Case Studies of Six State Personal Assistance Service Programs Funded by the Medicaid Personal Care Option. II. Program History


Montana began a personal care program in 1977. Up to that time, Title XX and state funds paid for county homemakers to do personal assistance and to transport people to doctor appointments. The state did a study to examine the possibility of getting Medicaid funding to maximize federal matching funds. It was projected that the state could train county homemakers in personal care, and then charge the personal care time to Medicaid. One hundred and fourteen full time county homemakers from all over the state were trained as personal care attendants. However, the counties were unable to keep an accurate record of personal care hours, so the state was unable to get the Medicaid match.

In order to centralize billing at a state level, in 1979 the Medicaid section of the SRS started awarding personal care service contracts directly to individual providers who were recruited by disabled individuals and billing this service through the PC-Option. There was no formal outreach conducted, only a word of mouth arrangement among county social service workers who would call the state Medicaid department when it appeared that homemaker services were not enough. Workers were paid minimum wage plus a small percentage intended to pay for withholding taxes, and county nurses provided the supervision. A single nurse in the DSRS was responsible for managing the PC-Option program, so oversight and enforcement of regulation was necessarily limited. Most of the first recipients were young disabled people, and the number of hours of service provided per individual per week could range as high as 130.

Then in 1983, a Medicaid Waiver program was started for people who were nursing home eligible. This program stressed case-management as well as PAS, and capped total service expenditures at 80% of nursing home costs (this service cap had apparently been part of the state Medicaid regulations on PAS prior to the advent of the Waiver program, but there was no systematic enforcement until this point). The program began slowly: regional case-management teams were phased in county by county. In 1984-85, the waiver program staff began an extensive outreach campaign, which included community meetings, brochures, etc. This increased the county social service systems' awareness of regular Medicaid personal care services as well as waivered services: people who were not eligible for the waiver (i.e. they were not nursing home eligible), could still receive PAS.

The caseload for Medicaid Personal Care Services began to rise dramatically, and administrative pressures on the limited staff in the state office also rose. Program administrators related anecdotes of early morning phone calls from angry and frustrated consumers who's attendants had not shown up. The increasing administrative demands for this program were further aggravated by a conflict with the state Department of Labor. Several attendants who wished to file for worker's compensation brought their case to the Department of Labor, who determined that attendants could in fact be considered state employees (see section on Liability for a further discussion of this issue).

Because of the labor issues and increased administrative demands, the DSRS made an internal decision to switch to a contract agency model of service provision. An RFP was let in the fall of 1986 for regional contract agencies and concurrently for a single statewide contract agency. The RFP required that the chosen provider would have to be ready to begin service provision on Jan. 1, 1987. No bids were received for one of the regions, so West Mont, a single nonprofit homecare agency, received the statewide contract to provide PAS throughout Montana.

The implementation period was extremely short; West Mont had less than three months to develop and implement a statewide administrative system. In this implementation period, personnel policies and intake and evaluation procedures needed to be developed, and staff had to be hired, and a personnel policies. All independent providers employed in this program were required to transfer onto the West Mont payroll. In essence, this meant a cut in an already low wage, because very few of the providers were actually paying their withholding taxes (see the Attendant Issues section for a discussion of withholding).

To structure the program, West Mont relied heavily on Medicaid program regulations that had, before this point, been enforced rather sporadically. This had a dramatic impact on the services received by some clients. Some providers had been performing paramedical services, despite prohibitions in the state's Nurse Practice Act. These services were now prohibited. Relatives who had not identified themselves as such were in some cases being paid as attendants (this was particularly problematic among Native American consumers, who traditionally rely on family for such assistance), but were not allowed to become West Mont employees. Medical supervision had been inconsistent, but West Mont stressed rigorous inclusion of nurses through their agency. The new emphasis on medical supervision seemed intrusive to some clients who were used to the previous system.

Also in 1987, the program changed the rules regarding provision of services outside the home. Prior to this decision, SRS had allowed attendants to accompany recipients outside the home to school, on vacations, on shopping trips, etc. The DSRS learned of three lawsuits in other states which ruled that the Medicaid statute on personal care is limited to the home, so the state decided to change their regulations to reflect this.

These program changes were met with considerable resistance from consumers, attendants, and the Independent Living Centers. The ILCs felt that the DSRS had not planned the transition well, and failing to consult with consumers, attendants, and advocates. In response to this conflict, the state formed an advisory body of providers, consumers, case managers from the waiver program, etc., to advise West Mont and the Dept of SRS. The Personal Care Advisory Committee has no budget and no statutory mandate (which is an ongoing frustration for at least some committee members), but it has created a "buffer" between the state program and the consumer because of the consumer and ILC representation.

The change to a single statewide provider agency has had both positive and negative repercussions for consumers. Older people appear to like the change; as one administrator observed: "they do not want as much involvement in choosing an assistant, in part because they receive less intrusive services". Program services are more available, particularly in rural areas, because the contract agency is statewide. The program is generally more accountable, attendants receive training, and availability of emergency workers has increased.

Some advocates and consumers feel that the agency model changed the relationship between attendants and consumers. Instead of hiring and managing their own attendants, they are now dependent on the agency for scheduling an increasingly limited number of PAS hours from numerous and constantly changing West Mont employees. In some cases (particularly among consumers with a high level of need), there was more attendant stability when the program used independent providers. One reason for this was that the consumer recruited and hired the attendant, so there was a more personal and individually accountable relationship. Advocates say that some consumers have experienced a decline in their quality of life because of limitations on paramedical services, limitation of PAS to the home, higher level of medical supervision, and a decline in total hours of PAS provided.

The program's caseload has continued to increase in recent years. This may reflect, in part, an increase in the number of older people with relatively less severe disabilities included in the program.

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