Assessing Daily Life: Standardization and Discretion in Home Healthcare Evaluations

Against the depiction of standardization as a process that inevitably flattens and homogenizes social life, scholars from science and technology studies, economic sociology, and valuation studies have documented the multiple ways in which local interpretations, moral meanings, and cultural contexts all influence how standards are experienced and implemented. Existing literature on standardization, quantification and metrics shows that there is always a gap between standards and their practical lives because standards require the active participation of people – who inevitably “tinker”, work around, manipulate, or otherwise embed standards into local worlds.

This paper argues that this is not the only way to understand the relationship between standards and discretion. We propose a framework for investigating the ways in which standards explicitly invite discretion and expertise, through an examination of the use of standardized tools for assessing home care needs across the United States. These tools aim at evaluating potential or ongoing candidates for Medicaid-funded home care services for individuals with physical and cognitive disabilities. To determine whether an individual meets a state’s eligibility criteria, state and private agencies use assessment tools to collect information on an applicant’s health conditions and functional needs.

Drawing on content analysis of 83 assessment tools, we find significant variation in how tests standardize definitions of health, physical ability and mental competence. More importantly, we find that a majority of the assessments include at least one (and more often a multiplicity of) open-ended question that invite comments from the test administrator.

We theorize these open-ended questions as “pockets of discretion.” We show that they open up space for judgment for three different purposes: contextualization, reconciliation, and adjudication. Our case provides a conceptual framework that is useful for investigating the embeddedness of discretion in other standardized assessments.