A. Total Services Allowed Per Consumer
Service is capped at 40 hours per week, although with prior approval by the DSRS, services above 40 hours can be provided for brief periods (e.g. post hospitalization). Over the years, as the cost per service unit has increased, the number of service units delivered has decreased. When independent providers were being paid $3.85/hour, the maximum number of hours per individual allowed was 70 per week. When the West Mont contract started in 1987, the unit cost was established at $5.25/unit, but wages (less required withholding) and maximum hours remained stable. Deciding that this pay rate was too low to retain attendants, West Mont terminated their contract with SRS on January 1, 1988. The contract went out for bid again. West Mont received a new contract in which the per unit cost was raised to $7.45, the attendant wage was raised back to $3.85 plus benefits, and the maximum hours per consumer were decreased to 56 hours per week. The per service rate was raised to $7.60 on 7/89. At that time, PCA wages began to go up, first to $4.00/hour, and then to $4.30/hour. When wages were raised, maximum services per person dropped to 40 hours/week. At the time of each change, those receiving the higher levels of service were grandfathered in (there are a few people receiving over 100 hours/week under this clause).
It is clear that quality of life for some consumers is being adversely affected by the service limits. Moreover, nurse supervisors point out that cutting hours may not decrease overall costs. The logistical demands of coordinating attendant services increase as the maximum hours decrease, because more attendants are needed to visit for brief amounts of time to meet minimum ADL needs of clients. This leads to increased administrative costs, which may offset some of the savings obtained by limiting billable hours.
B. Type of Services Offered
1. Paramedical Services
The state's nurse practice act prohibits the provision of "invasive medical procedures" by unlicensed individuals, and prohibits tasks like injections, internal catheters, bowel programs, etc. Although the regulation did not change when agencies took over service provision, adherence to the regulation increased markedly. Previously, IPs had apparently performed paramedical functions (i.e. injections, dressing changes). Currently, the state subcontracts with home health aides (HHAs) to provide medical services. Increasing nurse supervision and using HHAs has increased program costs.
2. Emergency and Respite Services
West Mont has on-call attendants at all times for emergencies. A recipient must have an ongoing need for services; respite by itself is not an allowed service.
3. Homemaker Services
The program doesn't allow attendants to perform heavy maintenance or chore services, e.g. chopping wood, shoveling snow. Housekeeping services are not provided except as incidental to personal care.
Supervision is not a primary task allowed in the Medicaid Personal Care program (although clients who need this service may be served by the Waiver). In practice, tasks may be spread out over the day or week, as a way to monitor some consumers.
As part of the referral process, physicians are required to assess the consumer's ability to take care of their own health and safety needs for the time they are not receiving attendant services. The program therefore makes the general assumption that the individuals referred are competent to self-manage when the attendant is not in the home.
West Mont and SRS administrators expressed concerns about this policy in some individual cases, but ultimately the decision to utilize the program rests in the hands of the consumer. If the nurse supervisor thinks a recipients' health and safety needs are in jeopardy, s/he may make a referral to Adult Protective Services (APS). In the past, such individuals would probably have been denied services altogether, and most likely referred to a nursing home. Now APS assesses an individual's competence and the risks of staying in the community with only 40 hours of service per week, and asks the individual or a guardian to decide if he or she is willing to take these risks.
C. Location of Service Provision
Provision of PAS is now limited to the consumer's home. With prior authorization, the state will provide PAS to people in foster or group homes if the individual's that are more than is normally provided for in these homes. An attendant sharing co-op facility for people with physical disabilities is currently under construction in Missoula with HUD funds, and PAS will be paid for by the Medicaid PC-Option to residents.