Bringing home the ‘medical home’ for older adults

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Mrs. Smith, age 82, has chronic heart failure. She also has difficulty walking because of arthritis in her knee and osteoporosis. Her son has taken the day off work to bring her in to see her primary care physician, Dr. Jones, because of increasing swelling of her legs and feeling tired.

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Even on a good day, Mrs. Smith faces challenges getting to the doctor’s office: she has difficulty getting dressed, taking the stairs, and transporting her walker and oxygen, not to mention parking the car, getting out, getting in to the doctor’s office, and then returning home.

After a careful evaluation Dr. Jones concludes that the leg swelling and fatigue are due to an exacerbation of heart failure triggered by excess dietary sodium and uncontrolled hypertension. She decides to increase the dosages of Mrs. Smith’s diuretic and angiotensin-converting enzyme inhibitor and advises her and her son about dietary sodium restriction. She reviews with them the symptoms that should trigger a call to the office, and she says she wants to see Mrs. Smith again in 3 days.

Mrs. Smith and her son do not seem to understand the instructions, and they explain how difficult it will be to make the follow-up visit, so Dr. Jones recommends hospital admission. Mrs. Smith protests, as she has had multiple hospitalizations during the past year and she dreads the idea of returning. And her son explains, “Mom always seems worse after going to the hospital. Last winter when she was there her days and nights got mixed up, and when she called out at night they gave her some drug that knocked her out for 2 days. Doctor, isn’t there any safe way to keep her at home?”


The growing number of older adults with chronic illnesses poses a serious challenge to the US health care system, placing unprecedented pressures on the financial sustainability and overall effectiveness of the Medicare program.1,2 Of particular concern is the plight of Medicare beneficiaries like Mrs. Smith who have multiple chronic conditions and whose activity and mobility are limited. These patients account for a disproportionate share of Medicare expenses and, despite all the money spent, often struggle without optimal care that is accessible, individualized, and coordinated.

But this challenge is also an opportunity. We may be able to improve the care of these vulnerable patients—and control costs—by taking their primary care to their own homes. To these ends, the Patient Protection and Affordable Care Act (ie, the “health care reform law”) has several provisions for pilot and demonstration projects.3–5 In light of the new policies and as part of a grassroots effort to change the delivery of care for patients with chronic conditions, primary care physicians like Dr. Jones are redesigning their practices to provide a patient-centered medical home.6

As envisioned, the primary care physician’s office will be the patient’s “medical home.” The primary care physician will lead, coordinate, and oversee the efforts of a multidisciplinary team, referring patients when necessary to specialists and community resources. Primary care practices that become medical homes would potentially be paid care management fees in addition to fees for visits, but with new expectations for care coordination and integration.

The health care reform law also includes the Independence at Home Act, funding a demonstration project in which primary medical care teams will visit patients at home. Beyond the medical home and independence-at-home concepts, the health reform law also promotes “accountable care organizations,” and changes the funding to Medicare Advantage private insurance plans. Both of these initiatives will likely require primary care physicians to redesign how they deliver chronic care to older patients with limited mobility and multiple comorbid illnesses.

The emergence of the medical home, independence-at-home, and related concepts makes it a good time for physicians to explore how they can collaborate with home health providers to better meet the needs of older patients with chronic illness (Table 1).

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