Administered by: Montana Department of Social and Rehabilitation Services
Date of Site Visit: October 22 to October 26, 1990
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I. Program Overview: Size and Type of Population Served, Service Delivery System, Expenditures, Program Objectives
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The Medicaid Personal Care Services Program is one of two personal assistance service programs in Montana administered by the State Department of Social and Rehabilitative Services (SRS). The program had a budget of $3,872,000 in FY1990, and served an average of 608 people per month. The program serves Medicaid eligible people (income eligibility is 74% of poverty level for single individuals and 83% of poverty level for couples) who need assistance with activities of daily living. Service is capped at 40 hours per week. Services are provided by a single statewide contract agency.
The Medicaid Personal Care program's main objective is to help people stay in their own homes as long as possible rather than rely on nursing homes. Cost containment is an explicit part of this objective. Roughly 60% of the clients are elderly, and receive an average of 14 hours per week.
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II. Program History
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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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III. Gatekeeping and Supervision Functions: Eligibility, Needs Assessment, Case-Management, Medical Supervision
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A. Eligibility Determination
Initial financial eligibility for Medicaid is assessed by the DSRS. Referrals can come from a number of sources (i.e. discharge planners, physicians, social workers, self, family, etc.). West Mont begins service upon verification of income eligibility, although in some cases they may initiate services for people who are not immediately income eligible but must spend down to Medicaid level. The agency technically has up to three weeks to notify the referral source of initiation of services, but in practice less time is required.
If there is a hazardous home situation or immediate risk of institutionalization, an emergency referral can be made. In these cases, the agency must contact the individual within 24 hours, and start providing services within 48 hours pending Medicaid verification.
Assessment of ADL needs is done by a West Mont nurse supervisor. At least one ADL is required for eligibility, and hands-on personal care rather than supervision must be the primary need of the applicant.
At the time of the assessment, the nurse supervisor give the referred individual a booklet which outlines the services which are and aren't covered, a list of West Mont contact personnel, and a description of the complaint procedure. There is an appeal process for denial of services, but some advocates felt that many consumers who are deemed ineligible for services realize that they can appeal.
B. Needs Assessment
A detailed plan of care is developed by the RN with the recipient, which assesses medical diagnosis, medications, diet, short and long term objectives, etc. As part of this plan of care, the type and frequency of specific ADL related tasks are listed. The client or surrogate is required to sign a consent and release form once the plan of care is adopted.
C. Case Management
Case-management is not a regular service of the Medicaid Personal Care program. People who need case-management are referred to the Waiver program. The SRS liaison, program mangers, and West Mont program director are all social workers.
D. Medical Supervision
The amount and consistency of nurse supervision increased when West Mont took over the program. West Mont RNs are required to complete a plan of care every 90 days. Originally RNs were required to complete a plan of care every 60 days, but the DSRS and West Mont decided that the majority of consumers were stable and the attendants consistent enough that this level of supervision was unnecessary.
The physician must order services, and is required to reauthorize services at least once a year. Nurse supervisors attempt to contact the recipient's physician verbally prior to assessment. In some cases, instead of waiting for the physician to initiate reauthorization of services, West Mont often completes the assessment and mails the results to the recipient's physician for a signature.
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IV. Service Limits
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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.
4. Supervision
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.
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V. Support Services Available
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A. Attendant Management
1. Attendant Recruitment
West Mont usually does this, although they actively encourage the consumer to recruit their own attendants and refer them to West Mont for hiring and training. The general impression among advocates and providers was that this did not occur very frequently. Consumer choice of attendants is therefore usually limited to the current attendant pool.
2. Attendant Screening
West Mont does an initial screening of applicants.
3. Attendant Interviewing
West Mont does all hiring procedures.
4. Attendant Certification
There is no certification required, although there was some talk of requiring attendant certification in the future.
5. Attendant Hiring
West Mont does all hiring procedures.
6. Attendant Training
An initial 16 hour training is required, but can be waived if the attendant is a certified Home Health Aide or LPN. The training includes orientation to the agency/community services, body mechanics/transfer/assisting patient mobility, personal care skills, care of home/personal belongings, safety/accident prevention, food/nutrition/meal preparation, and health oriented record keeping, including time records. West Mont may also set up one to one training with the consumer in order to learn techniques specific to that individual. Some attendants felt that more of this type of on the job training would be useful. This training requirement is apparently in conflict with the staffing demands in some of the local offices; training occurs on a regular schedule (e.g. monthly) but turnover occurs all the time, so attendants may end up working before they receive training if the nurse supervisor considers them competent.
An additional 8 hours of in-service training are required each year. Four hours are a review of the 16 hour training, and another 4 are in topic specific modules offered throughout the year, e.g., AIDS, death and dying, diabetes, etc.
7. Attendant Supervision
The nurse supervisor is required to make sure the plan of care is being followed. According to nurse supervisors, some informal monitoring may occur among attendants, i.e., since several attendants usually serve each recipient, they can tell whether the attendant who came in before them did the tasks required.
8. Attendant Payment
Attendants are paid an hourly wage and mileage reimbursement by West Mont.
9. Attendant Termination
West Mont is responsible for attendant termination.
10. Conflict Resolution
Recipients can contact the scheduler or nurse supervisor if there is a problem, and West Mont administrators stressed their willingness to respond to consumer complaints. In practice, some advocates say the Tole of West Mont as the single source of attendant services creates a power dynamic where consumers are afraid of "rocking the boat" by complaining about their attendants. The DSRS has a formal appeal process if the recipient is unable to resolve the conflict with agency staff.
B. Consumer Support
1. Consumer Advocacy
There is no formal mechanism for consumer advocacy outside the West Mont and DSRS system, although independent living centers provide advocacy and peer support in some areas. If services are terminated, a detailed explanation is provided for the discharge which also outlines options for appeal. Services are continued throughout the appeal process.
2. Consumer Training
No consumer training is offered.
3. Consumer Outreach
West Mont does some outreach to different professional groups to inform them of the services available.
4. Quality Monitoring
There is a bi-annual state compliance review of West Mont which looks at components mandated by the program, i.e. medical supervision, assessment, training, maintaining attendant pools, billing procedures. West Mont also conducts quarterly interviews with a small subset of service recipients to assess satisfaction level.
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VI. Attendant Issues: Family Providers, Wages, Benefits, Withholding
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A. Family Provider Regulations
The program has used a rigid HCFA definition of family exclusions (i.e. husband, wife, parent, child, sibling, adoptive child, stepparent, stepchild, stepbrother, stepsister, father in law, mother in law, daughter in law, sister in law, brother in law, grandparents, grandchild are not allowed to become providers) since 1982, but compliance wasn't monitored before West Mont. The exclusion of all family providers apparently caused particular problems for Native American consumers, who have a strong cultural tradition of family support. Many of these consumers simply dropped off the rolls.
B. Attendant Wages
The starting hourly rate for West Mont attendants is $4.00, which is raised to $4.30/hour after 3 months. This wage is paid for travel to and from the recipients home, as well as time on site. The demands of a growing caseload have increased pressure on West Mont to recruit and maintain an adequate labor pool. West Mont and the DSRS, pointing to an attendant turnover rate of approximately 150%, have lobbied the legislature for increases in the per unit reimbursement by the state, in order to pay for increased attendant training, wages and benefits, as well as increased administrative costs. The reimbursement level has been increased, but in order to curtail the increasing costs of the program, services have become more limited.
The state currently pays a total of $7.75/hour of service, 71% of which goes to attendants. Overall, West Mont Administration says that 89% goes to salaries and taxes and 11 % goes to fixed costs. The specific breakdown provided by the SDSD is:
$ 5.52 PCA Wages and Benefits (including overtime) $ 0.97 Administrative Staff (includes scheduling) $ 0.67 Rent, Supplies, Travel, etc. $ 0.47 Nurse Supervision for PCAs $ 0.12 PCA Training --- $ 7.75 Total Cost Per Hour C. Attendant Benefits
Social security and worker's compensation are deducted, and health insurance is offered. Personal leave and overtime for holidays are also offered.
D. Withholding and Liability Issues
As can be seen from the program's history, attendant liability issues were a critical catalyst in Montana's decision to switch to an agency provider. Until 1984, attendants were paid $3.85 an hour, $.50 of which was supposed to go to social security, worker's compensation and unemployment insurance. In fact, most attendants did not do any withholding, and pocketed the entire $3.85/hour. In 1984, some former attendants applied for unemployment insurance. The DSRS claimed that the attendants were independent contractors, but the Montana Department of Labor ruled that attendants were state employees eligible for worker's compensation and unemployment, and that the DSRS was responsible for withholding FICA. The DSRS appealed the decision, but ultimately paid back withholding to the DOL.
The state did not want the 1500 attendants considered as state employees, and feared that the DOL ruling would be used to lobby for provision of full government worker benefits to all attendants. To avoid this possibility as well as to be rid of withholding responsibilities, the state administration decided to shift to an agency mode as soon as possible. When a single state provider agency was selected, the majority of attendants working in the program became West Mont employees. Because West Mont began to do withholding, attendants received $3.35/hour and the other $.50 went for benefits. Attendants lobbied the legislature because they felt they had in fact received a pay cut. At that time, West Mont began to receive $5.15 per hour to cover the costs of nurse supervision, administration, and an additional $.19 needed to augment the withholding for attendants. Lobbying has continued to increase the state reimbursement rate in order to provide higher wages and benefits.
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VII. Program Context: The Relation of Medicaid Personal Care to the State Service Delivery System as a Whole
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A. An Overview of Other State Programs
The other source of PAS in DSRS the Medicaid Home and Community-Based Services Waiver program (which has a slightly higher budget and caseload). This program involves varying degrees of case-management and may provide services other than personal care. The Waiver program has an extensive waiting list. A Title III program offers services primarily homemaking services to older people.
In general, services for people with disabilities are fragmented among disability groups in Montana. There are departments in the state government concerned with the services for those with DD, ED or those who are aging, but adults with disabilities as a whole do not have a department which addresses their needs. There are referral relationships across departments, i.e. Social and Rehab Services, DD Council and Family Services.
B. Who is Falling Through the Cracks?
According to some advocates, people with exclusively cognitive or mental disabilities who primarily need supervision are not adequately served by either the waiver or personal care programs. Under the waiver, people who are nursing home eligible can theoretically get up to 40 hours of personal care per week as well as case management, as long as the total cost of services falls below the expenditure cap (if extensive case management or other support services are provided, less than 40 hours of attendant care are available). Homemaker services, respite services, adult day health, nursing, transportation, environmental modification and other services are also available under the waiver.
Individuals with an ongoing level of need higher than 40 hours (other than those who were grandfathered in before service caps were set) are not served by any attendant care program in the state, except for 7 slots on the Waiver program for people who otherwise would need 24 hour hospital care. When administrators were asked "what happens now to the people who come into the program needing more than 40 hours per week of services?", the answer varied with the respondent, from "there has been no increase in nursing home utilization rates so people are simply making do" to "those who can move to other states". Advocates say that such individuals are remaining in nursing homes, or attempting to link together additional community or personal resources.
C. The Political Future of the Personal Care Program
The state may soon switch to regional contract agencies rather than a single statewide contract. The contract with West Mont is coming up for renewal in June of 1991, and since there is a more reasonable implementation period, the regional approach may be feasible. State administrators suspect that cooperation and contentment may be higher because there is a perception in the counties "that anything administered from Helena can't be any good". The program would be administered closer to home and this would make dealing with individual problems easier. However, provision in rural areas might become even more difficult, and there is some concern that administrative costs may increase markedly with a decentralized administration.
The Personal Care Advisory Committee has proposed a more consumer-directed pilot project. The pilot is intended to serve a small number of people. This is because the rationale for the pilot was based primarily on the results of a conference the advisory committee hosted in Montana with New York's Options for Independence in December of 1989. Looking at utilization rates in New York, Options for Independence concludes that only 1% of the recipients in the state are actually functioning at a high enough level to be self directing. After examining their caseloads, West Mont supervisors and DSRS administrators concur with this figure (although other national disability advocates consider this estimate extremely low).
The pilot project was almost derailed when the chair of the committee, a person with a disability who was also a member of the state legislature, proposed a case-management based program during the legislative session, claiming he had the backing of the full advisory committee. This project was dramatically different from the self-management model many members of the committee had envisioned. Not surprisingly, the legislature was dubious of the dissention within the committee, but ultimately passed two pilot projects.
There has apparently been no follow-up on the case-management based pilot program, and problems have also emerged with the self-management pilot RFP. The first time the RFP was submitted, only one proposal came in. Some advocates felt that the RFP required too much nursing supervision and control, and all parties considered the timeline unrealistic. The RFP has gone out again with some changes in timing, and has apparently met with a better response.
There is also talk of requiring attendant certification and creating some sort of career ladder among attendants in order to cope with high turnover, but fiscal pressures may preclude such action. The wage rate will be raised to a starting rate of $4.25/hour on January 1, 1991, in order to reflect a rise in the minimum wage.
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Individuals Interviewed on Site
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Dept. of Social and Rehab Services:
- Nancy Ellery, Medicaid Bureau Chief
- Joyce DeCunzo, Services Director
- Jane Korin, Human Service Program Officer
- Mike Hanshew, LTC Bureau Chief
- Julia Robinson, Director of Social and Rehab Services
Vocational Rehab:
- Bob Maffit
Personal Care Advisory Council:
- Chris Bukula, Montana Advocacy Council
- Evelyn Hauskjold, Area Agency on Aging
- Barbara Larsen, Summit ILC
- Jan Miller, Council Member
- Joan Taylor, Case Management Association
- Dorinda Orell, Consumer Rep
- Lenke Puskas, Consumer Rep
West Mont Homecare Corporation:
- Maureen O'Reilly, West Mont PCA Program Director
- Myrna Moon, RN, Western Regional Coordinator
- Gwen Berry, RN, Central Regional Coordinator
- Ron Simpson, RN, Nurse Supervisor
- Karen Burland, RN, Nurse Supervisor
- Attendants at both Helena and Missoula sites
Summit Independent Living Center:
- Michael Mayer, Director
- Barbara Larsen, Support Services Coordinator, PCA Advisory Board President
- Consumer Forum, hosted at University of Montana
Montana Independent Living Project:
- Zana Smith, Director
- Consumer Forum, hosted at Montana ILP
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