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. The 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. 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 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 threeyear contract in September, 1985 to develop, pilot test and refine seven patient outcome measures for the quality of care provided by home health agencies. Three outcome measures were tested during the project's first year and two additional measures have been selected for testing during the project's second year. 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. APPENDIX B "THE BLACK BOX OF HOME CARE QUALITY" APPENDIX SUMMARY OF STATE REGULATIONS ON HOME CARE QUALITY The primary form of state regulation over home care services is licensure. Thirty-four Ohio requires the but states (including the District of Columbia) have licensure laws as of June 1986. registration of home health agencies, that is not treated as licensure for purposes of this summary. The table on the following pages compares the basic scope of licensure coverage and other selected aspects of existing state licensure laws and regulations. The focus of comparison is primarily on requirements relating to accountability to consumers. The Medicare Conditions of Participation are included in the table for comparison purposes. Six states (DE, DC, LA, MO, PA and VA) do not have final regulations; therefore, the information in the table is based only on their statutory provisions and could be significantly altered upon final passage of regulation. The table is derived only from provisions contained in licensure laws and state regulations. Therefore, inferences cannot be drawn the to 6. Program evaluation and advisory group functions. Every state with licensure requires some kind of formal agency self-evaluation mechanism, usually on an annual basis at a minimum. Most also require the creation of an ongoing advisory body to participate in evaluations and, more generally. advise the agency. This item of the Table identifies two requirements outside involvement in this process: minimum requirements for the involvement of persons who are neither owners nor employees of the agency (14 states require); and (B) minimum requirements for consumer involvement (16 states require). instances, the required level of involvement is minimal (e.g.. one or two persons) or undefined. In most for (A) |