Table 1

Distinguishing home-based primary care from other home-care models

Functional modelOngoing comprehensive primary care in the home14Home-based multidimensional geriatric assessmentsAcute medical care in the home16Medical care after hospital dischargeTargeted nursing, allied health, and social care services
Care focusComplex and interrelated chronic disease management and social care issuesNeeds assessmentsAcute illness or chronic disease exacerbationOften disease specific (eg, heart failure17 or chronic obstructive pulmonary disease18)Remediable conditions14 and supporting independent living
Time courseOngoingConsultation with possible limited follow-upTime-limited to the end of an acute episodeTime-limited to a designated period after dischargeTime-limited to ongoing
PersonnelPrimary care provider–led interprofessional teamsVaried, but typically nursing and allied health professionalsGeneral practitioners, specialists, nurses, and allied health professionalsGeneral practitioners, specialists, nurses, and allied health professionalsNursing and allied health professionals only
Goals of care
  • Improve access to primary care

  • Maximize independence and function

  • Reduce emergency department, hospital, and long-term care admissions

  • Enhance patient safety and quality of life

  • Link with supportive home-care services14,15

  • Assess needs and develop care plan (to be implemented by office-based primary care provider or specialist)

  • Serve as a substitute for acute hospital care

  • Reduce iatrogenic events (nosocomial infections, functional decline, pressure sores, delirium, falls, etc)16

  • Reduce overall costs

  • Prevent adverse outcomes after discharge from hospital (improve coordination and continuity of care, reduce readmissions)19

  • Reduce overall costs

  • Support independent living