8

Perspective from Providers

At several times during the course of the workshop, presented evidence was interpreted differently by different types of providers. Panel 6 provided an opportunity for three care providers working in different settings to share their thoughts on research issues related to birth setting assessment and to help identify future research needs. The three speakers were a medical doctor (MD) from a hospital (Frank Chervenak), a certified nurse midwife (CNM) from a freestanding birth center (Karen Pelote), and a certified professional midwife (CPM) who attends home births in private practice (Brynne Potter). This chapter summarizes their presentations and the brief discussion that followed. As is true throughout this workshop summary, the perspectives summarized here reflect the perspectives of the individual presenters, not the perspectives of the planning committee, the Institute of Medicine or the National Research Council, or any other group. The panel was moderated by Ellen Hodnett, R.N., Ph.D., University of Toronto, Ontario, Canada. Box 8-1 summarizes key points made by individual speakers.



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8 Perspective from Providers A t several times during the course of the workshop, presented evi- dence was interpreted differently by different types of providers. Panel 6 provided an opportunity for three care providers working in different settings to share their thoughts on research issues related to birth setting assessment and to help identify future research needs. The three speakers were a medical doctor (MD) from a hospital (Frank Chervenak), a certified nurse midwife (CNM) from a freestanding birth center (Karen Pelote), and a certified professional midwife (CPM) who attends home births in private practice (Brynne Potter). This chapter summarizes their presentations and the brief discussion that followed. As is true throughout this workshop summary, the perspectives summarized here reflect the per- spectives of the individual presenters, not the perspectives of the planning committee, the Institute of Medicine or the National Research Council, or any other group. The panel was moderated by Ellen Hodnett, R.N., Ph.D., University of Toronto, Ontario, Canada. Box 8-1 summarizes key points made by individual speakers. 133

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134 RESEARCH ISSUES IN THE ASSESSMENT OF BIRTH SETTINGS BOX 8-1 Perspective from Providers Key Points Made by Individual Speakers •  rank Chervenak discussed results of an unpublished analysis he and col- F leagues performed on U.S. Centers for Disease Control and Prevention data suggesting that depressed 5-minute Apgar scores, stillbirths, and neonatal seizures occur at greater rates in home settings than in hospital settings. He suggested that hospitals should do what is necessary to ensure safety and to consider creating alternative environments. •  aren Pelote described typical experiences of women who choose to deliver in K birth centers. She discussed safety and transfer results from the 2013 Ameri- can Association of Birth Centers (AABC) Uniform Data Set (UDS) outcomes study (Stapleton et al., 2013) and called for more research on the psychoso- cial, cost, and other benefits of birth center care. •  rynne Potter noted the significant disagreement among experts around some B of the outcomes reported in published literature. She discussed the safety of home birth from an absolute risk perspective and identified several areas of research that would help to make home birth as safe as possible: access to qualified care providers with appropriate equipment, appropriate risk assess- ment, communication and collaboration, integrated transfer of data, quality improvement measures, and access to licensure and reimbursement. NEONATAL OUTCOMES IN RELATION TO BIRTH LOCATION: ETHICAL IMPLICATIONS FOR CLINICAL PRACTICE AND RESEARCH1 After encouraging workshop participants to read two papers that he and his colleagues wrote (Chervenak et al., 2011, 2013a), Frank Chervenak highlighted two key points from earlier workshop presentations: (1) The public is insufficiently educated in the importance of maintaining vital data. (2) Centers for Disease Control and Prevention (CDC) birth certificate data are important when considering U.S. births. He remarked, “I think the best database we have today is CDC data.” Chervenak discussed results from an analysis based on 2007-2010 CDC data (Chervenak et al., 2013b [unpublished data]). The analysis was designed to address two questions: (1) Are there differences between hospital and home births, using Apgar scores and seizures as prognostic 1  his T section summarizes information presented by Frank Chervenak, M.D., Weill Cornell Medical College, New York, New York.

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PERSPECTIVE FROM PROVIDERS 135 data for future outcome? (2) If there are differences between hospital and home births, are they due to location or attendants? What are their ethical implications for clinical practice and research? Only term births greater than 2,500 grams were included in the analy- sis, bringing the size of the CDC database down (i.e., the database cover- ing all U.S. births from 2007 to 2010) from more than 16 million births to about 14 million births. This included more than 100,000 home births, 67,000 of which were home births delivered by midwives. All home births showed a threefold increase in depressed 5-minute Apgar scores (i.e., scores of 0 to 6), compared to hospital births. Midwife- attended home births, which Chervenak and colleagues considered an ac- ceptable measure of intended home births, showed a twofold increase in depressed 5-minute Apgar scores, compared to hospital births. Five-minute Apgar scores of 4 to 6 and 0 to 3 showed the same twofold increase among midwife-attended home births, compared to hospital births. Five-minute Apgar scores of 0 (i.e., stillbirths) showed an 18-fold increase among midwife-attended home births, compared to hospital births. Depressed 5-minute Apgar scores for midwife-attended home births were different for CNM-attended births and other midwife-attended births, but both groups had more depressed scores than hospital births. Chervenak interpreted these results as evidence that location, not attendant, determines outcome. Data for neonatal seizures showed even more dramatic differences, with a fivefold increase among midwife-attended home births compared to hospital births. Among all midwife-attended births, only 6 percent occurred at home, but 25 percent of neonatal seizures that occurred with midwife- attended births occurred at home. In sum, Chervenak said that, regardless of which of the three outcomes one examines, all were significantly increased among midwife-attended home births compared to hospital births: a twofold increase for depressed 5-minute Apgar scores, an 18-fold increase for stillbirths, and a fivefold increase for neonatal seizures. Ideally, Chervenak said, he and his colleagues would also include in their analysis long-term follow-up data. But even gathering these short- term outcome data was a “Herculean task,” he said. While they may not be as valuable as long-term follow-up outcomes, depressed 5-minute Apgar scores are still a very valuable outcome, in Chervenak’s opinion. Depressed 5-minute Apgar scores have been associated with neurological disability, death, cerebral palsy, respiratory distress, hypoxic ischemic encephalopathy, and childhood cancer. Likewise with neonatal seizures, which have been as- sociated with cerebral palsy, hypoxic ischemic encephalopathy, neurologic sequelae, and neurodevelopmental sequelae. Based on the same CDC database, Chervenak observed that about half of hospital births had at least one risk factor and about 15 percent

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136 RESEARCH ISSUES IN THE ASSESSMENT OF BIRTH SETTINGS of home births had a least one risk factor. The risk factors included prior preterm birth, tobacco use, diabetes, prior poor outcome, hypertension, prior Cesarean, breech presentation, or less than 11 pound weight gain. In his opinion, 15 percent is too high. One observation that raised questions for Chervenak was that average 5-minute Apgar scores were higher for midwife-attended births compared to hospital births. He asked, “How could this be happening, given the lower Apgar scores that I just reported?” He explained that the greater number of Apgar scores of 10 for home births accounted for the greater average Apgar scores, even though the rate of depressed Apgar scores at 5 minutes was higher for home births. In the hospital, regardless of whether the attendant was a midwife or physician, about 3.7 percent of Apgar scores were reported as scores of 10. At home, 40 percent of CNMs and 57 percent of other midwives reported Apgar scores of 10. Chervenak sug- gested that this difference be studied. He said, “Either something very good is happening, or people are not assigning Apgar scores correctly.” Chervenak indicated, in his view, one of the themes of this workshop was the need to encourage collaboration and trust. For him, the underpin- ning of trust is respect, and the underpinning of respect is truth. He encour- aged the correct assignment of Apgar scores. Chervenak emphasized that the observed differences between midwife- attended home births and hospital births were due to location, not atten- dant. He said, “An obstetrician or physician can deliver an infant no better than a midwife, maybe worse. It is due to the location. Hospital births prevent these outcomes.” Based on this evidence, Chervenak asserted, “Phy- sicians and other health care professionals should discourage home birth.” He encouraged hospitals to do what is necessary to ensure safety (e.g., see Grünebaum et al., 2011) and to consider creating alternative birthing environments. RESEARCH ISSUES PERTAINING TO BIRTH CENTERS: A PROVIDER’S PERSPECTIVE2 Karen Pelote began by disclosing that she is the mother of six children, two of whom were born in a hospital under obstetric care, two in a birth center, and the last two (twins) in a hospital under osteopathy care. She at- tended the workshop to give her perspective as a provider at a birth center. Pelote noted that there are 248 birth centers that are licensed across 41 states. She indicated that the majority of birth center primary providers are CNMs, with the remaining providers consisting of a combination of 2  his T section summarizes information presented by Karen Pelote, M.S.N., CNM, Commu- nity of Hope, Family Health and Birth Center, Washington, DC.

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PERSPECTIVE FROM PROVIDERS 137 different groupings of licensed midwives, CPMs, and CNMs. Pelote cur- rently practices at the Community of Hope Family Health and Birth Center (FHBC), the only freestanding birth center in Washington, DC. Midwifery means “with women.” Midwives involved in modern health care research are always aware that there are real people and real families behind all the numbers and statistics. In that spirit, Pelote shared two stories that reflect clients’ experiences at FHBC. Each story was made up of the experiences of several of their patients. The first story was about a 17-year-old woman named “Sally” who visited the birth center with her grandmother. Sally was very nervous. She did not speak much nor did she share much information. But she did agree to attend group prenatal care. Over time, as the group progressed, she began to open up. The second story was about “Jane,” a 34-year-old pregnant woman who transferred care to the birth center after she realized that her obstetrician did not appreciate what she was trying to achieve in her birth plan. She too agreed to attend the biweekly prenatal group care. Group is an integral part of prenatal care at FHBC, according to Pelote. The groups are dynamic and diverse, with clients and their partners repre- senting a variety of socioeconomic statuses. The emphasis is on education (prenatal, intrapartum, and postpartum), including care of the newborn and the benefits of breastfeeding. The two women, though very different, participated in the same group, where they shared their experiences and answered each other’s questions. When Sally came in for labor, she delivered normally and had an un- complicated birth at the birth center. She went home 4 hours after delivery and received a home visit the next day. Jane came in for labor about a week later. She too had a natural labor and birth, went home soon afterward, and received a home visit the next day. The two women, although very cultur- ally different, had similar outcomes. Both Sally and Jane, like 99 percent of the women who deliver at FHBC, chose to breastfeed. Pelote noted that the FHBC rate for breastfeed- ing initiation is 84 percent, compared to the U.S. rate of 54 percent. The FHBC rate for exclusive breastfeeding at 6 months is nearly three times that of the U.S. rate. When Jane first told her family that she would be transferring to a birth center from her obstetrician, her family was very concerned. She shared with them some safety statistics to alleviate their skepticism. Specifically, the 2013 American Association of Birth Centers (AABC) Uniform Data Set (UDS) outcomes study results showed that 84 percent of women who start care at a birth center deliver at the birth center, with 93 percent hav- ing vaginal deliveries regardless of the actual birth setting (Stapleton et al., 2013). The neonatal mortality rate is low, and there were no incidences of maternal mortality.

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138 RESEARCH ISSUES IN THE ASSESSMENT OF BIRTH SETTINGS In Pelote’s opinion, birth centers provide a unique opportunity to change people’s lives—not just their present lives, but their future lives as well. Both Sally and Jane developed a new sense of confidence from hav- ing had a birth center birth. Sally realized that she was more capable than she could be. She said, “I made this baby, I delivered this baby, and now I am feeding this baby all by myself.” She brought her baby in for regular check-ups and felt comfortable calling her provider with issues or concerns instead of going to the emergency department. Jane expressed that the care she received at the birth center was personalized and that it felt like a fam- ily. She said, “Instead of feeling like my pregnancy was a medical condition, I feel like it was an awesome, natural event.” Jane’s family was impressed that she was back home in 4 hours after delivery, since both of her parents had expected her to end up with a Cesarean delivery. Pelote said that, as midwives, she and her colleagues feel like these statements reflecting how women feel about the birth center are fact. In actuality, there are no studies on the psychosocial benefits of birth center births. With respect to cost, the decision to deliver at FHBC saved each woman about $8,000. Currently, only about 1.9 percent of pregnant women in the United States deliver at birth centers. Changing that number to just 10 percent would save approximately $2.6 billion annually, according to Pelote’s estimate. Not only do birth center deliveries save money, but they also educate women to care for their bodies in the long term. Sally, because of her African American race, had an increased chance of having a Cesarean delivery, a low-birth-weight baby, and no breast- feeding. Also, the maternal death rate among African American pregnant women is more than 10 times what it should be. Sally represents a very small percentage of African Americans who choose birth center deliveries. At the FHBC, 32 percent of births are to African American women. But only 5 percent of women who participated in the 2013 AABC UDS study were African American (Stapleton et al., 2013). The low participation rate raises questions about why African American women do not choose birth centers, even though birth centers are easily accessible and have excellent outcomes. Pelote believes that a greater understanding of the barriers to care for African American women and why they do not choose birth centers would help to improve outcomes for African American women. The 2013 AABC UDS study showed a 12 percent referral rate to hos- pitals among women admitted to birth centers for labor and fewer than 1 percent of the women required emergency transfer during labor (Stapleton et al., 2013). Pelote relayed a story about a recent experience with a pa- tient at FHBC who was committed to a birth center birth and was doing beautifully up until she reached nine and a half centimeters and her water broke. Pelote said that the woman had the “thickest, darkest meconium” that Pelote had ever seen. She and her colleagues discussed the situation

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PERSPECTIVE FROM PROVIDERS 139 and decided to transfer the woman to a hospital. It was not an emergency situation. It was a decision. Above all else, the woman’s contractions slowed to almost nothing during the transport. The woman labored beautifully. She had a spontaneous birth with no complications and was able to go home the next day with her 9-pound baby. The woman later wrote a letter to Pelote: “Because of all we have learned from our laboring and breastfeeding classes at the birth center, we felt prepared for labor and the first weeks at home with a new baby. We could not have asked for a better birth experi- ence. We really value the people and the services of the Family Health and Birth Center.” Pelote said, “That is how transfers should be.” The hospital standard may be receptive of transfers, but based on her experience, that is not always the case. In cases where it is not, patients suffer. Pelote identified five topics in birth center care worthy of future investigation: 1. Clinical issues. Pelote suggested that more clinical research is needed to reduce transfer rates. She identified premature rupture of membranes, prolonged labor, and obesity as specific research areas worthy of funding. 2. The benefits of group prenatal care. 3. The psychological benefits of birth center care. 4. Cost and reimbursement issues. 5. Disparity. In conclusion, Pelote asserted that every woman, regardless of socio- economic, racial, or educational background, should have the opportunity to be informed about the benefits of birth centers and should be able to make the best decision for her health and the health of the baby. Birth cen- ters have been shown to be safe, effective, and economical. Pelote expects that future research will also demonstrate their psychological benefits. She ended, “Birth centers cannot remain the best kept secret in health care today.” PROVIDER PERSPECTIVES: MIDWIVES AND HOME BIRTH3 Brynne Potter reflected on what she observed had already been “han- dled very well and respectfully in this setting [for the most part]”: that home birth providers are marginalized and not integrated into the system. She acknowledged that integrating home birth providers into the system will be disruptive; whether that is a “good” or “bad” thing depends on 3  his T section summarizes information presented by Brynne Potter, CPM, Private Practice, Charlottesville, Virginia.

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140 RESEARCH ISSUES IN THE ASSESSMENT OF BIRTH SETTINGS one’s perspective. She considered home birth in the United States a racial issue, with disparity in access and choice about where to give birth, and a political issue, with significant disagreement and mistrust among experts around some of the outcomes reported in published research. The media is also impacted when a professional association takes a position based on a controversial study and, for example, the New York Times draws conclu- sions about causal relationships extrapolated from but not demonstrated (e.g., as happened when the New York Times reported on the Wax et al. [2010] association between low intervention and higher neonatal deaths). Feeding into the politics of home birth is state variation in CPM legislation. CPMs legally practice in 27 states. In almost all the other states, licensure legislation is being either introduced or planned or licensure or advocacy being organized. Women choose home births for a range of reasons (Blix, 2011; Boucher et al., 2009; Hendrix et al., 2010; Hildingsson et al., 2003, 2010; Jackson ­ et al., 2012; Lindgren and Erlandsson, 2010; Symon et al., 2010). The overriding theme, according to Potter, is safety, control, and comfort. She quoted some clients’ reasons for choosing home birth: “Comfortable s ­ etting—we can make decisions without pressure from staff.” “I want to feel safe and comfortable. I have confidence in myself to have a natural birth. I like the one-on-one attention I will receive using a midwife.” “I think that I will be able to relax in a home setting and not feel pressured by time constraints.” In Potter’s opinion, these sentiments are consistent with research results. Potter mentioned the Olsen and Clausen (2012) Cochrane review and the questions its conclusions raise about autonomy. Potter questioned how high does absolute risk need to be to limit women’s choices for birth setting? Currently, women’s choices are limited based on an assumption around relative risk. Potter remarked that once established that home birth is safe from an absolute risk perspective, the next question is: how can it be made safer? Potter identified several areas of research on home birth safety that will help to make home birth as safe as possible: access to qualified care providers with appropriate equipment, appropriate risk assessment, communication and collaboration, integrated transfer of data, quality improvement mea- sures, and access to licensure and reimbursement. With respect to research on risk assessment, Potter suggested that the question be reframed as “Is it safe?” rather than “How risky is it?” Ques- tions about risk assume that risk can be reduced to zero. Questions about safety are based on level of acceptable risk, which varies (e.g., acceptable risk for a patient may be different than acceptable risk for a provider). Potter also emphasized the importance of considering the risks associated with other locations when access to one location is limited because of risk.

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PERSPECTIVE FROM PROVIDERS 141 For example, with respect to women with limited access to hospital vaginal births after Cesarean deliveries, Potter said that she would “love, as a home birth provider, to not have those women coming to me, to ask me for that option, because they have nowhere else to go.” Potter emphasized the importance of mutual respect during transports. Her practice in Charlottesville, Virginia, does not have a collaborative rela- tionship with the University of Virginia, but they do share an accepted un- derstanding that women are going to choose home births. With transports, physicians greet women with an understanding that a hospital delivery was not the intention and an acknowledgment of the expertise of the midwives. Engaging midwives in the process improves quality of care and patient sat- isfaction. Also important during intrapartum transport is data integration (i.e., home birth, birth center, and hospital data) and the ability to access the right data in a timely manner. The ethics of maternity care, including issues around birth setting choice, shared decision making, and patient autonomy, are complex (Plante, 2009). Especially in light of the Affordable Care Act, preference-sensitive care and its application to maternity care will be a critical issue to address while moving forward. Potter urged more focus on race disparity and encouraged greater con- sideration of community-based health workers and their role in maternity care. For example, Kozhimannil et al. (2013) reported lower Cesarean delivery rates among doula-supported births, compared to national rates for Medicaid patients. She also urged more focus on rural care and im- proving the safety of maternity care for rural women (Grzybowski et al., 2007; Klein et al., 2009; Kornelsen and Grzybowski, 2005; Kornelsen et al., 2011). Potter concluded with a discussion of the concept of “home birth–like.” For her, home birth–like means woman-centered, family friendly (engaging whoever the woman identifies as family), and community based. It is a feel- ing that is hard to replicate. Putting gingham curtains on the wall does not necessarily make a room feel home-like. Additionally, the entire course of pregnancy needs to be engaged, with recognition that pregnancy and birth are unified and that making the birth setting home-like requires accom- modating social, emotional, physical, cultural, and spiritual needs. Most importantly, a home birth–like environment is resolute for undisturbed, physiologic birth. There is a range of factors that can disturb physiologic birth, all of which need to be addressed in order to make a hospital setting more home-like (ACNM et al., 2012). Potter encouraged more research on the impact of these disruptive factors on epigenetics and the mother-baby dyad. Potter closed with a photo that she feels has clinical significance. She shared the photo because she felt many hospital providers are unaware of

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142 RESEARCH ISSUES IN THE ASSESSMENT OF BIRTH SETTINGS what home births are like. The photo depicts a woman who just delivered a physiologic birth. She is upright, with no provider nearby, holding her baby. She spent the last 30 minutes of the second stage of labor in a position that she found most comfortable; she was on her knees, bent over a mattress, making sounds, moving her body. After she pushed the baby out, in about three good pushes, she picked the baby up and brought him to her chest. All Potter could do was step back and witness what was an undisturbed physiologic birth. DISCUSSION WITH THE AUDIENCE4 After Potter’s presentation, there was a brief discussion between the panelists and audience on the following topics: the risk of labor and the need for standardization in out-of-hospital settings; the need for hospitals to be more supportive of undisturbed physiologic childbirth; the need for a paradigm shift to evidence-based care; questions about data presented by Frank Chervenak; and ways to make home births safer. The Risk of Labor and the Need for Standardization in Out-of-Hospital Settings Even at the lowest possible level of risk, for example, some of the low- risk deliveries reported in the United Kingdom, labor is, Nigel Paneth said, “one of the most dangerous things that we encounter as human beings.” He called for recognition of this reality—there are risks with labor that need to be addressed. In his opinion, slightly higher levels of low Apgar scores or the occasional extra seizure in out-of-hospital births might be acceptable as a trade-off for benefits. At the same time, advocates of out-of-hospital births are obligated to define their “universe” and apply standards of quality improvement (e.g., accreditation) such that their universe becomes “normative” in society. Just as medicine controls itself through its policies and standards, the out-of-hospital delivery movement needs to control the quality of planned home deliveries, in his opinion. The Need for Hospitals to Be More Supportive of Undisturbed Physiologic Childbirth A member of the audience asked the panelists what can be done to help hospitals become more supportive of undisturbed physiologic childbirth. She speculated that the increase in home births and out-of-hospital births 4  his T section summarizes some discussion that took place at the end of Panel 7, immediately following Potter’s presentation.

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PERSPECTIVE FROM PROVIDERS 143 more generally is partly a backlash to what is happening in hospitals today. Specifically, she asked, what can be done to support in-hospital birth centers or measures that will increase opportunities for in-hospital normal physi- ologic births? Frank Chervenak agreed that much of the out-of-hospital delivery movement is the result of failure of the obstetric profession to provide compassionate care. He mentioned the in-hospital birthing center at Roosevelt Hospital in New York City as an example of a setting that serves as an opportunity for in-hospital physiologic births. Debra Bingham explained that the Roosevelt Hospital birthing center provides evidence- based care. She suggested a paradigm shift; that is, regardless of where a woman chooses to have a baby, the standard of care should be evidence- based care. Additionally, in her opinion, providers are not always aware of their biases, with politics often overlaying whatever system has been set up in a particular location. At the Roosevelt Hospital, midwives are recognized as equal partners in the system. Brynne Potter added that not only are women who have undisturbed physiologic births unencumbered, but so too are home birth providers. She suggested examining and trying to remove liabilities and other “en- cumbrances” that make it difficult for hospital physicians to provide home birth–like care. Questions About Data Presented by Frank Chervenak Marian MacDorman pointed out that the neonatal seizure variable that Chervenak presented encompasses more than neonatal seizures. It also includes other neurological disorders. “So it is more than just seizures,” she said. Moreover, it is one of the items on the U.S. birth certificate that is considered to be very poorly reported. With respect to the 5-minute Apgar scores reported by Chervenak, MacDorman wondered how well lower Apgar scores were reported, given the poor reporting of higher Apgar scores. MacDorman mentioned her own unpublished 2009 data, which linked birth and death certificate data on infant mortality by place of birth and provider. Cautioning that the data are not risk-adjusted and that they reflect absolute risks only, she reported a birthing center infant mortality rate of 2 per 1,000 and a midwife-delivered home birth infant mortality rate of 3 per 1,000. These numbers are “very low,” in MacDorman’s opinion. She suggested that the risks associated with home births may not be “as dire” as reflected in Chervenak’s presentation. Making Home Births Safer MacDorman asked the question, “Even if it is a little more risky for home births, what do you do about that?” Rather than preventing home

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144 RESEARCH ISSUES IN THE ASSESSMENT OF BIRTH SETTINGS births, why not make them safer? She suggested licensing midwives, stan- dardizing training, providing support, and integrating home health care into the health care system such that the same measures of quality are used in both home and hospital settings.