Five Steps to In-Home Quality Care

By Applebaum, Robert | Aging Today, September/October 2003 | Go to article overview

Five Steps to In-Home Quality Care

Applebaum, Robert, Aging Today

In talking with care managers, administrators, funders, regulators and policy makers, I am always impressed by their commitment to quality services. Ironically, despite this universal interest in quality, in most instances these same respondents do not feel that their programs are as good as they can be. Many of them describe a scenario in which they are committed to quality, but others in their organizations do not share their view. Often care managers report being limited in realizing their goals for better quality by agency administrative staff and service providers.

Furthermore, providers who assert their commitment to quality have told me at times that they wonder why care managers do not share their vision. Why is it that agreeing on a common concept of quality is so difficult? And why is it so hard for care-management agencies to develop a working model of quality assurance and care?


Systems addressing quality care fail to achieve their goals for three critical reasons. First and foremost, quality is compromised because agencies do not keep a clear enough focus on their consumers. Those of us in the field of aging also experience being consumers every day. We know that good quality exists when a service or product does what we want it to do. If providers have no mechanism for consumer input, high quality seldom is possible. Because care-management programs serve older consumers who experience chronic disability, many assume that consumer input is difficult to ascertain and less important than moving ahead with care.

The second quality challenge results from a lack of agreement at care-management organizations about their major goals. When one unit makes its objectives more important than the goals of the overall agency, quality is compromised. One example occurs when the fiscal office of a care-management agency decides that getting the lowest unit price for purchased services is its most important objective, regardless of service quality. This decision may result in consumers receiving sub-par services and care managers spending more time monitoring services. The common goal of all units of a care-management oranization should be providing cost-effective, high-quality in-home services.

The third factor is an organization's quality-management approach. Efforts to assuring quality care long have been based on a model oriented toward inspections. The dominant strategy of this method relies on an annual inspection, which focuses primarily on measuring proxies of quality, such as the number of training hours employees complete, the thoroughness of paperwork and an accounting of expenditures. This approach has two major flaws: It largely ignores consumers of care and, regardless of how good an inspection process is, an annual monitoring visit cannot succeed in developing ongoing quality in a program. The unsuccessful efforts in the United States to regulate nursing homes using this model provide considerable evidence for the failure of this approach.


In response to these challenges, I propose five action steps to enable care-management agencies to achieve quality care.

Agency staff must be committed to changing practices when necessary. Most people and organizations have mixed feelings about feedback. On the one hand, they would like to know how they are performing; on the other, they generally like to hear words of praise. Unless there is a strong determination to improving practice by considering both positive and negative feedback, efforts to ensure quality will fail. This commitment must be shared across an agency. Many agencies set up a dichotomy by separating the staff that delivers services from those responsible for quality, but all staff need to be responsible for quality care.

Listening to consumers is integral to any quality strategy. There are many reasons why it is difficult to get older people, especially those with disability or chronic illness, to provide feedback to a healthcare program. …

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