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abled, dependent, depressed person is left to find their own attendant for homemaker or in-home supportive services worker.

We find the turnover to be exceedingly high in certain kinds of cases, and we find repetitive examples, anecdotal to be true, because title XX doesn't even have a simple data base-examples of our first witness where the person just doesn't show up or they quit on the spot. It is the kind of thing that if you are paying minimum wage or less, the second there is an opportunity the person is going to take it, and I can't really blame them very much. And, some illegal aliens into the country are employed in this program, too, sir.

The CHAIRMAN. Yes. I'm sure that minority groups in general and illegal aliens are employed in this field. The illegal alien would not have any protection of any kind, and many minorities would not know how to protect themselves as is the case with many of us in a situation that we are not familiar with. But in analyzing this testimony, I find that the Federal Government, then, has quite a responsibility. What we have to do, then, is to establish minimal standards and requirements on a national level.

We have to also establish guidelines that would have to be followed by those agencies or those organizations that do in fact provide health aides. The State licensing must also have minimal requirements, but done so in a manner that would not infringe upon the rights of the States. That is going to be the most difficult one of all. At the same time as this is being done, we have to protect the consumer and propose legislation where the procedures throughout the Nation would be uniform.

Does that more or less summarize what we have been talking about? Yes, Ms. Coleman.

Ms. COLEMAN. Congressman, about 31⁄2 years ago when the Commission looked at the board and care situation, we found that there were 122 State statutes in 49 States. When Mr. Sabatino testified earlier there were 33 State statutes which looked at home care, we find the same sort of problem; that is, we have looked at licensing in board and care, for instance, for the aged, for the disabled, for the mentally disabled, for the mentally retarded, and that bifercation of that system is very similar to what we are looking at now, and we haven't moved past the sort of point that we are now at now which I think you see, and that is a need for Federal standards setting certification standards.

The CHAIRMAN. I think there is one thing we haven't touched on, and that is the matter of case management, the monitoring of care, and particularly its effectiveness in maintaining quality. My question, then, is who should do the case management? Is case management essential for quality home care in every instance?

We can differ in opinion as to whether or not case management is essential to quality home care in every instance, but surely, I think we must come to some conclusion with regard to maintaining or seeing to it that quality be maintained in a manner that results in quality of the delivery system. The question then is if case management is to be effective in maintaining quality, who should do the case management?

I am going to ask Mr. Pickering do you have any suggestions?

Mr. PICKERING. I do not, Mr. Chairman, because this is a detail in the health field that I don't feel I have enough information. I would like Ms. Coleman to address that.

The CHAIRMAN. All right. He has passed the buck on to you, so let's hear from you.

Ms. COLEMAN. I think that case management is essential, and I think it has to be an independent agency. It cannot be the same agency which either provides a service or is the monitoring agent. The CHAIRMAN. Mr. Hall.

Mr. HALL. I would tend to agree with Ms. Coleman.

The CHAIRMAN. Mrs. Quinn, do you agree?

Mrs. QUINN. I agree, it is especially important in long-term care for older adults.

The CHAIRMAN. In that atmosphere of agreement, I think we must conclude the hearing. But I would want to take a moment to personally thank all of you who are present, thank the American Bar Association for working with us and developing this hearing and for the opportunity of releasing this report. There is no doubt that the American Bar Association has made a great contribution to the elderly and disabled in preparing this report, and has performed a great service to the Congress in providing us with the information we need to move forward with appropriate reforms.

What we have discussed, gives us the framework upon which we can proceed. On the other hand, I am sometimes disturbed by the fact that after all of these hearings and after all of these recommendations are made, and after the Congress puts things in order as we did with the bill, the Home Care Quality Assurance Act of 1986, that no one wants to support it.

Well, I think that organizations, including the American Bar Association and everyone else should take a stand either for or against it, because if they are not for it, they must be against it. Well, maybe that's not fair. I don't want to go that far, but it seems to me that a position should be taken because we need help. Without the help of the people who are actually involved in the day-to-day process of bringing this about, we can't do anything in the Congress of the United States, absolutely nothing. We need support, and I hope that down the line, after we introduce the bill, that the various organizations involved will take a position on it and make recommendations as to how it can be changed.

Don't forget that when these bills are introduced they can be changed in committee and subcommittee to begin with, and in the full committee. They can also be changed in the floor of the House and in the Senate, so the recommendations to change are welcome, and the introduction of the bill is not final. That is why we need some input. We need recommendations; we need the advice of experts because none of us are expert on everything in the Congress of the United States even though sometimes we pretend to bẹ.

Mr. PICKERING. Mr. Chairman, our Commission on Legal Problems of the Elderly will make your proposed legislation one of our priority items for study. As you know, the American Bar Association is a representative group. Its policy is developed by the recommendations of commissions or committees, such as the one as I chair, going to its house of delegates or to, in some stances, the board of governors. We will be very happy to work with you and

your committee in seeing whether we can agree on a common ground here, and I pledge that to you, sir.

The CHAIRMAN. Mr. Pickering, may I thank you. Thank you, Ms. Coleman, Mr. Hall, Mrs. Quinn for your testimony. It has been interesting.

I am being handed a little note here that I have 5 minutes in which to answer rollcall. I thank you very much for your very excellent testimony. The committee will take it under advisement, and we hope that we can work together to develop a piece of legislation that will be meaningful. Thank you very much.

[Whereupon, at 5:07 p.m., the hearing was adjourned, subject to

the call of the chair.]

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ADDITIONAL QUESTIONS AND ANSWERS

RESPONSES BY THE AMERICAN ASSOCIATION OF RETIRED PERSONS
TO ADDITIONAL QUESTIONS ON HOME HEALTH CARE
REQUESTED BY THE HOUSE SELECT COMMITTEE ON AGING

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Do you believe that a better quality assurance system for home care would uncover many more quality problems than we are aware of now?

While an effective quality assurance system is an essential
and intrinsically valuable management tool for any public
program, it is not possible to predict the results of such
a system other than increased consumer satisfaction and
confidence. We presently have few, if any reliable data
concerning the quality of home health care services being
provided. Since many of the elderly served by such services
are frail and homebound, however, it is possible that there
are many problems that are not now uncovered. A better
quality assurance system would help ensure that attention is
paid to problems on behalf of such individuals.

Given that HCFA surveys have uncovered significant patterns of non-compliance in one region of the county, what should be done to ensure that home health agencies comply with Medicare conditions of participation?

In addition to a well planned and regularly implemented survey of providers, HCFA needs to have the means to achieve prompt correction of deficiencies, when they are revealed by surveys. At present, the only sanction HCFA has is termination from Medicare participation. A more realistic and effective compliance tool would be a series of graduated sanctions similar to those proposed for nursing homes in the recent report by the Institute of Medicine.

How do you account for the fact that while home care
continued to expand rapidly, that expansion is less than that
predicted by HCFA actuaries, expecially in light of shorter
lengths of hospital stays and the aging of our population?

Dr. Shelah Leader's research on this issue suggests that HCFA
is curtailing use of home health care services by means of
claims denials. There is evidence that existing HCFA
eligibility standards are very narrowly construed and
applied in an arbitrary and capricious manner.

You said that studies are needed to compare cost and quality of home care services provided by non-profit and for-profit agencies. Do you have any prelimenary or anecdotal information of the effects of the growth of for-profit agencies on home care quality?

Unfortunately, we have not found any information on the
impact of ownership on quality of care. HCFA data do show
that total and per visit charges vary with type of ownership,
but this information is hard to evaluate without knowing the
medical condition of those being served.

What can we learn from our experience with hospitals as to whether or not a system of voluntary accreditation is sufficient to ensure the quality of home care services?

First, home care providers presently have few incentives to seek voluntary accreditation. And, most accreditation surveys are paper reviews of organizational structure and capacity to provide services. A true quality review should contain outcome measures of beneficiary health and functioning.

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In response to your kind letter of August 7, 1986 following up on your home care quality hearing of July 29, we are pleased to provide the following responses to the four questions you enumerated.

1. WHY IS IT THAT THE FORCES OF THE MARKET ARE NOT
PUSHING PROVIDERS WITH BAD REPUTATIONS OUT OF THE
HOME CARE BUSINESS?

Market forces can work only when consumers of
home care have access to reliable and relevant data
about home care quality, and they have adequate
alternatives from which to choose. As the "Black
Box" report makes clear, useful information is simply
not available upon which consumers can make informed
choices. Funding availability, rather than consumer
choice, often dictates the service and the provider.
The basic objective of our recommendations is to give
consumers the tools they need to become a true market
force capable of influencing the quality of home care.
2. WHAT, IN THE WAY OF STANDARDS, MONITORING,
SANCTIONS AND CONSUMER RIGHTS ARE NEEDED TO
ENSURE A QUALITY HOME CARE SYSTEM?

Standards

The ABA makes no recommendations regarding the specifics of standards. Specific standards need to be established through a collaborative process involving providers, public officials, advocates and consumers. A guiding principle in the standard setting process should be that, in home care, quality of care and the quality of life are different but intimately connected concepts; they are largely defined by the unique values and preference of each patient served. Therefore, standards should aim to "empower" consumers to enable and encourage them to exercise choice and control over their care. This is done by instituting consumer "checks and balances" at all points in the care system. For example, with respect to organizational standards, clearly defined consumer involvement in the home care agency's policy making body could be mandated. In addition, minimum liability insurance and bonding requirements could be dictated.

With respect to personnel standards, all home care workers need to be properly trained and certified to ensure that patients' needs and choices are being responded to adequately. Formal training and certification are especially important with respect to the services of the lesser skilled workers who provide the bulk of day-to-day help with activities of daily living, personal care, meals, housekeeping, and other support services.

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