A new article in the Public Policy and Aging Report highlights the important role of social determinants of health, as well as community-based organizations, in addressing the needs of older adults in Patient-Centered Medical Homes (PCMHs). PCMHs are designed to transform primary care delivery while also addressing the triple aim of improved patient experience, population health outcomes, reduced cost. To achieve this aim, PCMHs focus on five essential functions: patient-centeredness, comprehensive care, team-based care, coordinated care, accessible services, and commitment to quality and safety.
The John A. Hartford Foundation Change AGEnts PCMH Network developed a roadmap to guide PCMHs in providing quality care for older adults and their caregivers. The approaches outlined in the roadmap incorporate the needs of older adults into each of the five foundational building blocks of PCMH. CBOs, such as Area Agencies on Aging, are integral for each building block, and can help achieve the goals of PCMHs by providing evidence-based disease self-management programs, connecting older adults with nutrition services and transportation, and coordinating services.
This issue of the Public Policy and Aging report focuses on the John A. Hartford Change AGEnts initiative, which aims to engage at least 500 Change AGEnts to lead changes in health care delivery that will improve the health of older adults.