The Impact of Home-Based Primary Care on Outcomes Among Older Adults in South Korea

ObjectivesAlthough Korea issued a law and developed benefits of National Health Insurance (NHI) to enable the provision of home-based primary care (HBPC) along with implementation of a pilot project for community care for older adults in August 2019, the outcomes of HBPC services were not surveyed in Korea. This study aimed to assess the outcomes of HBPC among older adults.DesignAnalyses were conducted using data from the National Health Insurance Service in connection with administrative survey data. Difference-in-differences analysis was performed using a generalized estimating equation and Cox proportional hazards model.Setting and ParticipantsOverall, 538 older adults who used HBPC services in a pilot project for community care and 2059 propensity score–matched older individuals who did not use HBPC services in Korea were included.MethodsThe length of home stay, total costs of NHI, hospitalizations, and admission to long-term care (LTC) facilities were measured as outcomes, and the outcomes of the participants were compared to those of the control group.ResultsThe findings indicated an increase of 8.3 days (95% CI 2.1-14.5) in the length of home stay and a reduction of US$1241 (95% CI −2342 to −139) in total costs of NHI among older adults who used HBPC services compared to the control group. The odds ratio for rates of hospitalization among older adults who utilized HBPC services was 0.77 (95% CI 0.60-0.98) and the hazard ratio for the admission of LTC facilities was 0.12 (95% CI 0.04-0.32) in comparison to the control group.Conclusions and ImplicationsThe HBPC intervention has resulted in an increased length of home stay and reduced total costs, hospitalizations, and admission to LTC facilities among Korean older adults. In the future, new HBPC models must be developed to provide interprofessional team–based HBPC services with a standardized protocol of service provision.     

A Quality of Care Framework for Home-Based Medical Care

More than 6 million adults in the United States are homebound or semi-homebound and would benefit from home-based medical care (HBMC). There is currently no nationally recognized quality of care framework for home-based medical care. We sought to capture diverse stakeholder perspectives on the essential aspects of quality HBMC and create a quality of care framework for homebound adults. A qualitative analysis of semistructured interviews from purposive sampling of key HBMC stakeholders was performed. Leaders from 12 exemplar HBMC practices (clinicians and administrators), advocacy groups (American Association of Retired Persons, National Partnership for Women and Families, Kaiser Family Foundation), and representatives from 3 key professional medical societies associated with HBMC participated in phone interviews. Semistructured interviews were based on domains of quality developed by the National Quality Forum (NQF) for individuals with multiple chronic conditions. We identified 3 categories of quality HBMC: provider and practice activities; provider characteristics; and outcomes for patients, caregivers, and providers. Within these 3 categories, we identified 10 domains and 49 standards for quality HBMC. These included 3 new domains (comprehensive assessment, patient/caregiver education, and provider competency) as well as specification and adaptation of the NQF Framework for Multiple Chronic Conditions domains for HBMC. Notably, several quality domains emanating from the NQF Framework for Multiple Chronic Conditions (transitions, access, and patient/caregiver engagement) were applicable to HBMC. This quality of care framework serves as a guide for HBMC practices seeking to improve their care quality and as a starting point for health systems and payers to ensure value from HBMC practices with whom they work.     

Effects of Facilitated Team Meetings and Learning Collaboratives on Colorectal Cancer Screening Rates in Primary Care Practices: A Cluster Randomized Trial

PURPOSE

The purpose of this study was to evaluate a primary care practice–based quality improvement (QI) intervention aimed at improving colorectal cancer screening rates.

METHODS

The Supporting Colorectal Cancer Outcomes through Participatory Enhancements (SCOPE) study was a cluster randomized trial of New Jersey primary care practices. On-site facilitation and learning collaboratives were used to engage multiple stakeholders throughout the change process to identify and implement strategies to enhance colorectal cancer screening. Practices were analyzed using quantitative (medical records, surveys) and qualitative data (observations, interviews, and audio recordings) at baseline and a 12-month follow-up.

RESULTS

Comparing intervention and control arms of the 23 participating practices did not yield statistically significant improvements in patients’ colorectal cancer screening rates. Qualitative analyses provide insights into practices’ QI implementation, including associations between how well leaders fostered team development and the extent to which team members felt psychologically safe. Successful QI implementation did not always translate into improved screening rates.

CONCLUSIONS

Although single-target, incremental QI interventions can be effective, practice transformation requires enhanced organizational learning and change capacities. The SCOPE model of QI may not be an optimal strategy if short-term guideline concordant numerical gains are the goal. Advancing the knowledge base of QI interventions requires future reports to address how and why QI interventions work rather than simply measuring whether they work.     

Provision of Home-Based Primary Care to Individuals With Intellectual and/or Developmental Disability Is Associated With a Lower Hospitalization Rate Than a Traditional Primary Care Model

ObjectivesThe objective of this study was to determine if providing home-based primary care (HBPC) to individuals with intellectual and/or developmental disabilities (IDD) was associated with a lower hospitalization rate than a control group receiving traditional primary care.Design and InterventionIndividuals with IDD living in supported residential settings in Ohio were offered HBPC. Individuals electing HBPC made up the intervention group. Those who did not opt for HBPC continued to receive traditional primary care services and made up the control group. Hospitalizations were tracked in both groups.Setting and ParticipantsThe 757 study participants had IDD diagnoses and received residential support services throughout the study period.MethodsAnnualized hospitalization rate was determined in both groups and was compared using generalized estimating equations while controlling for patients’ age and hospitalization rate in the year prior to the study.ResultsThe results showed that group membership had a significant effect on the hospitalization rate (Wald χ² = 20.71, P < .01). Being in the control group was associated with a 2.12-fold increase in annual hospitalization rate for a given patient. The overall population hospitalization rate was 329 hospitalizations per 1000 per year in the HBPC-receiving individuals and 619 hospitalizations per 1000 per year in the control group.Conclusions and ImplicationsWe found that individuals with IDD receiving HBPC were hospitalized at a lower rate than a control group receiving traditional primary care. Expanding access to HBPC may be a worthwhile priority for organizations that support individuals with IDD.     

Sustainability for Planetary Health: A Seventh Domain of Quality in Primary Care

Climate change is one of the biggest threats to public health. Sustainability is characterized by using resources wisely in a way that protects finite resources and the environment, and takes into account the needs of our planets’ inhabitants in the future. Sustainability in health care should be considered as a seventh domain of quality, as it can lead to improvement of patient outcomes, and more capacity for health care workers to engage in quality improvement and thereby improve the quality of care.The carbon footprint of primary care is high, mainly due to prescribing medication, but also due to the transport of patients to hospitals and primary care services for interventions requested by family medicine. Other causes are the transport of staff and supplies, consumables and staff involved in laboratory analysis and radiation, medical and non-medical equipment, clinical and non-clinical waste, heating and cooling systems and other activities. Small adjustments in these areas could significantly decrease the carbon footprint of primary care practices. The suggested steps for primary care to achieve a more sustainable practice are fostering research, raising awareness, reducing the burden on primary care, engaging in quality improvement, and leadership and advocacy.Each individual primary care practice has the potential to be a leader and role model for sustainable health care. With the implementation of interventions to reduce carbon footprints, primary care could set an example within the health sector and for patients. This could significantly raise the awareness of the public about the need to take actions for a greener health system.     

Primary Care Physician Panel Size and Quality of Care: A Population-Based Study in Ontario,Canada

PURPOSE

The purpose of this study was to determine the relationship between the number of patients under a primary care physician’s care (panel size) and primary care quality indicators.

METHODS

We conducted a cross-sectional, population-based study of fee-for-service and capitated interprofessional and non-interprofessional primary health care practices in Ontario, Canada between April 2008 and March 2010, encompassing 4,195 physicians with panel sizes ≥1,200 serving 8.3 million patients. Data was extracted from multiple linked, health-related administrative databases and covered 16 quality indicators spanning 5 dimensions of care: access, continuity, comprehensiveness, and evidence-based indicators of cancer screening and chronic disease management.

RESULTS

The likelihood of being up-to-date on cervical, colorectal, and breast cancer screening showed relative decreases of 7.9% (P <.001), 5.9% (P = .01), and 4.6% (P <.001), respectively, with increasing panel size (from 1,200 to 3,900). Eight chronic care indicators (4 medication-based and 4 screening-based) showed no significant association with panel size. The likelihood of individuals with a new diagnosis of congestive heart failure having an echocardiogram, however, increased by a relative 8.1% (P <.001) with higher panel size. Increasing panel size was also associated with a 10.8% relative increase in hospitalization rates for ambulatory-care–sensitive conditions (P = .04) and a 10.8% decrease in non-urgent emergency department visits (P = .004). Continuity was highest with medium panel sizes (P <.001), and comprehensiveness had a small decrease (P = .03) with increasing panel size.

CONCLUSIONS

Increasing panel size was associated with small decreases in cancer screening, continuity, and comprehensiveness, but showed no consistent relationships with chronic disease management or access indicators. We found no panel size threshold above which quality of care suffered.     

The Critical Role of Social Workers in Home-Based Primary Care

The growing homebound population has many complex biomedical and psychosocial needs and requires a team-based approach to care (Smith, Ornstein, Soriano, Muller, & Boal, 2006). The Mount Sinai Visiting Doctors Program (MSVD), a large interdisciplinary home-based primary care program in New York City, has a vibrant social work program that is integrated into the routine care of homebound patients. We describe the assessment process used by MSVD social workers, highlight examples of successful social work care, and discuss why social workers’ individualized care plans are essential for keeping patients with chronic illness living safely in the community. Despite barriers to widespread implementation, such social work involvement within similar home-based clinical programs is essential in the interdisciplinary care of our most needy patients.     

Improving the quality of preventive cardiovascular care provided by primary care physicians: insights from a US Quality Improvement Organization.

BACKGROUND: During 2000-03, Qualidigm, a US Quality Improvement Organization, conducted a project to improve the care received by elderly Medicare patients with coronary artery disease or cardiovascular risk factors. METHODS: We recruited primary care physicians in private practice in the state of Connecticut. Then, we identified approximately 30-50 patients per physician from the periods 1 January 2000 to 31 December 2000 and 1 November 2001 to 31 October 2002. We abstracted medical records to assess processes and outcomes of care, and we provided the physicians with performance data and a variety of practice-enhancing materials. The physicians utilized those materials that they perceived to be most helpful. RESULTS: We identified and recruited 974 primary care physicians to participate. Of these, 103 (10.6%) committed to participate, and 85 of the 103 completed the project. Among the intervention tools, physicians and their office personnel utilized personal digital assistants (PDAs) (36.5%) and patient education materials (34.1%) most commonly. Overall, quality of care improved for most physicians (mean quality score 62.0 to 67.8%, P < 0.001). However, not all improved, and most improvements were modest [mean absolute improvement in quality score 5.8%, standard deviation (SD) 6.8%]. CONCLUSIONS: Quality Improvement Organizations and others interested in improving outpatient quality of care face significant challenges in recruiting self-employed primary care physicians to quality improvement projects and in bringing about transformational change. Future primary care quality improvement projects should include careful assessments of practice-specific barriers, interventions that are linked to these barriers, and support of the practices on implementation.     

The Interventions to Reduce Acute Care Transfers (INTERACT) Quality Improvement Program: An Overview for Medical Directors and Primary Care Clinicians in Long Term Care

Interventions to Reduce Acute Care Transfers (INTERACT) is a publicly available quality improvement program that focuses on improving the identification, evaluation, and management of acute changes in condition of nursing home residents. Effective implementation has been associated with substantial reductions in hospitalization of nursing home residents. Familiarity with and support of program implementation by medical directors and primary care clinicians in the nursing home setting are essential to effectiveness and sustainability of the program over time. In addition to helping nursing homes prevent unnecessary hospitalizations and their related complications and costs, and thereby continuing to be or becoming attractive partners for hospitals, health care systems, managed care plans, and accountable care organizations, effective INTERACT implementation will assist nursing homes in meeting the new requirement for a robust quality assurance performance improvement program, which is being rolled out by the federal government over the next year.     

Using Learning Teams for Reflective Adaptation (ULTRA): Insights From a Team-Based Change Management Strategy in Primary Care

PURPOSE The Using Learning Teams for Reflective Adaptation (ULTRA) study used facilitated reflective adaptive process (RAP) teams to enhance communication and decision making in hopes of improving adherence to multiple clinical guidelines; however, the study failed to show significant clinical improvements. The purpose of this study was to examine qualitative data from 25 intervention practices to understand how they engaged in a team-based collaborative change management strategy and the types of issues they addressed.METHODS We analyzed field notes and interviews from a multimethod practice assessment, as well as field notes and audio-taped recordings from RAP meetings, using an iterative group process and an immersion-crystallization approach.RESULTS Despite a history of not meeting regularly, 18 of 25 practices successfully convened improvement teams. There was evidence of improved practice-wide communication in 12 of these practices. At follow-up, 8 practices continued RAP meetings and found the process valuable in problem solving and decision making. Seven practices failed to engage in RAP primarily because of key leaders dominating the meeting agenda or staff members hesitating to speak up in meetings. Although the number of improvement targets varied considerably, most RAP teams targeted patient care-related issues or practice-level organizational improvement issues. Not a single practice focused on adherence to clinical care guidelines.CONCLUSION Primary care practices can successfully engage in facilitated team meetings; however, leaders must be engaged in the process. Additional strategies are needed to engage practice leaders, particularly physicians, and to target issues related to guideline adherence.     

The Medical Needs and Characteristics of Cancer and Progressive Neurologic Disease Patients Who Use Home-Based Medical Care in Korea: A Retrospective Study for 2011-2020

ObjectivesTo investigate the needs and characteristics of patients with cancer and neurologic disorders requiring home-based medical care (HBMC).DesignRetrospective observational study.Setting and ParticipantsPatients receiving HBMC on discharge from a tertiary hospital in Korea during 2011-2020.MethodsPatients were classified into 3 disease groups: cancer, progressive neurologic disorders (NR), and others. Characteristics and medical needs were assessed in each disease group. Medical needs were categorized based on functional items requiring support or management at the time of registration: respiratory, feeding, urinary system, drain tube, central catheter, wound, medication, and other. Patients with multiple medical needs were assigned to multiple categories. Patients who used HBMC for more than 3 months were defined as long-term users; their characteristics were evaluated in the same way.ResultsOf the total 655 patients, 47.0% (308) had cancer and 17.3% (113) were NR patients. Among all patients, 78.8% were partially dependent (44.0%) or completely dependent (34.8%) in daily activities, and there were more dependent patients in the NR group (80.5%) than cancer (26.6%). Patients with cancer needed central catheter management the most (43.5%), followed by wound care (36.7%), feeding support (35.1%), and drain tube management (22.1%). NR patients required feeding support the most (80.5%), followed by respiratory support (43.4%), wound care (41.6%), and urinary system support (19.5%). Of all patients, 30.2% (198) were long-term users (NR, 37.9%; cancer, 35.4%). Long-term users were common among patients who needed respiratory support (59.4%), feeding support (48.75), and urinary system support (34.6%).Conclusions and ImplicationsHomebound patients with cancer and progressive neurologic disorders need medical services at home after discharge. Patients who need feeding and respiratory support usually use HBMC for more than 3 months. Further studies are needed to design an optimal HBMC that continuously provides medical services to patients with serious illnesses living at home.     

Relationship Quality and Patient-Assessed Quality of Care in VA Primary Care Clinics: Development and Validation of the Work Relationships Scale

PURPOSE

Efforts to better understand the impact of clinic member relationships on care quality in primary care clinics have been limited by the absence of a validated instrument to assess these relationships. The purpose of this study was to develop and validate a scale assessing relationships within primary care clinics.

METHODS

The Work Relationships Scale (WRS) was developed and administered as part of a survey of learning and relationships among 17 Department of Veterans Affairs (VA) primary care clinics. A Rasch partial-credit model and principal components analysis were used to evaluate item performance, select the final items for inclusion, and establish unidimensionality for the WRS. The WRS was then validated against semistructured clinic member interviews and VA Survey of Healthcare Experiences of Patients (SHEP) data.

RESULTS

Four hundred fifty-seven clinicians and staff completed the clinic survey, and 247 participated in semistructured interviews. WRS scores were significantly associated with clinic-level reporting for 2 SHEP variables: overall rating of personal doctor/nurse (r² =0.43, P <.01) and overall rating of health care (r²= 0.25, P <.05). Interview data describing relationship characteristics were consistent with variability in WRS scores across low-scoring and high-scoring clinics.

CONCLUSIONS

The WRS shows promising validity as a measure assessing the quality of relationships in primary care settings; moreover, primary care clinics with lower WRS scores received poorer patient quality ratings for both individual clinicians and overall health care. Relationships play an important role in shaping care delivery and should be assessed as part of efforts to improve patient care within primary care settings.