Table 1.

Defining characteristics of home-based primary care models

Require for this review	Optional	Excluded
1. Visits by a primary care provider Visits by a physician, nurse practitioner, or physician assistant	Additional visits Nurses, physical therapists, social worker, counselors, etc.	Other models that do not include primary care home visits. Telephone call care only or nurse (or other provider) care only.
2. Visits to a patient’s home Home is defined as any noninstitutional setting where patient resides. It can include private houses or apartments, adult homes, senior housing or assisted living.	Following patient across care setting In hospital management and short-term postacute rehabilitation	Patients in institutions Patients who live in nursing homes, prisons, or long-term care hospitals
3. Longitudinal management The intention is to provide care for an indefinite period until admission to an institution, change in status, or death.	Not applicable	Short term One-time home visits or assessments, hospital at home models in which care is provided for an acute need and the patient returns to previous primary care, or transitional care, for a short defined period (e.g., 30 to 90 days posthospitalization, or 14 days after surgery).
4. Comprehensive primary care Includes medical care for, and the management of, chronic conditions and disabilities, preventive care, providing or arranging needed acute care and environmental assessments.	Inclusion of additional services such as mental health services, palliative care, long term services and supports or social services Assessment and management of serious mental illness including depression. Integration of palliative care or hospice with home-based primary care.	Single condition care or single topic risk assessment Fall risk assessments, programs that target a single condition such as congestive heart failure.

Adapted from Totten et al. AHRQ Publication No. 15(16)-EHC036-EF. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016.¹⁶⁾