Editor's Note: This post by guest author Nora Super, Chief, Program and Services at the National Association of Area Agencies on Aging (n4a), was originally published on The Huffington Post. The John A. Hartford Foundation supports both the Patient-Centered Medical Home Network of The John A. Hartford Foundation Change AGEnts Initiative and the n4a's partnership with other organizations to build the capacity of the aging and disability networks to ensure the delivery of quality integrated care. 

A new paper—Patient-Centered Medical Homes and the Care for Older Adults: How Comprehensive Care Coordination, Community Connections, and Person-Directed Care Can Make a Difference—argues that community-based organizations (CBOs) are essential partners for the patient-centered medical home (PCMH) team to provide comprehensive care to older adults. While CBOs are not new to filling the gaps outside of the primary care clinic walls, this concept of formal connection to CBOs is new to the PCMH model.

But connecting to community won’t be a novel concept much longer. On October 14, the Centers for Medicare and Medicaid finalized regulations for the Medicare Access and CHIP Reauthorization Act (MACRA). This new law dramatically changes the way Medicare providers will be paid, providing two pathways: the Merit-Based Incentive Payment System, or MIPS, and the Advanced Alternative Payment Model, or APM. The Advanced APM is designed for providers who are participating in specific value-based care models and allows physicians to earn a 5 percent lump sum incentive and avoid MIPS reporting requirements and payment adjustments. The Comprehensive Primary Care Plus Initiative has been selected as an APM and other PCMH models are likely to be approved as well.

This new paper, released as part of The John A. Hartford Foundation Change AGEnts Initiative, recognizes a fundamental truth: older adults want to live independently and when they successfully do, it benefits the health care system as well in terms of reduced costs and better outcomes. To achieve this independence, however, the report notes that older adults often rely on neighbors, friends, family, community, and CBOs, and thus live very much interdependently.

Our takeaway is this: APMs based on a PCMH model focused on complex older adults have the potential to achieve better care at lower cost and CBOs should position themselves to take advantage of this new opportunity. PCMHs are going to need engaged community partners who know how to leverage community resources so the CBOs in the Aging and Disability Networks need to step forward as the natural, most experienced choice.

Want to get started? Check out resources from our new Aging and Disability Business Institute.