Is every day at home a good day?

As health systems, insurers, and policy makers strive to transition to models of care that reward high-quality care, particularly for those with serious illnesses, the need for person-centered claims-based quality measures grows. A measure of days at home could fill this void. Days at home have good face validity, as most older adults express a strong preference to spend time out of hospitals and nursing homes at the end of life and to avoid burdensome transitions of care between settings. Furthermore, because this measure could be captured using claims data, it could be used as a quality measure across settings of care, from Accountable Care Organizations (ACOs) to Medicare Advantage plans to palliative care programs. Two recent papers, by Freed et al. and Shen et al., attempt to validate a day-at-home measure, with both raising questions on the challenges and implications of using this measure. Freed et al. examine variation at the ACO-level in days at home among a cohort with serious illness, finding an average of 349 days at home per person-year, with an interquartile variation of 5.3 days/year (4.2 days/year when risk-adjusted). Although this is a statistically significant difference, is it clinically significant, particularly in this population with a serious illness? Notably, even hip fracture, the condition associated with the largest reduction in days at home, results in only one less day at home per year on average. Given the relatively low variation in the Freed et al. study, it is unclear if days at home add new information relative to measures of hospital admissions or total Medicare expenditures. The Medicare Payment Advisory Commission reached a similar conclusion in writing that “(w)ith so little variation across local market areas . the Commission questions the immediate utility of the [Home and Community Days] measure in its current form. ” In examining the characteristics associated with days at home, these papers also raise the question of what is currently driving variation in the measure, and if implementing it could have adverse consequences. Freed et al. find that ACOs with the lowest quartile of days at home are more likely to care for Black and Hispanic older adults with serious illness, those in urban regions, and those in regions with a greater supply of hospital beds. If ACOs are penalized for days at home, could that widen racial and ethnic disparities by penalizing ACOs that serve communities of color? Shen et al. similarly find a weak but significant association of unmanaged pain and symptoms with fewer days at home among a cohort in a palliative care program. Employing this measure more broadly among older adults with serious illnesses could mean that payers and health systems would be more likely to bolster efforts to manage symptoms to increase days at home. Alternatively, it is possible that payers and health systems avoid individuals with conditions more likely to result in high pain and symptom burden. In raising the question of the relationship between days at home and pain and symptoms, Shen and colleagues draw attention to the challenge of relying on a day-at-home measure: a count of days at home says nothing about the quality of care or life during those days. It is unclear in the Shen et al. study if those with better pain management at home have more days at home, or if those with less pain regardless of management are those who can stay at the home. We propose that if measures of days at home are to be promoted, they should be tied to the rigorous quality of care at home measures, including both the presence of care needs and level of unmet needs, functional assessments, and responsiveness of care. The hospice Consumer Assessment of Healthcare Providers and Systems offers an example of how this sort of comprehensive patient or proxy-reported quality data could be operationalized. This Editorial comments on the articles by Freed et al. and Shen et al. in this issue. These measurement challenges around incorporating a count of days at home for older adults with serious illness highlight an underlying tension around quality of care for this population: it is difficult to avoid unnecessary and undesired treatments while also not inappropriately withholding access to potentially beneficial, desired, and yet costly care. Received: 29 June 2022 Accepted: 4 July 2022