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The findings from a new analysis of elderly consumers with both Medicare and Medicaid who receive personal care services in New York City were released in late December in a report entitled “Medicaid Personal Care in New York City: Service Use and Spending Patterns.”

The analysis, by the Medicaid Institute at United Hospital Fund (UHF), was designed to capture a profile of the characteristics of these personal care recipients, including Medicaid enrollment patterns, personal care service use, and overall Medicaid service use and spending.

UHF researchers Sarah Samis and Michael Birnbaum examined elderly dual eligible consumers who received personal care services in 2008. They also followed elderly dual eligibles who first began receiving personal care services in 2003, following them from 2002, before they started receiving services, through 2008.

Some of the Findings

Medicaid Enrollment Patterns

• The consumers receiving personal care services had been enrolled in Medicaid for a total of 7 years or longer.
• The average time on Medicaid before receiving personal care services was 13 months.

Duration of Personal Care Service Use

• Over 40 percent of the consumers receiving personal care services received them for at least 7 years, with an average of 4.75 years.
• The average length of time of care received tended to be either short-term (two years or less) or long-term (six years or more).

Amount of Care Received

• “High intensity users” of personal care services had higher rates of mental illness or cognitive impairment, as well as higher Medicaid spending on other long-term care services, before receiving personal care services.
• “High intensity users” received care for an average of 1.5 years longer than low-intensity users.

Personal Care Recipients Overall Medicaid Service Use and Costs

• Once these consumers began receiving personal care services, they typically did not revert to lower levels of service use or cost.

Rates of Personal Care Service Use Across New York City

• There was substantial variation in the patterns of personal care service use and spending across neighborhoods in New York City, with duals in some neighborhoods twice as likely as duals in other neighborhoods to receive personal care services. Other patterns — such as volume of services delivered per episode — showed some uniformity throughout the city.

“This report is a valuable contribution to understanding New York’s personal care program, the beneficiaries, and their service needs over time,” said PHI New York State Policy Director Carol Rodat. “These findings should encourage policymakers to pursue better data systems, as well as a standardized assessment process to help ensure uniform application of eligibility standards going forward.”

– by Deane Beebe

In a recently released analysis of New York State’s home care aide workforce, PHI concludes that the state could be getting better value for its Medicaid program’s $4 billion annual investment in home care aide services.

In light of the state’s current budget shortfall, PHI argues that rather than cutting services across the board and eliminating the jobs of thousands of New York home care workers, the state should rationalize the delivery system and improve training and compensation for the frontline workers.

Low-Investment, Low-Return Employment Model

These recommendations conclude a new series of reports by PHI New York Policy Director Carol Rodat with grant support from the United Hospital Fund. The series, which includes an Executive Summary (pdf), provides the most thorough description available regarding how New York employs, compensates, and trains home care aides, and the challenges the state faces in ensuring a sufficient supply of well-trained workers as the state’s population ages.

At 210,000 workers, home care aides make up the state’s third largest occupational grouping — and one of the fastest-growing — just behind retail salespersons and K-12 teachers.

“Home care aides,” Rodat said, “provide essential services to families across the state. Yet this workforce, despite its importance, is marked by poverty and is underutilized.”

One in seven low-wage workers in New York City is a home care worker.

The current low-investment, low-return employment model for home care aides is inefficient and undermines the state’s ability to provide quality long-term care services, Rodat reports.

Actions for Greater Value

The papers make the case that New York policymakers would get greater value from their multi-billion dollar investment in home care services by taking the following actions:

• Raise the floor. Increase wages for home care aides across the board and improve training standards. This policy initiative alone will help attract much-needed new workers to community-based direct-care work and help reduce turnover, which improves quality of care.
• Provide career ladders. Give aides the opportunity to become more skilled in a range of clinical areas — and be compensated for it. A more skilled and experienced workforce will make the entire long-term care system more stable and effective.
• Rationalize both the training and service delivery systems. Concentrate funding in a smaller number of “centers of training excellence” and employers that invest in their workforce. State lawmakers have the responsibility to ensure that public resources are directed toward those providers who are raising the bar, by ensuring that their workers have the skills and opportunity to provide the highest quality care.

New York Reports

PHI released the new companion reports on December 6 in New York City at a forum with Mayor Michael Bloomberg on the challenges and opportunities for the home care workforce.

The reports — as well as A Home and Community-Based Service System Reform Blueprint (pdf), recently issued by PHI and Independence Care System — can be downloaded from the PHI PolicyWorks site:

• New York’s Home Care Aide Workforce: Executive Summary (pdf)
• New York’s Home Care Aide Workforce: A Framing Paper (pdf), an overview of the challenges and opportunities to strengthen the workforce
• Preparing New York’s Home Care Aides for the 21st Century (pdf), which focuses on training
• Improving Wages for New York’s Home Care Aides (pdf), which delves into the industry structure and financing of aide services

– by Deane Beebe

Mayor Bloomberg speaking at the forum

New York City Mayor Michael Bloomberg was the guest speaker at a forum on the challenges facing the home care workforce and the opportunities for statewide system reform in the coming year.

The event was sponsored by PHI, 1199SEIU Training and Employment Funds, and 1199SEIU United Healthcare Workers East and held in New York City on December 6.

The Mayor and the forum panelists concurred that in light of the impending Medicaid cuts to home- and community-based services (HCBS), all of the stakeholders must work together to ensure that there are no broad across-the-board cuts, which has been the solution to the state’s budget woes in past years.

Budget Gap Is an Opportunity

Instead, all of the speakers — representatives from labor, government, consumer advocacy organizations, and a home care agency — view the anticipated cuts as an opportunity to reform the state’s HCBS system to become more:

• cost-effective
• simplified
• coordinated
• transparent
• accountable, and
• able to deliver services with a stable, well-trained direct-care workforce.

Bloomberg referred to the current management of the state’s HCBS system as “uneven at best.”

PHI President Steven Dawson

In referencing the state and city budget gap, he repeated the phrase made famous by President Obama’s former chief of staff, Rahm Emanuel, “a crisis is too important to waste.”

High Turnover Is Costly

The mayor addressed how the state’s home care industry was plagued by a 25 to 50 percent turnover rate, which “disrupts the continuity of care and raises administrative and overhead costs.”

“No one can run a railroad with that kind of turnover,” Bloomberg said. He added that “for the best well-trained workforce possible, the workers need to be compensated enough and feel like they are making a difference, to stay on the job a long time.”

Bloomberg’s Recommendations

Mayor Bloomberg said that the following elements are necessary for HCBS reform:

• capture better data
• develop and use a standardized client assessment tool
• mandate cost-effective incentives for subcontractors
• direct clients to programs that best meet their needs and are cost-effective
• reduce turnover by providing home care staff with better wages and benefits, training, and career ladder incentives

Investment in a Stable, Well-Trained Workforce

1199SEIU President George Gresham

“Across-the-board Medicaid cuts, without structural reform, would be the worst-case scenario for home care consumers, workers, and providers,” said PHI President Steven Dawson, a forum panelist whose presentation (PowerPoint file) is available for download.

“But true reform requires investment in a stable, well-trained workforce — and that will require new payment policies that reward ‘high road’ providers who demonstrate that they are creating decent jobs and providing quality care,” Dawson said.

In November, PHI and the Independence Care System issued a reform blueprint (pdf) for New York’s home- and community-based service system.

Forum Panel

Other panelists at the event included:

• George Gresham, president, 1199SEIU
• Aida Garcia, executive VP, 1199SEIU
• Kevin Finnegan, director, politics & legislation, 1199SEIU
• Dan Koken, director of business development, NYC Business Solutions, NYC Department of Small Business Services
• Judy Duhl, vice president for government affairs, Visiting Nurse Service of New York, and
• Jed Levine, executive vice president, Alzheimer’s Association, New York Chapter.

New York’s Home Care Workforce

At the forum, PHI released three reports that provide an in-depth look at New York State’s home care workforce, and an executive summary (pdf) with the challenges and recommendations outlined in these reports.

More information about home care in New York is available in the PHI Fact Sheet (pdf) on New York City’s Home Care Workforce.

– by Deane Beebe

In response to a recent report from the Citizens Budget Commission (CBC) that calls for a fundamental re-structuring of Medicaid spending in New York State, PHI and its affiliate Independence Care System (ICS) have released a major blueprint for home and community-based service reform.

The ICS/PHI blueprint (pdf), issued on November 24, is a detailed plan to simplify and rationalize the home and community-based service (HCBS) delivery system in New York City, which consumes $4.4 billion annually in Medicaid expenditures — accounting for at least 80 percent of all HCBS spending in New York State.

Currently, New York City’s HCBS delivery system suffers from a highly inefficient, fragmented, overlapping complexity of programs that provide Medicaid-funded services to elders and people living with disabilities.

CBC’s report (pdf) specifically targets these Medicaid-funded services as being “the primary focus for future cost control initiatives.”

The ICS/PHI reform blueprint directly addresses these challenges by proposing four essential reforms to New York City’s Medicaid-funded long-term care services for elders and people with disabilities:

• contain Medicaid costs;
• simplify the delivery system;
• improve quality outcomes by providing care management for consumers with complex needs; and
• stabilize the core HCBS workforce by establishing parity in wages for home care aides.

The blueprint builds on the strengths of the Medicaid-funded home and community-based service system, rather than turning to large managed care entities — which have limited, if any, experience in long-term care.

Stabilization of Workforce Critical

“We strongly believe that the fourth reform — stabilizing the home care workforce — is critical to any effort to achieve true efficiency in the Medicaid long-term care system,” emphasized PHI President Steven Dawson.

“In particular, home health aides in New York City remain poorly paid and inadequately trained. Therefore, even though the Medicaid program invests at least $1.9 billion annually in this workforce, the result is very high rates of staff turnover, which leads to poor quality services,” Dawson said. “It’s a tremendously inefficient waste of precious resources.”

“Across-the-board cuts, without structural reform, would be the worst-case scenario for both consumers and providers,” warned the blueprint’s author Rick Surpin, president of ICS, a New York City-based, nonprofit, Medicaid-managed long-term care plan, and PHI board chair.

“Instead, our ICS/PHI proposal provides a thoughtful blueprint of achieving genuine savings, while ensuring that the right type of services will be provided, at the appropriate level of need, by the right program.”

– by Deane Beebe

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PHI New York Policy Director Carol Rodat

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