Home-based Primary Care Practices Research Articles

Caring for caregivers and persons living with dementia under home-based primary care: protocol for an interventional clinical trial

BackgroundApproximately 7.5 million older adults are homebound, who have difficulty and/or need assistance to leave their homes. In this growing population, the prevalence of people living with dementia (PLWD) is approximately 50%. Current dementia care models in the USA were developed for traditional office-based primary care and have not been tailored to home-based primary care (HBPC) delivery models. Literature has shown that office-based collaborative interventions can improve caregiver outcomes including caregiver stress, well-being, and morbidity and patient outcomes including improved quality of life and reduced emergency department visits (Possin KL, Merrilees JJ, Dulaney S, Bonasera SJ, Chiong W, Lee K, JAMA Int Med 179:1658, 2019). To date, the evidence for HBPC dementia interventions is lacking. Though HBPC has demonstrated benefit in homebound older adults, there is limited literature on the effects of HBPC on persons living with dementia (Nguyen HQ, Vallejo JD, Macias M, Shiffman MG, Rosen R, Mowry V, J Am Geriatr Soc 70:1136–46, 2021). Our goal is to develop a HBPC-focused dementia care intervention that integrates the components of two previously developed dementia care models and test the feasibility of implementing it in HBPC practices to improve the quality of life and wellbeing of homebound PLWD and their caregivers.MethodsWe will first conduct qualitative focus groups at two HBPC practice sites, one in the Southeast and one in Hawaii in order to obtain preliminary feedback on the proposed intervention. At each site, there will be one focus group with caregivers of PLWD and another with HBPC clinicians and staff to help develop and refine our intervention. We will then conduct an open-pilot trial of the refined intervention at the two HBPC practices. A total of up to 25 patient/caregiver dyads will be recruited at each site (N = 50 total). Outcomes measured through pre-and-post assessments and exit interviews will include (a) feasibility for the caregiver to engage with and complete baseline assessments and access educational materials and community resources and (b) feasibility for the practice to identify potential caregivers/patients, assess eligible patient/caregiver dyads, use patient and caregiver assessments, recruit patient/caregiver dyads, recruit racial and ethnic minorities, use care modules, and engage with the tele-video case conference, (c) net promoter score, (d) acceptability of the intervention to caregivers and patients to participate in the intervention, (e) caregivers feeling heard and understood, and (f) caregiver well-being.DiscussionTesting the feasibility and acceptability of the adapted intervention in these two HBPC practices will provide the basis for future testing and evaluation of a fully powered intervention for PLWD and their caregivers cared for in HBPC with the goal of disseminating high-quality and comprehensive dementia-care focused interventions into HBPC practices.Trial registrationThis trial was registered with ClinicalTrials.gov NCT05849259 in May 2023.

“HE JUST WANTS HIS SERVICES BACK”: IMPACTS OF HOME CARE WORKER DISRUPTIONS ON PATIENTS AND CAREGIVERS DURING COVID-19

Abstract Home care workers (HCWs) have played a critical role in keeping homebound older adults safely at home during COVID-19, yet their essential work is often understudied. This study characterized the roles of HCWs during COVID-19 and examined how HCW service disruptions impacted patients and their caregivers. We performed a thematic analysis of medical records from 53 patients with HCWs in a home-based primary care practice in New York City. We abstracted unstructured clinical notes into a priori and emergent categories and identified core themes via team discussion. The following themes emerged: 1) Shifts to remote medical care and changing patient needs led to task shifting and new tasks for HCWs (i.e. getting food for patients experiencing food insecurity), 2) The risks associated with HCW tasks, such as exposure from caring for patients with COVID-19, increased during the pandemic, 3) Patient and family refusal of HCW services to avoid COVID-19 exposure as well as abrupt loss of HCW services due to HCW precarity or COVID-19 exposure left family caregivers with additional caregiving responsibilities, 4) Regulations surrounding return to work following COVID-19 exposure created additional difficulties in reinstating HCWs and left patients without adequate care, putting them at risk of hospitalization. In conclusion, pandemic-related disruptions created barriers to adequate home care, putting both patients and caregivers at risk. This analysis suggests a need for more robust HCW training and established regulations to protect HCW safety as well as a need for policies to support caregivers and ensure continuity of care during emergencies.

Home-based primary care in Canada: Five innovative urban practices.

While the home-based primary care model offers potential patient and system-level benefits, implementation of interprofessional home-based primary care teams has not been widespread. When caring for homebound patients, family physicians are often not included as regular contributors or participants in the team that coordinates and plans much of the care for these patients. To describe a selection of home-based primary care practices and to identify barriers to and facilitators of the creation and sustainability of these models within the publicly funded health care system. Five existing home-based primary care practices were examined: 1 each in Victoria and Vancouver in BC; 1 in Winnipeg, Man; and 2 in Toronto, Ont. The research team conducted semistructured team interviews, interviews with the physician leads, and informal observation of elements of team-based care planning at these 5 sites. From these sources, descriptions of each practice were developed in terms of practice history, context, and initiating factors; practice goals and performance management; and practice design elements, including target population, referral sources, and team composition. A qualitative thematic content analysis was used to extract and distil implementation barriers and facilitators across the 5 practices. Members of each practice team validated the interpretation of thematic information. Substantial heterogeneity was found in the composition of the interprofessional teams. The overarching initiating factor for the home-based component of all practices could be described as identifying and addressing unmet community need. Physician leadership, creative funding models, team camaraderie, and community partnerships were the main facilitators. Limited health system support, geography, and lack of existing models of care were the main barriers. Substantial barriers to wider implementation of home-based primary care practices persist. Examination of existing practices identifies the importance of physician leadership and commitment to meeting community need.

"I Depend on Her for Everything": A Retrospective Chart Review of Home Care Worker Service Disruptions for Homebound Older Adults During the COVID-19 Pandemic.

Home care workers played critical roles in meeting the complex medical and social needs of homebound adults during COVID-19, yet their contributions remain underappreciated. This study characterizes home care workers’ roles during COVID-19 and examines how home care disruptions impacted homebound individuals and caregivers. Using a qualitative analysis of electronic medical records among a randomly sampled subset of homebound patients in a home-based primary care practice, we found that home care workers were essential in meeting existing and new needs of homebound individuals. Insufficient home care worker services, including unstable schedules and inadequate hours of paid care, became particularly disruptive, leading to risks for patients and their caregivers. Given their integral role on care teams, home care workers must be a policy focus to prepare for emergent situations and ensure that homebound individuals have access to high quality, stable home care.

The National Home-Based Primary Care Learning Network: A Practice-Based Quality Improvement and Research Network.

Home-based primary care (HBPC) provides interdisciplinary, comprehensive care at home for homebound older adults and has been largely excluded from the national conversation on care quality and quality improvement. In this Pragmatic Innovations article, we describe the work of the National HBPC Learning Network (LN), which focuses on fostering a continuous learning culture among HBPC practices to improve practice quality, elevate the field of HBPC, and create a community of continuous growth and quality of care accountability. The LN recruits HBPC practices in waves of 9 to 10 practices. It currently comprises 38 HBPC practices that care for 58,000 patients across 25 states (approximately 26% of all patients receiving HBPC in the United States). In a Kickoff meeting, the HBPC practices in each wave are instructed in the basics of quality improvement, develop project aim statements and their first plan-do-study-act cycle, receive an introduction to the LN quality improvement software platform, and review plans for LN engagement. Each month, practices submit updates and receive real-time feedback on their quality improvement work. Monthly virtual workshops are held with all practices that include sharing results of a "1-minute survey" (a monthly 1-to 3-question survey sent to all LN participants on a topic relevant to HBPC practices), a didactic and discussion related to the 1-minute survey topic, and interactive progress updates from LN participants regarding their quality improvement work. Each wave ends with "Moving-up Day," where practices report on their overall project and reflect on how their practice has changed as a result of the LN. LN practices have addressed and improved performance in multiple HBPC-related quality areas including assessment of functional status and cognitive impairment, falls prevention, advanced care planning, COVID-19 vaccination, and others. We present case studies of 3 LN practices and how LN participation strengthened their practices.

Meeting the Challenges of COVID-19: Evaluation of Nurse-Led Changes to Telephonic Assessment.

The early months of the COVID-19 pandemic caused suspension of physician home visits at our NYC home-based primary care practice as well as disruptions in community-based services homebound patients rely on. This produced gaps in care for a vulnerable patient population that is considered underserved and medically and socially complex. Telephone triage nurses at Mount Sinai Visiting Doctors Program responded to these gaps in care with targeted enhancements to telephonic patient assessment: creating an encrypted email address to receive photographs, the use of two Epic dot phrases to screen and educate regarding COVID-19, assessment of patients' ability to complete a video visit, the reassessment of goals of care, and the assessment of changes in home care services. We surveyed 15 attending physicians in our practice to evaluate primary care providers' opinions regarding changes in nurse telephone triage and how helpful they were in managing patients at home during the early pandemic. We found enhancements to nurse telephone triage were viewed by physicians as beneficial, valuable, and improved patient care. Physicians found changes improved timeliness of care, could improve self-management, helped avoid transfer to emergency department, and helped manage patient care at home. As the pandemic continues and telehealth becomes more widely used, nurse telephone triage may be adaptable to help care for a variety of patient populations during future public health emergencies.

Home-Based Care in the Context of COVID-19: Disruptions, Innovations, and Lessons for the Future

During the initial surge of the COVID-19 pandemic, home-based primary and palliative care (HBPC) practices played a valuable role in maintaining access to health-related services and keeping older, medically complex patients out of hospitals and congregate settings that could heighten their risk for COVID-19. At the same time, these practices faced unique challenges in adapting a traditionally hands-on model of care to accommodate restrictions on in-person contact. In this symposium, we present innovative research highlighting the challenges faced by HBPC practices and patients during spring 2020, as well as their rapid innovations and adaptations. First, Ritchie et al. provide national context with findings from a survey of U.S. home-based primary care practices that highlights the field’s most pressing challenges and successful strategies. Shifting to the initial epicenter of the pandemic in New York City, Reckrey et al. present a qualitative study of the perspectives of paid and unpaid caregivers of dementia patients served by an HBPC practice, while Franzosa et al. describe care disruptions among individuals with dementia who died during the initial surge, using a novel chart-based abstraction technique. Finally, two studies (Gorbenko et al. and Kalicki et al.) explore HBPC practices’ experience of rapidly transitioning to telehealth through qualitative interviews with NYC-based practices and a provider survey exploring telehealth adoption and readiness in the homebound population. Together, these studies yield important insights into the challenges of providing community-based care for at-risk populations during a pandemic, and practical strategies for home-based models of care moving forward.

Providers’ Perceptions of Telehealth Barriers Among Homebound Adults in in a Home-Based Primary Care Practice

The COVID-19 pandemic resulted in a dramatic shift to video-based telehealth use in home-based primary care. We conducted an online 11-item survey exploring provider perceptions of patients’ experience with and barriers to telehealth in a large HBPC program in New York City. More than one-third (35%) of patients (mean age of 82.7; 46.6% with dementia; mean of 4 comorbidities/patient) engaged in first-time video-based telehealth encounters between April and June 2020. The majority (82%) required assistance from a family member and/or paid caregiver. Among patients who had not used telehealth, providers deemed 27% (n=153) “unable to interact over video” for reasons including cognitive or sensory ability. Fourteen percent lacked caregivers. Physicians were not knowledgeable about patients’ internet connectivity, ability to pay for cellular plans, and video-capable device access. These findings highlight the need for novel approaches to facilitating telehealth and systematic data collection before targeted interventions to increase video-based telehealth use.

The Psychological Impact of COVID-19 on Home Based Primary Care Providers in New York: A Qualitative Study

Research on professional burnout during the pandemic has focused on hospital-based health care workers. This study examined the psychological impact of the pandemic on home-based primary care (HBPC) providers. We interviewed 13 participants from six HBPC practices in the New York including medical/clinical directors, program managers, nurse practitioners, and social workers and analyzed the transcripts using inductive qualitative analysis approach. HBPC providers experienced emotional exhaustion and a sense of reduced personal accomplishment. They reported experiencing grief of losing many patients at once and pressure to adapt to changing circumstances quickly. They also reported feeling guilty for failing to protect their patients and reduced confidence in their professional expertise. Strategies to combat burnout included shorter on-call, regular condolence meetings to acknowledge patient deaths, and peer support calls. Our study identifies potential resources to improve the well-being and reduce the risk of burnout among HBPC providers.

COVID Challenges and Adaptations Among Home-Based Primary Care Practices: Lessons for an Ongoing Pandemic from a National Survey

ObjectivesApproximately 7.5 million US adults are homebound or have difficulty accessing office-based primary care. Home-based primary care (HBPC) provides such patients access to longitudinal medical care at home. The purpose of this study was to describe the challenges and adaptations by HBPC practices made during the first surge of the COVID-19 pandemic. DesignMixed-methods national survey. Setting and ParticipantsHBPC practices identified as members of the American Academy of Homecare Medicine (AAHCM) or participants of Home-Centered Care Institute (HCCI) training programs. MethodsOnline survey regarding practice responses to COVID-19 surges, COVID-19 testing, the use of telemedicine, practice challenges due to COVID-19, and adaptations to address these challenges. Descriptive statistics and t tests described frequency distributions of nominal and categorical data; qualitative content analysis was used to summarize responses to the open-ended questions. ResultsSeventy-nine practices across 29 states were included in the final analyses. Eighty-five percent of practices continued to provide in-person care and nearly half cared for COVID-19 patients. Most practices pivoted to new use of video visits (76.3%). The most common challenges were as follows: patient lack of familiarity with telemedicine (81.9%), patient anxiety (77.8%), clinician anxiety (69.4%), technical difficulties reaching patients (66.7%), and supply shortages including masks, gown, and disinfecting materials (55.6%). Top adaptive strategies included using telemedicine (95.8%), reducing in-person visits (81.9%), providing resources for patients (52.8%), and staff training in PPE use and COVID testing (52.8%). Conclusions and ImplicationsHBPC practices experienced a wide array of COVID-19–related challenges. Most continued to see patients in the home, augmented visits with telemedicine and creatively adapted to the challenges. An increased recognition of the need for in-home care by health systems who observed its critical role in caring for fragile older adults may serve as a silver lining to the otherwise dark sky of the COVID-19 pandemic.

Pharmacist medication review: An integrated team approach to serve home-based primary care patients.

BackgroundComprehensive medication review is a patient-centered approach to optimize medication use and improve patient outcomes. This study outlines a pilot model of care in which a remote corporate-based clinical pharmacist implemented comprehensive medication reviews for a cohort of medically complex home-based primary care (HBPC) patients.MethodNinety-six medically complex patients were assessed for medication-related problems. Data collected on these patients were: number of chronic conditions, number of medications, appropriate indication for each medication, dose appropriateness, drug interactions, recommendations for medication optimization and deprescribing. The number of accepted recommendations by the HBPC practice was analyzed.ResultsOn average, the patients were 82 years old and had 13 chronic conditions. They were taking a median of 17 medications. Over a four-month pilot period, 175 medication recommendations were made, and 53 (30.3%) of them were accepted, with most common being medication discontinuation, deprescribing, and dose adjustments. Sixty-four (66.7%) patients were on a medication listed as potentially inappropriate for use in older adults. The most common potentially inappropriate medication was a proton-pump inhibitor (38.5%), followed by aspirin (24%), tramadol (15.6%), a benzodiazepine (13.5%) or an opioid (8.3%). Eighty-one medications were recommended for deprescribing and 27 medications were discontinued (33.3%). There were 24 recommended dose adjustments and 11 medications were dose adjusted (45.8%). Thirty-four medications were suggested as an addition to the current patient regimen, 2 medications were added (5.9%).ConclusionPharmacist comprehensive medication review is a necessary component of the HBPC healthcare continuum. Additional research is needed to examine whether aligning pharmacists to deliver support to HBPC improves clinical outcomes, reduces healthcare expenditures and improves the patient’s experience.

“I felt useless”: a qualitative examination of COVID-19’s impact on home-based primary care providers in New York

ABSTRACT Research on professional burnout during the pandemic has focused on hospital-based health care workers. This study examined the psychological impact of the pandemic on home-based primary care (HBPC) providers. We interviewed 13 participants from six HBPC practices in New York City including medical/clinical directors, program managers, nurse practitioners, and social workers and analyzed the transcripts using inductive qualitative analysis approach. HBPC providers experienced emotional exhaustion and a sense of reduced personal accomplishment. They reported experiencing grief of losing many patients at once and pressure to adapt to changing circumstances quickly. They also reported feeling guilty for failing to protect their patients and reduced confidence in their professional expertise. Strategies to combat burnout included shorter on-call schedules, regular condolence meetings to acknowledge patient deaths, and peer support calls. Our study identifies potential resources to improve the well-being and reduce the risk of burnout among HBPC providers.

"At Home, with Care": Lessons from New York City Home-based Primary Care Practices Managing COVID-19.

COVID-19 required rapid innovation throughout the healthcare system. Home-based primary care (HBPC) practices faced unique challenges maintaining services for medically complex older populations for whom they needed to adapt a traditionally hands-on, model of care to accommodate restrictions on in-person contact. Our aim was to determine strategies used by New York City (NYC)-area HBPC practices to provide patient care during the first wave of the COVID-19 pandemic with the goal of informing planning and preparation for home-based practices nationwide. Cross-sectional qualitative design using semi-structured interviews. HBPC practices in the NYC metro area during spring 2020. HBPC leadership including clinical/medical directors, program managers, nurse practitioners/nursing coordinators, and social workers/social work coordinators (n = 13) at 6 NYC-area practices. Semi-structured interviews explored HBPC practices' COVID-19 care delivery challenges, adaptations, and advice for providers. Interviewers probed patient care, end-of-life care, telehealth, community-based services and staffing. Interviews were recorded and transcribed. Data were analyzed through a combined inductive and deductive thematic approach. Participants described care delivery and operational adaptations similar to those universally adopted across healthcare settings during COVID-19, such as patient outreach and telehealth. HBPC-specific adaptations included mental health services for patients experiencing depression and isolation, using multiple modalities of patient interactions to balance virtual care with necessary in-person contact, strategies to maintain patient trust, and supporting team connection of staff through daily huddles and emotional support during the surge of deaths among long-standing patients. NYC-area HBPC providers adapted care delivery and operations rapidly during the height of the COVID-19 pandemic. Keeping older, medically complex patients safe in their homes required considerable flexibility, transparency, teamwork, and partnerships with outside providers. As the pandemic continues to surge around the United States, HBPC providers may apply these lessons and consider resources needed to prepare for future challenges.

Variation in Value-Based Outcome Measures Among Assisted Living Communities Served by a Home-Based Primary Care Practice During COVID-19

We aimed to determine the hospitalization rate and average days spent at home in a population of assisted living (AL) residents served by a home-based primary care (HBPC) practice during the COVID-19 pandemic. We provided on-site HBPC to 1,699 AL residents and calculated hospitalization rate and days spent at home. The AL population had a mean age of 84 ± 10 years and 73% were female. The mean hospitalization rate was 449 admissions per 1,000 per year, and there was wide variation among AL communities. AL residents spent a mean of 358 days at home per year, and the average days spent at home varied during the COVID-19 pandemic. Use of these measures may help AL articulate its value proposition by enabling seniors with complex health needs to live in community settings for as many days as possible.

Home-Based Primary Care Led-Outbreak Mitigation in Assisted Living Facilities in the First 100 Days of Coronavirus Disease 2019

Residents of congregate care settings have been severely impacted by the current Coronavirus disease 2019 (COVID-19) pandemic. In this report, we describe the methods our home-based primary care practice has developed to mitigate the spread of COVID-19 in assisted living facilities (ALFs) and we present an initial evaluation of this innovation. Shortly after the first COVID-19 case was reported in the United States, our organization assembled an outbreak committee, designed to support the 1794 ALF residents and the 101 communities in which they reside. The committee led the development and deployment of a comprehensive COVID-19 prevention and suppression strategy. The average age of the cohort was 83 ± 11 years, and 74% were female. Seven individuals (0.4% of census) tested positive for SARS-CoV-2. The positive individuals were located in 3 ALFs, representing 3% of our total number of ALFs. There has been 1 death. Home-based primary care-led outbreak mitigation may be an enabler to suppress COVID-19 in ALFs.

Home Visits Improve Attitudes and Self-Efficacy: A Longitudinal Curriculum for Residents.

To develop a competency-based, adaptable home visit curricula and clinical framework for family medicine (FM) residents, and to examine resident attitudes, self-efficacy, and skills following implementation. Quantitative analysis of resident survey responses and qualitative thematic analysis of written resident reflections. Urban FM residency program. A total of 43 residents and 20 homebound patients in a home-based primary care program. A home-based primary care practice and accompanying curriculum for FM residents was developed and implemented to improve learners' confidence and skills to perform home visits. A 10-question survey with a 4-point Likert scale and open-ended responses. Written resident reflections following home visits. Over 3 years, 43 unique respondents completed a total of 79 surveys evaluating attitudes, skills, and barriers to home care. Some residents may have completed the survey more than once at different stages in their training. Overall, 86% are interested in home visits in future practice, and 78% of survey responses indicated an increased likelihood to perform home visits with more training. Learners with two or more home visits reported significantly improved confidence. Themes across all resident reflections included social determinants of health, patient-physician relationship, patient-home assessment, patient autonomy/independence, and physician wellness/attitudes. Residents described how home visits encourage more holistic care to improve outcomes for patients who are homebound. Our home visit curriculum provided new learning, an enhanced desire to practice home-based primary care, improved learner confidence, and could help residents meet the need of a growing population of adults who are homebound. J Am Geriatr Soc 68:852-858, 2020.

I Live Alone but Don't Feel Alone: Social Isolation and Loneliness From the Patient Perspective.

A growing homebound population may be at risk for social isolation and loneliness. Health-related social needs play a contributing role in these conditions. Research shows social isolation and loneliness are drivers of health outcomes. This pilot feasibility study seeks to explore patient-centered insight into perceptions of social isolation and loneliness in a homebound population. Eight participants were recruited from a home-based primary care practice within a family medicine residency program. One 30-minute semi-structured interview was completed in participants' homes. The interview focused on loneliness and social isolation, using the 6-item De Jong Gerveld loneliness scale. Three qualitative analysts open-coded transcriptions independently. Themes were defined using thematic analysis, then triangulated around a consensus of themes. Patients denied loneliness, but most described social isolation, highlighting the potential need for more targeted documentation and intervention in this arena. The most reported barrier affecting social isolation in our study population was mobility issues. The patient perspective is useful to focus the target of approach. Based on this pilot, additional research with a larger sample size across multiple sites is warranted to further explore homebound patients' experience of loneliness and social isolation in order to better guide assessment and interventions for these common problems.

Home and community-based services coordination for homebound older adults in home-based primary care

BackgroundMedically complex vulnerable older adults often face social challenges that affect compliance with their medical care plans, and thus require home and community-based services (HCBS). This study describes how non-medical social needs of homebound older adults are assessed and addressed within home-based primary care (HBPC) practices, and to identify barriers to coordinating HCBS for patients.MethodsAn online survey of members of the American Academy of Home Care Medicine (AAHCM) was conducted between March through November 2016 in the United States. A 56-item survey was developed to assess HBPC practice characteristics and how practices identify social needs and coordinate and evaluate HCBS. Data from 101 of the 150 surveys received were included in the analyses. Forty-four percent of respondents were physicians, 24% were nurse practitioners, and 32% were administrators or other HBPC team members.ResultsNearly all practices (98%) assessed patient social needs, with 78% conducting an assessment during the intake visit, and 88% providing ongoing periodic assessments. Seventy-four percent indicated ‘most’ or ‘all’ of their patients needed HCBS in the past 12 months. The most common needs were personal care (84%) and medication adherence (40%), and caregiver support (38%). Of the 86% of practices reporting they coordinate HCBS, 91% followed-up with patients, 84% assisted with applications, and 83% made service referrals. Fifty-seven percent reported that coordination was ‘difficult.’ The most common barriers to coordinating HCBS included cost to patient (65%), and eligibility requirements (63%). Four of the five most frequently reported barriers were associated with practices reporting it was ‘difficult’ or ‘very difficult’ to coordinate HCBS (OR from 2.49 to 3.94, p-values < .05).ConclusionsDespite the barriers to addressing non-medical social needs, most HBPC practices provided some level of coordination of HCBS for their high-need, high-cost homebound patients. More efforts are needed to implement and scale care model partnerships between medical and non-medical service providers within HBPC practices.

The Influence of Clinical Decision Support on Diagnostic Accuracy in Nurse Practitioners.

Clinical decision support systems (CDSSs) at the point of care are evidence-based interventions that have demonstrated incremental positive impact on quality of healthcare delivery over the past two decades. Existing best practices inform strategies to promote adoption and achievement of targeted outcomes. The purpose of this improvement project was to conduct a pilot implementation to understand the contextual factors and readiness for dissemination of a newly acquired electronic CDSS by evaluating its influence on diagnostic accuracy in nurse practitioners (NPs) functioning in a community health setting. The specific aims of this project were to measure and compare diagnostic accuracy in a pilot group before and after CDSS use, educate clinicians about the system and pilot its use, and then leverage the experience to design the practice-wide CDSS dissemination strategy. The project engaged a subset of NPs from a home-based primary care practice and other organizational stakeholders who provided tangible support and necessary resources for successful adoption of this innovation in practice. A structured conceptual model of Evidence-Based Practice Improvement enhanced with elements of the Promoting Action on Research Implementation in Health Sciences framework was used to guide the development, implementation and evaluation of this practice improvement initiative. A group of seven NP representatives of the practice participated in the project. Data collection was composed of small tests of change (plan-do-study-act) cycles at the local practice level, measuring achievement of improvement of the chosen outcome of correctness of medical diagnosis evidenced by appropriate substantiating clinical documentation. In this home visiting primary care practice setting, use of a CDSS by NPs achieved eventual improvement in diagnostic accuracy and clinical documentation, as demonstrated on chart audit, though the improvement was not sustained over time. The pilot findings ultimately informed decision making about CDSS dissemination strategies and future uses of the system. When appropriately deployed, a CDSS offers the potential to improve professional practice, support differential diagnosis and evidence-based treatment, and provide detailed information about the disease state to facilitate robust clinical documentation.

Home-based primary care practices in the United States: current state and quality improvement approaches.

To describe the characteristics of home-based primary care practices: staffing, administrative, population served, care practices, and quality of care challenges. Survey of home-based primary care practices. Home-based primary care practices in the United States. Members of the American Academy of Home Care Medicine and nonmember providers identified by surveyed members. A 58-item questionnaire that assessed practice characteristics, care provided by the practice, and how the quality of care that the practice provided was assessed. Survey response rate was 47.9%, representing 272 medical house calls practices. Mean average daily census was 457 patients (median 100 patients, range 1-30,972 patients). Eighty-eight percent of practices offered around-the-clock coverage for urgent concerns, 60% held regularly scheduled team meetings, 89% used an electronic medical record, and one-third used a defined quality improvement process. The following factors were associated with practices that used a defined quality improvement process: practice holds regularly scheduled team meetings to discuss specific patients (odds ratio (OR)=2.07, 95% confidence interval (CI)=1.02-4.21), practice conducts surveys of patients (OR=8.53, 95% CI=4.07-17.88), and practice is involved in National Committee for Quality Assurance patient-centered medical home (OR=3.27, 95% CI=1.18-9.07). Ninety percent of practices would or might participate in quality improvement activities that would provide them timely feedback on patient and setting-appropriate quality indicators. There is a substantial heterogeneity of home-based primary care practice types. Most practices perform activities that lend themselves to robust quality improvement efforts, and nearly all indicated interest in a national registry to inform quality improvement.