Home-Based Primary Care

Citation: Woodall, T., Russell, A., Tak, C., & McLean, W. (2023). Addressing Healthcare Utilization and Costs for Older Adults with Limited Mobility Through a Multidisciplinary Home-Based Primary Care Program. Journal of the American Board of Family Medicine : JABFM, 36(4), 550–556. https://doi.org/10.3122/jabfm.2022.220222R3

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  • | Peer Reviewed Article


Home-based primary care (HBPC) has shown promise in the management of multiple chronic conditions for patients who are homebound or who have limited mobility. The objective of this study was to implement and evaluate an HBPC program that integrates the services of clinical pharmacists and community aging services providers in a community-based setting.


Mountain Area Health Education Center’s (MAHEC) HBPC program brought together an interdisciplinary team including medical providers, pharmacists, and community aging services providers to conduct home visits with older adults (age 50+). A single-arm, prepost analysis was conducted to determine differences from the year before program enrollment to the year postenrollment. We examined the frequency of health care visits, high-cost health care utilization (emergency department [ED] utilization and hospitalizations), and health care costs. Descriptive statistics characterized the study population and outcomes. Fisher’s Exact Tests were used to determine if there was a significant difference between years.


There were 130 home visits with 62 patients enrolled in the program. The Medicare Annual Wellness Visit (AWV) was completed for 32 (51.6%) patients. There were 13 (21.0%) and 12 (19.4%) individuals who had at least 1 ED visit and hospitalization, respectively, pre-enrollment as compared with 8 (12.9%) and 9 (14.5%) individuals postenrollment (p-value = 0.05, p-value = 0.06). During the postenrollment year, patient enrollees had an average per-member-per-month (PMPM) cost of $1567.96 as compared with $3053.21 in the year prior.


Pharmacist and community agency services-integrated HBPC was implemented in the community setting. There was a decrease in high-cost health care utilization and total health care expenditures for patients as compared with the previous year.