Home-Based Primary Care
Longitudinal, relationship-based primary care delivered right in your home by your ACO care team.
For Patients & Caregivers
Care that comes home.
As a patient of At Home Harmony ACO, you're supported by a coordinated team focused on keeping you healthy and safely at home — and the family members caring for you are part of the team.
Your Health, At Home
A team designed around your life — and your home.
At Home Harmony ACO connects your home-based primary care team with the care navigators, specialists, and community resources you need. They share the same plan and the same goal: keeping you safely at home, with the care and support that fits your life.
Available & accessible
Scheduled in-home visits, virtual options, and 24/7 helpline support from your care team.
Caregiver-centered
Education, training, and ongoing partnership with the family members who care for you every day.
One coordinated plan
Your providers, pharmacist, and care navigator working from the same care plan and record.
Focused on staying home safely
Proactive monitoring, safety assessments, and chronic-care programs to keep you well at home, longer.
Coordinated Services
What the ACO coordinates for you.
Beyond primary care — At Home Harmony ACO surrounds each patient with the coordination and support that homebound older adults actually need.
Care Coordination
A care navigator who connects your providers, specialists, and community resources around one shared plan.
Dementia Care & GUIDE
Comprehensive dementia assessments, 24/7 support, and the CMS GUIDE program for eligible patients and caregivers.
Caregiver Support
Education, training, and respite resources for the family members who care for you every day.
GUIDE Program
Guiding an Improved Dementia Experience.
Where our practice is GUIDE-enrolled, At Home Harmony ACO patients can receive care through the CMS GUIDE program — a national model for dementia care that provides comprehensive assessments, 24/7 access, care navigation, caregiver education, and up to $2,500 in annual respite services per eligible recipient.
- Comprehensive caregiver and beneficiary assessments
- Personalized care plan addressing goals and preferences
- 24/7 helpline access to your care team
- Ongoing monitoring and care navigation
- Referral and support coordination
- Caregiver education and respite services
- Medication management and review
- Care coordination and transitions
CMS Program
About the CMS LEAD Model
At Home Harmony ACO participates in the Long-term Enhanced ACO Design (LEAD) Model, a Centers for Medicare & Medicaid Services initiative that rewards groups of doctors and other providers who come together to give coordinated, high-quality care to Medicare patients.
The goal of the LEAD Model is to ensure patients — especially those with chronic conditions — get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.
Visit the CMS LEAD Model