We thank Dr. Landers for taking the time to reflect on the national quality-of-care standards for home-based primary care. Fundamentally, Dr. Landers argues that our work should have paid more attention to creating indicators that are more holistic. It was precisely for this reason that our panelists spent many months reviewing and amending the ACOVE work. The changes and additions made to the ACOVE quality indicator set placed greater primacy on patient autonomy, added indicators for coordination of care, caregiver burden, and end-of life care and created new indicators for areas of care that reside in quality-of-life domains, such as insomnia and constipation.

The objections raised, however, do exemplify a belief pervasive in the field of home-based primary care—that traditional evidence-based paradigms cannot be applied to this unique patient care setting. We agree that the direct evidence collected on this patient cohort continues to be thin. We also agree that there are theoretical reasons to believe that current quality-of-care paradigms might not be appropriate to home-based primary care patients (1); however, supporting empirical evidence remains elusive. Given the lack of evidence and tools to evaluate this thesis, we hope that clinicians will welcome such work as the home-based primary care quality indicator set. This framework provides the tools to empirically verify the claim that "these guidelines could lead to lower-quality care as clinician attention is diverted from meeting patient and family goals to focus on irrelevant checklists."

Finally, the current health policy climate, with its emphasis on public reporting of health care quality (2) and on-the-horizon initiatives, such as pay-for-performance (3), necessitates that home-based primary care practitioners be prepared to be measured and evaluated on such categories as hypertension and diabetes management. We certainly agree that home-based primary care encompasses much more than can be captured in quality-of-care guidelines, but it would be folly to overlook the fact that in a few years' time, every primary care program, regardless of patient characteristics, may soon be held accountable to a similar core set of core processes.

As has been written by many before us (4), home-based primary care should be more central to internal medicine and family practice. The field, however, will continue to remain on the margins as no payer—government or private—will support the expansion of a model of care that cannot demonstrate the quality of its care.