Related Experiment Video
Updated: Mar 20, 2026
Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care
Published on: February 16, 2011
Development of an Interdisciplinary Team Communication Framework and Quality Metrics for Home-Based Medical Care
Roya Fathi1, Orla C Sheehan2, Sarah K Garrigues3
1Division of Geriatrics, University of California, San Francisco, San Francisco, CA; VA Quality Scholars Fellowship Program, San Francisco VA Medical Center, San Francisco, CA.
Background:
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.
Methods:
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.
Results:
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.
Conclusion:
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.
Related Concept Videos
01:29Documentation in Long-Term and Home Healthcare Setting
Long-Term Care Facilities
01:21Interdisciplinary Care: The Health Care Team-I
Physicians
The physician's primary responsibility is to diagnose illness and direct the medical or surgical treatment of the condition. The authority to admit patients to a healthcare agency or institution and practice care within that setting is granted to physicians by the healthcare agency or institution...
01:15Methods of Documentation VI: Case Management Model
For example, a patient with a chronic...
01:18Interdisciplinary Care: The Health Care Team-II
Physical Therapist
A physical therapist (PT) aims to restore function or prevent additional impairment in a patient following an injury or disease. Massage, heat, cold, water, sonar waves, exercises, and electrical stimulation are some treatments used by PTs to treat...
01:30Health Information Technology and Healthcare Information System
Health Information Technology, commonly called HIT, integrates advanced information systems and technology in healthcare settings. Its primary functions include:
01:24Data Reporting and Recording