to offer neither sufficient amounts of care nor “homelike” settings and the privacy that goes along with it. There are also indications that consumers may receive too little information to make informed choices regarding assisted living services.

Evidence regarding the quality of home health care is more limited than that for nursing home care, but also points to a mixed experience. Moreover, most of the research in this area measures satisfaction and unmet need, and not quality of care. Medicare-funded home health care generally appears to be of adequate quality in terms of the transactions between caregivers and care users. However, the program has suffered from problems of overuse and inappropriate use, leading to new constraints on payments that may adversely affect the availability of services for those with the most complex care needs. Access to HCBS and especially personal care services for people with disabilities needs to be improved and an array of options need to be developed and tested.

This review of the current quality of long-term care has highlighted for the committee several areas of concern, including lack of standard measurement tools and data to use in more systematic assessments of the quality of care in various long-term care settings, evidence of persistent problems in certain aspects of care (e.g., treatment of pressure sores) and in certain facilities, and indications that some problems can be traced to insufficient staff training or inadequate staffing levels. Subsequent chapters address various strategies for responding to these concerns with specific recommendations for improvements. Since no single strategy will be appropriate or sufficient to achieve the broad range of quality improvement goals in long-term care, the aim must be to find the mix of strategies that will most successfully balance differing views and goals.

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