Case Studies of Six State Personal Assistance Service Programs Funded by the Medicaid Personal Care Option. V. Support Services Available


A. Attendant Management

1. Attendant Recruitment

The private nurse supervisor is primarily responsible for this function. S/he is often assigned all consumers within a certain geographic area, and intensive recruitment occurs within this area. Various techniques a-re used to attract potential employees, from newspaper advertisements to posting notices in grocery stores and churches, to (in extremely rural areas) knocking on neighbors' doors.

2. Attendant Screening

Agencies will call employer and personal references. The state runs a criminal check on potential attendants, but hiring usually occurs before the results are available. Convicted felons are not allowed to become attendants.

3. Attendant Interviewing

The agency does initial attendant interviewing during the screening process, but the client is involved in interviewing and hiring.

4. Attendant Certification

No programmatic certification is required, although there is some discussion of developing certification requirements for special attendants, who would then be able to perform certain paramedical tasks.

5. Attendant Hiring

After an initial screening, the potential attendant is called in for a meeting with the RN supervisor in the client's home. The client is ultimately responsible for deciding if the attendant is hired, but some consumers say that this choice may be couched by the nurse supervisor with observations like "people who accept these wages are hard to find". These observations may be accurate, but ultimately limit real consumer choice. When hiring is done, it is usually described as conditional, pending a criminal check and satisfactory performance of job duties.

6. Attendant Training

The RN supervisor will work with the attendant if any tasks require special training. The nurse must also explain medical conditions and special medical and dietary requirements of the consumer.

7. Attendant Supervision

The case manager, RN supervisor, and prior approval nurse all may be involved in, attendant supervision. Case-managers and RN supervisors both call and drop-in to make sure the attendant is there and is doing the assigned tasks. Consumers complained that unscheduled drop-in visits by nurses and case monitors can be disruptive, and seem to imply that the consumer "has nothing better to do than wait by the phone or door".

8. Attendant Payment

Agencies are responsible for this function.

9. Attendant Termination

Either the consumer or the RN supervisor may terminate an attendant.

10. Conflict Resolution

Most conflict resolution between consumers and providers is done informally with the case manager or RN supervisor, but formal resolution may involve the consumer, attendant, caseworker, RN supervisor and prior approval nurse. Once a vendor is chosen, the recipient cannot change vendors until the next case-manager assessment (every six months) unless the agency is not meeting the state standards.

B. Consumer Support

1. Consumer Advocacy

Some RN supervisors and caseworkers interviewed described themselves as consumer advocates, but there is no formal advocacy system outside of TDHS and the agencies.

2. Consumer Training

No consumer training is offered except for basic health information from the RN supervisor if s/he considers it necessary.

3. Consumer Outreach

Program administrators consider outreach unnecessary, because the program has already become an entrenched part of the state service system. Vendors cannot actively recruit eligible clients through advertising campaigns, etc., instead they must rely on word-of-mouth recommendations from other consumers and caseworkers. Industry representatives and DHS administrators claim that the competition among vendors for client contracts improves overall service quality, because the program's reputation for quality are the only way to maintain a stable client base.

4. Quality Monitoring

The state has made administrative changes to clarify tasks among supervisory and gatekeeping personnel, solidify outcome monitoring procedures for provider agencies, and clarify client rights and client ability to chose. Over a two year period, a large manual was developed which defined the roles and relationships between the recipient, state attendant, case worker, agency nurse supervisor and state prior approval nurse.

The TDHS has also developed a compliance monitoring procedure for vendor agencies. The prior approval nurses are responsible for making sure that agencies maintain minimum standards of compliance in the following areas: referral response times, starting service times, continuity of services, reassessment procedures, determination of attendant competence, orientations of attendants with recipients, and explanations of complaint procedures to clients. Agencies must have a 90% compliance rate, or their contract is canceled. On the first compliance reading, 15 % of agencies fail to meet standards, but almost all manage to improve by the next reading. Only one agency has in fact lost its PHC contract for consistent failure to meet standards, but word of the contract termination "spread like wildfire" among the agencies. Some advocates question the process, saying that the compliance standards are designed to assure consistency within the documentation, rather than improve the quality of the services for consumers.

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