Home-based primary care: A systematic review of the literature, 2010-2020

Tailoring Household Disaster Preparedness Interventions to Reduce Health Disparities: Nursing Implications from Machine Learning Importance Features from the 2018-2020 FEMA National Household Survey

Tailored disaster preparedness interventions may be more effective and equitable, yet little is known about specific factors associated with disaster household preparedness for older adults and/or those with African American/Black identities. This study aims to ascertain differences in the importance features of machine learning models of household disaster preparedness for four groups to inform culturally tailored intervention recommendations for nursing practice. A machine learning model was developed and tested by combining data from the 2018, 2019, and 2020 Federal Emergency Management Agency National Household Survey. The primary outcome variable was a composite readiness score. A total of 252 variables from 15,048 participants were included. Over 10% of the sample self-identified as African American/Black and 30.3% reported being 65 years of age or older. Importance features varied regarding financial and insurance preparedness, information seeking and transportation between groups. These results reiterate the need for targeted interventions to support financial resilience and equitable resource access. Notably, older adults with Black racial identities were the only group where TV, TV news, and the Weather Channel was a priority feature for household disaster preparedness. Additionally, reliance on public transportation was most important among older adults with Black racial identities, highlighting priority needs for equity in disaster preparedness and policy.

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

BACKGROUND

Approximately 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.

METHODS

We 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.

DISCUSSION

Testing 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 REGISTRATION

This trial was registered with ClinicalTrials.gov NCT05849259 in May 2023.

Trajectories of care and outcomes of Veterans receiving home-based primary care

BACKGROUND

Veterans Affairs (VA) home-based primary care (HBPC) provides comprehensive longitudinal care to patients with complex, chronic disabling disease. While enrollment is associated with lower hospitalization rates and costs, detailed trajectories have not been well described.

METHODS

We performed a longitudinal descriptive study of patients newly enrolled in VA HBPC in fiscal year (FY) 2015. We extracted demographics, comorbidities, functional status, and social supports from VA and Medicare data and examined patterns of care and clinical outcomes, including hospital, nursing home (NH), hospice use and mortality from FY2015-2017. We present results using descriptive statistics, alluvial plots, and heat maps.

RESULTS

We identified 10,571 HBPC enrollees in FY2015; mean age was 77.7. HBPC patients commonly had chronic medical conditions with high self-management burden (e.g., diabetes 48.2%) and disabling conditions such as dementia (39.3%). Over half had ≥2 deficits in activities of daily living, 46% had caregivers with functional limitations or no caregiver, and 25% resided in a socially deprived area. Patients experienced variable care trajectories. Mean time enrolled in HBPC was 331 days, 8.3% of patients were discharged after 3 months, and 22.8% stayed enrolled for over 2 years. Institutional health care use declined in the 6 months after initial enrollment: (e.g., hospital: 41%-25%, NH: 34%-11%). At 2 years, 36% of patients had died; among decedents, 58% received hospice and 72% died in a non-institutional setting. In the last 180 days of life, 84% of time was spent at home, and once enrolled in hospice, 97% of time was spent outside of institutional care.

CONCLUSIONS

HBPC patients experience highly variable care trajectories but on average have reductions in acute care use and spend a majority of time in non-institutional settings. These data allow for a nuanced understanding of HBPC, providing a platform for monitoring, evaluating, and improving program function.

Implementation of patient priorities-aligned care in a home-based primary care program

BACKGROUND

Older adults may be limited in their ability to access care that meets their health goals owing to disease burden, financial instability, and psychosocial barriers. A home-based primary care (HBPC) program established in 2020 within a large family medicine practice uses the Patient Priorities Care (PPC) approach to identify and address patients' health priorities. When incorporated as part of the HBPC model of care, the PPC approach has the potential to enhance person-centered care for older adults in a way that best supports their health goals.

OBJECTIVE

The objective of this study is to summarize common recommendations for alignment of care with patients' health outcome goals after implementation of the PPC approach in an HBPC population.

METHODS

This retrospective study was exempt from review by an institutional review board. After enrollment in the HBPC program, patients participated in a PPC priorities identification conversation to identify their health outcome goals and care preferences. Through chart review, 2 researchers independently categorized these goals based on the set of values they most reflect: connecting, managing health, enjoying life, and functioning. Aspects of care in place before enrollment in HBPC were considered to determine any adjustments that needed to be made to align care with patients' identified priorities.

RESULTS

The most common value associated with patients' most desired health outcome goal was functioning (n = 33, 66%). For secondary and tertiary health outcome goals, the most common value identified was managing health (secondary, n = 28, 56%; tertiary, n = 22, 44%). Common recommendations made to align care with patients' identified priorities included stopping potentially harmful medications, starting medications for untreated conditions, starting physical or occupational therapy, and adjusting medications.

CONCLUSION

Through the PPC approach, patients' values were identified and care was assessed to aid in attainment of individualized health outcome goals and tailor care to What Matters most.

Effects of Home-Based Primary Care on Hospital Use for High-Need Medicare Patients: an Observational Study

BACKGROUND

High-need, high-cost Medicare patients can have difficulties accessing office-based primary care. Home-based primary care (HBPC) can reduce access barriers and allow a clinician to obtain valuable information not obtained during office visit, possibly leading to reductions in hospital use.

OBJECTIVE

To determine whether HBPC for high-need, high-cost patients reduces hospitalizations and Medicare inpatient expenditures.

DESIGN

We conducted a matched retrospective cohort study using a difference-in-differences analysis to examine patients 2 years before and 2 years after their first home visit (HBPC group).

PARTICIPANTS

The study included high-need, high-cost fee-for-service Medicare patients without prior HBPC use, of which 55,303 were new HBPC recipients and 156,142 were matched comparison patients.

INTERVENTION

Receipt of at least two HBPC visits and, within 6 months of the index HBPC visit, a majority of a patient's primary care visits in the home.

MAIN MEASURES

Total and potentially avoidable hospitalizations and Medicare inpatient expenditures.

KEY RESULTS

HBPC reduced total hospitalization rates, but the marginal effects were not statistically significant: a reduction of 11 total hospitalizations per 1000 patients in the first year (- 0.6%, p = 0.19) and 14 in the second year (- 0.7%, p = 0.16). However, HBPC reduced potentially avoidable hospitalization rates in the second year. The estimated marginal effect was a reduction of 6 potentially avoidable hospitalizations per 1000 patients in the first year (- 1.6%, p = 0.16) and 11 in the second (- 3.1%, p = 0.01). The estimated effect of HBPC was a small decrease in inpatient expenditures of $24 per patient per month (- 1.1%, p = 0.10) in the first year and $0 (0.0%, p = 0.99) in the second.

CONCLUSIONS

After high-need, high-cost patients started receiving HBPC, they did not experience fewer total hospitalizations or lower inpatient spending but may have had lower rates of potentially avoidable hospitalizations after 2 years.

Korean primary health care program for people with disabilities: do they really want home-based primary care?

BACKGROUND

Despite many studies on home-based primary care (HBPC)-related benefits and challenges, little is known about the perspectives of potential target groups of the care and their intention or preference for using it. This study aimed to explore the demand for HBPC from the perspective of people with disabilities (PWDs) and caregivers and identify relevant determinants for that demand.

METHODS

Data from the population-based survey conducted in the Gyeonggi Regional Health & Medical Center for People with Disabilities in South Korea were analyzed. Logistic regression analysis was performed to identify relevant determinants for the demand on HBPC.

RESULTS

Overall, 22% of respondents required HBPC, and 34.7% of persons aged ≥ 65 years demanded it. Older adults with disability, homebound status, and a need for assistance with daily living activities were associated with a demand for HBPC. Though having severe disability, only 19.49% of self-reported respondents demanded for HBPC, while 39.57% of proxy-reported respondents demanded for HBPC. Among self-reported group, only marital status was a predictor associated with a demand for HBPC. In contrast, among proxy-reported groups, PWDs with external physical disabilities, or with unmet medical needs due to availability barriers reported a higher demand for HBPC.

CONCLUSIONS

The demand for HBPC does not derive from the medical demands of the users themselves, but rather the care deficit by difficulty in getting out of the house or in outpatient care. Beyond an alternative to office-based care, HBPC needs to be considered to solve the care deficit and as well as to deal with PWDs' medical problems.

Caregiver Experiences Participating in a Home-Based Primary Care Program: A Pragmatic Evaluation Including Qualitative Interviews and Quantitative Surveys

The aim of this evaluation was to assess caregiver experience and burden during their first year in a geriatric home-based primary care (HBPC) program with qualitative interviews and surveys. HBPC included in-home visits for homebound, older adult patients. Seventeen caregivers, with varied amount of experience with HBPC, participated in semi-structured interviews. Change in caregiver burden from baseline was captured for 44 caregivers at 3 months post-enrollment, 27 caregivers at 6 months, and 22 caregivers at 12 months. Satisfaction survey was administered at these timepoints, but the last response of 48 caregivers was analyzed. Caregiver interviews revealed three themes: caregiving stressors, reliance on HBPC in relation to other medical care, and healthcare in the home. Surveyed caregivers were highly satisfied, but burden did not change substantially over the 1 year intervention. Caregivers appreciated HBPC reduced patient transportation and provided satisfactory primary care, but additional research is needed to tailor this care to reduce caregiver burden.

Home-Based Medical Care Use In Medicare Advantage And Traditional Medicare In 2018

The use of home-based medical care differed in Medicare Advantage and traditional Medicare in 2018. Having exactly one such visit was thirty-one times as likely for Medicare Advantage beneficiaries (18.6 percent) as for traditional Medicare beneficiaries (0.6 percent), likely reflecting incentives in the Medicare Advantage program to code all accurate diagnoses. Multiple home-based medical care visits were less likely in Medicare Advantage than in traditional Medicare (1.6 percent versus 2.1 percent of beneficiaries, respectively).

State Variation in the Utilization of Nurse Practitioner-Provided Home-Based Primary Care: A Medicare Claims Analysis

Nurse practitioners (NPs) provide an increasing proportion of home-based primary care, despite restrictive scope of practice laws in approximately one half of states. We examined the relationship between scope of practice laws and state volume of NP-provided home-based primary care by performing an analysis of 2018 to 2019 Medicare claims. For each state we calculated the proportion of total home-based primary care visits by NPs and the proportion of all NPs providing home-based primary care. We used the 2018 American Association of Nurse Practitioners classification of state practice environment. We performed chi-square tests to assess the significance between volume and practice environment. We found that 42% of home-based primary care is delivered by NPs nationally, but substantial variation exists across states. We did not find a discernible or statistically significant pattern of uptake of NP-provided home-based primary care across full, reduced, or restricted states. [Journal of Gerontological Nursing, 49(5), 11-17.].

Prevalence of use and characteristics of users of home-based medical care in Medicare Advantage

BACKGROUND/OBJECTIVES

Home-based medical care (HBMC) is longitudinal medical care provided by physicians, advanced practice providers, and, often, inter-professional care teams to patients in their homes. Our objective is to determine the prevalence of HBMC among older adults (≥65) insured by a Medicare Advantage (MA) plan and compare characteristics of those who receive HBMC to those who do not.

METHODS

Study used de-identified medical claims and enrollment records for MA beneficiaries during calendar years 2017 and 2018 linked with socioeconomic status data in the OptumLabs Data Warehouse. We defined a cohort of MA beneficiaries age ≥65 receiving HBMC for at least 2 months during 2017-2018, described the cohort using demographic, utilization, and comorbidity data and compared it to a 5% random sample of a population of MA beneficiaries age ≥65 not receiving HBMC (No HBMC).

RESULTS

Overall, 1.45% of the study cohort age ≥65 received HBMC. Compared to No HBMC (n = 132,147), those receiving HBMC (n = 38,800) were more likely to be: older (46.6% vs. 11.9% age 85+); female (70.8% vs. 58.5%); Black (12.3% vs. 11.3%); urban (90.3% vs. 81.3%); experience hospitalization (38.0% vs. 13.3%), emergency department visit (58.3% vs. 26.9%), ambulance trip (44.1% vs. 9.6%), skilled nursing facility (37.6% vs. 6.4%), or hospice care admission (21.1% vs. 3.5%). They also were more likely to experience a wide range of chronic conditions including dementia (58.1% vs. 5.2%), morbidity burden (Charlson score 3.4 vs. 1.8), and serious illness (77.1% vs. 29.5%). All comparisons p < 0.0001.

CONCLUSIONS

MA beneficiaries who received HBMC are older, experience greater chronic and serious illness burden, and higher levels of facility-based care than those who did not receive HBMC. MA plans need strategies to identify patients that would benefit from HBMC and develop approaches to deliver such care to this impactful, often invisible population.

Clinical Features of Hypoxemia Due to Infection Under Home-Based Medication During the COVID-19 Pandemic Period

BACKGROUND

Despite the growing demand for home-based medication during the COVID-19 pandemic period, there remains scarce evidence of hypoxemic infection in home-care settings. In this study, we investigated the clinical features of hypoxemic respiratory failure due to infection during the period under home-based medication (defined as 'home-care-acquired infection').

METHODS

This retrospective observational study enrolled patients with home-care-acquired infection, other than COVID-19, in two home-care clinics in Sapporo, Japan, between April 2020 and May 2021 (the early phase of the COVID-19 pandemic). The participants were divided into two groups according to whether they required additional home oxygen therapy, and were compared to assess the predictors of hypoxemic respiratory failure. Furthermore, the clinical features were compared with those in patients aged >60 years with COVID-19 who were admitted to Toyama University Hospital during the same period.

RESULTS

A total of 107 patients with home-care-acquired infections were included in the study (median age, 82 years). Twenty-two patients required home oxygen therapy, and 85 did not. Thirty-day mortality rates were 32% and 8%. Among the patients in the hypoxemia group, none had desired a care-setting transition, following the advanced care planning. Multivariable logistic regression analysis showed that initial antibiotic treatment failure and malignant disease were independently associated with hypoxemic respiratory failure (odds ratio, 7.28 and 7.10; p=0.023 and p<0.005, respectively). In comparison with hypoxemia in the COVID-19 cohort, the lower incidence of febrile co-habitants and earlier onset of hypoxemia were significant in those due to home-care-acquired infection.

CONCLUSION

This study demonstrated that hypoxemia due to home-care-acquired infection was characterized by distinct features, possibly different from those due to COVID-19 in the early pandemic period.

Pharmacist Identification of Older Patients’ Priorities in a Home-Based Primary Care Program

Background Patient Priorities Care (PPC) aims to identify and integrate patient goals and preferences into health care decision-making to provide more personalized care for multimorbid older individuals. Home-based primary care (HBPC) is a model of care delivery that supports aging in place. HBPC-integrated pharmacists can identify patient priorities and communicate with the team to ensure care is aligned with what matters most. Objectives Evaluate patients’ perceptions of having priorities identification conversations with the pharmacist; identify the value domains represented by patients’ health outcome goals. Setting HBPC program at a large family medicine practice where pharmacists are core members of the interdisciplinary team. Intervention Pharmacists led priorities identification conversations for patients newly enrolled in HBPC. Care preferences and health outcome goals were documented in the medical record and communicated during HBPC team meetings. Design This was a prospective, observational study of HBPC enrollees. After the priorities identification conversation, a three-question survey was administered to identify patients’ perceptions of the conversation and interaction with the pharmacist. Health outcome goals and care preference statements were reviewed to determine with which value domain(s) they most aligned. Descriptive statistics were used for results analysis. Results Pharmacists led conversations with 30 participants. Average overall satisfaction with the conversation was 4.6 on a 5-point Likert scale (1 = least, 5 = most satisfied). Ninety-three percent of patients felt it was appropriate to have a pharmacist lead these conversations. Ninety-seven percent believed it was important/very important to discuss their values and goals with their health care team. The predominant value domains represented were Managing Health (43%) and Functioning (40%). Conclusion Patients were mostly satisfied with having PPC conversations and felt it was appropriate for a pharmacist to lead these conversations. Managing health conditions and preserving function were the most frequent value domains associated with patients’ goals and care preferences.

[Evolution of the profile of patients attended by a hospital Geriatric Home Care Unit in the last 20 years]

OBJECTIVE

To describe the evolution of the profile of patients attended by a Geriatric Home Care (GHC) Unit and its care activity in the last two decades.

METHODS

Data on the historical activity of the AGD Unit from 2001 to 2020, grouped into 5-year periods, were recorded. Sociodemographic, clinical, functional (Functional Red Cross Scale and Barthel index) and mental (Mental Red Cross Scale) variables were collected, baseline and at inclusion to AGD. Also the waiting time until first visit, mean follow-up, origin of referral, destination at the end of the intervention, reason for consultation and cause of functional dependence were also included. A descriptive analysis was performed with the SPSSv.23 program.

RESULTS

Ten thousand six hundred fifty-four patients attended in AGD (1 January 2001 to 31 December 2020). A progressive increase in age and in the number of geriatric syndromes was observed. Patients presented higher functional and cognitive decline, and the number of patients living alone and in need of private assistance increased. The duration of the intervention decreases and Primary Care remains the main source and destination at the end of the intervention, with dementia standing out as the main cause for functional dependence.

CONCLUSION

The vulnerability of the populations in need of specialised geriatric care is increasing: patients are older, and have more geriatric syndromes, high functional and cognitive decline, and suffer social frailty; more work is needed to address the role of these support units in the community, as well as their coordination with Primary Care teams.

Growth of Fee-for-Service Medicare Home-Based Medical Care Within Private Residences and Domiciliary Care Settings in the U.S., 2012-2019

OBJECTIVES

Home-based medical care (HBMC) delivers physician or advanced practice provider-led medical services for patients in private residences and domiciliary settings (eg, assisted living facilities, group/boarding homes). We aimed to examine the time trends in HBMC utilization by care settings.

DESIGN

Analyses of HBMC utilization at the national and state levels during the years 2012-2019.

SETTING AND PARTICIPANTS

With Medicare public use files, we calculated the state-level utilization rate of HBMC among fee-for-service (FFS) Medicare beneficiaries, measured by visits per 1000 FFS enrollees, in private residences and domiciliary settings, both separately and combined.

METHODS

We assessed the trend of HBMC utilization over time via linear mixed models with random intercept for state, adjusting for the following state-level markers of HBMC supply and demand: number of HBMC providers, state ranking of total assisted living and residential care capacity, and the proportion of FFS beneficiaries with dementia, dual eligibility for Medicaid, receiving home health services, and Medicare Advantage.

RESULTS

Total HBMC visits in the United States increased from 3,911,778 in 2012 to 5,524,939 in 2019. The median (interquartile range) state-level HBMC utilization rate per 1000 FFS population was 67.6 (34.1-151.3) visits overall, 17.3 (7.9-41.9) visits in private residences, and 47.7 (23.1-86.6) visits in domiciliary settings. The annual percentage increase of utilization rates was significant for all care settings in crude models (3%-8%), and remained significant for overall visits and visits in domiciliary settings (2%-4%), but not in private residences.

CONCLUSIONS AND IMPLICATIONS

The national-level growth in HBMC from 2012-2019 was largely driven by a growth of HBMC occurring in domiciliary settings. To meet the needs of a growing aging population, future studies should focus efforts on policy and payment issues to address inequities in access to HBMC services for homebound older adults, and examine drivers of HBMC growth at regional and local levels.

Balancing the benefits of patient-clinician relationships with professional boundaries in Home-based Primary Care

In the home care setting, boundaries may be difficult to identify when behavioral changes are made to accommodate the nature of care being delivered. In this secondary qualitative study, we examined how Home-based Primary Care (HBPC) clinicians understand role and relationship boundaries with patients and how these dynamics support patient care. The data set consisted of 14 semi-structured interviews with HBPC clinicians representing multiple disciplines and field observations of 6 HBPC team meetings. Using a directed approach to content analysis, we identified and described how HBPC clinicians worked to build relationships with patients, experienced challenges with emotional attachment, and negotiated boundaries in the patient-clinician relationship. Our findings illustrate how the home care setting is a site for which strong, therapeutic patient-clinician relationships can be developed while also highlighting the work that clinicians must do to balance addressing patient needs stemming from social isolation and adherence to their own professional boundaries.

National Cohort Study of Homebound Persons Living With Dementia: Antibiotic Prescribing Trends and Opportunities for Antibiotic Stewardship

Background

Over 7 million older Americans are homebound. Managing infections in homebound persons presents unique challenges that are magnified among persons living with dementia (PLWD). This work sought to characterize antibiotic use in a national cohort of PLWD who received home-based primary care (HBPC) through the Veterans Health Administration.

Methods

Administrative data identified veterans aged ≥65 years with ≥2 physician home visits in a year between 2014 and 2018 and a dementia diagnosis 3 years before through 1 year after their initial HBPC visit. Antibiotics prescribed orally, intravenously, intramuscularly, or by enema within 3 days of an HBPC visit were assessed from the initial HBPC visit to death or December 31, 2018. Prescription fills and days of therapy (DOT) per 1000 days of home care (DOHC) were calculated.

Results

Among 39 861 PLWD, the median age (interquartile range [IQR]) was 85 (78-90) years, and 15.0% were Black. Overall, 16 956 (42.5%) PLWD received 45 122 prescription fills. The antibiotic use rate was 20.7 DOT per 1000 DOHC. Telephone visits and advanced practice provider visits were associated with 30.9% and 42.0% of fills, respectively. Sixty-seven percent of fills were associated with diagnoses for conditions where antibiotics are not indicated. Quinolones were the most prescribed class (24.3% of fills). The overall median length of therapy (IQR) was 7 (7-10) days. Antibiotic use rates varied across regions. Within regions, the median annual antibiotic use rate decreased from 2014 to 2018.

Conclusions

Antibiotic prescriptions were prevalent in HBPC. The scope, appropriateness, and harms of antibiotic use in homebound PLWD need further investigation.

Home-based primary care visits by nurse practitioners

BACKGROUND

With rapidly growing numbers of homebound older adults, the need for effective home-based health interventions is increasingly recognized. Advanced practice registered nurses (NPs) are one of the most common providers of home-based primary care. Limited information is available to address the scope and nature of NP-led home-based primary care and associated outcomes.

OBJECTIVE

To synthesize research evidence of NP visits in home-based primary care.

DATA SOURCES

Six electronic databases-PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, Cochrane, Web of Science, and Scopus-were searched to identify peer-reviewed research articles addressing home-based primary care interventions led by NPs. Independent screening resulted in 17 relevant articles from 14 unique studies to include in the review.

CONCLUSIONS

Nurse practitioners provided health assessments, education, care planning and coordination primarily by face-to-face home visits. Despite a variability in terms of study design, setting, and sample, NP-led home-based primary care was in general associated with less hospitalization and fewer emergency department visits. Evidence was mixed in relation to patient-reported outcomes such as subjective health, functional status, and symptoms. Costs and patient or caregiver satisfaction were additional outcomes addressed, but the findings were inconsistent.

IMPLICATIONS FOR PRACTICE

Recent policy changes to authorize NPs to independently assess, diagnose, and order home care services directly affect how NPs approach home-based primary care programs. Our findings support NP-led home-based primary care to decrease consequential health utilization and suggest the need for further evaluating the care models in diverse populations with more patient-reported and caregiver outcomes.

Home-Based Care Reimagined: A Full-Fledged Health Care Delivery Ecosystem Without Walls

The COVID-19 pandemic exposed the dangers of tying health care delivery to brick-and-mortar health care facilities. Both before and, more intensely, during the pandemic, health systems have struggled to support high-need patients, especially those unable to engage with virtual technology or needing urgent care in the home. The pandemic has highlighted an ongoing need to create a distributed health care delivery ecosystem centered in patients' homes and the community. This age-friendly ecosystem would initially focus on high-need patients, expand access, improve equity, and be of high value. It would integrate episodic and longitudinal care and expand to serve broader populations as it matures. We briefly describe the evidence base for home-based care models that constitute this ecosystem, define the guiding principles underlying it, and discuss what will be required to build out and scale it.