Personal Care Satisfaction among Aged and Physically Disabled Medicaid Beneficiaries
Khatutsky, Galina, Anderson, Wayne L., Wiener, Joshua M., Health Care Financing Review
One of the key rationales for expanding HCBS is the assumption that satisfaction with non-institutional long-term care (LTC) services is higher than with nursing home care. However, measuring and ensuring quality of care in the home and community setting is at an early level of development compared to nursing home care (Geron, 1996; Kane and Huck, 2000; Montgomery and Kosloski, 1995; Weissert et al., 1983). Much less is known about the quality of HCBS than nursing home care, even though increasing numbers of people are receiving paid care at home (Wiener and Brown, 2005). Reliable measures and data on quality of care for nonskilled HCBS, such as personal care, homemaker services, and adult day health care, are not readily available. In contrast, CMS gathers a great deal of data on nursing homes and home health agencies, although no quantitative data on the views of beneficiaries are routinely collected.
Developing measures of quality for HCBS is difficult partly because of the special characteristics of the service (Wiener and Tilly, 2003). HCBS cover a variety of disparate services, which are provided in large numbers of physically-dispersed locations, making data collection difficult and expensive. Moreover, the measures are not well-developed, and collecting data from persons with cognitive impairments or high levels of disability is difficult (Kane, 1999). In addition, States are reluctant to establish detailed standards for HCBS because they fear replicating the rigidity of nursing homes. However, as expenditures for HCBS increase (U.S. Congressional Budget Office, 2004), policymakers are focusing more on quality of care for these services. For example, CMS has launched a major initiative to improve the quality assurance systems for Medicaid-funded home care (Stanton, 2003).
In addition to health outcomes and costs, one important component of quality of care is satisfaction with services. Satisfaction relates to how beneficiaries experience the care received compared to their standards or expectations (Linder-Peltz, 1982). Satisfaction measures can provide important information about interpersonal aspects of care, such as interactions and communication between providers and clients, clients' perceptions on how much providers respect, understand and listen to them, and whether clients are treated with dignity (Aharony and Strasser, 1993; Keepnews, 2003).
Although satisfaction with care received at home is now recognized as an important outcome (Geron et al., 2000), little is known about what factors affect satisfaction with a range of home care services, including personal assistance with ADLs and IADLs. People who use home care and home health services typically report high levels of satisfaction (Office of Inspector General, 1995; Geron et al., 2000), but previous research found that the social desirability effect--the tendency of respondents to provide an answer they think an interviewer wants to hear--leads to reporting of high levels of satisfaction. High satisfaction ratings may also be related to clients' fears that negative ratings may result in an interruption of needed services.
Several studies examined Medicaid personal care services under 1915 (c) waiver programs and found that client satisfaction is positively associated with having more choice and control (Doty, Kasper, and Litvak, 1996), and that Medicaid beneficiaries receiving personal care under consumer directed programs were more satisfied than those getting their services via traditional agency-based programs (Foster et al., 2003; Benjamin, Matthias, and Franke, 2000; Beatty et al., 1996). A study by McCall et al. (2004) found that satisfaction with Medicare home health services is also associated with interpersonal aspects of client-staff interaction.
In reviewing research on patient satisfaction, Aragon and Gesell (2003) acknowledged that no generally accepted theory of patient satisfaction has emerged in the published health care research. …