Academic journal article Generations

Assuring Homecare Quality: A Case Study of State Strategies

Academic journal article Generations

Assuring Homecare Quality: A Case Study of State Strategies

Article excerpt

As homecare has expanded, the response to quality issues has taken multiple routes.

In-home care has become a major component of the health and long-term-care system in the United States, with spending on homecare topping $27 billion in I995 (Vladeck, I996). The increase has occurred in both the "high skilled" services funded primarily by Medicare and Medicaid home health programs and the "high touch" services funded by the Medicaid Home and Community Based Services waiver (1915c) and Medicaid personal care option, the Social Service Block Grant, the Older Americans Act, and state general revenues. Medicaid, which spent almost $10 billion on homecare in 1995, has become a major funder of services for individuals with chronic disability, with expenditures increasing from 1.2 percent of total long-term-care costs in 1982 to 19 percent by 1995 (Burwell, 1996). Home and community-based care waiver services spent $47 billion in I995, and personal care expenditures, an optional Medicaid service, spent $2.9 billion in 1995 (Burwell, 1996).

Accompanying this growth has been a persistent and somewhat nagging concern about the quality of in-home care. Research studies, congressional hearings, and federal and state legislation have sought to address the questions that continue to arise about quality. Despite this attention, little is known about the extent of quality problems, particularly for the personal care services designed for individuals with chronic disability. Even less information is available about possibly successful approaches used to ensure the quality of in-home care (Sabatino, 1986; Applebaum and Phillips, 1990; Kane et al., 1994). Because such homecare is primarily the responsibility of the states, our study focuses on state and local approaches. Using a case study methodology, we examine states that are considered leaders in homecare quality, with an eye toward identifying replicable quality initiatives.


As homecare has expanded, the response to quality issues has taken multiple routes. For homecare funded under the Medicaid home and communitybased care waiver, Medicaid personal care option, the Older Americans Act, the Social Service Block Grant, and state-funded homecare programs, the quality efforts have been varied. For example, while all Medicare home health providers require certification, about 8o percent of states license non-Medicare home health providers, and about onethird of the states license or certify providers of personal care (MacAdam, 1990). Largely left to the discretion of individual states, some programs have replicated the more "medicalized" Medicare approach, while others have used alternative strategies.

Two nationwide studies examining efforts to assure quality in state homecare programs have reported a wide variety of mechanisms designed to ensure homecare quality (Macro Systems, 1988; Health Care Financing Administration, 1993). The 1988 study identified three key strategies used by states to ensure the quality of in-home care: (I) the development of standards for providers, (2) monitoring activities, and (3) enforcement efforts. The standards approach typically included requirements for worker training, agency certification, and criminal background checks for workers. Monitoring activities used by states included supervision of workers, supervisory home visits, case management, contract reviews, and provider visits and audits. Enforcement included withholding contracts or reimbursement and the use of criminal penalties. The study reported that while all public programs had at least one monitoring method, in most states multiple homecare programs operated across various state and local units without common approaches. Although state homecare officials were interested in discussing issues surrounding homecare quality, the study found that most states were unaware of homecare quality mechanisms used in other states (Macro Systems, 1988). …

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