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.

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

OBJECTIVES: Approximately 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. DESIGN: Mixed-methods national survey. SETTING AND PARTICIPANTS: HBPC practices identified as members of the American Academy of Homecare Medicine (AAHCM) or participants of Home-Centered Care Institute (HCCI) training programs. METHODS: Online 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. RESULTS: Seventy-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 IMPLICATIONS: HBPC 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.

Views of Electronic Visit Verification (EVV) among home-based personal assistance services consumers and workers.

BACKGROUND: The 21st Century Cures Act, enacted in 2016, mandates that Medicaid programs must implement Electronic Visit Verification (EVV) for home-based personal assistance services (PAS) and home health care (HHC) by January 2020. EVV involves real-time tracking of arrival and departure times, locations, and sometimes activities of PAS and HHC workers for home-based consumers. OBJECTIVE: We examined the views and perceptions of consumers with disability and paid PAS workers about EVV. METHODS: Our qualitative study consisted of in-depth interviews with 21 home-based PAS consumers with significant disability and 20 PAS workers. Thirteen consumers and 10 workers commented on EVV. We audio-recorded interviews and had these recordings transcribed verbatim by a professional transcription service. We used conventional content analysis to identify key themes from the interviews. RESULTS: Qualitative interviews suggest that EVV is intrusive, reduces flexibility from the consumer-worker relationship, has technical difficulties, but may help certain consumers. Our results suggest that EVV interferes with the standard way PAS is provided and raises fears about EVV negatively affecting recruitment and retention of PAS workers. CONCLUSIONS: Policymakers should consider these perspectives and concerns as states implement EVV. Policymakers will need to monitor the effects of EVV on both PAS consumers and workers over time to ensure that EVV is not negatively affecting provision of these essential services.

Historical Mismatch Between Home-Based Care Policies And Laws Governing Home Care Workers.

Americans generally want to remain in their homes even if they develop chronic health problems or disabilities that qualify them for nursing home care. While family members or friends provide the preponderance of home-based support, millions of Americans use paid personal assistance services (PAS). Inexorable demographic trends are increasing the numbers of people who need paid home-based PAS, with this need rapidly outstripping the capacity of the paid PAS workforce. While many factors contribute to this widening discrepancy, its roots reach back more than eighty years to asynchrony among various policies affecting home-based supports for people with functional impairments and policies affecting home-based PAS workers. Finding solutions to the growing gap between demand for the services and the PAS workforce requires policies that cut across societal sectors and align incentives for consumers, workers, and other key stakeholders.