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Improving Patient Care |

Brief Communication: National Quality-of-Care Standards in Home-Based Primary Care FREE

Kristofer L. Smith, MD, MPP; Theresa A. Soriano, MD, MPH; and Jeremy Boal, MD
[+] Article and Author Information

From the Mount Sinai School of Medicine, New York, New York.


Disclaimer: The content and conclusions expressed herein are those of the authors and should not be construed as representing the official position or policy of the Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services or the U.S. government.

Acknowledgments: The authors thank Ethan Halm, MD, MPH, and Katherine Ornstein, MPH, of the Mount Sinai School of Medicine for their thoughtful review of early drafts of the manuscript.

Grant Support: By the Division of State, Community, and Public Health, Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services (grant no. 5 K01 HP 00053-02) and a Geriatric Academic Career Award (Dr. Boal).

Potential Financial Conflicts of Interest: Consultancies: J. Boal (Visiting Nurse Service of New York).

Requests for Single Reprints: Theresa Soriano, MD, MPH, The Mount Sinai Visiting Doctors Program, Mount Sinai School of Medicine, Box 1216, One Gustave L. Levy Place, New York, NY 10029; e-mail, theresa.soriano@mssm.edu.

Current Author Addresses: Dr. Smith: Department of Medicine, Mount Sinai Medical Center, Box 1118, One Gustave L. Levy Place, New York, NY 10029.

Drs. Soriano and Boal: The Mount Sinai Visiting Doctors Program, Mount Sinai School of Medicine, Box 1216, One Gustave L. Levy Place, New York, NY 10029.

Author Contributions: Conception and design: K.L. Smith, T.A. Soriano, J. Boal.

Analysis and interpretation of the data: K.L. Smith, T.A. Soriano.

Drafting of the article: K.L. Smith, T.A. Soriano, J. Boal.

Critical revision of the article for important intellectual content: K.L. Smith, T.A. Soriano, J. Boal.

Final approval of the article: K.L. Smith, T.A. Soriano, J. Boal.

Statistical expertise: K.L. Smith.

Obtaining of funding: J. Boal.

Administrative, technical, or logistic support: K.L. Smith.

Collection and assembly of data: K.L. Smith.


Ann Intern Med. 2007;146(3):188-192. doi:10.7326/0003-4819-146-3-200702060-00008
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With the declining number of nursing home beds (1), patients' continued preference to remain in the home (2), and an increasingly aged population, the number of permanently homebound seniors will increase to more than 2 million in 20 years (3). These patients have difficulty accessing medical care and are increasingly receiving primary care through home-based primary care programs (4). As home-based primary care expands, however, tools to support, measure, and improve quality of care for these complex patients have not been developed. One such tool would be a comprehensive set of evidence-based process quality indicators that is developed by experts in home-based primary care.

The Assessing Care of Vulnerable Elders (ACOVE) project has developed several quality indicator sets for ambulatory geriatric and nursing home patients (56). These quality frameworks, however, cannot be simply adopted. Home-based primary care patients have higher mortality rates and shorter life expectancies than the ACOVE-studied populations, with goals of care that focus on quality, rather than prolongation, of life (79). Home-based primary care programs are often multidisciplinary efforts that emphasize coordination and continuity of care (10). Furthermore, processes of care vital to high-quality care of the homebound patient may have been overlooked by the ACOVE researchers. Given these findings, the Home-based Primary Care Quality Initiative (HPCQI), a multistep, national expert panel process, was completed. The study, by adapting and expanding on earlier ACOVE work, identified a set of evidence-based process quality indicators that are valid and important to providing high-quality primary care to homebound seniors.

Setting

The study was conducted at the Mount Sinai Visiting Doctors program of the Mount Sinai Medical Center, New York, New York (11). The initiative was formally endorsed by the American Academy of Home Care Physicians (AAHCP) Board of Directors in 2005.

ACOVE Overview

The ACOVE project created a comprehensive quality-of-care management program for frail community-dwelling elders (5), including an evidence-based quality indicator set covering 22 geriatric conditions (12). The feasibility of using these indicators has been demonstrated (13).

HPCQI Overview

The HPCQI team used a multistep process for adapting and expanding the ACOVE quality indicators to home-based primary care. First, the study team modified language in the ACOVE community and nursing home quality indicators for the home care setting and eliminated hospital-based quality indicators. Second, the HPCQI team members developed evidence-based quality indicators for constipation and insomnia, 2 conditions that the ACOVE project did not cover but for which homebound patients have disproportionate morbidity. Third, a home-based primary care quality indicator development expert panel (development panel) assessed the new and modified quality indicators for applicability to the home-based primary care setting. Fourth, a second, discrete panel—the home-based primary care quality indicator evaluation expert panel (evaluation panel)—evaluated the applicable quality indicators for validity and importance. Finally, indicators that were deemed to be valid and important by the evaluation panel were accepted for use in the home-based primary care setting.

To form the panels, we contacted clinicians who were in home-based primary care program administration and quality management, had authored peer-reviewed scholarship in the area of home-based primary care, or had leadership roles within the AAHCP. A group of panelists that were diverse in practice type, location, and setting was a priority. (The Appendix lists the members of each panel.)

The development panel's primary task was to perform a face validity review through a mailed survey of the ACOVE quality indicators. Panelists rated the indicators as 1) likely to apply equally to the home-based primary care setting as to the nursing home or ambulatory care setting, 2) likely to need modification, or 3) unlikely to apply.

The evaluation panel rated the validity and importance of the applicable quality indicators through 2 rounds of mailed surveys. Panel members used a modified Delphi expert panel group judgment process, which has been shown to be appropriate for translating research from 1 area or study to a different population or setting (1415). Our study substituted conference calls and mailed surveys for the face-to-face approach—a modification that is shown to have acceptable reproducibility (16).

Throughout the study, panel members used widely accepted definitions of “home-based primary care” (17) and “homebound seniors” (18).

Role of the Funding Sources

This project was supported by funds from the Division of State, Community, and Public Health, Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services and a Geriatric Academic Career Award (Dr. Boal). The funding sources played no role in the design, process, or interpretation of the study or in the decision to submit the manuscript for publication.

Quality Indicator Development Panel

Of the 260 quality indicators evaluated by the development panel, 25 (10%) were rated as inapplicable and were removed from the quality indicator set.

Quality Indicator Evaluation Panel

On the basis of first-round survey results, 19 (8.1%) of the 235 applicable indicators, rated as both invalid and unimportant, were removed from the quality indicator set. One hundred seventy-six indicators, rated as valid and important, were included in the final quality indicator set. Forty (17.0%) indicators received indeterminate evaluations, were discussed by the panelists during 2 conference calls, and were then rerated. Of these rerated indicators, 24 were included and 16 were removed from the final quality indicator set.

Finally, the evaluation panel reviewed the indicators that the development panel eliminated and agreed that they were appropriately excluded.

Final Home-Based Primary Care Quality Indicator Set

The result is a quality indicator set with 200 process indicators for 23 geriatric conditions (Appendix Table). Of these 200 quality indicators, 21 (10.5%) were newly created, 52 (26%) were modified from the ACOVE work, and 127 (63.5%) were unchanged from the ACOVE work. Fifty-five ACOVE indicators and 5 newly created indicators, rated as inapplicable, invalid, and/or unimportant, were dropped from the quality indicator set.

The 21 new indicators were limited to 6 conditions: constipation (n = 9), continuity and coordination of care (n = 3), end-of-life care (n = 2), heart failure (n = 1), insomnia (n = 5), and preventive care (n = 1). The 52 modified indicators fell into 6 categories: documentation (n = 5); earlier screening, intervention, and follow-up (n = 19); more specific or explicit (n = 9); more specific to the home-based primary care setting (n = 6); promoting palliative care or patient autonomy (n = 6); and miscellaneous (n = 7) (Table 1).

Table Jump PlaceholderTable 1.  Examples of Modifications Made to the Assessing-the-Care-of-Vulnerable-Elders Indicators That Were Included in the Home-Based Primary Care Quality Indicator Set*

Tables 2 and 3 show selected characteristics of the evaluated indicators. According to domain of care, the highest percentage of rejected indicators was treatment-related (51.7%). Accepted indicators were more evenly dispersed among the 4 domains of care.

Table Jump PlaceholderTable 2.  Indicators Evaluated for Inclusion in the Home-Based Primary Care Quality Indicator Set according to Condition
Table Jump PlaceholderTable 3.  Indicators Evaluated for Inclusion in the Home-Based Primary Care Quality Indicator Set according to Domain of Care

Home-based primary care experts identified a core set of 200 processes that all home-based primary care practitioners should provide for their patients. For our study, we pursued adaptation and expansion of the ACOVE work, rather than adoption or de novo construction. The result is a quality indicator set that overlaps the well-established ACOVE framework with modifications for applicability to the home-based primary care setting.

The modifications, deletions, and additions made during the study demonstrate the unique challenges and preferences of homebound seniors (710). More than half of the eliminated indicators were from the treatment domain of care. Thus, treatment quality indicators make up a smaller percentage of the overall quality indicator set than in the original ACOVE work. Quality indicators for follow-up and continuity of care domains, on the other hand, have a higher proportional representation in the quality indicator set. The quality indicator modifications trended toward closer management. Reflecting the reality that homebound patients can decline quickly, many modifications were for more frequent screening and follow-up. Finally, the bulk of the new indicators were in quality-of-life domains, such as end-of-life care, constipation, and insomnia, further reinforcing the primacy placed on patient comfort.

Our most vulnerable seniors are increasingly relying on home-based primary care. Infrastructure to support the provision of high-quality home care is lacking. As such, our quality indicator set fills an essential need. These indicators should guide home-based primary care practitioners as they look to provide high-quality care.

In addition to improving quality, our quality indicator set will allow for future comparative research. An important question, yet unanswered, about home-based primary care is whether the model provides care that is similar in quality to that of more established systems. Without quality-of-care data, the medical community and government payers will probably continue to resist embracing home-based primary care. By creating a quality instrument that has substantial overlap with work done in other geriatric care settings, comparative quality of care can be studied.

Feasibility of implementation could be a limitation to our study. Home-based primary care programs are typically resource-poor and might have difficulty funding quality management infrastructure. Despite these feasibility concerns, all valid and important indicators were reported to encourage home-based primary care programs to search for innovative care solutions and novel funding sources. Future projects to decrease the cost of implementing the quality indicator set should be pursued.

Many home-based primary care patients have severe dementia or fewer than 6 months to live. These patients have different goals of care that render many processes inappropriate. Future studies, such as that completed by ACOVE researchers (19), should identify quality indicators that are not appropriate for these patients.

Another concern, common to expert opinion processes, is that many of these indicators need validation through prospective study. A process for regular update and review of this quality instrument should be coupled with prospective validation. Finally, our quality indicator set represents the expert opinion of a few home-based primary care practitioners. The diversity of the panelists and that they are recognized national experts suggests, however, that their opinions are broadly representative.

Homebound seniors typically have several chronic medical conditions that make providing high-quality primary care both critical and difficult. Using a multistep process, home-based primary care experts identified processes of care that are essential to providing high-quality care to homebound seniors. This quality indicator set should provide a rigorous structure for home-based primary care programs to build their quality-of-care management programs and should improve patient quality of life and longevity. The overlap of the set with previous ACOVE work also allows for future comparative study of quality provided by the home-based primary care model.

National Center for Health Statistics.  Health, United States, 2005 With Chartbook on Trends in the Health of Americans. Hyattsville, MD: National Center for Health Statistics; 2005.
 
Higginson IJ, Sen-Gupta GJ.  Place of care in advanced cancer: a qualitative systematic literature review of patient preferences. J Palliat Med. 2000; 3:287-300.
CrossRef
 
Executive Summary, Public Policy Statement: American Academy of Home Care Physicians, 2005. Edgewood, MD: American Academy of Home Care Physicians. Accessed athttp://www.aahcp.org/public_policy_2005.pdfon 31 July 2006.
 
Centers for Medicare & Medicaid Services.  Nonidentifiable Data Files: Physician/Supplier Procedure Summary Master File. Baltimore, MD: Centers for Medicare & Medicaid Services. Accessed athttp://new.cms.hhs.gov/NonIdentifiableDataFiles/06_PhysicianSupplierProcedureSummaryMasterFile.aspon 14 April 2006.
 
Wenger NS, Shekelle PG.  Assessing care of vulnerable elders: ACOVE project overview. Ann Intern Med. 2001; 135:642-6.
 
Saliba D, Solomon D, Rubenstein L, Young R, Schnelle J, Roth C. et al.  Quality indicators for the management of medical conditions in nursing home residents. J Am Med Dir Assoc. 2004; 5:297-309.
 
Kellogg FR, Brickner PW.  Long-term home health care for the impoverished frail homebound aged: a twenty-seven-year experience. J Am Geriatr Soc. 2000; 48:1002-11.
 
Saliba D, Elliott M, Rubenstein LZ, Solomon DH, Young RT, Kamberg CJ. et al.  The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community. J Am Geriatr Soc. 2001; 49:1691-9.
 
Fried TR, Wachtel TJ, Tinetti ME.  When the patient cannot come to the doctor: a medical housecalls program. J Am Geriatr Soc. 1998; 46:226-31.
 
Leff B, Burton JR.  The future history of home care and physician house calls in the United States. J Gerontol A Biol Sci Med Sci. 2001; 56:M603-8.
 
Smith KL, Ornstein K, Soriano T, Muller D, Boal J.  A multidisciplinary program for delivering primary care to the underserved urban homebound: looking back, moving forward. J Am Geriatr Soc. 2006; 54:1283-9.
 
Shekelle PG, MacLean CH, Morton SC, Wenger NS.  Assessing care of vulnerable elders: methods for developing quality indicators. Ann Intern Med. 2001; 135:647-52.
 
Min LC, Reuben DB, MacLean CH, Shekelle PG, Solomon DH, Higashi T. et al.  Predictors of overall quality of care provided to vulnerable older people. J Am Geriatr Soc. 2005; 53:1705-11.
 
Merrick NJ, Fink A, Park RE, Brook RH, Kosecoff J, Chassin MR. et al.  Derivation of clinical indications for carotid endarterectomy by an expert panel. Am J Public Health. 1987; 77:187-90.
 
Shekelle PG, Kahan JP, Bernstein SJ, Leape LL, Kamberg CJ, Park RE.  The reproducibility of a method to identify the overuse and underuse of medical procedures. N Engl J Med. 1998; 338:1888-95.
 
Washington DL, Bernstein SJ, Kahan JP, Leape LL, Kamberg CJ, Shekelle PG.  Reliability of clinical guideline development using mail-only versus in-person expert panels. Med Care. 2003; 41:1374-81.
 
Levine SA, Boal J, Boling PA.  Home care. JAMA. 2003; 290:1203-7.
 
U.S. Department of Health and Human Services.  Medicare and Home Health Care. Publication no. CMS-10969. Baltimore, MD: Centers for Medicare & Medicaid Services; 2003.
 
Solomon DH, Wenger NS, Saliba D, Young RT, Adelman AM, Besdine RK. et al.  Appropriateness of quality indicators for older patients with advanced dementia and poor prognosis. J Am Geriatr Soc. 2003; 51:902-7.
 
Appendix: Panel Members
Development Panel

Lisa Caruso, MD, MPH, Boston University School of Medicine, Boston, Massachusetts; Eric DeJonge, MD, George Washington University School of Medicine, Washington, DC; Kevin Jackson, MD Geriatric Solutions, Phoenix, Arizona; Deirdre Mole, RN, GNP, Weill Medical College of Cornell University, New York, New York; Jean Yudin, RN, CMSN, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.

Evaluation Panel

Peter Boling, MD, Virginia Commonwealth University, Richmond, Virginia; Thomas Cornwell, MD, Central DuPage Hospital, Wheaton, Illinois; Jennifer Hayashi, MD, Johns Hopkins Bayview, Baltimore, Maryland; Benneth Husted, DO, Housecall Providers Inc., Portland, Oregon; Sharon Levine, MD, Boston University School of Medicine, Boston, Massachusetts; Veronica LoFaso, MD, Weill Medical College of Cornell University, New York, New York; Sonni Mun, MD, Mount Sinai School of Medicine, New York, New York; Wayne McCormick, MD, University of Washington, Seattle, Washington; Edward Ratner, MD, University of Minnesota, Minneapolis, Minnesota.

Figures

Tables

Table Jump PlaceholderTable 1.  Examples of Modifications Made to the Assessing-the-Care-of-Vulnerable-Elders Indicators That Were Included in the Home-Based Primary Care Quality Indicator Set*
Table Jump PlaceholderTable 2.  Indicators Evaluated for Inclusion in the Home-Based Primary Care Quality Indicator Set according to Condition
Table Jump PlaceholderTable 3.  Indicators Evaluated for Inclusion in the Home-Based Primary Care Quality Indicator Set according to Domain of Care

References

National Center for Health Statistics.  Health, United States, 2005 With Chartbook on Trends in the Health of Americans. Hyattsville, MD: National Center for Health Statistics; 2005.
 
Higginson IJ, Sen-Gupta GJ.  Place of care in advanced cancer: a qualitative systematic literature review of patient preferences. J Palliat Med. 2000; 3:287-300.
CrossRef
 
Executive Summary, Public Policy Statement: American Academy of Home Care Physicians, 2005. Edgewood, MD: American Academy of Home Care Physicians. Accessed athttp://www.aahcp.org/public_policy_2005.pdfon 31 July 2006.
 
Centers for Medicare & Medicaid Services.  Nonidentifiable Data Files: Physician/Supplier Procedure Summary Master File. Baltimore, MD: Centers for Medicare & Medicaid Services. Accessed athttp://new.cms.hhs.gov/NonIdentifiableDataFiles/06_PhysicianSupplierProcedureSummaryMasterFile.aspon 14 April 2006.
 
Wenger NS, Shekelle PG.  Assessing care of vulnerable elders: ACOVE project overview. Ann Intern Med. 2001; 135:642-6.
 
Saliba D, Solomon D, Rubenstein L, Young R, Schnelle J, Roth C. et al.  Quality indicators for the management of medical conditions in nursing home residents. J Am Med Dir Assoc. 2004; 5:297-309.
 
Kellogg FR, Brickner PW.  Long-term home health care for the impoverished frail homebound aged: a twenty-seven-year experience. J Am Geriatr Soc. 2000; 48:1002-11.
 
Saliba D, Elliott M, Rubenstein LZ, Solomon DH, Young RT, Kamberg CJ. et al.  The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community. J Am Geriatr Soc. 2001; 49:1691-9.
 
Fried TR, Wachtel TJ, Tinetti ME.  When the patient cannot come to the doctor: a medical housecalls program. J Am Geriatr Soc. 1998; 46:226-31.
 
Leff B, Burton JR.  The future history of home care and physician house calls in the United States. J Gerontol A Biol Sci Med Sci. 2001; 56:M603-8.
 
Smith KL, Ornstein K, Soriano T, Muller D, Boal J.  A multidisciplinary program for delivering primary care to the underserved urban homebound: looking back, moving forward. J Am Geriatr Soc. 2006; 54:1283-9.
 
Shekelle PG, MacLean CH, Morton SC, Wenger NS.  Assessing care of vulnerable elders: methods for developing quality indicators. Ann Intern Med. 2001; 135:647-52.
 
Min LC, Reuben DB, MacLean CH, Shekelle PG, Solomon DH, Higashi T. et al.  Predictors of overall quality of care provided to vulnerable older people. J Am Geriatr Soc. 2005; 53:1705-11.
 
Merrick NJ, Fink A, Park RE, Brook RH, Kosecoff J, Chassin MR. et al.  Derivation of clinical indications for carotid endarterectomy by an expert panel. Am J Public Health. 1987; 77:187-90.
 
Shekelle PG, Kahan JP, Bernstein SJ, Leape LL, Kamberg CJ, Park RE.  The reproducibility of a method to identify the overuse and underuse of medical procedures. N Engl J Med. 1998; 338:1888-95.
 
Washington DL, Bernstein SJ, Kahan JP, Leape LL, Kamberg CJ, Shekelle PG.  Reliability of clinical guideline development using mail-only versus in-person expert panels. Med Care. 2003; 41:1374-81.
 
Levine SA, Boal J, Boling PA.  Home care. JAMA. 2003; 290:1203-7.
 
U.S. Department of Health and Human Services.  Medicare and Home Health Care. Publication no. CMS-10969. Baltimore, MD: Centers for Medicare & Medicaid Services; 2003.
 
Solomon DH, Wenger NS, Saliba D, Young RT, Adelman AM, Besdine RK. et al.  Appropriateness of quality indicators for older patients with advanced dementia and poor prognosis. J Am Geriatr Soc. 2003; 51:902-7.
 

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Home Primary Care Standards Missing Holistic, Patient-Centered Measures
Posted on February 12, 2007
Steven H Landers
Case Western Reserve University School of Medicine, Dept. of Family Medicine
Conflict of Interest: None Declared

Dr. Smith and colleagues should be commended for their efforts to introduce quality standards for home-based primary care (HPC).1 Unfortunately, their selection process and choice of indicators overlooked important qualities of elders with chronic illness and the role of HPC. They have exaggerated the importance of narrow, condition-specific guidelines and short-changed the value of measuring patient-centered aspects of care. Following these guidelines could lead to lower quality care as clinician attention is diverted from meeting patient and family goals to focus on irrelevant checklists.

HPC has tremendous potential to improve the care of vulnerable elders. In-home care reduces access barriers, provides a holistic view of patients, and demonstrates caring. These characteristics position it as a promising intervention for Medicare's great challenge: the care of elders with multiple coexisting chronic conditions. Eighty% of Medicare expenses are for the care of patients with >/=4 chronic conditions.2 Beyond the cost, elders with multiple conditions often suffer without medical leadership as care is provided in narrow and rigid categories.

So, how to measure the process of HPC so society can capitalize on the enormous unmet potential benefits? The answer starts with appreciating the limitations of 'evidence-based' approaches, there is minimal research to inform practice for elders with multiple conditions.3 The authors relied on the ACOVE project, a study that concluded adherence to their guidelines leads to decreased mortality and functional decline.4 But, ACOVE participants were quite different than the typical HPC patient. ACOVE participants had only ~2 conditions and ~.5 ADL deficits. The authors only needed to look at their own visionary HPC practice to see ~1000% higher prevalence of dementia, ~250% higher prevalence of heart failure, and markedly higher rates of ADL and IADL deficits compared with ACOVE.5 ACOVE's emphasis on survival may also not be in line with patient goals, ACOVE didn't assess the impact of adherence to caregiver burden. Using ACOVE as the foundation for developing indicators for HPC is a major conceptual flaw.

The beauty of HPC is that it uniquely focuses the clinician on the patient and family's individualized needs, goals, and values. Appropriate measures for ongoing improvement likely include adherence to goals of care, patient-centeredness, caregiver-burden, satisfaction, accessibility, and degree of caring along with some select condition-specific indicators. A new standards development process that starts with an appropriate conceptual framework and is more inclusive of patients, caregivers, and other types of clinicians will likely yield more useful results.

1. Smith KL, Soriano TA, Boal J. Brief communication: National quality-of-care standards in home-based primary care. Ann Intern Med 2007;146(3):188-92.

2. Partnership for Solutions: Better Lives for People with Chronic Conditions. 2004. (Accessed 9/30/06, at http://www.partnershipforsolutions.org/.)

3. Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. Jama 2005;294(6):716-24.

4. Wenger NS, Solomon DH, Roth CP, et al. The quality of medical care provided to vulnerable community-dwelling older patients. Ann Intern Med 2003;139(9):740-7.

5. Smith KL, Ornstein K, Soriano T, Muller D, Boal J. A multidisciplinary program for delivering primary care to the underserved urban homebound: looking back, moving forward. J Am Geriatr Soc 2006;54(8):1283-9.

Conflict of Interest:

None declared

Re: Home Primary Care Standards Missing Holistic, Patient-Centered Measures
Posted on March 8, 2007
Kristofer, L Smith
Mount Sinai Medical Center
Conflict of Interest: None Declared

We thank Dr. Landers for taking the time to reflect on the national quality of care standards for home based primary care (HBPC). Fundamentally, Dr. Landers argues that our work should have paid more attention to creating indicators that are more holistic in their view of patients. It was precisely for this reason that our panelists spent many months reviewing and amending the ACOVE work. The changes and additions made to the ACOVE quality indicator set placed greater primacy on patient autonomy, added indicators for coordination of care, caregiver burden, and end-of life care, and created new indicators for areas of care which reside in quality of life domains such as insomnia and constipation.

The objections raised however, do exemplify a belief pervasive in the field of HBPC; that traditional evidence-based paradigms cannot be applied to this unique patient care setting. We agree that the direct evidence collected on this patient cohort continues to be thin. We also agree that there are theoretical reasons to believe that current quality of care paradigms might not be appropriate to HBPC patients;(1) however, supporting empiric evidence remains elusive. Given the lack of evidence and the lack of tools to evaluate this thesis, we hope that clinicians will welcome such work as the HBPC quality indicator set. This framework provides the tools to empirically verify the claim that "guidelines could lead to lower quality care as clinician attention is diverted from meeting patient and family goals to focus on irrelevant checklists."(2)

Finally, the current health policy climate, with its emphasis on public reporting of healthcare quality,(3) and such on-the-horizon initiatives as pay-for-performance,(4) necessitates that HBPC practitioners be prepared to be measured and evaluated on such categories as hypertension and diabetes management. We certainly agree that HBPC encompasses so much more than can be captured in quality of care guidelines, but it would be folly to overlook the fact that in a few years time every primary care program, regardless of patient characteristics, may soon be held accountable to a similar core set of core processes.

As has been written by many before us,(5) HBPC should be more central to the fields of internal medicine and family practice. The field, however, will continue to remain on the margins as no payer - government or private - will support the expansion of a model of care that cannot demonstrate the quality of its care.

1. Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005; 294: 716-24.

2. Landers, SH. Home primary care standards missing holistic, patient -centered measures. 2007. (Accessed on 3/7/07 at http://www.annals.org/cgi/eletters/146/3/188).

3. Centers for Medicare & Medicaid Services. Medicare takes key step toward voluntary quality reporting for physicians. Vol. 2005. Washington, DC: Centers for Medicare & Medicaid Services Office of Public Affairs; 2005.

4. Medicare Value Purchasing (MVP) Act of 2005 US Senate Bill S.1356

5. Landers, SH. Home care: A key to the future of family medicine? Ann Fam Med. 2006; 4: 366-8.

Conflict of Interest:

Consultancies: J. Boal(Visiting Nurse Service of New York).

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