Over the next decade, demand for direct care is predicted to increase by 35 percent, far outpacing the projected growth of the traditional labor pool for direct-care workers (2 percent).

In the column, PHI National Policy Director Steve Edelstein is quoted: “Unless we pay attention to building the direct-care workforce we will need, we may well find that when the full impact of the Baby Boom hits, the pendulum may swing back toward nursing-home care.”

The column, written by Linda Valdez, explores several training efforts underway in Arizona, with the goal of developing a high-quality, professional home care workforce.

The Tucson-based adult home care company Catalina In-Home Services — recently identified by PHI as an industry best practice for providing quality direct-care jobs — is featured in the article.

Also featured is the CareGiver Training Institute, which came into existence when Catalina’s founder, Judy Clinco, recognized the need for a high-quality, well-trained home care workforce. The Training Institute helps prepare students to become certified nursing assistants.

Arizona state flag

A court order has been issued in one of the country’s most long-running and high-visibility Medicaid class action law suits affecting home and community-based services.

In Ball v. Betlach, a U.S. District Court Judge ruled on March 8 that Arizona’s Medicaid program failed to follow the court’s prior orders by not implementing a statewide hotline for beneficiaries to report gaps in critical home care services and by failing to require its program contractors to have backup workers on call to substitute for times when a gap in critical services occurs.

PHI Director of Policy Research Dr. Dorie Seavey provided expert testimony in the case.

Failure to Provide Adequate Home and Community-Based Care

The original class action lawsuit was filed in 2000 by attorneys from the Arizona Center for Disability Law and the AARP Foundation Litigation on behalf of Arizona Medicaid beneficiaries who are elderly or living with disabilities.

The plaintiffs alleged that the Arizona Health Care Cost Containment System (AHCCCS) was not providing these consumers with adequate home and community-based services (HCBS), such as attendant care, personal care, and homemaker services, which make it possible to live in the community rather than be forced into more institutional nursing homes.

After a trial in 2004, Judge Earl H. Carroll found that the state’s failure to provide home care workers caused the plaintiffs to be “trapped in bed unable to change position or care for personal hygiene, abandoned for hours in a bathroom, left without food or water.”

The court ruled that, by declining to provide all of the home care services authorized, Arizona “failed to provide the representative class members with the equal access, quality of care, and freedom of choice to which they are entitled” under the federal Medicaid statute. Carroll ordered Arizona to provide all critical home care services and to fill all gaps in services within two hours.

Expert Testimony from PHI’s Seavey

Seavey, who testified at the original trial, prepared an expert report (pdf) for the court’s most recent ruling that investigates the adequacy of the steps that AHCCCS has taken to address the problem of gaps in critical services.

“What’s notable about the Arizona case is that the judicial system has stepped up to insist on basic standards and program requirements for creating reliable backup mechanisms for authorized personal care services, and it also demanded accountability through system-wide tracking and monitoring,” Seavey said.

Without reliable backup, people with disabilities are put at risk when these Medicaid services are not delivered for whatever reason, as a national report coauthored by Seavey explains.

“The evidence I examined,” Seavey says, “suggests that two of the court’s prior orders were not being met: namely, to create a hotline for consumers to call if they experience a service gap, and a requirement that program contractors maintain pools of on-call backup workers. The courts new order seeks to rectify this situation.

“I also found serious deficiencies in the state’s monthly reporting on gaps in critical services and these remain, in my opinion, a serious problem requiring further attention,” Seavey continued. “Without better monitoring, it will be impossible to determine whether the root problem underlying this lawsuit — gaps in critical services — is getting better or, in fact, worse.”

Aspects of the Ball case are currently under appeal to the U.S. Court of Appeals for the Ninth Circuit.

– by PHI Policy Team

At least 34 states have been forced to enact cuts that hurt their vulnerable residents, according to the Washington-based Center on Budget and Policy Priorities (“An Update on State Budget Cuts,” March 18, 2009, pdf). But the Times reports that “Perhaps nowhere have the cuts been more disruptive than in Arizona, where more than 1,000 frail elderly people are struggling without home-care aides to help with bathing, housekeeping and trips to the doctor.”

When newly seated Republican Gov. Jan Brewer took office in January, she was faced with the task of cutting $1.6 billion from a $10 billion annual budget, and getting it done before the end of the current fiscal year on June 30. One of the casualties was a home-care program for elders.

Arizona is expecting to encounter a $3 billion budget deficit in the next fiscal year. According to the Center for Budget and Policy Priorities, although the federal economic recovery package includes about $140 billion for fiscal relief for state governments, this will only cover about 40 percent of the total shortfall that U.S. states expect to encounter over the next two-and-a-half years.

Mary Lynn Kasunic, president of the Area Agency on Aging in Phoenix, pointed to serious consequences from these developments. “If you don’t give people a bath a couple times a week, change the linens and make sure they get their medicines, their health will decline much faster,” she said. “They end up in the emergency room in a crisis, and then in a nursing home” (The New York Times).

Neither consumers or employers can afford to pay what workers deserve, says Clinco. “The solution is for the federal government to subsidize wages and benefits for this work force so that regardless of age, illness or economic status, everyone who needs long-term care will have it. A starting wage of $15 per hour is not excessive.”

Clinco is the founder of the Direct CareGiver Association, a Tucson, Arizona-based nonprofit that provides education and support for direct-care workers.

Elise Nakhnikian, Senior Online Editor
enakhnikian@phinational.org

Two stories in Vermont papers, one in the April 7 St. Albans Messenger and one in the April 4 Brattleboro Reformer, covered a new study about the state’s growing direct-care worker shortage. Both amplified its message and recommendations, stressing the need for higher reimbursement rates to long-term care providers, so they can increase pay and benefits for direct-care workers. “If employers are having trouble now with hiring and retaining workers, we’re really going to see a shift in the next 10 to 12 years as the baby boomers turn 75 and older,” said Alexandra Olins, PHI’s northern New England regional director, in the Messenger article.

The local experts quoted in the Reformer article included Susan Gordon, director of the Vermont Association of Professional Care Providers. Current funding levels “are not adequate to reimburse these people so they can make a living,” she said. “This is one of the top growing professions in the nation, and yet the people who do this work are at the very low end of the pay scale without access to benefits and have minimal training support.”

“These folks are caught in the middle,” Gordon added. “They want to do this and they know how important the job is and they care about their clients but if they can’t put food on the table or gas in their tanks, they can’t do it.”

In a March 25 editorial in the Des Moines Register, Executive Director Di Findley and Policy Director John Hale of the Iowa CareGivers Association wrote about the work being done in Iowa to “get beyond talking about meaningful health-care reform and may take actions that achieve it.” A health reform bill passed by the House on March 1, they note, “included more than many thought possible” and “set the stage for bolder action in the Senate.” Hale and Findley also explained the importance of the proposed expansion of health care coverage to direct-care workers, saying: “Too many direct-care workers are uninsured, and too many more are poorly insured. Too many care for others while being unable to get care for themselves. That’s just not right, and that needs to change.”

Earlier that month, a letter to the editor from a direct-care worker in Maine also explained why workers need better pay and benefits. “I believe low wages and lack of benefits resulting from low state reimbursements for these services are the problem when it comes to recruiting and retaining home care workers,” wrote personal support specialist Helen Hanson. “I do not have health insurance through my work. My husband and I buy our own. It comes with lousy coverage and very high deductibles. We have it so we won’t lose our home. If I ever got sick, I would have to find other work that does provide health benefits. That would leave the people I assist without their helper, on a long waiting list to get another. Some might have to enter a nursing home, costing taxpayers many times more.”

In an article in Inside Tucson Business, Judy Clinco outlines the need for better training and more respect for direct-care workers – as well as the personal experiences with caring for her own parents – that led her to found the Direct Caregiver Association. “”Within our society, within our country particularly, we don’t value and honor people who are aging and disabled and chronically ill,” she said. “And because we don’t honor those people, we don’t honor the people who provide the care to them.”

And an insightful feature about direct-care workers posted in blog format by Washington State’s Daily News Online elicited a string of sympathetic comments from readers. “Thank you for writing an article that highlights the heart of all nursing facilities; the staff that provides the care,” wrote one. “This is by far one of the most difficult jobs there is, one that is taxing to the back, the mind, and the heart. Caregivers are an extremely hardworking bunch that provide total care to those in their charge. They are the invaluable eyes, ears, and hands to the nurses they work with.”

Elise Nakhnikian, Senior Online Editor
enakhnikian@phinational.org