UAB House Calls

Advanced primary care at home

What is home-based primary care?

Home-based primary care (HBPC) delivers coordinated primary care services to patients in the comfort of their own home. Patients who benefit from HBPC have multiple chronic conditions and functional limitations that make it difficult for them to leave their home.

Whom do we serve?

Patients who live within 30 miles of the main UAB Hospital campus
Patients age 18 and up who have difficulty leaving their homes due to:
- Mobility problems
- Memory or thinking problems
- One or more serious chronic health conditions
- A recent major change in health or function due to a catastrophic event (i.e. serious injury, stroke, prolonged hospitalization)
Patients who may require palliative or end-of-life care
Patients who in many cases are not easily served by traditional health care settings

To learn more about our program, please call 205-930-6700.

Personalized care

HBPC teams partner with patients to learn what matters most to them, allowing for the development of personalized care plans.

Care coordination

HBPC providers work closely with other disciplines to manage medical conditions and address social stressors that may be present.

Proven results

HBPC patients have fewer emergency department visits and hospitalizations, allowing them to have more quality days at home.

How it works

Self-referral or referral from community health care partner
Intake screening for eligibility (telephone call with case manager)
Initial home visit by provider
- Comprehensive history and physical exam
- Medication review
- Diagnostic testing
- Personalized treatment plan
Assessment of social needs
Referrals/care coordination with specialists and other agencies
Routine follow-up through in-home visits or telehealth
24/7 access via phone triage or urgent care coordination

To learn more about our program, please call 205-930-6700.

Meet Our Team

Lydia Casey, MSN, MDiv, CRNP, FNP-C Geriatric Medicine, Internal Medicine

Marianthe Grammas, MD Geriatric Medicine, Internal Medicine

Linda Jones, DNP, CRNP, FNP Geriatric Medicine

Rachel Mathers, MD Internal Medicine, Palliative Medicine

Austin Oslock, MD Internal Medicine, Pediatrics

Kathleen Shields, MSN, CRNP Geriatric Medicine

Care coordinators

Ryan Doyle, MS, RN

Cindy Hoffman, BSN, RN

Aaleah Taylor, BSN, RN

Nursing

Adam Dunn, BSN, RN

Katelyn Law, RN

Amber Teter, BSN, RN

Nathan Thompson, ADN-Critical Care, RN

Sophronia Watford, LPN

Medical assistants

T’ana Black, CCMA

Briggitte Simpson, CCMA

Social work

Tiffany Battle, LMSW

Camera Gibson, LMSW

Jessica Nix, LICSW

Administration

Jacob Vaugh, MSN, RN, CNL

Resources

Frequently asked questions

Who can join the program?

Patients age 18 or older who live within a 30-mile radius of the main UAB Hospital campus and have difficulty leaving their home

Is it covered by my health insurance?

House Calls is billed just like a doctor’s office visit to your insurance, including Medicare, Medicaid, and most commercial plans. We participate in two Medicare programs: Advance Primary Care Management and Chronic Care Management, which may require a small additional co-pay. Other than your insurance co-pay, there is no additional out-of-pocket cost for home-based care.

How is this different from concierge medicine or direct primary care?

Concierge medicine and direct primary care require that patients pay a membership or retainer fee directly to the physician or practice to receive the specialized services and enhanced access from the physician. HBPC is billed to insurance. There is no retainer fee or other out-of-pocket costs for patients, other than their usual co-pay.

Is this the same as home health?

No. Home health provides skilled services such as physical therapy, nursing, occupational therapy, and speech therapy to help patients recover after a hospitalization or change in health status.

Can I have hospice and HBPC at the same time?

UAB House Calls does not enroll patients who are already active with hospice. If an enrolled House Calls patient transitions to hospice, the hospice team assumes primary responsibility for the patient’s care. This allows for streamlined communication and care.

How often will I get home visits?

Home visits are scheduled based on the needs of each patient. In addition to provider visits from a physician or advanced practice provider (APP), patients may have scheduled visits with other members of the team, including nursing and social work.

How do I get care after hours or in case of emergency?

Our staff is on call 24/7, including weekends and holidays, and can be reached by calling 205-930-6700.

Can caregivers be part of the visit?

Yes! We encourage caregiver participation in visits, at the level required to ensure that our team can understand the patient’s needs.