State of Oregon - Oregon Secretary of State: Home

State of Oregon

Department of Human Services

Aging and People with Disabilities

Consumer-Employed Provider Program Needs Immediate Action to Ensure In-Home Care Consumers Receive Required Care and Services

October 2017

Secretary of State Dennis Richardson

Audits Division, Director Kip Memmott

Report 2017 ? 23

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Secretary of State Audit Highlights

October 2017

DHS ? Aging and People with Disabilities: Consumer-Employed Provider Program Needs Immediate Action to Ensure In-Home Care Consumers Receive Required Care and Services

Report Highlights

The Secretary of State's Audits Division found that the Aging and People with Disabilities (APD) program should take immediate action to address gaps in program design and oversight in order to improve the safety and well- being of participants in the Consumer-Employed Provider (CEP) program.

Background

Oregon is a leader in providing in-home long- term care options for older adults and people with disabilities. The most used in-home care program is the Consumer-Employed Provider program, which positions consumers as employers of their homecare worker.

Key Findings

The effectiveness of the Consumer-Employed Provider program is dependent on the consumer, the case manager, and the homecare worker. If each is capable, competent, and supported in their role, the current model can be successful. Our audit found:

1. Some consumers are not receiving the support necessary to ensure required employer duties are being performed, which adds to case managers' and homecare workers' responsibilities.

2. Case managers are not consistently contacting consumers, or monitoring services consumers receive due to excessive workloads.

3. Agency requirements do not ensure that homecare workers are prepared to provide the care and assistance consumers need.

Purpose

The purpose of this audit was to assess the policies and processes used by APD to ensure the needs of consumers in the CEP program are met.

4. Due to current data collection and utilization practices, it is difficult for APD to determine if consumers are safe and receiving the care and services they need.

5. Current deficiencies in the program may put consumers' health and well-being at risk and keep the program from operating as intended.

To reach our findings, we conducted interviews and case file reviews, collected and analyzed CEP consumer data, and researched federal and state standards.

Recommendations

The report includes recommendations to improve Consumer-Employed Provider program implementation and support. Recommendations include consistently following existing monitoring policies, addressing case managers' excessive workload and responsibilities, and providing more support to consumers and homecare workers.

The Department generally agreed with our findings and recommendations. Its response can be found at the end of the report.

Secretary of State, Dennis Richardson Oregon Audits Division, Kip Memmott, Director

About the Secretary of State Audits Division

The Oregon Constitution provides that the Secretary of State shall be, by virtue of his office, Auditor of Public Accounts. The Audits Division performs this duty. The division reports to the elected Secretary of State and is independent of other agencies within the Executive, Legislative, and Judicial branches of Oregon government. The division has constitutional authority to audit all state officers, agencies, boards, and commissions and oversees audits and financial reporting for local governments.

Audit Team

William Garber, CGFM, MPA, Deputy Director Sheronne Blasi, MPA, Audit Manager Olivia M. Recheked, Principal Auditor Danielle Moreau, MPA, Staff Auditor Abigail Carroll, Staff Auditor

This report is intended to promote the best possible management of public resources. Copies may be obtained from:

website: sos.audits

phone:

503-986-2255

mail:

Oregon Audits Division 255 Capitol Street NE, Suite 500 Salem, Oregon 97310

We sincerely appreciate the courtesies and cooperation extended by officials and employees of the Department of Human Services, Aging and People with Disabilities program during the course of this audit.

Secretary of State Audit Report

Consumer-Employed Provider Program Needs Immediate Action to Ensure In-Home Care Consumers Receive Required Care and Services

Introduction

APD provides services for people needing long-term care

The older adult population in the United States is increasing at a steady rate. The number of people over age 65 is projected to reach more than 72 million people by 2030, up from 40.2 million in 2010. In comparison, 13.9 percent of Oregon's population was 65 years or older in 2010. By 2030, the percentage is expected to increase to nearly 20 percent, or about 900,000. States, including Oregon, will need to be prepared to support the growing older adult population.

Medicaid is used to help fund long-term services and supports in Oregon Many older adults and people with disabilities need help with basic daily activities to thrive. Paying for these services over prolonged periods of time can be challenging for many families, whether it's a daughter funding long- term care for an aging parent suffering from dementia or a mother providing care for her adult child with a physical condition caused by a traumatic spinal injury. The cost of care adds up quickly. Some older adults find that they have outlived their savings to pay for health care. The Oregon Department of Human Services (DHS) uses federal Medicaid and state funds to pay for long-term support services (LTSS) for many individuals who have no other options. Medicaid is a federal program funded jointly with states, who administer the program. The federal government allows states to be flexible in what Medicaid funded health care services they offer. Since the inception of Medicaid in 1965, Oregon has used Medicaid dollars to fund care for individuals living in nursing facilities (e.g., nursing homes). Recognizing the importance of offering other community-based options, in 1981 Oregon was the first state to apply for and use Medicaid to fund LTSS for

Report Number 2017-23 DHS-APD

October 2017 Page 1

APD Mission:

The Department of Human Services Aging and People with Disabilities (APD) program assists a diverse population of older adults and people with disabilities to achieve well-being through opportunities for community living, employment, family support and long-term services and supports that promote independence, choice and dignity.

individuals who would otherwise qualify for nursing level treatment but want to receive care in their homes or other community-based settings.1 In 2013, Oregon expanded its commitment to providing home and community-based care options by taking advantage of the federal Patient Protection and Affordable Care Act, Community First Choice option. Oregon's plan prioritizes an individual's choice and dignity by positioning the consumer as the driver in LTSS service planning. Consumers' preferences are paramount. This is referred to as person-centered planning. The new plan increased the amount of federal Medicaid dollars for Oregon's LTSS programs. Federal Medicaid funding for in-home services for the 2015-2017 biennium was $750,547,055 in comparison to $323,271,398 in state General and Other funds.

APD assists older Oregonians and people with disabilities DHS administers services to older adults and adults with physical disabilities through its Aging and People with Disabilities (APD) program and several public-private partnerships. The Aging and Disability Resource Connection of Oregon, a public-private partnership, provides information and assistance for individuals navigating options for care. If an individual is deemed likely to be eligible for Medicaid funded services, they are referred for an eligibility assessment (both financial and service needs) and case management. Once referred, local Area Agencies on Aging (AAA)2 offices or APD local offices provide direct case management services depending on where the consumer lives (see Figure 1 on next page).

Report Number 2017-23 DHS-APD

1 Community-based settings include assisted living facilities, residential care

facilities, memory care facilities, and adult foster homes. 2 Area Agencies on Aging are either community focused non-profit or government

entities that the state contracts with to provide services to people above the age of 65

and adults with disabilities in specific locations throughout the state.

October 2017 Page 2

Figure 1: DHS Aging and People with Disabilities District Map

Report Number 2017-23 DHS-APD

Source: DHS Aging and People with Disabilities

APD management, along with program and policy staff located in the Salem central office, set policy and provide program oversight. Their role with AAA offices is otherwise limited. While still receiving state oversight, these offices are allocated case manager Full Time Equivalent (FTE) positions and make their own decisions on how to divide workload and manage the CEP program on a day-to-day basis. Several other ancillary units within DHS provide support to APD programs. A quality control unit inside APD ensures that case managers are following state and federal guidelines. The Office of Adult Abuse Prevention and Investigation provides policy support, and specialized training and guidance for APD and AAA staff who investigate reports of abuse and neglect of older adults and people with physical disabilities in Oregon. APD has several legislatively-approved key performance measures (KPM) that relate to the CEP program, including:

KPM 10, which measures the percentage of seniors (65+) needing publicly-funded long-term care services;

October 2017 Page 3

 KPM 11, which measures the percentage of Oregonians accessing publicly-funded long-term care services who are living outside of nursing facilities; and

KPM 16, which measures the percent of abuse reports assigned for field contact that meet policy timelines.

Consumer-Employed Provider Program Prioritizes Choice

APD offers a range of programs and facilities for individuals' long-term care needs. Of the available programs, in-home care options are the most utilized. They allow consumers to remain in the comfort of their homes while receiving services to meet their basic needs. As of June 2016, 53% of consumers who are eligible for long-term care chose in-home care services. Options for in-home care services vary according to consumers' level of independence (see Figure 2 below). The following chart shows all in-home programs offered by APD. Of the 18,118 in-home care program participants, 13,230 are enrolled in the CEP program.3

Figure 2: APD In-home care programs descriptions

In-home care program type

Program description

Oregon Project Independence

Medicaid Consumer-Employed Provider (CEP) In-home care agency

State-funded program offering in-home services to individuals 60 years and older who have been diagnosed with Alzheimer's and related dementia. Recently expanded to include younger adults with physical disabilities. Consumers pay a sliding scale fee for services. Consumer responsibilities are similar to those in the Medicaid Consumer-Employed Provider program.

Medicaid and state-funded program. Consumers or their representative are responsible for selecting, hiring, training, and dismissing their homecare worker. Case managers provide ongoing support and monitoring.

Consumers receive services from a homecare worker provided by a licensed in- home care agency. Case managers provide ongoing support and monitoring.

Report Number 2017-23 DHS-APD

3 Figures were taken from APD's consumer count for the month of June 2016. For the purposes of this audit we include the consumers receiving in-home hourly paid care and consumers in the spousal pay program.

October 2017 Page 4

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