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Editor’s Note: This is the third of four ������ƵViews blog posts written by the Agency’s National Advisory Council members about their discussions on advancing healthcare quality in different care settings. The Council provides advice to AHRQ's director on Agency activities and priorities. This blog does not necessarily represent the views of AHRQ.

The COVID-19 pandemic revealed many truths about our Nation. Among them: Americans are increasingly able and, in many instances, willing to engage in new activities at home. These include work, school, shopping, exercise, social gathering, worship—and healthcare. During the pandemic, Americans took to home-based care as never before in the form of remote medical visits, at-home diagnosis, and self-administered treatment.

The pandemic did not create the demand for home-based care, but accelerated it. And, as in many other fields, the technologies, systems, expectations, and social understandings around home-based healthcare remain imperfect. But they are developing rapidly. Our job is to keep up. 

The quality improvement (QI) challenges around home healthcare are myriad. QI remains more established in other care settings (e.g., acute care and nursing homes), but it is advancing in home health. This is good news! More personalized quality metrics and better data are on the near-term horizon. We continue to face the challenge of turning data into usable information—a challenge that will always be with us.

One question must sit at the center of every QI initiative: what are we trying to improve? From this answer, we derive performance metrics. As usual, we start with the traditional forms of measurement—measures of structure, process, outcome, and cost. For instance, the expected home healthcare results we can measure include fewer hospitalizations, rehospitalizations, and emergency department visits.

Additional questions underlie QI in home healthcare: What makes care delivered in this setting unique? What unique aspects of care in our homes should be considered, monitored, and measured? Remember: patients’ homes are their inner sanctums, the refuges at the center of their private lives. When caregivers and medical devices enter a home, they enter a sacred space. We must minimize any sense of intrusion. Respect for the patient and the family under this circumstance is critical.

This is easy to say, but hard to do. Tailoring QI and performance measurement to what matters most to patients is challenging. In all cases, but especially in this one, we need to ensure that patients feel cared for and trust the systems, technologies, and people they allow into their homes.

To ensure this trust, patients and their families must be involved in selecting and designing what is measured. For example, what training and support do patients and their families receive to help them manage care in the home?  Do patients and their families get guidance about obtaining the necessary equipment or how to use it?  Do patients and their families understand medication regimens and administration?  This trust is paramount, for without it, the entire endeavor is at risk.

This is why we seek a measurement structure that is both considerate and comprehensive, yet straightforward, to inform the public (including patients and families, payors, and regulators) while minimizing provider burden. The goal is ensuring that healthcare processes are beneficial, affordable, safe, and culturally appropriate. 

One challenge we have observed with home health QI is its integration with care delivered in other settings. This reflects a pandemic-era lesson we have learned more broadly. While it is true that we can engage in more activities at home, it isn’t clear that we should always do so or if we even want to. Ideally, home-based work, schooling, and other endeavors can supplement, not replace, out-of-the-home activities. This is also true with home-based healthcare, and performance measurement should reflect this.

As we look to understand what QI should mean for home-based healthcare, we should look to the “quadruple aim” of healthcare—the proper care at the right time, an enhanced patient experience and engagement, transparent and efficient communication by providers finding joy in their work, and achieving equity—as our true north.

Susan Edgman-Levitan is Executive Director of the John D. Stoeckle Center for Primary Care Innovation.

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