American Journal of Law & Medicine

Quality improvement in community-based, long-term care: theory and reality. (Quality of Care and Health Reform: Complementary or Conflicting)


Community-based, long-term care has become an increasingly popular and needed service for the aged and disabled populations in recent years. These services witnessed a major expansion in 1981 when Congress created the Home and Community-Based Waiver authority for the Medicaid program.(1) Currently, all states offer some complement of community-based, long-term care services to their elderly and disabled populations and nearly all states have Medicaid Home and Community-Based Services waivers which extend these services to their Medicaid eligible clients.(2)

An ever increasing proportion of the population is in need of community-based, long-term care services. Between nine and eleven million Americans of all ages are chronically disabled and require some help with tasks of daily living.(3) In 1990, thrity percent of the elderly with at least one impaired activity of daily living(4) used a community-based, long-term care service.(5) Not surprisingly, expenditures for community-based, long-term care have increased. In Fiscal Year 1992 Medicaid alone expended $4.8 billion for home health care, the bulk of which was for unskilled services, -- an increase of nearly twenty percent over Fiscal Year 1991.(6) Much of this increase was due to a fifty-five percent increase in the number of visits between these years.(7)

There is every expectation that the demand for community-based, long-term care will increase in the future given demographic trends and pressures for health reform. By the year 2030, twenty-two percent of the population will be over age sixty-five and the number of people over eighty-five is expected to triple.(8) By 2020, twelve million Americans will need long-term care services.(9) Also, several health reform proposals, including the President's, call for expansion of community-based, long-term care services for the elderly and disabled.(10)

Despite the popularity of state community-based long-term care programs and their continued proliferation, little is known about how to assess or improve the quality of services in these programs. As Rosalie and Robert Kane have concluded: "quality assurance has barely been explored for home care and other community long-term care programs."(11) Other experts have observed: "although we have heard continual calls to improve the quality of care, little research exists to suggest which activities actually affect the quality of care delivered."(12) Yet the quest for quality assurance and improvement in community-based, long-term care is crucial. With enormous governmental expenditures for community-based, long-term care, taxpayers and their representatives demand quality as will the ever growing number of consumers of these services.

This article first examines the challenges of quality improvement in community-based, long-term care. It then discusses the degree to which the principles of total quality management (TQM), which are now sweeping the health care industry, can be applied to community-based, long-term care programs. As part of this discussion, this article reports on our experience in developing client-oriented quality improvement approaches in a state-wide demonstration project, funded by the Robert Wood Johnson Foundation to test and evaluate two quality improvement strategies for community-based, long-term care services provided through Indiana's IN-Home Services Program. This article concludes with some general observations about the effectiveness of various quality improvement approaches, particularly those inspired by theories of TQM and Continuous Quality Improvement (CQI) which are pervading the industry today and imported into the health care system(13) for community-based, long-term care services.



States offer community-based, long-term care services through a patchwork of federal and state programs. The major funding streams for these services are: (1) the Medicaid home and community based long-term care waiver for the aged and disabled,(14) (2) the Social Services Block Grant funds for Aging/Disabled Services,(15) (3) Older Americans' Act Title III funds (for the elderly only),(16) and (4) state-funded, case management programs.(17) The basic goal of community-based, long-term care services is to prevent premature institutionalization of clients.(18)

Most states administer these services through the state's "Aging Network" which includes a state agency designated under the Older Americans Act and local area agencies on aging (AAAs).(19) Most community-based, long-term care services are administered through case management programs.(20) Specifically, AAA case managers determine eligibility, assess client needs, determine service needs, and prepare treatment care plans requiring the procurement and coordination of various services from independent vendors. Case managers also monitor service provision and client progress.

Community-based, long-term care services are generally designed to meet the needs associated with activities of daily living as well as some instrumental activities of daily living that result from disease or disability.(21) Activities of daily living, as measured by established assessment measures developed by Sidney Katz,(22) include difficulty in eating, bathing, using the toilet, dressing, and transferring from a bed or chair.(23) Instrumental activities of daily living, similarly measured by established assessment measures,(24) include cooking, cleaning, doing laundry, handling household maintenance, transportation, using the telephone and managing money.(25) Thus, the most prominent services in community-based, long-term care are attendant care, homemaker and chore services, home-delivered meals, and transportation. Adult day care in a community facility is also included. All of these services may be provided on a respite basis as well.

Vendors of community-based, long-term care services vary widely. Home health agencies, of which there are an estimated 13,950 in the United States,(26) usually offer non-skilled home care services through home health aides and other workers. Indeed, it is fair to say that home health agencies comprise the largest vendor category for community-based, long-term care services. AAAs often provide attendant care services as well as transportation and home delivered meals. Other social service agencies and temporary employment agencies can provide attendant care and housekeeping workers. Finally, individuals with no corporate affiliation also provide community-based, long-term care services. As explained below, the bulk of these services require unskilled labor associated with attending a disabled individual, elementary nursing procedures or housekeeping.



States generally do not have sophisticated quality improvement systems for their community-based, long-term care programs.(27) AAAs are not directly regulated by either states or the federal government. Rather, states contract with existing organizations that must meet federal guidelines including standards designed to enhance the services they provide.(28) Many states do require AAAs to operate quality assurance programs as a contract requirement but these programs tend to be fairly rudimentary.(29)

Government regulation tends to focus on vendors of particular types of services, such as home health agencies which provide skilled nursing services. Thirty-eight states and the District of Columbia actually license home health agencies and require them to meet quality standards as a condition of licensure.(30) However, most states require licensure only if the home health agency provides skilled nursing services.(31) In general, however, state licensure of home health agencies tends to be undeveloped and narrow in coverage with inconsistent or lax enforcement.(32)

Home health agencies that participate in either the Medicare or Medicaid programs are subject to regulation. Specifically, the Social Security Act requires that home health agencies participating in the Medicare program meet the Medicare Conditions of Participation which set forth the requisite characteristics of agency management, staff, facilities and services as well as procedures that agencies must follow in providing care to assure high quality.(33)

Many home health agencies also are privately accredited and therefore

presumably meet the quality standards of the private accrediting organization. The National League of Nursing has accredited home health agencies for nearly thirty years.(34) It currently accredits about 600 home health agencies.(35) The National HomeCaring Council also has a program targeted at more nonskilled long-term care and hospice services.(36) This organization accredits about ninety-five home care agencies.(37)

In 1988, the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) issued its first standards for free-standing home health agencies.(38) JCAHO had been accrediting hospital-based home health agencies since the late 1970s(39) and free-standing home health agencies since the late 1980s.(40) JCAHO currently accredits more than 3,000 home care organizations, of which 1,700 are also Medicare certified agencies.(41) In May 1992, the Health Care Financing Administration (HCFA) issued a notice granting deemed status to home health agencies accredited under the Community Health Accreditation Program standards of the National League of Nursing.(42) A year later, in June 1993, HCFA issued a final notice providing that JCAHO accredited home health agencies would be "deemed" to comply with the Medicare Conditions of Participation for purposes of providing services to Medicare and Medicaid beneficiaries.(43) Both notices provided that private accreditation would be pursuant to an unannounced survey and contained other provisions to enhance government oversight. JCAHO has also become increasingly involved in quality issues in home-based, long-term care.(44)

Despite state and federal regulation of home health agencies, a regulatory "hole" exists with respect to the provision of non-skilled long-term care services which comprise the bulk of community-based, long-term care. …

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