The UT Southwestern Home-Based Primary Care (HBPC) program provides comprehensive, longitudinal primary care to homebound older adults with complex medical, functional, and cognitive needs. Our patients are typically unable to access traditional office-based care due to frailty, mobility limitations, or advanced chronic illness. The program’s goal is to deliver high-quality, patient-centered care in the home, reduce avoidable hospitalizations, and support patients in remaining safely in their preferred living environment.

Our interdisciplinary team includes physicians, advanced practice providers, nurses, social workers, and care coordinators who work collaboratively to address medical, functional, and psychosocial needs. Care is delivered in private homes, assisted living facilities, and group homes. In addition to routine primary care, the program provides transitional care management following hospitalizations, chronic care management, advance care planning, and coordination with home health, hospice, and community-based services.

Key features of the program include:

• Longitudinal primary care delivered in the home
• Management of complex chronic conditions and geriatric syndromes
• Transitional care to reduce readmissions
• Advance care planning and goals-of-care discussions
• Interdisciplinary team-based care
• Close coordination with caregivers, facilities, and community partners

Through this model, the HBPC program improves access to care, enhances patient and caregiver experience, and supports high-value, goal-concordant care for medically complex older adults.

The UT Southwestern Home-Based Primary Care (HBPC) program provides comprehensive, longitudinal primary care to homebound older adults with complex medical, functional, and cognitive needs. Our patients are typically unable to access traditional office-based care due to frailty, mobility limitations, or advanced chronic illness. The program’s goal is to deliver high-quality, patient-centered care in the home, reduce avoidable hospitalizations, and support patients in remaining safely in their preferred living environment.

Our interdisciplinary team includes physicians, advanced practice providers, nurses, social workers, and care coordinators who work collaboratively to address medical, functional, and psychosocial needs. Care is delivered in private homes, assisted living facilities, and group homes. In addition to routine primary care, the program provides transitional care management following hospitalizations, chronic care management, advance care planning, and coordination with home health, hospice, and community-based services.

Key features of the program include:

• Longitudinal primary care delivered in the home
• Management of complex chronic conditions and geriatric syndromes
• Transitional care to reduce readmissions
• Advance care planning and goals-of-care discussions
• Interdisciplinary team-based care
• Close coordination with caregivers, facilities, and community partners

Through this model, the HBPC program improves access to care, enhances patient and caregiver experience, and supports high-value, goal-concordant care for medically complex older adults.