CARE PROVIDERS FOR FRAUD. THIS IS SEVEN TOO MANY, BUT IS AN ENVIABLE RECORD COMPARED TO THE LITERALLY THOUSANDS OF OTHER PROVIDERS IN VARIOUS CATEGORIES OF HEALTH CARE WHO HAVE BEEN CONVICTED. NOW, HOME CARE HAS BEEN FREE OF SUCH PROBLEMS FOR MANY REASONS, ONE OF WHICH IS THAT THE FIELD WAS COMPARATIVELY SMALL. HOWEVER, THERE IS A GROWING APPRECIATION AND DEMAND FOR HOME CARE. THE INDUSTRY HAS GROWN AT A RAPID RATE IN RECENT YEARS, LARGELY BECAUSE OF DEMOGRAPHIC FACTORS AS WELL AS THE IMPACT OF THE HOSPITAL PROSPECTIVE PAYMENT SYSTEM. THIS GROWTH AND THE PREDICTIONS FOR THE FUTURE OF THE GROWING NUMBERS OF OLDER AMERICANS ARE SUFFICIENT TO WARN US OF THE POTENTIAL FOR DECREASED QUALITY OR ABUSE IN HOME CARE SEVICES. THE HOME CARE COMMUNITY HAS NO MORE VITAL INTEREST AT THE PRESENT TIME THAN TO ENSURE THE HIGH QUALITY OF SERVICE. THAT IS WHY I AM DELIGHTED TO BE HERE WITH YOU TODAY, TO DISCUSS WITH YOU A FEW AREAS IN WHICH PROBLEMS OCCUR AND WILL ESCALATE. I ALSO PLAN TO MAKE RECOMMENDATIONS FOR IMPROVEMENTS IN THOSE AREAS. THE MAJOR SOURCE OF POTENTIAL PROBLEMS RELATED TO HOME CARE IS THE FRAGMENTATION OF SERVICES, ELIGIBILITY, COVERAGE, REIMBURSEMENT AND STANDARDS WHICH EXIST AT THE FEDERAL, STATE AND LOCAL LEVELS. CURRENT STATUS OF FEDERAL PROGRAMS THE MOST IMPORTANT UNIFORM QUALITY CONTROLS FOR HOME HEALTH AGENCIES ARE THE FEDERAL "MEDICARE CONDITIONS OF PARTICIPATION". THE MINIMUM WITH WHICH MEDICARE-CERTIFIED HOME HEALTH AGENCIES MUST COMPLY; SEVERAL STATES REQUIRE HIGHER STANDARDS IN SOME AREAS. THE MEDICARE STANDARDS ARE APPROPRIATE AND REASONABLE. THE OTHER FEDERALLY FINANCED PROGRAMS, THAT IS, MEDICAID, TITLE XX (SOCIAL SERVICES BLOCK GRANTS TO STATES), AND THE OLDER AMERICANS ACT, DO NOT HAVE CONDITIONS OF PARTICIPATION WHICH CONTAIN UNIFORM STANDARDS FOR HOME CARE SERVICES. INSTEAD, THE PROGRAMS UTILIZE STANDARDS DEVISED BY VARIOUS STATE OR LOCAL GOVERNMENTS, SOME OF WHICH ARE EXTREMELY MINIMAL OR ABSENT. OTHERS HAVE NO STANDARDS, BUT SIMPLY RELY ON THE LOWEST UNIT PRICE BIDDER TO PROVIDE THESE SERVICES. ARE DEVELOPMENTALLY DISABLED. AS YOU CAN IMAGINE, A FUNDAMENTAL PROBLEM IN THESE FEDERAL PROGRAMS IS A LACK OF CONSISTENT BASIC STANDARDS FOR PARAPROFESSIONALS. THE HOME HEALTH AIDE OF THE MEDICARE PROGRAM IS ESSENTIALLY DOING THE SAME TASKS AS THE HOMEMAKER OF THE TITLE XX PROGRAMS, THE SAME TASKS AS THE PERSONAL CARE AIDE OF THE MEDICAID PROGRAM, AND THE SAME TASKS AS THE HOME AIDE IN SOME PROGRAMS FOR THE AGING, THOSE WITH MENTAL ILLNESS, OR PEOPLE WHO THE VARIOUS TITLES USED ΤΟ DESIGNATE THE HOME CARE WORKER REFLECT VARIOUS FUNDING SOURCES, NOT ACTUAL TASKS. THE PARAPROFESSIONAL FUNCTION IS THE SAME: TO PROVIDE APPROPRIATE SUPPORTIVE SERVICES TO PERSONS IN THEIR HOMES UNDER THE PROPER PROFESSIONAL SUPERVISION AND IN ACCORDANCE WITH A PLAN OF CARE. BUT THE PROGRAMS LACK MINIMUM MANDATORY SUPERVISION AND TRAINING REQUIREMENTS FOR HOMEMAKER-HOME HEALTH AIDES, WHICH IS THE PROPER NAME TO DESCRIBE THIS MOST IMPORTANT WORKER IN THE FIELD OF HOME CARE. PROBLEM AREAS IN PARAPROFESSIONAL SERVICES THE ISSUE OF STANDARDS FOR PARAPROFESSIONALS IN HOME CARE IS NOT NEW. TO DEAL WITH THE PROBLEM, THE NATIONAL HOMECARING COUNCIL HAS PROMULGATED NATIONAL STANDARDS FOR HOMEMAKER-HOME HEALTH AIDE SERVICES, AND HAS ADMINISTERED AN ACCREDITATION AND APPROVAL PROGRAM BASED ON THOSE STANDARDS SINCE 1962. A (ACCREDITATION REQUIRES A SITE VISIT, WHILE APPROVAL REQUIRES ONLY SELF-STUDY AND OTHER WRITTEN MATERIALS). THE STANDARDS COVER AGENCY STRUCTURE, STAFFING, TRAINING, SUPERVISION, SERVICE, AND COMMUNITY RELATIONS. THE NATIONAL LEAGUE FOR NURSING AND THE JOINT COMMISSION ON ACCREDITATION OF HOSPITALS ALSO ACCREDIT HOME HEALTH PROGRAMS PROVIDED THROUGH SOME COMMUNITY AGENCIES AND HOSPITALS. SUCH ACCREDITATION OR APPROVAL IS ENTIRELY VOLUNTARY, HOW EVER. ONLY A FEW HOME CARE AGENCIES IN THE COUNTRY ARE ACCREDITED OR APPROVED BY THE NATIONAL HOMECARING COUNCIL. THE NATIONAL HOMECARING COUNCIL ALSO DEVELOPED, UNDER CONTRACT TO THE U.S. PUBLIC HEALTH SERVICE, A MODEL CURRICULUM AND TEACHING GUIDE FOR THE INSTRUCTION OF THE HOMEMAKER-HOME HEALTH AIDE IN 1978. THIS CURRICULUM HAS BEEN UPDATED AND IS NOW IN ITS THIRD PRINTING (1984). THE CURRICULUM IS REFERRED TO IN THE FEDERAL HOME HEALTH AGENCY EXPANSION AND TRAINING GRANTS ADMINISTERED BY THE PUBLIC HEALTH SERVICE. THUS, CERTAIN BASIC STANDARDS AND CURRICULA ALREADY EXIST, BUT ARE SIMPLY NOT USED IN MANY FEDERAL AND STATE PROGRAMS. IT IS IRONIC THAT STANDARDS AND TRAINING CURRICULA ARE ESTABLISHED FOR INDIVIDUALS W HO ARE PROFESSIONALLY TRAINED AND LICENSED, SUCH AS PHYSICIANS AND NURSES, WHILE THERE ARE NO UNIFORM STANDARDS FOR PARAPROFESSIONALS, WHO REQUIRE GREATER TRAINING AND SUPERVISION. THE INDIVIDUALS PROVIDING THESE PARAPROFESSIONAL SERVICES ARE, IN LARGE MAJORITY, SINCERE, DEDICATED AND HARDWORKING PEOPLE WHO ARE UNDERPAID IN RELATION TO THE VALUE OF THE WORK THEY DO. WE HAVE NOT GIVEN ADEQUATE ATTENTION OR RECOGNITION TO THE PERSONS WHO PROVIDE THIS VITAL SERVICE; IN FACT, IN MANY RESPECTS WE HAVE EXPLOITED THEM. WE HAVE SOWN SEEDS FOR A POTENTIAL SCANDAL. WE HAVE IGNORED THE ESCALATING HUMAN NEEDS OF PARAPROFESSIONALS WHILE WE HAVE CONTINUED TO DELEGATE MORE CARE TO THEM, AND TO PLACE MORE DEMANDS ON THEM. ON IN JUNE, 1985, THE RENSSELAER COUNTY (NEW YORK) LONG TERM CARE COORDINATING COMMITTEE, A GROUP COMPOSED OF REPRESENTATIVES OF HOME CARE PROVIDERS, HOSPITALS, NURSING HOMES, HEALTH PLANNERS, AND COUNTY GOVERNMENT ISSUED A REPORT WHICH RECOMMENDED INCREASED USE OF HOME HEALTH AIDES AND PERSONAL CARE AIDES SERVICES, BASED ENHANCEMENT OF THE LABOR POOL. THE REPORT NOTED THAT "HOMEMAKER/PERSONAL CARE HAS BEEN A DIFFICULT SERVICE TO STAFF AND MAINTAIN WITH A STABLE PERSONNEL POOL OVER TIME. WITHIN THE LAST FIVE YEARS, THIS LABOR POOL APPEARS TO HAVE DIMINISHED EVEN MORE. IN LIGHT OF DEMOGRAPHIC TRENDS WHICH INDICATE A GROWING NEED FOR THIS TYPE OF SERVICE, IT IS ESSENTIAL THAT THE POOL OF WORKERS BE EXPANDED AND STABILIZED." "CLEARLY, MARKETING IS IMPORTANT IN TACKLING THIS TASK. THERE ARE SEVERAL REASONS WHY PERSONAL CARE IS NOT A HIGHLY DESIRABLE CAREER РАТН. WAGES ARE LOW; THE WORK ENVIRONMENT VARIABLE, AND OFTEN UNDESIRABLE. WORK HOURS ARE NOT GENERALLY GUARANTEED. TRANSPORTATION FROM CASE TO CASE IS GENERALLY THE WORKER'S RESPONSIBILITY. WORKER'S ROLE AND CONSUMERS ARE OFTEN UNCLEAR ABOUT THE RESPONSIBILITIES. CLIENTS OFTEN DEMAND INAPPROPRIATE CARE. THE COLLEGIAL ATMOSPHERE IN A CONTAINED WORK UNIT IS ABSENT, AS CAREGIVING IS OUTSTATIONED, RESULTING IN LACK OF REGULAR PEER SUPPORT. PUBLIC RECOGNITION OF THE VALUE OF SUCH A POSITION IS NON-EXISTENT. HOMEMAKER/PERSONAL CARE SERVICE IS A LOW STATUS, LOW PRESTIGE, LOW CEILING OCCUPATION. KEEPING THIS IN MIND, WHY WOULD ANYONE WANT TO PERFORM THIS FUNCTION?" (ENHANCING AIDE SERVICE IN THE HOME: RECOMMENDATIONS FOR ACTION, REPORT OF THE LONG TERM CARE COORDINATING COMMITTEE, RENSSELAER COUNTY, NEW YORK, 1985.) THE REPORT THEN WENT ON TO CALL FOR EXPANSION OF THE PERSONNEL BASE BY VIGOROUS MARKETING AND RECRUITMENT EFFORTS, STRUCTURED CAREER PATHS, BASIC BENEFIT PACKAGES, IN-SERVICE TRAINING, AND OTHER ACTIONS WHICH NOT ONLY WOULD ATTRACT AND RETAIN WORKERS, BUT ALSO GIVE THEM A FEELING OF SELF WORTH AND ADEQUATE PAY FOR THE WORK PERFORMED. CLEARLY, MUCH NEEDS ΤΟ BE DONE ΤΟ ATTRACT AND RETAIN PARAPROFESSIONALS, BUT THE QUALITY OF PARAPROFESSIONALS COULD BE ENHANCED BY MORE ADEQUATE REIMBURSEMENT FOR THEIR SERVICES. PROPOSED STANDARDS FOR PARAPROFESSIONAL SERVICES IN SHORT, TO IMPROVE THE HOME CARE SERVICES OFFERED IN FEDERALLY FUNDED PROGRAMS, UNIFORM CONDITIONS OF PARTICIPATION SHOULD BE DEVELOPED AND IMPLEMENTED, AND PARAPROFESSIONAL SALARIES AND FRINGE BENEFITS SHOULD BE INCREASED. THE CONDITIONS OF PARTICIPATION I PROPOSE WOULD APPLY TO ALL FEDERALLY REIMBURSED PROGRAMS PROVIDING PARAPROFESSIONAL HOME CARE SERVICES (MEDICARE, MEDICAID, TITLE XX, SOCIAL SERVICE BLOCK GRANT, OLDER AMERICAN ACT, ETC.). UNDER THE CONDITIONS, THESE FEDERAL PROGRAMS WOULD BE REQUIRED TO HAVE: 1. 2. CONSISTENT JOB TITLES, BASIC TRAINING REQUIREMENTS, ON WHICH COULD BE BUILT 4. BASIC BENEFITS, WAGE POLICIES, AND SAFEGUARDS FOR THE PERSONS WHO PROVIDE THIS VITALLY IMPORTANT SERVICE. IN ADDITION, REIMBURSEMENT FOR SERVICES IN THE HOME SHOULD BE ALLOWED TO INCREASE IN ORDER TO MORE ADEQUATELY COMPENSATE FOR THE VALUE OF THE SERVICES THESE PARAPROFESSIONALS ARE PROVIDING. STATE LICENSURE AND REGULATION OF HOME CARE STATE LICENSURE PROGRAMS SHOULD FILL THE GAP IN ESTABLISHING STANDARDS, AT LEAST FOR AGENCIES WHICH ARE NOT MEDICARE CERTIFIED. PRESENT STATE LICENSURE LAWS, HOWEVER, PRESENT A CRAZY QUILT OF WHO IS REGULATED, WHO IS PROTECTED, AND FROM WHAT. |