Bureau of Health Professions The Bureau of Health Professions (BHPr) provides national leadership in coordinating, evaluating and supporting the development and utilization of personnel required to staff the Nation's health care delivery system. Among the activities designed to improve home health care personnel are the Geriatric Education Centers program and Nursing Special Project grants. There are now twenty geriatric education centers funded under section 788 (b) of the Public Health Service Act. These are regional resources providing multidisciplinary training for health professions in geriatric care. In June 1986, HRSA conducted a conference for the centers on, "Geriatric Education, New Knowledge, New Settings, New Curricula" to explore opportunities for geriatric education in ambulatory care and home care settings. Nursing Special Project grants are for such purposes as: Continuing education in gerontological nursing for community health nurses. Development of a battery of learning materials, assessment instruments and evaluation tools for community health nurses in Kansas to use in case management that optimizes self-care for the frail elderly. Development and testing of learning modules at the University of Massachusetts to enable nursing students, faculty and community health nurses to provide nursing services and health education at a community nursing center and in clients' homes. Other broader training authorities which include an emphasis on improving the skills of persons delivering home health care are those which support geriatric training. In the Family Medicine residency training programs in FY 1985, 42 grantees received funds to provide curriculum content in geriatrics and gerontology to medical students. Twenty-four Faculty Development Training programs initiated training to medical students in this area. Under the Area Health Education Center program, 16 of 19 awardees indicated training and emphasis in geriatric activities impacting an estimated 120,113 individuals. The General Internal Medicine/General Pediatrics Residency program awarded 38 grants that included provision of geriatric activities. Twelve of the thirty Physician Assistant Training grantees specialized in geriatric activities. Indian Health Service The Indian Health Service (IHS) of the Public Health Service provides community health services to American Indian and Alaska Native communities which would include the elderly who reside within the designated service area served by IHS. Most IHS community health programs include the following disciplines: environmental health, mental health and social services, dental health, community health nursing, health education, field health physicians, emergency medical services and the services of Tribal Community Health Representatives (CHRS). CHRS are indigenous, community-based, well-trained, medically-guided paraprofessional health care workers who may include traditional native concepts in their work. IHS negotiates a contract/grant with individual tribes and tribal and Alaska Native organizations for the provision of specific services which are prioritized and designated by the community to be served. Gerontological health care services delivered to the home are within the CHR program scope of work. In several States, some CHR programs have been designated as home health agencies and are monitored by State health departments. All CHR programs are monitored by a project officer appointed by the IHS contracting officer. All CHRS account for their time and activities through their mandatory national reporting system known as the Community Health Representative Information System (CHRIS). CHRS providing home health care are involved in developing patient care plans and are supervised by a community health nurse and/or a field health physician. II. QUALITY ASSURANCE IN SOCIAL SERVICES DELIVERED TO THE HOME Most Federal assistance for social services for vulnerable persons in a residential living arrangement is provided through the Social Services Block Grant and the Older Americans Act. Both of these programs operate as grants to States which then allocate monies through regional or sub-State government entities based on annualized expenditure plans. Social Services Block Grant State Under the Social Services Block Grant (SSBG), a variety of social services are available to assist vulnerable persons to remain in their own homes or in community living situations. Each State has the flexibility to determine what services will be provided, who is eligible to receive services, and how funds will be distributed among the various services within the State. and/or local Title XX agencies (i.e. county, city, regional offices) may provide these services directly or purchase them from qualified agencies and individuals. Each State is responsible for setting standards for and monitoring the quality of these services. They also may use SSBG funds for training and technical assistance to establish or improve services. Before making any expenditure from SSBG funds, each State must submit an annual pre-expenditure report to the Office of Human Development Services, HHS, on the types of activities to be funded and the categories or characteristics of the individuals to be served. The State must make this report available within the State for review and comment by the public. At least every two years States must also prepare a report (post-expenditure report) showing how the SSBG program funds were expended and must audit their program every two years. Based on an analysis of pre-expenditure reports submitted by the States for fiscal year 1986, the list below indicates the number of States providing certain types of services under the SSBG which enable aged persons to obtain or maintain a maximum level of self-care and independence. * Includes 50 States, the District of Columbia, and the four eligible territories and insular areas. ** Includes homemaker, chore, home health, companionship and home maintenance services. The Department's Office of Human Development Services (HDS) has responsibility for administering the ongoing requirements of the "Keys Amendment," section 1616(e) of the Social Security Act. This statute requires each State to: (1) establish and enforce standards for residential facilities where significant numbers of SSI recipients reside; (2) make these standards (and any waivers of the standards) available for public review; and (3) certify annually to the Secretary that these requirements have been met. HDS also coordinates with the Health Care Financing Administration and the Department of Housing and Urban Development as these agencies have incorporated compliance with the "Keys Amendment" in their programmatic regulations. Older Americans Act Under Title III of the Older Americans Act, a variety of supportive and nutrition services that include home care services are provided to persons sixty years of age and older. States are provided funds, through a formula grant based on their population of older persons, to develop greater capacity and foster the development of comprehensive and coordinated service systems to serve older individuals to "(1) secure and maintain maximum independence and dignity in a home environment for individuals capable of self-care with appropriate supportive services; (2) remove individual and social barriers to economic and personal independence for older individuals; and (3) provide a continuum of care for the vulnerable elderly." The law requires the designation of an agency within each State to be specifically responsible for carrying out the purposes of the Act. The State Agency of Aging is required to subdivide the State into Planning and Service Areas (PSA) and to designate for each PSA an Area Agency on Aging (AAA). Funds are made available to the States upon approval of State plans by AoA regional Offices. States then allocate funds to area agencies upon approval of area plans. The Older Americans Act requires that the State plan assure that the provisions of the Older Americans Act and all applicable State and local laws be met. In their role as a focal point for aging interests in the community, area agencies on aging are expected to have general oversight of services which are being received by older persons in their homes with specific monitoring of the performance of any provider being funded under the Act. III. DEPARTMENTAL EFFORTS TO IMPROVE THE QUALITY OF HEALTH AND During the last decade, there has been tremendous growth in the availability of in-home and community based long-term care services. This has been accompanied by a significant increase in the number of provider agencies, large-scale experimentation on the cost-effectiveness of in-home and community-based services and new extensive collections of data on the characteristics of the chronically impaired population living in the community. Department has initiated a wide variety of research and programmatic efforts built on these activities to develop new strategies to improve the quality of home care. The As an illustration, the study on home care quality conducted by the American Bar Association, with support through a grant from the Administration on Aging, will be helpful to the Department of Health and Human Services as we focus our attention on this issue. A subcommittee of the Interagency Committee on Research in Aging (IACRA) which is attempting to identify and coordinate additional areas of research regarding home care quality which the Federal government should consider funding is one vehicle for coordinating the considerable activities within the Department regarding home care quality. IACRA is an informal body staffed by the National Institute on Aging to provide a forum for representatives of offices in HHS and other Federal departments to share information about proposed and ongoing research and demonstration efforts relevant to the elderly. Because IACRA membership includes representatives of a number of Federal departments, this subcommittee is also looking at home care activities in Federal agencies beyond the Department of Health and Human Services such as the Veterans' Administration and ACTION. Some of the specific recent steps undertaken in the Department of Health and Human Services are described in the material that follows. Health Care Financing Administration Recent initiatives of the Health Care Financing Administration to improve the quality of federally-financed home care include: HCFA has developed instructions for States to conduct visits to homes of beneficiaries receiving home health services to determine through an on-site verification whether Medicare health and safety requirements are met. Previously, the home health survey process primarily involved a review of various records maintained at the agency. HCFA's Health Standards and Quality Bureau (HSQB) is conducting an assessment of this new instrument, the results of which should be available in January, 1987. HCFA is also intensifying regional oversight of State agency HHA Fiscal intermediaries are to perform coverage compliance reviews to assure that HHAS are providing appropriately covered services. If during these reviews, problems involving quality of care are identified, they are referred to the State agency for follow-up. HCFA has revised its termination procedures to speed up the decertification of providers who are not in compliance with program requirements. HCFA central and regional office personnel conduct periodic training programs for HHA surveyors to familiarize them with program requirements and survey techniques. HCFA is examining the current survey process for all types of Medicare providers, including HHAs, with the intention of focusing on patient outcomes rather than paper compliance with conditions of participation. They have already developed a patient outcome oriented survey process for long-term care facilities, which was recently implemented nationally. Through its Office of Research and Demonstrations (ORD), the Health Care Financing Adminstration has funded several projects which should prove useful in developing strategies for improving the quality of home care. These include: Comparison of the Cost and Quality of Home Health and In The University of Colorado was awarded a $1.5 million grant Development of Patient Outcome Measures The Home Care Association of Washington was awarded a three- Need for Post-Hospital Services A major study is being planned by HCFA, in coordination with the Assistant Secretary for Planning and Evaluation, to determine the need for post-hospital services and the availability of these services. This study will look at the appropriateness of post-hospital care services, potential barriers to these services, program and benefit costs as well as out-of-pocket costs for beneficiaries. Medicare/Medicaid Hospice Demonstration This five-year demonstration initiated in October 1980 was On September 22, 1986, the Health Care Financing Administration issued a Request for Proposals (RFP) HCFA-87-003/JD, for "Development of a Patient-Oriented Approach for Surveying Home Health Agencies." HCFA seeks to revise the present survey report form for home health agencies that wish to provide care to Medicare/ Medicaid patients. This form (HCFA-1572) primarily focuses on structural and procedural elements rather than on patient outcomes and care. Since home visits are now a part of the survey, the Health Standards and Quality Bureau has decided to fund and support a contract to develop a patient-oriented approach to surveying home health agencies. The contract will include revising the present survey report form and guidelines and reviewing the requirements to identify areas of potential change needed to more effectively survey the quality of care provided by home health agencies. Administration on Aging The Administration on Aging, under its Older Americans Act, Title IV discretionary programs, is helping to build a knowledge base to assure the quality of home care for older persons. Research and demonstration efforts include the support of a project being undertaken by the Ohio Department of Aging, in conjunction with Miami University, to design, implement and evaluate a model quality assurance program for in-home services for elderly care recipients. The project will also provide training and guidance on quality assurance program standards and practices through a handbook and a regional conference in Ohio. A second demonstration project, being carried out by the Clackmus County (Oregon) Area Agency on Aging, will replicate and test a local/State quality assessment program. Title IV education and training projects provide support for preparation of health and social service professionals in geriatrics and gerontology as well as continuing education, training, and staff development for professionals and paraprofessionals who work with the elderly. By increasing the competencies of these personnel, a higher degree of quality care for the elderly can be provided in whatever settings older people are found such as: clinics, hospitals, nursing homes, board and care facilities, as well as in their own homes. In addition, AoA has provided support for a number of projects specifically focused on quality assurance in home care for the elderly. Recently completed projects include: paraprofessional training for providers of home care services to rural, minority elderly by the Southside Virginia Community College; and a training program for rural service providers and family caregivers of homebound elderly at Atlanta University. Currently funded projects include: a training program at the University of Maryland at Baltimore for social workers and in-home aides to facilitate communication between physicians and the elderly regarding drug use; and a continuing education program at New Mexico State University that increases the knowledge and skills of home health aides as well as managers and supervisors of home health agencies. The Administration on Aging will continue to place emphasis on activities such as in-home services and to assist State and area agencies on aging to build a responsive system of home-based care. Office of the Inspector General The Office of the Inspector General for the Department recently completed an inspection of home health aide services provided to Medicare patients. The report, entitled "New Performance Standards Can Improve Home Health Aide Services for Medicare Patients Without Increasing Costs", is undergoing final review and will be available around the end of the year. The report will contain recommendations relative to the training and certification of home health aides. |