California is bungling its planned transition to a less expensive way to care for older adults and disabled people trying to stay out of nursing homes, leaving thousands of vulnerable people at risk of being forced into institutions, critics say.
The chaos provides a case study in how the state manages a massive budget cut, and the picture isn’t pretty.
As part of last year’s budget and a later legal settlement, the Brown Administration planned to eliminate one program, known as Adult Day Health Care, and replace it with a smaller, more streamlined version, to be called Community Based Adult Services. The new program, while costing the state about half as much, is supposed to serve everyone in the original program who might be forced into a nursing home without the services provided by the state.
But clients, providers, lawyers and observers report that the transition has been beset by unrealistic deadlines, confusion within the state bureaucracy, conflicting statements to clients and a questionable process for determining who will get the new services and who will be turned away.
The most damning criticism, if true, is that the state has predetermined how many people it is prepared to serve and is manipulating the process for assessing individual clients so that the results fit within the new program’s slimmer budget.
As program director of one of the centers that provides these services, Altamedix ADHC in Sacramento, Sergey Ionov oversees 260 disabled and older adults, supervising their vast and complex medical needs – diabetes, Alzheimer’s, hypertension, brain injuries, various organ diseases, and other acute and chronic pains.
Ionov also provides an array of social activities to engage his vulnerable clients.
But these days he is dealing most with the uncertainty and fear surrounding this transition – for provider sites, clients, and their families.
At the beginning of this month, only a handful of Altamedix’ 260 clients had received letters from the state informing them whether or not they were being accepted into the new program.
For a program scheduled to start that very day, that was worrisome news.
“It’s too much work for the state and they cannot do this whole process according to their initial plans,” says Ionov.
Unable to complete its assessment of 35,000 disabled and older adults on time, state officials postponed until April 1st the introduction of Community Based Adult Services. The state says the federal government also requested a delay. But that still might not be enough time.
While many clients have already been accepted into the new CBAS program, thousands more are stuck in limbo, awaiting final decisions on the original assessment or an appeals process to decide their fate.
“These people have been so upset through this process,” says Jill Yungling, program director for Eskaton Adult Day Health Care Carmichael. The timelines, she says, are simply too rushed. “The families are all in an uproar.”
Adult day health care sites offer disabled and elderly clients with physical, mental and developmental disabilities a variety of services, including medical supervision, physical therapy, and community interaction. Many families depend on ADHC to care for their disabled or elderly relatives, and have no idea where they will send them if relatives are denied entry into the new program.
“It’s the exact wrong time to try and undo a proven cost-effective program,” says Assemblywoman Mariko Yamada, chair of the Assembly’s committee on Aging and Long Term Care. “It is no different in my mind than child care is for the working family.”
Final assessments are expected to be completed by mid-March “and then eligibility will be established,” said Jane Ogle, deputy director of Health Care Delivery Systems for the Department of Health Care Services,
Yet controversy abounds over an assessment process that has been called both confusing and secretive, and is slated for completion just two weeks before the new program begins – allowing virtually no time for a two-step appeal process.
State officials are uncertain how many appeals they will see.
“It’s a difficult situation and we really don’t know the answer to this yet,” says Ogle.
In the meantime, no services will be provided for denied patients – even for those making appeals – since the current program officially ends March 31.
“You don’t get aid… on a non-existing program,” says Ogle.
Feisty providers, who have historically fought budget cuts and attendance caps, say that ending services abruptly to this needy population is both unconscionable and unlawful.
“They’re not going to be able to send people letters and the next day discontinue the program,” says Yungling. “That’s not going to fly.”
State officials stand firm that budget cuts have forced a much needed change with the new program, and say those who truly need the services will continue receiving them.
The state’s mantra for adult day health care: “medical necessity.”
The new CBAS with its stricter guidelines is screening out two types of clients, says Ogle: those who attend simply for community interaction, and those with only one physical or mental disorder that could be treated elsewhere – less expensively.
If patients don’t meet the guidelines set forth in five categories, they will be forced to find services elsewhere as part of “enhanced care management.” Denied clients will be contacted by an outside contractor who, in theory, will help them find nearby alternatives to fulfill their needs.
But many current adult day health providers say those replacement services often don’t exist.
At San Francisco’s Golden State Adult Day Health Care in San Francisco, most clients are Russian, Ukrainian, or Chinese and have nowhere else to go for their mix of medical needs and social interaction.
“There is no other place to go,” says Katya Hope, acting director of the center. “They’re just going to go home, watch TV and decline.”
Hope is incensed that some lawmakers view locations like hers as little more than community centers.
“That is really the attitude, the prejudice, that this is just a social club,” says Hope. “Everybody here has finger pricks, blood pressure checked, terrible arthritis so they can’t move” or other significant chronic health concerns that require constant supervision.
Intended to keep clients out of vastly more expensive skilled nursing homes, last year the program became a casualty of budget cuts when Governor Jerry Brown targeted all ADHC centers for closure December 1.
A successful lawsuit by Disabled Rights California not only kept the centers open, but led the state to create the new CBAS program with more stringent eligibility requirements — for both patients and ADHC providers. Formerly, the ADHC program received $171 million. The new CBAS program will receive just $83 million during its first year. Both programs receive federal matching funds.
ADHC providers say they offer a wide swath of services to patients that include transportation and food – and do it inexpensively.
Medi-Cal pays ADHC providers $76 per client per day, or $11,441 annually for clients attending every weekday. That’s one-third to one-fifth as much as the state would spend if a client were forced into skilled nursing care.
Since December, field nurses for Medi-Cal, which oversees adult day health, have been sent out to the 271 facilities affected by the transition to conduct reviews of existing patients. Additional nurses have been hired to handle the overflow.
Critics claim that final decisions on eligibility are based not on medical need, but to fit the program’s new budget.
State officials deny the charges.
“We never ask the clinical people to take budget into consideration,” says Ogle.
Yet providers at the Golden State site, located in San Francisco’s Tenderloin district, say they were told unofficially by Medi-Cal nurses that 95% of their clients would qualify for the new program.
However, when clients received their state letters, half were denied.
“It was a wee bit of a shock,” jokes Hope of Golden State. “Then we found out it was pretty much this way all over the place.”
One attorney involved in the appeals process echoed the sentiments of many about the transition.
“From everything I’ve seen at this point it’s a total mess,” says Michael Keys, staff attorney for Bay Area Legal Aid, which is representing some of the Golden State clients in their appeals.
Keys says declined patients are pawns in a budget war, and that the state is forced economically to limit the number of accepted patients or “you’re going to blow your budget.”
Even before assessments began, DHCS director Toby Douglas told ADHC providers to anticipate that just 50% of their clients would be accepted into the new program.
This shocked many providers, who wondered how a target number could be decided even before assessments began.
The attorney who filed the lawsuit against the state to retain adult day health care services said all patients meeting the new guidelines must be accepted, regardless of budget.
“We were adamant that we will not accept a capped program,” argues Elissa Gershon, an attorney for Disabled Rights California who litigated to keep the program. “It’s an entitlement program,”
What will happen if too many patients are accepted to fit the new CBAS budget?
“Then we’ll have to go back to the Legislature,” says Ogle.
Critics of the assessment process also say that Medi-Cal nurses – some of them independent contractors hired solely to assess ADHC clients – weren’t given clear guidelines to assess patients.
“They weren’t sure the exact formula, the criteria that you have to follow,” says McGlothlin, owner of Golden Days Adult Day Health Care Center in West Sacramento, whose facility was one of the earliest to be assessed.
Like others around the state, clients at her facility received acceptance letters, followed by denials, adding to the confusion.
“They’re trying to be very fair,” she adds. “It’s a massive program they’re trying to convert in a limited amount of time.”