New Hartford Change AGEnts Network to Optimize Patient Centered Medical Homes for Older Patients and Their Families

For Immediate Release
September 18, 2014

Contact: Todd Kluss
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The Hartford Change AGEnts Initiative today announced the formal launch of the new Patient Centered Medical Home (PCMH) Network, which will seek to ensure that the PCMH — a highly coordinated, team-based model of primary care — delivers better outcomes for older adults.

The PCMH Network joins the Dementia Caregiving Network begun earlier this year as part of the Change AGEnts initiative (, a multi-year project funded by the John A. Hartford Foundation and headquartered at The Gerontological Society of America.  The Change AGEnts program is designed to accelerate sustained practice change that improves the health of older Americans, their families, and communities.

David Dorr, MD, MS, and Colleen Casey, PhD, ANP-BC, CNS, of the Oregon Health & Science University, will co-chair the new PCMH Network.

“The Network will transform PCMHs to better recognize, facilitate, encourage, and ultimately reward doing the right thing for older adults and their caregivers,” Dorr said. “We also want to enhance the connection between PCMHs and relevant resources, including family caregivers and community-based resources.”

Casey indicated that current PCMH definitions and implementations do not encourage the models and care practices known to improve outcomes for older adults.

“Both the national definitions from the National Committee for Quality Assurance and various federal demonstrations, as well as state and local definitions of the PCMH, contain little or no focus on advance care planning, functional status, comprehensive assessments, and geriatrics expertise, yet most of these initiatives contain a significant proportion of at-risk elders,” Casey said. “Many of the mixed results coming from studies of PCMHs demonstrate a gap in achieving the crucial outcomes of reduced disability, improved health, and reduced overutilization and cost.”  

Joining Dorr and Casey on this self-directed network for its initial phase is a multi-sector interprofessional team of five experts in the field of patient centered care models. This includes Molly Mettler, MSW, of Healthwise; Toni Miles, MD, PhD, of the University of Georgia; Aanand Naik, MD, of the Michael E. DeBakey Veterans Affairs Medical Center; Robert Schreiber, MD, of Hebrew Senior Life; and Tasha Woodall, PharmD, CGP, CPP, of the Mountain Area Health Education Center.

“Most of us at some point will be caregivers for one or more older adults — and anyone who has had an encounter with our healthcare system knows that current approaches often fail them,” said GSA Executive Director and CEO James Appleby, RPh, MPH. “The work of the PCMH Network is essential and will generate learnings that benefit all older adults and their families.”

The Network’s members will identify immediate opportunities to improve the care of older adults through enhancement of PCMH and similar primary care redesign models. They will focus on identifying change opportunities for professionals working with or in PCMHs — including geriatric nursing, medicine, pharmacy, and social work — in addition to professionals from other relevant disciplines.

“Today, patient centered medical homes represent the nation’s best hope for transforming the primary care, including for older Americans,” said Christopher Langston, PhD, Program Director for the John A. Hartford Foundation. “This Network and its expert leadership and members can make a truly critical contribution towards ensuring these medical homes deliver on this promise and create care that truly meets older patients’ needs.”


The Gerontological Society of America (GSA) is the nation’s oldest and largest interdisciplinary organization devoted to research, education, and practice in the field of aging. The principal mission of the Society — and its 5,500+ members — is to advance the study of aging and disseminate information among scientists, decision makers, and the general public. GSA’s structure also includes a policy institute, the National Academy on an Aging Society, and an educational branch, the Academy for Gerontology in Higher Education.

The John A. Hartford Foundation is a private philanthropy working to improve the health of older Americans. After three decades of championing research and education in geriatric medicine, nursing, and social work, today the Foundation pursues opportunities to put geriatrics expertise to work in all health care settings by advancing practice change and innovation, supporting team-based care through interdisciplinary education of all health care providers, supporting policies and regulations that promote better care, and developing and disseminating new evidence-based models that deliver better, more cost-effective health care. The Foundation was established by John A. Hartford in 1929.  Mr. Hartford and his brother, George L. Hartford, both former chief executives of the Great Atlantic & Pacific Tea Company (the A&P grocery chain), left the bulk of their estates to the Foundation upon their deaths in the 1950s.  Additional information about the Foundation and its programs is available at

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