Monogram Health
Transforming Outcomes with Holistic In-Home Care

True progress in chronic care starts when treatment accounts for a patient’s full medical history and the real-world factors that shape their health, not just their symptoms. Monogram Health brings that philosophy to life through a holistic, home-based model that integrates medical, social and environmental insights to treat the whole person.

As the only multispecialty provider in the U.S. delivering in-home care specifically focused on polychronic disease, it brings together nephrologists, endocrinologists, pulmonologists, cardiologists, pharmacists, dietitians, social workers and other specialists to deliver integrated care, tailored to each patient. This approach proactively manages all conditions from the impact of others, such as diabetes, hypertension, heart failure and COPD.

Rather than treating these conditions in silos, Monogram ensures that care plans are clinically aligned across conditions and socially informed, bridging gaps in access to care caused by limited health literacy, transportation challenges, or unstable housing.

Care begins with a comprehensive intake process that goes beyond lab results. Most patients enroll following a health event or new diagnosis. In addition to clinical intake, Monogram’s personalized assessments also gather critical information on diet, living conditions and caregiver support. These insights are captured and coordinated through a proprietary digital platform, enabling care teams to create highly personalized plans that reflect a patient’s clinical status and daily realities.

“We’re on their turf, in their home, seeing them under their circumstances where their comfort levels are the highest and trust can be established, rather than a clinic or facility,” says Dr. Shaminder Gupta, chief medical officer.

Dr. Gupta’s vision is shaped by deep clinical experience. As one of Monogram’s founding leaders, he remains closely involved in shaping the care model, working alongside a team of clinicians who have seen firsthand where traditional systems fall short. Their leadership ensures Monogram remains grounded in clinical excellence and responsive to real-world needs.

When Care is Connected, Outcomes Follow

Rendering care in 36 states, Monogram delivers measurable outcomes for patients and partners by lowering the number of hospitalizations and ER visits while helping reduce the overall cost of care. But for families, the most meaningful impact is the personalized care that meets them where and how they live.

That philosophy translates into tangible, high-touch care. Patients can receive same-day telehealth, same-day or next-day in-home visits and continuous support from nurse practitioners and a range of specialists. Supported by physician-led protocols and Monogram’s unified technology infrastructure, interdisciplinary teams operate from a single patient view, allowing for early interventions and seamless coordination that help prevent crises.

For more than two-thirds of adults nationwide living with multiple chronic conditions, Monogram helps bridge the fragmented touchpoints left by traditional care systems. Its unified approach is especially critical for rural populations, who face limited access to specialists and consistent care.

“We have a much more informed, patient-centered approach to care,” says Dr. Gupta. “One day, I hope ‘Monogram’ becomes a verb, because our approach should be the standard of care.”

Technology that Anticipates, Intervention that Delivers Results

A proprietary, clinician-informed digital platform sits at the core of Monogram’s proactive care model. Developed in-house, its proprietary system – Symphony - syncs structured data, such as lab results, medication lists and diagnostic histories, with real-time clinical observations to anticipate needs and prompt timely interventions. These might include adjusting medications for heart failure patients, flagging early dialysis risk or extending support after a hospital discharge.

Consider a patient with heart failure who begins exhibiting early signs of decompensation, such as weight gain or decreased response to diuretics. Instead of waiting for the condition to worsen and necessitate hospitalization, Monogram’s platform alerts the care team to intervene. By adjusting treatment and scheduling a prompt in-home evaluation, the system often prevents a hospital visit.

A similar approach applies to patients needing dialysis. In the hospital, it can cost from $20,000 to $25,000 per treatment, often driven by a lack of coordination rather than clinical necessity. Monogram’s platform helps shift treatment to outpatient settings when appropriate, supporting more timely, cost-effective transitions in care. It also enables individualized care paths, including conservative management or palliative support that honor patient preferences while maintaining clinical integrity.

Monogram’s responsiveness extends beyond regular hours. Through Monogram Health FIRST, a 24/7, 365-day-a-year urgent care program in which the team engages approximately 1,500 patient encounters monthly. Backed by physicians and telehealth tools, nurse practitioners and physicians remotely resolve up to 85 percent of concerns. It includes treating infections, managing lab abnormalities, stabilizing fluid shifts in heart failure patients, adjusting medications and answering patients’ questions and concerns in real time, at any time of the day.

Monogram’s approach prevents hundreds of ER visits in a representative month. For payers, it translates to savings of millions of dollars. For patients, it ensures consistent, timely support and treatment that adapts to their needs.

Preparedness is another key differentiator. When disasters or extreme weather threaten access to care, Monogram activates emergency protocols, ordering extra medication, coordinating alternative dialysis services and arranging patient transport. A proactive strategy is especially critical for vulnerable patients with complex conditions.

Its model pairs clinical agility with financial stewardship and trusted relationships. Every aspect of the model is designed to reduce unnecessary utilization, align care with patient goals and deliver better outcomes at a lower cost. That clarity of purpose has earned Monogram the confidence of national payers like Humana and Aetna, risk-bearing partners like Millennium Health and strategic investors such as Frist Cressey Ventures and TPG Capital, driving sustainable growth while upholding high clinical standards.

Advancing Chronic Care

Monogram’s next phase will be shaped by strategic growth and a clear focus on delivering value where unmet need is most prevalent. Its expansion is guided by the identification of communities where the model can drive measurable change while preserving the clinical rigor that defines its current success.

While Monogram has received international inquiries about its innovative care model, the company remains focused on transforming the U.S. healthcare landscape. Its goal is to strengthen that foundation and demonstrate, at scale, what consistent, whole-person care can truly achieve.

Monogram Health envisions a future where multispecialty, in-home care is the standard for managing chronic conditions. To bring that vision to life, the company is delivering a model of chronic care that is clinically strong, deeply personal and guided by a holistic view of health.