fying factors related to the use of services, for instance, existing frameworks often underemphasize the role that unrecognized need and provider attitudes and perceptions play in accessing and using services. Furthermore, quality indicators do not typically address issues of consumer empowerment and the important role that nonmedical support services play in maintaining health and avoiding hospitalizations (Burns et al., 1990).

Access to Use and Quality of Long-Term Support Services Related

to issues of access to and quality of primary health care are issues related to the access, use, and quality of long-term support services. The need for long-term support services to assist people with a disabling condition compensate for a functional limitation is well recognized. These services generally consist of attendant or personal assistance services, assistive technology, as well as institutional care for people with very severe limitations that require daily assistance from medical personnel. Not only do these services help the person with a disabling condition maintain his or her health, but they are also often required for performing activities of daily living comfortably and safely. In many cases, adequate attendant services and assistive technology provide an effective alternative to institutional care. There are very few published studies, however, that scientifically demonstrate the value of these services in improving health and well-being while reducing overall costs to the health care system and society at large (Nosek, 1993). The conduct of these studies will be critical in arguing for adequate coverage of these services by insurers and managed care organizations.

The importance of research on the access to and cost-effectiveness of support services was highlighted at the consensus conference on research priorities in the area of primary health care needs of people with disabling conditions mentioned above (Burns et al., 1990). Developing a better understanding of how personal attendant services are used and financed and their impact on the health and well-being of people with disabling conditions was consistently ranked among the highest priorities. Of particular note is that conference participants ranked access to appropriate attendant services as the number one issue to be addressed in reducing the high rate of rehospitalization among people with disabling conditions. Quantitative research is needed to establish the extent and nature of the relationship between personal assistance and health.

It is important that research focused on the use of and value of long-term support services recognize the critical role of the consumer in framing appropriate research questions and developing appropriate indicators of access and quality (Williams, 1994). Often, too little attention is paid to the needs and preferences of the consumer, leading to dissatisfac-

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