In-home clinical care
Hybrid-first in-home visits within 48 hours of hospital discharge. Physical presence from a Florida-licensed EMT. Clinical decision-making from a PA or NP, joining by video for most visits and in person for higher-acuity cases.
The hybrid model is how RBYS extends clinical capacity without sacrificing the physical presence that makes in-home care work. Both roles are licensed. Both are required for every visit. Neither replaces the other.
Physical presence
A Florida-licensed EMT arrives at the door, introduces themselves, sets up the visit, and stays present in the room throughout. Vitals, the medication cabinet review, and the family conversation all happen with the EMT physically there.
Clinical decision-making
A licensed Physician Assistant or Nurse Practitioner joins the visit by video on a secure device the EMT brings into the home. They review the discharge paperwork, conduct the assessment, ask clinical questions, and document the visit note.
In-person escalation
For patients with complex post-surgical needs, behavioral health concerns, or other higher-acuity situations, a PA or NP arrives in person instead of joining by video. The clinical team makes that call at intake.
A typical 48-hour post-discharge visit runs about 45 minutes from the EMT walking through the door to the visit note being sent back to your team.
0 min
Introductions with the patient and family. The EMT confirms the discharge paperwork, checks the home environment, and sets up the secure video device for the clinical portion of the visit.
WhoEMT in person
5 min
The EMT walks through the discharge summary, the patient's history, and any concerns the family has raised. The clinical team uses this time to prepare for the assessment.
WhoEMT in person
15 min
The EMT takes vitals on-site (blood pressure, heart rate, oxygen saturation, temperature) and reviews every bottle in the medication cabinet against the discharge medication list. Discrepancies are flagged in real time.
WhoEMT in person
25 min
The clinician conducts the assessment, asks clinical questions, reviews the medication reconciliation findings, and answers questions from the patient and family. The EMT stays in the room throughout, assisting with the exam where needed.
WhoPA or NP on video, EMT in person
40 min
The clinician documents the visit note, the medication reconciliation, and any escalation flags. If the patient is enrolled in care management, the plan is updated. If anything requires the referring case manager or PCP, that flag is set.
WhoPA or NP
~45 min
A documented visit note is sent to the referring hospital case manager, the PCP, and the care management team within 24 hours of the visit. Family receives a contact card and the next steps in writing.
WhoCare coordination team
SEQUENCE IS ILLUSTRATIVE. VISIT LENGTH AND ORDER VARIES BASED ON PATIENT COMPLEXITY AND ACUITY.
A defined set of capabilities that every in-home visit can deliver, regardless of whether the clinician is joining by video or in person.
01 / Vitals & assessment
Blood pressure, heart rate, oxygen saturation, temperature, weight. Visual assessment, gait observation, and home environment review. Captured by the EMT and reviewed by the clinician.
02 / Medication reconciliation
The EMT pulls every medication in the home. The clinician reviews each one against the discharge summary. Discrepancies are flagged and sent back to the PCP and case manager within 24 hours.
03 / Care plan review
The clinician reviews the care plan with the patient and family in plain language. Confirms upcoming appointments, follow-ups, and the patient's understanding of what to do if symptoms change.
04 / Family conversation
The patient's family is part of the visit. Questions about caregiving, signs to watch for, when to call us back, and what to do in an emergency are answered face to face.
05 / Documentation
Every visit produces a documented note sent to the referring case manager, the PCP, and the care management team within 24 hours. Standard formats supported.
06 / Escalation
If anything requires the PCP, the specialist, the hospital, or 911, the clinician makes the call before leaving the home. Escalations are tracked through the same care management system.
RBYS in-home clinical care is a defined service. It works because we are clear about what it isn't. The list below names the things we deliberately do not do, and what to do instead.
We are notPrimary care
We don't replace the patient's PCP. We work with the PCP. Our visits are a bridge from hospital to home, not a permanent clinical relationship. The patient stays with their primary care doctor.
We are notUrgent care or emergency care
If something is acutely wrong at the time of our visit, we escalate to the PCP, the specialist, or 911. We don't run an in-home ED. We are scheduled care, not urgent response.
We are notHospice or palliative care
RBYS in-home care is designed for patients recovering from a hospital stay or managing chronic conditions. We coordinate with hospice providers when appropriate, but we are not a hospice service.
We are notA specialist replacement
We don't replace cardiology, oncology, behavioral health, or any specialty team. We coordinate with them. The specialist's care plan is what we help carry through at home.
We are notHome health (Medicare benefit)
RBYS is not a certified home health agency under the Medicare home health benefit. We are a separate in-home clinical service, billed through Transitional Care Management, Chronic Care Management, and related pathways.
Our service is built for four patient profiles. Most members on our panel fit one of these or move between them as their needs change.
Profile 01
Patients leaving the hospital with a new diagnosis, a new medication regimen, or a complex discharge plan. The 48-hour visit catches the medication confusion and care plan gaps that cause readmissions.
Profile 02
Patients with two or more chronic conditions enrolled in CCM. The in-home visit grounds the relationship with a real-world encounter, not just a monthly phone call.
Profile 03
Patients eligible for both Medicare and Medicaid who often have complex social needs (housing, transportation, food access). The in-home visit lets us see the full picture, not just the chart.
Profile 04
Patients who haven't seen a primary care doctor in years, or whose PCP has limited availability. We bridge to a sustainable primary care relationship, we don't replace one.
At this stage, most of our work comes through partnerships with hospitals, SNFs, and insurance plans. The fastest path is usually to ask their care team.
01 / At the hospital
Hospital case managers and discharge planners refer patients to RBYS through their normal workflow. Coordinated alongside transportation home so the visit follows naturally within 48 hours.
Most common path02 / Through a health plan
Medicare Advantage, D-SNP, and Managed Medicaid plans contract with RBYS for in-home clinical care as part of their member benefits. Plan members are referred through their care management team.
Plan-coordinated03 / Through a SNF
Skilled nursing facilities coordinate the discharge home with RBYS so the in-home visit happens within 48 hours of leaving the SNF. Most useful for short-stay patients heading back to a community setting.
SNF-coordinatedTalk to us
Whether you're a hospital case manager, a health plan partner, or a family trying to figure out the right path, the conversation starts on the same line. A real person answers.