The Home Health Opportunity in Medical Home Models

As health care continues to transform for older adults, a preference for patient-centered care has emerged to improve outcomes and lower costs. One such patient-centered model focuses on delivering and organizing primary care through comprehensive and coordinated efforts, with plenty of opportunities for home health care providers to get involved.

As adults age, their personal goals and preferences might not always match up with forms of care delivery, which is why a Patient-Centered Medical Home (PCMH) model that delivers primary care while emphasizing the whole person could improve outcomes, health care experts wrote in a recent report by the John A. Hartford Foundation.

Defining the Model 


PCMHs are care models that provide coordinated care for patients based on their personal preferences and needs, and they have five functions and attributes to do it: comprehensive care; patient-centered care; coordinated care; accessible services; and commitment to quality and safety. That’s according to the report, “Patient-Centered Medical Home and the Care of Older Adults.” PCMHs, while not yet common care models, are gaining traction with some evidence that patients with access have fewer hospitalizations and emergency room visits, according to the report.

“The real focus is improving care delivery for older adults with comprehensive care focused on the whole person, where you have coordinated care and communication,” Robert Schreiber, MD, clinical instructor of medicine at Harvard Medical School, tells Home Health Care News. “The primary care team is critically engaged with the individual so the patient is empowered and activated. [The model] provides better access to care by meeting people where they are at so care is equitable, safe and high quality through a comprehensive, coordinated approach.”

In addition to his work at Harvard Medical School, Schreiber is medical director of evidence-based programs at Hebrew SeniorLife, a nonprofit organization that provides comprehensive care for senior living communities in Massachusetts, and medical director of the Healthy Living Center of Excellence, an organization that provides disease management programs to older adults.


Achieving these coordination and communication aims that Schreiber describes creates a model of care that encompasses many different health care providers and settings, including home health and community-based services. At the backbone of the model is the primary care provider, where, ideally, a team would identify a patient’s health care needs and provide services based on patients’ personal goals and values.

“It is a medical model to coordinate all the medical services, connect with community support services and correct social determinant challenges,” Schreiber says. “Care plans should be ideally developed with the individuals, based on their goals.”

For a lot of Americans—about 90%—aging in place is a top priority, which means services in a PCMH could be directed toward the home to manage conditions and keep people healthy.

Patient goals are becoming more closely tied within larger shifts in the health care system as it moves away from fee-for-service and toward value-based purchasing reimbursement at the federal payor level. Furthermore, the Centers for Medicare & Medicaid Services (CMS) is taking steps to recognize the importance of care coordination by providing reimbursements to practices that are willing to take on a little more risk, according to Schreiber.

As the value-based purchasing becomes more prevalent and reimbursement for care coordination services more accepted, patient-centered care may become the norm.

Home Health Opportunity 

However, building the infrastructure for PCMHs isn’t without its challenges, even if some of the recent changes across the health system incentivize patient-centered care.

PCMHs require care coordination between health care providers, and success hinges on the relationship with the primary care team. The home health and home care industries have already looked to become coordinators across the care continuum, with a majority of providers recently stating care coordination is a top priority.

However, care coordination between home health agencies and physicians may be easier said than done, as some home health agencies have voiced their struggles to attain physician signatures on care plans for the Pre-claim Review Demonstration (PCRD).

With aims to provide coordinated care that meets a patient wherever they are, the PCMH offers home health agencies a big opportunity to prove its worth as a partner to primary care teams and other care providers.

Furthermore, home health care providers can act as “the eyes and ears” for other providers in the continuum, Schreiber says. Providers who take care of patients in the home have an opportunity to see other aspects that can influence health outcomes, including accessibility to social supports and social determinants of health. Providers also need to ensure that they are meeting the personal preferences of patients in their care plans.

“Knowing what the person’s goals are, ensuring the care plan and the goals are met in the home, and having the home care team addressing and identifying the goals that are important to the patient is critical,” Schreiber says.

Written by Amy Baxter

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