HHS Logo: bird/facesU.S. Department of Health and Human Services

Review of State Quality Assurance Programs for Home Care

Executive Summary

Macro Systems, Inc.

April 1989

This report was prepared under contract between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and Macro Systems, Inc. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/daltcp/home.shtml or contact the office at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. The e-mail address is: webmaster.DALTCP@hhs.gov. The DALTCP Project Officer was Floyd Brown.


Publicly-funded home care for the elderly involves both Federal, state, and local responsibilities. The Federal Government partially funds home care services through Medicare, Medicaid, the Older Americans Act (Title III), and the Social Services Block Grant (Title XX). The primary responsibility for home care service delivery and quality assessment, however, lies with the states. The purpose of this study is to gather information about current state activities to ensure quality in publicly-funded home care programs for the elderly. This report describes the activities of 19 states to address quality assurance in home care; compares and contrasts the range of quality assurance mechanisms currently in place in these states; and presents the perspectives of a variety of state officials on home care quality issues. More than 135 individuals in state and local programs in 19 states participated in the study. The report is based on telephone and on-site discussions and the review of state documents provided to the study team. It is a descriptive report based on state-provided information and is not intended to be an evaluation or assessment of those programs.

In general, "home care" may be broadly defined to include all services provided in a client's home, ranging from skilled nursing care to chore services. For purpose of this report two categories of home care are defined--home health care and supportive care. Home health care generally includes those services provided through the Medicare and Medicaid home health benefits and delivered by registered nurses; licensed practical nurses; home health aides; speech, occupational, physical, and other therapists. Supportive care includes all other care provided in the home.


The rapid growth of the elderly population needing some type of long-term care has been accompanied by a dramatic expansion of in-home and community-based services. Home care programs are now providing an increasing variety of skilled and nonskilled health and supportive services to large numbers of people with chronic illnesses and impairments. Also accompanying this growth in the availability of home care is a rising concern about how to assure that consumers receive high-quality services.

Congress addressed home care quality issues in a number of bills introduced during 1987 and 1988. These bills proposed specific quality assurance mechanisms, uniform standards of care, and Federal regulation. Additionally, in 1987, Congress enacted changes to the Medicare program which included a patients' bill of rights and competency testing for home health aides as means of improving the quality of home care funded by that program. Federal home care funding agencies as well as nongovernmental agencies and organizations are also addressing home care quality issues through research efforts, national conferences, and accreditation and certification programs.


1. State Strategies

This study identified three broad strategies employed by states to assure home care quality:

Standards for providers. Standards are the criteria against which programs assess quality. The most frequently reported standards for home care providers pertain to worker training, worker certification, licensing, and provider approval. For example:

Monitoring of home care. Monitoring is the act of checking that standards are met. States employ several mechanisms to monitor the quality of home care in both home health and supportive care programs. Commonly reported monitoring mechanisms include supervision of workers, supervisory home-visits, client assessments and evaluations, care planning, case management, contract reviews, and provider surveys:

Nearly all monitoring mechanisms used by home care programs focus on the structure or process of service delivery. Although few programs have developed approaches to monitor service outcomes, one method reported to monitor subjective outcomes is client satisfaction surveys. Efforts to monitor objective service outcomes are even less common. Only three programs reported objective criteria to monitor service outcomes.

Enforcement in home care. Enforcement is the act of carrying out sanctions for failure to comply with standards. Mechanisms used to enforce program standards are predominantly economic in nature; however, some programs can invoke criminal penalties. Sanctions include:

2. The Impact Of Funding Sources

Analysis of state quality assurance mechanisms by program funding source shows both similarities and differences among programs. Medicaid home health and Personal Care Option Programs tend to have the most similar quality assurance mechanisms across states while Community-Based Waiver, Title III, and Title XX programs demonstrate greater variations in quality assurance efforts. Examples of those similarities and differences follow:

3. Expanded Ombudsman Programs

The study looked at expansion of the Long-Term Care Ombudsman Program as a mechanism to improve home care quality. Five of the study states have legislative mandates to expand their Long-Term Care Ombudsman Programs to address concerns and complaints about home care services; however, none of these programs is fully operational. Two states are in the planning stage, one state includes only clients in a specific state-funded program, and two states have not fully publicized the program for home care clients. None of the states have sufficient experience with this approach to draw conclusions regarding its impact on home care quality.


The study authors have drawn the following broad conclusions with respect to the status of home care quality assurance efforts:


The study identified five important factors, the absence of which may impede states from developing improved quality assurance initiatives:

  • Standardization of definitions of quality;
  • Development of service outcome measures;
  • Coordination of quality assurance efforts within states;
  • Recruitment, training, and retention of home care workers; and
  • Specification of roles for case managers and independent care providers.


    Home care quality assurance efforts vary widely among states as well as among programs within states. This variation is partly caused by the fragmentation of home care funding and program responsibility on both the state and Federal level.

    Additionally, there is no one state or Federal agency uniquely concerned with home care to serve as a catalyst or focal point for the systematic development of home care quality assurance efforts.

    The Department of Health and Human Services should consider identifying one agency to assume a leadership role in home care services and quality assurance efforts. This leadership role could stimulate the development of effective home care quality assurance through coordination among agencies and information dissemination.

    The lead agency should focus its efforts on knowledge development and information dissemination in the following areas:

  • Service definitions
  • Service standards
  • Program monitoring
  • Client satisfaction measures
  • Independent provider programs
  • Worker recruitment and retention
  • Ombudsman programs
  • Service delivery models
  • Training curricula and evaluation
  • Worker skills evaluation
  • Service outcome measures
  • Case management
  • Standards and monitoring for family-provided services
  • The lead agency can support knowledge development by promoting research, development, and demonstration programs in quality assurance. These activities should focus on testing the effectiveness of existing home care quality assurance efforts and developing new systems. Knowledge development must be coupled with a variety of knowledge transfer activities such as conferences, workshops, and publications.

    In addition to its communication and knowledge stimulation roles, the lead agency might also work to establish a Federal commitment to quality assurance in home care services by encouraging and supporting increased state attention to these important activities.