The Patient Centered Medical Home Network of The John A. Hartford Foundation Change AGEnts Initiative has released an important new paper: "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 provides a roadmap to guide primary care practices in how to enhance care to older, complex patients and their families.

Included in this detailed and practical publication are:


  • Descriptions of the challenges and opportunities for PCMHs in five areas: comprehensive care, whole-person care, patient empowerment & support, care coordination & communication, and ready access to care,
  • Recommendations for actions PCMHs can take in a variety of scenarios,
  • Examples of evidence-based models of care that can be implemented by practices,
  • Compelling stories of how PCMHs have transformed outcomes for older adults,
  • Illustrations of the integral role community-based organizations can have working in conjunction with PCMHs to maintain the independence and quality of life of older adults, and
  • Links to resources to aid PCMHs.

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.

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.

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.