“Eyes in the Home”: Addressing Social Complexity in Veterans Affairs Home-Based Primary Care

Elizabeth Hulen
Avery Laliberte
Sarah Ono
Somnath Saha
Samuel T. Edwards
Peer-Reviewed Article
January 2021


Home-based primary care programs enable care teams to gain insights on a variety of social factors that impact older adults’ health, which allows them to better tailor care to meet patient needs.


Home-based primary care supports adults who face significant challenges in attending office visits due to functional impairments, multiple chronic conditions, and social isolation. The Department of Veteran Affairs (VA) oversees the largest home-based primary care program in the United States. This program has been shown to reduce risks of hospitalization and improve patient satisfaction, but little is known about how these care teams address social needs. This qualitative study explored how VA care teams understand older adults’ social needs and tailor care to meet these needs.


Through interviews with interdisciplinary care team members, the authors reported four cross-cutting themes: (1) home-based primary care patients often experience social isolation in addition to medical and social complexities that overlap in ways that make it difficult for them to access needed care; (2) home visits uncover contextual information about patient lives that may not be understood from a clinic visit, particularly about safety concerns; (3) care team members meet patients’ immediate social needs by providing support services outside of their job descriptions, such as assistance with personal hygiene and food access; and (4) care design flexibility in this model allows for greater tailoring of services to meet patient needs, such as providing additional visits because of functional limitations and social isolation.


As home-based primary care allows providers to observe and address the complex health and social needs of patients in their environments, programs serving older adults and homebound individuals should consider how to incorporate home visits to better understand patients’ social needs and support care design flexibility to meet these needs.

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