Community-based organizations (CBOs) that provide non-medical services and supports are essential to high quality, patient-centered primary care. And given the changing dynamics of payment reform, CBOs are an increasingly important part of the primary care landscape. This report, from the The John A. Hartford Foundation Change AGEnts Patient-Centered Medical Home Network, provides a helpful resource for both primary care practices and CBOs as they seek to deliver better care for older people.
The paper describes a comprehensive set of strategies that primary care practices (and particularly those that are organized as PCMHs) can use to serve frail older adults and their caregivers. Connecting with community-based services is one of several critical steps in this effort, including better care coordination, a commitment to whole person care and providing improved access to care.
As primary care practices engage in practice change and adapt to evolving policies and community needs, it is critical for the Aging Network and other CBOs to equip themselves with the workforce, evidence-based programs, and business acumen needed to engage in effective partnerships with PCMHs, as well as other primary care providers, outpatient specialists, hospitals, and payers. To that end, this report includes specific suggestions and links to resources for partnering with CBOs.