NIH GUIDE, Volume 21, Number 18, May 15, 1992


P.T. 34



  Health Services Delivery 



  Community/Outreach Programs 

  Biomedical Research, Multidiscipl 

National Institute on Aging

National Center For Nursing Research

Agency for Health Care Policy and Research


The National Institute on Aging (NIA), the National Center for Nursing

Research (NCNR), and the Center for General Health Services Extramural

Research, Agency for Health Care Policy and Research (AHCPR), invite

qualified researchers to submit applications to investigate the nature,

use, and outcomes of different types of in-home health and supportive

services.  In-home health care and supportive services (hereafter

called home care) are defined broadly to include post-acute and

long-term health care and social services provided at home.  This

definition excludes nursing homes but includes individual residences

and the wide range of community-based residential settings (e.g.,

assisted living facilities) where supportive services and specialized

environments enable a dependent individual to remain in the community

for as long as possible.  Research is encouraged on home care in

general or on particular types of care (e.g., high technology home

care; skilled home health care; low technology/custodial care).

This program announcement supplements but does not replace earlier NIA

program announcements on related topics such as:  Aging and Formal

Health Care (NIH Guide for Grants and Contracts, Vol. 16, No. 19, June

1987) and Economics of Aging, Health, and Retirement (NIH Guide for

Grants and Contracts, Vol. 20, No. 15, April 1991).  It also

complements an earlier Program Note, "Research Agenda on Home Health

Care" by the AHCPR (September 1988).  Also relevant is the forthcoming

report by the NCNR on Long-Term Care of Older Persons.

The NIA was established to conduct and support research and training on

the biomedical, social, and behavioral aspects of the aging process, as

well as diseases and other special issues and needs of older people.

In line with the Congressional mandate for both medical and non-medical

research, long-term care needs of older people and their families is a

major priority.  The NIA is specifically interested in social and

behavioral research on the interaction between older people and their

caregivers with the health care system, the linkages between formal and

informal care, and the structure, processes, and outcomes of new models

of care. Of particular interest is research on home care and supportive

services including high technology care, skilled home health care, low

technology/custodial care, respite care, and board and care.

The NCNR supports basic and clinical research and research training in

patient care relevant to nursing including studies involving home

health care and other community-based settings.  The major NCNR

emphases in building the science related to long-term care in the home

have been on the processes and outcomes of care including the testing

of intervention strategies to encourage independence, facilitate

management of commonly experienced symptoms or health problems, prevent

the onset of disabilities in those who are chronically ill, improve

functional status and quality of life, maintain caregiver and other

family support mechanisms, and facilitate transitions between health

care settings and home.

The AHCPR was created to enhance the quality, appropriateness, and

effectiveness of health care services and access to such services.  The

Center for General Health Services Extramural Research (CGHSER)

supports multidisciplinary extramural research, demonstrations, and

evaluation activities on a broad range of health service research and

health care technology issues.  Studies focus on improvements in

clinical practice, delivery, cost, quality, and access to care.

Research on the elderly at CGHSER deals with issues of the

organization, delivery, quality, cost, and financing of health services

and the role of primary care in long-term care.

Approximately seven million older Americans require assistance with

basic tasks of daily living, a number that is expected to increase

dramatically as the baby boom generation ages.  Though nursing home

care is often equated with long-term care, it is but one part of the

long-term care continuum.  For every person who is institutionalized,

an estimated four or more persons in the community require some form of

long-term care.  The burgeoning long-term care needs of an aging

society and less restrictive eligibility requirements for Federal

reimbursement have fueled the expansion of the home-care industry.

Care for dependent, older Americans living in the community is a

priority area needing the attention of researchers, planners,

practitioners, and policy analysts.  The Bi-partisan Commission on

Comprehensive Health Care (The Pepper Commission) called for

substantial increases in long-term care research. The Commission

emphasized the need for intensified research on home and

community-based care to guide programmatic and policy decisions and to

strengthen the current health care system.

Due to an interest in cost-containment of health care services, home

care has been proclaimed to be a "cost- effective" alternative to

institutionalized care.  Yet, existing research on home care simply

does not provide an adequate basis for policy and program development.

Previous studies of cost-effectiveness of in-home and community-based

care have been limited by inconsistencies in definitions of services

and inadequate data sources. The resulting contradictory

cost-effectiveness studies point to the need for further study on this

issue and the need for studies focusing on broader quality of life


In collaboration with the Administration on Aging, the NIA sponsored a

conference in 1990 focussing on in-home care to identify a research

agenda in this area.  A detailed summary of identified research

concerns is available by writing the National Institute on Aging (see

INQUIRIES).  In an edited volume on In-Home Care for Older People (Ory

and Duncker, 1992), the authors identified three areas highlighted at

the conference that need immediate attention:  (1) the use of in-home

services for older people with different functional needs;  (2) the

effectiveness of different types or packages of services for different

populations, and  (3) the coordination (or lack of coordination) of

in-home services with physician-provided care.  In addition, the

significant contributions made by family and friends, the burdens

experienced by families providing care, and the need for better

integration and coordination of services and care providers across the

total continuum of health and social care were issues requiring further


The lack of a clear conceptualization of home and community-based,

long-term care has been a major research obstacle.  There is a need for

further development of theoretical concepts, including definitions of

home care and the boundaries between home care and institutional care.

To increase current understanding of home care, it is necessary for

investigators to begin to specify variations in the nature and types of

care currently used by older adults; to examine clinical strategies and

other processes of care on different populations; and to determine the

effects of different settings of home and community-based care.  More

attention is needed on the quality of life and functional outcomes that

are of crucial concern to older people and their families.  Cost

questions also need to be considered in research on in- home health

care and other community-based residential care alternatives.

Research is encouraged that specifies the broad conceptual boundaries

of home care and gives the field a strong base of data and

methodologies.  Advances will come through an awareness of the need to

draw upon interdisciplinary expertise in nursing, medicine and other

clinical sciences, behavioral sciences, and health service aspects of

health and aging.  For example, current models of health care

utilization can be expanded to pay more attention to the complex

interactions of clinical and social influences.  Similarly, researchers

are urged to design innovative sampling strategies for minimizing

typical methodological problems such as population selection bias.

Researchers should also be sensitive to all participants in the care

process, including clients, their families, and/or other informal care

providers, as well as the potential for variability across cultural,

ethnic, or gender lines.


The Public Health Service (PHS) is committed to achieving the health

promotion and disease prevention objectives of "Healthy People 2000,"

a PHS-led national activity for setting priority areas.  This RFA, Home

Health Care and Supportive Services for Older Adults, is related to the

priority area of educational and community based programs. Potential

applicants may obtain a copy of "Healthy People 2000" (Full Report:

Stock No. 017-001-00474-0) or "Healthy People 2000" (Summary Report:

Stock No. 017-001-00473-1) through the Superintendent of Documents,

Government Printing Office, Washington, DC 20402-9325 (telephone



Applications for research grants may be made by domestic and foreign,

public and private, for-profit and non-profit organizations, such as

universities, colleges, hospitals, and laboratories.  Women and

minority investigators, in particular, are encouraged to apply.

Foreign applicants are not eligible for the First Independent Research

Support and Transition (FIRST) (R29) awards.


The primary mechanisms for support of research under this program

announcement are the research project grant (R01), and FIRST Award

(R29).  Applicants are advised to contact the program staff of the NIA,

the NCNR, or the AHCPR for further information on levels and duration

of support.  The AHCPR does not support the FIRST Award.


This announcement seeks grant applications for studies on in-home

health care and supportive services to increase understanding of this

growing segment of the health care industry.  It is anticipated that

research funded under this initiative will contribute to the scientific

base for informed policy recommendations and changes.  Utilization and

availability of in-home health care and supportive services, process

and outcome of care, and populations requiring specialized care are a

few of the issues that require more attention.  Examples of relevant

research topics include, but are not limited to:

o  Nature Or Type Of Home Care

A broad range of studies, (i.e., clinical, epidemiological,

sociological, anthropological) are needed to examine the range of

existing in-home health and supportive services.  Specific examples

include: the impact of new health care policies on the nature and type

of community care options available (e.g., eligibility criteria for

coverage); impact of high-tech clinical care in the home and its impact

on the individual, caregivers, and/or the health care industry; the

specific content of home care services (e.g., the duration, place and

frequency of respite services and how these relate to caregiver use).

o  Use Of And Need For Home Care

Utilization of in-home health care and supportive services by older

people and their families, the extent to which needs remain unmet, and

the complex interactions between service need, service expectations,

and service receipt are important areas for study.  Others may include:

epidemiological studies of the use of in-home health care and

supportive services and changes in use over the course of an illness;

development of criteria to measure "need for care" and examination of

relationships between need and preferences; development of forecasting

models to predict need for and use of in-home health care.

o  Process Of Home Care

How care is provided in the home and what structures are available to

assist the older person, family, and/or other care providers are issues

of continued importance.  Research that examines different models of

home care and/or links specific outcomes to particular interventions is

needed.  Still more information is needed on the process of care from

the perspective of the client, the caregiver, or both.  Areas that need

further investigation are:  alternative approaches to care (e.g., board

and care) and structures for organizing care (e.g., shared-aide

services); efforts to link care providers (e.g., board and care

providers) with the larger community-based system; clinical

intervention strategies designed to effectively impact health-related

quality of life, functional status, and/or family relationships;

transitions, such as initiation of informal or formal care services or

transfer to and from nursing homes, and how they relate to the stage of

caregiving and changing need for services.

o  Outcomes Of Home Care

An especially crucial aspect of in-home health care and supportive

service research is defining and measuring quality.  Therefore,

research should focus on definitional and measurement issues related to

quality as well as effectiveness for specific interventions being

examined.  Research may include:  the effect of alternative approaches

to in-home health care (e.g., personal assistance, respite care, high

technology care or environmental modifications) on clients, family

members, and other care providers as well as the development of more

sensitive measures of stress, burden, satisfaction, and other outcomes;

relevant outcomes of care, especially those that lead to determination

of effective forms of relief that could be offered to caregivers;

strategies for increasing quality of life, health and/or socially

related; and strategies to improve the functional status of clients;

the cost and effectiveness of services, how services fit into the

caregiver's living arrangements, and how services fit into the dynamics

of kinship, friendship, and neighborhood networks.

o  Special Care Populations

Many subpopulations are served by in-home health care and supportive

services.  To target services more effectively, the identification of

care needs for specific subpopulations is necessary.  Areas requiring

additional study are:  access to and utilization of care in special

populations (e.g., the oldest old, women, minority and ethnic

populations, rural elderly), and; the needs and resources of adults of

all ages. Comparative research is encouraged on models of care for

younger disabled ("independent living") populations and their relevance

to care for older persons.

o  Data Resources

Maximum use should be made of existing data.  Primary data collection,

however, may be necessary and certain types of databases have been

highlighted as especially relevant.  Both large-scale studies and

smaller state, regional or local ones, as well as studies of board and

care homes serving particular subgroups are appropriate. Moreover, it

is important that studies capture the diversity of various forms of

home care (e.g., large v. small, ownership, urban/suburban/rural) and

the residents they serve (e.g., primarily private-pay v. SSI

recipients, racial and ethnic subgroups).  Studies may investigate:

(a) the characteristics of the environment, (b) extent and

characteristics of unmet care needs among residents, (c) relationships

between different forms of in-home health care and the larger system,

or (d) resident, owner/operator and staff "transitions". Attention

should be given to specific forms of the home care industry that remain

understudied, such as non- certified home health agencies, small,

unlicensed board and care homes, and unlicensed social service






NIH and ADAMHA policy is that applicants for NIH/ADAMHA clinical

research grants and cooperative agreements will be required to include

minorities and women in study populations so that research findings can

be of benefit to all persons at risk of the disease, disorder or

condition under study; special emphasis should be placed on the need

for inclusion of minorities and women in studies of diseases, disorders

and conditions which disproportionately affect them.  This policy is

intended to apply to males and females of all ages.  If minorities and

women are excluded or inadequately represented in clinical research,

particularly in proposed population- based studies, a clear compelling

rationale should be provided.

The composition of the proposed study population must be described in

terms of gender and race/ethnic group.  In addition, gender and

racial/ethnic issues should be addressed in developing a research

design and sample size appropriate for the scientific objectives of the

study.  This information should be included in the form PHS 398 in

Sections 1-4 of the Research Plan AND summarized in Section 5, Human

Subjects.  Applicants are urged to assess carefully the feasibility of

including the broadest possible representation of minority groups.

However, NIH recognizes that it may not be feasible or appropriate in

all research projects to include representation of the full array of

United States racial/ethnic minority populations (i.e., Native

Americans (including American Indians or Alaskan Natives),

Asian/Pacific Islanders, Blacks, Hispanics).  The rationale for studies

on single minority populations groups should be provided.

For the purpose of this policy, clinical research includes human

biomedical and behavioral studies of etiology, epidemiology, prevention

(and preventive strategies), diagnosis, or treatment of diseases,

disorders or conditions, including but not limited to clinical trials.

The usual NIH policies concerning research on human subjects also

apply.  Basic research or clinical studies in which human tissues

cannot be identified or linked to individuals are excluded.  However,

every effort should be made to include human tissues from women and

racial/ethnic minorities when it is important to apply the results of

the study broadly, and this should be addressed by applicants.

For foreign awards, the policy on inclusion of women applies fully;

since the definition of minority differs in other countries, the

applicant must discuss the relevance of research involving foreign

population groups to the United States' populations, including


If the required information is not contained within the application,

the review will be deferred until the information is provided.

Peer reviewers will address specifically whether the research plan in

the application conforms to these policies.  If the representation of

minorities or women in a study design is inadequate to answer the

scientific question(s) addressed AND the justification for the selected

study population is inadequate, it will be considered a scientific

weakness or deficiency in the study design and will be reflected in

assigning the priority score to the application.

All applications for clinical research submitted to NIH are required to

address these policies.  NIH funding components will not award grants

or cooperative agreements that do not comply with these policies.


Applicants are to use the research grant application form PHS 398 (rev.

9/91), available at the applicant's institutional Application Control

Office and from the Office of Grants Inquiries, Division of Research

Grants, National Institutes of Health, Westwood Building, Room 240,

Bethesda, MD  20892, telephone (301) 496-7441.  Complete item 2a on the

face page of the application indicating that the application is in

response to this announcement and print (next to the checked box)


The application (with five copies) must be mailed to:

Division of Research Grants

National Institutes of Health

Westwood Building, Room 240

Bethesda, MD 20892**


Applications will be reviewed for scientific and technical merit by

study sections of the Division of Research Grants, NIH, or by the

AHCPR.  Following scientific-technical review, the applications will

receive a second-level review by the appropriate national advisory



Applicants will compete for available funds with all other approved

applications assigned to the Institute/ Center/Division.  The following

will be considered in making funding decisions:

o  Quality of the proposed project as determined by peer review

o  Availability of funds

o  Program balance among research areas of the announcement


Written and telephone inquiries are encouraged.  The opportunity to

clarify any issues or questions from potential applicants is welcome.

Direct inquiries regarding programmatic issues to:

Dr. Marcia G. Ory

Behavioral and Social Research Program

National Institute on Aging

Gateway Building, Room 2C234

Bethesda, MD  20892

Telephone:  (301) 496-3136

Dr. Patricia Moritz

Nursing Systems Branch

National Center for Nursing Research

Westwood Building, Room 754

5333 Westbard Avenue

Bethesda, MD  20892

Telephone:  (301) 496-0523

Ms. Anne Bavier or Ms. Linda Siegenthaler

Center for General Health Services Extramural Research

Agency for Health Care Policy and Research

Executive Office Center,  Suite 502

2101 East Jefferson Street

Rockville, MD  20852-4908

Telephone:  (301) 227-8357

Direct inquiries regarding fiscal matters to:

Ms. Linda Whipp

Grants and Contracts Management Office

National Institute on Aging

Gateway Building, Room 2N212

Bethesda, MD  20892

Telephone:  (301) 496-1472

Sally A. Nichols

Grants Management Officer

National Center for Nursing Research

Westwood Building, Room 748

Bethesda, MD  20892

Telephone:  (301) 496-0237

Ralph Sloat

Grants Management Officer

Agency for Health Care Policy and Research

2101 East Jefferson Street, Suite 601

Rockville, MD  20852-4908

Telephone:  (301) 227-8447


This program is described in the Catalog of Federal Domestic Assistance

No. 93.866, No. 93.336 (Nursing Research), No. 93.180, and 93.226.

Awards are made under authorization of the Public Health Service Act,

Title IV, Part A (Public Law 78-410, as amended by Public Law 99-158,

42 USC 241 and 285) and Title IX, as amended (Public Law 101-239), and

administered under PHS grants policies and Federal Regulations 42 CFR

52 and 45 CFR Part 74 and 42 CFR 67, Subpart A.  This program is not

subject to the intergovernmental review requirements of Executive Order

12372 or Health Systems Agency review.


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