The ideal home care model is consist of indiscipline team work, and a continuous biopsychosocial-spiritual care. As new communication technologies developed, team member can easily contact with each other, collecting real-time, specific information. This lead to a better communication with the patient, and even more importantly, the family. The better understanding of each other may reveal the true cause of polypharmacy (possibly due to the complicated bio, psychosocial, and spiritual issues), leading to a more constructive discussion, and find a sustainable solution.