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

Abstract

Background: Home-based primary care for homebound seniors is complex, and practice constraints are unique. No quality-of-care standards exist. Objective:To identify process quality indicators that are essential to high-quality, home-based primary care.Design: 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.Participants: Two national panels whose members varied in practice type, location, and setting. Results:The panels considered 260 quality indicators and endorsed 200 quality indicators that cover 23 geriatric conditions. Twentyone (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. Limitations: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. Conclusions: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.Ann Intern Med. 2007;146:188-192. www.annals.org For author affiliations, see end of text. 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 (5, 6). 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 (7-9). 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 Homebased 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 e...

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