Asking the right questions: the key to discovering what works in home care.

1 Discovering what works in home care begins with asking the right questions. Two principles from the evaluation research field are useful in understanding what results should be expected of home care: First, examination of program activities may be the key to discovering program objectives (Deutscher, 1977); second, evidence of immediate effects of programs is much more likely to be found than evidence of less proximate effects (Rossi, Freeman, & Lipsey, 1999). Therefore, to understand what home care is likely to accomplish, we should start by examining the specific tasks involved in home care and focus on immediately achievable program objectives. The core set of home care activities consists of personal assistance services intended to compensate for self-care limitations largely as reflected in activities of daily living (ADL) and instrumental activities of daily living (IADL) measures. Home care does for those with self-care limitations what they cannot do for themselves. More specifically, home care provides assistance with bathing, dressing, meal preparation, shopping, and so on for those who cannot perform these tasks independently. The immediate aim of personal assistance , therefore, is to assure that recipients have adequate solutions to challenges of daily living (Caro, 1981). I have come to use the term " quality of circumstances " to describe largely objective measures of the adequacy of solutions to problems of daily living. (I avoid the term " quality of life " because it is typically conceived of as an entirely subjective construct.) Some examples of quality-of-circumstance content may be helpful. In the quality-of-circumstance framework, a highly favorable outcome for assistance with mobility is evidence that the recipient moves around in the living environment at will day and night with full access to all rooms in the residence and does so without experiencing injury. For those whose home care addresses inability to prepare meals, the quality-of-circumstance framework documents eating experiences from both a nutritional and enjoyment perspective. The nutritional aspect includes weight gain or loss, dietary balance, quantity of food available, and frequency of eating opportunities. Enjoyment of the eating experience includes the social context, satisfaction with the types and variety of food available, and satisfaction with the eating environment. For those who are unable to shop, the adequacy of assistance with shopping is measured by how fully the household is supplied with regularly needed items and how rapidly missing items are obtained. The quality-of-circumstance framework has content that corresponds …