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Our research, which has received a catalyst award from the National Academy of Medicine, will develop and validate an AI-powered home visit tool to help clinicians connect homebound patients with social support services.
Today, more than 4 million adults aged 70 and older in the U.S. are homebound. Many have more than one chronic health condition, face significant hurdles to access quality medical care, and have unmet social needs.
MedStar Health is developing an AI-powered home visit companion called Smart Assisted Geriatric Encounters (SAGE). This project was born out of a need we observed in the homes of older adults, and our vision has been recognized with a 2025 Healthy Longevity Global Grand Challenge award from the National Academy of Medicine.
Access to healthcare remains a significant challenge for many seniors, particularly those who have difficulty leaving home for medical appointments. House Calls can help bring an interdisciplinary team of providers to patients’ homes, but these services are often in short supply.
In the U.S, there is a critical shortage of geriatricians, specialists trained to manage the complexities of aging. To meet the needs of an aging population, we can’t wait for more doctors to be trained. That is why we are working with home-based primary care clinicians to make the care they offer more efficient and impactful.
Observing an opportunity to improve care.
The idea of SAGE did not start in a lab; it started in the living rooms of House Call patients. To begin finding ways to help, we start with observation. In this case, we shadowed House Call providers with MedStar Health Home Care to understand their work in the real world.
During these observations, we saw clinicians spending significant time coordinating important social resources for their patients. We realized that if the resource-gathering process could happen in real time, we could change the trajectory of that patient’s care. By offloading administrative tasks from the clinicians’ plates, we could help them spend more time with their patients.
Related: Read “New Research Confirms Staying Active as You Age Helps Combat Cognitive Decline and Dementia.”
What is SAGE?
SAGE is a smartphone application designed to act as a bridge between a doctor’s medical expertise and the community resources a patient needs to stay healthy at home.
The technology behind it is called retrieval-augmented generation (RAG). This allows the app to create a dynamic reserve of knowledge; a database of local community resources and patient needs that it can retrieve in milliseconds, much like a search engine.
For example, a doctor could speak into the app from a patient’s home, “Find grocery delivery resources in this ZIP code,” and SAGE will provide immediate, location-specific recommendations for community resources that can help.
SAGE is designed to identify resources for three main areas that are critical to homebound patients:
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Nutrition and basic needs
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Transportation and access
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Caregiver support
By getting this information to providers in the moment, they can address a patient’s social needs before leaving their home.
Addressing social determinants of health.
Health for homebound seniors is often driven by factors that do not appear in a patient’s health record. Social determinants of health (SDOH) can include challenges such as:
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Difficulty securing dependable transportation
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Lack of caregiver support
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Loneliness
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Low income
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Trouble getting enough healthy food
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Poor housing conditions
SDOH can significantly impact the health, well-being, and quality of life of aging patients. Social isolation and loneliness are associated with a higher risk of dementia, for instance, and transportation trouble can make it difficult to access high-quality medical care.
SAGE treats SDOH with the same level of importance as medical conditions. Reducing the time it takes to connect a family with a food program or a transportation service by even a few days can improve a patient’s health. This can also reduce the burden on family caregivers, who are often left to navigate complex support services on their own.
Related: Read ”Research Finds Caregiver Support Associated with Longer Survival in Homebound Older Adults.”
Building trust through co-design.
The SAGE project is underway, with our pilot study scheduled to kick off in March 2026. Because SAGE operates in a patient’s home, we are taking great care to prioritize their privacy and comfort. Our initial study will focus on whether SAGE works and if patients and providers find it helpful.
As we build this tool, we are committed to a co-design process that includes patients, families, and clinicians to ensure this technology is a helpful companion, not an intrusion.
A foundation for future independence.
Receiving funding from the Healthy Longevity Global Challenge is a testament to the breakthrough potential of this work. The Challenge was created to fast-track innovations that help people live longer and better.
Our goal is to pilot SAGE with the MedStar Health Home Care program to determine how well it empowers the doctors who care for our seniors. If this device helps more older adults access community resources in D.C., this model could be adopted by healthcare teams across the country.
We are excited to take this first step toward a future where homebound seniors and their providers have a smart companion for healthier aging in place.
