accompanied by reports of fraud and abuse, which unfortunately, are all too familiar to the members of this committee. These problems demonstrate the need for external quality assurance programs such as NLN's community health and home care accreditation program.

Because of mounting concerns about quality in the home health arena, the NLN Board of Directors, in February of this year, approved a position statement on ensuring quality in home health care. Given the prominent and well-established role of nurses as the primary provider of home healthcare, the Board:

"...affirmed their belief that it is the responsibility of the nursing profession, which historically has been the predominant home care provider group, to establish and to uphold standards of home health care. The quality of nursing care delivered in patients' homes should be monitored by nurses themselves through a self-regulatory process that relies on nursing expertise, augmented by the participation of professionals in other provider disciplines and representatives from the community."

At this point in time, it is more critical than ever before that an effective mechanism be in place for ensuring quality to consumers of home health care. The NLN accreditation program--with its sound reputation, nationally accepted standards, consumer and interdisciplinary involvement, and ongoing methods to incorporate changes--makes an important contribution towards those ends.

As you may know, NLN has applied to the Health Care Financing Administration (HCFA) for deemed status of our home health accreditation program. If the NLN were to receive deemed status, home helth agencies with NLN accreditation would be recognized as meeting the Medicare Conditions of Participation without having to go through a state agency certification process. We are working with HCFA to acquaint them fully with our program and we are optomistic that a favorable decision will be made this soon. We appreciate any support this committee might give on behalf of our application for deemed status.

We believe that deeming NLN's program is the first of many steps to be taken by the private and public sectors to guarantee a high level of quality to recipients of home health care. We also commend you, Mr. Chairman, and other committee members for your interest in home care and for convening these hearings.

The title of the hearings, "The Black Box of Quality for Home Health Care," reflects the substantial lack of information in this field, making policy recommendations more difficult. We believe that the NLN accreditation program, by setting rigorous standards and requiring accredited agencies to adhere to extensive reporting and evaluation procedures, will help answer some of the pressing questions, and provide greater accountability from agencies participating in the Medicare program.

We look forward to productive discussions with committee staff and members in the months ahead, as together we strive to fill in the gaps for such a critical area--the safety and quality of care rendered to our nation's recipients of home health services.

PREPARED STATEMENT OF EDWARD N. SAGE

ON BEHALF OF

THE NATIONAL ASSOCIATION OF AREA AGENCIES ON AGING

QUALITY ASSURANCE IN HOME CARE

Home care is a growing service industry, being requested more and more as an alternative to institutional care. A recent National Research Corporation survey of 1,000 consumers determined that home care was the top priority for alternative health services most needed in local communities. And as America's "old-old" population of persons 85+ continues its rapid growth in numbers, there will most likely be similar dramatic growth in the home care industry.

But such growth needs to be watched, for there are major unresolved issues facing home care in the U.S. A recent report compiled by the Oregon State Senior Services Division makes the following points.

"At the core of the problem is our approach, as a nation, to long-term care: we have defined long-term care as a medical problem; insisted on professional medical long-term care services (either directly provided or supervised); funded these services with state and federal medical dollars; and created a highly regulated system to provide these services, modeled after the acute medical services available through hospitals and home health agencies. All this we provide for the typical long-term care consumer, whose primary problem is functional, not medical.

"While the elderly have a greater incidence of medical problems than the
general population, these problems tend to be acute and short-term. Very
often, however, the aftermath of these medical problems is to leave the
elderly person in need of services to help them function on a day-to-day
basis. These services need not be medical (only the United States
considers them to be); are usually simple in nature (assistance in eating,
dressing, and moving are the most common); and do not require professional
medical provision or supervision." (1)

So home care is more than "home health" care: it includes home delivered meals, personal care, housekeeping services and minor home repair or chore services. "At its best, home care is holistic, providing in-home health, social, and other human services that can help you as a whole person, not just as a 'patient'." (2)

Yet home care is not always "at its best." There are abuses. There can be fragmentation services. Different from institutional care where a single provider cares for an accessible, centralized client population, home care often consists of a multiplicity of providers giving care to homebound clients.

Independently delivered home care can become a fragmented, scattered series
of services difficult for the client to manage to assure their own quality care.
One example of this problem was recently quoted in the book The Home Health
Care Solution by Janet Nassif:

"It took eighteen separate phone calls for Margaret B. to find help for
her mother in the city Margaret once called home. After her mother had
fallen and fractured her hip, Margaret came the thousand miles to help.
But now, two weeks later, it was time for her to go home. Her mother was
going to need help, mostly custodial long-term help. Mrs. B's doctor had
suggested nursing home care, which Margaret staunchly refused. But she
privately worried whether she had made the right decision and how long her.
mother would be able to remain at home."

Margaret, and other consumers of home care like her, would have benefitted from "case management" services. These services are designed to inform the client of their options, help in selecting the appropriate home care provider(s) and then monitor the services provided to assure that the client receives the appropriate level and quality of care.

The National Association of Area Agencies on Aging (NAAAA) recognizes that quality home care must be provided to America's frail and vulnerable older citizens. We believe the key to the development and assurance of quality home care programs is a strong local case management system. We also believe that Area Agencies on Aging are the best community organizations to provide such case management services.

Since 1973, the Older Americans Act has mandated that local Area Agencies on Aging (AAAs) "foster the development of comprehensive and coordinated service systems" as well as "secure and maintain maximum independence and dignity in a home environment for older individuals."

In 1978, Congress also required Area Agencies on Aging to "provide a continuum of care for the vulnerable elderly." More recently, Congress has mandated under the 1984 Amendments to the Older Americans Act that Area Agencies on Aging are "to facilitate the coordination of community based long term care services designed to retain older individuals in their own homes...and designed to emphasize the development of client centered case management systems."

Given this emphasis, AAAs nationwide are becoming more and more involved in developing and managing case management services as a way to assure quality care is provided to the elderly of our country. A recent study on case management completed by the University of Washington's Institute on Aging found that there are several reasons why case management is so important in assuring quality care:

"First, fragmented and complex delivery systems present formidable
obstacles for functionally disabled persons. Second are the perceived
needs of impaired elders, who require assistance from multiple providers.
Third, case management is consistent with professional values of enhancing
self determination, the primacy of client interests, confidentiality and
privacy." (3)

NAAAA believes Area Agencies on Aging are in a unique position within their own community to provide case management services. For the most part, Area Agencies on Aging are able to focus attention solely on client care needs without regard to any pecuniary interest in the direct services to be provided to the client.

Home care service providing agencies which also provide case management services often will not (or cannot, due to budget limitations) coordinate or assure the delivery of services to the client other than the services the provider agency manages directly itself. In areas where no other qualified provider of service exists, the AAA may have to act as both the case manager and the provider in order to assure the client the availability of an appropriate quantity and quality of services. But only 16% of AAAs nationwide provide direct services.

Congressional intent, plus the dramatic increase in the older population has propelled Area Agencies on Aging as advocates for the elderly into being the primary developers, case managers and evaluators of home care services in many parts of the country.

"One of the virtues of case management as a policy reform in long term care is precisely that it can be placed within the ongoing delivery system and does not require restructuring of interorganizational relationships." (4) Therefore, NAAAA recommends that Congress give priority consideration to the further development and strengthening of case management systems operated by AAAs to 1) reduce fragmentation of service delivery in the home care market and

2) assure the maximum amount of client choice and control of their own home care

services.

Success stories of assuring quality home services through case management services abound. Just one letter my agency has received as an Area Agency on Aging operating a case management program for home care clients is

representative of the many: