Quality of Long-Term Care

There are two major categories of home care. Home health care is skilled care that is provided to individuals and families in their place of residence for the purpose of promoting, maintaining, or restoring health, or for maximizing the level of independence while minimizing the effects of disabilities and illness. This care is primarily funded through the Medicare program and to a lesser extent, by Medicaid. Home and community-based services (HCBS) include a range of services that help with the tasks of daily living, such as personal care, homemaking, cooking, and laundry. These services are typically provided under the Medicaid program through HCBS waivers or the personal care option, through the Older Americans Act. or through the Social Service Block Grant. All fifty states and the District of Columbia now provide HCBS waivers for long-term care services, including personal-care services, care management, adult day care, home-delivered meals, emergency response systems, transportation programs, respite programs, caregiver support programs, and home modification programs.

Quality home-care services involve the provision of appropriate and competent medical and personal-care services, incorporating those values of significance to consumers: independence, choice, control, dignity, and privacy. A 1997 GAO report found that very poor care was provided by a number of home health agencies. Several examples were cited showing quality problems in home care, including agency administrators with no health care experience and agencies serving ineligible patients and falsifying records and staff credentials. Moreover, the report stated that only 3 percent of all certified home health agencies have been cited by the Centers for Medicare and Medicaid Services (CMS, formerly HCFA) for being out of compliance with one or more conditions.

Regulation and research help guide the process of assuring the quality of home care. The research on home health care points to a mixed experience in developing good strategies for ensuring the quality of care. The majority of the research in home care has examined structural and process measures, rather than outcomes of care. Medicare-funded home health care generally appears to be of adequate quality in terms of the transactions between caregivers and consumers. However, the program has suffered from problems of overuse and inappropriate use, leading to new constraints on payments that may adversely affect the quality of services for those consumers with the most severe needs. Access to home and community-based services, especially personal attendant services for people with disabilities, is not uniformly available across states and the need for these services appears to be largely unmet. Research shows that access to services and choice of appropriate services are essential to the quality of home care.

More research is needed towards developing an appropriate array of community-based long-term care services to meet the needs of consumers and assess the quality of the services and outcomes. Furthermore, consumers should ultimately define quality of care. As Kane, Kane, and Ladd point out, "Only the person receiving the care and help can judge how it enhances or interferes with their happiness, productivity, and social lives" (p. 193). Home-care programs are beginning to develop approaches to assessing consumer satisfaction with services and outcomes of importance.

An additional mechanism for assuring quality in the nursing home and home care settings is through the nursing home ombudsman program. Funded through the Older Americans Act legislation, this program establishes an advocacy and complaint system in each state. Typically administered by the state unit and regional area agency on aging, the ombudsman function involves the investigation of complaints received by consumers, advocates, or employees surrounding the quality of care received. Complaints can be received via a 1-800 hot line or through the mail. Ombudsman can either report problems to the legal or inspection system or negotiate a resolution to the problem with the provider and consumer. Although originally designed for nursing homes, the ombudsman function has been expanded to other long-term care settings in recent years.

Assuring the quality of long-term care is a complex undertaking. For instance, although researchers have developed or identified a variety of approaches for determining the quality of home-care services, no method has yet been judged entirely adequate. Problems with the quality of care being provided across all types of long-term care settings remain, and better mechanisms are needed to adequately assess quality in these settings. More attention should be given to issues such as consumer choice, safety, and broadening consumer participation in decision making.

Traditionally, long-term care has focused heavily on structure and process strategies to ensure quality of care. Recent experiences indicate that consumers can provide important input into the quality assessment process. Efforts to educate consumers directly, inform them of their rights, and inform them of reasonable costs for services all are elements of a strategy to promote quality.