Component plan. Long-term care : home health care services

COMPONENT PLAN LONG-TERM CARE: HOME HEALTH CARE SERVICES
GEORGIA STATE HEALTH POLICY COUNCIL and the
GEORGIA STATE HEALTH PLANNING AGENCY 4 Executive Park Drive, N.E. Suite 2100 Atlanta, Georgia 30329 January 1987
Publication of this document has been supported in part by the Department of Health and Human Services, Public Health Services, Grant and Policy Standards pertaining to Public Law 93-641 (Title XV, Section 1523), and amendments.

..

Joe Frank Harris
GOVEJllNOfII

STATE OF GEORGIA
OFFICE OF THE GOVERNOR
ATLANTA 3033<6

June 16, 1987

w. Douglas Skelton, M.D.
Chairman
State Health Policy Council Suite 2100 4 Executive Park East, N.E. Atlanta, Georgia 30329

Dear Doug:

In accordance with your request and with the authority granted me in Code Section 31-6-20 of the Official Code of Georgia Annotated, I have reviewed the Component Plan for Long Term Care: Home Health Care Services and do hereby approve it. I would like to commend the council and the State Health Planning Agency on the time and effort which have gone into the development of this plan.

I am particularly' pleased with the open, public participatory process which has been initiated by the council and the agency in the development of both the component plan and the certificate of need rules. If I can be of further assistance on this or any other matter of concern to you, please contact me.

With kindest regards, I remain

JFH:mbb

Sincerely,
~~ Joe Frank Harris ,~aWlE~

JUN 23 19I1

->, ,_ l,i1 _'"' ,,,or
HAUH PlAlHHG ASENCV

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8'i";;'ij

STATE OF GEORGIA
HEALTH POLICY COUNCIL

4 Executive Park Drive, N.E. Suite 2100
Atlanta. Georgia 30329 (404) 894-4899

May 15, 1987

The Honorable Joe Frank Harris Governor The State of Georgia The State Capitol Atlanta, Georgia 30334 Honorable Sir: It is with great pleasure that the State Health Policy Council transmits to you for your approval this Component Plan:
LONG-TERM CARE: HOME HEALTH CARE SERVICES The Plan is a product of the Council and the State Health Planning Agency, which operate within the authority of Georgia Law 552, Code Title 31, Chapter 6 amended. This Component Plan identifies and addresses issues related to home health care services and recommends goals, objectives and system changes to insure a statewide system of cost-effective and efficient care. The Plan is designed to achieve official state health policies relating to quality care and cost containment. This Plan has been produced through an open, publ ic participatory process initiated and monitored by the Policy Council. The Policy Council and the State Agency commend this Plan to you, and urge your approval of it. It is believed that the Plan provides a rational basis for the continued development of needed home health care services for Georgians.'

WDS/kbg Enclosure

PREFACE
This Component Plan is a product of the Georgia State Health Policy Council and the Georgia State Health Planning Agency which are funded through and operate within the authority of Georg i a Law Act 552 and formerly Federal Pub1i cLaw 93-641 and amendments. The purpose of this Pl an is to identify and address heal th issues, and recommend goals, objectives and system changes to achieve official State Health Policies. This Plan has been produced through an open, public participatory process developed and monitored by the 25-member Governor appointed State Health Policy Council. The Plan, once approved by the Governor, supersedes all related sections of both the 1981 and 1983 editions of the State Health Plan, and is designed to be consistent with the overall State Health Policies. For purposes of the administration and implementation of the Georgia Certificate of Need (CON) Program and Capital Expenditure Review under Section 1122 of the Social Security Act, criteria and standards 'for review (as stated in the Rules, Chapter 272-1, 272-2 and 272-3) are derived from this Component Plan. The Rules, which are published separately from the Plan and which undergo a separate public review process, are an official interpretation of any official Component Plans which the review function has the legal" authority to implement. The Rules are reviewed by the State Health Policy Council (prior to their adoption) for their consistency with the Plan. The Rules, as a legal document, represent the final authority for all review decisions. Any questions or comments on this Component Plan should be directed to the Planning and Implementation Division of the State Health Planning Agency, 4 Executive Park Drive, N.E., Suite 2100, Atlanta Georgia 30329; telephone (404) 325-8939.

TABLE of CONTENTS

PAGE

I. HOME HEALTH CARE

1

A. Background

2

B. Home Health Care Delivery System

2

C. Home Health Care Agencies

4

II. REIMBURSEMENT for HOME HEALTH CARE SERVICES

5

III. COST CONTAINMENT FACTORS in HOME HEALTH CARE

6

IV. QUALITY of CARE ISSUES

9

V. HOME HEALTH CARE in GEORGIA

12

A. Agency Organization

12

B. Patient Population Characteristics

13

C. Visits per Patient

15

D. Use Patterns - Urban/Rural

16

E. Referral Patterns

16

F. Community Care

17

G. Financial Accessibility

19

H. Range of Services

19

I. Cost Variables

21

VI. ESTIMATION of NEED for HOME HEALTH CARE SERVICES

22

VI I. GOALS, OBJECTIVES and RECOMMENDED ACTIONS

26

VIII. RECOMMENDED GUIDELINES for DEVELOPMENT of HOME

HEALTH CARE SERVICES

28

IX. APPENDICES

Appendix A - Task Force Membership List

39

Appendtx B - Home Health Agency Map and RO.ster

40

X. REFERENCES CITED

43

XI. ADDITIONAL REFERENCE.S.

45

NOTE: Numbers in parentheses in the text indicate references.

'The sick, without being pained by separation from their families, may be attended and relieved at home.'
- Boston Dispensary 1796
I. Home Health Care Home health care services are those services which enable health care, medical care, social support services and various other specific therapies to be delivered to patients in their place of residence. Provision of services in the operational 'home base' of the patient ideally should accentuate independence and augment the patient's natural support system, while providing a comfortable and safe site for the delivery of high quality health care services.
The patient is the focus of service delivery and generally, home care meets the need for:
1. acute care, as a substitute for or follow-up to acute hospital care; 2. chronic care as long-term services to meet the demands of long standing illness or disability; 3. long-term rehabilitation from a severe i11nessor injury; and 4. hospice care to provide support and care to terminally ill patients and their families.
This Component Plan discusses past, present and future parameters for the development of home health care services in Georgia.
1

A. Background Care of the- ill and disabled at home is not a new or unusual phenomenon. In earlier times, hospitals were not the principal locus of health care; medical care, as well as nursing services, were arranged at home. Even as late as the mid 1900's, people were receiving a substantial portion of their health care in their homes.{l)
Only as drug therapy, improved anesthesia, surgery and techology increased in scope and kind did hospitals become more desirable as the locus for medical treatment. Viewed in a broader context, the increased reliance on institutional care paralleled the decreased self-reliance that occurred after the shock of the depression. Reliance on formal institutions was a buffer to life's blows. (2) As this view developed" hospitals came to be seen as the hallmarks of healing technology.
Coming full circle, there has been a resurgence of interest in home care. This interest supports a coordinated system of facility-based and home care, to meet health care needs. The current interest in home care is also sustained by the retreat from the exclusively high technology application of health care. This evolution, rather than revolution, can be viewed as a balancing movement which seeks to balance the high technology of hospital c(lre with the high touch of home care, reinforcing the human side of health care. (3) This balancing action includes the organization of primary care services, as well as the efficient coordination of the services delivered to address the social and psychological needs of the person and the biomedical requirements of the medical care. Such options extend the abilities and resources of the family and natural support system, and reinforce the personal determination of the patient.
B. Home Health Care Delivery Systems The development of home health agencies has its roots in earlier home nursing services. The nursing services generally were organized as voluntary or governmental agenci es to provide nursing services in the home. By 1909, Metropolitan Life Insurance offered home nursing services to their policy holders. During the 1940's, home nursing was encouraged as a way to alleviate overcrowding in hospitals. The Montefiore Hospital Homecare Program,
2

founded in 1947 in New York became an often replicated program for delivery of a range-of -home health services.

The Montefiore Program encompassed nursing, housekeeping services, transportation, medication and medical goods, occupational therapy and physical therapy. In the development of subsequent services, four elements were conceived as being essential to home care servjces:
1. the careful selection of suitable cases; 2. the suitability of the home environment to support care; 3. cost containment of health care; 4. quality of care, inclUding the humanistic aspects.(4)

The Collllllni ty Health Services and Facilities Act was passed in 1961. It authorized project grants to public and non-profit agencies for the development of health services for the prevention, detection and treatment of disease and disability, and the improved care of non-hospitalized persons. Many of these funds supported the development of home care services.

Medicare legislation in 1965 further expanded home care services. The

federal definition of home care required that agencies have nursing services

and one additional service such as physical therapy, occupational therapy,

speech therapy, medical social services or home health aide services. By

October 1966, over 1,200 agencies were certified by Medicare. The graph

below illustrates the steady growth of Medicare home health services.

. ..


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I

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.. .. !+WI--..,_ .--...,.., ,..--~--:'!- :----~:~-'r"- "--r-- -::;:----t_ 1.1 50UICII ...u. ea.. rt.-J" ....u ...nU he , Dece .....e - c ... ScracI".

Dec. fr. eM Ga.tlt. 0' t.'.lWHt

".,a

3

During the growth of Medicare-covered services, Medicaid coverage of home care became mandatory for all states in 1970. Medicaid home health care, while growing, represents a much smaller share of the total Medicaid budget. (5)
The availability of reimbursement resources created incentive for the develo~ent of services. The Omnibus Reconciliation Act of 1980 provided for unlimited home health visits, and broadened the potential consumer group by el iminating the requirement of a prior three-day hospital stay under Part A of Medicare and the tax deductible under Part B. This effectively expanded both the number of patients eligible for se'rvices and the types of services offered. While still requiring the need for skilled nursing services, the market for home health services expanded beyond the post-hospital convalescent patients and included others who might require intermittent health care services. Between 1981 and 1984, about 1,600 new home health agencies were certified under Medicare. Further expansion has been noted in the period following the institution of the Prospective Payment System for hospital care in 1983. The Prospective Payment System rewards the hospitals for early discharge and effectively limits the number of allowable hospital days for various diagnostic related groups.(6)
During the calendar year 1984, use of home health care visits increased 8% to 41 million visits nationally. This represents a substantial increase, but it is less than any year-to-year increase since 1980. (7) The interaction of changes in the health care system, population changes and economic incentives continues to affect the growth and development of home health care services.
C. Home Health Care Agencies Home health care is delivered by various types of agencies. In the period of expansion of the number of Medicare-certified home health agencies, twothirds of the 1~600 newly certified agencies were proprietary.(8)
Recent changes in the type of agency serving Medicare enrollees are noted in the table below:
4

Medfcare-cartifi. ~ n.altft 19fnCiIS-USA

.Ii Tm
Vfsiti",

Alln.

it

O'C . . . .r 1913 520 51

iJtIawCft rita S
-lS
-~

Oec"'r 1985 518 57

Icto....t.y.......
-II... ,,-,ital....
S. .

1.230

-2

l'

~

579 ..ttl

130

-S

1,217 ZO
1.280 129

~.tary
P,,1.,.ta "~ra11t"

991

+93

sn - .t2

t .9%7 831

O~r

q

5

I' Z'. TOTAL
SOURCE: He'A. 1_.

4.%51 ..OS

5.9'\

~. 1n Hotpital'. 141, 1 0.49.

As demand for home heal th care services increased so has the response of providers. A climate of growth has resulted in increasing number of patients served, although there are variations among the states. The dominance of government and voluntary efforts in home health care has decreased, and private non-profit, proprietary and hospital-based services have increased.

II. Reimbursement for Home Health Care Services Medicare is the principal purchaser of home health services, paying 67~of the total reimbursement received by agencies. Whi le the present outl ay of Medicare funds reflects an average annual growth rate of 24~ since 1968, these payments amount to only 2~ of the total Medicare budget.(9) The growth rate reflects the increasi ng numbers of Medi care enrollees, the number of persons adnritted for care, and the number of visits made.

Presently Medicare reimbursement rates are based on cost factors. There are proposa1s to move toward a cost minus 1~ formul a to meet the demands of deficit reduction legislation. Various types of prospective payment systems have also been proposed.(lO) The proposals point toward a general trend away from cost-based reimbursement systems.

In the search for reimbursement mechanisms. the Department of Health &Human
Services has contracted wi th ABT Associates to test various reimbursement systems for home health care~ Three methods will be tested in a demonstration program: a) rates per visit (by type of service);
b) rates per diem; and c) rates per episodes of treatment.(ll)
5

Medicaid payments for home health care have also grown. In Georgia in 1985, over 9,000 persons were served at an annual cost of $14.5 million. The average payment per recipient has increased 23~ since 1982. In 1985, 2.0~ of Medicaid recipients received home health care compared to 1% in 1983. The total Medicaid expenditures for home health care amount to 2.1~ of the total pa)11lents.(12)
The COll1llJnity Care and Services for the Elderly Act provides home delivered services to Medicaid recipients or those who would become Medicaid-eligible within 180 days of nursing home admission. Funding is provided under a federal waiver which allows Medicaid funding of home and community services. The Oepar'bnent of Medical Assistance (OMA) is responsible for setting the reimbursement rates and for payments to the service providers. It has been recommended that the Oepar'bnent of Human Resources expand conmunity care
service programs t.o serve the functionally impaired elderly who can partially
or totally pay for the cost of services.(13)
Coordination of services and effective case management are important to providing comprehensive and needed home delivered services. Commercial insurers are increasingly covering physician, nursing and treatment services in the home setting. Nationally 90~ of all Blue Cross and Blue Shield plans offer home care benefits to their local and national accounts, and insurers are encouraging the use of home care as a less costly alternative to hospital care. The Health Insurance Association of America is working to establish home health standards and standards for case management and continuity of care. (14)
The benefits of home care. can extend beyond reimbursement amount by benefiting the patient directly by reducing the stress and anxiety of hospitalizati on, reduci ng the inci dence of nosocomi a1 infecti on, and offeri ng opti ons for independent living that supports and extends the informal care system.
III. Cost Containment Factors in Home Health Care Revenues and resources are major concerns in developing home health services, as is cost containment. Unless overall health care costs are contained, the total resources for health care are strained.
6

Related to cost containment is the relative cost effectiveness of home care

"

.

when cOqJared to the cost of hospital and nursing home care. Home health

care can be demonstrated to offer savings when compared to fac; 1; ty-based

services. Even a relatively intense course of home health care, including

nursing, therapy and home heal th aides may cost $50 to $200 per day as

compared to the daily rate of $300 to $500 per day in a hospital or

rehabilitation facility.(15)

If substi tution of services contains cost, it can become a cost effective
measure only if it also provides therapeutic outcomes for the patient. In a
study of a large VNA, physicians estimated that home health care saved an average of 18 hospital days per patient, and an average of 15.4 days of skilled nursing facility care. Average savings are estimated to be 15%
higher for privately insured patients than for Medicare patients, which tends
to support observations that privately insured patients are likely to be
younger and more likely to be recovering from an acute illness than an older
Medicare recipient with multiple and chronic problems.(16)

Such studies encourage the use of home health care as a cost effective al-
ternative to more costly care, and assume that outcomes for the pati ent are
appropri ate. Another study exami ned patterns of use of home health care by the elderly in an area where professional assessment of need was the only
criteria for service availability. It pointed out that only a small minority
of the elderly were actually admitted to home health .care. The need for home health care was found to be related to advanced age and difficulty with instrumental activities of daily living. Such studies re-focus concerns about home health services being expensive 'add on' services, and suggest further
areas for research on the.assessment of need for home health services.(ll)

Public policy on reimbursement shapes in large measure the cost of programs
where the majority of the costs are paid for with government funds. The
limitations of such programs can limit the use of home care services. It has been estimated that nearly half of the disabled elderly paid for some part of their home-based care, spending an average of $164/month out-of-pocket. Since Medicare home health benefits paid only for medically related home care, it was found that two-thirds of the total private expenditures for
7

home-based care went for assistance that was not provided by nurses or home health ai~_~. - The amount of payment out-of-pocket was directly related to the health status of the patient and prior medical service used. As these services .,.re used by persons also at high risk of nursing home admission, the home care services were viewed as comparatively cost effective.(18)

To develop data for use in forming cost containment public policy, the Subcommittee on Health' and Long-term Care analyzed 1982 home health care data. The survey describes a profile of an average home health agency operating in 1982. The data are summarized below.

sun

45 Ilnoua

2.7.9 Full e1M .qW..,Udca
7. 7 rrz'. UII4e~ COIlC~acC lIT. OT. &. st

77% of &ll a.eacy ...loy... d1~ecc rr1CI

2.3% of all a,lacy ...lo,. ad-in1.C:ac1oIl &. su~90rc S.rr1CI.

8UDG1't

52% L910-31 1Ac::e... 1D re.,..... 67% of rIT. . . . VII~a ltaiU.cua 43% of a.elld.a. had sur,lue F!' SZ 41% of enc1a. h&ci 4af1cic F!'S1
6S% of a.,.ra.e asancy F!'SZ bud.ac w.. pa:lollllel co.c.

CLIElIt I0PUUnOtf A.,.r a,ancy s.rv.d L.407 eliallc, (UD4u~l1cacad)

Av.r.,e elianc rlc.iv.d 9.6 Ylli-1 p.~ a~aion

I

ll.2% ~sa 4564 36.0% a,. 65-74

I

2.9.2% a,a 75-84

totAL 75.2% 6S y.ars of a,. or o.,.r

DIAGNOSIS

~st FUQIJIHT DIAGNOSIS:
Di.b.ta ny~.rcauaioa. neare/circulatory probl....
e.rciac.a. scroKa racov.ry. areh~it1a/joil1e probl....
I
r.~~i~.cory probl.... bowel/blaGdar. skin conGie1on.

CASE FLOW

ha.,. 48.2% r.fa~al. fra. nOlpieals

46.3% elilnc.

ea~a elra1l1acld b.caue. eh.y a~e

salf-.ufficilnc

l8.9% elilnc. eera1naced ~ue co no.~ieal aaission

, AGENCY

Av.ra,e A,ency l3.530 no. . Yisies

w.r. RN and n08l naaleh aid.

Chi most frequ.ne Yisies

~v.r.,a rr.! RN makl. 353 ho.. Yisies annually

rr.! aHA maKa' 590 ho.. Yisies annually

~vlra,. a,lncy sp.nds l8.36 hours cre.cin, a cliene/moneh

Aver.,. eliene eoses/moneh - S352.26 P'Y'SZ

i

Avera,a elienc receiv,s 9.6 Yisies cOle $364.32 per encry

I

AVlr elilnt plr year eose - S728.64- Sl.092.96

I

SOURCE:

aapore by cha Chairman of eh. Subcomaieee. on Rleh anG
~on,-eera Car S.l.ce Co.-1ce on Alin,. aousa of alpres.aeaeiv 8ui14in5 a ~on5tera Carl ['oliey: Roel Care aad ?!plications. Dlceao.r 1984.

8

The composite data are useful in establishing parameters for the use of home health services and identifying both patterns of care delivery and reasonable estimates of cost to the patient and the reimbursement agent. Cost containment efforts in home health, to be effective, should address the assessment of individual need for services, demand for services as reflected in actual use patterns, referral and information patterns, and the usefulness of home hea1th services as an alternative to insti tlttiona 1 care. Strategies which include the examination of the criteria for efficient and productive delivery of services, as well as the effective outcomes of home health care in meeting documented patient needs will ultimately affect overall health care cost containment.

IV. 9uality of Care Issues

Issues involving the quality of home health care are closely related to

issues involved in cost effectiveness. Ultimately the outcome for the

consumer is the primary evaluative criterion in both issues. In 1977, the

National League for Nursing issued criteria and standards for accreditation,

and more recently has issued a call for 'consumers to speak up and demand

~-,

"

accreditation of home health agencies to safeguard their well-being'.(19)

Licensing laws for home health agencies vary considerably among the states,

and the administrative structures of licensing agencies are not organized to

be immediately and directly responsive to the individual consumer. Ulti-

mately the quality of the services provided is the responsibility of the

agency and staff, the poli ci es and procedures whi ch govern the deli very of

specific services and the development of the specific plan of treatment.

On a national level, Medicare Conditions for Participation and related standards are the foundation for service delivery ; n certifi ed agencies. Onsite inspections and reviews address key areas that promote -quality of care. The areas surveyed are as follows:
1. compliance with state and local laws, 2. organization, services and administration, 3. professional personnel, . 4. medical plan of treatment, 5. skilled nursing servir.es,

9

6. therapy services, 1~ medical social services, 8. home health aide services, 9. clinical records, 10. evaluation.
In further analysis of data from specific agencies, the composite data are reviewed and compared in a quarterly report, 'A Comparison of State, Regional and National Deficiency Patterns in Home Health Agencies'. Each area reviewed relates to the overall quality of the home health care services provided, and evaluates the treatment plan as it relates to the actual services delivered. The lOth condition - termed the evaluation - refers to the agency's plan for ongoing evaluation and assesses the extent to which the agency's program is appropiate, adequate and effective. This condition also has two related standards which divide the evaluation into the policy and administrative review and the clinical record review. The evaluation provides a mechanism for quality assurance of all aspects of the home health agency. A condi ti on 1eve1 deficiency prec 1udes certi fi cati on unti 1 the conditi on is corrected. At the standard level, the agency can be certified if there is an acceptable plan of correction. (20)
Utilization review is another mechanism for quality assurance that operationalizes the Medicare conditions. Appropriate standards, review schedules and criteria must be part of the written policies of.an agency. The ongoing utilization review process provides the mechanism by which care given and documented is measured. There are many models for utilization review, and the model chosen should support state and federal standards, and provide evaluative data for self-assessment.
The most important component of quality assurance from the point of view of the consumer of home health services is the knowledge and expertise of the staff actually delivering the services. The personnel policies covering the employment, supervision and support of the staff form the foundation for the delivery of high quality home health services. The licensing and certification standards address specifically the duties of the registered nurse, and focus on the leadership functions utilized in the assessment of patient
10

needs, the plan of care developed and the provision of direct services. The registered--- nurse is also involved in the continuing education of paraprofessional personnel and the supervision of auxillary personnel.(21)
Contributing to the effective use of qualified staff is the staff development program of the agency. The American Nurses Association defines staff development as the 'process which includes both formal and informal learning opportunities to assist individuals to perfonn competently in fulfillment of role expectations within a specific agency'. Resources both within and outside the agency are utilized to facilitate the process.(22)
In a recent study of 237 home health care services in California, the administrators in those agencies were asked to rank the skills required most often of staff nurses. They ranked the following in order: client teaching, client interviewing, physical assessment, IV/perenteral nutrition, counseling, enterostomal care, physiotherapy and rehabilitation, chemotherapy and mechanical ventilation. (23) Additionally the nursing staff were asked the roles they wanted to upgrade. They ranked the following as important: health education, assessment of client/family health problems, coordination of client care, planning and evaluation of client care, supervision of paraprofessional staff and advocacy for client and family.(24) The breadth of their responses reflect the requirements for the expanding scope of home health care services.
The parameters of a Component Plan do not include the development of complete standards for qua 11 ty assurance in home health care. The plann; ng process does include the development of standards rel ated to qual i ty of care which support the requirements for licensure and certification.
11

v. Home ~~alth Care in Georgia
Home health care is a vital component of the total continuum of health care services. In planning for the future development of home health services, several topics were reviewed and related data were analyzed to assess their impact upon the use of home health services. The topics include:
a. agency designation b. patient population served c. visits per patient d. use patterns, urban/rural e. referral patterns f. Community Care Program g. financial accessibility h. range of services i. cost variables.
The planning process included a review of the literature, a survey of various states co~utation of need, and analysis of data from several state and federal sources. A Working Paper on Home Health Care: The Nation and Georgia was prepared and a 17-member Task Force was formed. (Task Force membership list, Appendix A.)
The following section contains a topical summary of the data related to the nine topics reviewed and considered by the Task Force. Comparisons of Georgia data and national data are made where appropriate to establish utilization patterns.
A. Agency Organization There are presently 73 certified home health agencies in Georgia. A map and accompanying roster is found in Appendix B, identifying the home health agencies and the counties they serve. There are 19 counties served by only one agency. All counties have basic home health services available.
When the overall patient-to-population ratios for each county were compared, 63% of the counties served by one home health agency had use
12

rates below the state average of 7.15 patients/lOOO population. Only
38.5%- of the counties served by two or more agencies had patient-to-
population ratios lower than the mean.(25)

Specific agencies are organized along various lines and receive

support from many sources. The table below notes the number of each organi zati ona1 type in Georgi a and the percentage of the total; n
Georgia and the U.S.

eo.. Mea1care-C.~1fiea

aaalCA AlenC1e.

lD.!

1986
Geo~I1&

s%etoonceaal

%toca1
~

VoluaCU1

1

1. It

8.7

~e~c

1

1..

.9

CoaDcy

6

8.J

20.10

Babab-Oaeci

J

SlIl..... ao..J.cal-baHcl

8

11.0

21. J.

2.%

m,m.eCU1

23

J1.J

J1.J

~....u NoD-,nUc

34

106.J

13.9

OcAa~

.08

SOUICI: IIC7A"DUI. c:.orl1& !ta~care-e.~1f1ecl ...~... May 27. 1986.

Private non-profit and proprietary agencies predominate in Georgia. There has been considerable growth nationwide in proprietary agencies, noted at 93~ in the two year period between 1983 and 1985.(26) There was considerable 'Iariati on in the number of patients, number of vi si ts and range. of services offered by Georgia agencies, regardless of organizational type.

B. Patient Population
The overall use of home health services is determined in part by the characteristics and requirements of the population. The elderly are the major consumers of home health services. In Georgia, 80.5% of 'persons receiving home health services were 65 years of age or over. The remaining 19.5% that are younger patients represent a sizeable group that is likely to grow as home care is perceived as a clinically and technically viable opti on, and as more thi rd-party payors encourage the use of home health care.

The population 65 and over constitutes 9.8% of the total 1986 Georgia population. Projections put this ratio at 10.2% by 1993, a 14.7% increase.
13

This increase will likely result in a greater number of people ~ho could benefit-from home health care, but the percentage increase is in line with the expected total population increase of 11.87~ for the same period.
Of greater significance to health care providers is the expected 27~ increase in the fra 11 el derly over 85 years of age, who tend to be the greatest consumers of health care. In real numbers, the projected statewide increase in persons 65 and over results in an increase of around 88,000 persons, with about 12,400 persons age 85 or over.
This demographic trend requires planning to develop services to meet the projected needs of the increased elderly population, but the incremental nature of the increase is not likely to require a reorganization of the health care delivery systems. There is a tendency toward increased use of . home health services with advanced age. Nationally 9~ of the Medicare population is 85 years or older, but this population uses 25~ of the Medicare home health services.(27)
The use of home health services by younger persons is expected to increase, and as reported earlier, younger patients are more likely to be recovering from an acute episode of illness and receive care for a shorter period of time.(28) A study of findings from the National Medical Care Expenditure survey reported on the growing number of persons who are ,"elatively healthy and younger than 65 years of age and noted they receive two to four visits duri ng a year. (29) in contrast to the mean of 29.7 vi si ts per pati ent in the Medicare patient population.
Programs are also bei"9 developed to serve the needs of children with chronic illness or disabi 11 ty, as well as programs which are governed by specific protocols for specific health care programs such as chemotherapy and nutritional support, newborn and family care and hospice care. Demand and reimbursement policies are likely to influence further development of programs. (30) The entrance of HMOs and PPOs into contract arrangements for home health services will also be a factor for utilization in the future. (31)
14

c. Visits per Patient
There is .c_onsiderable variation in the number of visits per patient according to the Home Health Agency Annual Ranking Report for 1985. The number of visits per Medicare patient ranged from a low of seven to a high of 188 visits. The average visits per Medicare patient was 30.75, with a median of 28 visi ts per patient~ Statewide, the average number of vi si ts per patient for all patients was 29.6 (as reported on the SHPA Home Health Questionnaire for 1984). Nationally, the average number of visits was 29.7 ; n 1984. (32)

While it might be expected that the number of visits per patient would increase with age, this was not apparent in Georgia as is illustrated in the table below. There is a small incremental increase noted in HSA V.

. . . IIIA1.D AGIICr nsns Pee PAnarr
I, AGI. " lIlA l'"

A. . C&C. . .rtl
~ lIMer U
. IIID ",.14
=[J 7" "I' Tocal aU a,

:0

,t
KSA [ , II
sana:

KIA ttl

lIlA I'

1'" aa. IleUcll ".-y S_,. Stau lteaJ.th Pla...1IIC "'-.,

..I ...
::% "0'-
IfS" 'lUI

Data on patients and visits per patient by age group ;s not available for each county. The tabl~ below illustrates the overall sJistribution of patients by age for each health service area.

15

PA%UI'rS by AGI

RIt'

f!llctu 6~

6.5-7t.

75 , \1!

t " tI tU

t.96
3.~~

951 5.128

2,323
8.477

tv

8~O

Z,020

Z.849

'1

816

979

1,1018

n

771

Z.404

L.870

'ltI S'l'AtE:

-L.221
3.016

-L.91'
L3.J97

- -2.930
L9.367

': Stac. !oCal. ,9. ~

n ..s

(,8. J.

"1. iOUllC%: itac. ~~t: ?laaD1ll1 _~.IlC~. :l1na

L986.

t o cal. 3.710 17.t.60 5. H9 3.213 5,0.'
-6.073
'.l.~SO

D. Use Patterns - Urban/Rural Differences in urban and rural use rates were examined by comparison of counties in which fewer than 7.15 patients/1000 were served by home health care. In urban areas (Metropolitan Statistical Areas), 63.2S of the counties had use rates below 7.15 patients/lOOO population. Correspondingly, in rural areas, only 40.5S of the counties had use rates below the average. It is acknowledged that services are sometimes more difficult to organize and deliver in rural areas, but the differences in level of service did not appear to be a factor resulting solely from an urbad or rural designation.

E. Referral Patterns The accessibility of home health care services is also a function of established referral patterns and knowledge about the services available. Until 1981, prior hospitalization was required as a condition for Medicare coverage. Presently the need for service has to be medically necessary and physician directed. Hospital referrals, however, still account for a sizeable number of the p'atients receiving home health care. Nursing homes represent a smaller proportion. Discharges from hospitals and nursing home to home health care are noted as follows:

16

saQ1c&1 01ac:Aule. co sa.. lIuJ.CA Cue

BS.\I I tI tII tV
11
71 nI
STAT!
SOUI.CI:

I au.
lafena.la
L984

sa.,1caJ.a V1cA
bbna.la co
D6/!ocaJ. Ban.

I au.
!lafanal.
L98'

312

L/%

3~

145

8/%t.

~%O

7.31%

34/54

~.al4

L.665

71ts

L.714

d64

L6/2.'

,89

~ .577

Ll/Z6

~.;69

3.348

L4/Zl

~ .J68

L6.163

H/l20

Lo .397

16.163 t 4l.280 ~ ~&c1auc 39.15%
ao.a Ba&lCA Alauc:y QueaC1oaD&1ra. L984 met 1985
Scaca lIuJ.cA ~1aDD1A1 Aleuey

aoa,1C&1.a 'nc:
bhn-ala co ~'t'Oc&.1. i!ou.
1/2 LO/Zt. 31/54 5/18 ~51 Z7 ~JI 26
~1/2l
37/172

1984 Iafeft&La co S - lIuJ.cA Cue - !uUq . . . .

,'.'

IRA labEW

lfua~ a.u r."oft1q aM
Iabmalf/!osaJ. lfusu. sa...

t

l21

4/6

II

83

7/44

III.

553

26/74

IV

94

18/3l

7

1;3

~6155

VI

7l

LO/40

VII

L6l

19/35

S'LU!

L.i46

LOO/279

Li46 - 4 L. :80 :mA. ;l&Ci.auCS ~.,'%

SOtJlC!: :to..!!aa.1.cA AI-CT Qua.c1OIUI&Ua. 1984. uut 1985 Stace aa&ltA tI"M'DI .\CaDC.,

As noted, all hospitals did not report home health. agency referrals so the total numbers may be higher.

F. Community Care Another referral patterrJ is a function of the operation of the Comnunity Care and Services for the Elderly Program, which is designed to serve persons who might otherwise be expected to require nursing home care if assistance on a regular basis is not provided. The persons receiving services I1IJst be in need of services, have an impairment of a chronic nature and be likely to need the services for six months or more, and be a Medicare patient or expected to be eligible within 120 days.

17

. ' : ..~.'

. In the Fiscal Year (July-March) Statewide Summary issued April 24, 1986 by the Co~ity Care Services Program, it is noted that a similar percentage of persons were referred by hospitals to community care, when compared to the home health data reported previously. Referral sources for assessment are presented below:

;m.r ASUSSllD'l' & UAS.SUSIIDT - .

1985 - :iAIC2l L986

:taianw_ :~oa:

# C11aucs

: ~f ~oc&L

SaU

34

.8

:'amly

54'

5.2

1r:Laa4

119

1.2

ao i . ca.1.

3.243

31.0

~.D.

475

S.O

DieS

37%

4.0

SVita
one'&"
!OUL

3,.54'
~
10,,311

34.0
-L7 .5
99.7
(4ua co :ouaAiAl)

S01JI.CI: C~CT cu. S.n'1.c:a. S~. n: 1986.

The actual number of clients reported may duplicate home health agency clients, as some persons receive home health services as well as home delivered services under the Community Care program. The data are presented to illustrate likely referral patterns. The numbers referred from SNFs reflect the mandatory assessment required and often not requested until Medicare eligibility needs to be established. As knowledge of services becomes more generally disseminated, self and family referrals might increase.

In a survey conducted by the National Association for Home Care, an assessment of a~reness and attitude toward home care and hospice services was made. It showed that tne elderly, hispanics, blacks, low-income groups and women were most aware of services. Further, awareness of home health care was most likely the result of useage of services by a family member. Only 18~ of public awareness was attributed to health care professionals.(33)

18

G. Financial Accessibility Financ1al.._ac;cessibility is a determinant of use of home health services. Medicare and/or Medicaid or third-party reimbursement make home health care possible for a large number of persons. However, as was noted earlier, out-of-pocket expenses can be considerable and limits on coverage can result in limited financial accessibility. At the request of the Task Force, the following data were compiled on indigent care.

tiSAI

In41IUC ?sc;'aacs

: !'oca.1. :iSA

'11.1c.

1 51 II

loa,

L2.3

L4.Z07

a.~

III

L.Ja3

7.9

20.43' '"

3.J

tV

75

L.J

702

.4

11

L4i

4.6

95:

.9

VI

63

L.Z

L .L.58

.6

VII

378

.su:rz 2.532

6.2

7.636 -

3.10

6.L

1o' .L4O

3.6

'" 941 of !SA !0C&l - ~ of AclaDc&
- '4% of !SA !0C&l - a.aJ.CA D.,u~c llCS - lJaycro' Jan,
SOUICI: ao- a.&1.ch AI.aCT Qu..c101111&i.ra L984
Scaca ae&1.cb Pl&DD1A1 AI.ac~
H. Range of Services

To be licensed and Medicare-certified, a home health agency ITIJst provide

skilled nursing services, and at least one other service. All agencies in

Georgia provide skilled nursing and home health aide services. The

availability of the full range of services in an area is the choice of the

specific agency. The choices are often influenced by availability of the

professional staff to provide the services, as well as the demand for the

services.

The table below illustrates the distribution of services by category as a percent of the total vis~ts made in an area.

VISITS by SERVICE - PERCENT of TOTAL VISITS

II sAl

Toeal Visits

Skilled
Nuninl

HOM flea Lth

Med/Soc.

P. T.

Aide

n.T.

Svcs.

Speech

Other

I l- II

Lft5.645

30.1

8.8

49.5

11.4

O. L

2.0

9.1

III

384,275

34.9

D.8

4&.9

1.8

0.5

1.1i

0.5

IV

157,509

38.]

7.4

52.2

n.7

0.1

0.4

0.5

V
vr
VII STAT" TOTAL

LO L,146 L87,427 227 386 1.2J3,388

32.6 46.6 45. ] 38.2

L.2

54.4

4.11

47.6

-3.0
8.8

37. 1 4n.9

0.7

0.2

n.o 0.1

Q.2

0.3

n.8

1.3

0.7

0.0

0.8

0.0

o.~

-l3.6

1.1

3.9

Iln lIoe proVi.de ~he serVice.

,nIlRCF.: 19114 Home Hea 1th Allency (lUll .. nonnll ire. StA ee Hea it h ? iann in~ Allencv. "ll r i l l 911".

19

While there are not great variations noted in each area, availability is 1im; ted by the services provided by a si ngle agency in an area served by only one agency. An agency may contract for a specific service, but all agencies do not actually provide all services. The percentage of agencies actually providing services in each category is noted in the table below.

RCHE REALTH AGENCIES SERVICES by CATEGORY

T"tll l Agencies

Ns~.

HH Aide P.T.

O.T.

Speech

5.\01.

7J

73

73

70

46

58

53

,~ elf Tocal

lOOX

lOOX

96%

63%

79%

73%

SOURCE: HCFA - Medicare-eerc1fied H.H.A - May 27. 1986

Equip. ~.D. Guidance

LOX

l.4%

The range of services is also likely to be influenced by staffing patterns. A specific ratio of staff per patient is not prescribed by Medicare Conditions of Participation, but an R.N. must make an initial evaluation visit, initi ate the plan of treatment, reevaluate the patient I s treatment needs regularly and coordinate services. Additionally, the nursing supervisor must be available at all times during operating hours to participate in all activities relevant to the professional services provided, including the qualifications and assignment of personne1.(34) Consequently, the number of R.Ns engaged in the delivery of services is of particular interest. There is considerable variation in the ratio of R.Ns per patient. All patients may not receive the direct skilled nursing care, and the supervision and assessment required makes the number of patients per RN an important consideration that supports the range of services offered and relates to the likelihood of adequate coordination of serv;ce~.

The table below indicates the range in the ratio of patients per RN and the average. These ratios also have implications for the cost effective management of home health care.

!!.U I 6r II
(It IV
V
VI IItt SOURCE:

PATIENTS per R.~.

Range Paciencs/R.N.

Avera!e Paciencs/R.~.

29-13Z

69.42

14-263

95.3 1

16-155

71.44

38-l22

72. l2

Z2-110

53.7

ll-3lJ

1;).2

1984 Home Heillth "~encv QlIestionnai["e Stllte Health Pl"nnin~ A~encv - ~eptembe[" 198~.

20

The avai-1ability of a full range of services makes home health care a viable health care option, but the complete assessment of patient needs, thoughtful planning and delivery of care, and careful coordination of services is paramount in assuring optimal patient outcomes. The establishment of realistic treatment goals for each patient is. the foundation for efficient utilization of services and ultimately cost effective care.
I. Cost Variables The costs associ ated with providing home health services can be divided into administrative (input) costs and direct care (output) costs. The relationship of these costs ultimately determines the financial viability of an agency. Reimbursement for Medicare and Medicaid is presently costbased and is reflective of average costs, so both types of costs are factored into the rate setting, subject to certain caps.
Home health services are highly labor intensive and labor costs are most significant. In a study of 73 home health agencies, regression analysis showed a strong relationship between total cost and output levels which in this study was 1imited to the number of skill ed nursi ng visits. In the study, the optimal production point was about 7,200 visits annually for skilled nursing visits. Output was seen as a more important variable in economi es of scale than case mix or di agnostic characteri stics of the patient population. (35)
The cost of nursing staff services is seen as a relatively fixed cost in that home health agencies are generally small purchasers on the labor market and can have little direct impact on the wage standards in an area. The patient-to-registered nurse ratio, as noted earlier, can affect the output level for both nursing services as well as home health aide and other professional services.
Analysis of the relationship of the size of an agency to the average cost of a visit showed some relationship. In the correlation analysis, when the smallest agencies (below 2,000 visits) and largest agencies (above 40,000 visits) were excluded, the lowest mean costs were found in agencies with an
output of ro,ooo visits or more. Conversely the highest mean costs were in
21

agencies reporting 10.000 visits or less. The relationship of size of agency and cost of a specific service was highly variable and may be more affected by local labor costs. volume of use of a particular service and patient-to-staff ratios.
The Task Force recommended at least 1.000 visits per month as a desired output level that would produce financial viability and reasonableefficiencies. Viability of an agency. especially concerning start-up cost. was also viewed as important in overall cost containment efforts. It was recommended that adequate capital be assured so that a new agency coul d operate and become financially viable.
VI. Estimation of Need for Home Health Care Services The work of the Task Force focused on the review of data related to the utilization of home health services and consideration of methods for determining need that was based on actual use patterns.
A review of the criteria to establish need in selected states was conducted. The criteria reviewed were demand-based. focusing on utilization and projected to a present or future population. Four variables were included in the majority of methods:
1. the proportion of the population over and under age 65; 2. the number of acute care hospital discharges to home health care; 3. the number of nursing home discharges to home health care; 4. data supporting use patterns as expressed by patients served per population in a given service area.
The Task Force reviewed .the data related to utilization of home health care services in Georgia and considered several alternatives to .compute an estimation of need for home health care in the future. The methods for computing need contained four basi c elements that were vi ewed by the Task Force as iqJortant contributing variables reflecting demand and probable future use of home health care services. They are:
1. the rate of patients served per 1000 population; 2. a calculation of expected home health patients based on the most recen~ use data and applied to the population by age;
22

3. an estimate from home health agencies of the portion of the total patients referred from hospitals; 4. an estimate of the total hospital discharges to home health agenci es.
The unmet need in a county is determined by the product of the need as determined by the formula, minus the actual patients served by home health care agencies as reported on the most recent Home Health Survey.
The designation of need is the basis for planning for the development of home health services in Georgia. Further criteria for Certificate of Need for home health agencies are found in the section, Recolllllended Guidelines for the Development of Home Health Care Services.
Method Computing Need for Home Health Care The use rates for home health care services are established by analysis of the data from the most recent official Home Health Agency Survey as edited and compiled by the State Health Planning Agency.
Total County Need = (C - A) + B
Where
C = Projected home health agency patients in the county by age cohort
(state rate of home health agency patients per 1000 population X projected county population by age cohorts in thousands) A Projected number of home health agency patients in the county to be referred from hospitals (the total number of home health agency patients from C above X the state percentage of home health agency patients who were referred from hospitals) B ~ected number of hospital discharges to home health in the county (number of projected hospital discharges in the county X the state percentage of hospital discharges to home health. The
number of projected hospital discharges = the county discharge
rate per 1000 population X the projected county population in thousands.)
Specific steps in the method for computing unmet need for home health care are as follows:
23

,.:,,,:
1. Project the number of home health agency patients in the ~ounty by
age-~ohort.
a) Compile data from the most recent official Home Health Agency Survey to determine the state rate of home health agency patients per 1000 population in age cohorts (under 65 and 65 and over).
b) Compile data from OPB population projections for the portion of the county population in each age cohort.
c) Multiply the state patient rate for each age cohort by the county population for each age cohort in thousands.
d) Add together home health agency patients in each age cohort to determine the total number of expected patients in the county.
2. Project the number of home health agency patients in the county who were referred from hospitals
a) Compile data from the most recent official Home Health Agency Survey to determine the state percentage of home health agency patients who were referred from hospitals.
b) Multiply the state percent of home health agency patients referred from hospitals by the projected total number of home health agency patients in the county, as derived in Step 1 above.
3. Pr~ect the number of hospital discharges to home health in the county.
a) Determine the number of hospital discharges in the county by multiplying the county hospital discharge rate from the Georgia Hospital Association Patient Origin Study by the projected county population in thousands.
b) Compile data from the most recent Joint Hospital Questionnaires to determine the state percentage of hospital discharges to home health.
c) Multiply the state percent of hospital discharges to home health by the total number of hospital discharges in the county.
24

4. Compute the total county need for home health services. --a) Subtract the projected number of home health agency patients in the county referred from hospitals (Step 2) from the total projected number of home health agency patients in the county (Step 1). b) Add the projected number of hospital discharges to home health in the county (Step 3) to the results of the calculation in Step 4 a.
5. Compute the total county unmet need. a) Determine the actual number of patients served in the county from the most recent official Home Health Agency Survey. b) Subtract the actual number of patients served in the county from the total county need derived in Step 4.
25

VII. Goals, Objectives and Recommended Actions
Goal: ............ Home health care services of high quality available and accessible to persons who need such services and delivered in a cost effective
manne~
Objectives: 1. The planned development of home health care services in Georgia based on the guidlines detailed in this Component Plan.
2. The cost effectiveness of home health care established through study of patient outcomes.
3. The coordination of health care services through effective crosssystem planning and service delivery which includes the appropriate use of home health care.
4. Development and application of national accreditation standards for home health care.
Recommended Actions Home health care services offer many options for the delivery of health and medical care. Home health care also supports the consumer of health care services in maintenance of personal autonomy in the choice of health care and related services to meet specific needs.
Providers of home health services are in a unique position to develop opportunities to deliver a variety of health care services in the home of the identified patient, while viewing the consumer in the larger context of his/her social system. This position affords numerous opportunities to develop 'user friendly' home health services that accentuate a person's self-care resources, extend the reciprocal resources of the family and social network, while serving the health care needs of the patient and extending the outreach of more traditional health care services.
26

Demand for home health services is a result of the interaction of many of the variables discussed in this component plan. Demand is likely to grow, however, in direct proportion to the actual and perceived effectiveness of home health care to the consumer, and the 1eve1 of awareness of the availability of effective services.
Providers of home health services can furthe~ the demand and develop services by the documentation and dissemination of knowledge about home health services. Such a data base might include:
1. development and evaluation of patient assessment tools; 2. documentation of treatment and services which provide the best outcomes for the consumer; 3. the cost effectiveness of such services; 4. consumer satisfaction and the acceptability of home delivered services.
The effectiveness of home health services will ultimately determine the long-range acceptabi 11 ty of such services. Cost effectiveness of home health services and overall health care cost containment supports consumer interest - they do not mandate acceptability and growth.
The future development of home health care depends on quality as well as quantity. It is incumbent on the home health care industry to:
1. document the cost and consumer effectiveness of home health care services; 2. support the development and application of accreditation standards to assure uniform standards for care to protect the consumer; 3. develop relationships, administrative and clinical, with health care providers and related health care systems that support the interests of the consumer; 4. develop models for team work and coordination of care to best serve the consumer; 5. confirm home health care as a practice domain for health care providers by establishing clinical liaison arrangements with educational institutions.
27

-'::-.'~"'"
VIII. Recommended Guidelines for Development of Home Health Services
Definitions: 1. 'Home health agency' means a public agency or private organization, or a subdivision of such an agency or organization, which is primarily engaged in providing to individuals who are under a written plan of care of a physician, on a visiting basis in the places of residence used as such individual's home, part-time or intermittent nursing care provided by or under the supervision of a registered professional nurse, one or more of the following services:
a. physical therapy b. occupational therapy c. speech therapy d. medical social services under the direction of a physician, or e. part-time or intermittent services of a home health aide.
2. 'Geographic service areal is a grouping of specific counties that is comprised of the county in which the headquarters of the agency is located and some counties contiguous to that county. For purposes of establishing a service area for a new home health agency, or for an expansion of an existing agency, the service area will be the county in which the agency headquarters is located and any counties contiguous to that county that show a need by the State Health Planning Agency's need formula.
3. 'Sub-unit' is a semi-autonomous organization which serves patients in a geographic area different than that of the parent agency. The sub-unit by virtue of distance between it and the parent agency is judged incapable of sharing administration,. supervision and services on a daily basis with the parent agency, and must, therefore independently meet the Medicare Conditions of Participation for home health agencies.
4. 'Sub-division', for purposes of this Plan, means any organizational part, sub-unit, segment,. branch, or section of an existing home heal th agency.
28

5. Offi ~j a1 State Health COlJ1)onent Pl an' means the document re1a ted to the above-named services developed by the State Health Planning Agency, established by the Georgia State Health Policy Council and signed by the Governor of Georgia.
6. 'Specialized high technology services' refers to those medical procedures which demand a high level of professional patient assessment and evaluation skills, procedurally specific training and staff development to assure the safe delivery of the service and the desired therapeutic outcomes for the patient. Such services are provided by a registered nurse, and may include - but are not limited to - nutritional support, intravenous therapy including the administration of antibiotics, pain control medication, specific electrolytes or chemotherapy and respiratory support. Such services are performed under a physician-directed plan of care for patients who are carefully selected to be appropriate for the delivery of such services in the home.
7. Headquarters county', for purposes of this Pl an, means the county in which the headquarters of the home health agency is located and the county to which all other counties served by the home health agency are contiguous. This definition applies to all agencies henceforth established, expanded or reconfigured by moving the headquarters county.
Standards: A. A Certificate of Need for a home health agency will be required prior to the establishment of a new home health agency, the expansion of the geographic service area of an existing home health agency, or the moving of the home health agency headquarters from one county to another.
B. Ava l1ahl1i ty Cri teri on I - Need for Servi ce Standard 1: A new or expanded home health agency will be approved in a geographic service area only when the following conditions are met: ( 1) need for a new or expanded home health agency ina defi ned geographic service area shall be established by the need formula
29

detailed in the most recent official State Health Component Plan on Home Health Care Services; and
(ii) an agency that has been in operation in a county for one year or less will be presumed to have operated at the mean state patient rate until the agency has been in operation for a full year, or until the subsequent official State Health Planning Agency Home Health Agency Survey data are available, whichever is less; and
(iii) the need for a new home health agency in the service area proposed by an applicant will be considered when the identified unmet need in the proposed geographic service area is sufficient to generate an expectation of at least 1000 visits per month, computed at the State mean number of visits per patient, and;
(iv) the need for an expanded home health agency to serve an additional county(ies) contiguous to the headquarters of the applicant agency will be considered when the unmet need in the proposed county(ies) is sufficient, in the judgement of the State Health Planning Agency, to justify the presence of an addi tional agency to serve the county need, and there is no reasonable expectation that the agency(ies) serving that county(ies) can or will meet the need; and
(v) any sub-division of an existing home health agency that proposes to be established as an autonomous (new) home health agency is subject to Certificate of Need review. Need for the establishment of the proposed new home health agency must be suffi ci ent to generate the service volume as described in (iii) above, by reflecting the number of patients actually served by the existing sub-division in the counties proposed to continue to be served by the new agency plus the unmet need [(b) 2.0] or [(b) 3] in any additional proposed county(ies) contiguous to the proposed headquarters county; and
(vi) the remaining portion of the home health agency from which the sub-division proposes to establish autonomy must have been actually
30

providing service in the remaining counties at a sufficient 'level to meet-the minimum level of 1000 visits per month, computed at the state mean number of visits per patient.
Rati onale for Standards Standards (i) and (ii): The need formula is the result of the work of the Task Force on Home Health Care which convened from June through July 1986. The concensus was that the number of patients actually receiving care is the best measure of availability. These estimates were based on actual use data. At this point, it is not possible to prescribe optimal levels of service availability, but it is possible to base need estimates on recent utilization patterns which will be updated as new information becomes avai 1able via the bi -annual Home Health Agency Questionnaire.(35)
It is acknowledged that supply often influences demand and the application of the need estimate is designed to be responsive to local use characteristics, population characteristics, and project estimates into a reasonable future (three years). Utilization data provide important information and the planning process is better served when this information is used in a need approach.(36)
The cal culation of unmet need and allocation of agencies to meet those needs supports the planned growth of home health services while not supporting inflated supplier-induced demand. The utilization based approach to predicting need is reflective of other operative considerations such as reimbursement, referrals, market and demand,
and would be expected to remain responsive to these other health care
variables if the use data are updated frequently.
The geographic service area is a basic tenet in the application of the need formula. The Task Force agreed that need should be demonstrated on a county-by-county basis, and that the overall service area for a new or expanded home health agency would include the agency headquarters plus any contiguous counties that show a need according to the need formula. Maintaining this integrity of the
31

service area was considered amd a major premise in the development of the 'standards in this Plan. Also, integrity of the service area should be upheld in application of these standards in development of new or expanded services.
Standard (iii): The projection of the expected number of needed visits by a proposed agency in a geographic service area is based on the calcutation of patient need multiplied by the state mean number of visits per patient as determined by the latest official Agency Survey. The relationship of size (number of visits) to cost variables is discussed in Section V of this Component Plan. It has been said that 'volume drives home care' and that a stabilized patient volume is essential for effective and efficient operation of a home heal th care agency. (37) It is further noted that patient volume is critical to ensure survival in the short and long run, and to enable the necessary specialized services.(38)
Standards (iv), (v) and (vi): An expansion of an agency, or the estab1ishment of a separate new agency in a previ ous ly underserved county that shows an unmet need is similarly subject to the expectations of service volume. The total unmet need identified must be of sufficient magnitude to justify a new home health agency and a need that could not reasonably be expected to be met by growth of the existing agency(ies). In the establishment of a new home health agency in a new geographic service area, reasonable expectations of accessibility apply. These expectations include, but are not limited to, adequacy of staffing, supervision, coordination and documentation of services rendere~ and patient outcomes so as to assure the timely and efficient delivery of patient care services, within a geographic service area as defined by the Task Force.
In addition to addressing sufficient volume for financial viability, the standards are also designed to maximize the flexibility of a home health agency in the internal management of its operation (whether through branches, sub-units or other organizational mechanisms) while
32

supporting geographic access via the service area, financial access, quaTfty and distribution of services.
Standard 2: An applicant for a new or expanded home health agency may be considered even if standard l(i) and (ii) is not met if all of the following conditions are met: (1) the appl icant demonstrates that a .need exists, but it is less than necessary to satisfy Standard l(iii) above, and it can be demonstrated that the existing agency(ies) in the geographic service area have not shown an increase in services or patients served in the most recent two years, and does not provide the range of services proposed by the applicant; and
(ii) the applicant IIIISt demonstrate the ability to meet the identified need and can document sufficient financial and personnel resources to achi eve a projected patient volume by the second year of operation sufficient to break even and remain financially viable; and
(iii) the applicant must propose charges comparable to similar existing services in the proposed geographic service area; and
(iv) the applicant must demonstrate that there are sufficient numbers of professional personnel available in the service area to provide. the ski 11ed nursi ng and therapeutic servi ces to be offered by the applicant agency, written documentation as to the availability of professional staff and evidence of availability for contracted services; and
(v) the applicant must provide written evidence that there is support for the proposed services and intent to use such services as demonstrated by written support from practicing physicians and community organi zations.
(vi) all standards related to accessibility and quality are met.
33

Rationale for Standards A need may exist in an area even when not established by application of the total need formula and consequently the level of service may be a result of ma~ community variables. The criteria for establishing such need requires documented evidence that identifies such a need and provides assurance that the proposed new services are feasible given reasonable demand, financial viability, availability of adequate professional staff and documentation of referral services.
Establishing the need and demand for home health services effectively detennines the level of home health services that will be utilized, if adequate services are made available. Demand can be an effective indicator of potential utilization if the potential consumer is identified and reached, and appropriate services are developed to create a knowledge of. demand for and appropriate utilization of proposed home health services.(39)
C. Accessibility An applicant for a new or expanded home health agency must meet the following standards related to accessibility.
Criterion I - Non-discrimination Standard 1: The applicant must document that the proposed agency will not deny services to any patient based on age, race, sex, creed, ethnicity or ability to pay. Such practices will be documented by written policies and procedures concerning non-discrimination on the part of the applicant and any agencies owned or operated by the applicant or by the p~rent company.
Criterion II - Financial Accessibility Standard, 1: An appl icant for a new or expanded home health agency must meet the following standards related to financial access: (i) the applicant must demonstrate the proposed charges are reasonable and comparable with the charges of existing home health agencies providing similar services; and
34

(ii) the applicant must demonstrate a proposed case mix of Medicare, Medicaid and private pay patients which is consistent with the population to be served and the proposed financial resources; and
(iii) in competing applications, favorable consideration will be given to an appl i cant who proposes and demonstrates the abi 1i ty to provide indigent care, and the applicant and/or agencies owned and/or operated by the parent company have a history of providing such care.
Criterion III - Geographic Access Standard 1: When an existing home health agency proposes to move the agency headquarters from one county to another, the following conditions must be met: (1) there is evidence that the intent of the move is to achi eve maximum efficiency and maximum geographic accessibflity to the service area population by making all counties served contiguous to the headquarters county, or
(ii) if due to the pre-existing service area configuration, it is not possible to make all counties served contiguous to the headquarters county, the applicant proposing to move the headquarters must provide evidence that the move will maximize efficiency and geographic access for providing services to the total service area.
Rationale for Standards Accessibility relates to the ability of a given population to obtain appropriate available services. (40) The financial accessibility of home health services is determined by the access to payor sources for which a patient may be eligible. This is operationalized by actual charges, as well as policies and procedures concerning non-discrimination and provision of indigent care, and knowledge of the availability of care where it is reasonable and necessary.
Geographic access for home health care services refers first to the accessibility of persons in need of care to the home health care
35

services they require. In a broader sense, geographic accessibility appTles to the accessibility of the agency headquarters, to the persons providing services as well as the persons requiring service. The geographic service area is based on counti es contiguous to the headquarters of the home health agency to assure accessibility in the broader sense, as well as operational efficiency and effectiveness.
D. Quality Criterion I - Services to Residents Standard 1: An app li cant for a new or expanded home health agency must meet the following standards related to quality of care: (i) the applicant has documented mechanisms for the provision of care to admitted patients other than during regular working hours; and
(i i) the applicant or agencies owned and/or operated by the parent company has no history of uncorrected or repeated 'condition level' vi 0 lati ons or uncorrected standard' defi ci ences as identi fi ed by 1icensure inspecti ons or equivalent level defi ci ences as noted from Medicare and Medicaid audits; and
(iii) an applicant or agency owned and/or operated by the parent company must have no previous conviction of Medicare or Medicaid fraud; and
(iv) an applicant must provide documentation that all staff who will provide the proposed services possess appropriate levels of education, credentials, experience and training to provide the proposed services in a manner consistent with high quality; and
(v) an applicant must demonstrate intent to obtain appropriate levels and numbers of professional and paraprofessional staff to meet the requirements of the services proposed, and that such personnel are available in the proposed geographic service area.
Rationale fOr Standards Quality is a measure of the degree to which home health services meet
36

established standards, and meet the health care needs of the consumeyo.
The standards related to qual; ty require documentation and wri tten policies and procedures assuring the operationalizing of the Quality of Care Issues discussed in Section IV of this component plan.
E. Development of Services Criterion I - Limited Purpose Home Health Agency Standard 1: An applicant for a new or expanded specialized high technology home health agency may be granted approva1 as ali mited purpose home health agency when all of the following conditions are met: (i) all standards relating to accessibility and quality of care are met; and
(ii) the specialized service is not presently available in the applicant's proposed service area, or the capacity of existing similar services offered by an existing agency(ies) is filled; and
(iii) the population to be served is limited to those patients for whom the proposed specialized, high technology home health service is necessary; and
(iv) the applicant must provide written documentation that the proposed specialized, high technology services cannot be provided in existing agencies, and that contracting with existing agencies would be impossible or more costly; and
(v) the applicant clearly documents an ability and intent to facilitate and maintain relationships with area service systems so that continuity of care is assured; and
(vi) the applicant must document with written policies and procedures to assure that the staff possess the necessary expertise to deliver the proposed services, including training, supervision and proficiency levels.
37

Rationale for Standards The development of a l1mited purpose home health agency to provide specialized, high technology home health services is designed to assure access to a range of services needed by consumers. High technology home care services can often extend the range of services offered at home, and provide continuity of care opportunities for many persons who would otherwise have to be hospitalized to receive such services.(41) The co ndi t ions speci fi ed, to be approved as a 11mi ted purpose home health agency are specific to the provision of high technology services that are cost effective and produce benefits to the patient equal to, or better than, other treatment facilities.(42)
38

APPENDICES

APPENDIX A TASK FORCE on HOME HEALTH CARE SERVICES

Eileen Bland, R.N., M.N. Health Department Home Care Servi ces Jesup, Georgia
Gary Bremer Central Health Services, Inc. Atlanta, Georgia
Ronald Cook, M.D. Medical Association of Georgia Atlanta, Georgia
Ed Fechtel St. Mary1s Hospital Athens, Georgia
Pam Galloway, R.N. River Valley Home Health Agency Albany, Georgia
Claudette Leak SHPC Financial Issues Committee Decatur, Georgia
Michael MacDonald
Hyatt, Imber, Ott &Blount, P.C.
Atlanta, Georgia
Don Maddock R. J. Taylor Memorial Hospital Hawkinsville, Georgia
Randy Marsha 11 Department of Human Resources Office of Aging Atlanta, Georgia
July-August-1986

Ma rg i e B. Mill s Georgia Association of Home Health Agencies ABC Home Health Care - Brunswick, Georgia Honorable Eleanor Richardson
House Health &Ecology Committee
Representative, District 52 Decatur, Georgia Paul Shanor Senate Human Resources Committee Atlanta, Georgia Russ Toal Deputy Di rector, Department of Medical Assistance Atlanta, Georgia Monty Veasy Non-profit Hospitals Ti fton, Georgi a Kay Wetherbee SHPC Plan Development Committee Atlanta, Georgia Susan Williamson, M.P.H., R.N. Georgia Nurses Association Atlanta, Georgia Kathy Zi egl er Executive Director Visiting Nurse Association of
Metropolitan Atlanta Atlanta, Georgia

39

HOME HEALTH AGENCY APPROVED SERVICE AREAS

APPENDIX B

S"ATE OF'

GEORGIA

~ j n I;QUM1 U P'WOt'WSlftt t:le 1;0Cle
~ a1 lien ~ l1ee I tl'l aqlftCY (an eo,. at'l:Ic:neca 11 OMDet' eli st a1 aqenc,.s i :''In j s aDlm'''. eo ,.~e :nu" :=un~. ~; ;ne ,.iew ~ne- "Ulmer ~"1~..3 ! :II"'tHI ,:ount., 100"'''1. . .. 1ne 1IlO". :1Ie 1waoer ~!)~ lantS :n. :sntral :ol"'t,on ,i i .~It' ':oun~ ~al"'t'll IlrY'ca lrwl !1l0","1 .

\ SOURC!: 5tanaaras ana i_ i censure recoras
as ~omo1iea oy State ~eaith 0lann1ng ~gency, 10/86
40

CERTIFIED HOME HEALTH AGENCIES

NUMBER CODE HOME HEALTH AGENCY

CITY

COUNTY

1. ABC Home Health of Albany, Inc.

Albany

Dougherty

2. ABC Home Health of Athens, Inc.

. Athens

Clarke

3. ABC Home Health of Atlanta

Atlanta

Fulton

4. ABC Home Health of Brunswick, Inc.

Brunswick Glynn

5. ABC Home Heal th of Dublin, Inc.

Dubli n

Laurens

6. ABC Home Health of Macon, Inc.

Macon

Bibb

7. ABC Home Health of Milledgeville, Inc. Milledgeville Bal dwi n

8. ABC Home Health of Savannah, Inc.

Savannah

Chatham

9. ABC Home Health of Sparta

Sparta

Hancock

10. ABC Home Health of Tifton, Inc.

Tifton

Tift

11. ABC Home Health of Valdosta, Inc.

Valdosta

Lowndes

12. ABC Home Health of Vidalia, Inc.

Vidal1 a

Toombs

13. ABC Home Health of Waycross, Inc.

Waycross

Ware

14. American Home Health Care of Ga., Inc. Jonesboro

Clayton

15. Archbold Home Health Services

Thomasvi 11 e Thomas

16. Atlanta Southside Comm. Health Ctr. Inc. Atlanta

Fulton

17. Central Georgia Home Health Agency, Inc. Macon

Bibb

18. Central Savannah River Area Home Health Washington Wi 1kes

19. Chattahoochee Valley Home Hlth. Care, Columbus

Muscogee

20. Clinical Arts Home Care Services, Inc. Covington

Newton

21. Community Home Nursing Care, Inc.

Atlanta

Fulton

22. Comprehensive Hlth.Care Svc.of Augusta Augusta

Richmond

23. Comprehensive Hlth.Care Svs.of Sand'vle Sander1ville Washington

24. Comprehensive Hlth.Care Svs./Washington Sparta

Hancock

25. Comprehensive Hlth.care Svs./Waynesboro Waynesboro Burke

26. Coosa Valley Home Health Care Agency Rome

Floyd

27. DeKalb Home Health Services, Inc.

Decatur

DeKalb

28. Floyd Home Health Agency

Rome

Floyd

29. Georgia Home Health Care Agency, Inc. Reidsville Tattnall

30. Georgia Home Rehabilitation Service

Va 1dosta

Lowndes

31. Griffin-Spalding Ct. Hospital HHA (AMI) Griffi n

Spalding

32. Hamilton Medical Center HH/Hospice

Dalton

Whitfield

33. Health Department. Home Care Services Jesup

Wayne

34. *Health Department Home Care Services Waycross

Ware

35. Helping Hand Home Care Services, Inc. Albany

Dougherty

36. Health Care Services of Lowndes

Valdosta

Lowndes

37. Health Care Services of Glynn

Brunswick

Glynn

38. Mary Maclean Visiting Nurse Service

Savannah

Chatham

39. The Medical Center Home Health Agency Columbus

Muscogee

40. Medical Personnel Pool of Atlanta, Inc. Atlanta

Fulton

41. Memorial Home Healt~

Adel

Cook

42. Metro Home Health Agency, Inc.

Atlanta

Ful ton

43. Mountain Home Health Agency, Inc.

Young Harris Towns

44. Hand in Hand, NE Ga. Med. Center

Gainesville Hall

45. North Georgia Home Health Agency, Inc. Ft Oglethorpe Catoosa

46. Northside Hospital Home Health Services Atlanta

Ful ton

41

47. Northwest Home Health Agency

Jasper

48. Ogeechee Home Health Agency, Inc.

Statesboro

49. Progressive Home Health Care, Inc.

Ft Oglethorpe

50. Public Health Home Health Services

Valdosta

5I. River Valley Home Health Agency, Inc. Albany

52. *River Valley Home Health Agency, Inc. Cordele

53. *River Valley Home Health Agency, Inc. Thomaston

54. St. Joseph's Hospital Home Health Care Augusta

55. St. Marys Hospital Home Health Care Svs Athens

56. Staff Builders Health Care Services

Atlanta

57. Three Rivers Home Health Services, Inc. Eastman

58. Tugaloo Home Health Agency, Inc.

Lavonia

59. *Tugaloo Home Health Agency, Inc.

Gainesville

60. Upjohn Healthcare Services, Inc.

Savannah

6I. Upjohn Healthcare Services, Inc.

Augusta

62. Upjohn Healthcare Services, Inc.

Atlanta

63. VNA of Appling County

Baxley

64. *VNA of Atkinson County

Pearson

65. *VNA of Charlton County

Folkston

66. VNA of Greater Colquitt County, Inc. Moultrie

67. VNA of Cordele, Inc.

Cordele

68. VNA of Decatur County, Inc.

Bainbridge

69. VNA of Telfair County, Inc.

McRae

70. VNA of Greater Tift, Inc.

Tifton

7I. VNA of Ware County

Waycross

72. Visiting Nurses Assn. of Metro Atlanta Atlanta

73. West Georgia Medical Center, Inc. HH LaGrange

74. Home Health Svcs.of Greater Savannah Savannah

* = Sub unit

Pi cken s Bulloch Catoosa Lowndes Dougherty Crisp Upson Richmond Clarke Fulton Dodge Franklin Hall Chatham Ri chmond Ful ton Appling Atkinson Charlton Colquitt Crisp Decatur Telfair Tift Ware Fulton Troup Chatham

SOURCE: State Health Planning Agency, October 1986

42

REFERENCES

x. REFERENCES CITED
1. Spiegel, A., Home Health Care, National Health Publishing Ltd., Maryland, 1983, p.3.
2. Naisbett, J., Megatrends, Warner Books, New York, 1982, pp.131-132. 3. Naisbett, ibid., pp.42-43. 4.Spiegel, op.cit., pp.5-7. S. Spiegel, ibid., pp.10-12. 6. Livengood, W., Smith, C., Hallstead, S., 'The Impact of ORG's'on Home Health Care', Home Healthcare Nurse, September/October 1983, p.29. 7. Callahan, W., 'Medicare Use of Home Health Services', Health Care Financing Review, Winter 1985, Vol.7, #2, p.89. 8. Callahan, ibid. 9. Reuben, E. and Hamilton, R., 'Entry and Competition in the Home Health Care Industry', Health Care Strategic Management, January 1986, p.7. 10. Hay, J. and Mandes, G., 'Home Health Care Cost-function Analysis', Health Care Financing Review, Spring 1984, p.1IS. 11. House of Representatives, Select Committee on Aging, 'Building a Long-term Care Policy: Home Care Data and Implementation', Dec~nber 1984, Committee Publication #98-484, U.S. Government Printing Office, Washington, 1985, p.48. 12. Georgia Department of Medical Assistance, Annual Reoport 1985, pp.14, 18, 22, 24. 13. Performance Audit, Georgia Department of Human Resources, Community Care Services Program, June 1986. 14. Sandrick, K., 'Home Care: Cutting Health Care's Safety Net',. Hospitals, May 20, 1986, p.49. 15. Burke, G. and Koren,.M.J., 'Home Health Care - An Industry on the Horizon', Business and Health, December 1984, p.10. 16. Berry, E., 'Cost Effectiveness of Home Care as an Alternative to Inpatient care', Home Health Services Quarterly, Winter 1985/86 as reported in Medical Benefits, June 30, 1986, p.6.
43

17. Shapiro, E., 'Patterns and Predictors of Home Care Use by the Elderly When Need is the Sole Basis for Admission', Home Health Care Services Quarterly, Spring 1986, p.29.

18. Liu, K., Manton, G. and Liu, B., IHome Care Expenses for the Disabled Elderly', The Urban Institute as reported in Health Care Financing Review, Winter 1985, pp.Sl-57.

19. Maralda, P., NLN Executive Director, as reported in Health Professions Report, September 15, 1986, p.S.-

20. Gray, J.W., 'Home Health Agencies: Overall Evaluation', Chapter 9, Unpublished Manuscript, 1985.

21. Rules of the Department of Human Resources/Physical Health, Home

Health Agencies, Chapter 290-5-38.08 (a-1).

----

22. ANA, Guidelines for Staff Development in Stuart-Siddal, S., Home Health Care Nursing, Aspen Publishing Company, Maryland, 1986, p:IIi.

23. dela Cruz, F., Jacobs, A. and Wood, M., 'The Educational Needs of Home Health Care Nurses', Vol.4, #3, May/June 1986, pp.11-17.

24. dela Cruz, et -al, ibid.

25. State health Planning Agency, 1986.

26. Health Care Financing Administration, 1986 as reported in Hospitals, May 29, 1986, p.49.

27. Callahan, W., op.cit, 1985, p.89.

28. Berry, E., op.cit, 1985/86, p.6.

IUse of Home Care

r-' -_. as reported in NCHSR- . , , . , x.. xx_ --_...-

---_. -""

u" _
i

n. " - _n



.18

-J

30. Williams, D., 'Diagnostic Specific Home Care', Home Care, Vol.77, #2, February 1985, Post Graduate Medicine, pp.79-88. 31. Williams, ibid, 1985: 32. Home Health Agency, Annual Ranking, Georgia, 1986. 33. Cetran, M., 'The Public Opinion of Home Care', Caring, October 1985, Vol.9, #10, pp.12-15. 34. HCFA-1572, Home Health Agency Survey Report, OM8 #09 38-0011.

44

35. Report of the Task Force on Home Health Care, August 1986. 36. Sharma, R., 'Forecasting Need and Demand for Home Health Care: A Selective Review', Public Health Reports, November/December 1980, p.578. 37. Tanner, D., Director, York Home Care Enterprises, Yale-New Haven Medical Center, as reported in Hospitals, May 20, 1986, p.51. 38. Frasca, C., Executive Director, South HilJs Health System Home Health Agency, Pittsburgh, as reported in Hospitals, May 20, 1986, p.50. 39. Berry, N., 'Measuring and Projecting Demand for Home Health Care', Home Health Review, Vol. III, #2, June 1980, p.24. 40. Institute for Health Planning, 'A Glossary of Health Care Delivery and Planning Terms', August 1981. 41. McCormick, B., 'High-tech Home Care Becomes New Growth Area', Hospitals, February 1986. 42. Williams, D., Ope cit, 1985, p.79.
XI. ADDITIONAL REFERENCES Benjamin, A. E., 'State Variations in Home Health Expenditures and Utilization under Medicare and Medicaid', Home Health Care Services Quarterly, Vol. 7(1}, Spring 1986, pp.5-27. Culyer, A. J. and Birch, Stephen, 'Caring for the Elderly: A European Perspective on Today and Tomorrow', Journal of Health Politics, Policy and Law, Vol. 10, #3, Fall 1985, p.469. Detmee, S., 'The Future of Health Care Delivery Systems and Settings', Journal of Professional Nursing, January/February 1986, pp.20-27. Hammond, J., 'Analysis of County-level Data Concerning the Use of Medicare Home Health Benefits', Public Health Reports,
January/February 1985, Vol. 100, #1.
Health Policy Weekly, 'Home Care: Congress More Concerned', August 11, 1986, pp.i-J: Health Policy Weekly, 'Study Says No Savings from Home Care Aid',
February 3, 1986.
Hewner, S., 'Bringing Home the Health Care: Nurses Make a Difference' Journal of Gerontological Nursing, Vol. 12, #2, 1986, pp.29-35.
45

Hogstel, M., Home Nursing Care for the Elderly, Prentice-Hall, Bowie, MD., 1985':Jaywiecki, T., 'Financing Options for Long-term Care Services', Business and Health, April 1986, pp.18-24. 'JCAH Standards for Hospital-based Home Care Programs', Questions and Answers about Interpretation, American Hospital Association. Kramer, A., Shaughnessy, P. and Pettigrew, M., 'Cost-effectiveness Implications based on a Comparison of Nursing Home and Home Health Case Mix', HSR: Health Services Research, Vol. 20, #4, October 1985, pp.387-405. Lavin,. J., 'You'd better learn to love home care', Medical Economics, April 29, 1985, pp.127-136. Levit, K., Lazenby, H., Waldo, D. and Davidoff, L., 'National Health Expenditures, 1984', Health Care Financing Review, Fall 1985, Vol. 7, #1, pp.1-35. Moldafsky, Annie, 'Home health Care: An Old Idea is Takinq on New Dimensions', Sylvia Porter's Personal Finance, April 1984, pp.77-80. Moore, W, 'CEO's Plan to Expand Home Health Outpatient Services', Hospitals, January 1, 1985, pp.74-77.
: Mundingen, M., Home Care controvers Too Little, Too Late, Too r Costly, Aspen Publications, Rockv;l e, MD, 1983.
NLN, 'Criteria and Standards Manual for NLN/APHA Accreditation of Home Health Agencies and Community Nursing Services', National League for Nursing, 1980. 'Priority shifts indicated for long-term care', Hospitals, November 16, 1985, p.56. Tiersten, S., 'Home Care 8lueprintsfor the 1980's: The National League for Nursing and the National Association of Home Health Agen~ies', Rx Home Care, April/May 1980, pp.36-40.
46