Care in the Community

Ambulatory care is designed for the 90–95% of primary care practice, but is neither clinically nor economically efficient for the subset of patients who have become non-ambulatory. As care moves into a community setting, success is contingent on the management of the patient’s needs in three domains: healthcare delivery, long-term social supports (LTSS), and appropriate housing. Home-based primary care (HBPC) provides a richer view of the patient’s clinical, social, and environmental circumstances for that selected group of patients with complex needs and at high-risk for high-cost services. Translating diagnostic and clinical characteristics into a prescription for LTSS and upgrades to the patient’s living situation is best done through the lens of a functional assessment, i.e., activities of daily living (ADLs). We describe two tools that will help the interdisciplinary team focus on interventions with the most impact on helping patients maintain their independence and age-in-place. The Diagnosis/Function Matrix prioritizes medical interventions. The Patient/Caregiver Dyad focuses attention on those functional elements that require caregiver education and skills training or by engaging additional services through informal (unpaid) or formal resources in the community. The third part of this chapter outlines the range of community resources that should be available in most communities to evaluate the environment for assistive devices and home modifications, as well as reducing barriers to promote functional independence in the home versus seeking alternative arrangements. LTSS, through a range of governmental, non-governmental, private pay, and voluntary organizations can be arranged to meet each patient’s specific needs. Chronic Care Management reimbursements through Medicare help cover the time in coordinating and monitoring these services through the practice. Finally, we introduce those interested in HBPC to the growing list of new ventures to support the practice and promote growth in this field.