E. delivery." As pointed out earlier, there are significant differences in the modes of service delivery, however the definition of mode was never accurately defined. The countles in the State use one of three modes: (c) IP plus county welfare department The Study Report continually confuses the reader by implying that the IP mode, the contract mode and the county welfare department mode are options for counties who can choose any one of them. The reality is that due to the cost of a small percentage of severely impaired clients, there is no such thing as a "pure" contract or county welfare department mode. The choice, therefore, is not between modes but in selection of the best balance of modes to provide quality assurance and cost effectiveness. It would appear from the study that a combination of contract and IP is the most cost effective and gives the best chance of quality assurance. San Bernardino and San Joaquin counties demonstrated this. Statewide, 27 IP only counties serve 62.7% of the clients and use 65.7% of the dollars. Sixteen IP plus contract counties serve 33.7% of the clients and use 30.1% of the dollars. "Enhance the IP mode to insure 'good' service can be The Study Report states: "Enhancing the IP mode with fundamental components to promote efficiency combine the best attributes of providing IHSS as seen in the county welfare department and contract modes with the low cost service the IP mode affor cs. The result could be a cost efficient hybrid serving the State's IHSS population at greater overall savings." The way in which "enhancing" would take place would be to have county staff: F. SUMMARY (d) Monitor IP service These endeavors would certainly enhance the IP program We but it does not come to grips with the basic problem as "DSS conduct a study to determine if Social Security This recommendation is opting for the concept of block grants to be given recipients for domestic services. This program change would promote over-utilization, since it does not relate to sensible assessment and reassessment of client need and did not work before. The Report took basic IHSS program data from eight study counties and were unable to come to the conclusion that a combination of IP and contract modes was the most cost effective mode and provided the best quality assurance. The Report authors were unable to discern that uniform needs assessments conducted with some frequency, will lead to appropriate utilization, and appropriate utilization will lead to a cost effective and abuse free program. It was found that the study data showed that Los Angeles County with 38,492 recipients at a cost of $319.95 per client per month (Fiscal Table V) with 31% of the state population (Department of Finance), having 40% of the clients and consuming 43% of the total IHSS budget. This inequity was never mentioned. The Report failed to comment on the fact that Los Angeles County (all IP) has 9 more clients than their population would indicate. The Report failed to comment on the fact that Los Angeles County utilizes 13% more of the budget that its population would seem to warrent. The Report seems to indicate that since Los Angeles has a higher average disability Index, it is justified in more hours per case since its recipients are more disabled. We fail to agree with this implied conclusion since it was stated elsewhere in the Report that the uniformity of assessment is in question, and that IP's receive more hours to get them to work and thus the disability index is selffulfilling. In conclusion, the "Study" Report contains valuable raw data that has been ignored or manipulated to obfuscate. We fail to understand the reasons for this, however it seems apparent that the largest county in the state will not be asked to improve their service mode by the State Department of Social Services. APPENDIX E PREPARED STATEMENT OF JO-ANN FRIEDMAN While I have worked in health care and health care communications for the past 19 years, it was my personal experience in home care (as a provider and as a patient) that underscored the benefits and the challenges of this "new" health care treatment setting. In 1982, I was hospitalized with a sudden, paralyzing illness called Guillain Barre Syndrome, a viral attack on the nervous system. Muscle movement sparked by the affected nerves became progressively weakened. I had seen patients with this illness before and I knew of its rapid onset. As my arms and legs became weaker and weaker, so-called simple activities such as eating and walking became almost impossible. Everyone, including me, waited to see which abilities I would lose and which would remain. Fortunately, I knew that with time and physical therapy, my weakened muscles would grow strong again. Once the viral attack subsided, the comfort and convenience of my own home seemed the ideal place to be. Clearly, I needed help just to get around: my eyes were paralyzed, my coordination and balance were reminiscent of a drunk's. I was so weak that my then six-year old niece was able to push me over with the touch of her finger. I knew I needed physical therapy to help me regain my lost strength and balance. As a patient I learned that many health professionals lacked comprehensive information about home health care. The hospital staff doctors, nurses, therapists and social workers -- were unable to answer my questions about arranging home care. Despite my own expertise I was unsuccessful in my attempts to get the hospital to "officially" place me on home care. Eventually my wish to go home outweighed my wish to untangle the hospital's administrative web. arranged for my own housekeeper and physical therapist. I No Home care demands a great deal of informed consumer involvement. other health setting requires such a high level of knowledge of what's needed, where to find it, how to pay for it, what to expect from therapists, aides and nurses, where to go for support and information, and what to do when you're not receiving quality care. A My experience convinced me of the benefits of home care. It also alerted me to the frustration and difficulties which patients and their families encounter in arranging and coordinating quality care. In writing the almost 600-page consumer guide HOME HEALTH CARE: Complete Guide for Patients and Their Families (W.W. Norton) I assembled the practical information needed to ease the road to recovery or to manage an ongoing illness in what can be the best of all possible treatment settings: home. PREPARED STATEMENT OF THE NATIONAL LEAGUE FOR NURSING The National League for Nursing (NLN) welcomes the opportunity to express its views regarding quality in home health care. Recognized by the U.S. Department of Education as the official accrediting agency for nursing education, the League's 1,800 agency and 1,800 individual members comprise a unique non-profit coalition that promotes quality nursing care to the public. As a national accrediting organization for home and community health care, we are committed to upholding and improving standards of home health care so that consumers receive care of the highest possible quality. The NLN accreditation program is a voluntary peer review process, established in 1961. It represents our commitment to working with other health professions with particular focus on consumers as recipients of care. NLN's community and home health accreditation program has encouraged providers to adhere to nationally accepted standards. It has also stimulated improvements in the way accredited agencies provide care by requiring them to examine the evolving relationship between providers and clients. This relationship has come under closer scrutiny lately as a result of multiple changes in the health care system. These changes are the result of new pressure from private third party payers and from the enactment of Medicare's prospective payment system, which introduced new incentives for the provision of hospital care to Medicare beneficiaries. Changes in financial incentives have led hospitals to discharge patients "quicker and sicker," resulting in a stepped up demand for post-acute care services, and in particular, home health services. Once dominated by public and voluntary agencies the home health field now comprises a broad spectrum of providers, ranging from family-run businesses to large multi-unit corporations. Proliferation in the types of facilities that are available in the community has helped to improve patient access to home care, but little has been done to improve coordination in continuity of care. Fragmentation of care has exacerbated the need for greater coordination of and attention to quality. Consumers are often confused as to which resources are available and under which conditions. Furthermore, rapid growth in the field has been |