As Secretary Bowen indicated to you in his letter of September 26, enclosed is a statement for the record of the July 29 Select Committee on Aging hearing on home health care quality. The statement addresses the questions outlined in your August 1 correspondence. The Department certainly appreciates the opportunity to respond to your questions on this important issue. Sincerely, Patricia Jawis for Patricia Knight Deputy Assistant Secretary enclosure PREPARED STATEMENT OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES OVERVIEW The Department of Health and Human Services (HHS) is responsible for administering several laws which provide reimbursement for health and social services to persons residing in their own homes or non-medical group living facilities. Except for Medicare, these programs usually allocate funds to States for distribution according to broad Federal guidelines. The major programs providing vulnerable persons with home health care are Medicare and Medicaid. In-home social and supportive services, including nutrition, are provided through the Social Services Block Grant, the Older Americans Act, and under two provisions of the Medicaid program: the home and community-based waiver and the personal care services option. In addition, the Indian Health Service of the Public Health Service provides home care to American Indian and Alaska Native communities. The Health Resources and Services Administration of the Department of Health and Human Services administers a number of programs which finance training to impart and improve the personnel skills needed in the delivery of high quality home health care. When appropriate, the HHS Inspector General conducts inspections of various aspects of home care which is financed in whole or in part by this Department. In general, the quality of home care is addressed through two different approaches: on the one hand, home health services are governed by specific regulations covering provider participation, the amount, scope and duration of allowable services and patient eligibility. This is because Medicare is the dominant source of payment for home health services; it is administered by one government body, namely, the Federal government; and it is intended primarily to provide skilled home health services under the supervision of a physician as part of the continuum of care in an acute medical episode. The context of quality assurance for in-home social and supportive services is quite different. States are usually expected to add State funds to their Federal grants and, in return, are provided considerable flexibility in determining which services are to be made available, how service delivery should be organized, to whom services should be provided and how quality should be maintained. Given the wide range of social services from home-delivered meals to assistance with bathing to grief counseling ... and the variation among States and communities in the availability, organization and delivery of services, State and local entities are the most appropriate locus for setting standards and monitoring provider performance. The tremendous growth in the population receiving formal home care services as well as the increasing amount of Federal and State tax dollars spent on these programs have resulted in renewed efforts by HHS, many States, professional associations and others to review and update information on the quality of care and to develop new strategies for assuring quality in home care services to vulnerable persons. However, the development of new strategies should not be limited to a review and revision of Federal and State standards. There are several other elements which influence the "quality" of formal home care services. These include: staff training, supervision, industry accreditation, professional certification, consumer (including family) advisory bodies and third-party oversight bodies. The American Bar Association (ABA), in its study on "The 'Black Box' of Home Care Quality", outlines a number of legal controls which transcend the formal regulatory framework. This ABA undertaking was funded in part by the Administration on Aging (AoA) and also serves as a good example of partnership between the Federal government and the private sector in seeking to improve the quality of home care. Any discussion of home care services must also recognize the important role of the non-agency "individual contractor". The National Long-Term Care Channeling Demonstration, a landmark tenState experiment sponsored by HHS over a five-year period beginning in 1981, confirmed the high quality of personal care services that can be given by persons carefully recruited by family members through newspaper ads, neighborhood contacts and friends. Volunteers in one of the several ACTION programs, such as Senior Companions, and many community-sponsored programs also have an important role in providing services to vulnerable persons in their homes. The remainder of this statement describes the major Federal home care programs administered by the Department of Health and Human Services and recent efforts by HHS to improve the quality of home care services. I. QUALITY ASSURANCE IN HOME HEALTH CARE Medicare Medicare is an acute care program with services designed to support this concept. Consistent with this principle, Medicare's home health benefits are oriented toward a need for skilled care with the benefits designed to be part of the continuum of care in an acute episode, usually following hospitalization. Under the Medicare home health benefit, the following types of services are covered: Part-time and intermittent skilled nursing care provided by or under the supervision of a registered professional nurse. Physical, occupational and speech therapy. Medical social services which contribute significantly to the treatment of a patient's health condition. Part-time and intermittent services from a home health aide. O Medical supplies (other than drugs and biologicals) and medical appliances. The Medicare law limits payment for home health services to those beneficiaries whose conditions are of such severity that the individuals are under the care of a physician, confined to their homes (homebound) and in need of skilled nursing care on an intermittent basis, or in need of physical or speech therapy. The care must be prescribed by a physician, and the services must be provided by a Medicare certified home health agency in accordance with the physician's treatment plan. Conditions of participation In order to participate as a home health agency (HHA) in the Medicare and the Medicaid programs, an agency must meet a number of specific requirements, or conditions of participation. These conditions of participation were developed in cooperation with professional individuals and organizations, and other Federal agencies, and have been in effect since 1973. They prescribe certain requirements which are necessary to ensure the health and safety of beneficiaries when they receive services at their place of residence. The conditions govern three broad areas: personnel requirements for those rendering care, administrative requirements for an agency to effectively render care, and those requirements which discuss the provision of specific types of care. Certification of HHAS The Department makes a determination of whether a facility meets the requirements for participation in the Medicare program based on the survey/certification recommendations of a State survey agency. The State survey agency performs an initial survey and periodic resurveys of all facilities that participate or want to participate in the Medicare program as HHAs. These surveys assess the extent to which the facilities meet the conditions of participation. States make visits to homes as part of the survey and certification process for certain HHAS. The survey agency forwards its findings and recommendations to the Health Care Financing Administration (HCFA), which then makes a determination regarding whether the facility is in compliance with the conditions of participation. The most frequent deficiencies cited by surveyors over the past several years have been in the areas of: personnel policies, plans of treatment, clinical record review, and conformance with physician's orders. These deficiencies are similar in nature to those found prior to the rapid increase in the number of home health agencies participating in Medicare. The following chart lists terminations of home health agencies over the past several years: Reasons for voluntary termination include mergers, closings, dissatisfaction with reimbursement, and risk of involuntary termination. The only other Medicare component which focuses on home care is the hospice program, which became recognized for Medicare participation in 1983. As a part of the survey process for hospices, the Department of Health and Human Services includes visits to beneficiaries' homes to obtain information concerning the care a patient receives, and to assure that program requirements are met. No specific quality violations have been discovered. Medicaid Under the Medicaid program, the State agency responsible for administration of the State Medicaid plan must ensure that home health services are provided to all individuals entitled to skilled nursing facility services under the State plan. health services must include, at a minimum, the following services: Home Medical supplies, equipment, and appliances suitable for use in the home The home health services must be provided at the recipient's place of residence upon the orders of the recipient's physician as part of a written plan of care that the physician reviews every 60 days. The home health agency must meet the Medicare requirements for participation in order to receive reimbursement under Medicaid. States determine the method and level of reimbursement for home health agency services under their Medicaid programs. These include negotiated rates, fee schedules, cost-based reimbursement and other methods. Home and Community-Based Waiver Section 2176 of the Omnibus Budget Reconciliation Act of 1981 authorizes the Department to grant waivers of certain Medicaid requirements in order to permit States to offer a wide array of home and community-based services that an individual may need in order to avoid institutionalization. Among the services that may be provided under this waiver are: case management; homemaker/home health aide; personal care; adult day health care and habilitation care. To have a waiver request approved, a state must describe its proposed home and community-based service program, and must provide adequate assurances as required by the statute and regulations concerning the health and welfare of individuals under the waiver, the cost of services under the waiver, and recipient need for services. Almost thirty States have Personal Care Services Option adopted this Medicaid option. Personal care services in a recipient's home mean services prescribed by a physician in accordance with a recipient's plan of treatment and provided by an individual who is qualified to provide the services, is not a member of the recipient's family and is supervised by a registered nurse. The services usually assist in such activities of daily living as bathing, eating and dressing. Health Resources and Services Administration The Health Resources and Services Administration (HRSA) has responsibility for several programs which have an impact on home care including: Bureau of Health Care Delivery and Assistance The Bureau of Health Care Delivery and Assistance (BHCDA) administers the Home Health Services Program authorized under Title III of the Public Health Service Act through September 30, 1987. Awards in FY 1986 totalled $1,435,000. Eleven awards are being used to develop or expand home health services. Twentyeight awards are providing basic training for homemaker/home health aides. Some of the continuing education will cover orientation to high tech equipment now being used in the home and care of the homebound AIDS patient. These grantees are expected to meet the certification standards for home health agencies and conditions of participation established by the Health Care Financing Administration. In addition, curriculum content for training homemaker/home health aides is to include the scope of material presented in "A Model Curriculum and Teaching Guide for the Instruction of Homemaker/Home Health Aides" as published by the National Homecaring Council, Foundation for Hospice and Home Care. Although some States, such as California, have established higher standards for the training of homemaker/home health aides, this referenced curriculum provides the minimum standards necessary for reimbursement of homemaker/home health aide services under Medicare. BHCDA is also funding the development of a supplement to the Model Curriculum for homemaker home health aides on the care of patients receiving high technology therapy in the home. The training will help the aide understand the various types of equipment or therapies they may encounter, and risks associated with the provision of care to these patients. The aide will not be trained to provide professional care. This supplement to "A Model Curriculum and Teaching Guide for the Instruction of Homemaker Home/Health Aides" should be available December 1986. |