Built for home-based care
Workflows, staffing, and tools designed for the realities of visiting patients in their homes — not retrofitted from clinic-based care.
For Physicians & Providers
A stronger home-based practice, backed by a full care team.
An Accountable Care Organization built around physician leadership, a multidisciplinary home-care team, and quality-aligned incentives.
Financial alignment
Value-based revenue streams through the CMS LEAD Model and the GUIDE program that reward outcomes and caregiver support — not visit volume.
Shared infrastructure & technology
EHR integration, analytics, remote monitoring, and care-coordination tools ready on day one.
A multidisciplinary team behind you
Pharmacists, social workers, care navigators, and chronic care nurses extend every primary care visit.
Dementia & complex care programs
GUIDE-aligned dementia care plans, caregiver education, and 24/7 helpline support for the families you serve.
Measured outcomes
Reduced LOS, decreased readmissions, and successful transitions home — tracked and reported every quarter.
Quality programs
Evidence-based protocols and internal benchmarking that lift care across every visit.
Continuous education
CME, MIPS guidance, and clinical program support for your full team.
Transition-to-Home Model
Designed for high-need, homebound patients.
Our Transition-to-Home model pairs a Clinical Integration Specialist inside the hospital with protocolized information exchange and an expedited home evaluation — built to decrease inpatient length of stay, establish primary care for the homebound, and reduce readmissions.
100%
Success rate of TCM visits resulting in no hospitalizations within 30 days.
70%
Of patients complete the APP TCM visit; remaining cases reflect hospice, SNF, or rehospitalization within 4 days of discharge.
5.14 days
Average length of stay prior to hospital discharge for patients we transition home.
Ready to learn more?
Let's talk about your practice.
Schedule a conversation with our ACO team about how At Home Harmony ACO supports your patient population, quality goals, and day-to-day workflow.
ACO Training
Complete required ACO training online.
Physicians, advance practice providers, and staff can access the full At Home Harmony ACO compliance, privacy, and code-of-conduct training module and print a completion record.