CONNECTICUT COMMUNITY CARE, INC.

August 12, 1986

The Honorable Edward R. Roybal

Chairman

U.S. House of Representatives
Select Committee on Aging
Washington, DC 20515

Dear Representative Roybal:

Thank you for the opportunity to present testimony at the
Committee's July 29th Hearing on the Quality of Home Care.
I believe it is an issue that is very important, as the
home care area is such a growth area at the moment.

With regard to the additional questions that you sent in
your August 1st letter, I will answer them sequentially.
1. Is the home care consumer able to judge quality

adequately? If not, what protections are needed to
ensure that home care services are of high quality?
Answer: I do not believe that the home consumer is
able to adequately judge the quality of care delivered.
In addition, older people--even if the quality is
poor--might not comment about it because of a fear that
they will loose the service. Certainly, standards for
services delivered in the home should be developed.
Those standards should be uniformly applied across
states and home care workers should be properly
educated and supervised in the home care setting.
Currently, there is much diversity among states with
regard to both education standards and supervisory
requirements.

2. What impact has cost containment and the move to DRG's had on the quality of home care services? Where do providers make cuts when the budget axe falls and what will happen to quality if additional cuts are made?

more

Answer: Secondary to the implementation of DRG's, home
care providers are receiving referrals of much sicker
clients. The hospital attempts to discharge a person
before the DRG diagnostic time limit, and work diligently to
see that clients get home before the DRG expires. Home care
providers, because of a fear of retroactive denials or
erroneous Medicare interpretations by fiscal intermediaries,
are reluctant to even admit selected clients for home care
services. The amount of time allocated for reimbursement by
H.C.F.A. for home care services has become more and
constricted. Therefore, any professional judgement regarding
assessment of the client's needs when determinining how much
service is needed is not considered, rather cost containment
is the driving force for the amount of service approved or
disapproved. Providers, when cuts occur, have few options
other than to alter their labor pool or hire temporary help
for home care for whom they do not have to pay benefits, as
the home care service area is so labor intensive. Temporary
help is often non-continuous, so that different people may
serve the client every day disrupting continuity.

4.

3.

What effect do staff turnovers and low wages

ly among home care sides, have or quality care and DON
problems be corrected?

Acsver: The home care aide position is a low status, Joom
Ang position. There is little opportunity far

mare

and additional education necessary to move on to a
.evel position. In addition, DORE cate aides
female. There is a definite need tc lactease
vages, to
working conditions better, auc
engage them 10 the care planning for the silent.
found at C.C.C.I. that engaging para-professional staff a
meetings with professional staff around silent pris less sues
Kas 2 positive effect of the side perception of area, because
they are delivering the majority of on-going care Cid se
at-home individuals. Deficitely, providing some education and
career mobility, as well as improving the status of this
position will help retaic bome care gare-professional staff.
Again, the amount of assistance that the agency can provide in
these areas is highly dependent upon adequate third party
reimbursement for the services that the sides deliver.

At what point do you believe that a quality assurance system becomes so burdensome that it is counterproductive?

Answer: If a quality assurance system is extremely rigid and
does not allow for individual idiosyncrasies, it becomes
counterproductive. To deny access to an agency because of the
stipulations of a quality assurance system has occurred, i...
the patient "is not safe," renders the situation more unsafe
for the patient/client. For instance, if a client determines
that be she would prefer to stay home and risk the chance of
falling, and makes that decision competently, he/she should be
allowed to remain at home. If the person needs agency help in
this situation, they will often be denied by the agency
because the home care agency determines that the person is
The
unsafe, and thereby accelerates the unsafe situation.
agency justifies their decision by utilizing their quality
I believe that
assurance system rules and regulations.
anytime a quality assurance system does not allow for client,
family independent decision-making, it is counterproductive.
The other significant area that is counterproductive to the
provider agency 18 one where there is a mandated different
quality assurance system for each contract/grant that they may
implement. There can be no uniformity in the program in COLS
situation and the agency staff have to keep changing the
quality assurance system for each reimbursement source.
situation can be extremely complicated, counterproductive,
expensive. This situation occurs with both public and private-
ly financed programs.

If you have further questions, please feel free to
with me at your convenience.

Cordially,

Joon

Joan Quinn
President

This 424

COMBURicate

This is in response to 1 or letter with rament to ga hearing on the issue of home health care quality.

I appreciated var cenart of the hosting stated before. I agree that this 15 at Laportant

We are working on a statement Eve the razvē requested, and that will be forwarded to car is the near Eltur

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 Joris for

Patricia Knight

Deputy Assistant Secretary
for Legislation (Health)

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