National Conference on Home Care Quality: Issues and Accountability--Volume I Proceedings

01/01/1989

U.S. Department of Health and Human Services

National Invitational Conference on Home Care Quality: Issues and AccountabilityVolume I: Summary of Proceedings

1989

PDF Version: http://aspe.hhs.gov/daltcp/reports/1989/88cfproc.pdf (88 PDF pages)


This report--which summarizes a national conference held at the Madison Hotel, Washington, D.C. on June 1-2, 1988--was prepared by the Office of Social Services Policy with the U.S. Department of Health and Human Services. For additional information, you may visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the Office of Disability, Aging and Long-Term Care Policy, 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 Pamela Doty.

The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.


TABLE OF CONTENTS

ACKNOWLEDGMENTS
INTRODUCTION
KEYNOTE ADDRESS: HOME HEALTH CARE QUALITY
OPENING GENERAL SESSIONS SUMMARY
Home Care Quality: Identifying the Issues
BREAKOUT SESSION SUMMARIES
Measuring Home Care Quality: How Far Have We Come in Developing Outcome-Oriented Measures? What is the Appropriate Mix of Structure, Process, and Outcome Measures?
Empowering Consumers: Possibilities and Limitations
Post-Acute Care: The Effects of Diagnosis-Related Group (DRG) Payment Reform on Home HealthIssues in the Recruitment, Training, Motivation, and Supervision of Home Care Workers
Accountability of State and Local Programs
Medicare/Medicaid Survey and Certification: Its Strengths and Weaknesses
Accreditation Programs: Strengths and Weaknesses
Special Needs of Special Populations and Ethical Issues
CLOSING GENERAL SESSION SUMMARY
Summary and Conclusion
APPENDICES
APPENDIX A: Conference Agenda
APPENDIX B: Conference Participants

ACKNOWLEDGMENTS

Arnold Tompkins, Deputy Assistant Secretary for Social Services Policy, and Mary Harahan, Director of the Division of Disability, Aging, and Long Term Care, provided leadership in organizing and sponsoring this conference. Pamela Doty and Glen Harelson were the principal conference organizers. Brenda Thorne, Jewell Griffin and Azalee Lattimore supplied invaluable support services. Other ASPE/SSP staff--Floyd Brown, Bob Clark, Peg Porter, and Paul Gayer--pitched in where needed.

Editorial services for the conference report were handled by The Circle, Inc., of McLean, Virginia. Staff members who assisted were Joanna Ebling, Mary Gardner, Rick Keir, Daniel F. McLaughlin, and Pamela J. Wilson.

We are also grateful for the enthusiastic participation of over 300 attendees at the conference who generously contributed their time and ideas. The views expressed in these proceedings are those of the conference participants. No official endorsement by the Department of Health and Human Services is intended.

INTRODUCTION

More than 300 practitioners, regulators, payers, and other interested parties attended the National Conference on Home Care Quality: Issues and Accountability, sponsored by the U.S. Department of Health and Human Services, on June 1 and 2, 1988, at the Madison Hotel in Washington, D.C. Volume I of the conference report presents the keynote address by Otis R. Bowen, Secretary of the Department of Health and Human Services, summaries of the opening and closing general sessions, and summaries of the breakout sessions. The conference agenda and participant list are included as appendices. Volume II presents a research agenda for home care quality. Prepared by Pamela Doty, Ph.D., Senior Analyst in the Office of the Assistant Secretary for Planning and Evauation, the research agenda highlights issues and themes raised by conference attendees as well as speakers and includes feedback received from participants following the conference. Volume II also cites recently published and ongoing projects related to the issues discussed at the conference.

Robert B. Helms, Assistant Secretary for Planning and Evaluation, called on conference participants to help set the Federal government's home care quality research agenda for the next few years. New initiatives in home care fielded by Federal and State governments have led to growth in formal home care services.

Several other factors are also fueling the expansion of home care. Earlier hospital discharges under Medicare's Prospective Payment System have had a significant impact on the demand for post-hospital home health care. An increase in the number of the elderly, especially those "oldest old" whose long term care needs are greatest, and a desire by the public to find alternatives to institutional care have increased demand for less medically oriented types of home care as well.

Between 1966 and 1987, home health agencies certified by Medicare increased by almost 400 percent--from 1,275 to 5,794. The number of proprietary or for-profit agencies has increased the most, largely in response to the 1980 Omnibus Budget Reconciliation Act that removed the ban on Medicare certification of for-profit agencies in those States without licensing laws. Previously, State licensure, and often certificate-of-need approval, had been required of for-profit agencies. Although accreditation programs exist for homemaker chore services, Medicare/Medicaid certification is limited to agencies offering nursing and other health-related services. Moreover, registries of independent providers are not eligible for certification or accreditation. It is estimated, therefore, that only half of the approximately 12,000 organizations delivering home care are certified or accredited.

Conference sessions dealt with many of the major issues of the burgeoning home care industry. The opening session presentations set the tone dealing with such issues as the definition of "quality" in home care, difficulties in measuring quality, adequacy of the home care work force, and the appropriate regulatory roles of the Federal and State governments.

The need for more effective quality assurance mechanisms was a theme throughout the conference. The strengths and weaknesses of quality assurance efforts through government regulation and voluntary self-policing of the industry were debated vigorously. The strong influence of the Medicare certification process in setting standards was stressed. State and local government representatives discussed how they go about assuring the quality of social services funded via Title XX, the Older Americans Act, or State programs.

Private standard-setting bodies, such as the Joint Commission on Accreditation of Healthcare Organizations, the National League for Nursing, and the National Home Caring Council, emphasized their commitment to maintaining high quality accreditation programs. They also stressed the advantages of voluntary accreditation.

The recent role of Congress in mandating more stringent Federal regulations in response to quality concerns was outlined. The effectiveness of State regulatory requirements was examined as well. Strategies were also proposed to empower consumers of publicly funded home care services.

The role of research in identifying measurable quality assurance findings was a central conference topic. The Robert Wood Johnson Foundation, the National Center for Health Services Research and Health Care Technology Assessment, and the Health Care Financing Administration pledged their support for more and better research. Methods of developing reliable information by focusing on outcomes were detailed. Methods were also delineated that take into account the distinctive nature of home care in contrast to institutional care. Ethical issues involving, for example, the rights of clients were discussed. The needs of special groups of home care clients, such as AIDS patients and children, were also reviewed. Presentations in the closing session reflected the new interest in home care as conference participants were urged to develop innovative and dynamic research proposals.

HOME HEALTH CARE QUALITY

Keynote Address By:Otis R. Bowen, M.D.Secretary, Department of Health and Human Services

I am happy to have this opportunity to speak to this conference on home care quality. The issue you are addressing is among the priorities that I have listed in what I call "The Bowen Agenda." The Department of Health and Human Services is sponsoring this conference to bring together three groups of people who need to talk with one another if we are to improve the quality of home care: researchers, regulators, and, of course, the hands-on practitioners who deliver home care.

We need to talk about home care quality for several reasons, not the least of which is the rapid growth of home care services. It has been nothing short of phenomenal. From 1974 to 1985, Medicare outlays for home health services grew by an average of more than 31 percent a year. And in the fiscal years from 1985 to 1986, Medicaid outlays for this purpose grew by nearly 30 percent. Growth in more recent years has slowed somewhat, but most see this as only temporary. The underlying truth of the matter is that we are spending more and more public money on home care, yet we are not really sure that we are getting true value for it.

We do know for certain that home care meets with the enthusiastic approval of people. Receiving care in your own home is an immensely popular idea. If you are an older person, it means you may get to leave the hospital sooner. Better still, it may mean postponing or avoiding altogether the need to go into a nursing home for there is, indeed, "no place like home." But the very fact that home care services are delivered in the person's own home poses something of a problem for us--and it is this very problem that brings us here today. Part of the problem stems from the fact that home care takes place outside of an organizational setting where care can be observed, measured, and evaluated. Also, we know something about how to measure quality in a hospital because we have been at it for some time now.

A second aspect of the problem is how to establish accountability. The fragmentation of the home care service system and the mechanisms that fund it can make it difficult to decide just who is responsible for what. This makes it doubly important that you address the whole range of home care services from the medically intensive ones to those that are primarily social services. Difficulties notwithstanding, it is important that we assume a strong Federal role in ensuring quality home care services. First of all, we have a responsibility under Medicare to be prudent buyers of care. But it is also in keeping with this administration's strategy to make health care more competitive. If we are to create a medical marketplace, we must ensure alternative settings for delivering care.

Putting "the right patient in the right setting of care at the right time" does not just make sense medically. It also makes sense economically. It is absolutely vital to the establishment of a working medical marketplace that the most appropriate care be delivered at the lowest feasible cost. Medicare's Prospective Payment System has created an economic incentive for hospitals to discharge older patients as soon as they are well enough to go home. But this very incentive to discharge means that there have to be sound alternatives to care for those who are still in the convalescent stage of their illness. This makes it imperative that home care services not only be available, but of good quality as well.

Beyond all these considerations, I have a few personal observations to make as one who was once a family physician. Back when I was practicing medicine, the family physician had the major responsibility for ensuring that his patients received quality care. This responsibility was deeply impressed on us when we were in medical school. We felt it was a vital part of that unwritten compact that we called "the doctor-patient relationship." And we believed it would be an abrogation of that compact if government or a third-party insurance payer were to take over this responsibility.

But times have changed. Back then, medicine was as much an art as a science. So little was known or developed then that ensuring quality care was a fairly simple obligation for the doctor. Those days are gone. Today's health care has reached a level of technological and organizational complexity that goes beyond the scope of the family doctor.

Today many specialized personnel other than the family doctor are involved in delivering care. Indeed, much of the post-acute and long term care that today's patients receive is outside the direct supervision and control of the patient's personal physician. So it simply is not feasible nowadays to hold the family doctor personally accountable for this care.

The family physician, however, can prescribe medically centered home health care, such as the services of a registered nurse or therapist, and should learn more about the home care options available and the coverage rules for public programs. But usually these providers of home care do not work for or report directly to the patient's physician. So it is highly unlikely that the physician will be aware of the quality of home care provided, unless the patient complains about it or the condition worsens because it is so bad.

There is an even greater distance between the family doctor and those who provide home support services of a nonmedical nature. These social services do not even require a physician's prescription. Yet many patients living at home need meals prepared for them, housekeeping services, or someone just to look in on them from time to time if they live alone. Indeed, at times, the availability and quality of these support services can mean the difference between staying in a hospital or nursing facility and going back home. Frankly, as a doctor, I do not know how one can measure the therapeutic value of being at home. But I have often observed that it makes all the difference in the world to a patient's sense of well-being, and probably to the recovery.

I am the first to declare that government has a solemn responsibility in these times of public deficits to ensure that the taxpayers' money is wisely spent. Medicare must indeed be a prudent shopper for health care services. But this does not absolve us from constantly seeking that optimal mix of high quality service and reasonable cost. And as we seek that ideal mix, we must be ever mindful that sometimes better is cheaper. This is precisely the area in which you at this conference must apply your know-how and share your insights because the task of ensuring quality is far from getting any easier and is in fact getting harder.

There are several other factors as well. Firstly, new categories of home care patients have emerged: persons with AIDS, ventilator-dependent children, the growing number of elderly with Alzheimer's, and the increase in working adults who now survive head injuries and other once-fatal conditions. All of these home care patients are going to place unprecedented pressures on the skills and resources of those who provide home care services.

Secondly, the elderly, who are the biggest users of home care services, keep increasing in number. From 1967 to 1984, their number went up from 19.5 to 27.7 million. Sometime early in the next century that number will grow to over 50 million. More of them will live to age 85 and beyond, and 25 percent of Medicare home health services are used by the elderly in this latter age group.

Thirdly, there are new developments in portable medical technology. These make it possible for some patients to receive certain high-tech services at home that were once available only in hospitals. As high-tech medicine is infused into home care, the job of ensuring quality is going to get more complicated, not less.

All of these emerging factors are affecting a home care industry that is still far from solving its quality assurance problem.

Last year, the Office of the Inspector General published an eye-opening report on the current state of Medicare services performed by home health aides. It found that, while these aides performed most of their personal care tasks well enough, they were doing only half of what they should be doing in areas that represent an extension of nursing and rehabilitation care. For example, aides often failed to give catheter care, foot soaks, or special skin care, and failed to assist with dialysis or to record the intake and output of fluids. They would neglect to take temperatures, pulse, and respiration, to supervise exercises or to record the patients' progress in achieving daily living needs. This study laid the blame for these shortcomings on a lack of attention in training and on-site supervision by registered nurses. This needs looking into. It seems to me it is something that can be remedied.

Another problem that needs attention s the training and pay of home care workers. Some say it is not always equal to the responsibilities we expect them to handle. But if that is so, then we face an issue that may not be easy to resolve: Just how far can we go in establishing training standards for home care workers without over-professionalizing the service and pricing home care out of the market? I hope you will give this rather sensitive issue your careful attention.

I also hope you will take a good look at how we should go about measuring the quality of home care. We already do this in several ways, one being the setting of "conditions of participation" for home health providers. We monitor all this through a system of surveys and certification, operated in conjunction with each State. We also fund peer review organizations. Recently they have been given a mandate to review post-acute care, including home health care. Under the Medicare home- and community-based long term care waivers, States operate their own quality assurance programs. They must, however, provide us with assurances that appropriate quality safeguards are in place. Experiments are underway to apply the ombudsman program of the Older Americans Act to home care as well as nursing home care to give consumers an independent outlet for voicing their complaints. So we have these quality review mechanisms in place.

The trouble is that they often do not relate to one another in a coherent way. And medicine has not come very far in creating a coherent and useful structure for measuring quality. But recent times have seen the development of a unifying concept of quality assurance that holds forth some promise.

Quality is viewed from three perspectives. The first emphasizes structure. The adequacy of the physical structures and organizations that provide care and the professional qualifications of those who give it are examined. The second involves process. It is a measure of how well specific procedures are carried out and whether those procedures meet the criteria of reasonableness for a particular patient with a particular condition. The third is a bottom-line measure of quality called outcome. Or, put another way, what happened to the patient? Did he or she live or die, or get better or worse, as a consequence of the care?

Right now, quality assurance is strong on measuring structure, but not so good at measuring process or outcome. We appear not yet ready to fully measure all three as a kind of cross-check on the others. That is what we ought to be shooting for. From your perspective at this conference, making use of this structure, process, and outcome concept might offer you some useful points of departure when you start to talk about measuring the quality of home care services. I am far from suggesting that this conference go it alone. Your value here will be to lay the groundwork and set directions. out of your dialogues here should come issues to which researchers can begin seeking answers.

Particular attention needs to be devoted to developing outcome, input, and process measures of home care quality; determining the training and supervision needs of home care workers; and coming up with guidelines that will tell us when home care is appropriate and, if so, at what level of medical intensity. You might also want to provide some guidance in how we should go about forecasting the labor pool for home care workers and how we can better understand what motivates people to enter the field and stay in it. Finally, you might help shed light on how we can do a better job of telling consumers how to judge the quality of home care they receive or how to pick a home care agency that will best meet their need.

In closing I have only this to add: The work you do here can be seen in its narrowest sense--as merely a job of defining the problem to be accomplished with the perspectives and expertise you bring to this conference--but I would suggest to you that if you see your mission only in these terms, you may very well fail your purpose here. To succeed requires in each of us a capacity to care about those your work here is meant to help.

I take leave of you now filled with the cheerful conviction that I am talking to just such a group of people. You would not be here were it otherwise. It is my own heartfelt wish that you succeed in your efforts because there can be not the slightest doubt that you are indeed performing important work here that will ease the plight of many people. I pray that you proceed in that hope and spirit and I thank you for being so attentive.

OPENING GENERAL SESSION SUMMARY

HOME CARE QUALITY: IDENTIFYING THE ISSUES

Moderator: Pamela Doty Office of the Assistant Secretary for Planning and Evaluation U.S. Department of Health and Human Services Washington, D.C.
Presenters: Val Halamandaris President National Association for Home Care Washington, D.C.
Elma Holder Executive Director National Citizens Coalition for Nursing Home Reform Washington, D.C.
Charles SabatinoAssociate Director Commission on the Legal Problems of the Elderly American Bar Association Washington, D.C.
Kathryn Schulke Administrator INOVA Health Professionals Springfield, Virginia
Peter Shaughnessy Director Center for Health Services Research University of Colorado Denver, Colorado
Nancy Smith Staff Member U.S. Senate Special Committee on Aging and Legislative Aide to Senator John Heinz Washington, D.C.

Speakers at this opening general session put forward key issues in home care quality that were discussed more fully in the following two days of breakout sessions. Major topics included the need for improvement in training and supervision of home health aides and other unlicensed home care workers, strategies for empowerment of clients, and the expanding regulatory role of the Federal and State governments. The nature of the quality assurance responsibility of home care agencies was also discussed.

Great stress was placed on the need for research in two broad areas. Research is needed to find out exactly what kind of quality problems exist. There is anecdotal evidence but little information available resulting from rigorous, generalizable reporting systems. Research is also needed to develop ways of measuring quality that speak to the distinctive features of home health care. The important differences between home care and institutional care should be addressed in developing quality assurance procedures.

The six speakers expanded on these topics. Elma Holder’s presentation centered on an example of how one elderly client named Violet suffered from inept care. Her experience served to spotlight flaws in the selection and training of home health aides as well as in the administrative procedures of agencies. Although most of the aides who cared for this 80-year-old woman were indeed caring, only some were well trained, and several admitted they had no training at all. Absenteeism was not unusual. There were attempts at theft and check forgery. When complaints were registered, the agency did not take effective action and the client even experienced retaliation. There was never a home visit by a supervisor.

Violet was not able to die at home because of a failure of the system. Toward the end, she suffered through a night of extreme pain, receiving extremely poor care from an aide who had never before attended a dying person. In the morning, the day shift aide did not show up and the agency could not send one until noon. Violet had to be transported to a hospital where officials insisted on painful tests. She died there three days later.

The irony of this particular client's experience was that she happened to be a politically active advocate for a national home health care program. She was characterized as one who, had she recovered, would still be promoting a national program despite her personal experience. According to her friend and informal caregiver Elma Holder, Violet would be highlighting the need for better training for the aides and better monitoring of the system.

A portrait of home care aides also emerged from the session. They generally have little formal education. They are untrained initially and receive very little orientation into the home setting. They are paid very low wages with no benefits or guaranteed working hours. Generally, the pay scale begins at the minimum wage of $3.35 per hour depending on the agency and labor supply. It was alleged that many potential home care workers join the fast food industry instead because they can obtain higher wages and better benefits and hours at McDonald's or Burger King.

In a study, 15 aides were asked to rank their needs. Behind better salary and benefits, they cited the need for respect. It was emphasized that they are not unskilled workers, that the work requires a good measure of skill. But motivation is lacking because of the insufficient training and compensation. There is no career ladder in the field. In one example, the aides were given a raise of 10-15 cents across the board instead of raises tied to level of skill or seniority.

The three components of skill, motivation, and supervision were cited as essential to improving the quality of aide services. Recommendations included that training for aides must be paid by the employer, continuing education must be provided and perhaps linked to certification, decent wages must be provided, a career ladder must be established, and timely supervision must be guaranteed. One suggestion was that Medicare could reimburse based on the level of skill required of the aide.

The concept of client empowerment was viewed as a way to enhance a basic advantage of home care, that the home environment can be a positive factor in outcomes. A well-publicized and well-accepted statement of client rights would strengthen the role of the client in influencing his or her quality of care. Rights statements would include provisions like these in the Code of Ethics of the National Association of Home Care:

  1. The patient is fully informed of all his rights and responsibilities.

  2. The patient has the right to appropriate and professional care relating to physician orders.

  3. The patient has the right to choice among care providers.

  4. The patient has the right to receive information necessary to give informed consent prior to the start of any procedure or treatment.

  5. The patient has the right to refuse treatment within the confines of the law and to be informed of the consequences of his action.

  6. The patient has the right to privacy.

  7. The patient has the right to receive a timely response from the agency to his request for service.

  8. A patient will be admitted for service only if the agency has the ability to provide safe professional care at the level of intensity needed. The patient has the right to reasonable continuity of care.

  9. The patient has the right to be informed within reasonable time of anticipated termination of service or plans for transfer to another agency.

  10. The patient has the right to voice grievances and suggest changes in service or staff without fear of restraint or discrimination. A fair hearing shall be available to any individual to whom service has been denied, reduced, or terminated or who is otherwise aggrieved by agency action. The fair hearing procedure shall be set forth by each agency as appropriate to the unique patient situation (e.g., funding source, level of care, diagnosis).

  11. The patient has the right to be fully informed of agency policies and charges for services, including eligibility for third party reimbursements.

  12. A patient denied service solely on his inability to pay shall have the right of referral.

  13. The patient and the public have the right to honest, accurate, forthright information regarding the home care industry in general and the chosen agency in particular (e.g., cost/visit and employee qualifications).

Charles Sabatino noted that the Commission on the Legal Problems of the Elderly of the American Bar Association is studying client rights statements in various States and will propose the elements that should be included in an effective one.

Several other ideas for enhancing the client's influence were discussed. There should be accountability from the inception of the service. The care plan should incorporate the client's perceptions of needs; too many times the client is just given a plan. Clients should not be allowed to control the situation but their perceptions and preferences should be considered. One example was given in which a client's home was infested with cockroaches and the care worker set about finding him another place to live. All the client wanted was someone to call the exterminator, but that was not in anyone's job description.

There shouldalso be a system of accountability for services that could be as simple as a checklist with questions for the client: Did your worker show up today? Were you given your pill? Were you given a bath? How did you get those bruises on your arm?

There is a need for effective grievance mechanisms. Models might be the State ombudsman programs mandated by the Older Americans Act for long term care and a hotline program mandated by other Federal legislation.

There is also a need for consumer input in home care program policy and development. Consumers should sit on panels at the community, State, and Federal levels.

Another aspect of client empowerment is the teaching that should be part of the job for a well-trained home care aide. The client and family will become more comfortable and secure as they learn from the aide about care techniques and equipment.

The role of the Federal and State governments was discussed, especially in the context of the present level of quality of home health care. Val Halamandaris expressed the industry's view that the quality of care is extremely high now and has been historically high, especially compared to nursing home care. He expressed concern that pressures generated by Federal and State policies may reduce quality.

The Medicare Prospective Payment System, using diagnosis-related group classifications, has resulted in the discharging of patients from the hospital sooner. This has increased the use of Medicare home health care by 38 percent.

At the same time, however, the industry is concerned because reimbursement has gone down and denials for payment have increased. Also, the three percent denial rate went up 12 percent on the average; in some States it went up 33 percent. In addition, the average number of visits a client on Medicare could expect decreased from 27 to 12. All in all, it is alleged, fewer people qualify for fewer benefits because of rule changes.

In addition, industry representatives complain that the amount of paperwork has increased by 50 percent over the last three years and nurses who normally work in the field providing care have to be brought into the office to do this paperwork. These nurses are worried about malpractice because they know they cannot provide decent care with just 12 visits so they are beginning to leave the home health field.

Another problem, as the industry sees it, is that States are trying to cut costs by contracting directly with individuals and bypassing agencies. Still another problem is the increase of unregulated fly-by-night operations.

Representing the congressional staff perspective, Nancy Smith responded that there are quality concerns in the home health industry and this is the reason Congress is moving to beef up regulatory standards. However, she stressed that Congress is not on a "witch hunt". Recently, Congress passed legislation to require that States set up toll-free hotlines and investigative units for home health care. Also, funding for peer review organizations was doubled so they could begin to move more aggressively into such areas as home care, nursing home care, and physicians' offices. She also pointed out that Congress and the States will probably be dealing with non-health related home care in the future.

Kathryn Schulke spoke from her experience as a nurse who has worked for both nonprofit and proprietary home health agencies. In her view, some home care agencies let quality slip by not training and motivating aides because they are overly concerned with profits. She suggested that the Federal and State governments establish policies that provide positive financial incentives to promote quality and discourage promoting profit-making at the expense of quality.

Peter Shaughnessy identified a need for more research on the definition of quality including quality measures covering the usual range of structural, process, and outcome considerations as well as a suggested paradigm of global, focused, and broad measures of quality.

Global measures were defined as those that pertain to all clients in a given agency, such as mortality rates and staff mix. Focused measures were defined as those that pertain to specific types of patients, such as diabetic patients and congestive heart failure patients. Broad measures were defined as those that would come somewhere between global and focused measures.

Peter Shaughnessy suggested that several points should be considered in conducting research on ways of measuring quality of care that take into account the unique aspects of home care. The positive value of the home environment in contrast to the institutional environment can have a big impact on quality of care as well as cost.

In addition, there is less control over care in the home than in an institution because the provider is a quest. A new dimension is the knowledge that both the client and family gain from the aide in learning about self-care.

Finally, all agreed that compliance with quality standards cannot be measured as easily at home as it can in an institution. Nevertheless, providers should still be held accountable for effective service.

BREAKOUT SESSION SUMMARIES

MEASURING HOME CARE QUALITY: HOW FAR HAVE WE COME IN DEVELOPING OUTCOME-ORIENTED MEASUES? WHAT IS THE APPROPRIATE MIX OF STRUCTURE, PROCESS, AND OUTCOME MEASURES?

Moderators: Pamela Doty Office of the Assistant Secretary for Planning and Evaluation U.S. Department of Health and Human Services Washington, D.C.
Tony Hausner Health Care Financing Administration/ORD Baltimore, Maryland
Presenters: Karen Barger Executive Director Visiting Nurse Association of Coastal Georgia Savannah, Georgia
June Gray Nurse Consultant Health Standards and Quality Bureau Health Care Financing Administration Atlanta, Georgia
Thomas Hoyer Director, Division of Provider Coverage Policy Bureau of Eligibility, Reimbursement and Coverage Health Care Financing Administration Baltimore, Maryland
Bernadette Lalonde Principal Lalonde Research and Consultation Services Seattle, Washington
Samuel Kidder Chief, Long Term Care Branch Bureau of Eligibility, Reimbursement and Coverage Health Care Financing Administration Baltimore, Maryland
Peter Shaughnessy Director Center for Health Services Research University of Colorado Denver, Colorado

Topics addressed in this session included the quality assurance program of a small home health agency in Georgia, an analysis of how to tailor outcomes research to the distinctive nature of home care, a project to develop outcome measurement scales for home care, and procedures used in certification surveys of Medicare-certified home care agencies.

Karen Barger described the quality assurance program of the Visiting Nurse Association of Coastal Georgia in Savannah, a nonprofit agency that provided 23,000 visits last year, which has internal and external components. The internal component is defined as procedures developed by the agency itself and the external component is defined as related to oversight by outside parties such as Federal and State licensure reviews.

The internal component consists of staff selection processes, orientation, ongoing in-service training for professional and nonprofessional staff, supervision, standardized nursing plans based on nursing diagnosis, and a self-audit of the professional disciplines.

An auditing process identifies problems that are corrected through the training of practitioners on an individual or group basis. The charts with problems are then re-audited eight weeks later to measure improvement.

There is also a Utilization Review Committee composed of two nurses, a pharmacist, a nutritionist, and a physical therapist, all volunteers not employed by the agency. The committee meets quarterly and each member reviews 4-6 charts. Committee members are requested to ask these five questions: Was the assessment right that directed the client to a home health agency? Were the services right for the client? Were the client's total health needs met? Was there consideration of other community agencies that might have been needed in addition? Were services coordinated for an integrated plan of care?

Twenty percent of all visits are reviewed on a yearly basis. Revised versions of an already established patient satisfaction questionnaire and a physician evaluation of services will be introduced in the near future. The development of a peer review process is 18 months away but could be linked to client satisfaction or outcome criteria.

In their discussion of outcomes research at the session, both Peter Shaughnessy and Bernadette Lalonde emphasized outcomes related to changes in patient status rather than utilization outcomes (e.g., hospitalization use, emergency room use). Peter Shaughnessy discussed using two "time points" to judge whether or not a transition from one stage to another was successful. The patient's mobility status could be measured this way. This approach also emphasized tracking the stability of this change: Did the patient progress steadily during the time period? Or was there some regression and then progression, some back and forth, that eventually resulted in the final positive result?

In one example, patient outcomes were compared in home care and nursing home care. It was stressed that the comparisons will be deceiving if the analysis does not adjust for case mix. In the instance of catheterization, nursing home care may outshine home care because it is a difficult procedure to carry out as well in the home environment. This would bring up an issue of patient placement. However, when the outcomes data in this example were adjusted for case mix, the results did not show much difference in general between home care and nursing home care.

It was also strongly suggested that the community health nursing model should be used in developing outcome measures rather than the medical model because home care is predominantly nursing care provided by a variety of caregivers--the registered nurse, practical/technical nurse, and the homemaker/home health aide.

Emphasis was placed on the need to relate outcome measures to goals that the nurse and patient develop together. Additionally, the definition of clinical indicators that are the most predictive of care quality should be developed by the nurses themselves.

That approach was incorporated into one aspect of Bernadette Lalonde's project in Washington State. This ongoing federally funded project to develop outcome scales for home care was described in detail. The input of staff members from the Washington Home Care Association was utilized.

Five scales have been developed and two more are completing the development process. The scales are broad-based rather than diagnosis-specific so they can potentially be used for all clients. They measure outcomes on an intermediate basis rather than a long term basis and they measure client centered outcomes rather than service utilization outcomes.

The scales were tested in pilot programs over a six week period. They take 5-15 minutes to administer. They were designed to be much more sensitive to changes than other scales. For instance, a distinction is made between upper body dressing and lower body dressing instead of just dressing in general. A client's progress is charted in specific increments.

One agency used the scale to reform its approach to easing pain reported by clients. After the need for pain relief was stressed by a set of clients filling out the questionnaire, a new procedure was started to alleviate the problem. At specified intervals, there was consultation with the physician on modifying pain medication. As a result, the responses on the follow-up survey showed the agency had reduced the number of clients complaining of pain.

Widespread use of these scales by the home care industry could facilitate case management, improve the quality of care, test outcome practice measures, and allow aggregate data collection across agencies.

June Gray reviewed procedures for carrying out certification surveys of Medicare/Medicaid participating home health agencies. The survey consists of ten conditions of participation. it covers compliance with local, State, and Federal regulations; the agency's organization, services, and administration; and other quality assurance requirements.

June Gray presented figures to show the categories with the highest number of deficiencies for the 5,984 Medicare-certified agencies at the beginning of 1987. They were Policies (18 percent), Plan of Treatment (13 percent), Compliance with Physician Orders (12.7 percent), Clinical Record Review (12.6 percent), and Coordination of Patient Care (9.7 percent). Wide variations were found within regions of the country.

Although surveyors do make some home visits, much of the data collection and analysis is done by reviewing agency records. Some agencies simply modify their paperwork after the fact to look better. Since a new Federal law requires an assessment of the client at the beginning of service, this allows comparison of the client's original condition to his or her present condition. June Gray recommended that administrative law support the surveyor in judging the client's change in condition by seeing the client rather than by just studying records.

The benefits to the Federal government would be to identify outcomes appropriate for measuring home care quality, provide data for interagency comparisons, and provide data on client centered outcomes to facilitate process outcome studies.

Samuel Kidder and Thomas Hoyer briefly outlined the new survey and certification requirements mandated by the Omnibus Budget Reconciliation Act of 1987 and the Health Care Financing Administration's plans to write regulations implementing these new statutory provisions.

EMPOWERING CONSUMERS: POSSIBILITIES AND LIMITATIONS

Moderators: Katie Maslow Office of Technology Assessment U.S. Congress Washington, D.C.
Brina Melemed Consultant, Long Term Care Bethesda, Maryland
Presenters: Elizabeth Mullen Director, Women’s Initiative American Association of Retired Persons Washington, D.C.
Patricia Murphy Director, Ombudservice for Home Care Clients Community Council of New York City New York, New York
Ellen Reap Survey and Certification Program Review Specialist Health Standards and Quality Bureau Health Care Financing Administration, Region III Philadelphia, Pennsylvania
Carmine Striano Director of Professional Relations Keystone Peer Review Organization, Inc. (KeyPro) Lemoyne, Pennsylvania
Tony Young Chairperson Personal Assistance Services Together (PAST) and Fairfax Opportunities Unlimited, Inc. Springfield, Virginia

The panel confronted a broad range of topics: How is client involvement ensured in quality assurance of home health care? How is client satisfaction measured? Are clients satisfied with the home care currently being provided?

Regulatory agencies can help empower home care beneficiaries through home visits. Ellen Reap noted that, as of 1985, home visits were added to the inspection process of the Health Care Financing Administration (HCFA) for Medicare certification. The home visit verifies that patient needs are being met and all appropriate treatments are being provided. Specific policies govern home visits. The agencies contact the beneficiary and gain written consent for the visit which the beneficiary can cancel at any time.

HCFA also administers a complaint process. All complaints are evaluated at the State level to determine if they should be referred to the Federal authorities. Serious allegations are investigated within two working days. The States make unannounced visits to providers in investigating consumer complaints. The number of complaints by home care beneficiaries is often low for several reasons. Many beneficiaries live alone or with family where their care is largely unobserved. They often do not understand the process of filing a complaint with the proper government agencies. Many fear loss of benefits if they do complain.

The Omnibus Budget Reconciliation Act (OBRA) of 1987 will have a major effect on quality standards for home health services. The law formalized patient rights and compelled the States to establish complaint hotlines and to create units to investigate consumer complaints.

Carm Striano reported that peer review organizations (PROs) have recently been directed to undertake consumer outreach. Through a review of sample cases, PROs assure that the quality of care meets professional standards. The Keystone Peer Review Organization, Inc. (KeyPro) of Pennsylvania has prepared a pamphlet explaining the right of patients to appeal decisions and the right to a review of their case. KeyPro has established a beneficiary hotline and responds to all complaints. In responding to a complaint, the organization reviews the case to determine the quality of care. KeyPro has also developed a speakers' group to educate senior citizens on these issues.

Patricia Murphy explained how ombudsman programs can facilitate consumer empowerment. Ombudsman programs serve both the independent but disabled client and the dependent client, for whom the ombudsman program is most important. Consumers should be able to define their needs and understand their plan of care. On a community level, consumer empowerment can be accomplished through consumer advocacy groups, which are often able to push State regulatory agencies into action. According to Patricia Murphy, consumers should be involved in developing government regulations but should not supervise home care or assess the technical quality of care.

Elizabeth Mullen of the American Association of Retired Persons (AARP) stressed that the home care industry must be held accountable to those it serves. There needs to be a sufficient number of providers who can offer a full range of affordable and high quality services. Providers have certain responsibilities:

  • Delivery of high quality care.

  • Comprehensive needs assessments.

  • Care plans developed with the consumer.

  • Services appropriately documented.

  • Education and training consistent with the needs of the scope of service.

  • Employees supervised by professional personnel.

  • Care that reflects standards of practice.

  • Client Bill of Rights with a clearly defined grievance procedure.

  • Quality assurance programs include consumer input.

Pressure on providers often lowers the quality of care. Cost containment and quality assurance can be seen as conflicting issues. A shortage of providers means that they sometimes engage in questionable hiring practices. A fragmented provider system is a hindrance to coordinated care. The regulatory framework sets only minimal, not normative, reimbursement standards. There are insufficient licensure requirements. Recommendations for government action included requiring licensure of all home care workers, developing a standard definition of home care services, and mandating certification training and continuing education of paraprofessionals.

Recent legislation strengthened the conditions for participation in Medicare by including a client Bill of Rights, homemaker/home health aide training, and improved surveys.

AARP educates the public on home care and how it can be accessed. AARP is currently doing a study on the role of volunteers in home care. Another study is being done on the value of case management.

On behalf of AARP, Elizabeth Mullen offered the following recommendations to the Department of Health and Human Services:

  • Develop a systematic method of collecting information from patients.

  • Monitor and evaluate the effectiveness of OBRA.

  • Study whether quality is increased by paraprofessional training.

  • Determine whether ombudsman and hotline programs improve access to and quality of care.

  • Examine the role of physicians in home care.

According to Tony Young who is active as a consumer advocate for the younger disabled populations, the key to quality assurance for long term personal assistance service lies in helping the client to monitor the quality. The provider and client must be full partners in the needs assessment and service design process. The client should be involved in training and managing those who will come into his or her home. Another helpful procedure would be an independent grievance procedure with a third-party mediator. The consumer should be able to terminate an unsatisfactory situation without the fear of losing service altogether. Emergency services should be improved, as should recruiting and referral services.

POST-ACUTE CARE: THE EFFECTS OF DIAGNOSIS-RELATED GROUP (DRG) PAYMENT REFORM ON HOME HEALTH

Moderators: Robert Clark Office of the Assistant Secretary for Planning and Evaluation U.S. Department of Health and Human Services Washington, D.C.
William Saunders Chief, Long Term Care Coverage Branch Office of Research and Demonstrations Health Care Financing Administration Baltimore, Maryland
Presenters: Rosalie Kane Professor School of Public Health and School of Social Work University of Minnesota Minneapolis, Minnesota
Shelah Leader Health Policy Analyst Public Policy Institute American Association of Retired Persons Washington, D.C.
Korbin Liu Senior Research Associate Urban Institute Washington, D.C.
Kenneth Manton Research Professor Duke University Durham, North Carolina
Barbara Phillips Senior Researcher Mathematica Policy Research Princeton, New Jersey

There is a lack of definitive data on the Prospective Payment System (PPS), but the rate of growth in Medicare outlays has dropped sharply to the lowest level ever. Some of the effects of PPS discussed by the panelists included placement of patients in home care after hospitalization, strong pressure to discharge patients faster, and to discharge patients who are too sick for family care. Shelah Leader noted that the American Association of Retired Persons (AARP) has received 2.2 million requests for its pamphlet "Know Your Rights," indicating the extent of unmet needs for home health care. The RAND Corporation is conducting a study on home care as a substitute for traditional institutional health care. However, data are not available on readmission rates for discharged hospital patients. The research agenda should include studies on the role of fiscal intermediaries. These studies should result in the production of data on the clinical condition of discharged hospital patients. AARP conducted a panel on patients who had been hospitalized that provided the first solid data on PPS beneficiaries.

Korbin Liu reported on the study he and Kenneth Manton conducted on utilization patterns of post-acute care by functionally disabled Medicare beneficiaries. Special attention was given to hospital readmissions and mortality. The results indicated a decline in the average hospital length of stay and an increase in post-hospital home health episodes of care. Mortality declined following the use of PPS and home health utilization increased. No adverse effects of PPS on Medicare beneficiaries were uncovered.

Barbara Phillips described Mathematica Policy Research's survey in progress of post-acute care for frail elderly Medicare recipients, particularly those over 85. The study is looking at quality challenges and patterns of combining services among hospitals, rehabilitation centers, nursing homes, and home care agencies as they relate to outcome measures. Two key questions are what factors account for the type of post-acute care chosen and why. Factors include patient, discharge, and hospital elements. The survey, which is funded by the Heinz Foundation, will also study the caregiver burden to develop a better view of home care challenges, including rehabilitation, case management, education, personal care, quality of family care, and quality of service needs assessment.

Rosalie Kane reported on a related study concerned with access to post-hospital care and denial of services in conjunction with PPS. The major question being addressed is whether Medicare beneficiaries are getting adequate care. The goals of this study are to identify and validate guidelines for defining minimally adequate care and to develop a risk classification system identifying outcomes, using data to determine a broad range of measures. Potential applications include the extension of this study to other areas, such as process measures and adverse outcomes, and its use by researchers and consumer groups in care planning.

ISSUES IN THE RECRUITMENT, TRAINING, MOTIVATION, AND SUPERVISION OF HOME CARE WORKERS

Moderators: Pamela Doty Office of the Assistant Secretary for Planning and Evaluation U.S. Department of Health and Human Services Washington, D.C.
Suzanne Resner Division of Nursing U.S. Public Health Service Rockville, Maryland
Presenters: Robert Applebaum Assistant Professor Miami University Scripps Gerontology Center Oxford, Ohio
Jeff Barnes Policy Analyst New York State Department of Social Services Albany, New York
Rebecca Donovan School of Social Work Hunter College New York, New York
Jo Eleanor Elliott Director, Division of Nursing U.S. Public Health Service Rockville, Maryland
Elizabeth Gordon Vice President for Clinical Services Kimberly Quality Care Boston, Massachusetts
John Mullin Clackamas County Social Services Division Oregon City, Oregon

A major topic of this session was the need for methods to ensure quality of care. The development of new methods is important because close supervision of home care workers is difficult. Some examples include a consumer checklist, a supervisory checklist for the home health agency to complete each month, random home visits, and such support programs as a recognition lunch for workers.

Low salary for home care aides is a major problem. They are usually poorly educated, poorly trained, and poorly paid. Additionally, more research is needed on the best methods to help the aides improve the quality of care.

Jo Eleanor Elliott reviewed the Public Health Service Division of Nursing activities related to issues in recruitment, retention, and supervision of home health care workers. Recently, the Division held a conference on home health care. The Division also provides leadership in response to legislative initiatives through Title VIII of the Public Health Service Act. It currently funds demonstration projects to improve care and access to care, continuing education of nurses, and advanced nurse education in home care. A sample survey of nurses will give an indication of how many nurses work in the home care field. The Division has also developed criteria for home care nursing.

The Health Resources and Services Administration will be funding demonstration grants for home care service. Much-needed research on the outcomes of care is eligible for funding from the National Institutes of Health. The American Nurses Association has issued standards for home care practices for registered nurses.

Elizabeth Gordon focused on the lack of well-defined job descriptions for home health personnel. The scope of practice for registered nurses is well defined from State to State. However, the scope of practice for licensed practical nurses (LPNs) and licensed vocational nurses (LVNs) is less well-defined. As the home care worker shortage becomes more acute, there is more use of LPNs and LVNs. Training requirements for paraprofessionals vary widely among the States. The length of training required varies from 16 to 120 hours. The titles used in different States also vary widely.

There is no central registry or board for home care workers. Regulation by such boards would allow the competency of the individuals to be assessed more easily. In States with mandatory ongoing continuing education there is no follow-up procedure to make sure the education is completed. It was recommended that national regulations should be established that define the scope of practice of LPNs and LVNs and that the minimum training should be standardized.

Jeff Barnes described three studies New York State is carrying out regarding the home care labor force. New York's Long Term Care Policy Coordinating Council (LTCPCC) advises the Governor on health care policy. LTCPCC is studying recruitment, retention, and motivation of home care workers. High turnover and falling recruitment are becoming problems in New York. LTCPCC’s research includes a survey to every agency in the State, a labor market study, and a survey of current and former home care workers.

These studies have two broad goals: (1) providing baseline data to document the extent of the problem in the State; and (2) helping the New York Legislature develop policy. One of the issues that will be studied is compensation of home care workers. Wages can run as low as $3.45 per hour and the average range is $4-$5 per hour. The study will concentrate on compensation package, rate reimbursement, wage security, and wage increase strategies. The rate of retention of home care workers is difficult to document because of reporting problems. Some data indicate that home care is a labor market entry mechanism. One possible method of attracting other potential home care workers is by offering day-care services. There also needs to be more support of home care workers to prevent burnout. Many times workers infer that they constitute a temporary work force because of the way the work is assigned. A new aspect of the study will concentrate on recruitment.

Rebecca Donovan reported the preliminary findings from her study of New York City's home care workers. Publicity regarding these findings provided the impetus for a recent campaign to improve wages and benefits. In New York City there are an estimated 60,000-70,000 home care workers. The survey was done of 404 home care workers. The workers in the study were exclusively minority women and 54 percent were born in the United States. The foreign born came from 26 countries with a large contingent from the Caribbean. The average age was 47 years old. Some 86 percent had children and 75 percent were the sole wage earners for their household.

The Medicaid office controls the terms of employment so there is little leeway for the vendor agencies in their employment practices. The most common salary for the previous 12 months was $5,000. Annual income is low because the worker is treated like a temporary and the work tends to be intermittent. Some 80 percent reported that they were unable to acquire adequate housing. Eighty-five percent reported that they did not earn enough money as home care aides to buy food for themselves or their families. Negative aspects indicated were isolation, lack of training, lack of supervision, and marginalization of their position. Fifty-two percent reported suffering from psychological stress symptoms. However, most of the workers felt that they were doing important and valuable work. Fifty-two percent reported that they were somewhat satisfied with their jobs. In New York City home care workers have begun to unionize. Through the unions workers have gained benefits and wage increases.

John Mullin described how the Clackamas County Social Services Program in Oregon and the Medicaid State-funded Oregon Project Independence Program addresses recruitment, training, and supervision of home care workers. Both programs recognize the importance of flexible hours, vacation time, and training requirements.

The Client Employee Program of Oregon's Project Independence Program was able to obtain unemployment coverage for home care workers. It developed a clearinghouse project to screen, check references, and provide a minimum amount of training. A registered nurse was added to the staff to help employees working with clients requiring special assistance. The program provided respite, hospice, and chore services; a Seniors Resource Guide to encourage people to be smart consumers; and a case management system called risk intervention.

In Oregon, adult foster care is an important issue. Recruiting in the rural areas of Oregon is a problem and wages remain low. Adequately trained employees are in short supply.

ACCOUNTABILITY OF STATE AND LOCAL PROGRAMS

Moderators: Floyd Brown Office of the Assistant Secretary for Planning and Evaluation U.S. Department of Health and Human Services Washington, D.C.
Pamela Doty Office of the Assistant Secretary for Planning and Evaluation U.S. Department of Health and Human Services Washington, D.C.
Presenters: Darrel Balmer Manager, Division of Administrative Compliance Illinois Department on Aging Springfield, Illinois
James Focht Associate Macro Systems Silver Spring, Maryland
William Foley Assistant Professor of Industrial Engineering Department of Decision Sciences and Engineering Systems Rensselaer Polytechnic Institute Troy, New York
Nancy Mumma Director, Long Term Care Project Community Service Council of Greater Tulsa Tulsa, Oklahoma
Maryann Nardone Pennsylvania Department of Aging Long Term Care Assessment and Management Program Harrisburg, Pennsylvania

Topics included State quality assurance programs for home care, long term care assessment and management programs, a systems view of home care quality, and an overview of quality assurance.

The lead speaker, James Focht, described a study, funded by the U. S. Department of Health and Human Services, being carried out by Macro Systems that focuses on State activities in home care quality assurance. The challenge is the difficulty in obtaining an overview, given variation among the 19 States in the study. The report will include profiles of each State covering a generalizable picture of program organization and history of home care services, the degree of fragmentation, service delivery mechanisms, resources, demographics, availability of providers, and community involvement as well as regulatory standards and methods.

The basic question is whether there is a tendency to be less critical when care is given in the home and whether standards are compromised as a result. Issues include standard definitions, outcome measures, licensing of providers, case management, and risk management.

Nancy Mumma's presentation described efforts to contain home care costs in Oklahoma by coordinating various State agency funding and organizing a local voluntary effort by non-professionals to provide home care. Contributing f actors were Federal cutbacks, loss of revenue sharing, and methods to improve accountability. Agency coordination prevented duplication of services for proposals, contracting, monitoring, and evaluation. A survey of referrals was recommended as a good mechanism f or measuring quality.

Results included services more responsive to client needs, better coordination of State and local services, cost reduction, ability to serve more clients, collection of aggregate data, and services provided at 50 percent less than Medicare. Recommendations included Federal and State coordination of reimbursement; more research on process, outcomes, cost, and quality of care; more flexibility of service needs for chronic and long term care; and client-centered approaches to quality assurance.

Maryann Nardone described quality assurance under Pennsylvania’s Long Term Care Assessment and Management Program. Local agencies perform assessments and offer alternatives to a long term care facility. Supplemental services are available to the individual and all services are pre-approved. The population is well-defined and a standard assessment tool is used. All staff receive standard training. The client caseload is identified. Direct providers are not allowed to perform assessments and onsite monitoring is done. Maryann Nardone recommended that the research agenda include service protocols on client care and family care.

William Foley of the Rensselaer Polytechnic Institute presented a systems engineering view of the home care delivery system. The systems definition of quality is delivering the right services to the right people at the right time. Issues in focusing on the right people include the opportunity for home placement, discharge planning, and screening those who will benefit most from the kind of assistance home care is best suited to provide. Issues related to the right time include identification of problems, resources available to solve the problems, specification of goals for these services, and availability and accessibility of services when required.

A decision-making tool was devised that achieved economy of home care resources in reviewing prospective clients for home care placement. A client classification system to match clients to home care programs and a uniform client assessment for care planning were devised.

Innovative delivery and payment systems, productivity improvements, and introduction of technology are needed in dealing with the "right time" issue. Since demand cannot be anticipated, accessibility is the greatest challenge.

Darrel Balmer presented an overview of Illinois' quality assurance approach. Structure, process, and outcome measures are incorporated into contract reviews of vendor performance. This process determines the continuation of contracts for the agencies. Technical assistants are used for the compliance review. The threat of corrective action is an incentive to improve quality. A thorough review is conducted following corrective action. The results showed that compliance reviews were strengthened and plan of care reviews were more appropriate.

MEDICARE/MEDICAID SURVEY AND CERTIFICATION: STRENGTHS AND WEAKNESSES

Moderators: Pamela Doty Office of the Assistant Secretary for Planning and Evaluation U.S. Department of Health and Human Services Washington, D.C.
George Greenberg Office of the Assistant Secretary for Planning and Evaluation U.S. Department of Health and Human Services Washington, D.C.
Presenters: Marly Auerbach Executive Director NCOSS Nursing Services Red Bank, New Jersey
Mike Goldman Chief, Laboratory and Ambulatory Services Branch Health Standards and Quality Bureau Health Care Financing Administration Washington, D.C.
Charlene Harrington Associate Professor Institute for Health and Aging University of California San Francisco, California

The issues discussed at this session included enforcement of outcome measures, whether quality deteriorates when flexible survey cycles are used, the effectiveness of voluntary accreditation, and recent changes in the omnibus Budget Reconciliation Act of 1987 (OBRA) designed to raise quality standards and improve the survey and certification process.

Mike Goldman of the Health Care Financing Administration highlighted the following new requirements mandated by OBRA:

  • Each patient must be informed of his or her rights in advance, including the right to express grievances, to confidentiality, and to information on services provided.

  • Home health agencies will have to notify State survey agencies of all changes in ownership.

  • A home health aide training program will be developed. A regular performance review must be conducted, and after January 1, 1990, no home health agency may use an untrained person.

  • Training standards will be developed for personnel using durable medical equipment.

  • An individual plan of care for each patient is required.

  • Home health agencies are subject to an outcome-oriented survey process, based on home visits, to ensure that services promote the highest functional capability of the patient receiving medical, nursing, and rehabilitation care.

  • Prior notification of a survey visit is subject to a fine.

  • Facilities found to be providing substandard care will be subject to an extended survey and a review of policies to determine compliance. Penalties may include intermediate sanctions (civil fines and suspension of Medicare payments) or termination.

  • A toll-free hotline will be established for client complaints, monitored by an investigative unit.

  • Peer review organizations (PROs) will review specific complaints of beneficiaries.

Charlene Harrington discussed her study in progress of the quality of home care in California and Missouri. This study looks at the quality of care, the extent of State regulations, and changes that have occurred. Statistical data were obtained from key providers, State regulators, consumer organizations, PROs, home care agencies, and State legislators. Preliminary results indicate that the number of regulations are decreasing because of budgetary restrictions. The study is also measuring the extent of State licensing, which is decreasing, as well as Medicare/Medicaid certification surveys. Because of resource constraints, there is a lack of surveyors, and fewer than half of the home health care agencies are surveyed annually.

Questions were asked about State priorities for certification and the kind of enforcement actions taken if there is a lack of compliance. Enforcement is limited, but there is some decertification action. It was suggested that State authorities hear few complaints because consumers do not know which agency is responsible for regulation. Also, the States do not have the resources to respond. Half of all complaints are about unlicensed agencies. There is a funding problem if regulations are expanded, and one political barrier to expansion is the influence of interest groups.

Quality problems were found in personnel policies, supervision, clinical records review, administration, and coordination of patient services. Coordination among the various agencies is also problematic, and there are few resources to focus on outcome measures.

Changes in the Federal survey and certification process have occurred because of the increase in the number of proprietary agencies, the use of diagnosis-related groups in the Prospective Payment System of Medicare, and the growth of the elderly (over 75) population.

Marly Auerbach presented the view of a home health agency director whose agency is subject to Medicare/Medicaid regulatory standards. She criticized Medicare/Medicaid quality requirements for not being integrated with reimbursement and expressed the opinion that increased scrutiny has not improved care. Home care agencies did not have sufficient input into the development of Medicare Form 485 (for filing reimbursement claims); consequently, this form is difficult to relate to the plan of care. This results in less time for clients and more time on paperwork, increasing the cost to the agency of compliance. Surveyors who determine noncompliance do not have a home health care background; therefore the need for inter-rater reliability is crucial.

Marly Auerbach's recommendations for improving survey and certification standards and processes included the following:

  • Distinguish between long term and short term acute care.

  • Strengthen standards jointly.

  • Coordinate reimbursement policy and survey development.

  • Consult health care leaders.

  • Work with providers on reimbursement policy.

  • Consider the cost of compliance.

  • Increase certification criteria.

  • Do not require as much paperwork.

  • Work with home health care providers, not against them.

ACCREDITATION PROGRAMS: STRENGTHS AND WEAKNESSES

Moderator: Ruth Galten Director of Clinical Services National Association for Home Care Washington, D.C.
Presenters: Nola Aalberts Director, Homemaker/Home Health Aide Division National Association for Home Care and Acting Director of Accreditation and Education National Home Caring Council Foundation for Hospice and Homecare Washington, D.C.
Carol Kurland Administrator Office of Home Care Programs New Jersey Medicaid Program Trenton, New Jersey
Maria Mitchell Senior Vice President Community Health Accreditation Program National League for Nursing New York, New York
Anne Rooney Associate Director Hospice and Home Health Accreditation Programs Joint Commission on Accreditation of Healthcare Organizations Chicago, Illinois
Ellen Yung-Fatah Nurse Consultant District of Columbia Department of Consumer and Regulatory Affairs Washington, D.C.

This panel focused on the accreditation programs of three national professional groups and an accreditation commission established in New Jersey to assist the State Medicaid program. The issue of private accreditation programs qualifying to grant agencies "deemed status" under Medicare was debated. If an accreditation program is assigned the authority to grant deemed status by the Health Care Financing Administration (HCFA) , the agencies accredited by it are eligible for participation in Medicare just as if they had qualified through the Medicare certification process.

According to Carol Kurland, the Commission on Accreditation for Home Care in New Jersey was developed to address the problem of the rapid growth of home care agencies since the early 1970s. The number of homemaker/home health aide agencies grew from 25 in 1975 to 225 in 1984. In 1984 the State developed the option of personal care assistance services. Administrators of the Medicaid program realized they could no longer rely on only Medicare-certified agencies for service to the increasing number of eligible clients, so they turned to the largely unregulated homemaker/home health aide segment of the industry.

However, they were concerned about the unregulated nature explored using this segment. They used existing accreditation organizations, the National Home Caring Council and the New Jersey Home Care Council. There was no difficulty with the national organization but the certified agencies argued that a private provider industry organization with an accreditation program was not appropriate. Consequently, New Jersey developed the commission, a separate, legally incorporated entity. They sought input from many organizations. All interested parties are represented on the commission's board.

This State commission and the national council submit accreditation recommendations on agencies to the Medicaid program which makes the final decision. One advantage cited was running such a commission without the taxpayer's money. Seventy-four percent of the commission's $94,000 budget comes from fees and the rest comes from the Robert Wood Johnson Foundation, based in New Jersey.

The commission has established a task force to study the shortage of home health aides. It also facilitates periodic meetings of home health agencies with the Medicaid director to discuss issues.

This model of State-sponsored accreditation was described as promoting a very good private industry/government working relationship. It was also seen as the first step in an evolving quality care program for the New Jersey's Medicaid program.

According to Anne Rooney, the new Home Care Accreditation Program of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) represents a national industry consensus on standards. The program was two years in the making and had just begun implementation the day before the conference.

In the development process, four versions of draft standards were reviewed by some 7,000 health care professionals, professional and trade associations, and consumers. The standards were also discussed at regional conferences and JCAHO staff members made some 60 presentations at national meetings. The standards focus on the interaction between the care worker and the client.

Pilot surveys were conducted at home health agencies around the country. The agencies were asked not to prepare f or an accreditation survey because the intent was not to accredit but to find out if the proposed standards were realistic as ways to improve the quality of care. Seventeen organizations participated and the standards were modified according to the results.

Representatives from 18 professional and trade associations make up a Home Care Advisory Committee that is involved in the new accreditation process. The accreditation program not only includes home health agencies but also equipment management firms and personal care and support services organizations.

The survey process includes a minimum of f our home visits for each organization. Some 70 peer reviewers will be trained by this fall. They will be nurses with clinical and administrative experience in the field, equipment managers who have owned or managed an equipment company, and pharmacists.

Maria Mitchell characterized the Community Health Accreditation Process (CHAP) of the National League for Nursing (NLN) as setting a standard of excellence rather than going along with the more common minimum safety standards. The NLN has been accrediting home health agencies for 25 years. CHAP is a subsidiary of NLN with its own board of directors.

The standards and criteria were broken down into the five key areas of planning, organization and management, finance, human resources, and operations and service delivery. A major emphasis is placed on management and finance.

The NLN has done quite a bit of work in the area of outcomes in home care and the standards focus on outcome measures.

The accreditation process includes an agency self-appraisal, a site visit, and home visits. In general, two site visitors stay for four days. They typically include a professional with experience in a service delivery area and one with experience in the management and finance area. Site visitors undergo rigorous training. A consultation approach with the agency is stressed. The agency is left with a clear view of any problems and a good idea of how to build on the strengths. A board of review composed of 12 home care managers then makes a decision based on the site visitors' report.

According to Nola Aalberts, the National Home Caring Council Accreditation Program is geared to the homemaker/home health aide component of the industry. The council was founded at the request of eight government agencies and 26 national organizations for the express purpose of developing standards.

Standards are set for training at the beginning of employment, in-service training, and specialized training. Emphasis is placed on case supervision (i.e., monitoring specific tasks done for the client) and administrative supervision (i.e., monitoring payroll and personnel records). The standards also require an annual evaluation of services, a periodic in-depth self-evaluation, and consumer input. Community agencies that fund the agency's programs or that refer clients are surveyed.

Board members and staff members on all levels are interviewed during site visits. Case records are reviewed. Hiring procedures, reference checking, and performance evaluations are studied.

Debate on deemed status centered on whether or not the JCAHO and NLN would be able to abide by Federal rules and regulations if their accreditation programs were given the authority to assign such status. In the view of Ellen Yung-Fatah, the two organizations could not meet the standards and should not be empowered to grant deemed status. Representatives of both organizations responded vigorously that they would be able to meet the requirements.

HCFA announced last year that it had decided to give authority to the two organizations to grant deemed status, but the Omnibus Budget Reconciliation Act of 1987 stipulated that such a decision could not take effect until new Federal rules on the conditions of participation in the Medicare program were released. That was not expected until the last few months of 1988.

One of Ellen Yung-Fatah's concerns about the ability of the two organizations to meet the requirements was the contrast between the three year review cycle of the accrediting organizations and the required one year survey and certification review cycle. Another of her concerns was the problem of how special compliance reviews will be funded because private accrediting bodies generally bill the client agency for reviews. Will the accrediting bodies pay for follow-up reviews when problems are discovered if the agencies are unwilling to do so?

Her third concern was that the organizations' approach of stressing consultation and education in motivating agencies to comply voluntarily with regulations might be at odds with their role in enforcing standards. Similarly, Ellen Yung-Fatah asked whether accrediting bodies could move fast enough to satisfy timeliness requirements in compliance investigations. She also questioned whether they could carry out the required home visits.

Finally, Ellen Yung-Fatah expressed doubts about whether the accrediting bodies could protect the individual client's rights under the Freedom of Information Act. Conversely, she asked, would the accrediting bodies agree to release information on abuses by agencies to the government, given their policies of protecting the confidentiality of their surveys?

In rebuttal, the representatives of accrediting bodies stressed that their organizations do conduct special follow-up surveys and pay for these themselves. The consultation approach was defended as not being inconsistent with the regulations. It was emphasized that the accrediting bodies could move in a timely fashion to carry out compliance reviews and satisfy the specific requirements regarding home visits.

The ability to protect client's rights was also asserted as a key strength of both home health accrediting organizations. The organizations' representatives also stressed that the results of their investigations would be sent to the Federal government and in this way could become public record even though disclosure procedures have not been finalized.

SPECIAL NEEDS OF SPECIAL POPULATIONS AND ETHICAL ISSUES

Moderators: Marcy Gross Office of the Assistant Secretary for Planning and Evaluation U.S. Department of Health and Human Services Washington, D.C.
Aurora Zappolo Office of Legislation and Policy Health Care Financing Administration Washington, D.C.
Presenters: Peggy Beckman Assistant Administrator for Nursing Services Inova Home Care Professionals Springfield, Virginia
Ann Hallock Director, Home Care Services Division of Medical Assistance New York State Department of Social Services Albany, New York
Linda Maurano Director, Home Health Care Services Children’s Hospital National Medical Center Washington, D.C.
Connie Zuckerman Department of Epidemiology and Social Medicine Montefiore Hospital New York, New York

The AIDS population was discussed first. Peggy Beckman stated that home health care agencies will be dealing with more AIDS patients in the future because their number is increasing and the best way to provide care is at home. The United States has 42,000 reported AIDS cases as well as 1-3 million people infected with the human immunodeficiency virus of whom 60 percent are expected to develop AIDS.

What are the needs of the AIDS patient? Confidentiality must be closely protected and the AIDS patient's right to medical care must be upheld. Reimbursement for health care is needed because many AIDS patients lack private insurance. Data should be collected on the costs of AIDS care.

Because many AIDS patients are homosexuals or intravenous drug abusers, there are differences in culture and values that the health care system should understand. A comprehensive home care program would have these essential components:

  • good quality assurance criteria and standards;
  • knowledge of local epidemiology;
  • a strong system of case management;
  • a multi-disciplinary approach;
  • staff education on the management of symptoms and psychosocial issues;
  • staff support mechanisms;
  • ongoing evaluation and monitoring of care; and
  • better data collection.

When dealing with AIDS patients, the worker generally confronts a very complex nontraditional family structure. There are also issues involving the care of terminally ill patients. Statistics show that AIDS patients will die within 2-3 years following diagnosis.

Another issue is the shortage of nursing home beds for AIDS patients. Those with AIDs are reluctant to seek hospice care because they are usually young and vital. There is also a problem of recruiting people to work with AIDS patients.

Children make up a second population frequently served by home care workers. Linda Maurano described the Pediatric Home Health Care Services of Children's Hospital National Medical Center. Home care returns as much responsibility for care as possible back to the family. Family values and participation play a central role in home care for children. The package of services should be designed to serve children on a wellness-illness continuum. There is an increased need for home care for children for several reasons. The number of children disabled by chronic illness has doubled over the past 25 years. The technology that was once available only in the hospital has been miniaturized and is available in the home setting. Children can be cared for at one-fifth of the cost at home.

There are some significant differences between pediatric care and adult care. The focus of teaching is on the caregiver (parent, etc.) not the care receiver, and extra emphasis is placed on family unit. Children often do not meet the criterion for adult home care of being homebound so another more accurate standard needs to be developed. Children get sick quicker and their condition is more fragile.

Staff members caring for a child should have pediatric experience. They must be taught that they are to care for the child, but not replace the parent. Administrative costs for pediatric home care are much higher. Usually the social and psychological factors in a family situation make caring for the child difficult so health care workers need support to prevent burnout.

Ann Hallock described New York State's personal care program which has 70,000 clients and deals with several different client groups. One client group in particular, the adult disabled under age 65, want self-directed care. The Medicaid personal care program provides three levels of assistance of nutrition and environmental support, personal hygiene, and health related tasks. The personal care program only permits the third level for self-directing patients with a stable medical condition who are chronically but not acutely ill. Even though the program is State supervised, it is administered at the local level.

Many of the clients have been the self-directing physically disabled. In New York City an agency, Concepts for Independence, was established to be run directly by disabled people. The board of directors includes one representative from each of the disability-related organizations in the city. This organization was set up as a home attendant vendor. In this arrangement, the disabled client actually does the hiring and firing, and some training of the home care worker. Concepts for Independence acts as a fiscal intermediary and keeps employment information, prepares paychecks, and provides a registry of potential emergency workers. It also provides peer support in managing home care workers.

Connie Zuckerman addressed ethical issues posed by in-home care from a legal perspective. The United Hospital Fund of New York recently completed a study of home care in New York City that documented the change from a system of care dominated by nursing homes to one in which a growing number of elderly clients receive services in their home. Despite large numbers of clients receiving home care, very little is known about the quality of the care. Medicare had certified about 5,000 home care agencies by 1984. From a medical and consumer law perspective, home care agencies are businesses that are isolated from the operation, scrutiny, values, and peer review involved in more conventional medical care. As of yet, there has been little focus in the area of bio-ethics on issues raised by home care. Recent literature on legal issues in home care reflects a defensive risk management approach. Home care has not been subjected to the intense regulatory scrutiny of hospital and nursing home care. It is not susceptible to the peer review that occurs in congregate settings. Many elderly clients cannot be self-directing in terms of their care and comfort needs because they have diminished mental capacity. Who will monitor these interactions in the private home? Elderly home care clients live in a netherworld without official or self-appointed advocates. These issues raise a series of questions:

  • Who makes decisions for the elderly with regard to the determination and provision of appropriate levels of' home health care?

  • Are some of the elderly too readily transferred from home care to institutions?

  • What role is played by agency policies?

  • Is there any social or ethical consensus about the appropriate family responsibility in the home care setting?

  • Should we be encouraging or demanding family responsibility in home care?

  • How are the wishes of clients with diminished mental capacities respected?

The courts have ruled that patients capable of making decisions have the right to decide on proposed medical care even if the consequence of refusal is serious injury or death. What is the responsibility of home health care providers on this issue?

Ethical issues and values often lie hidden by financial and regulatory imperatives. It is difficult to disentangle issues of' client rights, autonomy, quality, and ethical concerns from the issues of cost control, payment, and reimbursement. It is imperative to recognize the primary role of clients.

CLOSING GENERAL SESSION SUMMARY

SUMMARY AND CONCLUSION

Moderator: Mary Harahan Director, Division of Disability, Aging and Long Term Care Office of the Assistant Secretary for Planning and Evaluation U.S. Department of Health and Human Services Washington, D.C.
Presenters: Linda Hamm Director, Division of Long Term Care Experimentation Office of Research and Demonstration Health Care Financing Administration Baltimore, Maryland
Andrea Kabcenell Robert Wood Johnson Foundation Princeton, New Jersey
Jerry Weston Senior Research Manager Division of Extramural Research National Center for Health Services Research and Health Care Technology Assessment Rockville, Maryland

The contributions to home care research of three major research funding sources were outlined in this concluding session. Representatives of the National Center for Health Sciences Research and Health Care Technology Assessment (NCHSR), Health Care Financing Administration (HCFA), and Robert Wood Johnson Foundation also discussed their organizations' future research agendas.

Jerry Weston highlighted three of the two dozen or so past projects on home care funded by NCHSR. The first was a study of comprehensive home care programs for the elderly. Conducted by Susan Hughes at Northwestern University, it evaluated a collaborative home care program involving five voluntary hospitals on the north side of Chicago.

The program differed from that of most Medicare-reimbursed home health care in that services were not restricted to patients requiring skilled nursing visits and no limits were placed on the number of visits. It also bridged the gap between nursing and medically oriented visiting nurse services and social service homemaker services.

The evaluation used a quasi-experimental design with a nonequivalent control group and pre-hospitalization and post-hospitalization measures of two groups of homebound individuals over the age of 60. The findings included a significant reduction in the rate of institutionalization for those receiving comprehensive care and a reduction in their unmet needs. These positive findings were accompanied by a decline in functional status. The researchers suggested that the subjects might have reported greater prevailing disability in order to retain compensated support for their daily activities.

The second study was a randomized trial of a new approach to home care. It evaluated the impact of a nurse practitioner/social worker team approach to home care for patients with chronic or terminal illness who wished to be treated at home rather than in an institution. The project was conducted by the University of Rochester Medical Center and the Visiting Nurse Association of Monroe County. Ann Marie Groth-Juncker at the University of Rochester was the principal investigator. The program included a 24 hour telephone service by team members and home visits by physicians as necessary. It emphasized supportive care by family and friends. The findings showed that this team approach was very well received by patients and their families. The patients were institutionalized for fewer hospital days (38 percent less institutionalization) and fewer nursing home days (59 percent less institutionalization) than nonteam-care patients. Costs were ten percent lower for team-care patients.

The third study, entitled The Effects of an Emergency Alarm System for the Aged, was done by Sylvia Sherwood at the Hebrew Rehabilitation Center for the Aged in Boston. It resulted in one of the first technologies approved by Medicaid for reimbursement for use in home care.

The Lifeline system was the focus of the study. It automatically dials for help if a disabled or high-risk person living alone does not respond to a telephone call at a preset time.

Factors considered in the research were health status, quality of life, institutionalization, cost of formal and informal health services, and time of death. The findings indicated that Lifeline users felt more comfortable living alone. They also showed that nonusers required 13 days in a nursing home for every one day required by users. Cost of care savings were also shown.

Three ongoing projects were described as well. The first, entitled the Impact of Diagnosis-Related Groups (DRGs) on Public Home Health Nursing services, is being conducted by Elaine Kornblatt Phillips of the University of Virginia School of Nursing. The major component of the project is a study of resource use before and after DRGs. The sample is 20 percent of the recipients of home nursing visits made by agencies in Virginia. Agencies are especially eager to participate in the study because it involves analyzing patient records to get a handle on some of the nonreimbursable costs such as telephone consultations and paperwork. The second is a study by InterStudy of Excelsior, Minnesota on the delivery of home health services by health maintenance organizations (HMOs). It is based on a supplement to a survey of HMOs conducted for the Federal government each year. The research includes studies of innovative agencies and statistics on the HMOs providing home care, types of eligible enrollees, the scope and types of services, and quality assurance provisions.

The third project, conducted by researchers at the University of Maryland, examines the impact of home care on the family of an infant being monitored for apnea.

For the future, NCHSR is particularly interested in considering process and outcome studies for funding. Several examples of methodologies that need refinement include:

  • Construction of a valid and reliable system for classifying home visits in terms of the presenting problems that are potentially amenable to health care provider interventions. This "reason-for-visit" taxonomy would group patients in an organized and retrievable fashion, which would facilitate evaluations of interventions and patient education efforts.

  • Development and testing of measures of case mix and severity of illness as a basis for the intensity of care required in a home visit or episode of care. These measures can be used to describe the practice of home care providers. Coupled with a reason-for-visit taxonomy, these measures would provide a basis for the development of DRGs for home health practice.

  • Development and adaptation of methods for assessing the quality of home care. They should accommodate a wide variety of acute and chronic problems. Methods for measuring patient outcomes should be developed and tested. There is a particular need to examine relationships among patient assessment, care plans, and patient and family outcomes.

  • Development of a uniform needs assessment instrument. This instrument should evaluate the functional capacity, nursing and other care requirements, and social and familial resources of an individual.

Linda Hamm described studies funded by HCFA that have involved the history, payment approaches, and quality of home care. She noted, in particular, a project to develop outcome scales for home care being carried out by Bernadette Lalonde in Seattle, Washington, whose preliminary findings had been reported earlier in the conference. Five scales have been developed and two more are in final stages of development. They measure client-centered outcomes rather than service utilization outcomes. A study on the impact of the Prospective Payment System (PPS) on nursing home care and home health agencies is being conducted by Peter Shaughnessy at the University of Colorado. He also had reported preliminary findings earlier in the conference.

HCFA is also sponsoring a related project to compare the quality and cost of care provided by capitated (HMO-type) and non-capitated (fee for service) organizations at the University of Colorado. The project is comparing the care for Medicare patients receiving home health services immediately after hospitalization with those who do not start home care until at least 30 days after hospitalization. The emphasis is on process and outcome quality measures.

A recent contract was awarded to the Georgetown University School of Nursing to collect and analyze data about home care patient characteristics, resource use, and outcomes. The goal is to develop a classification system that predicts resource use and outcomes.

A pilot study is being conducted by System Sciences on the impact of Medicare's PPS on post-hospital care. Researchers have developed medical condition guidelines for high-risk patients that examine process and outcome measures. There are plans to award a contract next year to apply this methodology to a nationwide sample of patients.

A four year study to develop outcome-based quality measures for home health services is scheduled to be awarded this fiscal year. The results might potentially be used by HCFA in the future in a variety of ways. For example, the measures could be incorporated into the HCFA survey and/or peer review process. New quality assurance systems could be established, possibly using incentives or sanctions. Or the measures could be used to assure quality under alternative payment systems for home health agencies. Additionally, HCFA is developing a national demonstration project to test the quality and effectiveness of home care services for Medicare-covered Alzheimer's patients and their families.

Andrea Kabcenell reported that the Robert Wood Johnson Foundation has embarked on a reordering of priorities this spring, and quality of care in home care fits in very well with the new priorities. Examples of subjects the foundation would like to address are developing sound techniques to measure and assure quality of care and altering financing, training, and delivery of care to improve the outcomes of care.

There are three projects underway currently. A multi-State study on support services for the elderly is designed to show that there is a private market f or such services. It is run mainly out of visiting nurse home health agencies. Peter Shaughnessy is conducting a project to develop ways of identifying indicators of quality of care in home care. The Community Council of Greater New York was awarded a grant to test an ombudsman program for low-income, frail elderly receiving home attendant services, which was described earlier in the conference.

The Robert Wood Johnson Foundation is interested in entertaining other bold new approaches to home care quality assurance.

APPENDIX A. AGENDA

NATIONAL CONFERENCE ON HOME CARE QUALITY: ISSUES AND ACCOUNTABILITYThe Madison HotelWashington, D.C. 20005June 1-2, 1988

Wednesday, June 1
8:00 am - 9:00 am (DOLLY MADISON BALLROOM)
Breakfast and Registration  
9:00 am - 9:15 am (DOLLY MADISON BALLROOM)
Welcome Robert B. Helms, Ph.D. Assistant Secretary for Planning and Evaluation Department of Health and Human ServicesArnold R. Tompkins, J.D. Deputy Assistant Secretary for Social Services Policy DHHS/Office of the Assistant Secretary for Planning and Evaluation
9:15 am - 10:45 am (DOLLY MADISON BALLROOM)
Home Care Quality: Identifying the Issues (General Session) ModeratorPamela Doty, Ph.D. DHHS/Office of the Assistant Secretary for Planning and EvaluationVal Halamandaris National Association for Home CareElma Holder, M.S., Ph.D. National Citizens Coalition for Nursing Home ReformCharles Sabatino, J.D. Commission on Legal Problems of the Elderly, American Bar Association Kathryn Schulke, R.N. INOVA Health ProfessionalsPeter Shaughnessy, Ph.D. Center for Health Services Research, University of Colorado Nancy Smith Senate Special Committee on Aging
10:45 am - 11:00 am
Break  
11:00 am - 12:30 pm (BREAKOUT SESSION NO. 1)
(1) Measuring Home Care Quality: How Far Have We Come in Developing Outcome-Oriented Measures? What is the Appropriate Mix of Structure, Process, and Outcome Measures? (EXECUTIVE CHAMBERS I & II) ModeratorTony Hausner Health Care Financing Administration/ORDKaren Barger, R.N. Visiting Nurse Association of Coastal GeorgiaJune Gray, E.DD., R.N.C. Health Care Financing Administration, Region IVThomas Hoyer Health Care Financing AdministrationBernadette Lalonde, Ph.D. Lalonde Research & Consultation ServicesSamuel W. Kidder, D.Ph. Health Care Financing AdministrationPeter Shaughnessy, Ph.D. University of Colorado
(2) Empowering Consumers: Possibilities and Limitations (DRAWING ROOMS 1 & 2) ModeratorKatie Maslow, M.S.W. U.S. Congress, Office of Technology AssessmentElizabeth K. Mullen American Association of Retired PersonsPatricia Murphy, M.P.A. Community Council of New York CityEllen Reap Health Care Financing Administration, Region IIICarm Striano Keystone Peer Review (KeyPro)Tony Young Personal Assistance Services Together (PAST)
(3) Post-Acute Care: The Effects of Diagnosis-Related Group (DRG) Payment Reform on Home Health (DRAWING ROOMS 3 & 4) Moderator:Robert Clark, D.P.A. DHHS/Office of the Assistant Secretary for Planning and Evaluation Rosalie A. Kane, D.S.W. University of MinnesotaShelah Leader, Ph.D. American Association of Retired PersonsKorbin Liu, Sc.D. Urban InstituteKenneth Manton, Ph.D. Duke UniversityBarbara Phillips, Ph.D. Mathematica Policy Research
12:30 pm - 2:00 pm (DOLLY MADISON BALLROOM)
Luncheon Break Keynote Address Otis Bowen, M.D. Secretary Department of Health & Human Services
2:00 pm - 3:30 pm (BREAKOUT SESSION NO. 2)
(1) Measuring Home Care Quality: How Far Have We Come in Developing Outcome-Oriented Measures? What is the Appropriate Mix of Structure, Process, and Outcome Measures? (EXECUTIVE CHAMBERS I & II) ModeratorPamela Doty, Ph.D. DHHS/Office of the Assistant Secretary for Planning and EvaluationKaren Barger, R.N. Visiting Nurse Association of Coastal GeorgiaJune Gray, E.DD., R.N.C. Health Care Financing Administration, Region IVThomas Hoyer Health Care Financing AdministrationBernadette Lalonde, Ph.D. Lalonde Research & Consultation ServicesPeter Shaughnessy, Ph.D. University of Colorado
(2) Empowering Consumers: Possibilities and Limitations (DRAWING ROOMS 1 & 2) ModeratorBrina Melemed Consultant, Long Term CareElizabeth K. Mullen American Association of Retired PersonsPatricia Murphy, M.P.A. Community Council of New York CityEllen Reap Health Care Financing Administration, Region IIICarm Striano Keystone Peer Review (KeyPro)Tony Young Personal Assistance Services Together (PAST)
(3) Post-Acute Care: The Effects of Diagnosis-Related Group (DRG) Payment Reform on Home Health (DRAWING ROOMS 3 & 4) Moderator:William Saunders Health Care Financing AdministrationRosalie A. Kane, D.S.W. University of MinnesotaShelah Leader, Ph.D. American Association of Retired PersonsKorbin Liu, Sc.D. Urban InstituteKenneth Manton, Ph.D. Duke UniversityBarbara Phillips, Ph.D. Mathematica Policy Research
3:30 pm - 3:45 pm (MOUNT VERNON SALON)
Break  
3:45 pm - 5:15 pm (BREAKOUT SESSION NO. 3)
(1) Issues in the Recruitment, Training, Motivation, and Supervision of Home Care Workers (DRAWING ROOMS 1 & 2) ModeratorPamela Doty, Ph.D. DHHS/Office of the Assistant Secretary for Planning and EvaluationRobert Applebau, Ph.D. Miami University, OhioJeff Barnes New York State Department of Social ServicesRebecca Donovan, D.S.W. Hunter College School of Social WorkJo Eleanor Elliott Public Health ServicesElizabeth L. Gordon Kimberly Quality CareJohn Mullin Clackamas County Social Services Division
(2) Accountability of State and Local Programs (DRAWING ROOMS 3 & 4) ModeratorFloyd Brown DHHS/Office of the Assistant Secretary for Planning and EvaluationDarrel Balmer Illinois Department on AgingJames M. Focht, M.P.A. Macro SystemsWilliam J. Foley, Ph.D. Rensalear Polytechnic InstituteNancy Mumma, M.S. Community Service Council of Greater TulsaMaryann Nardone, D.S.W. Pennsylvania Department of Aging
5:30 pm - 7:00 pm(MOUNT VERNON ROOMS)
RECEPTION at The Madison  
Thursday, June 2
8:00 am - 9:00 am (MOUNT VERNON ROOMS A, B, & C)
Continental Breakfast  
9:00 am - 10:30 am (BREAKOUT SESSION NO. 4)
(1) Issues in the Recruitment, Training, Motivation, and Supervision of Home Care Workers (MOUNT VERNON ROOW A) ModeratorSuzanne Resner, R.N., DN.Sc. Public Health ServicesRobert Applebau, Ph.D. Miami University, OhioJeff Barnes New York State Department of Social ServicesRebecca Donovan, D.S.W. Hunter College School of Social Work Elizabeth L. Gordon Kimberly Quality CareJohn Mullin Clackamas County Social Services Division
(2) Accountability of State and Local Programs (MOUNT VERNON ROOMS B & C) ModeratorPamela Doty, Ph.D. DHHS/Office of the Assistant Secretary for Planning and Evaluation Darrel Balmer Illinois Department on AgingJames M. Focht, M.P.A. Macro SystemsWilliam J. Foley, Ph.D. Rensalear Polytechnic Institute Nancy Mumma, M.S. Community Service Council of Greater TulsaMaryann Nardone, D.S.W. Pennsylvania Department of Aging
10:30 am - 10:45 am (MONTICELLO ROOM)
Break  
10:45 am - 12:15 pm (BREAKOUT SESSION NO. 5)
(1) Medicare/Medicaid Survey and Certification: Strengths and Weaknesses (MOUNT VERNON ROOM A) ModeratorGeorge Greenberg, Ph.D. DHHS/Office of the Assistant Secretary for Planning and EvaluationMarly Auerbach, R.N. NCOSS Nursing ServicesMike Goldman Health Care Financing AdministrationCharlene Harrington, Ph.D. University of California
(2) Accreditation Programs: Strengths and Weaknesses (MOUNT VERNON ROOMS B & C) ModeratorRuth Galten National Association for Home CareNola Aalberts Foundation for Hospice & HomecareCarol H. Kurland New Jersey Medicaid Program Maria K. Mitchell National League for NursingAnne Rooney Joint Commission on Accreditation of Health Organizations (JCAHO)Ellen Yung-Fatah District of Columbia Department of Consumer & Regulatory Affairs
(3) Special Needs of Special Populations and Ethical Issues (DRAWING ROOMS 1 & 2) Moderator:Marcy Gross DHHS/Office of the Assistant Secretary for Planning and EvaluationPeggy Beckman, R.N. Inova Home Care ProfessionalsAnn Hallock New York State Department of Social ServicesLinda Maurano Childrens Hospital National Medical CenterConnie Zuckerman, J.D. Montefiore Hospital
12:15 pm - 2:00 pm
Lunch Break (Reconvene at 2:00 pm)  
2:00 pm - 3:45 pm (BREAKOUT SESSION NO. 6)
(1) Medicare/Medicaid Survey and Certification: Strengths and Weaknesses (MOUNT VERNON ROOM A) ModeratorPamela Doty, Ph.D. DHHS/Office of the Assistant Secretary for Planning and EvaluationMarly Auerbach, R.N. NCOSS Nursing ServicesMike Goldman Health Care Financing AdministrationCharlene Harrington, Ph.D. University of California
(2) Accreditation Programs: Strengths and Weaknesses (MOUNT VERNON ROOMS B & C) ModeratorRuth Galten National Association for Home CareNola Aalberts Foundation for Hospice & HomecareCarol H. Kurland New Jersey Medicaid Program Maria K. Mitchell National League for NursingAnne Rooney Joint Commission on Accreditation of Health Organizations (JCAHO)Ellen Yung-Fatah District of Columbia Department of Consumer & Regulatory Affairs
(3) Special Needs of Special Populations and Ethical Issues (DRAWING ROOMS 1 & 2) Moderator:Aurora Zappolo Health Care Financing AdministrationPeggy Beckman, R.N. Inova Home Care ProfessionalsAnn Hallock New York State Department of Social ServicesLinda Maurano Childrens Hospital National Medical CenterConnie Zuckerman, J.D. Montefiore Hospital
3:45 pm - 4:00 pm (EXECUTIVE CHAMBERS II & III)
Break  
4:00 pm - 5:00 pm (EXECUTIVE CHAMBERS I, II, & III)
Summary and Conclusion -- General Session ModeratorMary Harahan Director, Division of Disability, Aging, & Long Term Care Policy DHHS/Office of the Assistant Secretary for Planning and EvaluationLinda V. Hamm Director, Division of Long Term Care Experimentation Health Care Financing AdministrationAndrea Kabcenell Robert Wood Johnson Foundation Jerry L. Weston, Sc.D., R.N. Senior Research Manager, Division of Extramural Research National Center for Health Services Research

APPENDIX B. PARTICIPANTS

NATIONAL CONFERENCE ON HOME CARE QUALITY: ISSUES AND ACCOUNTABILITY

HONORED GUESTS

Gerald Britten, Deputy Assistant Secretary for Program Systems, Department of Health & Human Services, ASPE, Room 447D, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, (202) 245-9774

Thomas R. Burke, Chief of Staff, Department of Health & Human Services, Room 606G, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, (202) 245-6133

Carl Dahlman, Deputy Assistant Secretary for Income Security Policy, Department of Health & Human Services, Room 404E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, (202) 245-2409

Carol Fraser Fisk, Commissioner, Administration on Aging, Department of Health & Human Services, Room 4760, W.J. Cohen Building, 330 Independence Avenue, S.W., Washington, D.C. 20201, (202) 245-0556

Richard P. Kuserow, Inspector General, Department of Health & Human Services, Room 5250, W.J. Cohen Building, 330 Independence Avenue, S.W., Washington, D.C. 20201, (202) 472-3148

Richard P. Kuserow, Inspector General, Department of Health & Human Services, Room 5250, W.J. Cohen Building, 330 Independence Avenue, S.W., Washington, D.C. 20201, (202) 472-3148

Stephanie Lee-Miller, Assistant Secretary for Public Affairs, Department of Health & Human Services, Room 647D, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, (202) 245-1850

Donald M. Newman, Under Secretary, Department of Health & Human Services, Room 614G, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, (202) 245-7431

Sydney Olson, Assistant Secretary for Human Development Services, Department of Health & Human Services, Room 309F, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, (202) 245-7246

Dr. William L. Roper, Administrator, Health Care Financing Administration, Department of Health & Human Services, Room 314G, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, (202) 245-6726

Dr. Robert E. Windom, Assistant Secretary for Health, Public Health Service, Room 616G, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, (202) 245-7694

SPEAKERS/MODERATORS

Nola Aalberts, Director, Accreditation & Education, Foundation for Hospice & Home Care, 519 C Street, N.E., Washington, D.C. 20002, (202) 547-6586

Dr. Robert Applebaum, Assistant Professor, Scripps Gerontology Center, Miami University, 327 Hoyt Hall, Oxford, Ohio 45056, (513) 529-2914

Marly Auerbach, Director, NCOSS Nursing Services, 141 Bodman Place, Red Bank, New Jersey 07701, (201) 747-1204

Darrel L. Balmer, Manager, Division of Administrative Compliance, Illinois Department on Aging, 421 East Capitol, Springfield, Illinois 62701, (217) 785-3348

Karen G. Barger, Executive Director, Visiting Nurse Association of Coastal Georgia, 3025 Bull Street, Savannah, Georgia 31410, (912) 651-2604

Jeff Barnes, Policy Analyst, New York State Department of Social Services, 40 North Pearl Street, Albany, New York 12243

Peggy Beckman, RN, BSN, Assistant Administrator for Nursing Services, Inova Home Care, 8003 Forbes Place, Springfield, Virginia 22151

Dr. Otis R. Bowen, Secretary, Department of Health & Human Services, Room 615F, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, (202) 245-7000

Floyd Brown, Research Analyst, Department of Health & Human Services, ASPE/SSP, Room 410E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, (202) 245-6443

Charlotte C. Carnes, Manager, Community-Based Care, Department of Medical Assistance Services, Commonwealth of Virginia, 600 East Broad Street, Richmond, Virginia 23219, (804) 786-1465

Robert F. Clark, Program Analyst, Department of Health & Human Services, ASPE/SSP, Room 410D, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, (202) 245-6172

Rebecca Donovan, DSW, Assistant Professor, Hunter College, School of Social Work, 129 East 79th Street, New York, New York 10021, (212) 570-5037

Pamela Doty, Department of Health & Human Services, ASPE/SSP, Room 410D, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, (202) 245-6172

Jo Eleanor Elliott, Director, Division of Nursing, Public Health Service, HRSA/BHPr/DN/OD, Room 5C-26, Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857, (301) 443-5786

Jim Focht, Associate, Macro Systems, Inc., 8630 Fenton Street, Silver Spring, Maryland 20410, (301) 588-5484

Dr. William J. Foley, Assistant Professor, Decision Sciences & Engineering Systems, Rensselaer Polytechnic Institute, Troy, New York 12180-3590, (301) 966-6669

Ruth Galten, Director of Clinical Services, National Association for Home Care, 519 C Street, N.E., Washington, D.C. 20002, (202) 547-7424

Mike Goldman, Chief, Laboratory & Ambulatory Services Branch, Health Care Financing Administration, HSQB/OSC, Meadows East Building, 6325 Security Boulevard, Baltimore, Maryland 21207, (301) 966-6813

Betty L. Gordon, Vice President, Clinical Services, Kimberly Quality Care, 29 East Street, Seventh Floor, Boston, Massachusetts 02111, (800) 533-9735

June W. Gray, Nurse Consultant, Health Care Financing Administration, Region IV, DHSQ, Room 702, 101 Marietta Tower, Atlanta, Georgia 30323, (404) 331-0119

George Greenberg, Department of Health & Human Services, ASPE/HP, Room 432E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, (202) 245-1860

Marcy Gross, Senior Policy Analyst, Office of the Assistant Secretary for Health, Room 740G, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, (202) 245-3033

Mr. Val J. Halamandaris, President, National Association for Home Care, 519 C Street, N.E., Washington, D.C. 20002, (202) 547-7424

Ann B. Hallock, Director, Home Care Services, New York State Department of Social Services, Division of Medical Assistance, 40 North Pearl Street, Albany, New York 12243, (518) 474-9451

Linda Hamm, Director, Division of Long Term Care Experimentation, Health Care Financing Administration, ORD, Room 2424, Oak Meadows Building, 6325 Security Boulevard, Baltimore, Maryland 21207

Mary F. Harahan, Director, Division of Disability, Aging and Long-Term Care, Department of Health & Human Services, ASPE/SSP, Room 410D, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, (202) 245-6172

Dr. Charlene Harrington, Associate Professor, University of California, Institute for Health & Aging, N-631, San Francisco, California 94143-0612, (415) 476-4030

Tony Hausner, Research Analyst, Health Care Financing Administration, ORD, Room 2-f-5, Oak Meadows Building, 6325 Security Boulevard, Baltimore, Maryland 21207, (301) 966-6662

Dr. Robert B. Helms, Assistant Secretary for Planning & Evaluation, Department of Health & Human Services, ASPE/SSP, Room 415F, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, (202) 245-1858

Elma Holder, National Citizens Coalition for Nursing Home Reform, 1424 16th Street, N.W., Washington, D.C. 20036

Thomas Hoyer, Director, Division of Provider Services Coverage Policy, Health Care Financing Administration, Room 405, East High Rise, 6325 Security Boulevard, Baltimore, Maryland 21207, (301) 966-4607

Andrea Kabcenell, Program Officer, Robert Wood Johnson Foundation, College Road & U.S. Route 1, P.O. Box 2316, Princeton, New Jersey 08543-2316, (609) 452-8701

Rosalie Kane, Professor, Division of Health Services Research and Policy, University of Minnesota, School of Public Health, 420 Delaware Street, S.E., Minneapolis, Minnesota 55455-0392

Samuel W. Kidder, Chief, Long-Term Care Branch, Health Care Financing Administration, BERC, Room 429, East High Rise, 6325 Security Boulevard, Baltimore, Maryland 21207, (301) 966-4620

Carol H. Kurland, Administrator, Office of Home Care Programs, New Jersey Medicaid Program, CN-712, 7 Quakerbridge Plaza, Trenton, New Jersey 08625, (609) 588-2620

Dr. Bernadette Lalonde, Principal, Lalonde Research & Consultation, 408 Northeast 95th Street, Seattle, Washington 08115, (206) 525-6329

Dr. Shelah Leader, Health Policy Analyst, American Association of Retired Persons, 1909 K Street, N.W., Washington, D.C. 20049, (202) 728-4859

Korbin Liu, Urban Institute, 2100 M Street, N.W., Washington, D.C. 20015

Kenneth Manton, Research Professor, Duke University, Demographic Studies, 2117 Campus Drive, Durham, North Carolina 27706, (919) 684-6126

Katie Maslow, Project Director, Congress of the United States, Office of Technology Assessment, Biological Applications Program, Washington, D.C. 20510, (202) 228-6688

Linda Maurano, Director, Children’s Home Health Care Services, Children’s Hospital, National Medical Center, 111 Michigan Avenue, N.W., Washington, D.C. 20010, (202) 939-4663

Brina B. Melemed, Consultant, Long Term Care, 4630 Edgefield Road, Bethesda, Maryland 20814, (301) 530-6945

Maria K. Mitchell, Senior Vice President, National League for Nursing, Community Health Accreditation Program, 10 Columbus Circle, 24th Floor, New York, New York, (212) 582-1022

Elizabeth K. Mullen, Director, Women’s Initiative, American Association of Retired Persons, 1909 K Street, N.W., Suite 525, Washington, D.C. 20049, (202) 728-4482

John Mullin, Director, Clackamas County Social Services Division, 821 Main Street, Oregon City, Oregon 97045, (503) 655-8640

Nancy L. Mumma, M.S., Director, Long Term Care Project, Community Service Council of Greater Tulsa, 1430 South Boulder, Tulsa, Oklahoma 74119, (918) 560-7185

Patricia H. Murphy, Director, Ombudservice for Home Care Clients, Community Council of Greater New York, 275 Seventh Avenue, New York, New York 10001, (212) 741-8844

Dr. Don Muse, Principal Analyst, Congressional Budget Office, Washington, D.C. 20515, (202) 226-2820

Maryann Nardone, Director, Bureau of Long Term Care, Pennsylvania Department of Aging, 231 State Street, Harrisburg, Pennsylvania 17101-1195, (717) 783-6207

Barbara R. Phillips, Senior Researcher, Mathematica Policy Research, P.O. Box 2393, Princeton, New Jersey 08543-2393

Ellen Reap, Review Specialist, Survey & Certification Program, Health Care Financing Administration, DHSQ, 3535 Market Street, Room 3200, P.O. Box 7760, Philadelphia, Pennsylvania 19101, (215) 596-4550

Suzanne S. Resner, RN, DNSc, Nurse Consultant, Public Health Service, HRSA, BHP, DN, Room 5C-26, Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857, (301) 443-5763

Anne Rooney, Associate Director, Hospice & Home Care Accreditation Program, Joint Commission, 875 North Michigan Avenue, Chicago, Illinois 60611, (312) 642-6061 ext.287

Charles Sabatino, Associate Staff Director, American Bar Association, Commission on Legal Problems of the Elderly, 1800 M Street, N.W., Washington, D.C. 20036, (202) 331-2297

William Saunders, Chief, Long-Term Care Coverage Branch, Office of Research & Demonstrations, HCFA, Room 2-F-5, Oak Meadows Building, 6325 Security Boulevard, Baltimore, Maryland 21207

Kathryn Schulke, R.N., Administrator, Inova Health Professionals, 5274 Lyngate Court, Springfield, Virginia 22152, (703) 425-2300

Dr. Peter W. Shaughnessy, Director, University of Colorado, Health Sciences Center, Center for Health Services Research, 1355 South Colorado Boulevard, Suite 706, Denver, Colorado 80222, (303) 756-8350

Nancy Smith, Minority Staff, Senate Special Committee on Aging, Room 628, Hart Building, Washington, D.C. 20510, (202) 224-1467

Carmine Striano, Keystone Peer Review Organization, Inc., 635 North 12th Street, Lemoyne, Pennsylvania 17043, (717) 975-9600 ext.54

Arnold R. Tompkins, Deputy Assistant Secretary for Social Services Policy, Department of Health & Human Services, ASPE, Room 410D, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, (202) 245-6443

Jerry L. Weston, Sc.D., R.N., Senior Research Manager, National Center for Health Services Research, Room 18A-19, Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857, (301) 443-2716

Tony Young, Chairperson, Personal Assistance Services Together (PAST), Springfield, Virginia

Ellen Yung-Fatah, Nurse Consultant, D.C. Department of Consumer & Regulatory Affairs, 614 H Street, N.W., Washington, D.C. 20001, (202) 727-7190

Aurora Zappolo, Social Science Research Analyst, Office of the Assistant Secretary for Health, Room 717H, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201

Connie Zuckerman, Attorney, Department of Epidemiology & Social Medicine, Montefiore Medical Center, 111 East 210th Street, Bronx, New York 10467, (212) 920-4630

INVITEES

Angel Abaya, Program Director, Seneca Center Home Attendant Program, Inc., 1241 Lafayette Avenue, Bronx, New York 10474, (212) 378-1300

Michael Abroe, Consulting Actuary, Milliman & Robertson, Inc., 55 West Monroe, Chicago, Illinois 60603, (312) 726-0677

Christine Achorn, Associate Editor, Older American Report, 951 Pershing Drive, Silver Spring, Maryland 20910, (301) 587-6300

Judy Adams, Special Projects Coordinator, North Carolina Association for Home Care, 1005 Dresser Court, Raleigh, North Carolina 27609, (919) 878-0500

Gerald Adler, Program Evaluator, Health Care Financing Administration, OR, 10308 Nightmist Court, Columbia, Maryland 21044, (301) 966-7150

Michele Adler, Biostatistician, Department of Health & Human Services, ASPE/ISP, Room 405E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, (202) 245-7148

Jane Aldermoor, Administrator, HMS Home Health Agency, P.O. Box 2933, Clarksburg, West Virginia 26301

Dorothy M. Amey, Principal Analyst, Congressional Budget Office, Second & D Streets, S.W., Washington, D.C. 20515, (202) 226-2655

Laurel Anderson, Director, Sunrise Home Health Care, 194 Lee Street, Warrenton, Virginia 22186

Shirley Andrews, Rehabilitation Service Line Manager, Visiting Nurse Association of Washington, 1842 Mintwood Place, N.W., Washington, D.C. 20009

Patricia Annis, Executive Director, Coordinated Home Care, Inc., P.O. Box 401, 800 Livermore, Suite Southwest 2, Yellow Springs, Ohio 45387, (513) 767-1449

Kenneth Apfel, Legislative Assistant, c/o Senator Bill Bradley, Room 731, Hart Building, Washington, D.C. 20510, (202) 224-5700

Jane August, President, TPC Home Care Services, Inc., 175 Fulton Avenue, Suite 302, Hempstead, New York 11550, (516) 489-6414

Dr. Nancy R. Barhydt, Bureau Director, New York State Department of Health, Empire State Plaza, Corning Tower, Room 1970, Albany, New York 12237, (518) 474-2006

Dean Barlow, Consumer Safety Officer, Public Health Service, FDA/CDRH/OTA/DTD, 1901 Chapman Avenue, Room 216, HFZ-240, Rockville, Maryland 20857, (301) 443-2436

Deborah Bass, Director, Executive Secretariat, Office of Human Development Services, Room 300E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, (202) 245-3176

Howard Bedlin, Legislative Representative, American Association of Retired Persons, 1909 K Street, N.W., Sixth Floor, Washington, D.C. 20049, (202) 728-4612

Ann Bell, Associate Director, Paralyzed Veterans of America, 801 18th Street, N.W., Washington, D.C. 20006, (202) 872-1300

Laura Beltran, Program Director, BHRAGS Inc., 1212 East New York Avenue, Brooklyn, New York 11212, (718) 647-6752

Karen Bernhardt, Assistant Clinical Officer, Visiting Nurse Association of Central Massachusetts, Inc., 120 Thomas Street, Worcester, Massachusetts 01608-1280, (617) 756-7176

Charles Betley, Research Assistant, Employee Benefit Research Institute, Suite 600, 2121 K Street, N.W., Washington, D.C. 20037, (202) 775-6356

Kathleen Bond, Health Scientist Administrator, National Institute on Aging, NIH/BSR, Room 4C-32, Building 31, Bethesda, Maryland 20892, (301) 496-3136

Paula Booth, Waynesboro Community Home Health, 501 Oak Avenue, Waynesboro, Virginia 22980, (703) 942-6267

Judith Bowman, Senior Program Specialist, American Association of Retired Persons, 1909 K Street, N.W., Suite 525, Washington, D.C. 20049, (202) 728-4482

Sharon S. Boyd, Director, Advocacy Department, Regional Council on Aging, 177 North Clinton Avenue, Rochester, New York 14604, (716) 454-3224

Bonnie Boyer, Quality Assurance Coordinator, Home Care Services Agency, Lutheran Social Services, 144 South Eighth Street, Chambersburg, Pennsylvania 17201, (717) 264-8178

Lucy Brand, R.N., M.S.N., President, Michigan Home Health Care, Inc., 955 East Commerce Drive, Traverse City, Michigan 49684, (616) 943-8450

Larry Brewster, Director, Aging Services Division, Department of Human Services, State Capitol Building, Bismarck, North Dakota 58505, (701) 224-2577

Dr. Abraham Brickner, Director, Health Services Research & Program Development, Cleveland Clinic Foundation, 9500 Euclid Avenue, KK-43, Cleveland, Ohio 44106, (216) 444-2400

Vernell Britton, Chief, Survey & Certification Review Branch, Health Care Financing Administration, Region IV, Room 702, 101 Marietta Tower, Atlanta, Georgia 30323

Harriet Brockington, Chairperson, D.C. Commission on Aging, 1424 K Street, N.W., Second Floor, Washington, D.C. 20005, (202) 724-5622

Barbara Brodie, University of Virginia, School of Nursing, McLeod Hall, Charlottesville, Virginia 22903-3395, (804) 924-2256

Constance Brown, Administrator, Indiana Department of Human Services, 251 North Illinois Street, P.O. Box 7083, Indianapolis, Indiana 46207-7083, (317) 232-7122

Sandra Brown, Department of Human Services, Medicaid Certification, BMS/DLC, State House Station #11, Augusta, Maine 04333, (207) 289-2606

Sharon Brown, MS, RN, Acting Administrator, Home Health Care, Johns Hopkins Health System, 600 North Wolfe Street, Adm. 230, Baltimore, Maryland 21205, (202) 966-3443

Thomas E. Brown, Jr., Director, South Carolina Department of Health & Environmental Control, Office of Program Management, 2600 Bull Street, Columbia, South Carolina 29201, (803) 734-4930

Sean Browne, Program Coordinator, Oklahoma Department of Health, Eldercare Program, 1000 Northeast Tenth, Oklahoma City, Oklahoma 73152, (405) 271-4072

Robert J. Buchanan, Assistant Professor, Cornell University, N-132, MVR Hall, Ithaca, New York 14853, (607) 255-2504

Val Buck, Director, Medicaid Certification, Arkansas Department of Health, Little Rock, Arkansas 72205, (501) 661-2201

Karen Buhler-Wilkerson, Associate Professor, Bayada Nurses/University of Pennsylvania, School of Nursing, Nursing Education Building, Philadelphia, Pennsylvania 19104, (215) 898-4725

Dr. Robert E. Burke, Senior Health Policy Advisor, U.S. General Accounting Office, 5521 Hoover Street, Bethesda, Maryland 20817, (202) 275-6001

Lisa Butterfield, Assistant Director, CIGNA, 900 Cottage Grove Road, Bloomfield, Connecticut 06002, (203) 726-5870

Chester J. Buzzelli, Standards Development Specialist, New Jersey State Department of Health, CN 367, Trenton, New Jersey 08625, (609) 588-7771

Warren Calderone, Program Analyst, Health Care Financing Administration, OPHC, Department of Health & Human Services, Room 4360, W.J. Cohen Building, 330 Independence Avenue, S.W., Washington, D.C. 20201, (202) 245-0217

Kathleen E. Campbell, Administrator, Visiting Nurse Association of Morris County, 38 Elm Street, Morristown, New Jersey 07960, (201) 539-1216

George Carcagno, Executive Vice President, Mathematica Policy Research, P.O. Box 2393, Princeton, New Jersey 08543-2393, (609) 275-2303

Dr. William S. Cartwright, Chief, Demography & Economics Office, National Institute of Health, NIA, Room 612, Federal Building, 7550 Wisconsin Avenue, Bethesda, Maryland 20892

Jaci Casanova, Program Specialist, Department of Social Services, Office of Adult Services & Aging, 700 Governors Drive, Pierre, South Dakota 57501, (605) 773-3656

Elizabeth Z. Cathcart, Executive Director, Visiting Nurse Association of Pennsylvania, 21369 Path Valley Road, Dry Run, Pennsylvania 17220, (717) 349-2511

Michele Cavanaugh, RN, MS, Director, Professional Services, Delaware County Home Health Services, Old Main, 15th Street & Upland Avenue, Chester, Pennsylvania 19013, 876-5544

Paula Cell, Director of Nursing & Allied Health, Visiting Nurse Association of Trenton, P.O. Box 4562, Trenton, New Jersey 08611, (609) 695-3461

Arlene Chabanuk, Corporate Director, Kennedy Home Health Care, Kennedy Memorial Hospital University Medical Center, Cherry Hill Division, P.O. Box 5044, Cherry Hill, New Jersey 08034, (609) 488-6555

Bianca M. Chambers, Project Director, Graduate Program in Home Health Care, Boston University, School of Nursing, 635 Commonwealth Avenue, Boston, Massachusetts 02215, (617) 353-4067

Ralph Cherry, Director, Gerontology Center, Purdue University, Calymet, Hammond, Indiana 46323, (317) 463-7300

Gary Claxton, Insurance Issue Analyst, American Association of Retired Persons, Insurance Services, 1909 K Street, N.W., Room 368, Washington, D.C. 20049, (202) 728-4586

Robert M. Clinkscale, President, La Jolla Management Corporation, 5950 Symphony Woods, Suite 310, Columbia, Maryland 21045, (301) 730-8855

Pat Cloonan, University of Virginia, School of Nursing, McLeod Hall, Charlottesville, Virginia 22903-3395, (804) 924-2256

Hannah Cohen, Director, Home Attendant Services of Hyde Park, 1414 Utica Avenue, Brooklyn, New York 11203, (718) 629-4800

Phyllis Cohen, In-House Aide Service, Prince Georges Department of Social Services, 6111 Ager Road, Hyattsville, Maryland 20782, (301) 431-7078

Cheryl A. Colbert, 2 Beall Spring Court, Potomac, Maryland 20854

Gregory L. Coleman, Executive Director, Homemaker Services of the Metropolitan Area, Inc., 801 Arch Street, Sixth Floor, Philadelphia, Pennsylvania 19107, (215) 592-0002

Barbara Colliander, Supervisor, Home & Community Care Services, Minnesota Department of Human Services, 444 Lafayette Road, Saint Paul, Minnesota 55155-3844, (612) 296-2274

Kathleen M. Collins, Vice President, Moorestown Visiting Nurse Association, 16 East Main Street, Moorestown, New Jersey 08057, (609) 235-0462

Carolyn T. Connelly, RN, Health Care Analyst, Michigan Department of Public Health, 3423 North Logan, P.O. Box 30195, Lansing, Michigan 28909, (517) 335-8634

Virginia Anne Coombs, MSN, JD, Executive Director, Delaware County Home Health Services, Old Main, 15th Street & Upland Avenue, Chester, Pennsylvania 19013, 876-5544

Margaret Coopey, Program Analyst, Health Care Financing Administration, Room 2-F-5, Oak Meadows Building, 6340 Security Boulevard, Baltimore, Maryland 21207, (301) 966-6667

June Cosnotti, Roanoke Memorial Hospital, 127 McClanahan Avenue, Suite 209, Roanoke, Virginia 24014

Carole Coulom, Visiting Nurse Association Group, Inc., 146 New Britain Avenue, Plainville, Connecticut 06062, (203) 747-2761 ext.77

Janet Coyle, Executive Director, Visiting Health Service, P.O. Box 1032, 18 West Blackwell Street, Dover, New Jersey 07801, (201) 328-4866

Ann Cruse, Associate Publisher, Home Health Line, Port Republic, Maryland 20676

Karen Cummins, Monongahela Valley Association of Health Centers, Inc., Home Health Service, P.O. Box 1112, Fairmont, West Virginia 26554, (304) 366-0700 ext.315

Ann Cunningham, Kelly Assisted Living Service, Inc., 999 West Big Beaver Road, Troy, Michigan 48084, (313) 244-4408

Rick Curtis, President, Center for Health Policy Development, 2033 K Street, N.W., Suite 304, Washington, D.C. 20006, (202) 785-0707

Nancy Dale, Director, Office of the Secretary, Massachusetts Executive Office of Elder Affairs, 38 Chauncey Street, Boston, Massachusetts 02111, (617) 727-8005

Nancy Daniels, Kimberly Nursing, 8630 Fenton, Suite 604, Silver Spring, Maryland 20910, (301) 587-7788

Marilyn Dean, National Director, Health Care, Medical Personnel Pool, Corporate Office, 303 Southeast 17th Street, Fort Lauderdale, Florida 33316, 1-800-752-7665

Elvira L. dela Torre, BSN, RN, Administrator, Home Extend Care Health Services, 231 Highland Street, Sykesville, Pennsylvania 15865, (814) 894-2233

Mary Derrickson, RN, BSN, Nursing Service Supervisor, Delaware County Home Health Services, Old Main, 15th Street & Upland Avenue, Chester, Pennsylvania 19013, 876-5544

Milton DeZube, Associate Director, Federal Relations, American Hospital Association, 50 F Street, N.W., Suite 1100, Washington, D.C. 20001, (202) 638-1100

Susan Dickinson, Research Associate, Washington Business Group on Health, 102 Irving Street, N.W., Washington, D.C. 20010, (202) 877-1196

Kathy Dodd, Corporate Director, Home Care Services Development, American Nursing Resources, 11050 Roe Boulevard, Suite 101, Overland Park, Missouri 66211, (913) 491-0010

Mark G. Doherty, Director of Research, Society of Actuaries, 500 Park Boulevard, Itasco, Illinois 60143

Molla S. Donaldson, Senior Staff Officer, Institute of Medicine, National Academy of Sciences, 2101 Constitution Avenue, N.W., Washington, D.C. 20148, (202) 334-2165

Sharon Donnelly, Association of University Programs in Health Administration, 1911 North Fort Myer Drive, Suite 503, Arlington, Virginia 22209, (703) 524-5500

Veronica Donovan, Administrator, Advanced Home Health Care, Inc., 49 South Main Street, Pittston, Pennsylvania 18640, (717) 655-2428

Joan Dougherty, Aging Services Specialist, Pennsylvania Department of Aging, 231 State Street, Harrisburg, Pennsylvania 17101-1195, (717) 783-6207

Kathleen Downing, Executive Director, Mobile Meals, Inc., 619 North Howard Street, Akron, Ohio 44310, (216) 376-7717

Theresa Dudek, Administrator, Home Nursing - Patient Care, Inc., 1534 Route 315, Wilkes Barre, Pennsyvania 18702, (717) 822-9117

Dr. Burton D. Dunlop, Project Hope, 2 Wisconsin Circle, Suite 500, Chevy Chase, Maryland 20815, (301) 656-7401

Beverly D’Anjolell, RN, BSN, Nursing Services Supervisor, Delaware County Home Health Services, Old Main, 15th Street & Upland Avenue, Chester, Pennsylvania 19013, 876-5544

Gerald Eggert, Executive Director, Monroe County Long Term Care Program, Inc., 349 West Commerical Street, Suite 2250, East Rochester, New York 14445, (716) 248-8770

Carolyn Erickson, R.N., Home Care Coordinator, North Charles Hospital, 2724 North Charles Street, Baltimore, Maryland 21218, (301) 338-2220

Madeline Erinson, Mercy Hospital, 3663 South Miami Drive, Miami, Florida 33133, (305) 285-2710

Mary Ann Falcone-Bolland, Secretary, Pennsylvania Association for Home Care, Inc., 121 Bridge Street, W.B., Beaver, Pennsylvania 15009, (412) 774-4002

Janet I. Feldman, Area Coordinator, Nursing Management, Center for Nursing, Northwestern University, 750 North Lake Shore Drive, Chicago, Illinois 60611, (312) 908-8298

Geraldene Felton, Professor & Dean, University of Iowa, College of Nursing, Iowa City, Iowa 52242, (319) 335-7009

Barbara H. Ferguson, Physical Therapist Training Specialist, Food & Drug Administration, CDRH, HFX-250, 5600 Fishers Lane, Rockville, Maryland 20857, (301) 443-4600

Rhona Fisher, Intergovernmental Health Policy Project, George Washington University, 2011 I Street, N.W., Suite 200, Washington, D.C. 20006, (202) 872-1445

Daniel J. Foley, Statistician, National Institute of Aging, NIH, Room 618, Federal Building, 7550 Wisconsin Avenue, Bethesda, Maryland 20892, (301) 496-1178

Jane Ford, Director, Alternative Services, Kansas Hospital Association, P.O. Box 2308, Topeka, Kansas 66601, (913) 233-7436

Dr. Richard Fortinsky, Research Associate, University of Southern Maine, 96 Falmouth Street, Portland, Maine 04103, (207) 780-4430

Patrick Fox, Senior Analyst, Institute for Health & Aging, University of California, N-531, San Francisco, California 94143-0646, (415) 476-9483

Pat Fradley, Complex Care Service Line Manager, Visiting Nurse Association of Washington, 1842 Mintwood Place, N.W., Washington, D.C. 20009

Barbara Frankel, New York State Department of Social Services, 40 North Pearl Street, Albany, New York 12243

Dr. Carol Frattali, Assistant Director, Reimbursement Policy DW, American Speech, Language & Hearing Association, 10801 Rockville Pike, Rockville, Maryland 20852, (301) 897-5700

Janet Gaffney, Director, Nursing, Comprehensive Geriatric Services, Inc., d/b/a Comprehensive Home Care, 414 Route 111, Smithtown, New York 11787, (516) 360-1313

Gwen Gampel, Professional Staff, Subcommittee on Health, House Committee on Ways & Means, Room 1114, Longworth Building, Washington, D.C. 20515, (202) 225-7785

Paul D. Gayer, Senior Economist, Department of Health & Human Services, ASPE/SSP, Room 410D, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, (202) 245-6613

Georgia Georgeson, Associate Director, Clinical Affairs, Paralyzed Veterans of America, 801 18th Street, N.W., Washington, D.C. 20006, (202) 872-1300

Lillian Glickman, Product Manager, Lifeplans, Inc., 1 University Office Park, 29 Sawyer Road, Waltham, Massachusetts 02154, (617) 893-7600

Lydia Gonzalez, Program Director, BHRAGS Inc., 1212 East New York Avenue, Brooklyn, New York 11212, (718) 756-0400

Dr. Evelyn W. Gordon, Assistant Director for Health Programs Research, Food & Drug Administration, CDR, HFZ-70, 8757 Georgia Avenue, Silver Spring, Maryland 20910, (301) 427-7576

Joyce Gould, Assistant Administrator, United Home Health Services, 5308 Rising Sun Avenue, Philadelphia, Pennsylvania 19120, (215) 329-3550

June R. Grace, Chief Planning & Development Officer, Visiting Nurse Association of Central Massachusetts, Inc., 120 Thomas Street, Worcester, Massachusetts 01608-1280, (617) 756-7176

Mary Lou Gradisek, Administrator, Home Call of Prince Georges County, 96 Harry Truman Drive, Largo, Maryland 20772, (301) 350-4900

Barbara Graham, University of Virginia, School of Nursing, McLeod Hall, Charlottesville, Virginia 22903-3395, (804) 924-2256

Joan Gravely, Supervisor, In-House Aide Service, Prince Georges Department of Social Services, 6111 Ager Road, Hyattsville, Maryland 20782, (301) 431-7078

Elinor Griffin, 129 Concord, El Segundo, California 90245, (213) 322-7172

Crystal Groth, Nursing Service Line Manager, Visiting Nurse Association of Washington, 1842 Mintwood Place, N.W., Washington, D.C. 20009

Jack Guildroy, Board Member, American Association of Retired Persons, National Activities, 1909 K Street, N.W., Washington, D.C. 20049, (202) 728-4233

Marni Hall, Scoilogist/Research Analyst, Health Care Financing Administration, ORD, DR, Room 2-B-14, Oak Meadows Building, 6325 Security Boulevard, Baltimore, Maryland 21207, (301) 966-6595

Gael A. Hallenbeck, Project Coordinator, Center for Aging Research & Educational Services, University of North Carolina, School of Social Work, CB-8065, 900 Airport Road, Chapel Hill, North Carolina 27599-8065, (919) 962-0650

Dr. Burton P. Halpert, Associate Professor, Sociology & Gerontology, Center on Aging Studies, University of Missouri, Kansas City, 5245 Rockhill Road, Kansas City, Missouri 64110, (816) 276-1747

Dr. Barbara Hanley, Coordinator, Nursing Health Policy Program, University of Maryland, School of Nursing, 655 West Lombard Street, Baltimore, Maryland 21201, (301) 328-3187

Mary S. Harper, Coordinator, Long Term Care Programs, National Institute of Mental Health, Room 11C-03, Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857, (301) 443-1185

Cynthia Harpine, Statistician (Demography), Bureau of the Census, U.S. Department of Commerce, Room 2375, Federal Building #3, Washington, D.C. 20233, (301) 763-7946

Jo Harris-Wehling, Program Officer, Institute of Medicine, National Academy of Sciences, 2101 Constitution Avenue, N.W., Washington, D.C. 20148, (202) 334-2165

Catherine Hawes, Senior Policy Analyst, Research Triangle Institute, P.O. Box 12194, Research Triangle Park, North Carolina 27709, (919) 541-6340

Julie Hindmarsh, Baltimore County Area Agency on Aging, 611 Central Avenue, Townson, Maryland 21204, (301) 494-2001

Esther Hing, Mathematical Statistician, National Center for Health Statistics, 818 Richmond Avenue, Silver Spring, Maryland 20910, (301) 436-8830

Dr. Lilo Hoelzel-Seipp, R.N., Michigan Home Health Care, Inc., 955 East Commerce Drive, Traverse City, Michigan 49684, (616) 943-8450

Joan Holmes, Chief Operating Officer, Halifax Home Health, 2200 Halifax Road, South Boston, Virginia 24592, (804) 575-7961

Beverly Horn, Associate Professor, University of Washington, School of Nursing, SM-24, Seattle, Washington 98195, (206) 545-0842

Susan Hughes, GSW, Director, Programs in Gerontological Health, Northwestern University, Center for Health Services Research, 629 Noyes Street, Evanston, Illinois 60208, (312) 491-5108

Doris Carol Hunt, Training Coordinator, Division of Licensing & Regulation, 275 East Main Street, 4-E, Frankfort, Kentucky 40621, (502) 564-2800

Joan Hutcherson, RN, MM, Vice President, Health Care Services, Professional Nurses Bureau, 23622 Calabasas Road, Suite 205, Calabasas, California 91302, (818) 999-5300

Nancy Imes, Chief Operating Officer, Home Nursing Agency, Box 352, 201 Chestnut Avenue, Altoona, Pennsylvania 16603, (814) 946-5411

Dr. Solomon G. Jacobson, Consultant, 1234 Massachusetts Avenue, N.W., #723, Washington, D.C. 20005, (202) 638-3058

Barbara E. Joe, Quality Assurance & Program Evaluation Specialist, American Occupational Therapy Association, 1383 Piccard Drive, P.O. Box 1725, Rockville, Maryland 20850, (301) 948-9626 ext.382

Jean Johnson, Director, Regulator Affairs, American Health Care Association, 1200 15th Street, N.W., Washington, D.C. 20005, (202) 833-2050

Julianne Johnston, Home Care Project Director, Minnesota Department of Health, Health Resources Division, 717 Delaware Street, S.E., Minneapolis, Minnesota 55440, (612) 623-5627

Deborah Jones, Director of Nursing, Staff Builders Home Health Care, 1717 K Street, N.W., Suite 505, Washington, D.C. 20036, (202) 293-6997

Phyllis T. Jones, R.N., Senior Nurse Consultant, Department of Health Services, Community Nursing & Home Health Division, 150 Washington Street, Hartford, Connecticut 06106

Mary Margaret Just, Social Work Consultant, Oklahoma Department of Health, Eldercare Program, 1000 Northeast Tenth, Oklahoma City, Oklahoma 73152, (405) 271-4072

Diane Justice, Deputy Director, National Association of State Units on Aging, 2033 K Street, N.W., Suite 304, Washington, D.C. 20006, (202) 785-0707

Stephanie Karsten, Principal, Birch & Davis Associates, Inc., 8905 Fairview Road, Suite 300, Silver Spring, Maryland 20910, (301) 589-6760

Mildred Kashmere, Administrator, Southern Maryland Home Health Service, 7501 Surrats Drive, Suite 307, Clinton, Maryland 20735, (301) 899-4662

Maryanne Keenan, American Association of Retired Persons, Public Policy Institute, 1909 K Street, N.W., Washington, D.C. 20009, (202) 728-4744

Mary Kelly, Controller, Delaware County Home Health Services, Old Main, 15th Street & Upland Avenue, Chester, Pennsylvania 19013, 876-5544

Peter Kemper, Service Fellow, National Center for Health Services Research, DIR, Room 18A-55, Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857, (301) 443-2560

Kathleen M. Kennedy, Research Analyst, Community Services Institute, Inc., 137 North Narberth Avenue, Suite C, Narberth, Pennsylvania 19072, (215) 668-2030

Vicky P. Kent, R.N., M.S., University of Maryland, 725 Gorsuch Avenue, Baltimore, Maryland 21218, (301) 467-8241

Rochelle Kerchner, Director, Comprehensive Geriatric Services, Inc., d/b/a Comprehensive Home Care, 414 Route 111, Smithtown, New York 11787, (516) 360-1313

Bernard M. Kilbourn, DDS, Regional Director, Department of Health & Human Services, 26 Federal Plaza, Room 3835, New York, New York 10278, (212) 264-4600

Dorothy B. Kilbourn, Department of Health & Human Services, 26 Federal Plaza, Room 3835, New York, New York 10278, (212) 264-4600

Kathy Kimmel, University of Virginia, School of Nursing, McLeod Hall, Charlottesville, Virginia 22903-3395, (804) 924-2704

Edward C. King, Actuarial Research Corporation, 6928 Little River Turnpike, Suite E, Annandale, Virginia 22003, (703) 941-7400

Marty Kinkead, Division of Operations, Home Call, Inc., 30 East Patrick Street, Frederick, Maryland 21701, (301) 663-8818

Gail Kiser-Brown, University of Virginia, School of Nursing, McLeod Hall, Charlottesville, Virginia 22903-3395, (804) 924-2704

Christine Klejbuk, Director of Public Policy, Association of Non-Profit Homes for the Aging, 3425 Simpson Ferry Road, Camp Hill, Pennsylvania 17011, (717) 763-5724

Anne Kohl, Labor Economist, Department of Labor, Patrick Henry Building, Washington, D.C. 20212, (202) 272-5285

Lois Kollmeyer, Chief, Bureau of Home Health Licensing & Certification, Missouri Department of Health, 1738 East Elm, Jefferson City, Missouri 65201, (314) 751-6336

Peter Komlos-Hrobsky, Staff Attorney, National Senior Citizens Law Center, 1052 West Sixth Street, Los Angeles, California 90017, (213) 482-3550

Barbara Krimgold, Consultant, National Health Policy Forum, 2921 Argyll Drive, Alexandria, Virginia 22305, (703) 548-9446

Lawrence E. Kucken, Senior Analyst, Health Care Financing Administration, Room 2504, Oak Meadows Building, 6325 Security Boulevard, Baltimore, Maryland 21207, (301) 966-6694

Linda Laliberte, Project Director, Center for Gerontology & Health Care Research, Brown University, Box G, Providence, Rhode Island 02912

Reve LeBlanc, Registered Nurse, Pennsylvania Department of Public Welfare, Bureau of Long-Term Care, Client Services, Box 2675, Harrisburg, Pennsylvania 17105, (717) 657-4358

Howard C. Lerner, Public Health Service, HRSA/BHCDA, Room 7A-55, Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857, (301) 443-5295

M.A. Lilienthal, Director, Professional Services, Home Cross Nursing Services, 1930 Chestnut Street, Suite 700, Philadelphia, Pennsylvania 19103, (215) 563-2500

Kathryn W. Ling, Alzheimer’s Disease & Related Disorders Association, 70 East Lake Street, Suite 600, Chicago, Illinois 60601, (312) 853-3060

Dr. Nathan L. Linsk, Associate Professor, University of Illinois, Chicago, Department of Medical Social Work, M/C 778, 800 South Wood Street, Room 173, Chicago, Illinois 60612, (312) 996-1426

Nancy Lombardo, Alzheimer’s Disease & Related Disorders Association, 70 East Lake Street, Suite 600, Chicago, Illinois 60601, (312) 853-3060

Gwendolyn E. Long, RN, Medicare Administrator, Ohio Department of Health, Bureau of Medical Services, 246 North High Street, Columbus, Ohio 43266-0588, (614) 466-2070

Deborah J. Lower, Management Analyst, Colorado Department of Social Services, Aging & Adult Services, 1575 Sherman Street, Tenth Floor, Denver, Colorado 80203-1714, (303) 866-2694

John Luehrs, Director, Health Policy Studies, National Governor’s Association, 444 North Capitol Street, N.W., Suite 250, Washington, D.C. 20001, (202) 624-7812

Yvette Luque, President, Visiting Nurse Association of Los Angeles, Inc., 3755 Beverly Boulevard, Los Angeles, California 90004, (213) 667-1050

Joseph P. Lydon, Kendal Management Services, Box 100, Kennett Square, Pennsylvania 19348, (215) 388-2790

Barbara Lyons, Research Associate, Johns Hopkins University, 624 North Broadway, Hampton House 455, Baltimore, Maryland 21205, (301) 955-3625

Judith S. Magel, Senior Health Policy Analyst, American Medical Association, 535 North Dearborn Street, Chicago, Illinois 60610, (312) 645-4727

Carol Mahr, President, Home Care Research, 30 East Patrick Street, Frederick, Maryland 21701, (301) 694-6935

Bonnie Malkin, Director, Division of Prof. Practice, Food & Drug Administration, 1901 Chapman Avenue, Rockville, Maryland 20857, (301) 443-4600

Evelyn Marder Relkin, Vice President, Counseling Home Care Services, 902 Broadway, Ninth Floor, New York, New York 10010, (212) 995-2537

Karen Marek, Research Assistant, University of Wisconsin, Milwaukee, Center for Nursing Research & Evaluation, P.O. Box 413, Milwaukee, Wisconsin, (414) 229-3993

John Paul Marosy, Executive Director, Home Health Agency Assembly of New Jersey, 760 Alexander Road, CN-1, Princeton, New Jersey 08543-0001, (609) 452-8855

Joan Marren, Director, Patient Services, Visiting Nurse Services, 107 East 70th Street, New York, New York 10021, (212) 794-9200 ext.828

Alan R. Martell, ACSW, Deputy Director, Long Term Care Procurement & Analysis, Philadelphia Corporation on Aging, 111 North Broad Street, Philadelphia, Pennsylvania 19107, (215) 496-0520

Evelyn Mathis, Chief, Long-Term Care Branch, National Center for Health Statistics, Room 2-43, 3700 East-West Highway, Hyattsville, Maryland 20904

Judy Matthews, Community Home Health, 501 Oak Avenue, Waynesboro, Virginia 22980, (703) 942-6267

Dr. John L. McCoy, Senior Analyst, Social Security Administration, PAS, Van Ness Center, 4301 Connecticut Avenue, N.W., Washington, D.C. 20008, (202) 282-7111

John E. McDonough, Evaluator, U.S. General Accounting Office, Room 575, O’Neil Federal Building, 10 Causeway Street, Boston, Massachusetts 02222

Rosalie McGinnis, PASSPORT Health Services Administration, Ohio Department of Aging, 50 West Broad Street, Columbus, Ohio 43215, (614) 644-7635

Norma S. Mengel, President/CEO, Visiting Nurse Association Home Health Services, Visiting Nurse Association of York County, 218 East Market Street, York, Pennsylvania 17403, (717) 846-9900

Joseph Menzin, Senior Policy Analyst, Project Hope, Center for Health Affairs, 2 Wisconsin Circle, Suite 500, Chevy Chase, Maryland 20815, (301) 656-7401

Penny Milanovich, Visiting Nurse Association, Butler County, 154 Hindman Road, Butler, Pennsylvania 16601

Susan Miller, Assistant Professor, University of Illinois, Chicago, Department of Medical Record Administration, 808 South Wood Street, Room 164C-ME, Chicago, Illinois 60612, (312) 996-3530

Pamela Mittelstadt, Assistant Director, Congressional & Agency Relations, American Nurse Association, 1101 14th Street, N.W., Washington, D.C. 20005, (202) 789-1800

Dr. Patricia Moritz, RN, Chief, Nursing Systems Branch, National Institutes of Health, NCNR, Room B2-E17, Building 38A, Bethesda, Maryland 20817, (301) 496-0523

Richard J. Morrissey, Director, Bureau of Adult & Child Care, Kansas Department of Health & Environment, Landon State Office Building, 900 Southwest Jackson, Suite 1001, Topeka, Kansas 66612-1290, (913) 296-1240

Jill Mueller, Executive Director, Visiting Nurse Association of Trenton, P.O. Box 4562, Trenton, New Jersey 08611, (609) 695-3461

Judith A. Muskett, Director of Communications, National Committee for Quality Health Care, 1730 Rhode Island Avenue, N.W., Suite 803, Washington, D.C. 20036, (202) 861-0882

Janet Neumann, Assistant Director, Potomac Home Health Care, 8600 Old Georgetown Road, Bethesda, Maryland 20814, (301) 530-3114

Betty Newell, Executive Director, MJH Home Care, Inc., 423 Lexington Avenue, Charlottesville, Virginia 22901, (804) 293-0394

Susan Nicholas, Program Manager, Community Services, Pima County Aging & Medical Services Department, 601 North Wilmot, Suite 36, Tucson, Arizona 85711, (602) 745-8866

Helen Q. Nunley, RN, MSN, Director, Professional Services, IVNA, 908 North Thompson Street, Richmond, Virginia 23230, (804) 355-7100

Linda Nuttall, Director, Home Health, Walter Reed Memorial Hospital, Route 17, Glouschester, Virginia 23061, (804) 874-8240

David Oatway, Project Director, Home Care Project, Georgetown University, Saint Mary’s Hall, 3700 Reservoir Road, N.W., Washington, D.C. 20008, (202)687-4647

Tracy Orloff, SysteMetrics/McGraw-Hill, Inc., 3939 Wisconsin Avenue, N.W., Suite 300, Washington, D.C. 20016, (202) 244-1610

John F. Owens, North Atlantic Regional Manager, Upjohn Health Care Services, 5000 Tilghman Street, Suite 250, Allentown, Pennsylvania 18104, (215) 398-7445

Dr. Patricia O’Hare, PHN Clinical Research Director, Home Care Project, Georgetown University, Saint Mary’s Hall, 3700 Reservoir Road, N.W., Washington, D.C. 20008, (202)687-4647

Mary Parker, GSA Fellow, Fairfax County Area Agency on Aging, 11242 Waples Mill Road, Fairfax, Virginia 22030, (703) 246-5419

Pamela J. Parker, Director, Long Term Care Management, Minnesota Department of Human Services, 444 Lafayette Road, Saint Paul, Minnesota 55155-3844, (612) 297-3209

John P. Parman, Assistant Commissioner, Indiana State Board of Health, 1330 West Michigan Street, Indianapolis, Indiana 46206, (317) 633-0716

Margaret Peisert, Research Analyst, Service Employee International Union, 1313 L Street, N.W., Washington, D.C. 20005, (202) 898-3317

Audrey Peterson, Executive Director, United Home Care Services, Inc., 484 Rockaway Avenue, Brooklyn, New York 11212, (718) 498-2900

Dr. Eric Pfeiffer, Director, Suncoast Gerontology, University of Southern Florida, 12901 North 30th Street, MDC 50, Tampa, Florida 33612, (813) 974-4355

Joyce Philen, Director, Area Agency on Aging, Southeast Texas Regional Planning, P.O. Drawer 1387, Nederland, Texas 77627, (409) 727-2384 ext.52

Ann Pierson, Program Coordinator, Area Agency on Aging, Region I, 1366 East Thomas Road, Suite 108, Phoenix, Arizona 85014, (602) 254-2255

Carla Pittman, Director, Fairfax County Area Agency on Aging, 11242 Waples Mill Road, Fairfax, Virginia 22030, (703) 246-5419

Lou Ann Poppleton, President, Maryland Association for Home Care, Meridian Health Care, 7C Cross Keys Road, Baltimore, Maryland 21210, (301) 494-8153

Dianne M. Porter, Professional Staff, Senate Special Committee on Aging, Room G-41, Dirksen Building, Washington, D.C. 20510, (202) 224-5364

Caroline Post, Nursing Manager, Visiting Nurse Home Care Association of Lancaster, 1347 Fruitville Pike, Lancaster, Pennsylvania 17601, (717) 397-8251

Elaine J. Power, Analyst, Office of Technology Assessment, U.S. Congress, Washington, D.C. 20510-8025, (202) 228-6590

Ann Quinlan, Consultant, Older Women’s League, 2020 F Street, N.W., Suite 107, Washington, D.C. 20006, (202) 223-3815

David L. Rabin, Professor, Georgetown University, School of Medicine, Department of Community & Family Medicine, 3900 Reservoir Road, Washington, D.C. 20007, (202) 687-1605

Terry Raskauskas, Policy Analyst, Public Health Service, Room 740G, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, (202) 472-3033

Tim Redmon, Director, Regulatory Affairs, National Association of Medical Equipment Suppliers, 625 Slaters Lane, Suite 200, Alexandria, Virginia 22314, (703) 836-6263

Dr. Laura J. Reif, RN, Associate Professor, University of California, San Francisco, N-611Y, San Francisco, California 94143-0612, (415) 476-4658

Eleanor D. Rhinier, R.N., Director, Professional Services, Visiting Nurse Association of Chester County & Vicinity, 119 West Wayne Avenue, Wayne, Pennsylvania 19087, (215) 688-3077

Trish Riley, Consultant, 265 Main Street, Brunswick, New Jersey 04011, (207) 729-9702

Lynn T. Rinke, Chief Operating Officer, Visiting Nurse Association of Metro Detroit, 7700 Second Avenue, Detroit, Michigan 48202, (313) 876-8531

Michele L. Robinson, Staff Editor, Hospitals Magazine, 50 F Street, N.W., Washington, D.C. 20001, (202) 626-2339

Betty Rogers, Salem Home Health, Salem, Virginia 24152, (703) 989-4826

Nancy R. Root, Executive Director, Home Health Plus, 203 Roanoke Street, Christiansburg, Virginia 24073, (703) 382-5484

Nancy Ryskie, Director, Case Management Unit, 3157 South Wolcott Avenue, Chicago, Illinois 60608, (312) 247-1290

Dr. Virginia K. Saba, Project Director, Home Care Project, Georgetown University, Saint Mary’s Hall, 3700 Reservoir Road, N.W., Washington, D.C. 20008, (202)687-4647

Mary C. Sandell-Gober, 2008 Gray Birch Way, Tallahassee, Florida 32308

Elizabeth Sanders, Program Director, BHRAGS Inc., 1212 East New York Avenue, Brooklyn, New York 11212

Judy Sangl, Research Analyst, Health Care Financing Administration, ORD, Room 2-B-14, Oak Meadows Building, 6325 Security Boulevard, Baltimore, Maryland 21207, (301) 966-6596

Yvonne Santa Anna, House Committee on Aging, Washington, D.C. 20515

Elissa Sauer, Executive Director, Holy Family Home Health Care, 900 West Market Street, Orwigsburg, Pennsylvania 17961, (717) 366-0990

Anita M. Saynisch, Associate Legislative Counsel, Office of Legislative Services, State House Annex, CN-068, Trenton, New Jersey 08625, (609) 292-1646

Mary Ann Schmidt, Director, Program & Operations, South Hills Health System Home Health Agency, 1800 West Street, Homestead, Pennsylvania 15120, (412) 464-6100

Gary Schneider, Director, Policy Evaluation, Health Industry Manufacturers Association, 1030 15th Street, N.W., Washington, D.C. 20005, (202) 452-8240

Judy Schultz, Home Health Manager, Lake Region Hospital Home Health Care, 712 South Cascade, Fergus Falls, Minnesota 56537, (218) 739-5475 ext.309

Joel Schwartz, Comprehensive Geriatric Services, Inc., d/b/a Comprehensive Home Care, 414 Route 111, Smithtown, New York 11787, (516) 360-1313

Edward Sekscenski, Health Statistician, National Center for Health Statistics, Room 2-43, 3700 East-West Highway, Hyattsville, Maryland 20904, (301) 436-8830

Patricia Sevast, Director, Quality Assurance, Visiting Nurse Association, Baltimore, 525 Saint Paul Place, Baltimore, Maryland 21202, (301) 576-8440

Scott R. Severns, Attorney, Policy Analyst, United Senior Action of Indiana, Inc., 36 South Pennsylvania Street, Indianapolis, Indiana 46204, (317) 633-4090

Ann Seweryn, Director, Home Health Services, Philadelphia Geriatric Center, 5301 Old York Road, Philadelphia, Pennsylvania 19141, (215) 455-6363

Indi L. Shelby, Vice President, Patient Services, Visiting Nurse Association of Central New York, Inc., 1050 West Genesee Street, Syracuse, New York 13204, (315) 476-3101

Yasuko Shiraishi, Director, Home Care Program, Veterans Administration, Central Office, 810 Vermont Avenue, N.W., Washington, D.C. 20420, (202) 233-5995

Sharon Shoff, Vice President, Quality Control, Southern New Jersey Visiting Nursing Service System, Inc., P.O. Box 508, Woodbury, New Jersey 08096, (609) 845-0460

Jonathan L. Shreve, Actuary, Milliman & Robertson, Inc., 259 Radnor-Chester Road, Suite 300, Radnor, Pennsylvania 19087, (215)687-5644

Geoff Shuster, University of Virginia, School of Nursing, McLeod Hall, Charlottesville, Virginia 22903-3395, (804) 924-2256

Gerald L. Shuttlesworth, Chief Executive Director, Albert Gallatin Visiting Nurse Association, Inc., 22 South Main Street, Masontown, Pennsylvania 15461, (412) 438-6660

Dr. Lori Simon-Rusinowitz, Director, Fellowship Programs in Applied Gerontology, Gerontological Society of America, 1275 K Street, N.W., Suite 350, Washington, D.C. 20005-4006, (202) 842-1275

Joan Smith, In-House Aide Service, Prince Georges Department of Social Services, 6111 Ager Road, Hyattsville, Maryland 20782, (301) 431-7078

Michael A. Smith, Executive Director, Hampton Roads Home Health Care Agency, Inc., P.O. Box 1694, Grafton, Virginia 23692

Suzanne C. Smith, R.N., M.B.A, Director, Patient Services, Visiting Nurse Association of Albany, Inc., 35 Colvin Avenue, Albany, New York 12206, (518) 489-2681 ext.38

Lois Snyder, Policy Analyst, American College of Physicians, 4200 Pine Street, Philadelphia, Pennsylvania 19104, (215) 243-1200 ext.1509

Robert Snyder, Fiscal Analyst, Iowa Legislative Fiscal Bureau, Second Floor, Capitol Building, Des Moines, Iowa 50319, (515) 281-6256

Bruce Spitz, Director, American Red Cross, National Headquarters, Special Projects Division, 1730 E Street, N.W., Washington, D.C. 20006, (202) 639-3071

Roberta R. Spohn, Deputy Commissioner, NYC Department for Aging, 2 Lafayette Street, Seventh Floor, New York, New York 10007, (212) 577-0827

Grace Starbird, Planner, Fairfax County Area Agency on Aging, 11242 Waples Mill Road, Fairfax, Virginia 22030, (703) 246-5419

Halyna I. Stegura, Executive Director, Visiting Nurse Association of Pottstown, 1035 High Street, Pottstown, Pennsylvania 19464, (215) 326-0254

Jane Stenson, Executive Assistant, Catholic Charities USA, 1319 F Street, N.W., Washington, D.C. 20004, (202) 639-8400

Genevieve Strahan, Survey Statistician, National Center for Health Statistics, 1008 Trebing Lane, Upper Marlboro, Maryland 20772, (301) 436-8830

Jane Takeuchi, Senior Research Associate, American Association of Retired Persons, New Roles in Society, 1909 K Street, N.W., Washington, D.C. 20049, (202) 728-4089

Sandra Talavera, Bronx Jewish Community Council, Home Attendant Services, Inc., 2930 Wallace Avenue, Bronx, New York 10467, (212) 652-5500

Debra Tallon, Clinical Supervisor, Chicago Visiting Nurse Association, 322 South Green Street, Chicago, Illinois 60607, (312) 738-8622

Susan F. Tate, Assistant Secretary, Institutional & Interprofessional Affairs, American Dental Association, 211 East Chicago Avenue, Chicago, Illinois 60611, (312) 440-2667

Cleonice Tavani, Program Analyst, Public Health Service, HRSA/OPEL, Room 14-36, Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857, (301) 443-1900

Gregory Taylor, In-House Aide Service, Prince Georges Department of Social Services, 6111 Ager Road, Hyattsville, Maryland 20782, (301) 431-7078

Linda M. Taylor, Executive Director, Visiting Nurse Service, Inc., 125 West Hills Road, Huntington Station, New York 11746, (516) 351-1200

Al Thomas, Food & Drug Administration, 1901 Chapman Avenue, Rockville, Maryland 20857

Bernice Thomas, Americare, 933 North Kenmore Street, Suite 404, Arlington, Virginia 22201, (703) 522-4646

Phyllis Torda, Director, Health & Social Policy, The Villers Foundation, 1334 G Street, N.W., Washington, D.C. 20005, (202) 628-3030

Herbert G. Traxler, Economist, National Center for Health Services Research, DER/CF, Room 18A-09, Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857, (301) 443-6990

Betty B. Treager, Executive Director, Westmoreland Home Health Care, 532 West Pittsburgh Street, Greensburg, Pennsylvania 15601, (412) 837-6220

Joan Turek-Brezina, Director, Division of Technical Support, Department of Health & Human Services, ASPE/PS, Room 438F, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, (202) 245-6141

Joan F. Van Nostrand, Deputy Director, Division of Health Care Statistics, National Center for Health Statistics, 10765 Deborah Drive, Potomac, Maryland 20852, (301) 436-8522

Delores Vasquez Freda, Program Director, Henry Street Settlement, 265 Henry Street, New York, New York 10002, (212) 254-4700

Carol Vetter, Assistant Director, Division of Consumer Affairs, Food & Drug Administration, 1901 Chapman Avenue, Rockville, Maryland 20857, (301) 443-4190

Madeline Vincent, Public Health Nurse Consultant, Rhode Island Department of Health, 75 Davis Street, Providence, Rhode Island 02908, (401) 277-2566

Otto von Mering, Professor & Director, University of Florida, Center for Gerontological Studies, 3355 Turlington Hall, Gainesville, Florida 32611, (904) 392-2116

Dr. Betsy S. Vourlekis, ACSW, Staff Director, Health & Mental Health, National Association of Social Workers, 7981 Eastern Avenue, Silver Spring, Maryland 20910, (301) 565-0333

Cynthia Walls, D.C. Commission on Aging, 1424 K Street, N.W., Second Floor, Washington, D.C. 20005, (202) 724-5622

Joseph A. Walsh, Executive Director, Upper Bucks Home Health Services, Inc., LifeQuest Home Care, P.O. Box 911, 124-126 South Tenth Street, Quakertown, Pennsylvania 18951, (215) 538-2232

Audrey S. Weiner, Assistant Administrator, Hebrew Home for the Aged, Riverdale, 5901 Palisade Avenue, Riverdale, New York 10471, (212) 549-8700 ext.229

Elizabeth Weiss, RN, MSN, Coordinator, Home Care Support, Iona House Senior Services, 4000 Albemarle Street, N.W., Suite 100, Washington, D.C. 20016, (202) 895-0234

Dr. William G. Weissert, Professor, Department of Health Policy & Administration, University of North Carolina, CB-8140, Kron Building, Chapel Hill, North Carolina 27599-8140, (919) 966-5587

Perla Werner, M.A., Research Associate, Research Institute of H.H.G.W., 6121 Montrose Road, Rockville, Maryland 20852, (301) 231-7463

Linda S. Wertheim, Social Worker, Montgomery County Department of Social Services, 5630 Fishers Lane, Rockville, Maryland 20852, (301) 468-4350

Maureen Whitman, Manager, Health Care Survey Section, Oregon Health Division, 1400 Southwest Fifth, Portland, Oregon 97201, (503) 229-5686

Dr. Julie A. Wilcox, University of Illinois at Urbana/Champaign, 1207 West Oregon Street, Urbana, Illinois 61801, (217) 333-2261

Rubenia Winston-William, In-House Aide Service, Prince Georges Department of Social Services, 6111 Ager Road, Hyattsville, Maryland 20782, (301) 431-7078

Kristy Wright, Visiting Nurse Association, Butler County, 154 Hindman Road, Butler, Pennsylvania 16601

Ruby Wyche, Branch Manager, Kimberly Quality Care, 1413 K Street, N.W., Third Floor, Washington, D.C. 20005, (202) 289-0440

Barbara Yost, Director, Home Health, Riverside Hospital, 500 South Clyde Morris Boulevard, Newport New, Virginia 23601, (804) 599-2656

Grace S. Zaczek, Registered Nurse, Division of Public Health, Health Facilities Licensing & Certification, 3000 Newport Gap Pike, Wilmington, Delaware 19808, (302) 995-6674

Marsha Zellem, Director, Potomac Home Health Care, 8600 Old Georgetown Road, Bethesda, Maryland 20814, (301) 530-3114

David Zimmerman, Director, Center for Health Systems Research & Analysis, University of Wisconsin, Madison, 1300 University Avenue, Madison, Wisconsin 53706, (608) 263-4875


PRACTITIONERS CONFERENCE ON QUALITY ASSURANCE IN HOME CARE REPORTS AVAILABLE

National Conference on Home Care Quality: Issues and Accountability--Conference Package
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National Conference on Home Care Quality: Issues and Accountability--Volume I Proceedings
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