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Review of State Quality Assurance Programs for Home Care: Final Report

Publication Date


U.S. Department of Health and Human Services

Review of State Quality Assurance Programs for Home Care

Executive Summary

Macro Systems, Inc.

April 1989

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


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

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



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

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



1. State Strategies

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

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

  • Worker training, the most common standard, ranges from simple worker orientation to highly developed training courses. While home health programs tend to have more rigorous training requirements, some supportive care programs also have highly developed standards for training homemakers and personal care aides.

  • Worker certification is required by a number of state programs and is usually tied to training requirements for home health aides or personal care attendants. Very few supportive care programs have worker certification standards.

  • Four-fifths of the study states license home health agencies, and there is little variation in approaches to licensure. By-and-large, state licensing requirements mirror the Medicare Conditions of Participation.

  • Some programs require providers to be state- or program-approved. Provider approval is more common for supportive care providers who are not regulated by licensure.

  • A number of other standards for home care, such as bills of client rights, accreditation, codes of ethics, and criminal record checks, are used less frequently.

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

  • Worker supervision is almost universally required, but the specific requirements for supervision vary considerably. Medicaid home health program requirements are the most consistent, largely because Medicaid follows the Medicare Conditions of Participation. A few supportive care programs pattern supervision requirements after home health programs.

  • Supervisory home-visits, required by all home health programs, are also used by many supportive care programs. The nature and frequency of these visits range considerably.

  • Client assessments and evaluations, present in almost all home care programs, differ in the method and frequency of assessments. Most programs require annual assessments.

  • Case management, reported by many home care programs, varies greatly in application. Although sometimes used in home health, case management is more common in supportive care programs.

  • Provider surveys are tied to Medicaid certification, state licensure, and accreditation review. This is a universal monitoring method in home health and is used in some supportive care programs.

  • Most supportive care programs employ purchase of service contracts which include quality standards. Periodic contract reviews are used to check provider compliance.

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

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

  • Withholding contracts or funds. These are the most frequently cited economic penalties. Other economic penalties include reassigning clients to competing providers, withholding client referrals, and limiting the services of a provider. Use of these mechanisms is influenced by service provider availability. Programs located in areas with only one or two home care agencies are restricted in the number of economic penalties they can employ without adversely affecting service delivery.

  • Imposing criminal penalties including imprisonment and fines. These are almost always tied to home health agency licensure laws and seldom apply to supportive care services, except in cases of abuse or neglect.

2. The Impact Of Funding Sources

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

  • States are required by the Federal Government to follow the Medicare Conditions of Participation for all Medicaid home health services. Although many states impose some additional requirements through licensure laws for home health agencies, few states go significantly beyond the Medicare Conditions. The most prevalent additional requirements pertain to patient rights, personal care assistants, and provider agency quality assurance programs.

  • Medicaid Personal Care Option Program and home health programs are administered by the same state agency and generally follow similar quality assurance mechanisms. Some programs obtain personal care services from licensed home health providers, but most contract for services with supportive care agencies or independent providers. In these cases, agency approval, contract reviews, and worker certification are important quality approaches.

  • Medicaid Community-Based Waiver programs are similar to Title III and Title XX programs in the use of quality mechanisms. In cases where waiver programs are operated by state units on aging, quality assurance mechanisms for waiver and Title III services are identical. Case management, almost universally found in waiver programs, is both a service and monitoring mechanism. Most waiver programs consider case management a major quality mechanism, but the models of case management vary considerably among states.

  • Although the Federal Government imposes few requirements to address the quality of home care funded by Titles III and XX, most states have developed some standards, monitoring, and enforcement mechanisms. Title XX programs tend to have more standards than Title III programs, but monitoring and enforcement mechanisms are very similar. A few states have patterned quality assurance efforts in Title III and/or Title XX after Medicaid home health quality assurance programs.

3. Expanded Ombudsman Programs

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



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

  • A wide variety of mechanisms addressing home care quality are in place in publicly-funded programs. Nearly all programs reported one or more standards relating to quality assurance, all reported at least one monitoring mechanism, and almost all have enforcement measures.

  • Multiple state program agencies encourage fragmentation of service delivery and quality assurance systems. The majority of study states operate multiple home care programs within different agencies. This fragmentation appears to follow the Federal funding pattern and results in divergent efforts among programs to address the quality of home care.

  • State officials believe that quality in home care programs is generally good. Most program officials indicated that they were comfortable with the quality of care being provided through their programs and the vast majority rated it as "good to excellent."

  • Quality in home care programs is not currently a major public or political issue in most states. Almost all program officials reported that home care receives attention as part of larger human service issues, but with two notable exceptions, home care quality is not attracting critical political attention in the study states.

  • Availability of publicly-funded services is perceived to be a major problem. Almost all officials participating in this study indicated concern with the availability of services and called it a major issue. The shortage of services is related to funding levels and the number of provider agencies and home care workers in most states.

  • Assuring quality in home care programs is difficult and requires continual and systematic attention to quality assurance mechanisms. Although program officials generally expressed satisfaction with their programs' quality assurance systems, they also consistently expressed a professional awareness of the need to constantly monitor and upgrade those efforts.

  • The lack of a standardized framework for defining and measuring quality is a major barrier to understanding and ensuring quality of home care services. Although some standardization exists in home health services, the field of home care, as a whole, has no universally accepted standards of care. It will be difficult to evaluate the quality of home care received by consumers of public home care programs or to effectively implement home care quality assurance systems until generally accepted models of service definitions, standards, and measures are developed.

  • Officials are open and candid in discussing their home care quality programs. The vast majority of officials contacted during the course of this study were interested and willing to participate in discussions of their home care service delivery and quality efforts. These officials demonstrated an openness about their programs and seemed to recognize and be willing to discuss shortcomings as well as strengths.

  • Officials are not well-informed about home care quality mechanisms in other states. With some exceptions, program officials are unfamiliar with home care services and quality assurance programs outside their state. These officials demonstrated an interest and desire to learn from the experiences of other programs.

  • State home care provider organizations consistently support licensing legislation and other quality assurance programs. Provider organizations are reported to consistently support licensing legislation, and no state reported provider resistance to such legislation.

  • Expansion of the Long-Term Care Ombudsman Program to include home care clients is an untested and unproven quality mechanism. Although five states currently have a legislative mandate to expand their ombudsman program to include home care clients, none is fully operational. Two states are in the planning stage, one state limits the expansion to include clients in one state-funded program, and two states are officially operational but have not significantly publicized the program for home care clients.



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


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



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

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

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

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


  • Service definitions
  • Service standards
  • Program monitoring
  • Client satisfaction measures
  • Independent provider programs
  • Worker recruitment and retention
  • Ombudsman programs
  • Service delivery models
  • Training curricula and evaluation
  • Worker skills evaluation
  • Service outcome measures
  • Case management
  • Standards and monitoring for family-provided services

    The lead agency can support knowledge development by promoting research, development, and demonstration programs in quality assurance. These activities should focus on testing the effectiveness of existing home care quality assurance efforts and developing new systems. Knowledge development must be coupled with a variety of knowledge transfer activities such as conferences, workshops, and publications.

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