A Checkup for Home Care

Although conventional wisdom contends that caring for the elderly at home is cheaper, better, and more natural than sending them to nursing care facilities, experts worry that home care takes place behind closed doors. Now researchers are developing a scientific way to assess home-care quality.

When faced with the choice of moving into a nursing care facility or staying home, many seniors opt for "aging in place." About 7.6 million people currently receive some form of caregiving at home, many more than inhabit nursing facilities, according to the National Association of Home Care.

As home care becomes more popular, however, experts worry that its quality is hard to evaluate. Caregivers, relatives, and regulatory agencies have had no standardized, scientifically validated way to tell whether grandma is getting the best care for her needs. Families are often hard pressed to know whether weight loss or a tendency to trip on the carpet is an inevitable part of their loved one's growing old or a sign of neglect on the part of the home-care provider. Even in cases where decline clearly isn't an unavoidable by-product of aging, the home-care agency might not be responsible: For example, a helpful relative might be preparing grandma's meals, but leaving out some essential nutrients or a physical therapy center that is unrelated to the home-care agency, might be failing to monitor the exercises that grandma needs for her difficulty walking.

Families aren't the only ones in the dark. Monitoring the care of patients in scattered settings with diverse services can prove difficult for home-care providers as well. Agencies that try to keep careful tabs on all their clients encounter another hurdle: a dearth of benchmarks that differentiate good quality care from poor performance in specific real-world situations.

Now researchers in a multinational research consortium called interRAI (for international Residential Assessment Indicators) have taken an important first step toward remedying these problems. In the January 2005 issue of Gerontologist, the group described 22 standards that can be used to assess the quality of home care for the elderly and disabled. The indicators--which include conditions such as weight loss, dehydration, skin ulcers, incontinence, social isolation, skipped flu vaccinations, inadequate pain control, difficulty with daily activities, and cognitive deficits--are "reliable measures, and they'll give you relevant information” about the kind of care a person needs, says Brant E. Fries of the University of Michigan's Institute of Gerontology and School of Public Health, and a member of the interRAI team. In the 1990s, interRAI developed a similar program for nursing homes, which all facilities in the United States and many internationally, have adopted.

Taken together, the Home Care Quality Indicators provide a picture of an individual's state of health -- a critical component for developing an appropriate plan of care. The assessment might suggest that grandma needs nutritional oversight, blood sugar monitoring, and speech therapy, but not cognitive therapy or mental health services. And agencies can use the indicators to periodically reassess their clients' health and adjust their care plans accordingly.

Agencies can also use the assessments to evaluate their own overall performance and determine whether they could do better, says John Williams, director for Long-term Care at Utah's Department of Health Services, which has begun using the interRAI indicators to assess and compare the various home care programs under its auspices. Some home-care agencies are surprised at how well they're doing, others at how poorly, says John Morris of the Hebrew SeniorLife's Research and Training Institute in Boston, Massachusetts, another member of interRAI. Even agencies that excel in most areas lag in others, typically in reviewing patient medication, giving flu vaccinations regularly, and providing rehabilitation or physical therapy.

In addition to assessing the strengths and weaknesses of individual home-care providers, the standards enable researchers to pool information from providers across regions, states or nations. Collecting this data should allow home-care providers and researchers to develop "best practices" for handling clients with specific conditions. For example, one agency might maintain that it does a great job managing pain in patients with chronic arthritis--even though a client suffers ongoing discomfort--because it follows the same practices as others in its immediate area. But a broader comparison might reveal that what is par for that region is below standard in another locale--and provide examples to emulate.

Uniform quality standards are sorely needed, the researchers indicate, because home care is currently a regulatory wasteland when it comes to quality assessment. The only federal monitoring of home care is a under a Medicare-sponsored, short-term program for postacute care and rehabilitation, such as after a heart attack or operation. For longer-term situation--which include the bulk of home care for the elderly--some programs fall under diverse state regulations that generally deal with efficiency and cost rather than quality, says Fries. And with no standards imposed from above, Morris adds, "it takes a lot of initiative to think of quality first in the economically driven world of health care."

Institutional hurdles and the peculiarities of politics mean that home-care quality indicators aren't likely to be incorporated into federal standards anytime soon, the researchers note. But enthusiasm is growing at the state and regional level. So far, 11 states have adopted interRAI's assessment tool in some of their Medicaid-funded programs. Many private agencies and a growing number of nations, including Switzerland, Estonia and Iceland, are also following the interRAI system. "Agencies adopt it for different reasons," says Morris. In Utah, for example, the Department of Health Services is using the program to monitor a variety of Medicaid-funded programs, including home care, community-based and managed-care services. “We look at who's being served in one versus the other programs. It helps us know what level of services we can support in home-care programs," as well as how to set reimbursement rates for clients receiving different types of care, Williams says.

"But ultimately, it's the impact on the lives of people that matters," says Morris. Fries concurs, "We always stress that the primary purpose is not to evaluate quality but to improve the quality of care." That's a sentiment anyone planning to “age in place”, or anyone wanting to make sure their elderly parents are in good hands in their own homes,would enthusiastically second.

Cathryn M. Delude is a science writer in Andover, Massachusetts, who hopes that her children will put quality first when the time for home care arrives.