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Home and Community Care of the Elderly: Tntrocluction Mat 0. Mundinger T would like to welcome you to the first day of this forum devoted to ~ technology issues in the care of the elderly patient. The Council on Health Care Technology has a cent and enduring concern for appropn- ate use of technology in the delivery of care, and the two days of the forum are opportunities for us to deliberate these issues in teens of the settings in which we care for older patients. Today we win focus on the community sewing, where more and more care is being delivered, pardy because of reimbursement incentives under diagnosis-related groups and pardy because technology has brought Be possibility of transferring more care to the home and community settings. One of our concerns in the council has been the absence or un- availability of data on home and community care. Very little is known about Be parameters of care delivered in me home to elderly patients. Although Medicare pays for home care, it does so on the basis of payment per visit, requiring only that the care be "skilled," or primarily hands-on, short-tenn illness resolution services. It is not clear what the scope of services is Cat are actually delivered or what those services accomplish. It is the sense of most policy analysts that Medicare home care was not established to meet Be home care needs of elders, but was intended only as a substitute for extended hospitalization. Substituting care in the home for hospital care requires more than transporting the technology; success- fid home care relies on the presence of a supportive environment and back-up services, and on the stability of the patient's condition. None of the Medicare criteria for home care addresses these necessities. As an observer of how Medicare home care policy is operationalized and evalu- ated, ~ have learned that the link between what is aBowed under the law 14
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HOME AND COMMUNITY CARE: I~RODUCTION 15 and what is actually provided is very different, with providers giving care Mat is needed, whether reimbursable or not. Evaluation of care is faulty because what is provided is not what is documented for reimbursement purposes. We lack data not only on Medicare home care, but also on commu- nity-based services that may be available but inadequately accessed be- cause me population has no organized way to take advantage of me services. Our assessment of Me burden of illness on patients is seriously biased by the lack of data about out-of-hospital care its cost, both direct and indirect, and the nature of infonnal supports Mat are needed. These data deficits impact on me council's ability to evaluate technology application and quality in Me home setting. The nation's research and policy agendas for community care are growing in impor- tance as health care continues to shift toward commuruty-based care and as me demographic profile shifts dramatically toward an aging population whose care needs win be chronic and long-term. Our discussions today are aimed at shaping Pose research and policy agendas to yield the important data Hat we win need to plan for that future.