Inconsistent Evaluation of Client Needs

Evaluation of client needs under the homemaker-chore services program is inconsistent in that some clients receive insufficient services and others receive too much. A primary cause of this inconsistency is the lack of communication between the social workers and the client, and between the provider and the contract agencies.

State regulations require all clients, except those judged to be severely impaired, to be evaluated every 6 months by the county welfare department to determine their current need for homemaker or chore services.

Our review of the program in 10 counties disclosed that the frequency of reevaluation of nonseverely impaired clients ranged from 1 month to over 1 year. Those counties which exceed a 6-month reevaluation period are out of compliance with State regulations.

In those counties that complied with the 6-month review requirement, we found that semiannual reevaluations were often not sufficient to adequately monitor the client's condition. Some clients required more attention than the social workers could afford because of their growing caseloads or inability to keep up with the clients' changing conditions.

An example of this involved a 74-year-old client in one county with a duodenal ulcer whose physician recommended the services of a provider solely for the purpose of meal preparation. The county authorized 9 hours of service a week and, in violation of State regulations, did not review the client's situation for a year. At the time of our review, it was determined that for the past year the client had been taking his meals two or three times a day at a local diner and having the homemaker clean his studio apartment rather than prepare meals. Since the client needed only 9 hours of service per week, the county had contracted with a proprietary agency at the rate of $6 per hour for the service. The annual cost was $2,808. While this was an extreme example of the 90 clients receiving homemaker or chore services, whom we interviewed in their homes, it is illustrative of the abuses and excessive levels of care that can occur in the absence of proper administration.

An example in the other direction involved a couple who were both receiving "chore" services and who had been visited twice annually by their social worker. On a regular reevaluation visit, the social worker found that the health of both the husband and wife had deteriorated. The social worker then authorized an increase in the amount of service. The social worker said that the couple could have qualified for the increased service much earlier if she had been aware of their need.

While the conditions of certain types of recipients of homemaker and chore services are not reviewed often enough, review requirements provided by statute for the severely impaired are excessive and costly. Section 12304 (f) of the Welfare and Institutions Code requires county social workers to visit clients classified as "severely impaired" once every 3 months. A severely impaired client is defined by law as someone who requires at least 20 hours per week of personal care. These clients have acute physical disabilities, such as paralysis, and are usually confined to a wheelchair or bed.

In the course of our study, social workers and severely impaired clients agreed that this legal requirement forced unnecessary visits to the client and inefficient use of social worker time. Generally, severely impaired clients have been allowed to live independently only after lengthy hospitalization and only after expert medical testimony that their condition will not deteriorate. These clients have stable and well-defined disabilities.

Revising existing law to reduce the number of mandated visits to one per year would save an estimated $252,000 of social services money annually.

In counties where a contract agency provides program services, it is more difficult for the social worker to maintain contact with the clients. Social workers are still required to make the specified reevaluations and we found that this regulation is generally being followed. However, because the client deals almost exclusively with the agency-employed provider, effective commuication between the client and the social worker is restricted. This results in the provision of inadequate or excessive services to the client.

An example of this involves an elderly client who was assigned a provider from a contract agency. Although the provider performed her duties to the satisfaction of her employer and the client, the client's condition steadily

declined to the point where hospitalization was considered by the contract agency and the client's family. At no time during this period was the social worker consulted concerning this client or the need for modified services.

More frequent review requirements would not be necessary if improved methods were devised for the client to contact the social worker as his need changed. We recognize that if the social workers are more accessible to the needs of the client it may result in increased costs. However, more frequent contact may result in reduced levels of services.

Inconsistent Payments to Relative-Providers

During our interviews with clients, providers and social workers, we found a marked inconsistency in the methods for determining the payments to be made to providers who are relatives of the client. (We have defined "relative" as a spouse, child, or parent of the client who occupies the same home as the client.)

We found that some counties allowed payment to the relative for normal household routines (cooking, cleaning, washing). For example, a county authorized payment for cooking, cleaning, and washing services which a wife had been doing as a normal part of her daily routine, and which were not increased as a result of her husband's needs. On the other hand, in other counties a relative is paid only for those tasks which are extraordinary to the normal household routine. In still other counties, a relative is paid for normal household activities only if he or she has quit a job to care for the client. The department of health regulations are not specific about payment for services when a relative-provider lives in the home. As of December 31, 1974, there were approximately 8,000 relative-providers in the program. We were not able to estimate the household incomes of relative-providers. It appears that the majority are low-income households and it was also clear in some cases that the relative-provider terminated regular employment to provide homemaker or chore services. Administrators in seven of the counties we visited stated that relative-providers should not be compensated for this service unless the services provided are of an unusual nature. Another administrator stated that consideration should be given to establishing a "low income" definition for household income.

Inconsistent Methods of Treating Social Security Contributions for Individual Providers

Department of health guidelines state that individual providers are either employees of the county or the client and as such are entitled to social security contributions which must be equally shared by the employer and the provider. In cases where the county has elected to act as the employer, the county pays the employer's share of social security and deducts the employee's share from his earnings. Both shares are forwarded to the Internal Revenue Service (IRS) by the county. In cases where the county considers the client to be the employer, there are various methods of handling the payment:

-The county adds the employer's and employee's share of the social security payment to the provider's hourly salary rate and relies upon the client to collect the social security tax and forward both shares to the IRS. A typical example of this is where the hourly rate is $2.25; $2.01 represents the actual provider salary, 24 cents is both the employer's and the employee's share of social security. The client is supposed to collect both deductions and forward these payments to the IRS. -Some counties pay nothing toward social security. From the $2 hourly salary, both the employer's and employee's shares are deducted. This means that the provider receives only $1.88 in wages, from which he must pay the employee's share of social security. The client again is expected to collect both deductions and forward these payments to the IRS.

In both of the above instances, the result is that the responsibility for handling the details of social security computations, deductions, and forwarding to the IRS falls on the client, who is the person least equipped to meet this responsibility. The counties have maintained that to assume the responsibility for social security contributions lends credence to the argument that the clientemployed provider is actually a county employee and thus eligible for county salaries and benefits.

These discrepancies over the handling of social security contributions could be resolved if the counties were to act as the fiscal agent for their homemakerchore services program clients. Serving as the fiscal agent would allow counties to treat client-employed providers as the employees of the clients and thus assure that the provider receives full credit for his payroll taxes and preclude the responsibility that the provider would be considered a county employee.

Inconsistent Use of Existing Community Resources

The department of health's manual of policies and procedures requires the counties to establish a registry of available community service organizations. The purpose of such registries is to allow county welfare departments to use available community resources, many of which are publicly supported, to the greatest extent possible.

In the course of our review, we observed that counties authorize homemaker and chore services which are already available from existing community resources. While the cost of this duplication is not possible to determine, it does place an unnecessary burden on the restricted resources of the homemakerchore services program, thereby preventing some clients from receiving needed services. Among the services most duplicated is meal preparation, which is available through congregate feeding sites for the elderly and needy or mealson-wheels programs. Another duplicated service is transportation, which is available through local volunteer or public transit programs. Other services available in some communities include day care centers for the elderly which can eliminate reliance on the homemaker-chore services program for supervision, meal preparation, ambulation, exercise, and client training. Sacramento and San Francisco Counties are now offering such centers on a demonstration project basis.

An example of failing to use community resources involves a client who was dependent upon a chore worker to provide frequent transportation to and from medical appointments, despite the fact that some use could have been made of volunteer transportation services for the elderly and needy.

Conclusion

The inconsistencies in the county administration of the homemaker-chore services program, caused by the absence of adequate State regulations, have resulted in inconsistent evaluation of client needs, varied payments to relativeproviders, inconsistent methods of treating social security contributions for individual providers and inconsistent use of existing community resources.

Recommendations

We recommend that the department of health: -Establish regulations to require improved channels of communication between the clients and county welfare workers so that changes in a client's condition will be met with appropriate changes in the level of service. -Establish regulations allowing payments to relative-providers only when they are from low-income households or when they are providing extraordinary services which are in addition to normal household routine. -Establish regulations requiring the counties to perform the bookkeeping functions now imposed on the client. To do this the counties would report both the employee's and the employer's share of the social security contributions to the proper authorities.

-Enforce regulations to use existing available community service organizations. In those cases where clients have been diagnosed as having stable disabilities, we recommend that the legislature revise existing law to mandate an annual review of the service needs of the severely impaired client, instead of the presently mandated quarterly review.

Benefits and Savings

Implementation of our recommendations would make the administration of the individual county homemaker-chore services programs more uniform and consistent with client needs. In addition, excessive costs would be reduced to the extent of any payments currently being made for unnecessary services or to persons who should not receive payment.

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Furthermore, the statutory requirement that severely impaired clients be visited by social workers quarterly promotes inefficient use of social worker time and the unnecessary expenditure of an estimated $252,000 annually.

FUNDS TO PROVIDE HOMEMAKER AND CHORE SERVICES HAVE NOT BEEN APPROPRIATED IN A WAY TO PROMOTE FISCAL RESPONSIBILITY IN THE ADMINISTRATION OF THE HOMEMAKER-CHORE SERVICES PROGRAM

In fiscal year 1974-75, the department of health allocated a total of $229.7 million to county welfare departments to provide adult and family social services in California. Of this amount, $172.3 million (75 percent) represented Federal social services moneys and $57.4 million (25 percent) represented the required State and county matching moneys.

The State legislature (Welfare and Institutions Code Section 12306) elected to fund $16.25 million of the local social services share and specifically allocated this money to the homemaker-chore services program. Combined with the matching Federal money, $48.75 million, a total of $65 million in social services moneys, was allocated to the counties for homemaker and chore services.

The counties were also allocated the remaining $123.5 million Federal social services moneys and were required to provide the local $41.15 million matching funds. These moneys were to be used for all other social services provided by the counties.

The net effect of this funding procedure was to separate homemaker and chore services from "other" social services and to provide for 100 percent Federal and State funding of this program which is administered by county welfare departments. In addition, "other" social services are funded 100 percent with Federal and county moneys. The absence of county participation in homemaker and chore funding does not encourage fiscal restraint.

This separation of funds in the State budget has led to the general belief that the homemaker-chore services program is a program for which the State has full fiscal responsibility. Therefore, there has been minimal effort by the counties to control program costs based on the assumption that any cost overruns had to be borne by the State. The separation of homemaker and chore services from "other" social services has resulted in the failure of the counties to establish appropriate fiscal and program priorities for the total package of social services that they provide. For example, county officials have stated that they did not have sufficient funds for the homemaker-chore services program for fiscal year 1974-75. Based on claims received from the counties for the quarters ending September and December 1974, the department determined that the counties did, in fact, have "other" social services moneys that will not be expended by the end of the current fiscal year. Consequently, in March 1975, the department reallocated in excess of $5.3 million to the homemakerchore services program from the "other" social services appropriation (see appendix C [p. 195] of this report).

In some of the counties that we visited, officials stated that even before the March reallocation they had been forced to reduce their "other" social service programs in order to fund the social worker staff responsible for the homemaker-chore services program. Most of these counties had placed freezes on the hiring of social workers, which had an overall effect of increasing existing social worker caseloads thereby reducing the ability of the county to provide a total package of social services to current and prospective clients.

Conclusion

Fiscal responsibility has not been achieved in the administration of the homemaker-chore services program, in part because the method of budgeting social service moneys does not require the counties to share in a portion of the cost of the program.

Recommendation

We recommend that the legislature discontinue the practice of separating the homemaker and chore services allocation from the total social services allocation and apply the State's matching moneys to all social services instead of only to the homemaker-chore services program.

Benefits

Implementation of this recommendation will promote sound management of the homemaker-chore services program by requiring the counties to share in the cost of that program.

THE DEPARTMENT OF HEALTH DOES NOT PROVIDE THE FULL RANGE OF IN-HOME SUPPORTIVE SERVICES AUTHORIZED BY LAW; AS A RESULT, CERTAIN IN-HOME MEDICALLY-RELATED SERVICES ARE EITHER FURNISHED BY UNQUALIFIED PROVIDERS OR ARE NOT BEING PROVIDED AT ALL

Presently, homemaker and chore services are viewed primarily as social services despite the fact that clients, in order to be eligible for these services, have some medically-related infirmity. The result of this view is that clients are authorized those services which are designed to meet their social need to remain in their own homes. As a client's medical condition deteriorates, these services continue to be the only source of in-home aid until his condition requires institutionalization. Thus, a gap exists between the domestic kinds of services authorized under the homemaker-chore services program and the medically-related services provided by an institution.

Some counties have formally recognized the medical aspects of in-home supportive services by requiring an assessment by a physician of the client's medical needs prior to the authorization of homemaker and chore services. Some of these counties currently authorize home health agencies to provide medically-related personal services such as bed baths and passive exercises in addition to authorizing homemaker and chore services.

As previously noted, in 3 of the 10 counties included in our review we observed medically-related services being provided by unqualified persons. For example, we visited a client with acutely high blood pressure who was under medical advice to monitor her blood pressure on a regular basis. During our visit we observed the provider taking the blood pressure and noted that she did not know how to properly read the instrument.

In another instance, a relative-provider was performing renal dialysis for the client. Although this is clearly a medically related task, it was funded under the homemaker-chore services program. An analysis of the service needs of the client indicated that only 7 hours a month were needed for homemaker or chore services. Therefore, it was costing the homemaker-chore services program $400 per month when as much as $385 per month could have been funded through a medically-related program.

In our interviews with county officials, we found that these officials are aware that medically-related activities are being performed by unqualified providers. One welfare department administrator said, "I shudder at the idea that some providers go from waxing the floor to irrigating a catheter or giving an insulin shot." But he added, because the clients ask the providers to perform these tasks, the counties have virtually no control or means to prevent it even though it is recognized that these activities could result in a serious injury to the client and a potential liability for the county and provider.

Chore and homemaker services represent the first and second levels of a range of both social services and medical care that have been authorized for recipients of public assistance by both State and Federal law. The following table shows the position of homemaker and chore services in this range and their approximate monthly costs.

TABLE 2, THE RELATIONSHIP AND COST OF HOMEMAKER AND CHORE SERVICES AND OTHER MEDICAL SUPPORTIVE SERVICES AND CARE AUTHORIZED FOR RECIPIENTS OF PUBLIC ASSISTANCE

1 The actual upper limit was $24.32/h but applied to so few persons that $7.75 was assumed to be more repre tive.

* Clients classified as severely impaired may receive up to $450/mo.

Home health aides are primarily used in California to provide services as a followup to hospitalization.

4 Funded through public assistance, not Medi-Cal.

Rate determined by bed space.