Integrating social services and home-based primary care for high-risk patients

Popul Health Manag

There is a consensus that our current hospital-intensive approach to care is deeply flawed. This review article describes the research evidence for developing a better system of care for high-cost, high-risk patients. It reviews the evidence that home-centered care and integration of health care with social services are the cornerstones of a more humane and efficient system. The article describes the strengths and weaknesses of research evaluating the effects of social services in addressing social determinants of health, and how social support is critical to successful acute care transition programs. It reviews the history of incorporating social services into care management, and the prospects that recent payment reforms and regulatory initiatives can succeed in stimulating the financial integration of social services into new care coordination initiatives. The article reviews the literature on home-based primary care for the chronically ill and disabled, and suggests that it is the emergence of this care modality that holds the greatest promise for delivery system reform. In the hope of stimulating further discussion and debate, the authors summarize existing viewpoints on how a home-centered system, which integrates social and medical services, might emerge in the next few years.

Feinglass J, Norman G, Golden RL, Muramatsu N, Gelder M, Cornwell T. Integrating social services and home-based primary care for high-risk patients. Popul Health Manag. 2017;21(2):96-101. PMID: 28609187. DOI: 10.1089/pop.2017.0026.

Publication Year: 
2017
Resource Type: 
Peer Reviewed Research
Study Design: 
Review
Social Determinant of Health: 
Food/Hunger
Housing Quality
Housing Stability
Legal Services
Social Support/Social Isolation
Transportation
Population: 
Complex Patients
Elderly
Medicaid-insured
Medicare-insured
Screening Research: 
No