title: Development of an Interdisciplinary Team Communication Framework and Quality Metrics for Home-Based Medical Care Practices.
abstract: The unique needs of homebound adults receiving home-based medical care (HBMC) (ie, home-based primary care and home-based palliative care services) are ideally provided by interdisciplinary care teams (IDTs) that provide coordinated care. The composition of team members from an array of organizations and the unique dimension of providing care in the home present specific challenges to timely access and communication of patient care information. The objective of this work was to develop a conceptual framework and corresponding quality indicators (QIs) that assess how IDT members for HBMC practices access and communicate key patient information with each other.
  
  
  
  A systematic review of peer-reviewed and gray literature was performed to inform a framework for care coordination in the home and the development of candidate QIs to assess processes by which all IDT members optimally access and use patient information. A technical expert panel (TEP) participated in a modified Delphi process to assess the validity and feasibility of each QI and to identify which would be most suitable for testing in the field.
  
  
  
  Thematic analysis of literature revealed 4 process themes for how HBMC practices might engage in high-quality care coordination: using electronic medical records, conducting interdisciplinary team meetings, sharing standardized patient assessments, and communicating via secure e-messaging. Based on these themes, 9 candidate QIs were developed to reflect these processes. Three candidate QIs were assessed by the TEP as valid and feasible to measure in an HBMC practice setting. These indicators focused on use of IDT meetings, standardized patient assessments, and secure e-messaging.
  
  
  
  Translating the complex issue of care coordination into QIs will improve care delivered to vulnerable home-limited adults who receive HBMC. Guided by the literature, we developed a framework to reflect optimal care coordination in the home setting and identified 3 candidate QIs to field-test in HBMC practices.
authors.affiliation: Division of Geriatrics, University of California, San Francisco, San Francisco, CA; VA Quality Scholars Fellowship Program, San Francisco VA Medical Center, San Francisco, CA. Electronic address: roya.fathi@ucsf.edu.
authors.forename: Roya
authors.initials: R
authors.lastname: Fathi
authors.affiliation: Center on Aging and Health, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Orla C
authors.initials: OC
authors.lastname: Sheehan
authors.affiliation: Division of Geriatrics, University of California, San Francisco, San Francisco, CA.
authors.forename: Sarah K
authors.initials: SK
authors.lastname: Garrigues
authors.affiliation: UCLA/JH Borun Center and Los Angeles VA GRECC, Los Angeles, CA.
authors.forename: Debra
authors.initials: D
authors.lastname: Saliba
authors.affiliation: Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Bruce
authors.initials: B
authors.lastname: Leff
authors.affiliation: Division of Geriatrics, University of California, San Francisco, San Francisco, CA; Jewish Home of San Francisco, San Francisco, CA.
authors.forename: Christine S
authors.initials: CS
authors.lastname: Ritchie
mesh_terms: D003210:Concept Formation; D006699:Home Care Services / Q000592:standards*; D018577:Homebound Persons; D006801:Humans; D033183:Interdisciplinary Communication; D011320:Primary Health Care; D019984:Quality Indicators, Health Care / Q000458:organization & administration*
keywords: Long-term care; care coordination; communication; home care; house calls; interdisciplinary access