Analysis of the California In-Home Supportive Services (IHSS) Plus Waiver Demonstration Program. Functional and Other Limitations of IHSS Recipients


The IHSS program authorizes PAS based on consideration of four broad areas of assistance need. These include cognitive limitations (i.e., memory, orientation, judgment), assistance in ADLs (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual care; eating), IADLs (i.e., housework, laundry, shopping and errands, meal preparation and clean-up, mobility inside), and problems in breathing. Each of these areas is evaluated and scored on a 1-5 (some on six) point scale.23

  1. Independent -- able to perform functions without human assistance though recipient may have difficulty; and completion of the task with or without a device poses no risk to safety of the recipient.

  2. Able to perform, but needs verbal assistance such as reminding, guidance, or encouragement.

  3. Can perform but needs some human help (e.g., direct physical assistance from the provider).

  4. Can perform with a lot of human assistance.

  5. Cannot perform function at all without human assistance.

  6. Paramedical services needed.

The number of limitations were compiled for each recipient during every month of their IHSS participation in 2005 and averaged over these participation months. An average of score of 3.0 or more indicates a task in which individuals were determined to have task assistance needs requiring at least direct physical assistance from a provider in 2005. Table 6, shows the group mean of the number of tasks that received an assessment score of three or more. The results are organized by age group and provider type; and by new and continuing IHSS recipients. ADL assistance dependence in three or more areas predominates for all recipient age groups, with at least one-third of recipients having task assistance needs in four or more areas. Children as a group, have somewhat more recipients with higher numbers of task assistance needs, averaging 3.6 such limitations compared to averages of two+ among the other age groups. IADL limitations are even more pervasive, with more than 95% of the aged and non-aged IHSS recipients needing direct physical assistance in four or more tasks. The proportion among children is somewhat lower, with two-thirds having this level of assistance needs. Cognitive limitations as represented in this compilation are also indicative of the level of impairment requiring human assistance. Levels of assistance that require only “reminding, guidance, and supervision-level” are not included in this scoring. Rates of cognitive limitations at this level of need are higher within the adult recipients than among children. Children on the other hand are more commonly characterized (about 15%) with severe breathing limitations (i.e., require human assistance to use self-administered oxygen or the cleaning of this equipment. This rate is about double those of the other age groups).24

The main interest in these analyses is whether there are differences among provider subgroups in each recipient age cohort. Among children, there are essentially no differences in the mean number of cognitive, ADL, or IADL limitations. This is generally true, as well, comparing new versus continuing recipients. The most notable difference is in the percentage of recipients with severe breathing limitations. This rate is lower among the entering recipients than among those continuing, but it is relatively consistent among the provider subgroups. Parents continue to be the predominant providers for this condition, but the percentage of recipients needing this level of care is more uniformly distributed among the other providers. Non-Relative providers proportionately serve more such recipients among the new recipients than either of the other provider groups. A striking difference is in the number of authorized IHSS service hours. On average the continuing recipients are receiving about 40 more hours per month than new recipients. This difference is constant among provider types. Some of this seeming disparity may be an artifact of the CMIPS data system, where authorized hours are adjusted with changes in functional conditions and living arrangements, but where revisions in the recorded assessment data may lag by a number of months. In other words, continuing recipients may be somewhat more functional limitations than new recipients, with this difference being reflected in authorized hours rather than in the number of functional limitations recorded in the data set.

Recipients age 18-64 and those 65+ have several patterns in common. First, Spouse providers tend to have proportionately more impaired recipients than the other provider types, and to be comparable to each other going across the age groups. These patterns are reflected in the mean number of cognitive and ADL limitations, and in the percentage of recipients with severe breathing limitations. Other Relatives and non-relatives, tend to have proportionately similar levels of impairment in their recipients across these aged and non-aged adult groups, and comparing new with continuing recipients. Parents (represented only among non-aged adults) tend to have recipients with cognitive and ADL impairment levels somewhat in between those of recipients with Spouse and the other providers. Paradoxically, Parent providers receive the highest average number of authorized IHSS service hours. Perhaps this occurs because of higher acuity needs of recipients known to the social workers that are not well represented in the CMIPS measures. Spouses receive hours comparable to those of non-relatives. Other Relatives have fewer authorized hours, with some of this difference possibly reflective of the household size and the downward adjustments made with IHSS hours when there are parents, spouses, or other non-disabled individuals residing in the household who are able to do routine household chores. Finally, the pattern of systematic differences in authorized hours comparing continuing with new recipients is also present among adult recipients. This difference tends to be in the range of 20-30 hours, rather than 40 hours observed with minor children recipients.

Table 7 shows the distribution of physical and cognitive limitations by age for recipients in the Restaurant Meals voucher and Advance Pay programs. Those receiving Restaurant Meals vouchers generally have at least three limitations in IADL. At the same time fewer than one-third have three or more ADL limitations for which human assistance is necessary. About half have one or fewer such limitations. Very few recipients have cognitive or breathing problems. Similar patterns hold for IADL, cognition, and breathing limitations among recipients in Advance Pay. This group, however, is predominated by high levels of ADL limitations. More than 90% of recipients in each group have at least four ADLs for which human assistance is necessary. The difference in frailty mix between these two programs is consistent with their target recipients.

  1. Laundry is scored as 1, 4 or 5; shopping and errands as 1, 3 or 5; eating as 1, 5 or 6; breathing as 1, 5 or 6; memory, orientation and judgment as 1, 2 or 5. Meal preparation and eating both include a six point score.

  2. Table B-2 in Appendix B provides the frequency distribution of the functional task limitations of IHSS recipients in 2005.

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