Home and Community-Based Services Coordination for Homebound Older Adults in Home-Based Primary Care

Gregory J. Norman
Amy J. Wade
Andrea M. Morris
Jill C. Slaboda
Journal Article
October 2018

This resource describes how HBPC practices assess the non-medical social needs of older adults who are homebound and identifies barriers to coordinating home and community-based services (HCBS) for patients.

  • The study was based on an online survey of members of the American Academy of Home Care Medicine (AAHCM).
  • Nearly all practices assessed patient social needs, with 78% conducting an assessment during the intake visit, and 88% providing ongoing periodic assessments.
  • The most common needs were personal care, medication adherence, and caregiver support.
  • The most common barriers to coordinating HCBS included cost to patient and eligibility requirements.
  • More efforts are needed to implement and scale care model partnerships between medical and non-medical service providers within HBPC practices.
Posted to The Playbook on
Population Addressed
Frail Older Adults
Key Questions Answered
  • How are home-based primary care (HBPC) practices addressing the non-medical social needs of older adults who are homebound?
  • What are the most common needs for these patients?
  • What are the barriers that these practices face?
Level of Evidence
Expert Opinion
What does this mean?