Skip to main content

Patients With Special Needs

Reaching the underserved through community-based, in-home, and on-site medical care.

Essen Health Care builds its services around the patients hardest to reach — those who cannot easily come to a clinic, or who need ongoing coordination across multiple settings. Our model brings primary care, specialty consultation, and care management directly to the patient, wherever they are.

How We Serve

Home-bound Patients

Through the Essen House Calls program, physicians, nurse practitioners, and physician assistants deliver primary care, chronic disease management, and diagnostic services in the home for patients who cannot leave it due to medical conditions, disability, or frailty.

  • In-home primary and routine care
  • Mobile diagnostic testing and imaging
  • Chronic disease management (diabetes, COPD, heart disease, hypertension)
  • Care coordination across specialists and pharmacies
Learn About House Calls

Post-Hospital Care

Patients discharged from a hospital or rehabilitation facility are at highest risk in the first 30 days. Our transitional-care program combines virtual check-ins, in-home visits, and active discharge management to reduce readmissions and keep recovery on track.

  • Transition-of-care (TOC) visit within 7 days of discharge
  • Medication reconciliation and home-safety review
  • Virtual follow-ups between in-person visits
  • Direct coordination with the discharging facility
See Transition of Care

Nursing Home Patients

Essen provides on-site medical services to nursing facilities across the Bronx and surrounding boroughs — including medication management, specialist consultations, and acute-event response — so residents receive care without disruptive transfers.

  • On-site primary care rounds
  • Specialist consultations (cardiology, podiatry, psychiatry, etc.)
  • Acute-event response and triage
  • Family communication and care planning
See Nursing Home Services

Need In-Home or On-Site Care?

Speak with our care coordination team to find the right program for the patient.

Patients With Special Needs | Essen Health Care