State Long-term Care Programs: Balancing Cost, Quality, and Access

Home Care Quality Indicators

Presenters: Brant E. Fries, Ph.D., Senior Research Scientist, Institute of Gerontology, School of Public Health, University of Michigan, Ann Arbor, MI. Scott M. Geron, Ph.D., Associate Professor, Research and Policy, School of Social Work, Boston University, Boston, MA.

Considerable work has been done in recent years to measure and improve quality in home- and community-based services programs. Brant Fries from the University of Michigan and others have developed the Resident Assessment Instrument for Home Care (RAI-HC) to collect clinically relevant data for care planning and building quality indicators. The instrument is currently used in 10 States, the Department of Veterans Affairs, and three foreign countries.

The Home Care Quality Indicators based on the RAI-HC assessment data can be used to identify who is doing a good job, how well services and programs are being managed, best practices, and how staff, programs, or organizations compare with others. Prevalence measures, or the proportion of clients with a quality problem after entering a program, have been identified in 22 areas including:

• Nutrition.
• Pain.
• Physical functioning.
• Psychosocial functioning.
• Medication.
• Safety/environment.
• Vaccinations.
• Hospital use and others.

Incidence measures, whether existing conditions failed to improve or new conditions were acquired after receiving services, are used for:

• Incontinence.
• Ulcers.
• Physical functioning.
• Psychosocial functioning.
• Health.

The process adjusts the data based on case mix and risk of encountering consumers with greater health and functional limitations. The system was used to evaluate home care services in Michigan. Dr. Fries reported that over a two year period, 16 indicators improved, four remained the same, and two declined.

The perspective of consumers is also an important component of home care quality. Scott Miyake Geron, Boston University School of Social Work, described his research to develop the Home Care Satisfaction Measure (HCSM), a consumer-derived quality measure that assesses five commonly received home care services in areas considered important to consumers.

The HCSM contains 60 items, with specific sub-scales for each service that contain 10 to 13 items. The services assessed in the HCSM are:

• Homemaker.
• Home health aide (personal care).
• Home delivered meals.
• Case management.
• Grocery service.

The items for the HCSM were derived from focus groups that identified eight domains of quality:

• Competency.
• Choice.
• Adequacy.
• Accessibility.
• Advocacy.
• Continuity of care.
• Dependability.
• Humaneness.

Sub-scale measures for particular services include dimensions such as:

• Worker competency.
• System adequacy.
• Interpersonal characteristics of the service provider.
• Service choice, dependability, and convenience.
• Quality.

The questions include a balance of positive and negative statements and use words commonly used by consumers such as: "my homemaker leaves too early," "my homemaker is very thorough," "...has become a friend," "...is rude to me," and "...takes an interest in me as a person." Each sub-scale takes from three to five minutes to complete, has been shown to be valid and reliable, and has been designed for face-to-face or telephone administration. Satisfaction can be measured in relation to specific services or by dimensions within services, and national benchmarks for each service are being developed.

Dr. Geron concluded that the HCSM provides useful, statistically interpretable information about home care quality. The HCSM is being used by over 20 states and programs and has been adopted by the Administration on Aging as a key performance outcome measure.

Additional Resource

Hirdes JP, Fries BE, Morris JN et al. Home care quality indicators (HCQIs) based on the Minimum Data Set-Health Care (MDS-HC). Unpublished; 2002 April 12.

Geron SM, Smith K, Tennstedt S, et al. The home care satisfaction measure (HCSM): a client-centered approach to assessing the satisfaction of older adults. Journal of Gerontology: Social Sciences 55B(5):S259-70 2000 Sep.

Geron SM. Survey instrument: home care satisfaction measure: homemaker service (HCSM-HM13). Boston (MA): Boston University School of Social Work; 2001.

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