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Direct-care workers in training

A new PHI analysis found that only 15 states require home health aides to have more training hours than are federally mandated, yet 30 states and the District of Columbia require certified nurse aides (CNAs) to have more training hours than the federal requirements.

In 1987, the federal government set a training standard of 75 hours, including a minimum of 16 hours of clinical training, for both home health aides and CNAs who are employed by Medicare-certified nursing homes or home care agencies.

“Our analysis shows that state home health aide training requirements have not kept pace with their nursing home aide training requirements, even though these direct-care workers provide essentially the same care and services,” said Steve Edelstein, PHI national policy director.

“Although it is clearly time to revisit the federal standards, having states move ahead on their own to upgrade training requirements is a step in the right direction.”

In Retooling for an Aging America, a 2008 report, the Institute of Medicine (IOM) recommends that the federal minimum training requirement be raised to at least 120 hours for both CNAs and home health aides and that competency in elder care be demonstrated as a criterion for certification.

Other Findings

The PHI analysis also found that:

• 4 states meet the IOM recommended training standard for home health aides;
• 14 states meet the IOM recommended training standards for CNAs;
• 13 states require more than 16 hours of clinical training for home health aides — the federal minimum training requirement; and
• of the states that exceed the federal training standard, 9 require home health aides to be CNAs, and 4 allow CNAs to become home health aides with supplementary training.

Trend Toward Home and Community-Based Care

Today, the majority of direct-care workers, including personal care aides, are employed in home and community-based settings (pdf).

By 2018, home and community-based direct-care workers are likely to outnumber facility workers by nearly two to one.

“Current federal training standards have not kept pace with changes in public policy and services delivery and do not adequately prepare the direct-care workers who provide the lion’s share of paid hands-on long-term care,” Edelstein said.

“The federal government must modernize training requirements for direct-care workers to help them gain the skills and knowledge they need to help elders with chronic and complex medical conditions live as independently as possible where they prefer — in their homes and communities.”

To compare the training requirements for home health aides and certified nurse assistants in each state, visit the PHI PolicyWorks website.

– by Deane Beebe

Senator Al Franken (D-MN)

With the support of three of his colleagues from the U.S. Senate Committee on Health, Education, Labor and Pensions (HELP), Senator Al Franken (D-MN) introduced the Home Care Consumer Bill of Rights Act (S. 1750) on October 20.

Franken plans to incorporate the bill (pdf) into the upcoming reauthorization of the Older Americans Act (OAA).

The bill aims to guarantee basic rights, including protection from abuse and neglect, to older Americans who receive long-term services and supports in their homes and communities.

Specifically, the Act would:

• direct states to develop a Home Care Consumer Bill of Rights;
• establish a voluntary Home Care Ombudsman Program to support states that choose to provide ombudsman services to resolve the concerns and complaints of older adults who receive home and community-based services; and
• develop quality standards for home and community-based services so that older adults and their families can make more informed decisions about who provides their services.

Remaining at Home a Top Priority

“It became very clear to me after meeting with seniors from Moorhead to Winona that remaining independent and at home is a top priority for our seniors,” Franken said.

According to a May 2010 environmental scan (pdf) of Medicaid-funded long-term services and supports by the Center for Health Care Strategies, 41 percent of Medicaid expenditures for long-term services and supports are for home and community-based services.

The increasing number of older Americans in need of long-term services and supports who choose to receive services in their homes and communities rather than in nursing homes makes Franken’s bill particularly relevant.

These rights, protections, and standards are already available for nursing home residents.

– by Gail MacInnes, PHI National Policy Analyst

Three brief stories on direct care:

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Standards Lowered for Some Hawaii Caregivers

Hawaii has reduced its qualification requirements for part-time caregivers working in community-based adult foster homes.

As a result of legislation signed by Governor Neil Abercrombie (D) in July, nurse aides who provide less than five hours of care daily (or less than 28 hours weekly) in adult foster homes no longer have to be certified.

To become certified, nurse aides must take a state-administered test every two years to demonstrate continued mastery of their skills. Uncertified nurse aides are trained but not tested.

Advocates for the elderly say that the degraded qualifications could lead to worse quality of care in adult foster homes.

The lowered qualifications apply only to adult foster homes with three residents, the maximum allowable in Hawaii’s Community Care Foster Family Homes program.

The changes to the qualifications are set to expire in June 2013, at which point lawmakers will decide whether to extend them permanently.

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Boston College Receives HHS Grant to Improve Home- and Community-Based Care Competencies

The Department of Health and Human Services (HHS) has awarded $2.25 million to Boston College’s Graduate School of Social Work to bolster consumer direction in home- and community-based care settings.

The grant will fund a three-year program called Accelerating Participant Direction Philosophy and Models in the Aging Network.

The program’s overarching goals are to identify the skills necessary to jobs that help people obtain home- and community-based services, and to enhance providers’ ability to ensure consumer direction.

Announcing the grant on July 26, HHS Assistant Secretary for Aging Kathy Greenlee said that the grant is “an investment that will help strengthen our commitment toward providing home- and community-based services…based on both the needs and preferences of the consumer.”

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PHI Board Member Calame Honored in San Francisco

San Francisco Mayor Edwin Lee (D) proclaimed July 21, 2011, to be “Donna Calame Day” in honor of the executive director of the San Francisco In-Home Supportive Services (IHSS) Public Authority.

Calame, a PHI board member, was honored for her career-long dedication to helping people with disabilities exercise their right to “the widest range of choices possible for [living] outside of institutional settings with appropriate assistance,” according to the city’s proclamation.

Since 1996, the San Francisco IHSS Public Authority has served as the employer of record for the city’s home care workers, fighting for better wages, benefits, and supports.

– by Matthew Ozga

Kansas State Building in Topeka

Advocates say that Kansas’s ability to care for people with disabilities in home- and community-based settings will be further hampered by proposed cuts to state Medicaid costs.

One proposal, advanced by Lieutenant Governor Jeff Colyer (R), would lower Kansas’s Medicaid spending to $400 million, from $600 million.

“Deep cuts to services, an increase in the eligibility threshold, or other negative changes to home- and community-based services are some of the feared consequences of a large Medicaid budget reduction,” said Mike Oxford, executive director of the Topeka Independent Living and Resource Center.

“These consequences could cause the nursing-facility census — already approaching record levels — to really go up,” he continued.

A Violation of Olmstead

The loss of this choice could also put Kansas in violation of a 1999 Supreme Court ruling in the case Olmstead v. L.C.

The Olmstead decision says that states are responsible for ensuring that people with disabilities can choose the most integrated care settings possible in order to meet their needs.

Since the proposed Medicaid cuts would reduce home- and community-based options for many Kansans with disabilities, the federal government could find that the state has violated Olmstead.

Already Poised

Indeed, the Department of Health and Human Services already appears poised to do just that.

Although an announcement won’t be made until mid-August, reports suggest that Kansas will be among the states identified as being in violation of Olmstead. Federal officials have met with disability advocates there several times in recent months.

They have paid special attention to the length of waiting lists for people who want to transition from nursing homes into home- and community-based care.

According to Nick Wood of the Disability Rights Center of Kansas, it is “not unusual at all” for people with disabilities who are seeking community-based services in Kansas to be placed on waiting lists of up to two years.

In certain cases, those waits can be even longer, Wood said. People with developmental disabilities, for example, can face wait times of up to five years for community-based services, Wood told the Kansas Health Institute News Service.

Renee Wohlenhaus, a deputy chief in the Disability Rights Section of the Department of Justice, said that the federal government views wait times of longer than six months as violations of the Olmstead decision.

– by Matthew Ozga

NY Capitol Building in Albany

Recently the New York State Department of Health (DOH) announced the members of some of the workgroups for Governor Andrew Cuomo‘s Medicaid Redesign Team (MRT) effort.

The MRT was charged with identifying the best ways to reduce costs and improve the health delivery system in the state. Most of the team’s 79 recommendations were incorporated into the 2011-2012 New York State budget, which passed on March 31.

The budget included sweeping legislation that will dramatically alter the way the state pays for and delivers Medicaid services, particularly in home- and community-based settings.

PHI Role within Reform

PHI New York Policy Director Carol Rodat and Marilyn Saviola, director of advocacy at Independence Care System (ICS) — the PHI-affiliated managed long-term care organization — were both named to the MRT Managed Long Term Care (MLTC) Implementation and Waiver Redesign Workgroup.

The MRT Managed LTC Workgroup is charged with, among other things, the task of advising DOH on:

• the development of care coordination models to be used in the mandatory enrollment;
• processes to ensure patient protections and access;
• continuity of services; and
• avoidance of nursing home placement and hospital stays.

PHI and ICS have been active proponents for wage improvements for home health aides, as well as for the greater use of care management models. Both of these provisions were in the blueprint (pdf) they presented to the MRT.

Profound Impact of MLTC Reforms

Included in the New York State budget is a proposal to expand the use of capitated care management models, which — combined with reimbursement cuts — has the potential to change the landscape of home care.

Beginning with New York City residents in April 2012, all adults over the age of 21 covered by Medicaid — or “dually eligible” for Medicare and Medicaid coverage — who need community-based long-term care services for more than 120 days will be required to enroll in a MLTC plan or another care coordination program. New York State will first need the federal government’s permission to implement its plan.

DOH anticipates transitioning approximately 2,000 clients a month into a MLTC plan over a period of three years. A MLTC plan is a term that applies to New York’s Medicaid Managed Long Term Care plans, Medicaid Advantage Plus, or the Program of All-inclusive Services for the Elderly (PACE).

The New York State MRT website contains a list of members and meeting dates for three of the nine MRT workgroups, as well as additional information.

– by Meghan Shineman, PHI New York Policy Analyst

Texas state capitol building in Austin

After several months of debate, potentially devastating cuts to Texas’s Medicaid reimbursement rates have been deleted from the state budget proposal, which was approved by a House-Senate committee on May 17.

The cuts — which had been supported primarily by the Republican-dominated Texas House — would have slashed Medicaid reimbursement rates for nursing homes by up to 10 percent. With the loss of matching federal funds factored in, the overall cut would have been closer to 33 percent.

Health care advocates had argued that as many as 80 percent of Texas’s nursing homes would have been forced to shut down as a result of the proposed cuts.

In a statement, the Texas Health Care Association said that, by maintaining the current Medicaid reimbursement rate, the latest budget proposal “will bring the Texas nursing home profession back from the brink of disaster and avert significant nursing home closures and job losses” if it is signed into law.

Concerns Remain

Health care advocates say they still have concerns about the latest version of the budget proposal, however.

Although the current Medicaid reimbursement rates are maintained in the next budget, advocates say they are still not high enough to genuinely influence the quality of care in Texas.

“We should never let ourselves become convinced that current reimbursement rates to nursing homes or home care providers are truly adequate to cover costs or entice direct-care workers to seek employment within this sector,” said Jane Bavineau, the executive director of Care for Elders, a Houston-based organization that focuses on eldercare issues.

“It is difficult now, and it will surely become more difficult in the years ahead,” Bavineau continued.

Indeed, the decision to maintain the current reimbursement rate for nursing homes will create an instant shortfall of $4.8 billion, which lawmakers will have to reckon with in 2013, the next time Texas has to submit a budget.

Community-Based Care Targeted

Additionally, the House-Senate committee agreed to cut $15 million from Community Based Alternatives (CBA), Texas’s Medicaid waiver program.

CBA coordinates the delivery of home care to Medicaid-eligible older adults and people living with disabilities who would otherwise have to live in a nursing home.

The cut represents approximately half of CBA’s budget.

The proposed $15 million cut “will harm home care agencies, which by definition harms consumers and direct-care workers,” said Dennis Borel, executive director of the Coalition of Texans with Disabilities.

“The tighter the belt, the harder it is for us to provide the care needed,” said Renee Tillman, a direct-care worker in Texas and the founding president of the Texas Association of Nurse Assistants.

Borel also said that he suspects that some home health agencies — particularly those in Texas’s sparsely populated rural areas — would not survive such a severe reduction in funding.

Health care advocates — including the Coalition of Texans with Disabilities — successfully fended off an attempt by the legislature to also cut CBA home care workers’ wages to the federal minimum of $7.25 an hour, from approximately $8.

– by Matthew Ozga