signs and intervene before complications arise. Through regular home visits or virtual check-ins, they can track recovery, address concerns and help prevent avoidable hospital readmissions. By stepping into these roles, primary care strengthens its relevance in a health care system that is rapidly embracing home-based care while improving outcomes for patients.

Collaboration with health systems

In rural America, where 80% of areas are classified as medically underserved, innovative care models like HaH are necessary. These regions often face provider shortages, high poverty rates, elevated infant mortality and a growing population over 65. Addressing these challenges requires solutions that bring care closer to patients — many of whom are shifting their care preferences.

A recent Vivalink survey highlights this shift, showing that most U.S. patients prefer integrating some form of home care into primary care. Rural patients, in particular, expressed the strongest preference for remote primary care, with 36% favoring this option compared with just 19% of urban patients. Rural patients face unique challenges that urban patients don’t, and remote care from primary care providers offers a convenient and accessible solution to address those needs.

For smaller practices, establishing the full infrastructure needed for at-home care services can be daunting. Collaborating with larger health systems offers a practical path forward. These partnerships allow smaller practices to focus on managing care while leveraging the resources of larger systems, such as home health staff, advanced medical equipment and logistical support. These partnerships ensure primary care providers remain central to the patient experience while health systems handle operational complexities.

While HaH has gained momentum in the United States in recent years, it has been an established and successful practice in several countries for decades. Spain is a strong example of how at-home hospital-level care can succeed with multidisciplinary collaboration. Programs in regions like Barcelona and Catalonia integrate doctors, nurses and specialists to address comprehensive patient needs. These efforts have reduced hospital readmissions, improved outcomes and lowered costs.

The role of technology in at-home care

Technology is the backbone of at-home care, particularly RPM and telemedicine. RPM enables providers to monitor vital signs — such as blood pressure, heart rate and oxygen levels — without requiring office visits. With real-time continuous data, RPM allows health care teams to track recovery, spot complications early and intervene before issues escalate.

Telemedicine complements RPM by supporting virtual check-ins and follow-ups. These interactions help primary care providers gauge patient progress, address concerns and adjust care plans without the need for travel — an especially valuable feature for those who face mobility challenges or live in areas with limited access to traditional health care services.

While technology enhances efficiency and accessibility, it’s important to balance remote and in-person care. Telemedicine works well for routine needs, like medication refills, but it cannot replace the depth of face-to-face visits. Together, telemedicine, RPM and traditional care form a hybrid model that combines the convenience of virtual care with the trust and personal connection of in-person interactions.

This approach aligns with evolving patient preferences, particularly among older adults. According to the Vivalink survey, 35% of patients aged 60 to 69 and 31% of those aged 70 to 79 preferred primarily at-home care with occasional hospital or office visits. Meanwhile, 29% of individuals aged 40 to 49 still preferred hospital-centered care. Notably, the strongest preference for at-home care came from patients aged 70 to 79, reflecting a growing demand for more accessible and convenient options as people age.

Evolving roles for providers

As telemedicine, RPM and HaH continue to reshape health care, providers’ roles will evolve. Physicians will spend more time analyzing RPM data, conducting virtual visits and coordinating care with specialists. While these tools reduce the demand for in-office visits, they introduce challenges, such as managing the influx of digital information and ensuring patients stay connected with their care teams.

Integrating telemedicine and RPM into practices requires thoughtful planning, training and adopting new workflows. This shift also changes how practices handle patient flow. With routine appointments moving to telemedicine, in-person visits will likely focus on more complex cases that require hands-on care, diagnostics or intensive provider involvement. Practices will need to adopt flexible scheduling models that balance virtual and in-office care.

Primary care has always been closely tied to the home. As health care evolves, primary care continues to anchor care in the home. By embracing RPM and telemedicine, smaller and independent practices can extend high-quality care to those who need it most.

Jiang Li, PhD, is CEO of Vivalink, a Silicon Valley company developing medical wearable sensor solutions for patient monitoring and telemedicine.