Under the Patient Protection and Affordable Care Act, our healthcare system is moving from one that rewards those who provide a high volume of services to one that rewards high-value services to patients. Value is often defined as the quality of care provided, divided by the cost to provide such care. High-quality care provided at low cost wins top marks. However, without quality standards, judging value is impossible.
Such standards have been developed for many patient populations. Unfortunately, no such quality standards exist for homebound older adults who receive ongoing medical care from doctors who make house calls.
Contrary to popular belief, doctors who make house calls have not gone the way of the horse and buggy. In fact, these doctors' work has become more vital and more difficult than ever as they serve some of the nation's frailest and most isolated patients.
The 4 million homebound adults in the U.S. are among the most vulnerable and costly of Medicare beneficiaries. Home healthcare costs are expected to rise from $77.9 billion in 2014 to $124.5 billion by 2019. These patients commonly suffer from multiple chronic conditions and are limited in their ability to perform basic activities, such as walking or using the toilet. Because of these problems, they often cannot get to a doctor's office for primary care.
Many studies have shown that home-based primary care is a great benefit to these patients, who otherwise have no alternative but to call 911 when they get sick.
For this population, home-based medical care is the best option, offering them ongoing care in the comfort and safety of their homes. But there is no set standard of care to ensure quality medical services are provided. In essence, home-based medical care lives in a quality desert.
In a recent study published in Health Affairs, we bring this issue to light and discuss ways to improve. Our report describes the current status of home-based medical care in the U.S. and offers a brief narrative of a fictional homebound patient and what she faces with regard to the fragmented care available today. It also lays out the framework needed to ensure quality standards are met.
Because quality standards are lacking for this area, providers can't benchmark their work against others to help them improve their practices. To prove the value of the care they provide to payers, they currently must use quality measures designed for ambulatory patients. This can have serious, unintended and harmful consequences for patients. For example, applying a blood pressure quality measure to a 92-year-old woman with hypertension who is homebound, bedbound and has severe dementia is infinitely more likely to lead to harm than benefit.
We have been working to remedy this situation. We founded a first-of-its-kind National Home-Based Primary and Palliative Care Network composed of patients, healthcare providers, representatives from 12 exemplary practices, three professional societies, and three patient and consumer advocacy groups. The network allows providers to collaborate, partner and improve care.
Our network established a quality-of-care framework, which includes 10 quality-of-care domains, 32 standards and 20 quality indicators that are being field-tested. Half the quality indicators focus on assessment, a critical step in the care of homebound people with multiple chronic conditions. Three indicators focus on patient safety, two on quality of life, and another two on patient and caregiver experience. Three other domains each had a single indicator—access to care, goal attainment and care coordination. These quality indicators show the need to think about these patients' quality of care in a manner that is more holistic than disease-specific.
We also developed and are testing a registry so that home-based medical practices can benchmark their performance, engage more effectively in quality improvement and performance reporting, and help us get these new quality measures recognized by national quality-of-care organizations.
Together, these steps should help ensure better care for the homebound. Over time, we hope these patients will become increasingly visible to the healthcare system. Our goal is to help bring home-based medical care further into the mainstream of U.S. healthcare.