Concerns Raised Over Adult Day Health Care Transition, Assessments

by David Gorn, California Healthline Sacramento Bureau

TOPIC ALERT:

Corinne Jan doesn't quite know what to say to some of her patients at the Hong Fook Mental Health Center in Oakland.

Many of them are frail, elderly, monolingual in Cambodian, Mandarin or Thai and have been receiving Adult Day Health Care services. ADHC will be eliminated on Mar. 31 as a Medi-Cal benefit and replaced with a new program, Community-Based Adult Services. Medi-Cal is California's Medicaid program.

According to Jan, the Department of Health Care Services has made a slew of mistakes in assessing eligibility for CBAS -- getting names wrong, having duplications on their lists and even sending contradictory notices to patients.

"The participants come up to us, they keep asking us, how come I got something in the mail [from the state] that says I'm eligible, and now I got something in the mail that says I'm not eligible?" Jan said. "They all want to know: Can they keep coming here on April 1?"

Jan called the transition process "a royal mess" and said the people hired to do the eligibility assessments often ignore the state-mandated Individual Plan of Care developed for each patient. Many of the patients who should qualify for eligibility are being shut out, Jan contended.

"It has been horrible," Jan said. "The process has been so flawed, there are lots of errors. These people are really frail, and they don't know what's going to happen to them. Now we're just in a big mess, because there's a big discrepancy between who [DHCS] thinks is eligible and who we think are eligible."

ADHC advocates across the state have voiced similar concerns. Peter Behr, who runs an ADHC center in El Sobrante near Richmond, said nurses with little experience in elder care or working with people who have dementia are conducting the face-to-face assessments to determine eligibility.

"These are very nice people," Behr said. "Nice, contract people who don't have a clue. We've had 18 denials, and I'm going to help people protest almost all of them."

In November, DHCS Director Toby Douglas said he expected about half of the current ADHC population to be eligible for CBAS. Behr said Douglas' estimate is being used as a rough guideline for eligibility.

"They are obviously looking to disqualify people," Behr said.

"My problem is with the level of competence. If I sound like I'm angry," he said, "hell yes, I am. This is flat-out wrong."

'It's Going Fine'

The state has an entirely different view of the transition to the CBAS program. Carol Gallegos, assistant chief of the Long-Term Care Division of DHCS, said critics are wrong.

"That isn't accurate," Gallegos said. "The [nurses] look at everything that's available to them -- the medical record, the IPCs, the face-to-face interview ... Our nurses are trained in clinical skills. [The full assessment] is not just based on a one-to-one shot."

Gallegos said that the transition has gone relatively well. The state is on a tight timeline, trying to place 34,000 ADHC patients in the proper programs in a three-month timeframe.

A lawsuit settlement on Nov. 17 set the stage for this transition to CBAS, which is designed to address the health needs of an elderly population at risk for institutionalization. Like ADHC, CBAS will provide nursing home-like care during the day, so frail patients can stay home at night and out of expensive institutional care.

The original deadlines for completing the assessments and launching CBAS were Feb. 29 and Mar. 1, respectively. Those deadlines were recently extended a month each. That one-month reprieve may help make the transition smoother, but Gallegos still expects the assessment process to meet the end-of-February deadline.

"It's going fine, it's moving forward, we are proceeding," Gallegos said. "We believe we will be done by the end of February still. It may go into March a little, but we're very close."

Assessments Under Way

According to DHCS consultant, Steve Ruhnau, senior manager at Hubbert Systems Consulting, initial assessments indicate slightly more than 9,000 of the 34,000 ADHC beneficiaries are either categorically eligible for CBAS --  meaning they are eligible without an interview -- or presumptively eligible, which means they are extremely likely to be eligible but still must go through a face-to-face assessment.

Presumptively eligible individuals will receive CBAS services during the assessment process. If the assessment determines they are ineligible, they will continue to receive CBAS services until they get a hearing on their eligibility, according to Douglas Press of the DHCS legal team.

All told, about 25,000 people will need face-to-face assessments of their conditions and care needs. As of mid-February, more than 20,000 assessments had been completed, Ruhnau said.

"The total count of [eligibility] notices sent that are in people's hands right now is 12,825," he said. (That number excludes the roughly 9,000 people determined presumptively or categorically eligible.)

Ruhnau would not say how many of those letters were notices of eligibility and how many reflected ineligibility, in part, he said, because the process of ineligibility is a much more complex and spread-out affair.

"One of the issues we have is that there's a significant lag time in how ineligibles are handled, so it's not reflective of actual numbers, what's actually happening," Ruhnau said. "There is a significant difference in process, and it skews the data in a way that's misleading."

All current ADHC beneficiaries will receive those benefits through March, Ruhnau said. "Then, if they are found to be ineligible [for CBAS], they will receive enhanced case management."

One Month's Leeway

The one-month extension for eligibility assessments could help iron out some of the details of eligibility criteria, according to Elissa Gershon of Disability Rights California. Disability Rights filed the lawsuit that resulted in the settlement creating CBAS.

"We are working with the Department [of Health Care Services], and we've heard the reports from providers," Gershon said. "It's our job to monitor the assessment process, to see how eligibility and ineligibility are determined."

That process still needs a little work, Gershon said.

"It's our understanding that, contrary to what the department says, their [eligibility] review hasn't been done as specified in the settlement agreement," Gershon said.

As for the final number of people deemed eligible, Gershon said that no estimate was ever part of the settlement. DHCS officials agree, saying 50% of the ADHC population was an estimate, not a target.

"We've always said it will be way higher than 50%," Gershon said.

Gershon said a number of people who were sent eligibility confirmations were then declared ineligible.

"Yes," she said. "That is problematic."

The extra month does give both sides a little breathing room to resolve some of these issues, she said.

"Many, many people still have not been notified of their status, one way or the other," Gershon said. "For those people, to have a care plan in place, to have services available, to know what's happening to them, is very important."

Adam Abraham
According to the agreement, the state will accept adults considered at risk of institutionalization into the new program; those who are not sick enough to qualify will be put on managed-care plans set up to coordinate all aspects of a patient's health care.

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