States expanding CD-PAS programs to offer flexibility and independence
Consumer direction of personal assistance services (CD-PAS) can offer Medicaid beneficiaries flexibility and independence to individualize their services. Analysts recognize that having greater control over these services is a high priority for some, but not all, disabled Medicaid beneficiaries.
In a new report funded by the Kaiser Commission on Medicaid and the Uninsured, Paraprofessional Health Institute's Henry Claypool says it's important that Medicaid beneficiaries with disabilities continue to have a choice regarding assuming the responsibilities that come with consumer direction and that it not be forced on those who don't desire such an arrangement.
Consumer direction is defined as the process by which Medicaid beneficiaries are allowed varying degrees of responsibility for hiring, scheduling, and paying personal care attendants who provide assistance with activities of daily living. CD-PAS is available in an increasing number of state Medicaid programs, although a relatively small number of Medicaid beneficiaries currently take advantage of it.
Central elements of consumer direction differ from more traditional home health services in that the Medicaid beneficiary has control over how, and by whom, their personal assistance services will be provided. That can include instructing a direct care worker to provide services in a fashion that is consistent with their personal preferences, and having control over when services will be delivered. Beyond such core principles, there are three general models in operation:
1. Agency with choice. These programs range from a traditional home health agency that assumes most of the responsibilities for arranging services to agencies that involve beneficiaries in arranging multiple aspects of their personal care services.
2. Public authority. These programs rely on the beneficiary to structure and arrange who, when, and how personal assistance services will be provided. The public authority makes information on screened individual providers available to the beneficiary.
3. Fiscal/Employer agent. These programs typically rely on the beneficiary to assume the role of employer and the responsibility for arranging most aspects of their personal assistance and submitting information to a fiscal agent that performs payroll functions for the beneficiary under contract with the state.
Mr. Claypool reports that while the total number of Medicaid beneficiaries directing their own personal assistance services remains small, compared to those receiving traditional agency-directed services in the community, participation is growing. (Participation rates in the four state programs he studiedCalifornia, Colorado, New York, and Virginiaran approximately 10%.)
"We're still at the beginning of the program," he tells State Health Watch, "and don't know yet what an optimal percentage of participants would be. Consumers have clearly indicated this program is not appropriate for everyone. In the next couple of years, we should get closer to knowing what number of participants makes sense."
Whether current participation rates are due to a lack of knowledge about the opportunity to self-direct or a lack of ability to assume the required responsibilities, Mr. Claypool says, it is clear from his review that the majority of Medicaid beneficiaries with personal assistance needs who live in the community currently rely on traditional provider networks to deliver their personal assistance services.
Take on different responsibilities
Beneficiaries who are served by traditional home health agencies don't have the responsibility of supervising, training, or scheduling the direct care work force. But in CD-PAS programs, they must take on those responsibilities to varying degrees. Officials are finding that management of employees and record keeping for payroll purposes requires skills that some Medicaid beneficiaries don't have. Balancing the responsibilities that Medicaid beneficiaries enrolled in consumer direction programs must assume with the beneficiary's capacity to perform these skills appears to be a process that is under way in some CD-PAS programs, Mr. Claypool says.
Some training of beneficiaries to handle their responsibilities appears to be an important program feature, although the four programs studied have considerable range in requirements placed on beneficiaries. Thus, those in Colorado must attend a 20-hour training course and successfully complete a proficiency examination. In Virginia, a service facilitator works with the beneficiary to help carry out the responsibilities. California offers peer support through the public authority, while New York has two staff positions working with beneficiaries to ensure they are able to supply the information needed to process consumer-directed payroll.
Another significant issue identified by Mr. Claypool is finding workers who are willing and able to assist Medicaid beneficiaries with intimate daily tasks. "If a Medicaid beneficiary is unable to develop and maintain a group of direct care workers to provide personal assistance services, the beneficiary is unlikely to find consumer direction a viable option for addressing their personal assistance needs," he says. "In consumer direction, it is very difficult for Medicaid beneficiaries to offer a full-time position like traditional employers can. In many cases, for a direct care worker to secure a 40-hour work week with one beneficiary, they would need to work almost every day of the week, often coming to the Medicaid beneficiary's home more than once a day. When these factors are added to the current direct care work force shortage, it can make recruiting workers for customer direction difficult."
While earlier demonstration programs found little evidence of fraud and abuse when family members are allowed to be paid for providing personal assistance services, Mr. Claypool found that waiving the Medicaid prohibition against parents and spouses being paid to deliver services is not available in all CD-PAS programs, although states do appear to embrace that flexibility.
Contingency plans needed
One key responsibility of individuals participating in consumer direction is to develop contingency plans for unanticipated events. The type of events Medicaid beneficiaries must plan for include arranging for assistance when an unscheduled need arises, finding someone to fill a shift when the regular direct care worker is sick, or finding a last-minute replacement when an unanticipated event affecting the worker prevents him or her from being available. Although an appropriate backup system or plan to deal with unanticipated events is an essential part of consumer direction, not all states view it as a state responsibility.
A number of work force issues have been identified that affect those who would consider becoming a direct care worker. For example, many Americans receive health care benefits from employer-sponsored policies but many direct care workers are believed to lack access to a group policy because their employer does not offer one.
Mr. Claypool's study found that wages, benefits, and training are key issues that influence a worker's decision to accept a position as a community-based direct care worker. The California and New York programs offered an affordable healthcare and dental benefit to direct care workers. But in Colorado and Virginia, CD-PAS direct care workers were unable to purchase a group health care policy as a benefit of their employment.
In contrast to facility-based long-term care settings that have training requirements for direct care workers, the home health care industry often has different training requirements for different types or levels of service. Only California had a formal voluntary training program available to prospective employees in consumer-directed programs. The training provides an opportunity to learn about the basic skills that most direct care workers should have when providing personal assistance to people with significant disabilities.
Difficulties have arisen in determining how to evaluate quality of CD-PAS services. Some Medicaid beneficiaries and their advocates have been critical of using measures developed for institutional settings to assess and monitor the quality of service delivered in home- and community-based locations. Development of quality standards that respect the needs and preferences of individuals with disabilities living in the community and address health and safety concerns of the beneficiaries is important, Mr. Claypool says. Currently, consumer satisfaction is the exclusive measure for the quality of service in consumer direction programs.
Issues to analyze
Mr. Claypool reports that as states move forward with consumer-directed options in Medicaid, there are several issues that need further examination and analysis, including building additional support for people who desire these arrangements so when they enter into the programs they are able to have a sense of security that should part of their support system fail them on a particular day, they have resources to turn to for assistance. Secondly, the need to better understand the issues that affect direct care workers such as wages and benefits is important.
"In the field of home- and community-based services, the evolution of consumer direction warrants close monitoring and further examination to identify ways to optimize delivery of the services and supports and maximize the positive outcomes for Medicaid beneficiaries," he says.
Mr. Claypool tells State Health Watch it will be important for states to invest in helping consumers develop skills they need to hire and manage direct care workers so there will be greater uptake of the program. Such training, he says, can lead to a positive experience and greater interest in the program.
But the flip side of training for those who are directing their own care is to also train and invest in the work force, Mr. Claypool says. Consumers in the study reported difficulty in finding people who want to do that work and with whom they felt comfortable. "We need to look at the pay, benefits, and skill-level training needed for the work force," he says. "A larger investment in developing the work force also will lead to better quality outcomes."
While CD-PAS programs will vary from state to state because the nature of state Medicaid programs varies, Mr. Claypool says it would be helpful to look at national or regional ways in which information could be shared.
For the future, he says, the best thing would be to move forward on both helping consumers develop the skills they need as employers and helping develop an appropriate work force.
Download the report at http://www.kff.org/medicaid/7757.cfm. Contact Mr. Claypool at (202) 812-8831.
Consumer direction of personal assistance services (CD-PAS) can offer Medicaid beneficiaries flexibility and independence to individualize their services.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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