Home-based primary care services for managing non-communicable diseases in rural India: a retrospective multiple time-point observational study

Purpose: Limited access to healthcare can worsen the burden of non-communicable diseases (NCDs). Home-based primary care models, supported by trained health workers enabled with digital platforms, offer a potential strategy to improve NCD prevention and management. Yet, evidence on how such models perform in real-world settings is limited. Methods: We conducted a retrospective analysis of routinely collected data from September 2022 to March 2025 on participants in NEEM, a subscription-based, home-delivered primary care program for managing NCDs in rural Maharashtra, India. Participants received regular home visits for screening, monitoring, medication delivery, and telemedicine follow-up. Among participants with >1 visit, >30 days of follow-up, and at least two complete observations, we used generalized estimating equations to estimate within-person changes in systolic blood pressure (SBP), diastolic blood pressure (DBP), and random blood sugar (RBS), overall and by control status at screening, and changes in the population-average odds of hypertension (HTN) and diabetes (DM) control. Results: The primary analytic sample comprised 1,668 participants (12,769 observations; median follow-up 252.5 days). SBP changed by −1.19 mmHg (95% CI: −1.38, −1.01), DBP by −0.75 mmHg (−0.86, −0.64), and RBS by −0.77 mg/dL (−1.40, −0.14) per 90 days. The odds of HTN control increased by 21% (adjusted odds ratio [aOR]: 1.21 [95% CI: 1.17, 1.25]) and of DM control by 6% (aOR: 1.06 [1.04, 1.08]) per 90 days. Conclusions: Among NEEM-engaged participants, blood pressure improved, with weaker evidence for blood sugar. Comparative evaluations are needed to establish whether such models improve control relative to traditional facility-based care.