Questions Raised About the State’s New Independent Provider Program

Published in the Woonsocket Call on July 15, 2018

In the waning days of the 2018 legislative session, the Rhode Island General Assembly passed legislation (S 2734 Sub A, H 7803 Sub A) that establishes in the Ocean State the “Independent Provider” (IP) model of at-home care, which allows consumers to hire and manage caregivers of their own choice while the state takes on certain responsibilities, such as setting caregivers’ wages, qualification standards and hours. With Gov. Gina M. Raimondo’s signature, the legislation became law on June 29th.

The enacted legislation is backed by the Rhode Island Campaign for Home Care Independence and Choice, a coalition that includes the Senior Agenda Coalition, RI Working Families Party, RI Organizing Project, District 1199 SEIU New England, RI AFL-CIO, Economic Progress Institute and the RI Chapter of the National Organization of Women (NOW). But, although on the losing side of the legislative debate the Rhode Island Partnership for Home Care continues to express its concern about the impact on the delivery by IPs to seniors and persons with disability.

Overwhelming Support on Smith Hill

The health care legislation, sponsored by Senate Majority Whip Maryellen Goodwin (D-Providence) and Rep. Christopher R. Blazejewski (D-Providence), easily passed both the House and Senate Chambers. The Senate Committee on Labor unanimously passed the measure by a 9-0 vote. By a count of 33-0, the legislation easily passed on the Senate floor. Meanwhile, in the other chamber, the House Committee of Finance put its stamp of approval on the measure by a vote of 13-0, with the legislation ultimately passing of the House floor by a vote of 60-11. But, because the House amended the bill (in committee and on the floor), it had to come back to the Senate for consideration again. The Senate vote on the revised legislation was 28-3.

In a statement announcing the new law, Goodwin and Blazejewski, say “By increasing both availability and quality of at-home care options, the new law’s ultimate goal is to move Rhode Island toward greater use of care in the community rather than in nursing facilities, since at-home care is both more comfortable and satisfying for consumers and less expensive than nursing facilities.”

“Presently, Rhode Island ranks 42nd in the nation in terms of investment in home care. Ninety percent of older Americans prefer home care. Not only is it more comfortable for seniors, it’s more cost-effective, as we’ve seen in states like Massachusetts. High-quality home care is what people want, and it saves money. I’m proud to support this effort to help make excellent home care available to more Rhode Islanders,” said Goodwin.

Adds, Blazejewski, “There is little question that people prefer to stay in their homes as long as possible. Particularly now, as the over-65 population in our state is rapidly expanding, Rhode Island must shift more of our long-term care resources toward supporting home care. Our legislation will help provide more options for home-based services, enhance access to them and establish standards that assure high-quality care.”

Hiring, Finding and Managing a Caregiver

Currently around 77 percent of Medicaid funding for long-term services and supports goes to nursing facility care rather than community-based care. Those who use community-based care generally go through agencies or find, hire and manage a caregiver on their own. This bill would create a third option.

Under the Independent Provider model, which has been in place in Massachusetts since 2008, consumers would still be the direct employer who determines when to hire or fire an employee, but the state would take on responsibilities for maintaining a registry of qualified caregivers, and would set parameters such as rates, qualifications and hours.

While the new law stipulates that they are not employees of the state, it would give home care workers the right to collectively bargain with the state over those parameters. Allowing them to organize would ensure that this otherwise dispersed workforce has a unified voice and a seat at the table to tackle the issues facing Rhode Island’s long term services and supports system, said the sponsors.

Consumers in states with independent provider models report higher levels of client satisfaction and autonomy, received more stable worker matches, improved medical outcomes, and reduced unmet need with agencies delivering fewer hours of care relative to the needs of the consumer.

In testimony supporting the health care legislation, Director Charles J. Fogarty, of Rhode Island’s Division of Elderly Affairs (DEA), told lawmakers that the health care legislation supports two goals of DEA, first it would enable elderly and disabled Rhode Islanders who are medically able to stay at home and second, it would address Rhode Island’s direct service provider workforce shortage.

Fogarty said it’s critical for older adults and people with disabilities to have access to the quality of care that is right for them. “In some cases, care from an independent provider they know and trust will best meet their needs to remain independent. In other cases, a home care agency will be the right fit. And for some, particularly those with complex medical needs, our quality nursing homes are the right option,” he said.

When quizzed asked about The Rhode Island Health Care Association’s position, Virginia Burke, President and CEO, recognized the value of home care in the state’s long-term care continuum but stressed that residents in the state’s nursing facilities “are too sick or impaired to mange at home.” She said, “Our only concern with this proposal is the suggestion that it could drain Medicaid funding from the frailest and most vulnerable among our elders in order to pay for a new Medicaid service. Surely our elders deserve good quality and compassionate care in all settings.”

Calling for More Education, State Oversight of IPs

While most who testified before the Senate and House panel hearings came to tout the benefits of bringing IP caregivers into the homes of older Rhode Islanders and persons with disabilities, Nicholas A. Oliver, Executive Director of the Rhode Island Partnership for Home Care, sees problems down the road and calls the new policy “duplicative and costly.”

In written testimony, if the legislation is passed Oliver warns that Rhode Island will be authorizing untrained and unsupervised paraprofessionals to deliver healthcare to the state’s most frail seniors without Department of Health oversight, without adherence to national accreditation standards for personal care attendant service delivery and without protections against fraud, waste and abuse.

Furthermore, his testimony expressed concern over the lack of oversight as to the quality of care provided by IPs to their older or disabled clients. Although the legislation called for supervision from the Director of Human Services (DHS), this state agency does not have the mandated legislative authority to investigate IPs to ensure that patient safety is met and the recipients of care are protected against harm in their homes. Nor does it require daily supervision for adherence to the patient’s authorized plan of care, he says, noting that is a requirement for licensed home health and hospice agencies.

Oliver observes that the legislation does not require IPs to receive the same level of intensive training that Certified Nursing Assistances (CNAs) receive from their home health care and hospice agencies. While the state requires all CNAs to complete 120 hours of initial training, pass a written and practical examination, become licensed by the Department of Health and maintain a license by completing a minimum of 12 hours of in-service training annually, the legislation only requires IPs to take three hours of generalized training and no continuing in-service training is required.

CNAs deliver the same personal care attendant services as the IPs but have a specific scope of practices that they must follow as regulated by the Department of Health and their licensure board while IPs do not have these requirements, says Oliver.

Finally, Oliver says that “to ensure quality of care [provided by home care and hospice agencies], CNAs are supervised by a registered nurse (RN) that is actively involved in the field and who is available to respond to both the patient’s and the CNA’s needs on-demand to reduce risk of patient injury, harm or declining health status and to reduce risk of CNA injury, harm or improper delivery of personal care.” IPs do not have this supervision., he says.

Safe guards are put in place by home health and hospice agencies to ensure the safety of patient and direct care staff, says Oliver, noting that these agencies are nationally accredited by The Joint Commission, the Community Health Accreditation Program (CHAP) or the Accreditation Commission for Health Care (ACHC) in partnership with the Department of Health for compliance of state and federal rules and regulations, as well as national clinical standards for personal care attendant service delivery.

With the Rhode Island General Assembly bringing IPs into the state’s health care delivery system, the state’s Executive Office of Health and Human Services, granted authority by the legislation to develop the program, might just consider establishing a Task Force of experts to closely monitor the progress of the new IP program’s implementation to ensure that quality of care is being provided and to make suggestions for legislative fixes next year if operational problems are identified. Unanticipated consequences of implementing new rules and regulations do happen and every effort should be state policy makers that this does will not happen in Rhode Island with the creation of the new IP program.

To watch Oliver talk about the Rhode Island Partnership for Home Care’s opposition to the enactment of IP legislation that would increase state involvement in the home care sector, go to http://m.golocalprov.com/live/nicholas-oliver.

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New Uniform Act Good News for Rhode Island Caregivers

Published in Woonsocket Call on November 29, 2015

With the quick stroke of her pen, Rhode Island Governor Gina Raimondo signed guardianship legislation into law during the 2015 legislative session that would help Rhode Islanders avoid costly and time-consuming red tape when exercising health care, financial and other legal responsibilities for their out-of-state, elderly loved ones. It takes effect on January 1, 2016.

Like motherhood and apple pie, the changes made to the State’s guardianship law had broad bipartisan support in the Rhode Island General Assembly. The House bill and a similar Senate companion measure (entitled the “Uniform Adult Guardianship and Protective Proceedings Jurisdiction Act”) passed overwhelming by votes of 72-2 and 37 to 1, respectively.

Representative Robert E. Craven (D-North Kingstown) who Chairs the House Committee on Municipal Government, says his legislation (introduced with Representative Michael A. Morin (D-Woonsocket) simply helps to protect those who are unable to protect themselves.  “When appointing guardians and instituting protective orders for adults, the law must be clear and concise to ensure someone’s rights are not violated while also keeping them safe,” he says, noting that the new law makes the rules and procedures very clear for this process and it will offer both the protected persons and petitioning guardians the legal causes and safeguards that are needed in such complex situation,” he said.

Fixes Jurisdictional Issues over Guardianship

According to Division of Elderly Affairs Director Charles J. Fogarty, the new law “provides consistency, reciprocity, and procedural efficiency in the best interest of seniors, creating a hospitable and healthy Rhode Island for our elders.”

Fogarty says that the new law would benefit caregivers in many way.  It clarifies state jurisdiction issues and even facilitates the transfer of guardianship from one state or another.  It also would enhance interstate recognition and enforcement of guardianship orders and simplifies communication and cooperation between courts.

Fogarty notes that Rhode Island’s new guardianship law is a law that 37 other states, as well as the District of Columbia and Puerto Rico, have already enacted, allowing for cooperation on and simplification of inter-state issues.  “It will be easier for out-of-state caregivers to focus on supporting their loved ones as opposed to becoming mired in current laws.  This legislation ensures that seniors and caregivers don’t waste time and resources in cases involving simultaneous and conflicting jurisdiction,” he says.

“We are very pleased that our staff, our terrific State House advocacy volunteers and a strong network of partners worked hard together to ensure that Rhode Island became the 42nd jurisdiction to enact the Uniform Adult Guardianship and Protective Proceedings Jurisdiction Act,” said AARP State Director Kathleen Connell. “Now, Rhode Island joins the national effort that focuses on care, not courts, by removing the barriers that prevent caregivers from providing for their loved ones, regardless of where they live.”

According to the AARP Public Policy Institute’s recent report “Valuing the Invaluable: 2015 Update,” the number of caregivers in our state is 134,000. Their work has an economic value of $1.78 million. That, Connell said, is why AARP Rhode Island strongly supported the legislation and was joined by judges, lawyers and families throughout Rhode Island.

Many Benefits, No Cost to Rhode Island Taxpayers

Connell notes that when the uniform guardianship jurisdiction becomes law, it will carry no cost to taxpayers and makes no changes in the state’s substantive guardianship procedures. However, Rhode Islanders will benefit as it will save them time and money. In addition, they will be safeguarding the health and financial well-being of their loved ones.

“It may seem very technical,” Connell continued. “But the bottom line is easy to understand:  We all recognize that we are a mobile society, and with that we need laws pertaining to caregivers and their families to reflect that reality. AARP strongly supports legislation that removes barriers that prevent guardians in Rhode Island from providing for their loved ones, regardless of where they live. “For Rhode Islanders, the uniform guardianship act is a step in the right direction to help protect the interests of vulnerable incapacitated adults who need guardians,” Connell said. “With this law, our guardianship system will function more efficiently, fairly, and cost-effectively.”

Court-appointed guardians step into the shoes of at-risk adults who can no longer make their own decisions, and make judgments about property, medical care, living arrangements, lifestyle and potentially all personal and financial issues. As a judicial proceeding, guardianship can be expensive, time-consuming and combative. It can remove fundamental individual rights. It can prevent or redress elder abuse – or can create an opportunity for exploitation or abuse of vulnerable adults.

This new uniform act addresses initial jurisdiction regarding a guardianship case; recognition of one state’s guardianship orders by another; and interstate transfers of guardianship cases when such transfers would benefit the incapacitated person.

Another key reason AARP strongly supported enactment stems from concern over elder abuse, neglect and exploitation. It will reduce the enticement of a vulnerable person to another state ― to gain control over assets. The law now will permit a court to consider which jurisdiction can best protect a person subject to abuse, and facilitate communication between courts in different jurisdictions about allegations of abuse.

Partners included the Uniform Law Commission. The Commission provides states with non-partisan, well-conceived, and well drafted legislation that brings clarity and stability to critical areas of state statutory law. In addition, the Act has a broad range of support from organizations including the National College of Probate Judges, National Academy of Elder Law Attorneys, National Guardianship Association, Conference of Chief Justices and the Alzheimer’s Association.

With the graying of Rhode Island’s population commonsense laws like the “Uniform Adult Guardianship and Protective Proceedings Jurisdiction Act” need to be enacted.  Last session, state lawmakers worked together to pass this legislation that makes guardianship system more efficient, less time-consuming and costly for Rhode Island caregivers.  At no cost to Ocean State taxpayers.  Hopefully, best policy practices from across the nation can be brought to the Rhode General Assembly for full consideration.  If it happened once it might just happen again.