Case Studies of Six State Personal Assistance Service Programs Funded by the Medicaid Personal Care Option. VII. Program Context: The Relation of Medicaid Personal Care to the State Service Delivery System as a Whole


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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