Home Based Primary Care (HBPC) provides primary care to complex, chronically ill patients in Medical Foster homes. The patients are managed by a physician-led interdisciplinary team. HBPC's goal is to decrease unnecessary hospitalizations, and triage visits, and assist with preventing nursing home placement. The HBPC RN functions as a case manager for 25-30 assigned patients and is responsible for assessing and continually reassessing the needs of the veterans and caregivers, delivering nursing care in the home, and keeping physicians and interdisciplinary team members aware of changes in the patients' conditions. The HBPC RN is also responsible for assessing potential patients, presenting findings at the Interdisciplinary staff meeting, and recommendin
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