Efforts to control rising home health costs during the 1980s offered managers incentives to modify organizational behavior with respect to cost per visit or quantity of visits. Most attempts failed. Why? This study examined patient, organizational, payor, and nurse care planner characteristics and their relation to planned nursing and home health aide visits.

Qualitative and quantitative data were collected. Information about organizational objectives, operations, and payment experiences came from site visits and interviews with key managers in each agency. Thirty-nine nurse care planners answered a written survey questionnaire. Nurses provided information about education, experience, family demands, orientation to traditional nursing values, and attitudes. Nurses in each site also participated in small group discussions exploring care planning experiences and influences. Finally, patient diagnosis and socio-demographic data were drawn from 1168 patient admissions records. Multiple regression techniques were used for analysis.

Organizations varied in the desire and ability to respond to external incentives and requirements. Slippage occurred between what payors wanted, what organizations attempted to do, and nurse decisions about the amount of care patients would receive.

The best predictors of nursing visits were related to patient characteristics. Site and payor effects differed for nurses with certain characteristics. Nurses who planned more visits for similar patients were older, had more education, were more satisfied with their job, and credited administration (via inservice education, meetings, written expectations) as strong influences. Nurses who planned fewer nursing visits had less than five years of nursing experience, chose to work per visit, were married, and credited personal-oriented influences (amount of paperwork, caseload, relationship with patient/family, personal schedules) in their planning decisions.

In planning home health aide visits, nurses were less directly influenced by patient need. The greatest differences were explained by payor and site interactions in unpredictable ways that varied among nurses with different characteristics.

These exploratory findings suggest that policies focused on care planners and patient goals may be expected to improve the responsiveness of home health to desired outcomes of quality and efficiency.