Caring for the “Invisible Homebound”: The Importance of Quality Measures
An estimated 1.9 million U.S. adults age 65 or older are completely or mostly homebound, while another 5.3 million have functional limitations that make it hard to leave their homes. Many of these individuals have profound difficulty accessing office-based primary care, and some are unable to do so altogether. As a result, many homebound people struggle to manage their illnesses and depend on overwhelmed family caregivers.
When these adults experience a health crisis, perceived or real, they typically take an ambulance to the emergency department, where they receive care from providers who are unfamiliar with their conditions and care goals. And when they are discharged from hospital stays, the homebound often experience fragmented follow-up care. New research shows that health care use and costs are much higher in people with multiple chronic conditions and functional impairments—a significant portion of whom are likely homebound—than those without functional impairments.
To improve care for homebound patients and lower costs for the health system at large, a set of quality metrics for people receiving care at home is needed. One challenge to monitoring the quality of homebound patients’ experiences, however, is that many homebound people are invisible to health care providers. While more health systems and insurers are turning to approaches like “hotspotting” to identify patients who incur high health care costs and better serve their needs, you can’t “hotspot” patients who are simply hard to spot.
Who Are the Homebound?
There is no good system for tracking the entire homebound population, as there is for tracking those living in long-term care facilities. Instead, we have to extrapolate from large national studies. Recent data from the National Health and Aging Trends Study find that compared with people who are not homebound, the homebound are more likely to be African American, Medicaid beneficiaries, unmarried, and unable to walk a few blocks. They are also more likely to have lower educational attainment, poor self-reported health status, symptoms of depression or dementia, and to have been hospitalized in the past year.
We also know from our own qualitative research that homebound individuals and their caregivers are greatly affected by social determinants of health such as poverty and lack of access to usual ambulatory care. In interviews with homebound patients and their caregivers, they reported the need for assistance with activities of daily living and the importance of caregiver respite and support. These patients and their caregivers also said that reliable, consistent access to affordable home-based medical care provided “peace of mind” and reduced hospital and emergency department use.
New Quality Framework and Quality Measures Needed
To reach the homebound, some health systems are engaging in home-based primary or palliative care. These models have a strong evidence base and the ongoing Independence at Home Demonstration from the Center for Medicare and Medicaid Innovation has found that home-based primary care is associated with substantial cost savings. However, to foster the spread of home-based primary care, it is also necessary to have an appropriate quality framework and quality indicators suitable for this population.
To date, we haven’t developed quality measures for home care, but have focused instead on services delivered in clinics, nursing homes, or hospitals. These measures are usually oriented toward a single condition or disease and fail to capture homebound individuals’ experiences. Some even encourage inappropriate and dangerous care for homebound patients. For instance, for many frail homebound adults, cancer screening, lipid monitoring, and tight control of blood glucose—common primary care quality indicators—may offer little benefit. In fact, enforcing tight glucose control for homebound patients could lead to low blood sugar and falls. Further, applying multiple single-condition, disease-specific quality measures designed for ambulatory patients to frail and functionally impaired vulnerable individuals with multiple chronic conditions can result in harm from overtesting and overtreatment.
New quality metrics for older homebound people that align with their goals and medical needs can help ensure that home care is effective and providers are compensated fairly for their treatment of this high-need population—especially as payment is increasingly tied to the value of care. In future posts, we will share what we have learned from our efforts to explore how homebound individuals, their caregivers, and home-based providers define high-quality care.