KEY FEATURES. Teams of geriatricians, nurse practitioners, and social workers make house calls to patients too sick or weak to visit primary care physician. Patients' caregivers receive support and skills training. TARGET POPULATION. Elderly patients whose frailty or disability puts them at risk of needing hospital, emergency department, or nursing home care. WHY IT'S IMPORTANT. Care provided to this population can be costly and unresponsive to patient preferences. BENEFITS. Increased continuity of care, adherence to care plan, and respect for patients' care preferences at end of life. Early results suggest model can reduce Medicare spending for highest-risk patients by 20 percent or more. CHALLENGES. Convincing payers to support model nationwide.
Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY license. (More information)