comes. In common with most complex human endeavors a perfect regulatory system is likely to be beyond human reach. Nonetheless, it is important for policy makers, regulators, and advocates to consider and weigh both the expected benefits and the expected burdens of regulations. Moreover, by listening to the concerns of those subject to regulation as well as the beneficiaries of regulations, policy makers may be able to develop effective, yet less costly and less resisted ways of achieving their goals. The challenge is to design and implement a system that does what it is intended to do at an acceptable cost.


In principle, some basic standards for long-term care could be developed that apply regardless of the setting or provider of care. In practice, however, most standards are designed for specific categories of providers or services. In general, it may be useful for policy makers, providers, consumer advocates, and others to think about standards applicable across various care settings. Such thinking may become increasingly necessary if concepts of consumer-centered and -directed care are to be developed. Indeed, regulatory standards related to outcomes have become an increasingly important objective in long-term care. This approach, however important, is beyond the scope of what the committee is able to address in this report.

Reflecting the differences in current regulatory programs in various long-term care settings, this chapter focuses on selected settings separately. As is typical of most long-term care issues, nursing homes have been the focus of most attention in standard-setting and enforcement activities. This again reflects a long history of concern about abuse, neglect, and poor quality of care in nursing homes and public concern about this frail and vulnerable group of long-term care users, who are subject to the greatest degree of provider control over their lives. The discussion that follows focuses on nursing homes, residential care facilities, home health care, and home care and other home and community-based services.

Nursing Homes

Both federal and state governments employ regulation as a strategy to protect quality of care in nursing homes. The federal government has defined standards or requirements for provider participation in Medicare, and Medicaid relies primarily on the states for assessment. The federal government retains authority to enforce compliance with nursing home standards of care, but generally delegates enforcement authority to states for other health care providers. States also independently regulate

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