The John A. Hartford Foundation Change AGEnts initiative has released a new and much-needed resource: "Patient-Centered Medical Homes and the Care of Older Adults: How comprehensive care coordination, community connections, and person-directed care can make a difference.” The paper, developed by the project’s PCMH Network, provides a roadmap to guide primary care practices in how to enhance care for older, complex patients and their families.

PCMHs are uniquely positioned to provide outstanding care for older adults by embracing approaches to care that are whole person-oriented, coordinated, and comprehensive, with an emphasis on safety and quality of care. In focusing on their older patients, PCMHs can achieve their goals of great patient care to their most vulnerable populations AND succeed in the emerging value-based payment health care environment.

This detailed and practical publication describes:


  • Compelling stories of how PCMHs have transformed outcomes for older adults;
  • How practices can improve outcomes by implementing evidence-based models of care;
  • How community-based organizations can play an integral role in helping PCMHs maintain older adults’ independence and quality of life;
  • Recommendations for actions PCMHs can take to enhance primary care delivery;
  • How advanced PCMHs can benefit under MACRA and employ APMs without putting themselves at risk of financial loss;
  • The challenges and opportunities PCMHs face in serving older patients in five areas: comprehensive care, whole-person care, patient empowerment and support, care coordination and communication, and ready access to care; and
  • Links to resources to aid PCMHs in addressing workforce issues, partnering with community-based organizations, accessing clinical assessment tools, ensuring patient safety, and more. 

For the full paper, click here.

For a one-page overview of the paper, click here.

For the four-page "Guide to Special Considerations for an Aging Population," click here​.

For a two-page overview highlighting how consumer advocates can help promote PCMHs, click here.

Note: A limited number of hard copies of the paper are available. If you would like one or more, please email with how many you would like and how they will be used.