Long-Term Care: Status of Quality Assurance and Measurement in Home and
Community-Based Services (Letter Report, 03/31/94, GAO/PEMD-94-19).

This report examines how quality is ensured and measured in home and
community-based long-term care services for elderly persons with
disabilities.  These services range from skilled nursing services to
help with activities such as bathing, dressing, shopping, and meal
preparation.  GAO answers the following questions: How is "quality"
defined for home and community-based long-term care services?  What
measures are now being used to monitor or ensure quality?

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  PEMD-94-19
     TITLE:  Long-Term Care: Status of Quality Assurance and Measurement 
             in Home and Community-Based Services
      DATE:  03/31/94
   SUBJECT:  Elder care
             State-administered programs
             Federal/state relations
             Licenses
             Home health care services
             Health care planning
             Quality assurance
             Quality control
             Monitoring
             Elderly persons
IDENTIFIER:  Medicaid Program
             Medicare Program
             Connecticut
             Connecticut Home Care Program for Elders
             New York
             New York Extended In-Home Services for the Elderly Program
             Wisconsin
             Wisconsin Community Options Program
             New York Quality Assurance Project
             Medicaid Home and Community-Based Waiver Program
             Medicare Home and Community-Based Care for the Functionally 
             Disabled Elderly Program
             
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Cover
================================================================ COVER


Report to the Chairman, Committee on Finance, U.S.  Senate

March 1994

LONG-TERM CARE - STATUS OF QUALITY
ASSURANCE AND MEASUREMENT IN HOME
AND COMMUNITY-BASED SERVICES

GAO/PEMD-94-19

Long-Term Care


Abbreviations
=============================================================== ABBREV

  ADL - Activities of daily living
  CHCPE - Connecticut Home Care Program for Elders
  HCFA - Health Care Financing Administration
  IADL - Instrumental activity of daily living
  NASUA - National Association of State Units on Aging
  WID - World Institute on Disability

Letter
=============================================================== LETTER


B-256835

March 31, 1994

The Honorable Daniel Patrick Moynihan
Chairman, Committee on Finance
United States Senate

Dear Mr.  Chairman: 

At your request, we are examining aspects of how quality is assured
and measured in home and community-based long-term care services for
persons with disabilities.  Although we will provide further
information at a later date, as we arranged with your staff, we
present in this report interim findings for such services available
to disabled persons who are elderly.  These findings address two of
the questions you posed: 

1.  How is "quality" defined for home and community-based long-term
care services? 

2.  What measures are currently used to monitor or assure quality? 

By "home and community-based long-term care services," we mean
health, personal care, and social services provided over a sustained
period to persons who live outside of congregate residential settings
and who have lost some capacity for self-care because of a chronic
condition or illness.  These services include a broad range of
supports, from skilled nursing services to assistance with basic
activities of daily living (ADLs) (such as bathing, toileting, and
dressing) and help with instrumental activities (such as shopping,
meal preparation, housekeeping, and laundry).  The services may be
provided singly, by one or more providers, or in combination, as when
a home health aide provides incidental assistance with ADLs. 

Since the elderly persons to whom these services are targeted receive
them in varied combinations, we have inquired about methods for
assuring or measuring the quality of the package of home and
community-based long-term care services or the plan of care provided
to a particular client.  However, we have also identified methods
used to assure and measure the quality of one specific type of
service--personal care, which generally involves the provision of
assistance with basic ADLs in the client's home and is among the most
frequently used services in community-based care. 

Briefly, our findings indicate the following: 

  The complex financing structure that supports home and
     community-based long-term care services has resulted in the
     application of different quality assurance requirements to
     similar services, based on the source of their payment. 

  Goals for home and community-based long-term care are articulated
     differently by administrators, service providers, and customers,
     with some potential for conflict.  This raises the issue of how
     these goals can be harmonized and what the locus of that
     function should be.  Even case managers may not be ideal for
     this purpose, because their gatekeeping responsibilities involve
     them in very close relationships with administrators and
     providers. 

  Goals for personal care services are less formally developed than
     goals for the network of home and community-based services
     provided under Medicaid waivers. 

  Current quality assurance strategies cannot be judged sufficient to
     assure the delivery of high-quality services, in part because
     the undeveloped state of program and outcome measurement
     prohibits establishing the extent of relationship, if any,
     between these strategies or requirements and the quality of
     services rendered.  (See page 24.)


   METHODOLOGY
------------------------------------------------------------ Letter :1

To develop the information in this report, we performed four types of
activities more or less simultaneously: 

1.  We reviewed the research literature, program documentation,
regulations, and findings of recent state surveys conducted by the
Administration on Aging, the National Association for Home Care, the
National Association of State Units on Aging, and the World Institute
on Disabilities. 

2.  We interviewed experts, federal officials, and organizations
representing providers of home and community-based long-term care. 

3.  We convened a focus group on the topic at the 1993 annual meeting
of the Gerontological Society of America. 

4.  We conducted site visits to interview officials associated with
Medicaid and other programs providing home or community-based
services in Connecticut, New York, and Wisconsin. 

The states we visited were identified to us as ones with progressive
programs of quality measurement or integrated administrative
structures that could facilitate such measurement.\1

We conducted our work between November 13, 1993, and March 14, 1994,
in accordance with generally accepted government auditing standards. 


--------------------
\1 Accounts of Medicaid spending for home health care, personal care,
and services provided under home and community-based waivers for the
aged indicate that these three states collectively accounted for over
70 percent of fiscal year 1991 Medicaid expenditures for the home and
community-based long-term care of aged persons. 


   BACKGROUND
------------------------------------------------------------ Letter :2

The projected growth in the need for long-term care services, along
with a preference among elderly persons for services that allow them
to remain at home and in their community, have led to the expansion
of noninstitutional long- term care services and have contributed to
an increase in public expenditures on home health care.  (Table 1
shows historical data on Medicare and Medicaid payment.) This rising
expenditure, combined with the vulnerability of the target population
and the increasing demand for services, augments the public interest
in assuring service quality. 



                                     Table 1
                     
                      Medicare and Medicaid Payment for Home
                      Health and Nursing Facility Services\a



Fiscal
year       Amount  Percent   Amount  Percent   Amount  Percent   Amount  Percent
--------  -------  -------  -------  -------  -------  -------  -------  -------
1980         $0.7     2.0%     $0.3     1.0%     $0.3     1.4%    $ 7.9    33.8%
1985          1.8      2.8      0.5      0.8      1.1      3.0     11.6     30.9
1988          1.9      2.4      1.0      1.2      2.0      4.1     14.3     29.3
1989          2.4      2.6      2.8      3.3      2.6      4.7     15.5     28.5
1990          3.7      3.7      1.8      1.8      3.4      5.2     17.7     27.3
1991          5.3      4.5      2.2      1.9      4.1      5.3     20.7     26.9
--------------------------------------------------------------------------------
Source:  U.S.  Department of Health and Human Services, Health Care
Financing Review--1992 Annual Supplement (Baltimore, Md.:  1993);
U.S.  Bureau of the Census, Statistical Abstract of the United States
(Washington, D.C.:  varied years). 

\a All amounts are expressed in billions.  Percentages indicate the
proportion of all annual Medicare or Medicaid expenditures
represented by the figure in the corresponding amount column. 

\b Services provided at patient's place of residence in compliance
with a physician's written plan and include nursing services, home
health aide services, medical supplies, equipment, and appliances
suitable for use in the home; physical, occupational, and speech
therapy; personal care services; and services provided under a home
and community-based waiver. 

\c Nursing facility payments cover both skilled nursing facility
services and intermediate care facility services for all other than
the mentally retarded. 


      CURRENT ORGANIZATION OF
      SERVICES
---------------------------------------------------------- Letter :2.1

At present, public programs that finance home and community-based
long-term care services include Medicaid, Medicare, Older Americans
Act initiatives, social services block grants, and initiatives run
with general state revenues.  Some of these programs require or
encourage recipients to pay a share of the costs. 

Home and community-based services are provided through a variety of
avenues under Medicaid, which covers physician-ordered home health
services and may, at a state's option, provide an entitlement to
personal care services prescribed by a physician or authorized under
an approved state plan.  In addition, programs run under Medicaid
waivers pay for a variety of primarily nonmedical support services. 
However, states may limit eligibility for waiver services to
functionally disabled aged or handicapped individuals who are
qualified for nursing home placement based on both financial and
functional criteria or to elderly persons in certain geographic areas
for whom such services can be provided without budgetary impact. 
State revenues are commonly used to extend this coverage for home and
community-based long-term care to individuals who meet the functional
but not the financial criteria established for participants in the
Medicaid waiver programs.  Medicare, in contrast, finances home-based
services that are focused on skilled nursing and therapy rather than
nonmedical support services and that appear to be less likely to be
used as a form of long-term support.\2


--------------------
\2 Both aged and disabled Medicare beneficiaries may receive home
health care, including incidental personal care, with no copayment
required as long as they are homebound and have a simultaneous need
for "intermittent" nursing or skilled therapy.  Need for skilled
care, not prior hospitalization, is a prerequisite for these
benefits, which afford up to 35 hours per week of combined skilled
nursing and home health aide services in addition to skilled therapy
services for an indefinite period where indicated.

There is some evidence that, at least in the recent past, Medicare
home health benefits have not generally been used for long-term care
purposes.  However, we were told that the Health Care Financing
Administration (HCFA) does not routinely report on this issue.  A
recently published special study conducted under contract to HCFA
collected data on this issue from a self-selected group of agencies. 
The authors approached 235 home health agencies that had earlier
indicated willingness to participate in a demonstration project and
succeeded in collecting data from 37 percent on the length of home
health episodes financed by Medicare for clients who began service in
1986.  The study matched these clients with Medicare home health
claims received through September 1987.  Thus, ignoring delays in
claims processing, even a client who began an episode on December 31,
1986, could be associated with up to 9 months of subsequent care. 
Extrapolating from the sample, the authors estimated that only 17.2
percent of cases beginning episodes in 1986 received continuous care
for 90 days or more and only 5.5 percent received care for at least
180 days.  (L.  G.  Branch et al., "Medicare Home Health:  A
Description of Total Episodes of Care," Health Care Financing Review,
14:4 (1993), 59-74.)


      PROPOSED EXPANSION
---------------------------------------------------------- Letter :2.2

In contrast to the existing programs, the administration's health
care reform proposal expands home and community-based long-term care
services for persons with functional disabilities by introducing a
program for home and community-based long-term care that places few
limits on the eligible population or states' service selection,
although functional eligibility requirements may be more restrictive
for new beneficiaries than under some current programs.  The proposal
also includes some explicit provisions regarding quality. 
Specifically, each state must specify how it will assure and monitor
the quality of services, including

1.  safeguarding the health and safety of individuals with
disabilities;

2.  establishing minimum standards for agency providers and how such
standards will be enforced;

3.  setting minimum competency requirements for agency provider
employees who provide direct service and describing how these will be
enforced;

4.  obtaining meaningful consumer input, including consumer surveys
that measure the extent to which participants receive the services
described in the plan of care and participant satisfaction with such
services;

5.  participating in quality assurance activities; and

6.  specifying the role of the long-term care Ombudsman and the
Protection and Advocacy Agency (under the Developmental Disabilities
Assistance and Bill of Rights Act) in assuring quality of services
and protecting the rights of individuals with disabilities. 

The states are also directed to provide safeguards against physical,
emotional, or financial abuse or exploitation.  Many of these tactics
are controversial among state administrators and experts, who have
widely divided views on the utility of survey measures of client
satisfaction, the practicality of ombudsman involvement, and the
unintended consequences of minimum standards for agency providers. 

Meaningful performance review for these services, of course, would
require clearly articulated service goals.  Under the proposed plan,
personal assistance is the only service that must be covered, but
matching funds would be available for others.  (See table 2.)



                           Table 2
           
            Services Eligible for Federal Matching
                  Funds Under S. 1757 (1993)

                  Service
----------------  ------------------------------------------
Mandatory state   Consumer-directed personal assistance
plan components   Agency-directed personal assistance

Optional state    Case management
plan components   Homemaker and chore assistance
                  Respite services
                  Adult day services
                  Habilitation and rehabilitation
                  Supported employment
                  Home health services
                  Assistive devices
                  Home modification
                  Any other care or assistive services
                  (approved by the secretary of the
                  Department of Health and Human Services)
                  that the state determines will help
                  individuals with disabilities to remain in
                  their homes and communities
------------------------------------------------------------

      NATURE OF SERVICES
---------------------------------------------------------- Letter :2.3

As indicated in table 2, many different services are provided under
the rubric of home and community-based long-term care.  This variety
has resulted in some debate regarding the application of medical
standards to home care, particularly for persons who need primarily
unskilled services to compensate for functional deficits not likely
to respond to medical treatment.  While some disabled elderly persons
living in the community have chronic illnesses for which medical
intervention can be beneficial, if only to prevent complications,
others have functional deficits resulting from conditions not likely
to improve.  Nonetheless, even the latter group may require help or
instruction on such tasks as meal preparation, housekeeping, and
shopping. 


      DEMAND
---------------------------------------------------------- Letter :2.4

The demand for such services is not limited to persons who live in
nursing homes or would seriously consider doing so; more people in
need of long-term support live outside nursing homes than in them. 
For every person age 65 or older residing in a nursing home, there
are nearly two living in the community who require some form of
long-term support.  According to a Brookings Institution report,
approximately 4.9 million elderly persons were residing in the
community in 1985 (18 percent of the population over age 65) who had
ADL limitations.  About two thirds of these elderly persons had only
moderate impairments--that is, fewer than three ADL limitations. 
However, some 850,000 elderly persons were severely impaired (which
is defined as having a limitation in five or six ADLs).\3

The increase in the use of home health services has been driven at
least partly by increasing acceptance that most elderly consumers
prefer to receive long-term care at home.  However, as access to such
services has been expanded both in order to satisfy consumer
preferences and in the hope of reducing public costs for long-term
and hospital care, questions have arisen regarding how the states are
assuring and measuring the quality of these services. 


--------------------
\3 A.  M.  Rivlin and J.  M.  Wiener, Caring for the Disabled
Elderly:  Who Will Pay?  (Washington, D.C.:  The Brookings
Institution, 1988), p.  6. 


      QUALITY
---------------------------------------------------------- Letter :2.5

Quality, access, and cost have traditionally made up the three
pillars of health care policy.  This is so because attempts to
improve a program's performance on one dimension, such as cost, may
affect its performance on others, such as accessibility or quality. 
Thus, information on service quality should be interpreted in
combination with data on access and cost, and optimal policy choices
depend on monitoring all three aspects of service delivery.  We use
the term quality to refer to "the extent to which service increases
the probability of desired outcomes and reduces the probability of
undesired outcomes given the constraints of existing knowledge."\4
Table 3 illustrates various indicators that can be used to define,
assure, and measure quality across the various stages and components
of care. 



                                     Table 3
                     
                      Illustrative Framework of a System to
                         Improve the Quality of Home and
                          Community-Based Long-Term Care

Activity            Key questions                  Possible goals or measures
------------------  -----------------------------  -----------------------------
Define quality      What goals and outcomes can    Maintain functional capacity
                    be identified?                 Optimize autonomy and
                    Who should be involved in      mobility
                    identifying goals and          Ensure safety
                    outcomes?                      Optimize health
                    To what extent do these goals  Prevent inappropriate
                    and outcomes                   institutional placement
                    apply across disability        Satisfy clients
                    categories, functional needs,  Improve quality of life
                    and diagnostic groups?         Reduce informal caregiver
                    How are goals and outcomes     burden
                    articulated to stakeholders?   Reduce public costs

Identify            Based on the goals and         Structural indicators
indicators of       outcomes identified,           Caseload per worker per day
quality             what indicators of program     Staff certification level
                    implementation or performance  Staff knowledge
                    can be identified and what     Staff turnover at consumer
                    additional information is      level
                    needed to properly interpret
                    these?

                                                   Process indicators
                                                   Frequency of supervision
                                                   Compliance with medication
                                                   orders
                                                   Time between service request
                                                   and provision
                                                   Appropriateness of care plan
                                                   Prescription of inappropriate
                                                   medications
                                                   Availability and frequency
                                                   of informal care

                                                   Outcome indicators
                                                   Functioning
                                                   Change in ADL and IADL
                                                   status
                                                   Ability to toilet as
                                                   needed

                                                   Safety
                                                   Falls
                                                   Burns
                                                   Financial exploitation

                                                   Health
                                                   Appearance of decubitus
                                                   ulcers
                                                   Infections
                                                   Adverse drug reactions
                                                   Symptom distress
                                                   Weight gain or loss

                                                   Client satisfaction
                                                   Client perception of unmet
                                                   need
                                                   Perceived quality of meals
                                                   Freedom from fear
                                                   Comfort
                                                   Sense of control
                                                   Freedom from unwanted
                                                   disruption
                                                   Preference for current living
                                                   arrangement
                                                   Duration of preferred living
                                                   arrangement

Establish review    What processes are used for    Presence of a quality
of system and       periodic or on-going review    assurance and improvement
implement feedback  of quality indicators?         plan
                    How are review findings used   Checks on implementation of
                    to correct or prevent          plan
                    problems?                      Evidence of enhanced
                                                   achievement of desired goals
                                                   and outcomes
--------------------------------------------------------------------------------

--------------------
\4 Office of Technology Assessment, Confused Minds, Burdened
Families:  Finding Help for People with Alzheimer's and Other
Dementias (Washington, D.C.:  1990), p.  159.  See also Office of
Technology Assessment, The Quality of Medical Care:  Information for
Consumers (Washington, D.C.:  1988).  Although "quality" is sometimes
defined as the difference between "efficacy," the level of effect
that could be achieved under ideal conditions, and "effectiveness,"
the level of effect that is currently achieved, this definition makes
the a priori assumption that effectiveness can easily be measured. 


   PRINCIPAL FINDINGS
------------------------------------------------------------ Letter :3

To preface our discussion of our findings regarding current quality
assurance and measurement efforts, it is important to note that
states are facing challenges in extending access to home and
community-based services to all those in need, with sizable waiting
lists reported by the state officials with whom we spoke.  Partly as
a result, in the three states we visited, work on the measurement of
quality is in early stages of development.  However, this is not an
indication of the relative importance of efforts to measure the
quality of home and community-based long-term care.  In fact, the
measurement of quality provides the data necessary to address
questions about performance, efficiency, and appropriateness, which
ultimately hold implications for both access and cost. 

Since quality is perhaps the most difficult aspect of service
delivery to measure, you asked that we describe how quality has been
defined, assured, and measured for home and community-based long-term
care services as well as the methodological challenges that the
states are encountering in their attempts to do so. 

We begin by discussing the definition of quality from the viewpoints
of service administrators, service providers, and service consumers. 
We follow this with a description of current quality assurance
requirements under Medicare and Medicaid programs providing home and
community-based long-term care services and a brief description of
methods the states are using to measure the quality of home and
community-based long-term care services. 


   HOW QUALITY IS DEFINED
------------------------------------------------------------ Letter :4

As noted earlier, we use the Office of Technology Assessment's
definition of quality as the extent to which service reduces the
probability of poor outcomes and increases the probability of good
outcomes within the constraints of existing knowledge.  Thus,
defining quality for a particular service or program requires
identifying goals and operationalizing these in the form of outcomes. 
Moreover, a coherent program of quality assurance and measurement
requires that program goals be articulated well enough to identify
the types of performance or outcomes to be assured, measured, or
prevented. 


      THE GOALS THAT ARE
      IDENTIFIED
---------------------------------------------------------- Letter :4.1

From our discussions with experts and program officials and our
review of pertinent literature, we found that the goals of home and
community-based care for the elderly, and therefore the appropriate
grounds for assessing its quality, are poorly articulated, especially
at the individual service level.  Such goals are, in any case, the
subject of some disagreement. 

We found that no single set of desired goals and outcomes of home and
community-based long-term care has been accepted by the network of
organizations representing and serving the aged population.  For
example, one study asked that persons representing several
perspectives rate the relative importance of 21 outcomes of care for
which home care providers might be held accountable.\5 The authors
reported substantial agreement on the relative importance of such
outcomes as "freedom from exploitation and abuse" and "maintenance or
improvement of physical functioning," but even for a particular
patient type, substantially less agreement was observed on the
relative importance of goals such as client knowledge, regimen
compliance, and hospitalization.\6 Below, we briefly discuss the
goals expressed by administrators, providers, and consumers, as they
were identified in documents or interviews. 


--------------------
\5 The "outcomes" studied included freedom from abuse; satisfaction
with care; client choice and knowledge; affordability; satisfaction
with life; physical, cognitive, physiological, and psychological
functioning; family knowledge and stress; symptom control; nursing
home admission; social activity; morbidity; hospitalization;
compliance with exercise, drug, or dietary regimen; physical safety;
and death. 

\6 R.  A.  Kane et al., Quality of Home Care:  Concept and
Measurement (Minneapolis, Minn.:  University of Minnesota, School of
Public Health, Division of Health Services Research and Policy,
1991). 


      HOW GOALS ARE DEFINED BY
      STATE PROGRAM ADMINISTRATORS
---------------------------------------------------------- Letter :4.2


         GOALS FOR THE PERSONAL
         CARE OPTION
-------------------------------------------------------- Letter :4.2.1

We visited two states (Wisconsin and New York) offering the personal
care option under the Medicaid state plan.  In neither did officials
readily articulate goals for such services.  Similarly, the World
Institute of Disability (WID) surveyed states in 1990 regarding the
goals established for services under the Medicaid personal care
option.  The authors described the responses as "not illuminating."
In their 1990 site visits to six states offering the personal care
option, WID staff found that program goals varied among states but
that, in almost all cases, state officials made some reference to
prevention of institutional placement.\7 Other goals cited by at
least one state included encouraging self-determination, authorizing
services "only to the extent necessitated by the individual's
functional limitations," maintaining informal supports, and
supporting informal caregivers.\8


--------------------
\7 S.  Litvak and J.  Kennedy, Policy Issues Affecting the Medicaid
Personal Care Services Optional Benefit (Oakland, Calif.:  World
Institute on Disability, 1991).  WID reports that Oregon officials
saw the personal care option as incompatible with the goal of
reducing the nursing home population, because eligibility for the
personal care option under Oregon's Medicaid program entails meeting
an income eligibility limit far lower than that required for Medicaid
nursing home eligibility.  Thus, Oregon indicated it relies on
Medicaid waivers for services that other states have provided under
the personal care option and instead uses this option to serve
disabled children. 

\8 WID specifically noted that no personal care option program
surveyed at the time had the goal of enabling participants to work,
although it was conceivable, with recent changes in Medicaid
eligibility laws, that personal care option recipients could sustain
gainful employment without losing their Medicaid eligibility. 


         GOALS FOR OTHER SERVICES
-------------------------------------------------------- Letter :4.2.2

The goals cited by state officials for their waiver programs
mentioned reducing inappropriate institutionalization, controlling
expenditures, and providing consumers with a choice of living
arrangements, control, enhanced dignity, and improved quality of
life.  Notably, all three of the states we visited had attempted to
involve clients in a discussion of goals and service characteristics
that would contribute to quality, indicating endorsement of client
satisfaction as a program goal.  We briefly review below the goals
specifically cited for various home and community-based long-term
care programs by administrators in the three states. 

Connecticut.  During our interviews, Connecticut officials indicated
that no goals had been developed for particular services, although
the state's home and community-based long-term care programs had the
collective goal of keeping people at home in a cost-effective manner. 
The annual report to the state legislature on the Connecticut Home
Care Program for Elders (CHCPE) notes that "The program helps
families who are caring for older relatives at home and enables older
persons themselves to maintain dignity, control, and an improved
quality of life in their later years."\9 The goals of the newly
consolidated CHCPE were "(1) to create a 'seamless' program in which
individuals could receive appropriate services according to their
needs, without having to negotiate the complexities of various
programs and funding restrictions; [and] (2) to control program
growth and expenditures." The goals that state documents indicate
have guided decisions about home care in the past and continue to be
important include the following: 

  "to establish a continuum of care through which individuals can
     easily progress as their needs and circumstances change;

  "to develop a balanced long-term care system with a full range of
     community-based and institutional services;

  "to avoid inequities between state-operated home care programs
     except where federally imposed restrictions are inconsistent
     with state policies;

  "to eliminate duplication and overlap of services; and

  "to allow the freedom of choice, to the extent that resources
     allow, to assure that individuals will not be forced into
     institutions due to the lack of home care alternatives."

New York.  In presenting work on the quality assurance project for
New York's Extended In-Home Services for the Elderly Program, the
State Office for the Aging noted that outcomes for the program would
include things like "judgement by the case manager that the customer
can be maintained safely at home with the service plan, and that the
services ordered are delivered as specified." Neither of these
examples, however, goes beyond implementation goals or expectations. 
Outcome indicators of this nature would not assess whether, for
example, the services accomplished anything for the service
recipients, nor establish the level of safety and security that
service recipients actually experienced while staying at home. 
Tellingly, a 1993 report of New York State's Task Force on Long-Term
Care notes that

     "There is no comprehensive mission and policy direction for
     long-term care for aged and disabled individuals in New York;
     instead, divergent funding streams out of individual service
     systems have driven the design and supply of long-term care
     services."\10

Wisconsin.  In this state, officials readily articulated goals for
Medicaid waiver and state programs providing home and community-based
long-term care services.  However, at least one official did not view
service-based goals as appropriate and noted that there was no
all-inclusive list of services allowable under the state's Community
Options Program.  They indicated that the goals of their home and
community-based program for the elderly were to provide services at
the location of the customer's choice, to involve customers in all
service decisions, and to allow people to live with as much
independence and dignity as possible.  Promotion of client control
and respect were mentioned as values guiding their efforts. 


--------------------
\9 Office of the Commissioner, State of Connecticut Department of
Income Maintenance, Home Care for a New Era:  Annual Report on the
Connecticut Home Care Program for Elders to the Human Services
Committee and the Appropriations Committee of the General Assembly
(Hartford, Conn.:  1993), p.  iv. 

\10 Task Force on Long Term Care, Reforming Local Access and State
Structure for Long-Term Care in New York (Albany, N.Y.:  1993), p. 
3. 


      HOW PROVIDERS DEFINE GOALS
---------------------------------------------------------- Letter :4.3

From our review of the literature and discussions with some provider
organizations, we found that while service providers have begun to
identify outcome indicators for home health clients, for clients
requiring only assistance with personal care or instrumental ADLs,
service goals are relatively ill defined and discussion focuses
primarily on the process of service delivery.  For example, providers
interviewed by the United Seniors Health Cooperative identified the
following factors for emphasis in measuring the quality of home care: 

  coordination of care;

  appropriateness of the procedure, plan of care, or treatment;

  appropriateness of setting;

  credentials of providers (that is, Do they have the right training
     and experience to perform the assigned tasks?); and

  skill in performance of treatment or procedure. 

In contrast, for patients requiring home medical services, relatively
elaborate matrixes of health care outcomes have begun to be
identified, although these may not be fully reflected in day-to-day
operations. 


      HOW CONSUMERS DEFINE GOALS
---------------------------------------------------------- Letter :4.4

We reviewed a variety of studies in which groups of consumers of home
and community-based care were asked about their criteria for quality
service.  It is important to note that most work with consumers has
focused on the characteristics they associate with good or bad
services rather than their views of the goals of home and
community-based care.  Most of the studies involve small groups of
home care consumers and are generally limited to consumers who can
respond to interview questions.  In addition, they address attitudes
of consumers in a limited geographic area.  In studies of quality in
personal care services, consumers cited factors such as

  workers' arrival on scheduled days,

  workers' arrival at the scheduled time,

  working for the scheduled amount of time,

  completion of work,

  service consistency,

  neat and clean appearance,

  care for and protection of the customer's safety (for example,
     assistance with seatbelts during transportation),

  careful treatment of the customer's property,

  honesty and trustworthiness in dealings with the customer (for
     example, in completing grocery purchases for the customer),

  courtesy and respect in interactions with the customer,

  responsiveness to the customer's preferences, and

  empathetic and cheerful demeanor. 

The United Seniors Health Cooperative has advanced the promotion of
three major goals for home care identified through focus groups with
consumers:  (1) independence, or supporting resumption of ordinary
activities and enhanced control; (2) health preservation and
improvement; and (3) happiness, or maintaining social engagement and
promoting mental health. 

To summarize, differences in the definition of goals by these three
important stakeholders in home and community-based services may have
implications for how quality is assured and measured.  Program
administrators' goals in many cases are not even formally
articulated, much less generally endorsed.  Providers' goals are
developing, but the differences between the development of medical
and personal care outcomes are clear.  Among consumers, there appears
to be some consensus around goals, but they may be far from the goals
of the two other groups with some apparent potential for conflict. 
However, one important characteristic of the consumer goals noted
here is that the majority imply attitudinal changes on the part of
service providers rather than service improvements that would
necessarily involve additional financial resources to be supplied by
administrators or providers. 


   HOW QUALITY IS ASSURED IN
   VARIOUS SERVICE DELIVERY
   SYSTEMS
------------------------------------------------------------ Letter :5

The terms "quality assurance" and "quality measurement" are used in a
variety of ways.  As noted, we have used "quality assurance" to
describe prospective processes or requirements--such as licensure,
inspections, or training--generally intended to promote a certain
level of performance on criteria that might be the subject of a
quality measurement program (that is, indicators of the achievement
of program goals or the capacity to achieve such goals). 

State and federal agencies have implemented a variety of quality
assurance strategies.  However, the presence of such quality
assurance requirements is not sufficient to assure a level of
quality.  For example, the Quality Assurance Project conducted under
New York State's In-Home Services for the Elderly Program found that,
although the general quality of communication between case managers
and elderly customers was good, interviews of clients by project
staff often revealed problems and incidents that were previously
unknown even to case managers.  It is important to note that this
occurred despite the presence of standards requiring case managers to
inform clients to contact them in case of difficulties; the problems
in question were only discovered in an independent attempt to measure
program quality. 

It is also important to note that the complexity of the system
through which services are organized and delivered complicates the
states' efforts to assure and measure the quality of home and
community-based long-term care.  Consistent with the structure of
federal financial support for these services, the delivery of home
and community-based long-term care services is still frequently
accomplished through a difficult organizational structure with no
single point of entry, although we found evidence of intentions to
enhance administrative coordination.\11

This lack of integration is noteworthy not only because it may cause
confusion for elderly persons trying to gain access to services, and
may lead to inequities and administrative duplication in the
allocation of long-term care resources, but also because it results
in the application of different quality assurance requirements to
similar services. 

Agencies providing service financed by the Medicare program must meet
Medicare's conditions of participation for home health agencies,
which incorporate a variety of measures "considered necessary to
assure patients' health and safety."\12 These include requirements
addressing patients' rights; compliance with federal, state, and
local laws; mandated organizational and administrative structures;
standards of training and qualifications for personnel; and
establishment of a professional advisory group.  Agencies and
individuals providing service financed under Medicaid must also meet
training and qualification requirements, although they differ by
specific type of benefit.\13 Appendix I identifies the variety of
quality assurance requirements that the states must impose on
personal care when it is financed through various Medicaid benefits
and programs.  State-funded programs and services financed by the
Older Americans Act and title XX may invoke yet another set of
requirements, although these may be more or less inclusive than the
applicable federal requirements.  Specific quality assurance
strategies associated with the Medicare and Medicaid waiver programs
are summarized below. 


--------------------
\11 According to an Administration on Aging survey of
state-administered home and community-based services for functionally
impaired elderly persons, as of fiscal year 1992, only 16 states had
established a single point of entry to such services (integrating at
least waiver and state-funded services) and only 13 had implemented
this policy statewide.  The 16 states reporting a single point of
entry were Colorado, Connecticut, Delaware, Illinois, Indiana, Iowa,
Louisiana, Maryland, Massachusetts, Ohio, Oregon, Nevada, North
Dakota, South Dakota, Virginia, and Wisconsin. 

\12 42 C.F.R.  484.1. 

\13 For example, for home health services, agency providers of home
health aide services must meet the same requirements (including 75
hours of training) that they would under Medicare, while individual
providers must meet the requirements for nursing as defined in the
state's nurse practice act.  For services under the personal care
option, qualification and training standards are also invoked,
although they are far less specific.  Standards vary considerably
regarding employment of relatives, nurse or physician supervision,
and planning and supervision of services.  This variation is
confusing insofar as one could receive personal care services, in
some circumstances, under each of these options. 


      MEDICARE
---------------------------------------------------------- Letter :5.1

Medicare has developed several conditions of participation for home
health agencies that are designed to assure the health and safety of
patients.  These requirements apply not only to home health services
covered by Medicare but also to home health benefits under Medicaid
when these services are provided by agencies or organizations.  (See
appendix I.)


      MEDICAID WAIVER PROGRAMS
---------------------------------------------------------- Letter :5.2

In order to receive approval for a Medicaid home and community-based
service waiver, the states must assure that necessary safeguards have
been taken to protect the health and welfare of individuals who are
provided services under the waiver.  However, the statute does not
prescribe the mechanisms that the states must use to do so.  In order
to assist the states in learning about approaches other states had
taken to assure quality under their waivers, in November 1993 HCFA's
Medicaid Bureau summarized the approaches to quality taken by 13
states operating Medicaid home and community-based waiver programs
for aged and disabled persons.  The 13 states were selected for the
sufficiency and variety of material available to the Medicaid Bureau
(for example, waiver applications, annual reports, independent
assessments, regional office reviews) describing the mechanisms the
states had employed to assure the health and welfare of waiver
recipients.\14 Thus, these 13 states may have more-developed quality
assurance strategies than states not selected.  HCFA's review
identified three major approaches to quality assurance--use of case
management, training, and client involvement--and also addressed
quality measurement under the rubric of "program monitoring."


--------------------
\14 The states were California, Colorado, Georgia, Illinois, Maine,
Minnesota, New Jersey, Ohio, Oregon, Tennessee, Virginia, Washington,
and Wisconsin. 


         CASE MANAGEMENT AS
         QUALITY ASSURANCE
-------------------------------------------------------- Letter :5.2.1

A case manager typically develops a plan of care for a waiver client
and is required to maintain contact with the client at a fixed
frequency that varies among the states, as do caseload limits and
average caseloads.  All the state programs that were reviewed by the
National Association of State Units on Aging (NASUA) require that a
case manager conduct at least some in-home visits.  NASUA reports
that, in 75 percent of these programs, case managers are required to
contact clients, at least by phone, within 3-month intervals.  Most
of the remaining states require such contact at 6-month intervals. 
No rationale is apparent for the particular frequencies states have
selected, and the effect of differences in frequency of contact has
not been reported in the literature we reviewed. 

In addition to caseloads and rates of client contact, conflicts of
interest may affect case managers' capacity to receive or collect
unbiased information on service quality.  HCFA's review of 13 states'
case management strategies notes that "Case managers review items
such as (1) whether providers arrive timely and provide the services
outlined in the plan of care; (2) whether there are unmet needs; (3)
whether the client is satisfied; and (4) whether the provider met the
standards for services."\15 However, in instances in which the case
manager is involved in selecting services, it would seem that
opinions on these matters would be compromised by the case manager's
accountability for care plan costs and role in identifying and
selecting providers, as well as clients' probable reluctance to
disclose their views to persons seen as service gatekeepers. 
Moreover, in Wisconsin, an official from the state's ombudsman
program indicated that home care clients in the state's Community
Options Program generally are not aware of the availability of case
managers, who are normally county government employees. 


--------------------
\15 Health Care Financing Administration, Approaches to Quality under
Home and Community-Based Services Waivers (Baltimore, Md.:  1993), p. 
63. 


         TRAINING REQUIREMENTS
-------------------------------------------------------- Letter :5.2.2

Training may be used to ensure competence before a provider is
authorized to deliver services, to correct deficiencies identified
through monitoring, or to enable family members to care for a client
in the home.  HCFA reported that responsibility for providing or
arranging training in the 13 state waivers it reviewed frequently lay
with state government agencies or with provider agencies, such as
home health agencies.  When the states cited factors influencing the
selection of training topics, the most frequent factors included
provider requests, statewide needs assessments, and monitoring
reports.  Thus, in this instance some link was apparent between
ongoing measurement efforts and the contents of quality assurance
activities. 


         CLIENT INVOLVEMENT
-------------------------------------------------------- Letter :5.2.3

Client involvement was the third type of strategy that HCFA found the
states were using to assure the quality of services in terms of their
ability to protect the health and safety of waiver participants. 
HCFA identified four major types of client involvement (in addition
to the use of client satisfaction surveys, which are addressed later
in our report).  The four were (1) client involvement in care
planning, (2) voluntary attendance at provider training sessions, (3)
client participation in policy advisory groups, and (4) mechanisms
for handling client complaints. 

Some states and subunits have developed advisory councils composed of
providers and consumers that may hold hearings or collect information
to advise program officials about service quality and other program
matters.  All three of the states we visited had made some use of
this strategy. 

Additionally, HCFA reports that "A number of states now permit
clients or their representatives to have some input into the
development of the plan of care.  This is normally done by having the
client or representative act as a member of the interdisciplinary
team which develops the plan of care."\16 In addition, HCFA reports
that most states have the client sign the plan of care, and agencies
we interviewed indicated that a copy of the plan of care is usually
left in the client's home.  The client's signature on the plan of
care can help assure state surveyors that the plan reflected in the
provider agency's case record has actually been presented to the
client.  Although some states may not require that providers obtain
the client's signature as proof of service delivery, we were told
that agencies often adopt this practice for purposes of internal
control. 

Some state-funded programs, such as the Community Options Program in
Wisconsin, have extended client involvement to the point of giving
clients the funds necessary to pay care providers directly, but the
Medicaid program restricts both this practice and the hiring of
family members to provide care. 

Finally, HCFA reports that the states collect client complaints,
which may be directed to the case manager or to a toll-free hotline. 
HCFA reports that, very often, states provide clients with printed
information on their rights and responsibilities, detailing
complaint-handling procedures.  The states we interviewed also made
reference to the Medicaid fair hearing process as a quality assurance
avenue. 


--------------------
\16 Health Care Financing Administration, p.  72. 


      STATE LICENSURE
---------------------------------------------------------- Letter :5.3

Most states require licensure of at least some home care agencies or
providers.  This can act as a quality assurance mechanism insofar as
it bestows a privilege that the state may withdraw if the agency
develops a pattern of poor performance.  Some state licensure
requirements exceed federal requirements for participation in
Medicare or Medicaid.  To exert control on the number and quality of
agencies providing home care services, some states have also imposed
a requirement that agencies receive a "certificate of need" before
beginning operations.  The National Association of Home Care
Providers conducted a survey of state licensure requirements for home
care agencies during the summer of 1992 and found that 39 states
applied licensure requirements to Medicare-certified home care
agencies, 35 states applied such requirements to
non-Medicare-certified home care agencies, and 20 required individual
providers of home care (home care aides, homemakers, and personal
care aides) to obtain a license.  In addition, certificates of need
were required in 23 states for Medicare-certified agencies and in 11
states for non-Medicare-certified agencies. 

To summarize, our findings illustrate that quality assurance
requirements, per se, are insufficient to assure quality services. 
In any case, the variety of requirements that different programs
apply to similar services is consistent with the scant data on the
problems the requirements are intended to address and the absence of
precise definition of the qualities they are apparently intended to
assure. 


   HOW QUALITY IS MEASURED
------------------------------------------------------------ Letter :6

We use "quality measurement" in this report to refer to the
retrospective quantitative or qualitative assessment of specific
criteria of care or service.  For example, the percentage of
appointments in which the provider arrived within 1 hour of the
scheduled time would be a measurable process criterion, while the
unnecessary use of emergency services or nursing home beds might be
seen as an outcome indicator if an important program goal were the
reduction of use. 

In the field of acute health care, the service characteristics that
are the focus of quality measurement mechanisms have usually been
divided into structure, process, and outcome criteria.  Where there
are multiple goals or multiple stakeholders with different goals, it
is important to measure multiple aspects of structure, process, and
outcome in order to (1) prevent key stakeholders from rejecting the
entire process as irrelevant or counterproductive and (2) develop the
capacity to address arguments about the relative importance of key
structural and process characteristics to the improvement of outcome
measures.  Even if this relationship is assessed while designing a
quality measurement system, the lack of a relationship between
certain variables at that point does not assure that they will
continue to be unrelated.  Although the three states we visited had
begun to implement measures of home care quality, these measures
included few objective indicators of outcomes and lacked a fully
articulated system for linking service characteristics to these
outcomes. 

For some potential goals, defining objective outcomes for which
services can be held accountable or identifying measures that are
reasonably interpretable as indicators of service quality is
methodologically complex.  Despite this complexity, the states are
pursuing some efforts to monitor the quality of beneficiary outcomes
that deserve attention.  These include surveys of home health
agencies, client satisfaction surveys, on-site inspection and
supervision, reviews of client records and care plans, fiscal audits
of providers, and focus groups or hearings. 


      SURVEYS OF AGENCY OPERATIONS
---------------------------------------------------------- Letter :6.1

HCFA contracts with states for periodic surveys of home health
agencies that receive Medicare payments in order to determine whether
they have complied with the standards that HCFA has established for
such agencies.  The provisions of the 1987 Omnibus Budget
Reconciliation Act require that, in assessing the quality of care
that home health agencies provide, the states measure how home health
care has affected patients' health by assessing whether it has
enabled beneficiaries to achieve the highest practicable health
status.  The law also requires that the states begin to measure
quality of care using measures of medical, nursing, and
rehabilitative care. 

Although HCFA has sponsored research that has resulted in preliminary
criteria for measuring the quality of the medical aspects of home
health care, officials of HCFA's Health Standards and Quality Bureau
acknowledged difficulties in measuring the current effect of home
health spending.  In addition, HCFA has not yet released a
standardized assessment instrument and minimum data set that were
required for the Home and Community-Based Care for the Functionally
Disabled Elderly Program created under the 1990 Omnibus Budget
Reconciliation Act.  In an earlier report, we detailed some of the
technical weaknesses in HCFA's guidance to the states regarding
survey procedures.\17 Unfortunately, we were told that case managers
in more than one state had no systematic access to results of state
surveys of home health agencies and had little systematic comparative
information to draw upon in referring clients to particular
providers. 


--------------------
\17 U.S.  General Accounting Office, Medicare:  Assuring the Quality
of Home Health Services, HRD-90-7 (Washington, D.C.:  October 10,
1989). 


      CONSUMER SATISFACTION
      SURVEYS
---------------------------------------------------------- Letter :6.2

State officials appear to endorse patients' satisfaction as an
important outcome of home health care.  In support of this view,
research indicates that satisfied patients are more likely to comply
with health care regimens, to participate in their own treatment, and
to cooperate with health care providers by disclosing important
medical information.  However, an alternative interpretation of this
research is that satisfied patients are merely more compliant than
dissatisfied ones.  Indeed, some research suggests that people who
are more satisfied with their health care are more satisfied with
other aspects of life, suggesting that some measures of health care
satisfaction may not be measuring anything linked particularly to
health care services.  However, measures specific to the types of
care received and the conditions of the recipient may be less subject
to these criticisms. 

Although some states and providers are using client satisfaction
surveys to measure experience with home care, the quality of the
surveys varies and their results can be difficult to interpret.  The
population in need of home and community-based care services is
methodologically difficult to survey.  First, survey respondents are
highly dependent on the services they receive in order to remain in
the community; they may fear that negative feedback will endanger
their ability to continue to receive services.  This is consistent
with a pattern of differences between overwhelmingly positive written
survey responses and findings from trained interviewers in New York
and Wisconsin who reported uncovering problems sometimes unknown even
to the case manager. 

Second, in many cases, the only response available comes from a
guardian or a patient's representative, whose views may represent
different sets of interests.  Since guardians and informal care
providers are rarely surveyed separately--although we understood that
they are more likely to provide critical comments--survey findings
that mix the two types of responses are difficult to interpret. 
Finally, given the variety of services provided, the sample sizes of
the surveys were not always large enough to produce reasonably
accurate results about particular providers or services, even if the
validity of survey findings had been less problematic. 


      ON-SITE INSPECTION AND
      SUPERVISION
---------------------------------------------------------- Letter :6.3

Because of the numerous sites in which home and community-based
long-term care is delivered, inspection and direct supervision can be
expensive means of monitoring care.  Consequently, this technique is
not applied with great frequency within the Medicaid programs for
which we reviewed regulations.  In most states, case managers must
make at least quarterly contact with each client and, for home health
aide care provided under Medicaid, a nurse must conduct an in-home
visit while the home health aide is present at least once each 60
days.  However, the contents and results of this supervision may be
highly variable given the lack of specific regulation. 


      REVIEWS OF CLIENT RECORDS OR
      CARE PLANS
---------------------------------------------------------- Letter :6.4

Providers' billing documents are reviewed against care plans to
establish that services ordered have, in fact, been billed.  In
addition, providers may be audited to assure that services for which
the states are billed are documented by appropriate case notes in
providers' files.  However, audit procedures may be applied as long
as 18 months after services are actually rendered, reducing their
value as information on ongoing service performance. 

Of more importance in this regard is the review of client care plans
or records conducted by case managers and, sometimes, by external
reviewers to assure that care is appropriately planned and modified
to fit patients' needs.  We found that in the states we visited,
these reviews were implicit--that is, based on the professional
knowledge of reviewers rather than on explicit criteria for care.  As
such, they are probably incapable of assuring that services are
equitably authorized or that they consistently meet specific
standards.  In particular, reviewers lack (1) normative data on the
amounts of service authorized for patients within the state's program
who have particular levels of functional difficulty and patterns of
informal support and (2) explicit standards that might be used to
evaluate a patient's care plan. 


      OTHER METHODS
---------------------------------------------------------- Letter :6.5

State officials also identified other methods for gathering
information about the quality of services.  These included conducting
client focus groups or hearings and registering complaints through a
toll-free hotline.  Although these strategies may be worthwhile for
purposes other than measuring quality, they cannot provide either
systematic or representative information needed to measure or to
understand service quality and how it is changing over time. 

In summary, efforts to measure service quality are in early stages of
development and appear focused on structural and process indicators
rather than indicators of program or service outcomes.  Although the
state officials we interviewed had attempted to measure client
satisfaction through formal surveys, the approaches to and experience
with this strategy varied widely, sometimes yielding results of
questionable validity.  Moreover, the goals states had identified
were not systematically linked to quality measurement strategies, nor
were the results of existing measurement and assurance processes
consistently used to influence ongoing program operations. 


   CONCLUSION
------------------------------------------------------------ Letter :7

As we noted earlier, it is difficult to establish either the
necessity or sufficiency of current quality assurance requirements
because of the lack of well developed and systematic measurement of
service quality.  In this context, it is not surprising that quality
assurance strategies applied to the same service are quite varied
depending on the source of service financing. 

As the Congress considers new programs serving functionally disabled
elderly persons, our interim findings suggest careful consideration
of provisions for the independent assessment of services in order to
develop unbiased information about program performance and quality. 
We believe that the prospects for independent assessment of quality
would be strengthened by (1) better articulated program goals (to
permit clear identification of the types of performance or outcomes
to be assured, measured, or prevented) and (2) a consistent framework
for measuring quality and performance characteristics across service
providers.  Knowing where to intervene when important outcomes are
poor will depend, in part, on having enough information about system
characteristics to assess their relationship to outcomes independent
of stakeholder perspectives.  Without such information, poor
performance on outcome indicators may be explained with equal
persuasiveness by workers' unions as the consequence of inadequate
staffing, by administrators as the consequence of poor staff
training, by consumers as the consequence of inadequate amounts of
service, or by patients as the result of client characteristics. 

With regard to consumer satisfaction surveys, we think it is
important to note, first, that it is a very vulnerable and
service-dependent population that is being asked to provide
potentially negative feedback.  The three states we visited were each
involved in surveys of clients regarding their receipt of services
under Medicaid or other programs.  However, this methodology has a
weakness with regard to this population, and the states and providers
that had attempted to apply it told us that even clients who would
reveal problems in the context of an interview did not typically do
so on written survey instruments.  In summary, although direct
inquiries of consumers may certainly be useful, a survey approach may
be expensive and difficult to apply with validity in this population. 


   AGENCY COMMENTS
------------------------------------------------------------ Letter :8

At your request, we did not ask federal agencies to comment formally
on this report.  We did obtain their views and they were in general
agreement with our findings. 

We are sending copies of this report to the Secretary of Health and
Human Services, the Administrator of the Health Care Financing
Administration, the Assistant Secretary for the Administration on
Aging, and other officials.  Upon request, we will send copies to
others who are interested. 

If you have any questions or would like additional information,
please do not hesitate to call me, at (202) 512-2900, or Mr. 
Kwai-Cheung Chan, Director of Program Evaluation in Physical Systems
Areas, at (202) 512-3092.  Other major contributors to this report
are listed in appendix II. 

Sincerely yours,

Eleanor Chelimsky
Assistant Comptroller General


SERVICE-SPECIFIC REQUIREMENTS FOR
INDIVIDUAL AND AGENCY PROVIDERS OF
MEDICAID BENEFITS
=========================================================== Appendix I


                                                                Home and
                                                                community-based
                                                                care for
                                                Home and        functionally
                                                community-      disabled elderly
Requirement     Home health     Personal care   based waiver    persons
--------------  --------------  --------------  --------------  ----------------
Pertinent
statutes and
regulations

Statutory       Social          Social          Social          Social Security
basis           Security Act,   Security Act,   Security Act,   Act:
                1905(a)(7)      1905(a)(22)     1915(c), (d),   1905(a)(23) and
                                                (e)             1929(a)(1,3,4,5,
                                                                8, and 9)

Regulations     42 CFR          42 CFR          42 CFR
                440.70(b),      440.170(f)      440.180(c),
                441.15(a),                      (d), (g), (h)
                484.30,
                484.36
                Public Law
                101-508/
                4721(a)

Eligibility

Target group    Eligibility     None specified  For recipients  Functionally
                does not                        who are not     disabled
                depend on need                  inpatients of   elderly, as
                for or                          a hospital,     defined in the
                discharge from                  SNF, ICF, or    law; states may
                institutional                   ICF/MR and who  narrow the
                care                            would require   target group
                                                the level of
                                                care provided
                                                in a SNF or
                                                ICF if not
                                                furnished with
                                                home and
                                                community-
                                                based
                                                services;
                                                states may
                                                narrow the
                                                target group\a

Entry           Provided on     Prescribed by   Membership in   Comprehensive
requirement     physician's     a physician     the target      functional
                orders                          group, as       assessment to
                                                established at  determine
                                                state level     whether
                                                                individual is
                                                                functionally
                                                                disabled

Plan of care
requirements

Plan required   Plan of         Plan of         Written plan    Individual
                treatment       treatment       of care         community care
                                                                plan

Qualifications  Physician       Registered      States assure   Qualified
for reviewer                    nurse           health and      community care
                                                well-being of   case manager
                                                recipients

Frequency of    Every 60 days   Every 60 days   Unspecified     Periodically
plan of care
review

Locations in
which service
may be
provided

Private home    Yes             Yes             Yes             No

Facility        Home health     No              Respite care    Small or large,
                services can                    may include     nonresidential
                be provided in                  payment for     or residental
                an ICF/MR if                    placement in a  community care
                the services                    certified       settings;
                are not                         facility        unrelated adults
                required to be                                  residing in
                provided by                                     setting provided
                the facility                                    with personal
                                                                services

Outside a home  The second      As of fiscal    Community-      No
or facility     circuit has     year 1995, as   based
                held that home  part of home
                health nursing  health
                services may    services or,
                be used at any  according to
                location in     policy, while
                the community,  being
                but this        transported to
                decision        receive
                currently       medical care
                applies only
                in
                Connecticut,
                New York, and
                Vermont

Agency
providers,
organizations,
and facilities

Requirement to  Yes;            No              No              No
meet Medicare   conditions of
conditions of   participation
participation   for home
                health
                agencies

Registered      Yes             Yes             No              No
nurse
supervision
requirements

References to   Yes; medical    No              No              Yes; state must
requirements    rehabilitation                                  survey and
in state law    facility                                        certify
                licensed by                                     providers;
                state                                           setting must
                                                                meet applicable
                                                                state and local
                                                                requirements

Direction or    Yes; medical    No              No              No
supervision     rehabilitation
requirement     facility must
                be under
                competent
                medical
                supervision

Independent
and individual
providers

Family members  No              Yes; provider   Yes\b           No
prohibited or                   may not be a
restricted                      member of the
                                recipient's
                                family

Direction or    Yes; home       Yes; service    No              No
supervision     health aides    must be
requirements    must be under   supervised by
                the             a registered
                supervision of  nurse
                a registered
                nurse

References to   Yes; nursing    No              For all         No
requirements    as defined in                   independent
under state     State Nurse                     providers, the
law             Practice Act                    state must
                                                assure that
                                                state
                                                standards for
                                                licensing and
                                                certification
                                                are met

Specific        Yes; for        Yes;            Yes; state      Yes; providers
individual      physical        individual      must assure     must be
provider        therapist;      must be         adequate        competent to
requirements    occupational    qualified to    standards for   provide care
                therapist;      provide         all providers
                speech,         services;       and
                hearing, and    training        qualifications
                language        requirements    for
                services; home  for personal    individuals
                health aide     care            developing
                (training);     attendants      plans of care
                and registered  employed by
                nurse           home health
                providing       agencies
                visiting nurse
                care
--------------------------------------------------------------------------------
Source:  Health Care Financing Administration, Community-Based Care: 
Options Under Medicaid (Baltimore, Md.:  1993). 

\a SNF = skilled nursing facility; ICF = intermediate care facility;
ICF/MR = intermediate care facility for persons with mental
retardation. 

\b Prohibits payment to legally responsible relatives (spouses and
parents of minor children) for personal care and other home and
community-based services; allows payment for extraordinary
requirements and specialized skills under certain conditions. 


MAJOR CONTRIBUTORS TO THIS REPORT
========================================================== Appendix II

PROGRAM EVALUATION AND METHODOLOGY
DIVISION

Sushil K.  Sharma, Assistant Director
Betty A.  Ward-Zukerman, Project Manager
Brett S.  Fallavollita, Deputy Project Manager
Penny Pickett, Supervisory Reports Analyst
Venkareddy Chennareddy, Referencer

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