This resource describes how HBPC practices assess the non-medical social needs of older adults who are homebound and identifies barriers to coordinating home and community-based services (HCBS) for patients.

• The study was based on an online survey of members of the American Academy of Home Care Medicine (AAHCM).
• Nearly all practices assessed patient social needs, with 78% conducting an assessment during the intake visit, and 88% providing ongoing periodic assessments.
• The most common needs were personal care, medication adherence, and caregiver support.
• The most common barriers to coordinating HCBS included cost to patient and eligibility requirements.
• More efforts are needed to implement and scale care model partnerships between medical and non-medical service providers within HBPC practices.