instructional materials have been developed by the armed forces, the Hospital Research and Educational Trust and others that may prove useful in training. With the many types of health workers involved, the problem is to make sure their jos and training do not overlap with similar or closely-related functions of other workers. Continuing education built around a career ladder to help employees advance to higher skilled and higher paid jobs is an essential part of any plan to expand manpower supply.

QUALITY OF CARE: STANDARDS AND ENFORCEMENT

Along with licensure, accreditation of programs and agencies is another alternative strategy to certificate of need. Salkever and Bice" suggested that more attention to quality care mechanisms should be included along with a critical examination of the need to improve CON. Of course, any quality control effort must also be able to enforce standards to prevent abuse and exploitation.

Accreditation is the process by which a designated organization evaluates and attests that an institution or program of study meets certain standards of administration, physical plant, scope and organization of services, including staffing, records and community relations. Many involved in home health care regard the voluntary joint accreditation program of the National League for Nursing and the American Public Health Association" as representing the optimum standards of quality care.

In early 1977, Home Health Services of Louisiana became the first home health agency accredited under the NLN-APHA standards 88. If this level of accreditation is established as the norm, the federal government might consider accepting it as certification for reimbursement, just as it does for the standards of the Joint Commission on Accreditation of Hospitals.

Standards have been developed for the homemaker-home health aide by the National Council for Homemaker-Home Health Aide Services, Inc. 57, along with supplementary services guidelines. These standards are widely accepted.

In addition, the Joint Committion on Accreditation of Hospitals, widely respected for its regulatory activities, has a section of standards for hospital-based home care programs in its accreditation manual. This home care section includes standards for administration, organization, medical staff responsibilities, personnel and qualifications, program review and evaluation, clinical records and community participation.

Witnesses testifying at the five regional public hearings% were united in their call for quality assurance. More than half of the witnesses expressed this concern and identified the following problems:

• Inherent difficulties in assuring the delivery of quality care in the home.

• Variability in quality of care under the differing standards of existing support programs.

• Importance of clearly defined, measurable, and enforceable standards for personnel and institutions.

• Need to protect both the patient receiving services and the public's tax dollars from abuse and exploitation.

Quality assurance in the home is particularly difficult because workers in so many locations cannot be easily supervised. Monitoring of care will, therefore, require costly, onsite observations. Furthermore, since the diseases being treated tend to be chronic, incurable and interrelated, it is difficult to separate them.

Evaluations should reflect the patient's ability to function and meet the activities of daily living. Because of the diseases or conditions involved and the realistic expectation that changes in health status may be slight, evaluation should not concentrate on a narrow definition of health status changes.

Some of the difficulty with quality control activities in home health care programs relates to the concepts of "curing" and "caring." Howell30 equates curing with the technological aspects of health care and caring as more closely related to the art of healing. Measurements of caring usually use the following indicators: satisfaction, the effects on family members, compliance with treatment regimens, and broken appointments. The qualifications of a physician who handles home care patients are succinctly stated by Alex2: "Not only must he be thoroughly qualified professionally, but he must have warmth, understanding, a feeling for people, sensitivity, empathy, and ability to understand chronic illness and its impact upon people and families." He must be able to work with other professional groups. He is practicing "medicine with a heart." Philosophical concerns about caring should be part of the basic and continuing education of health professionals and other health workers.

Physicians and others in positions of making referrals to home health care services must be knowledgeable about those services. Physician referral failure was pointly reported by Nash and Arno" who noted that 58 out of 100 elderly patients were not referred to home care by physicians. Of those 58 patients, 33 were judged to need home care and 10 others required hospitalization. In non of those 43 patients was an appropriate referral made by a physician. Furthermore, their study of 2,652 referrals in 1974 showed 36% were by friends, family and community agencies, 32% by hospitals, and only 18% by physicians. Nash" believes that the main problem is to educate physicians. A survey of a local medical society revealed that those physicians who knew about the home care services evaluated them favorably, whether they used them or not.

Quality assurance in home health care could be linked to existing mechanisms for quality control such as Professional Standards Review Organizations, utilization review committees, medical care evaluations and governmental review bodies. PSRO guidelines exist for about 300 diseases and conditions. It may be possible to proceed in a similar fashion in developing baseline norms, standards and criteria for use by home health care agencies. The PSRO model might be adaptable.

A movement in this direction is supported by research studies such as Stone's86 that showed the results of health care were not statistically different for a random group of general hospital patients, regardless of whether they were treated in the home or the hospital. Neither diagnosis nor prognosis made a difference in the end results at the level of care tested, and physicians and patients strongly preferred home care. Nielsen67 reported that it was statistically significant that fewer patients in his home care group of geriatric patients were

admitted to long-stay institutions. Patients also had fewer days stay in those institutions with no difference in survival rates. Home care patients, particularly those with fractures, arthritis and stroke, had a tendency toward higher levels of contentment. In its review of patients discharged from home health agencies in 1974, the Massachusetts Department of Public Health showed that 75% of the patients remained at home after care was completed, 19% had to be readmitted to an acute care hospital, and only 2% had to be readmitted to a nursing home.

Many of the factors in current evaluations of health care quality have limited application to home health. As Spiegel and Backhaut83 note, most of the norms, standards and criteria do not include measurements that deal with the caring aspects of health care. These types of evaluations would be particularly pertinent for home care patients, since the changes in health status could be minor.

Under the federal government auspices, a series of monographs are being developed that deal with evaluating six identified components of a health care system. These components should apply to the home health care system, for example:

• Is access to services equitable, easy, affordable to all?

• Are services acceptable to groups with varied sociocultural backgrounds?

• Are services available within the geographic community? • Is continuity of care provided with someone responsible for the patient?

• Is the cost reasonable while still maintaining high quality care?

• Is the quality of care up to standards set by experts?

A commonly used quality measurement topology divides health care into three elements for consideration: structure, process, and outcome. Examples of the components of each are illustrated below:

Structure: Facilities, equipment, staffing patterns and job descriptions, personnel with qualifications and experience requirements, organizational arrangements and financing mechanisms.

Process: Technical competence of the providers judged primarily by peers or by accepted standards of care, patient behavior as it influences care.

Outcome: Changes in health status that are reflected in mortality and morbidity rates, disability limitation, distress and dissatisfaction measures.

A major investigation of quality control is underway to try to find relationships between structure, process and outcome. Some believe outcome may not be affected by structure or process and may depend more upon genetics, for example.

Witnesses appearing at the 1976 Regional Public Hearings% overwhelmingly endorsed the need for increased and improved quality assurance and standards with emphasis upon expanded and coordinated services of high quality in a continuum of comprehensive care.

Protection against abuse and exploitation is directly linked to the enforcement of elements such as licensure, accreditation and standards. Spiegel and Podair82 explicitly detail a variety of

monitoring methods, utilization review techniques and medical record auditing activities used in medicaid. A key factor in preventing abuse is the manpower needed to enforce the quality guidelines. In addition, the required legal and political power to carry out rigid enforcement has at times proved problematical. Without enforcement, quality control of home health care will remain in never-never land.

As one focuses on the consumer movement in the health field generally, one advocates that consumers of home health care should play a larger role in determining the quality of care. Van Dyke and Brown 105 advocated the involvement of patients on a consumer advisory committee of home health care agencies. For consumers of home health care, many of the measurements would necessarily deal with elements that are difficult to evaluate in terms of satisfaction. At times, the satisfactions of professionals are also measured as part of the quality control effort.

Allen3 reported on the sources of dissatisfaction of professionals associated with home health agencies especially factors affecting home care referrals. Dissatisfaction was expressed with the quality of home care, with the lack of feedback about patients, with transportation services, with emergency assistance for patients and with the lack of support from the administration on home care referrals, even though quality was rated high on responses.

COST CONTAINMENT AND COST EFFECTIVENESS

We've hardly scratched the surface as far as exploiting health care at home as a cost-saving device. Home visits directed by a physician/nurse team can save dollars and provide good care in a good setting. What's required is for physicians to support this activity more widely than they do at 69 present.

Home health care can be a cost effective method at many levels of care. Its expansion should be encouraged by larger allocations of federal and state health budgets. There are many illustrations that show home health care has reduced patient need for expensive acute hospital care. The illustrations come from insured home care programs, hospital-based programs, and health maintenance organizations (HMOs). Some 113,000 days were saved by the limited home health care benefits of New York Blue Cross'. Denver Health and Hospitals early discharge program reduced hospital stays by 19.2 days per patient; and a Portland HMO home health care program reduced acute hospital stays from an average of 5.4 days to 4.9 days. As for long-term care, the Congressional Budget Office13 says: "there is evidence that 20 to 40 percent of the nursing home population could be cared for at less intensive levels were adequate community based care available."

If the presumption can be made that unit costs of home care compared to unit costs of acute care and, often, nursing home care are less expensive, then a number of questions are raised. Why do third-party payers including medicare and medicaid limit home health care use so severely? Why do physicians and hospitals make relatively little provisions for cost saving home health care in treatment plans? Why do private insurers and their premium payers including businesses, unions, local governments and individuals demand so

little home care? Why do HEW planners make so little effort to place home health care higher on the agendas of HSAs?

The response seems to be a fear of the aggregate costs of taking patients away from hospitals and nursing homes, or overutilization of home health care, of expansion of home health care by the addition of more social services to the medical services, and of destructive competition through uncontrolled proliferation of home health care providers. Clarification should tell which fears are groundless and show where and how to be on guard against genuine dangers.

Many see CON as a means of protection against cost increases. All too frequently, CON has been looked upon as though it were a proven method of cost containment that could be applied to home health care. On the contrary, as Salkever and Bice" have concluded, "While the composition of hospital investment is altered by CON, the total level of investment is not reduced. . . These findings are at variance with the presumption that inflation in the costs of hospital services can be reduced substantially by CON controls on hospital investment."

They have urged rate review and PSROS be considered as potentially more useful for cost containment. At the institutional level, cost containment techniques that appear to work in the short run, involve the crude method of reducing labor costs by attrition or by layoff and government wage and price controls. These are all outside the scope of both CON and HSAs.

Furthermore, CON may be mistakenly thought by some to address cost effectiveness, which it does not. CON is not a monitoring mechanism as rate setting and PSROs are. CON does not explicitly deal with quality and manpower. The concept of cost containment is related, but not identical to cost effectiveness. Only the concept of cost effectiveness goes beyond containment and links cost to the quality of care and the impact on the patient.

Michigan's Office of Services for the Aging" in a report to Governor Millikan has recognized that the types of services available are a major influence on cost. The report contends that in northern states, the reliance is on hospitals and nursing homes-with no evidence of a shift in emphasis to home health care. In contrast, they have found southern states are coping with heavy use of health and social care by the elderly with increased use of in-home, outpatient and community services. The Michigan report contends that this is happening in southern states because, "they can no longer afford the higher cost options and personal choice is predominantly for care in one's own home.'

In advocating a substantial increase in home health care, the Michigan report" recounted the institutional dislocation and cost shifts that could follow:

As there is greater reliance upon in-home and community services, there should be a decreased reliance upon institutional services, hospital services in particular. The effect is likely to be a declining hospital population, increased per capital costs for hospital services, and subsequent increases in reimbursement rates. If this issue is not addressed, and alternative care services are developed, it is near certainty that the aggregate costs for health/social care will increase at a greater rate than at present.

The danger is real; however, the burden may be misplaced. Given the documented extraordinary costs of hospitalization

and the generally acknowledged inappropriate placements in hospitals and nursing homes, the burden should be on these institutions to prove that, at the very least, continued institutionalization is an alternative to home health care. The hypothesis could be advanced that one reason for restricting the expansion of home health care is that no way has been found to offset the expenditure by a reduction in spending for often inefficient institutional care. In terms of long-term care, the Congressional Budget Office13 has been blunt: "Public programs disproportionately support nursing home care. Less than 10 percent of public funds are for home based services... If all services were readily available, the distribution of the disabled and elderly among levels of care would be quite different from its present distribution. There is a large, unmet demand for sheltered living arrangements, congregate housing, and home health care."

In one of the most methodologically sound studies, Greenberg24 estimated 9% of the 1974 Minnesota nursing home population could be cared for less expensively at home. He found that only at the worst disability level is home care as or more expensive than nursing home care. The Congressional Budget Office13 has noted the danger of a net cost increase by deinstitutionalizing patients and providing them with home health care without considering restructuring long-term care.

Despite evidence of possible savings from deinstitutionalizing some present nursing home residents, the number of the noninstitutionalized disabled who are bedridden or need personal care assistance is so great that patients removed from nursing homes would be quickly replaced. Moreover, home health services, if not limited to those who had first been institutionalized, would be demanded and needed by so many of the noninstitutionalized disabled that there would be a net increase in expenditures.

The evidence is far stronger on the hospital side that home health care could be used without replacement of patients in hospitals. How hospitals and nursing homes cope with the financial loss of patients will be one factor in assessing the rate of increase in the nation's health care costs.

The total costs of health care will increase in any event as a higher proportion of our population becomes elderly and suffers from chronic disease. However, home health care may be able to slow the rate of increase. A substitution of home health care for hospital and nursing home care would seem to meet patient preferences while lowering cost to third-party payers.

The Michigan report" recognized the need for a definition that can provide a balance and prevent abuse.

Additionally, while the report continually refers to possible cost savings, in no way is it suggested that cost savings automatically occur when lower unit cost services are made available. For example, reimbursing a family $16 per day to care for a mom,' rather than pay $20 a day to a nursing facility would not save program dollars if nine other families who would care for their 'mom' without reimbursement now apply for and receive membership in the program.

Despite such dangers, many reports come out strongly for home health care, not only as an alternative to acute care, but as an alternative to nursing home care. One strong cost argument in favor of such care compared to nursing home care is stated this way.

Just as significantly when discussing costs, home care can be phased out or lessened for many people over time, while nursing home care usually results in dependency and continual use until death. Thus, even if temporary home health or home service costs are not truly 'cheaper' to the State for the first few days compared to a nursing home, they very likely will be over a longer period."

The favorable comparisons between institutional care and home health care make the further expansion of home health care an important policy direction. Present government policies are restricting that expansion. Medicare requires 3 days of prior hospitalization before granting eligibility for home health care. Medicare Part A also restricts the number of home health visits to 100. While the federal medicaid regulations are on the surface more liberal, these regulations permit states to use medicare eligibility requirements for medicaid, which many have. If government planners are serious about cost effectiveness, they must consider an expanded definition of home health care need that permits greater access and, at the same time, balance it by requiring enforcement to prevent abuse.

A distinction needs to be made between two views of cost effectiveness: cross-institutional comparisons of home health care, usually with a hospital or nursing home (which have just been examined) and comparisons among home health providers (which will be reviewed).

The comparisons of cost effectiveness among home health care providers pose many metholodogical problems, which make it impossible to draw firm conclusions. One key need is to develop uniform reporting58 of costs and services so that firm conclusions can be drawn. Failure to provide for uniform reporting will further complicate attempts to assess crossinstitutional cost effectiveness.

Provider financial reports rarely show what was included or excluded in the cost calculation. It is not possible to tell whether capital costs, professional services applied by another body, such as a public welfare department, or physicians' fees were included. There are also no longitudinal studies that could provide a basis for judgments on the duration of care from year to year. Neither is financial and statistical data linked to the intensity, duration, or complexity of the services rendered.

Meanwhile, rough comparisons are being made between not-for-profit agencies, proprietary ones, and among established and newer not-for-profit agencies. Florida found a wide range of costs and staffing ratios among not-for-profits. It also found that so many not-for-profits had relatives on the board that the recommendation was made to set a limit to two relatives per board. Etzioni19 examined the legally permissible but no less unethical abuses that some established and new not-for-profits in health are able to get away with because of their structure. These small numbers of abuses are tainting the good works of the vast not-for-profit area. On the other hand, there have been findings among proprietary providers that suggest excessive billings to medicare for lavish comforts of the providers. A number of other serious scandals have broken out among proprietary providers. What these findings reveal on the cost issued is that agency auspices is not a useful way of examining cost, and may, in fact, be irrelevant. If any generalizations can be made, it will after more uniform cost reporting.

The expansion of home health care is warranted on cost grounds based on the present federal and state definitions of need. Decision makers considering expanded definitions of need for federal and state reimbursed services will find, as the Congressional Budget Office has, that the area of unmet need is frequently in home health and not in new institutional care.

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