Coordinating Care for Adults with Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solutions

Patients with complex health needs require both medical and social services and support from multiple providers and caregivers, and the patient-centered medical home (PCMH) offers a promising model for providing them comprehensive, coordinated care. Smaller practices, however, face challenges in coordinating care for these patients. This white paper for the Agency for Healthcare Research and Quality explores the current landscape of PCMH services for patients with complex needs. It details five programs that have addressed the challenges of caring for these patients, and offers programmatic and policy changes that can help smaller practices better deliver services to all patients, including those with the most complex health needs.