Kristofer L. Smith, MD, MPP; Theresa A. Soriano, MD, MPH; Jeremy Boal, MD
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, firstname.lastname@example.org.
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.
Home-based primary care for homebound seniors is complex, and practice constraints are unique. No quality-of-care standards exist.
To identify process quality indicators that are essential to high-quality, home-based primary care.
An expert development panel reviewed established and new quality indicators for applicability to home-based primary care. A separate national evaluation panel used a modified Delphi process to rate the validity and importance of the potential quality indicators.
Two national panels whose members varied in practice type, location, and setting.
The panels considered 260 quality indicators and endorsed 200 quality indicators that cover 23 geriatric conditions. Twenty-one (10.5%) quality indicators were newly created, 52 (26%) were modified, and 127 (63.5%) were unchanged. The quality indicators have decreased emphasis on interventions and have placed greater emphasis on quality of life.
The quality indicator set may not apply to all homebound seniors and might be difficult to implement for a typical home-based primary care program.
The quality indicator set provides a comprehensive home-based primary care quality framework and will allow for future comparative research. Provision of these evidence-based measures could improve patient quality of life and longevity.
Table 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 2. Indicators Evaluated for Inclusion in the Home-Based Primary Care Quality Indicator Set according to Condition
Table 3. Indicators Evaluated for Inclusion in the Home-Based Primary Care Quality Indicator Set according to Domain of Care
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Steven H Landers
Case Western Reserve University School of Medicine, Dept. of Family Medicine
February 12, 2007
Home Primary Care Standards Missing Holistic, Patient-Centered Measures
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.
Kristofer, L Smith
Mount Sinai Medical Center
March 8, 2007
Re: Home Primary Care Standards Missing Holistic, Patient-Centered Measures
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.
Consultancies: J. Boal(Visiting Nurse Service of New York).
Smith KL, Soriano TA, Boal J. Brief Communication: National Quality-of-Care Standards in Home-Based Primary Care. Ann Intern Med. 2007;146:188–192. doi: 10.7326/0003-4819-146-3-200702060-00008
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Published: Ann Intern Med. 2007;146(3):188-192.
Geriatric Medicine, Healthcare Delivery and Policy.
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