The absence of a personal care aide classification (described on page 193), the limited use of home health aides and the absence of a clear distinction between homemaker and chore services have widened the gap in the range of services available to the clients of public assistance. The transfer of social services from the former State department of social welfare to the department of health in July 1973 was partially designed to provide the administrative machinery to facilitate this perspective. Despite this intention, homemaker and chore services have yet to be integrated into a total medical-social service package. An integrated perspective would enable county welfare departments to respond more quickly in determining the optimum level of service for each recipient of benefits. For example, clients could more easily be moved from the homemaker-chore services program as their physical condition deteriorated. The need for flexibility in medical-social intervention becomes especially significant as a client begins to require increased medical care which is not the primary offering of the homemaker-chore services program. Provision of in-home medical service, while more expensive than homemaker and chore service, is less expensive than the alternative which is often institutionalization. Conversely, patients in institutions could be reviewed in light of all the medical and social services available in the community, a step which might enable a return to a less dependent and less expensive living arrangement. As a client begins to require increased and more costly homemaker and chore services, his condition should be evaluated by a medical-social review team (as institutional patients currently are) to determine if medically related inhome services are indicated or if, in fact, he can still benefit from an independent living arrangement. In cases where the client is determined to be incapable of further benefiting from his independent living arrangement, he might be transferred to a program offering more intensive care and supervision, a move which would be more appropriate to his need and more appropriate to the homemaker-chore services program. Medical-social review teams are currently used to review patients in intermediate care facilities (ICF) and nursing homes for appropriateness of care. Criteria could be developed to permit the use of this or a similar resource to review selected recipients of the homemaker-chore services program. The criteria could be based exclusively on medical indicators, on a combination of medical and fiscal indicators or be triggered semiannually by fiscal indicators only. Whatever criteria are used, they could be developed so as to apply to only those recipients showing a heavy reliance on homemaker and chore services and/or deteriorating health. They would not need to apply to all users of these services. Conclusion In spite of statutory authorization to provide for a full range of in-home supportive services, the department of health has not done so. This has resulted in either the provision of medically-related services by unqualified providers or medically-related services which are not being provided at all. Recommendations We recommend that the department of health adopt regulations which would permit the use of the full range of in-home medical-social services so that homemaker and chore clients will not have to depend on unqualified providers for medically-related services. We also recommend that the department require the use of medical-social review teams or their equivalent, where indicated, to assure provision of appropriate levels of services to clients. Benefits Implementation of these recommendations will permit the provision of the optimum levels of service at the minimum cost. THE DEPARTMENT OF HEALTH RELIES EXCLUSIVELY ON A SINGLE SOURCE OF FUNDS TO FINANCE HOMEMAKER AND CHORE SERVICES. CONTINUATION OF THIS PRACTICE WILL RESULT IN AN ESTIMATED ANNUAL LOSS OF $11.3 MILLION IN FEDERAL MEDICAL MONEYS WHICH COULD BE USED TO FINANCE SOME PERSONAL CARE SERVICES CURRENTLY PROVIDED ΤΟ CLIENTS UNDER THE HOMEMAKER-CHORE SERVICES PROGRAM The department of health has not exercised its full authority to obtain Federal moneys to fund homemaker type services. Section 12301.5 of the welfare and institutions code authorizes the State department of health to fund in-home suportive services, where appropriate, under the Medi-Cal Act. Section 249 of the Code of Federal Regulations, title 45 shows personal care service as a Médi-` Cal eligible service. Other States, including New York and Nevada (see appendix D [p. 196], have recognized the use of personal care services as a medically related expense. Despite this authority, the department has not developed the necessary procedures for transferring the personal care components of homemaker and chore services to a personal care program under title XIX of the Social Security Act (Medi-Cal). Also, the department has not identified the amount and type of services which could qualify for Medi-Cal funding. In the course of our review, we asked the counties to estimate the personal care component of their homemaker-chore services caseload. (We defined personal care to include passive exercise, bowel and bladder care, special dietary meal preparation, ambulation, and medicated bed baths.) Our analysis of the information that we received from the county welfare departments discloses that approximately 35 percent of the clients in the homemaker-chore services program require an average of over 25 hours of personal care per month. Based upon this analysis we have estimated that qualifying personal care services under Medi-Cal would result in an additional $11.3 million annually in Federal title XIX money received by the State. It has been argued that title XIX money requires a 50 percent State match, while title VI social services money requires only a 25 percent State match and therefore it would be monetarily advantageous for the State to continue to fund all aspects of the program under title VI. Although the basic concept of this argument is true, the Federal title VI is a fixed allocation which has not been increased for the last 3 years. When title VI is fully committed, as it now is, any additional program cost must be borne by State and local governments without additional Federal funds. The following example illustrates the monetary and social effects of total reliance on a single funding mechanism. In March 1975, the State augmented the homemaker-chore services program by $12.4 million in order to avoid a cutback in the level of services (see appendix C [p. 195]. Of this amount, $8,448,000 was unspent State adoption funds from the 1973-74 fiscal year which were carried over as a fiscal year 1974-75 general fund surplus. Of the $8,448,000, $1,333,267 was used to replace county funds which had originally been budgeted by the counties for nonhomemaker social services. This money was used by the State to earn $4,000,002 in Federal social service funds to produce a total of $5,333,269. This action by the State, therefore, made available a total of $12,448,002 for the purchase of homemaker and chore services as follows: State unmatched funds... State matched funds_. Total State Federal funds... Total available.... $7, 114, 733 1, 333, 267 8, 448, 000 4, 000, 002 12, 448, 002 However, this increase in the amount of money for homemaker and chore services also resulted in a $5,333,269 decrease in the amount of funds available for social services to children and nonhomemaker social services to adults. Therefore, the net effect of the State's allocation of $8,448,000 in State funds for homemaker services was to increase by only $7,114,733 the total pool of funds available for all social services ($12,448,002 less $5,333,299 equals $7,114,733; see Appendix C). While the precise impact of the March 1975 action on the provision of social services for fiscal year 1974-75 cannot be measured, it is clear that because of inflationary pressures, the impact in fiscal year 1975-76, in the absence of corrective action, will be either a cutback in the level of services or the funding of such services exclusively from State and county funds. By March of 1975, however, the use of title XIX funds to supplement homemaker and chore type services was not an available option for fiscal year 197475. The reason for this is that the title XIX mechanism did not exist in State regulations when the deficit became apparent. Section 249 of the Code of Federal Regulations, title 45 provides definitions for two classes of personal care providers. They are home health aide (section 249.10 (b) (7) (iv)) and personal care aide (section 249.10(b) (17) (vi)). The home health aide differs from the personal care aide primarily because the home health aide must be employed by a home health agency. The personal care aide, on the other hand, can work under an individual contract with the client or county. Current regulations permit the counties to use home health aides; however, county administrators have informed us that they are reluctant to use home health aides partially because the non-Federal share of their cost (50 percent) comes entirely from county funds. There are no regulations which permit the use of personal care aides. Conclusion In light of the fact that the cost of the homemaker-chore services program will exceed its original allocation during fiscal year 1974-75 which has resulted in an augmentation, the department of health should take the necessary step to transfer the funding of the personal care elements from the homemakerchore services program to Medi-Cal. Recommendations We recommend that the department of health exercise its existing authority to change the regulations which would permit the use of Medi-Cal funds for the purchase of personal care aide services. In the absence of such action by the department of health, the legislature should amend section 12301.5 of the Welfare and Institutions Code to require the department of health to issue appropriate regulations. Savings By using Medi-Cal funds in conjunction with the homemaker-chore services program, the department of health will be able to obtain an estimated $11.3 million annually in Federal matching Medi-Cal funds. SUMMARY OF COMMENTS BY DEPARTMENT OF HEALTH REPRESENTATIVES Representatives of the department of health stated that because of the limited time available for their review of this report, they could not provide detailed comments at this time. Our summary of the comments made by the department's representatives at the exit conference are as follows: -The estimated cost of total statewide implementation of the management information system, which has been piloted in two counties, would be approximately $2 million. -If the State were to distribute its matching funds to all social services programs, and assuming the same program level, those counties that have a higher proportion of homemaker and chore services to total social services, when compared to the statewide proportion of homemaker and chore services, would have to use additional county moneys to partially fund that part of their program which exceeds the statewide proportion. -There are two "myths" generally associated with the homemaker-chore services program. The first myth is that failure to provide homemaker or chore services will automatically result in institutionalization; it has been estimated that only 28 percent of those now receiving homemaker or chore services would have to be placed in an institution for care if these services were not provided. The second myth is that the use of the homemakerchore services program to maintain a person in his own home always saves the State money when compared to the cost of institutional care; in actuality, in many cases the cost to the State for homemaker or chore services exceeds the cost to the State for institutional care, but the social value of in-home care must be considered even though a dollar value cannot be placed on it. A MODEL FOR PROVIDING IN-HOME SUPPORTIVE SERVICES Appendix A The following descriptions of five provider classifications and their duties has been synthesized from suggestions and practice by State and county administrators and staff. They are presented here only for reference, and are not necessarily intended as a recommended course of action. CHORE PROVIDER (TITLE VI FUNDS) -Provider is employee of either client, county, or contract agency. (Current providers may qualify for this position.) -County coordinates provider assignments. -Function of the provider is to perform domestic services (i.e., cleaning, laundry, shopping, and cooking). -Relatives of the client are paid only for the extraordinary services they provide. -County deducts employee's share of social security contribution and adds the employer's share of social security. -Taxes are paid to Internal Revenue Service by the county. HOMEMAKER PROVIDER (TITLE VI FUNDS) -Provider is a county employee, or an employee of a contract agency. -Special training and certification required. -Function of provider is to train clients to perform personal and household activities which are difficult to perform due to accident or illness. -Service is expected to be of short duration. -Client must have a high probability of being trained and becoming selfreliant. PERSONAL CARE AIDE (TITLE XIX FUNDS) -Aide is under contract to county, or is an employee of a contract agency. -Special training and certification required. -Supervised and coordinated by registered nurse. -A doctor's plan is required to qualify for Medi-Cal funding. -County is responsible for social security contribution as previously described. -Service is not to exceed 20 hours per week. -Services are of a personal care nature (i.e., bed baths, passive exercises, ambulation, and special diet preparation). -Relatives of client do not qualify for this classification. -Section 249.10 (b) (17) (vi) of the Code of Federal Regulations, title 45, defines the conditions under which personal care services are Medi-Cal eligible: "Personal care services in a recipient's home rendered by an individual, not a member of the family, who is qualified to provide such services, where the services are prescribed by a physician in accordance with a plan of treatment and are supervised by a registered nurse." HOME HEALTH AIDE (TITLE XIX FUNDS) -Aide is an employee of a home-health agency. -Special training and certification required. -Supervised and coordinated by a registered nurse. -A doctor's authorization is required to qualify for Medi-Cal funding. -County is responsible for social security contributions as previously described. -Services are of a personal care nature. 1 ATTENDANT PROVIDER (TITLE VI AND TITLE XIX MIXED FUNDING) -Services are combined chore and personal care for clients requiring in ex- -County is responsible for social security contributions as previously described. 1 This class of provider embodies the chore providers who are now full-time providers for severely impaired clients and represents a mechanism whereby the personal care element of that service is Medi-Cal eligible. |