Development of an Interdisciplinary Team Communication Framework and Quality Metrics for Home-Based Medical Care Practices

Abstract

Translating the complex issue of care coordination into QIs will improve care delivered to vulnerable home-limited adults who receive HBMC. Guided by the literature, we developed a framework to reflect optimal care coordination in the home setting and identified 3 candidate QIs to field-test in HBMC practices.

Ten Things Every Geriatrician Should Know About House Calls

“…A survey of non‐Department of Veterans Affairs (VA)‐based HBPC practices in the United States showed a variety of practice personnel, ranging from 16% of practices having physical or occupational therapists to 61% with administrative staff, and 85% having at least one full‐time physician . In fact, use of an IDT to coordinate care for complex patients is one key factor noted to be associated with better patient outcomes . Characteristics of successful HBPC programs include scheduled interdisciplinary meetings with the patient care team that could include physicians, advanced practice practitioners such as nurse practitioners, physician assistants, social workers, dieticians, pharmacists, physical and occupational therapists, behavioral health specialists, and nurses to discuss the plan of care for patients served by the program .…”

“…Older adult spouses who experience caregiver burden have a mortality risk that is as much as 63% higher than non‐caregivers . HBPC clinicians should assess for caregiver burden and evaluate the risk of abuse and neglect of vulnerable adults while offering caregiver education and support from local or national networks …”

“…2 In fact, use of an IDT to coordinate care for complex patients is one key factor noted to be associated with better patient outcomes. 3 Characteristics of successful HBPC programs include scheduled interdisciplinary meetings with the patient care team that could include physicians, advanced practice practitioners such as nurse practitioners, physician assistants, social workers, dieticians, pharmacists, physical and occupational therapists, behavioral health specialists, and nurses to discuss the plan of care for patients served by the program. 1 A systematic review with an expert panel identified that the best ways to facilitate communication among the team members are shared electronic medical records, IDT meetings, team-based standardized patient assessments, and available secure e-messaging.…”

“…1 A systematic review with an expert panel identified that the best ways to facilitate communication among the team members are shared electronic medical records, IDT meetings, team-based standardized patient assessments, and available secure e-messaging. 3 It is important to advise patients and caregivers at enrollment that house call services may include visits from multiple members of the team.…”

“…4 HBPC clinicians should assess for caregiver burden and evaluate the risk of abuse and neglect of vulnerable adults while offering caregiver education and support from local or national networks. 3 Patients and caregivers invite providers into their homes as a sign of trust. It is important to be courteous and respectful, no matter what preconceived notions exist about what a "safe home" should be.…”