More Quality Measures for Homebound Seniors - Not Hardly

Quality measurement focus has resulted in higher cost, distractions from care, and lower productivity. Articles proposing more quality measure emphasis may be popular but will not move homebound seniors toward the care that they need. An understanding of the situations facing homebound seniors is required.
Based on higher levels of disabled payments, Social Security payments, Medicare patients, Medicaid patients, seniors, obesity, smoking, and sedentary lifestyle at least 45% of homebound seniors are found in 2621 lowest physician concentration counties.
It helps to have access to care and workforce to provide care and local resources and many other areas addressed before more quality measures.
Homebound seniors where care is needed face
  • Lack of mobility - condition, housing
  • Lack of transportation - due to family situations and lesser public transportation
  • Lack of insurance competition
  • Insurers who avoid them due to cost and complexity
  • Providers who avoid them due to payment too low
  • Lack of access to basic health care due to least local workforce also due to payment design - 21% of physicians for 40% of the population with only 23.5% of mental health providers and only 26% of NP and PA
  • Lack of access to a local pharmacy - insurance companies and drug companies have created mail order diversions away from local as well as middlemen driving up prices and also driving small pharmacists out
  • Providers who avoid them as their needs cannot be met within the payments provided (despite EMTALA and requirements by insurance) 
  • Burnout increasing for the local workforce including 36% of family physicians to serve this 45% segment. The lowest concentration county workforce that remains is left increasingly alone
  • Declining health care situations due to fastest growing populations, fastest growing elderly, and fastest growth in complexity and demand
  • Austerity focus that is depleting local resources, food, cash flow, jobs, and resources.
  • Small increases in Social Security of 20 dollars a month can result in $50 or more dollars lost in food stamps.

Quality measures and the increased costs of quality measures and the increased distractions of quality measures and the greater burnout due to quality measures is a questionable intervention. 
At least the authors did mention social determinants and home bound interventions that can actually help cost, quality, and access - but they chose to focus on measures rather than solutions to address care and outcomes.

Outcomes Are About People Factors, Not Measures

Changes in people are needed for quality improvements in ways that cannot be measured well. Investing more in clinical interventions is the problem, not the solution.

Changes are needed in behaviors, situations, environments, social determinants. Changes in access are needed. Changes in people changing payments are needed - up for primary care mental health office cognitive basic and oldest - which we have neglected for decades causing the physician deficits and access barriers. Real payment reform is needed.

Leaders Point to Solutions

We need leaders to point to the right changes in health care design and in designs for nutrition, housing, transportation, child development, and other people changing investments.


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