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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Rethinking Rhode Island’s LTC Delivery System

Published in the Woonsocket Call on April 12, 2015

AARP Rhode Island releases a state-specific analysis, of the 2014 edition of “Raising Expectations: A State Scorecard on Long-Term Services and Supports (LTSS) for Older Adults, People with Physical Disabilities, and Family Caregivers” that just might give state officials cause for concern, a low rating on its long-term care delivery system, when compared to other states.

The 2011 Scorecard was the first multidimensional assessment of state performance of LTSS. Like this earlier version, the release of the 109 page 2014 report, referred to as the LTSS Scorecard, and its state-specific analysis (prepared by policy consultant Maureen Maigret), measuring how well the nation and each of the states is doing in providing long-term care services, does not bode well for the nation’s littlest state. It finds the Ocean State ranks 38th nationally on 26 performance indicators, with it achieving the lowest rank of all New England States.

“Our analysis provides a closer look at where Rhode Island is keeping pace and where we fall short,” said AARP State Director Kathleen Connell. “The report indicates that, as the state with the highest percentage of persons 85 and older, we face exceptional challenges. It is our hope that the General Assembly and state policymakers find the analysis to be a valuable tool,” she says.

Failing Grades

The 2014 LTTS Scorecard indicates that Rhode Island:

• Ranks 4th highest among states in nursing home residents per 1,000 persons age 65 and over

• Has a high percent of low-care nursing home residents and spends a far higher percent of its LTSS dollars than the national average on nursing home care as opposed to home and community-based services.

• Has some of the highest long-term care cost burdens in the country making private pay long-term services unaffordable for the vast majority of older households.
But, on a positive note, the state-specific analysis noted that Rhode Island’s best progress was made in the Legal and System Supports dimension largely due to the 2013 passage of the Temporary Caregiver Insurance program and Caregiver Assessment requirements for Medicaid Home and Community Based Services (HCBS).

In addition, to revisiting the 19 recommendations made following the release of AARP’s 2011 Scorecard, the more recent 2014 analysis recommends five new major policy initiates to improve the littlest state’s LTSS. Among the recommendations: funding of an Aging and Disability Resource Center; the developing an online benefits screening tool to allow access to income-assistance benefits and conducting outreach programs to increase participation; reviewing the Rhode Island’s Nurse Practice Act to allow nurse delegation of certain health maintenance and nursing tasks to direct care workers; requiring hospitals to provide education and instruction to family caregivers regarding nursing care needs when a patient is being discharged; and exploring emerging medical technologies to better serve home and community based clients.

The current analysis finds that only four recommendations out of the 2011 recommendations have been implemented, most notably those to promote coordination of primary, acute and long-term care and to strengthen family caregiver supports.

Meanwhile, only six recommendations were partially implemented, including the expansion of the home and community co-pay program and authority (but not implementation) under the 1115 Medicaid waiver renewal to provide expedited eligibility for Medicaid HCBS and for a limited increase in the monthly maintenance allowance for persons on Medicaid HCBS who transition out of nursing homes. Finally, nine recommendations, although still relevant, have not been implemented.

Response and Comments

Responding to the release of AARP’s 2014 Scorecard and state-wide analysis, Governor Gina Raimondo says, “we need to ensure that we have a strong system of nursing home care for those who truly need those services, but we must invest our Medicaid dollars more wisely to support better outcomes. We cannot continue to have the fourth highest costs for nursing home care (as a percent of median income of older households) and also rank near the bottom of all states in investments in home and community-based care.”

According to Raimondo, the state’s Working Group to Reinvent Medicaid is looking closely at AARP’s Scorecard and state-specific analysis and Rhode Island’s spending on nursing home and long-term care. Health & Human Services Secretary Elizabeth Roberts has directed her staff to look directly at the proposals recommended by AARP Rhode Island.

“I expect the Working Group will include specific proposals stemming from these findings in their April budget recommendations and their long-term strategic report they will complete in July,” says the Governor.

AARP Rhode Island Executive Director Connell, representing over 130,000 Rhode Island members, was not at all surprised by the findings of the recently released 2014 Scorecard. “Based on benchmarks set in the 2011 Scorecard, it was apparent that there was much work to do,” she says, recognizing that there are “limited quick fixes.”

“Some steps in the right direction will not lead to an immediate shift in the data. This is a big ship we’re trying to steer on a better course. We were encouraged, however, by ‘improving’ grades for lower home-care costs and the percentage of adults with disabilities ‘usually or always’ getting needed support rising from 64 percent to 73 percent,” adds Connell.

Connell says that the Rhode Island General Assembly is considering legislation to improve the delivery of care, which might just improve the state’s future AARP ‘report’ cards.” “In this session, there is an opportunity to improve long-term supports and services with passage of several bills, including one that would provide population-based funding for senior centers,” she says, stressing that it’s a “responsible investment that will help cities and towns provide better services.”

Connell adds, “The proposed CARE Act gives caregivers better instruction and guidance when patients are discharged and returned to their homes. This can be a cost saver because it can reduce the number of patients returned for treatment or care.”

The larger mission for state leaders is the so-called ‘re-balancing’ of costs from nursing care to home to community-based care. That’s where real savings can occur and home is where most people would prefer to be anyway.”

Finally, Virginia Burke, Executive Director of the Rhode Island Health Care Association, a nursing facility advocacy groups, supports the implementation of the policy initiatives recommended by AARP’s state-specific analysis. But, “The primary driver of our state’s nursing facility use is the extremely advanced age of our elders,” Burke says, noting that the need for nursing facility care is more than triple for those aged 85 and older than for seniors just a decade younger. Due to the state’s demographics you probably won’t see a change of use even if you put more funding into community based home services, she adds.

Governor Gina Raimondo and the General Assembly leadership will most certainly find it challenging to show more improvement by the time the next Scorecard ranks the states. Older Rhode Islanders deserve to have access to a seamless system, taking care of your specific needs. Creative thinking, cutting waste and beefing up programs to keeping people in their homes as long as can happen might just be the first steps to be taken. But, the state must not turn its back on nursing facility care, especially for those who need that level of service.

Herb Weiss, LRI ’12 is a Pawtucket writer who covers aging, health care and medical issues. He can be reached at hweissri@aol.com.

Rhode Island General Assembly Tackles Senior Issues

Published in Pawtucket Times, July 19, 2013

At the end of June, Rhode Island lawmakers passed the state’s $8.2-billion FY 2014 state budget bill, sending it to Governor Lincoln D. Chafee’s desk for his signature. Even with $ 30 million ultimately slashed from the state’s fiscal blueprint because of lower-than-anticipated revenues, cash strapped taxpayers were happy to learn that they will not see any state tax or fee increases.

            Political correspondents in print, electronic media and in web site blogs zeroed in on specific items in the state’s enacted budget plan, those that they judged as weighty and newsworthy to be detailed to their audience.  Like the phoenix rising from the ashes, the FY 2014 state budget brought back to life the state’s historic tax credit (through the efforts of Executive Director Scott Wolf, of Grow Smart and a broad based coalition of over 100 groups), also putting dollars into workforce development, even helping the Ocean State’s burgeoning artist community by enacting a state-wide sales tax exemption on specific types of art purchased.  With the budget now signed into law, Rhode Island liquor retailers are able to compete against competitors in nearby Massachusetts because of a new 16-month trial period for tax-free wine and liquor sales.  

            One of the more controversial items in the FY 2014 state budget that fueled heated discussions on WPRO and WHJJ radio talk shows was putting funds in the state budget to pay the first installment payment of $2.5 million on the bonds issued to the now bankrupt 38 Studios. 

 

Funding Programs and Services for Seniors

            Although not widely reported in many media outlets, Rhode Island lawmakers did not turn their back on aging baby boomers or seniors.   

            The FY 2014 budget provides $1.0 million in Community Service Grants to organizations serving the elderly, including $200,000 for meals on wheels, $25,000 for Home and Hospice Care and level funding for Senior Centers across the state.

            It also consolidates funding for care for the elderly, consistent with the Integrated Care Initiative.  This initiative will coordinate care of the elderly, many of whom are eligible for both Medicare and Medicaid and who navigate disjointed payment and delivery systems.  With the state’s enacted budget, there will be a single funding and delivery system that integrates long term, acute and primary care to dually-eligible individuals.

            Also, the state’s budget plan maintains the Rhode Island Pharmaceutical Assistance to the Elderly program (RIPAE), coordinating with benefits provided through the Affordable Care Act and ensuring no gaps in coverage for low income seniors.

            It also directs funding for programs and personnel within the state’s Office of Health and Human Services to combat waste, fraud and abuse, including the new Medicaid Fraud Control Unit, to ensure Medicaid dollars return as much value for participants as possible.

            The enacted budget also establishes $80,000 for the Emergency and Public Communications Access Fund to improve emergency communication and to support emergency responder training for the deaf and hard of hearing population in the State.

TDI Expansion Becomes Law

            Meanwhile, on July 3rd, Rhode Island lawmakers approved legislation (S 231 B, 5889A), sponsored by Sen. Gayle Goldin (D-District 3, Providence) and Rep. Elaine Coderre, (D-District 60, Pawtucket) to expand temporary disability insurance to employees who must take time out of work to care for a family member or bond with a new child in their home (see my May 17 issue of the Pawtucket Times, May 19 issue of Woonsocket Call).

            Women’s Fund of Rhode Island CEO Marcia Conė and the WE Care for RI coalition, consisting of over 40 groups, brought in national politico operative, Steve Gerencser, who consulted and developed the game plan and messaging needed to get the TDI legislation passed and onto the Governor’s desk for signature.  Rhode Island becomes the third state in the nation to pass a paid family leave law.

            Signed by Democratic Governor Chafee, the new law will increase the state’s TDI program to cover up to four weeks of wage replacement for workers who take time off to care for a seriously ill child, spouse, domestic partner, parent, parent-in-law or grandparent or to bond with a new child, whether through birth, adoption or foster care. Temporary caregiver benefits would be limited to those who are the caregiver of their sick or injured family member, and the program would require documentation from a licensed health care provider.

            “The most important reason for this legislation is to provide support to help families in times of need, but it has many good ripple effects for Rhode Islanders,” noted Coderre. This includes saving on avoidable medical costs for people who will be able to stay home with a family member instead of needing to admit their family member to an expensive medical facility. It can mean that someone keeps their job.

            Adds Senator Goldin, unpaid leave isn’t always an option, and it’s a very difficult option for most families. “Paid caregiver leave is a cost-effective way to keep people from losing their jobs, jeopardizing their financial security or risking their family’s well-being when a family member needs care,” she said.

            The expansion would be funded through employee contributions, just as the rest of the TDI program is currently funded. In order to support the expanded benefits, employees would contribute another 0.075 percent of their income to TDI. For a worker earning about $40,000 a year, this would mean he or she would pay an additional 64 cents a week for the expanded benefit.

Also Becoming Law…

            Governor Chafee has also signed the Family Caregivers Support Act of 2013 passed by the Rhode Island General Assembly.    

            Aiming to improve the quality of life for the elderly and the disabled in the comfort of their own homes, an approved  legislative proposal requires the Executive Office of Health and Human Services to develop evidence-based caregiver assessments and referral tools for family caregivers providing long-term care services.

            Sponsored by Rep. Eileen S. Naughton (D-Dist. 21, Warwick) and Senate Majority Whip Maryellen Goodwin (D-Dist.1, Providence), the legislation calls for an assessment that would identify specific problems caregivers or recipients might have, carefully evaluate how those situations should be handled and come up with effective solutions.

            The legislation defines “family caregiver” as “any relative, partner, friend or neighbor who has a significant relationship with, and who provides a broad range of assistance for, an older adult” or an adult or child “with chronic or disabling conditions.” Rep. Naughton said people should be aware that there are support systems and an abundance of resources available for home care before deciding to put an elderly person in a nursing home or an expensive facility.

            Senator Goodwin added that without the proper support, the current system can place an unnecessary burden on both facilities and caregivers.

            “We want fewer individuals going into nursing homes and similar facilities if we can help it,” says Rep. Naughton. “It’s upsetting for an elderly or disabled individual to have to trade the comfort of his or her home for an unfamiliar place. Family caregivers not only know the medical needs of these individuals, but are often aware of their emotional needs, too,” she said.

            The comprehensive assessment required as part of Medicaid long-term service reform is meant to provide assistance with activities of daily living needs and would serve as a basis for development and provision of an appropriate plan for caregiver information, referral and support services. Information about available respite programs, caregiver training, education programs, support groups and community support services is required to be included as part of the plan for each family caregiver.

Addressing Long Term Care Needs

            Other approved legislative proposals, supported by the state’s nursing facility industry, were also signed by Governor Chafee.  

            Lawmakers passed and the Governor signed legislation to permit pharmacies that sell medications to nursing homes to buy them back, with a “restocking” fee.  Under the new law, medications that are individually packaged, unopened, and meet other safety requirements as determined by a pharmacist can be used rather than being discarded.

            Also signed into law were measures that promote “aging in place” and direct the state’s Department of Health to review regulations to permit this.

            Finally, the Governor signed the Palliative Care and Quality of Life Act, which establishes an advisory council and program within the Department of Health. Also, beginning in 2015, every health care facility must establish a system for identifying patients or residents who would benefit from palliative care and provide information and assistance to access such care.

             Virginia Burke, CEO and President of the Rhode Island Health Care Association (RIHCA), observed that this year’s legislative session had mixed results for nursing home residents.  Most of the bills that the group supported did pass, which “should lead to enhanced care for our residents,” she says. 

            According to Burke, “Unfortunately, providers were anticipating an adjustment to their rates this fall to address price increases in things like insurance, food, and utilities and that was taken away due to the budget deficit.  We’re very lucky that Rhode Island providers are known throughout the nation for their delivery of quality care, but quality begins to suffer when providers don’t have adequate resources to do the job.”

            This year difficult budgetary choices were made to balance the state’s budget.  Although aging advocates did not get everything they pushed for, Governor Chafee and the Rhode Island General Assembly did fund programs and services that are sorely needed by the state’s growing senior population.  I urge lawmakers to continue these efforts in the next legislative session.  

            Herb Weiss LRI ’12 is a Pawtucket-based writer who covers aging, health care and medical issues.  He can be reached at hweissri@aol.com