Medicare constrains social workers' and nurses' home care for clients with Alzheimer's disease.

The Medicare home health prospective payment system (PPS) has existed for 13 years, yielding significant profits to providers. However, studies indicate many unresolved questions about whether PPS improves patient quality of care, is cost-effective, and reduces patient levels of unmet need. In addition, PPS has undermined the provision of social work home health services. The article presents the views of 29 home health care nurses regarding the impact ofPPS on their care decisions for people with Alzheimer's disease and their caregivers. The nurses identify Alzheimer's disease symptom management and psychosocial needs as phantoms, omnipresent below the surface but not attended to by home care clinicians. The interviews support the greater involvement of social workers to more adequately address the psychosocial needs of Medicare home health patients. The article contends that the current failure to simultaneously address the cost, needs, and quality-of-life issues of people with Alzheimer's disease who are cared for at home is analogous to the end-of-life care situation before passage of the Medicare Hospice Benefit. A collaborative demonstration project--social work and nursing--is proposed to determine how PPS might better address quality of life and costs of home-based people with Alzheimer's disease and their caregivers.