County characteristics are included in the analyses, primarily because of a concern about some variation in IHSS practice among the counties. The IHSS program is administered by county governments and IHSS program social workers in the counties are responsible for conducting program recipient assessments. Assessments are conducted at the time of program application and at least every two years for the regular IHSS recipients (annually for those in the IHSS Plus Waiver). They are also supposed to be conduct when there is a major change in status, there may be practice variation in this. Additionally, variation can occur in how social workers evaluate (or score) the level of the recipient’s limitations. A computer-based algorithm is applied against the assessments to determine the number of IHSS authorized hours. The algorithm adjusts hours based on household size and the availability of household members to provide domestic services. Other potential sources of program variation among counties include the mix of long-term care services available to those with personal care assistance needs, and the county’s discretion (within a cap set by the state) in setting the hourly rate paid to IHSS workers, and whether (and to whom) they offer health care benefits to IHSS workers. Counties share 17% of the cost of the IHSS program (34% of the pre-waiver Residual Program expenditures), and vary substantially with each other on wage rates. Within a county, the hourly rate paid for IHSS services by independent providers is relatively uniform. The combination of alternative service supply, IHSS wage rates, and per capital income (a proxy for cost of living), may influence the relative supply of IHSS workers. These factors may contribute to differences in whom recipients “select” as their IHSS provider.21
The following describes the measures compiled and used for county-level adjustments:
IHSS provider wage rates. These data are available on individual IHSS provider payment records. These were used to compile modal wage rates by county, information used in analyses of provider “choice.”
Per capita income was used to adjust for the cost of living in the county.
21. Residential care facilities for the elderly (RCFEs), adult residential facilities (ARFs), community care facilities (CCFs) beds are licensed by the DSS to provide room, board, and some levels of IADL and ADL support (ARFs service non-aged adults, CCFs serve the developmentally disabled, both those under and over age 18); nursing home beds, and state developmental centers (hospital-like settings for the developmentally disabled) and intermediate care facilities-DD and ICF-DD-H beds (freestanding nursing homes that specialize in custodial care for persons with developmental disabilities) are licensed by the Department of Health Care Services. These facilities in a county were initially considered as competing alternatives to IHSS use, but these services were found to be more associated with selection into IHSS, than IHSS use once in the program. Consequently, these measures were dropped from the analyses predicting provider type or health outcomes.