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Leveraging the Patient-Centered Medical Home for Older Adult Care

Elderly patients can benefit from a patient-centered medical home that prioritizes their wishes while delivering safe, efficient, coordinated care.

- The patient-centered medical home (PCMH), one of the nation’s most promising care coordination and population health management frameworks, may be ideally suited to ensuring that older adults receive the services they need to maintain a high quality of life during their golden years. 

Patient-centered medical home for elderly adults

The PCMH’s ability to develop a patient-centered medical neighborhood that prioritizes prevention, chronic disease management, and community connections could be key for helping elderly patients maintain their independence while providing the family and caregiver support they need to make informed decisions about their health.

In an effort to help patient-centered medical homes improve their techniques for delivering care to elderly patients, the John A. Hartford Foundation PCMH Change AGEnts Network has released a new report breaking down the specific challenges and opportunities involved in elder care.

The paper emphasizes the importance of helping older adults remain grounded in their communities by addressing socioeconomic vulnerabilities, setting individualized goals for the future, and guiding elderly patients through the complicated tasks of managing complex conditions.

"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.

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"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."  

The paper highlights several key strategies that may help patient-centered medical homes improve their ability to manage older adults while simultaneously strengthening the overall primary care ecosystem for other types of patients seeking coordinated, high quality care.

Focusing on whole-person, comprehensive care

Proactive, comprehensive, coordinated care is at the heart of every patient-centered medical home, and this approach becomes even more important for elderly patients who are facing the many health and social challenges of aging. 

Older adults are likely to experience a number of difficult issues as they advance in years, including physical frailty and cognitive decline, grief and loss if a spouse or partner predeceases them, financial difficulties, social isolation, and diminishing ability to provide self-care – not to mention the demands of becoming full-time caregivers themselves if their partners or family members experience similar health issues.

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PCMH providers should take these special considerations into account when developing care plans for the elderly, the report suggests, and collaborate with patients to define outcomes that matter to them.  These may include the ability to continue with favorite hobbies, enjoy the company of family members, maintain friendships in the community, or retain an independent living situation.


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In order to help elderly patients achieve these goals, the PCMH must forge strong relationships with community organizations such as local councils on aging, meal delivery services, social workers, home healthcare providers, long-term care providers, and senior centers that provide education, enrichment, and social opportunities.

Providers must also engage the patient by recording personal preferences in the electronic health record, creating advanced care plans in case of serious illness, paying attention to patient concerns, and giving elderly adults the opportunity to discuss issues that may seem embarrassing, unimportant, or burdensome.

“To provide the best possible care, PCMH team members should be conscientious about listening to the concerns of older adults,” the guide states. “Societal biases regarding aging can lead health care providers, families, and patients themselves to dismiss health and social problems as ‘just getting old.’”

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“Shared decision-making, an essential skill for members of the PCMH, can be a useful tool for avoiding problems of undertreating or overtreating. Keeping the care plan and older adult’s goals at the forefront can help ensure that care is personal and tailored to each patient.”

Providers must also offer support, resources, and education to family members and other caregivers, the paper adds, since many older adults receive help from relatives or friends.

“For the whole-person orientation to be fully realized, a constellation of family members and caregivers must be involved in the care of the older adult,” the brief says. “Patients and families are central members of the care team and often are caregivers, and thus they need to be offered tools and support to fulfill their roles and responsibilities.”

Coordinating care across the continuum

In addition to creating a tight network of support for patients within their communities, the patient-centered medical home is responsible for coordinating clinical services and ensuring that older adults receive the highest possible quality of care from specialists, hospitals, long-term care providers, behavioral health providers, pharmacies, and other members of the care continuum.

The PCMH’s team-based approach to care can be instrumental in helping patients navigate the complicated healthcare environment while ensuring that older adults do not fall through the gaps. 

Using the holistic, patient-centered care plan as a compass will help PCMH providers understand the obstacles and opportunities involved in coordinating multiple services.

“Facilitating safe, coordinated care among treatment settings through the PCMH is an essential component of care coordination, especially for older adults who may be more complex in their health conditions and needs for support,” says the report.

Insufficient follow-up from primary care providers, miscommunications between organizations, a lack of seamless health information exchange, and overreliance on the patient as care coordinator can increase the risk of elderly adults falling through gaps in care.

“A care transitions coach who monitors patients and flags patients at higher risk—based on a history of hospitalizations, types of conditions, and quantity and type of medications prescribed—may be particularly useful for the older adult population,” the paper suggests.

If they do not do so already, PCMHs should consider employing dedicated care coordinators or patient navigators that can facilitate transitions of care, collect health information from multiple providers, guide patients through the process of managing complex or chronic diseases, and engage patients on a regular basis to maintain good health.


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Primary care providers should also investigate deploying electronic alerts, such as admission, discharge, and transfer (ADT) notifications, which can allow PCPs to engage in proactive follow-up that may reduce avoidable readmissions and improve outcomes. 

Joining a health information exchange, crafting care coordination contracts with local business partners, and forging strong relationships with complementary community services, such as transportation or nutrition programs, can also facilitate a patient’s journey.

Ensuring convenient access to care

The patient-centered medical home framework encourages providers to offer extended hours, after-hours hotlines, and other access to patients in an effort to reduce unnecessary emergency department use and prevent patients from leaving issues to worsen if they cannot see a provider during the traditional business day.

Ensuring convenient access to care is especially important for elderly patients who may be unable to leave their homes easily, do not think an office visit is worth the hassle, or who rely on family members or caregivers for transportation.

As part of the transition away from episodic care and towards more continuous monitoring and more personal relationships, PCMH providers are encouraged to develop innovative ways to communicate with patients and deliver care. 

Some of the paper’s suggestions for designing flexible, meaningful interactions include:

Scheduling primary care assessments for elderly patients that include mental and behavioral health screenings

Allowing more time during routine visits for patients who may need a longer appointment to discuss complex conditions and multiple concerns

Modifying physical spaces to accommodate patients with assistive devices such as wheelchairs, walkers, and crutches

Designating a single point of contact within the PCMH for elderly patients so that they can develop a comfortable relationship with a staff member who understands their needs

Educating patients and their families about alternative means of communication, including email, text message, phone consults, or telehealth appointments

Offering home visits, home care, and residential safety assessments to patients who have difficulty traveling to an office appointment

Providers may also wish to specifically train PCMH team members in geriatrics, a growing field of study that highlights the unique needs of elderly patients. 

While geriatricians are currently hard to find in the primary care setting, rising demand due to the shift in patient demographics may produce additional opportunities for primary care providers to gain experience in this area.

Meeting high standards for quality and patient safety

“Quality and safety improvement strategies are the hallmarks of the PCMH and must be supported by effective organizational leadership,” the guide states. “A PCP cannot effectively deliver on the other components of a PCMH model if it does not first address patient safety and care quality.”

Maximizing an elderly patient’s enjoyment of his or her remaining time may produce higher patient satisfaction than aggressively treating a disease if the therapy comes with negative side effects, the paper points out, and patients may often choose courses of action that do not align with what would be considered a best practice for a younger patient.


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PCMHs should encourage shared decision-making and allow older adults to express their preferences for care in order to ensure that “quality” means the same thing to the provider as it does to the patient.

Patient safety is a similarly complex topic.  Providers and patients must balance the benefits of a new medication with the risks of interactions with existing therapies, for example, or decide whether a surgery is worth the potential complications inherent in any invasive procedure.

Frail older patients are also more susceptible to falls, may be unable to juggle a large number of medications, and they may be more likely to take on more daily tasks than they can manage as they struggle with relinquishing some of their independence. 

Providers should encourage caregivers to make the patient’s home environment as safe as possible, monitor medication adherence habits, report concerns to the care team, and participate in shared decision-making tasks.

Leveraging EHRs and patient portals for shared decision-making

Data provides the underpinning for all of these activities, and the electronic health record should be a foundational tool for patient-centered medical homes caring for older adults. 

While the majority of EHRs are currently unable to serve as real-time, collaborative documentation platforms that can automatically reconcile changes and suggest the best course of action for the future, they do allow providers to record and share patient data to some degree.

Ideally, the patient’s individual care goals would feature prominently on every screen, the report says, so that providers keep those preferences in mind during every decision.  EHRs would allow for asynchronous care coordination through a web-based wiki-style editing tool, and the record would be completely transparent to the patient and designated caregivers.

The current technical landscape may not allow for such a high level of interaction and coordination, but providers can still leverage existing health IT tools for patient engagement and patient-centered care.

PCMH providers should utilize patient portals and open notes initiatives to bring patients and families into the decision-making process, expand communication options, and deliver tailored education to patients considering a new course of action.

Bidirectional patient portals available to patients and family members “can record their thoughts and questions about interventions,” the report says.

“Patients and family members can be alerted to certain chosen activities in the patient portal. As this technology becomes more sophisticated for two-way communication, its applicability and usefulness to the PCMH model for older adult care will grow.”

Open communication and a centralized digital record will help to ensure that patients receive coordinated care, understand their options, and can connect with providers in a convenient manner.

By using health IT tools to tie together the patient-centered, coordinated care landscape, patient-centered medical homes can deliver individualized, high-quality care to elderly patients with complex needs.

“Older adults comprise a population that matters and great strides can be made in their care and well-being,” the report concludes. “As a moral imperative, older patients deserve respect and quality care that meets their goals.”

“By addressing these essential components of care delivery through a PCMH, older adults, even those with complex needs, will be able to live healthy lives in communities of their choice.”

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