Perspectives on home care quality - Issues in Reforming Home Health Care

Health Care Financing Review, Fall, 1994 by Rosalie A. Kane, Robert L. Kane, Laurel H. Illston, Nancy N. Eustis

INTRODUCTION

Home care poses difficulties for QA because it encompasses a wide variety of procedures and services delivered to a diverse range of patients and clients by diverse health and social service agencies, independent vendors, and families. Before elaborating a technology of QA in home care in response to the call for accountability, it is necessary to consider, in a more general way, what health and social goals home care should be expected to meet, and what will count as success or failure.

The information reported here on key stakeholder perspectives on the quality of home care is the first part of an ongoing HCFA-funded series of linked studies that were designed to examine quality issues with attention to socially oriented and nonskilled home care as well as Medicare-certified home care (Kane et al., 1991). Other tasks include development of a system for reliable measurement of quality for nonskilled home care; examining the adequacy of home care in late stages of Medicare coverage; analyzing issues regarding recruitment, retention, and quality of a paraprofessional workforce for home care; and identifying and describing best practices in QA for home care. The last task is further subdivided into examining consumer-protection mechanisms, agency-initiated QA practices, external case management as a QA tool, and State regulatory approaches. As a result of all these studies, a research and demonstration agenda on QA in home care will be proposed. Early reports of these approaches are found in Yee and Capitman (1994); Kane (1994); Crown, McAdam, and Sadowsky (1991); and Sabatino (1992).

This article describes the challenges of defining and achieving an acceptable quality of in-home services for older people, including ways of classifying different types of home care, possible goals for home care, and ways that achievement of these goals might be or has been measured. It then identifies multiple perspectives on the quality of home care held by different stakeholders.

BACKGROUND

Home Care Defined

Home care, simply stated, is any kind of health care, personal care, or assistance with independent living given to functionally impaired, disabled, or ill persons in their own homes. Some expand this definition to include the assistance to family members who are caring for relatives in their homes and to care given to residents of other community home-like settings, such as assisted living (Russell, 1977). Home care may include modification of the home and provision of equipment so that a consumer may remain at home. Some argue that home care also includes a wider range of community services, such as delivered meals, adult day care, and transportation that may be organized for frail elderly persons living at home. Spokespersons for some younger disabled persons reject the term "home care" entirely, urging "personal assistance services" as the preferred term and concept. To them, "care" carries an affective rather than instrumental meaning, and "home" violates the principle that assistance should be extended to persons with functional disabilities regardless of whether they are at home, at their job, in school, or pursuing recreational or social activities outside their homes. Depending on the view of home care endorsed, the scope of QA activities may become very broad (Litvak, Zukas, and Heumann, 1987).

Home care falls in a gray zone of health and human services. It includes both acute-care services (some involving equipment and procedures that formerly were found only in hospitals [U.S. Congress, 1992!) and the more amorphous personal care services associated with long-term care. It is a social service that allows disabled persons to maintain more independent lifestyles or remain in the community. It draws upon the talents of a multidisciplinary range of professionals (for example, nurses, physical therapists, physicians, social workers), but it also is provided by paraprofessional home health aides, homemakers, attendants, personal assistants, and chore workers. It runs the gamut from a highly technical, health-related service that can be judged by explicit criteria, to a social service with broad, general, and sometimes individualized goals. Often, clients receive both extremes of services as part of their home care, either sequentially or simultaneously. The very alternation between the designation of "patient" and "client" reflects this dual sponsorship.

Home care is funded many ways--Medicare, Medicaid, title XX, title Ill of the Older Americans' Act, the Department of Veterans Affairs, and special State initiatives--as well as by direct consumer purchase of care. Again, clients may well receive services sequentially or simultaneously from more than one provider agency or independent vendor and under more than one payment source, all in addition to the services provided by family and friends.

Why Consider Home Care Quality Now?

Long-term care at home has been an ideal long advocated by older persons and their spokespersons, as well as by many professionals who serve the elderly. But home care is more than an ideal--it is also a rapidly expanding reality. The number of certified home health agencies (HHAs) has increased markedly over the past decade, increasing 43 percent from 1983 to 1989 and leveling off at 6,000 agencies in 1991 (Branch et al., 1993). The number of uncertified home care, homemaker, or personal care agencies also has increased markedly, although it is more difficult to enumerate the organizations, as Harrington and Grant (1990) attest from their work in California. Spending on the Medicare home health benefit increased from about $2 billion in 1988 to $10.5 billion in 1993, with a 96-percent increase in visits per beneficiary over the 3 years from 1989 to 1992 (Vladeck, 1994). Expenditures on home health as a total share of Medicare went from 2.4 percent in 1988 to 5.5 percent in 1992 (Arnold, Gage, and Harris, 1994). Given trends towards greater treatment of chronic disease in the home, interests in the integration of acute-care and long-term care, and interest in designing benefits that serve persons with disabilities with all ages (Vladeck, Miller, and Clauser, 1993), HCFA recently launched the Medicare Home Health Initiative (1994) to examine the extent to which this ever more costly benefit is designed to meet the needs of beneficiaries. Views are being sought on the extent to which the Medicare home health benefit meets goals of responsiveness to consumers, flexibility, and fiscal responsibility (Vladeck, 1994).