SOURCE: The John A. Hartford Foundation

The John A. Hartford Foundation

October 03, 2016 08:00 ET

Patient-Centered Medical Homes and the Care of Older Adults -- How Comprehensive Care Coordination, Community Connections, and Person-Directed Care Can Make a Difference

New Paper From The John A. Hartford Foundation Patient-Centered Medical Home Change AGEnts Network Provides a Roadmap for Developing Age-Friendly Primary Care

NEW YORK, NY--(Marketwired - October 03, 2016) - The Patient-Centered Medical Homes (PCMH) are a powerful driver for transforming primary care, but too often they miss opportunities to provide quality care to a high-cost, high-need part of their panels -- older adults with complex health concerns. A new paper released today by The John A. Hartford Foundation PCMH Change AGEnts Network, Patient-Centered Medical Homes and the Care of Older Adults: How Comprehensive Care Coordination, Community Connections, and Person-Directed Care Can Make a Difference provides guidance for how PCMHs can improve health outcomes for this population and achieve an improved system of care.

"PCMHs are uniquely positioned to provide outstanding primary care for older adults by embracing approaches to care that are whole person-oriented, coordinated, and comprehensive, with an emphasis on safety and quality of care," said David Dorr, MD, MS, Professor and Vice Chair, Medical Informatics and Clinical Epidemiology at Oregon Health & Science University, and a contributor to the paper. "This guide will help PCMHs focus on their older patients, achieve their goals of providing great patient care for their most vulnerable populations, and succeed in the emerging value-based payment health care environment."

This detailed and practical publication describes:

  • Compelling stories of how PCMHs have transformed outcomes for older adults;
  • How practices can improve outcomes by implementing evidence-based models of care;
  • How community-based organizations can play an integral role in helping PCMHs maintain older adults' independence and quality of life;
  • Recommendations for actions PCMHs can take to enhance primary care delivery;
  • How advanced PCMHs can benefit under the Medicare Access and CHIP Reauthorization Act (MACRA) and employ Advanced Alternative Payment Models (APMs) without putting themselves at risk of financial loss.
  • The challenges and opportunities PCMHs face in five areas: comprehensive care, whole-person care, patient empowerment and support, care coordination and communication, and ready access to care; and
  • Links to resources to aid PCMHs in addressing workforce issues, partnering with community-based organizations, accessing clinical assessment tools, ensuring patient safety, and more.

"We know that primary care practices and health systems can achieve transformational change and enhance the care they provide to older, complex patients and their families through Patient-Centered Medical Homes," said Robert Schreiber, MD, Medical Director of Evidence-based Programs at Hebrew SeniorLife Department of Medicine, Clinical Instructor of Medicine at Harvard Medical School, and a contributor to the paper. "We also know that there are barriers, challenges, and gaps in the current care approach to older adults. This paper provides a roadmap to better care, not just for older adults, but for all of us."

You can download a copy of the paper here. For a hard copy, please email changeagents365@geron.org.

About the Change AGEnts PCMH Network
The Patient-Centered Medical Home (PCMH) Network is a group of The John A. Hartford Foundation Change AGEnts Initiative. The Network aims to transform PCMHs and similar initiatives to recognize, facilitate, encourage, and ultimately reward doing the right thing for older adults and their caregivers. The Network is co-chaired by David Dorr, MD, MS, Associate Professor and Vice Chair, Medical Informatics and Clinical Epidemiology at Oregon Health & Science University in Portland, OR, and Rob Schreiber, MD, CMD, Medical Director of Evidence-based Programs at Hebrew SeniorLife and Medical Director of the Healthy Living Center of Excellence in Boston, MA.

About The John A. Hartford Foundation
Founded in 1929 by John and George Hartford of the Great Atlantic & Pacific Tea Company (A & P), The John A. Hartford Foundation, based in New York City, is a private, nonpartisan philanthropy dedicated to improving the care of older adults. Every eight seconds, someone in America turns 65. The largest-ever generation of older adults is living and working longer, redefining later life, and enriching our communities and society. Comprehensive, coordinated, and continuous care that keeps older adults as healthy as possible is essential to sustaining these valuable contributions. The John A. Hartford Foundation believes that investments in aging experts and innovations can transform how care is delivered, lowering costs and dramatically improving the health of older adults. Additional information about the Foundation and its programs is available at www.jhartfound.org.

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