The home-based chronic care model: a platform for partnership for the provision of a patient-centered medical home.

Even as the way forward for health care reform was recently thrown into turmoil, key players at Baptist Health Home Health and Hospice break down the components of true health care reform for patients with complex chronic conditions. For these individuals, a reformed system would improve and coordinate their care, base this care on the patients' (rather than the system's) needs, empower patients to self-manage their illnesses, and deliver care through physician-led, interdisciplinary teams. All of this would be done while reducing unnecessary costs in the system and helping patients achieve their best quality of life. But how could such reform be accomplished, and what systems, competencies, and partnerships are available right now to facilitate the transition?