In -Home Supportive Services (IHSS) · In-Home Supportive Services (IHSS) ... entitlement program...
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IHSS Annual Report 2015 Page 0
In-Home
Supportive
Services (IHSS) FY 2015 Annual Report
Social Services Agency, Department of Aging and Adult
Services
IHSS Annual Report 2015 Page 1
IN-HOME SUPPORTIVE SERVICES (IHSS) ANNUAL REPORT
Presented to the Children, Seniors and Families Committee
Board of Supervisors, Santa Clara County
September 3, 2015
Introduction
The Children, Seniors, and Families Committee last reviewed the IHSS Annual Report
in September 2014. This report will update the Committee as to the status of current
administrative and service issues specific to the IHSS program and the IHSS Public
Authority.
IHSS Program Overview
The IHSS program provides in-home care for persons who cannot safely remain in their
own homes without such assistance. Created in 1973, the core goal of the IHSS
program remains the prevention of premature or unnecessary placement of recipients in
institutions (skilled nursing facilities, community care facilities or hospitals). IHSS is an
entitlement program and all clients found to be eligible and at risk of out-of-home
placement are accepted. To be eligible, recipients must be assessed and found to be
aged (65 years of age or older), blind or disabled (as determined by the Social Security
Administration) and are unable to remain safely in their own home without assistance.
Recipients must also meet specific income requirements consistent with eligibility for
Medi-Cal. Services offered include domestic and related tasks such as laundry,
shopping, meal preparation, and light housecleaning; personal care services such as
assistance with feeding, bathing, and ambulating; transportation to and from medical
appointments; and certain paramedical services ordered by a physician. County social
workers perform an assessment to determine the number of hours and type of services
to authorize an IHSS recipient. The recipient is responsible for hiring, training,
supervising, and firing a provider. Based on the submittal of timesheets, the IHSS
providers are paid with a combination of state, federal and county funds.
IHSS is a state mandated and regulated program that is operated by the County level in
accordance with the California Welfare and Institutions Code. Both federal and state
laws serve, effectively, to make IHSS an entitlement program. Interested individuals
have a right to apply for IHSS services and are guaranteed services if they meet the
financial and functional eligibility criteria. Consistent with all public entitlement
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programs, IHSS provides applicants certain rights—timely decision of eligibility, timely
notice of change in eligibility or service, and an appeals process to dispute eligibility
decisions.
The California State Department of Social Services (CDSS) and the counties share
administrative responsibilities for the IHSS program. CDSS oversees the IHSS data
and payroll system known as CMIPS II (Case Management and Information and Payroll
System II), serves as the payroll agent for the IHSS providers, and writes the IHSS
regulations. Counties are responsible for the day-to-day administration of the IHSS
program. County staff also determines consumers’ program eligibility and the number
of hours and type of services each consumer needs.
Components of IHSS
IHSS Program Funding
IHSS services are provided under four programs: Personal Care Services Program
(PCSP), Federal Plus Waiver Program (converted to State Plus Option in 2009),
Residual Program, and Community First Choice Options (CFCO).
Eligibility
To be eligible for IHSS, a person must be aged, blind or disabled and usually have
monthly income at or below the SSI/SSP grant level ($889.40 per month for individuals
as of January 2015). Those individuals with income in excess of this grant level may
still be eligible for IHSS with a share of cost (SOC). An IHSS recipient with a SOC must
make an out-of-pocket monthly payment towards the receipt of IHSS services before
the IHSS program pays the remainder of the cost of their services. Eligibility for IHSS is
generally limited to individuals with no more than $2,000 in assets and couples with no
more than $3,000 in assets (with certain exclusions for such assets as homes and
vehicles).
Application and Social Worker Assessment
When a prospective IHSS recipient applies for the program, the determination of their
eligibility is a two-step process that takes into account both their income and need for
services. Once verified that an individual is financially eligible for IHSS, a social worker
visits the home of the recipient to determine whether there is a need for services. To
perform this assessment, the social worker uses a uniform assessment tool to
determine the number of hours for each type of IHSS service for which a recipient
qualifies in order to remain safely in his/her own home. The uniform assessment tool,
known as the Hourly Task Guidelines (HTGs) assists the social worker in ranking the
recipient’s impairment level on a five-point scale known as the functional index (FI)
ranking. Figure 1 shows each of the potential FI rankings that may be assessed by a
social worker, and what they mean for the impairment level of the recipient.
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Figure 1:
Functional
Index
Impairment Implications
1 Able to perform function without human assistance-
independent.
2 Able to perform a function, but needs verbal assistance
(reminding, encouraging).
3 Able to perform a function with some human, physical
assistance.
4 Able to perform a function with substantial human assistance.
5 Cannot perform the function with or without human
assistance.
Each FI ranking corresponds to an established range of service hours for a particular
task. For example a recipient who receives an FI ranking of 2 on the “feeding” task may
be authorized to receive between 0.7 hours and 2.3 hours of feeding per week. The
corresponding range of hours varies depending on the particular task being assessed.
For example, meal preparation services range from three to seven hours. Also if an
individual is assessed as having an FI ranking of 1 for any given task, he/she will not
receive any authorized hours for that task. The weighted average of the FI rankings for
each task is used to create a total FI score. Although the HTGs provide a standard tool,
the assessment process is individualized. Social workers may, with written justification,
authorize hours above or below the range established by the HTGs.
Assignment of Hours
Once a social worker has determined the number of hours to authorize for a recipient,
the recipient is notified of the number of hours they have been authorized for each task.
Using the HTGs, social workers may authorize between 1 and 283 total hours per
month of IHSS services. Recipients who receive over 195 hours of service each month
are considered to be severely impaired. Once it has been determined that a recipient
meets the eligibility criteria for IHSS, that individual is granted those IHSS services. As
a result, there is no waiting list or cap on program enrollment.
IHSS Annual Report 2015 Page 4
IHSS Budget Overview
The Governor’s budget provides $8.2 billion ($2.5 billion GF) for the IHSS program,
reflecting a 14.4 percent increase over the 2014-15 level. The IHSS caseload in 2014-15
is anticipated to grow by 3.8 percent from the prior fiscal year to 446,053, and is
projected to increase again by 3.7 percent in 2015-16 to 462,648 recipients. While the
2015-16 projections are increasing at a slower rate compared to prior years, the
Administration estimates approximately one percent of newly eligible individuals under
the Affordable Care Act (ACA) will utilize IHSS services, resulting in 19,679 newly
eligible IHSS cases per month in 2014-15 and 20,126 cases per month in 2015-16.
According to the Administration, this 6.4 percent growth reflects expected increases in
negotiated wages and benefits, the impact of the State’s minimum wage increase and
the impact of limiting payment of overtime. Additional details on the overtime proposal
are provided below.
Federal and State Legislation Affecting IHSS
Restoration of Across the Board Reduction
The Governor’s Budget restored the current 7 percent across the board reduction in
service hours with proceeds from the new tax on managed care organizations effective
July 1, 2015. The cost to restore the 7 percent reduction is estimated to be $483.1
million in 2015-16 ($215 state General Fund).
Community First Choice Options (CFCO)
The federal Patient Protection and Affordable Care Act (ACA) of 2010 (Public Law 111-
148) was enacted March 23, 2010 and established CFCO as a new State Plan Option,
which allows States to provide Home and Community-Based Attendant Services and
Supports.
In December 2011, the California Department of Social Services (CDSS) and the
California Department of Health Care Services (DHCS) submitted a State Plan
Amendment (SPA) for the CFCO Program to the Centers for Medicare & Medicaid
Services (CMS). This SPA allowed California to receive an additional 6% in federal
funding for services for CFCO-eligible Personal Care Services Program (PCSP) and
IHSS Plus Option (IPO) program recipients, who were moved into CFCO, and for new
CFCO-eligible applicants. This initial CFCO SPA was approved by CMS on August 31,
2012, retroactive to December 1, 2011.
IHSS Annual Report 2015 Page 5
The initial SPA was based on the draft CFCO federal regulations and was approved with the understanding that a new SPA would be submitted for approval to include Nursing Facility Level of Care (NF LOC) eligibility criteria as required, per the final CFCO regulations. The new CFCO SPA was approved by CMS on July 31, 2013, with an effective date of July 1, 2013. California was the first state in the nation to receive approval for implementing the
CFCO Program. With this addition, California now operates four IHSS programs: IHSS-
Residual (IHSS-R), PCSP, IPO and CFCO.
All CFCO participants must be eligible for Full-Scope, Federal Financial Participation
(FS FFP) Medi-Cal (as in the PCSP and the IPO programs), and meet CFCO NF LOC
eligibility. The new CFCO eligibility requirements are more stringent than those in effect
from December 1, 2011 through June 30, 2013; therefore, individuals with FS FFP
Medi-Cal eligibility who were, but are no longer, eligible for CFCO, due to the NF LOC
criteria, will be served in the PCSP or IPO programs, effective July 1, 2013.
As in the IPO program, recipients in CFCO may also receive Restaurant Meal
Allowance, Advance Pay, service(s) provided by a recipient’s spouse, and service(s)
provided by a minor recipient’s parent.
Although CFCO regulations allow States to provide permissible services and supports,
such as expenditures for transition costs, California did not elect to include permissible
services.
The federal ACA provides an additional 6% in Federal Medical Assistance Percentage
(FMAP) for CFCO Home and Community-Based Attendant Services and Supports. The
required CFCO services eligible for the enhanced FMAP are: (1) assistance with ADLs,
IADLs, and health-related tasks and (2) acquisition, maintenance, and enhancement of
skills necessary for recipients to perform ADLs, IADLs, and health-related tasks.
Effective January 2014, the ACA provided an enhanced FMAP rate for services to
newly eligible individuals between 19 and 65 years of age whose household income
does not exceed 138 percent of the federal poverty level. Due to the changes in Medi-
Cal eligibility resulting from the ACA, newly eligible adults, some of which were
previously covered under other programs such as the Low Income Health Program, are
transitioning into Medi-Cal and seeking IHSS services.
Provider Overtime
In September 2013, the United States Department of Labor issued its Final Rule
concerning domestic workers under the FLSA. The regulation is effective January 2015
and contains several significant changes impacting the IHSS program, including: (1)
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more clearly defining the tasks that comprise “companionship services” and (2) limiting
exemptions for companionship services and live-in domestic service employees to the
individual, family, or household using the services, and not third-party employers.
Compliance with the final federal pay regulations for direct care workers require
compensation for IHSS provider overtime, payment for commute time between multiple
recipients and wait time associated with medical accompaniment.
Under the Final Rule, the state, as a third-party employer, can no longer claim the
“companionship services” or “live-in domestic service employee” exemption under the
federal minimum wage and overtime regulations. The state will be required to pay IHSS
providers overtime under the FLSA. In addition, as the state is no longer able to claim
minimum wage and overtime exemptions, the state is required to compensate providers
for commute time between multiple recipients and wait time during medical
accompaniment.
SB 855 (Chapters 29, Statutes of 2014) added section 12300.4 to the W&IC to specify
that IHSS providers are not permitted to work a total number of authorized hours within
a workweek that exceed 66 hours, as reduced by the net percentage defined in W&IC
sections 12301.02 and 12301.03.
Overtime during FY 2014-15 was estimated to cost $6.22 per hour (overtime costs for time and a half based on regular wages of $12.44 per hour) and $6.29 per hour in FY 2015-16 (based on regular wages of $12.57 per hour).
Eighteen percent of providers serve multiple recipients. It is estimated providers will spend an average of ten hours per month traveling between recipients. Eighty-seven percent of recipients will have a provider accompany them to medical visits. It is estimated providers will spend three hours per month waiting for recipients to complete their appointments during medical accompaniment.
The FY 14/15 budget assumed implementation of the FLSA regulations on January 1,
2015. However, in late December 2014, a federal district court ruled that the regulations
exceeded the federal Department of Labor’s authority and delayed implementation of
the regulations. Under state law, the state’s implementation of overtime, commute time,
and wait time is also delayed pending further action by the federal court.
Coordinated Care Initiative (CCI) Update
The State 2012 budget authorized the Coordinated Care Initiative (CCI) which marks an
important step toward transforming California's Medi-Cal care delivery system to better
serve the state’s low-income seniors and persons with disabilities. The CCI has been
IHSS Annual Report 2015 Page 7
implemented in seven pilot counties: Los Angeles, Orange, Riverside, San Bernardino,
San Diego, San Mateo, and Santa Clara. The CCI is composed of two major parts:
Long-Term Supports and Services (LTSS) as a Medi-Cal Managed Care Benefit: CCI includes the addition of LTSS into Medi-Cal managed care. LTSS includes nursing facility care (NF), In-Home Supportive Services (IHSS), Multipurpose Senior Services Program (MSSP), and Community Based Adult Services (CBAS). In the seven pilot counties, this change impacts about 5 million Medi-Cal only enrollees. Most Medi-Cal beneficiaries, including dual eligibles, partial dual eligible, and previously excluded Seniors and Persons with Disabilities (SPDs) who are Medi-Cal only, are required to join a Medi-Cal managed care health plan to receive their Medi-Cal benefits.
Cal MediConnect Program: A three-year demonstration project for persons eligible for both Medicare and Medi-Cal (dual eligibles) to receive coordinated medical, behavioral health, long-term institutional, home and community-based services through a single organized delivery system (health plan). Statewide, no more than 456,000 beneficiaries would be eligible for the duals demonstration in the seven counties. This demonstration project is a joint effort with the federal Centers for Medicare and Medicaid Services (CMS).
The purpose and goal of CCI is to promote the coordination of health and social care for
Medi-Cal consumers and to create fiscal incentives for health plans to make decisions
that keep their members healthy and out of institutions (given that hospital and nursing
home care are more expensive than home and community-based care).
Under the current system (prior to CCI), dual eligibles must access services through a
complex system of disconnected programs funded by different government programs
(e.g., federal CMS, DHCS-Medi-Cal, IHSS-county based). This fragmentation often
leads to beneficiary confusion, delayed care, inappropriate utilization and unnecessary
costs.
As one of the seven pilot counties, Santa Clara County implemented the LTSS portion
of the CCI effective July 1, 2014 and the Cal MediConnect Program was launched on
January 1, 2015. Santa Clara County’s two identified health plans are Anthem Blue
Cross and Santa Clara Family Health Plan. As of July 1, 2015, there are 10, 964
beneficiaries enrolled into the Cal MediConnect Program in Santa Clara County.
Information and input regarding the CCI have been disseminated through various
avenues:
IHSS Annual Report 2015 Page 8
CCI Communications Committee meetings are held every other month and are
co-chaired by Anthem Blue Cross and Santa Clara Family Health Plan to
communicate the initiative to dual eligible beneficiaries.
CCI Stakeholder Advisory Committee meetings are conducted quarterly and
there is well-received attendance from a number of community stakeholders.
State level and County level information are communicated out via monthly
Department of Health Care Services (DHCS) CCI Stakeholder Call Ins/Webinar
and bi/weekly email blasts from Calduals.org.
The Santa Clara County’s CCI Coordination Guide has been completed and
distributed to the health plans and IHSS staff. The guide serves as a tool for
clearly defining roles and responsibilities of the health plans and IHSS staff.
As part of the Maintenance of Effort (MOE), Santa Clara County’s IHSS program
received mid-year budget approval to hire for the following positions: 1 Social Services
Program Manager I, one Social Work Coordinator II, 4 Social Worker I/II’s and one
alternately staffed Office Specialist III/Client Services Technician. These positions will
comprise the CCI Unit which will work collaboratively with the two health plans, Anthem
Blue Cross and Santa Clara Family Health Plan while also providing support to the 75
Social Workers who solely carry a caseload of continuing and intake cases.
The primary function of the unit will be to collaborate with IHSS staff and the health
plans to address the provision of services for dual eligible consumers. Specifically, the
CCI Unit will assist with processing new referrals from the health plans, participate in
Interdisciplinary Care Team (ICT) meetings and conduct assessments on expedited
applications and reassessments. Additionally, the CCI Unit will be integrated with the
Application Readiness Unit. The incorporation of the two cited units will result in IHSS’
ability to provide more seamless services to recipients.
Santa Clara County’s IHSS Program
Housed within the Social Services Agency, IHSS is one of four programs along with
Adult Protective Services, Senior Nutrition, and the Office of the Public
Administrator/Guardian/Conservator that together comprise the Department of Aging
and Adult Services.
Currently, the IHSS program employs 146 full time equivalent positions and is staffed as
follows: Administration/Quality Assurance: 12; Social Work/Supervisory: 89;
Eligibility/Supervisory: 10; Payroll/Data Specialists: 17; and Clerical support: 17.
IHSS Annual Report 2015 Page 9
Also as part of the MOE, IHSS augmented its staff by 11 full time equivalent positions
through the FY 15/16 budget. IHSS received approval to hire 1 additional Social Work
Supervisor, 8 Social Workers, one Quality Assurance Social Work Coordinator I, and
one Program Services Aide. We are currently in the hiring process for all of these
positions. We anticipate the new staff will arrive between the months of August and
November. For the social worker recruitment, efforts were made to best reflect the
IHSS recipient population regarding language and ethnicity. The table below highlights
the social work staff hired to date including the results of our recruitment efforts to best
serve the needs of our clientele.
Figure 2:
Staffing Summary
Language/Position Program
Requested
Program
Hired
Status
Monolingual Social Services Program Manager I 1 1 Hired
Monolingual Social Work Supervisor 1 1 In Position
8/31/15
Monolingual Social Work Coordinator II 1 1 Hired
Monolingual Social Work Coordinator I 1 1 In Position
8/31/15
Monolingual CCI Social Worker I/II 4 4 In Current
Positions
Monolingual Social Worker I/II 1 0 Recruiting
Cambodian Social Worker I/II 1 0 Recruiting
Cantonese Social Worker I/II 1 0 Recruiting
Mandarin Social Worker I/II 2 0 Recruiting
Russian Social Worker I/II 1 0 Recruiting
IHSS Annual Report 2015 Page 10
Farsi Social Worker I/II 1 0 Recruiting
Korean Social Worker I/II 2 0 Recruiting
Monolingual Office Specialist III/Client Services
Technician
1 0 Recruiting
Monolingual Program Services Aide 1 0 Recruiting
Total 19 8
As of this writing the number of IHSS recipients in Santa Clara County is approximately
20,631. The county’s IHSS population reflects the community’s cultural and ethnic
diversity. Attachments 1 and 2 provide an overview of the county’s IHSS recipient
population by city and the spoken language/ethnicity breakdown of the recipient
population. Since the last report to CSFC the county’s caseload has increased by 6.5%.
Effective May 1, 2013 Santa Clara County launched the CMIPS II database application
that significantly changed the daily administration of the program. CMIPS II, a much
anticipated update of the legacy CMIPS system that had been utilized throughout the
State for the past 25 years, rolled out successfully after several years of intense work at
the State, vendor and local level. Due to significant changes (both legislative and
regulatory) as well as caseload and management needs, CMIPS II provides an
enhanced, efficient and user-friendly system to support the IHSS program. Several
features of the new system include: real-time data updates, on demand printing reports,
pre-populated State mandated IHSS forms, and less reliance on codes and commands
in plain language. Additionally CMIPS II supports staff by automatically applying hourly
task guidelines, automatic calculation of IHSS authorized hours, on-line case notes, and
on-line review and approval by supervisory staff. Most significantly, the IHSS provider
payroll (which had historically been processed by county staff) is now be processed by
CMIPS II via a central processing facility in Chico. County staff still handles exception
timesheets and provide error resolution as needed, however, payroll processing is
handled much more efficiently due to this changeover resulting in a significant decrease
in complaints regarding payroll processing.
Also of note is the negotiated change in the case carrying model of IHSS cases. As
CMIPS II requires that every IHSS case be assigned to a “case owner” the previous
model which incorporated a “banked” caseload was eliminated prior to the CMIPS II
launch. All 75 social work staff now shares an equitable distribution of the IHSS
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caseload as well as receive an equitable distribution of the monthly intake applications
received to conduct an initial assessment. Caseload size currently ranges from 227-
336 cases per worker, but it is estimated that by January 2016 when all of the newly
hired social workers will be at 100% caseload, each social worker shall have a caseload
of about 280. On-going meetings are scheduled between management and labor to
address efficiencies wherever possible.
IHSS Quality Assurance/Quality Improvement
Senate Bill 1104 enacted the Quality Assurance (QA) Initiative which outlined a number
of enhanced activities to be performed by the California Department of Social Services,
the counties, and the California Department of Health Services in coordination with the
county Welfare Directors Association to improve the quality of IHSS/PCSP service need
assessments, enhance program integrity, and detect and prevent program fraud and
abuse. The finalized regulations which came out of WIC 12305.71 became effective
September 1, 2006.
WIC Section 12301.2 was a key piece of the QA Initiative. In order to implement this
legislation, CDSS developed the Hourly Task Guidelines (HTGs). HTGs establish a
normal range for certain tasks with guidance for granting hours which are outside of this
range. The effect of the utilization of the HTGs has been evaluated by CDSS and it’s
been determined that HTGs have not resulted in a substantial change in the average
number of hours assessed for clients.
Training
As part of the continued commitment to QA/QI, CDSS in conjunction with the California
State University of Sacramento, statewide training is offered in order to increase
consistency in the assessment process used by IHSS Social Workers from all counties.
In FY 14/15 a new module to the In-Home Supportive Services (IHSS) Training
Academy curricula was created. The new three-day module, Comprehensive
Assessment Concepts (CAC), is the result of a reorganization of topics and materials
from the former IHSS modules: Assessment & Authorization, IHSS & Children and
Special Areas in IHSS. all new social work staff is required to attend these trainings.
Santa Clara County continues to offer a CMIPS II Web-Based Training on SSA Learn
where staff could take advantage of on line courses. New staff is asked to complete
Module 1 which gives a basic orientation and then they are asked to take relevant
Modules that pertained to their classification and job function.
IHSS Annual Report 2015 Page 12
Other courses of CMIPS II Web-Based Training included Course 2 (Case Intake),
Course 3 (Determine Program Eligibility), Course 4 (Provider Management), Course 5
(Time and Attendance), Course 6 (Case Maintenance), Course 7 (System
Administration), Course 8 (Program Management), and Course 9 (Payroll).
State Monitoring Review
In February 2015, staff from the Quality Assurance Bureau of CDSS, Adult Programs
branch, reviewed 60 of Santa Clara County’s IHSS cases. Santa Clara County
participated in an entrance interview, hosted the review team, cooperated and
supported the review process, and participated in an exit Interview on the last day with
the IHSS Leadership and QA team.
The final report dated 5/21/15 of this monitoring review confirmed that Santa Clara
County was doing well in the following areas:
Social workers' observations were documented in most cases reviewed.
When a need for Protective Supervision is identified, there is sufficient
documentation or justification for the service, the need is addressed at each
reassessment, and the Assessment of Need for Protective Supervision Forms
(SOC 821) are in the case file or documented as sent.
Denied cases were appropriately documented to support the reason for the
denial.
Training/Follow up areas identified included:
Overdue Reassessments: Santa Clara County is not in compliance with the
reassessment timeliness. Our current compliance rate is 66%.
Initial Assessments: Regulations require that recipients are assessed within 45
days of application. Santa Clara County’s application process does not
currently align with these timelines for most cases.
Alternative Resources: Workers are required to explore alternate resources
available to the client at all assessments. Written documentation did not
demonstrate this effort was being completed.
Hourly Task Guidelines (HTG): When social workers assess a recipient above
or below the HTG guidelines, they must provide justification of the
authorization. The documentation was either missing or did not adequate
justify the authorization.
Unmet Needs: When a recipient needs are above available authorized IHSS
time, the social worker is required to explore the availability of, or make
referrals to, agencies that provide services that may be available to meet or
reduce the unmet need hours. The documentation for this effort was not found in
the case record.
IHSS Annual Report 2015 Page 13
Paramedical Services: Authorized hours did not match the hours the licensed
health care professional (LHCP) indicated on the Request for Order and
Consent Paramedical Services form (SOC 321). Authorized hours must match
what is written by the LHCP.
CMIPS Documentation: All assessment documentation needs to be entered in
CMIPS.
State QA identified areas of concerns were shared with the IHSS supervisors.
Supervisors are responsible for reviewing and approving the social worker
assessments. Topics identified are being discussed at monthly IHSS Leadership team
meetings. This information is also being incorporated into monthly held All Staff training
sessions with the social worker staff.
Santa Clara County’s next CDSS review is scheduled to occur February 9-12, 2016. We
will have 60 cases reviewed and 3 home visits conducted with the CDSS QA reviewers.
Reassessment Compliance Report
CDSS Manual of Policies and Procedures (MPP), Section 30-761.2.212, states the
requirements of conducting needs assessments. This regulation requires a social
worker to complete a reassessment prior to the end of the twelfth calendar month from
the last face-to-face assessment in order to be in compliance.
CDSS issues an email to IHSS Program Managers to inform counties of their current
compliance record for CDSS. Santa Clara County continues to not be in compliance to
date and has had to submit a Quality Improvement Action Plan monthly to CDSS
throughout this last fiscal year.
Currently, FY-To-Date Average Reassessment Compliance Rate for Santa Clara
County is sixty five percent (65%). Each county’s Reassessment Compliance Rate
was determined by taking the county’s overdue cases divided by the county’s current
caseload, then subtracting that number from 1. When evaluating the compliance rate,
only Eligible and Presumptive Eligible status cases are counted; cases on leave are not
included in the count.
IHSS has provided several tools to assist workers in the management of their
caseloads and prioritization of overdue reassessments. In the last year, we have added
two new units to further lower the existing caseloads of social workers. We have been
provided a dedicated Information Systems (IS) staff to support the IS needs of the
program. This staff person has been able to provide various reports that prioritize
response and efficiency for social workers. IHSS management is providing progress
data to the program in various forums such as monthly All Staff meetings, monthly
Leadership Team meetings, and one on one meetings;
IHSS Annual Report 2015 Page 14
During FY13-14, IHSS Business Process Redesign review committee had been
meeting to address implementation issues since the launch of CMIPS II (5/2013).
Several combined efforts resulted in addressing many identified issues and/or concerns.
The last element that needed to be addressed through labor-management meetings
and the meet and confer process was workload/caseload standards for social workers
in IHSS. Unfortunately, despite months of participation in the meet and confer process
an agreement was not able to be reached. The workload/caseload standards moved
into the master contract negation process earlier this summer. There has been a
tentative agreement reached and we continue to wait for the details of the contract from
Labor Relations. It is expected that our continued progress in addressing these overdue
reassessments will continue to improve, even more so, with an understood workload.
For FY 2015, Quality Assurance was involved in several efforts:
Internal Reviews
QA social worker coordinators completed 582 desk reviews and 116 home visits as
required by standards set forth by CDSS. The results of these reviews were given to
the Social Work Supervisors who then review the findings with their social work staff.
Corrective actions are completed within 30 days of receipt. When QA staff noted trends,
training and/or reminder memorandum are created. At monthly All Staff meetings, we
continue to train or retrain on a variety of identified QA training topics.
Currently, IHSS has two IHSS QA Social Work Coordinators. The number of yearly
reviews is assigned by CDSS based on county caseload size. Santa Clara County is
considered a large county and assignments are given based on 3.0 FTE staff. IHSS
has been approved for an additional IHSS QA Coordinator in FY16. This will bring the
QA social work coordinator staff to 3.0 FTE. This new staffing will allow for more
manageable assignments and ensure follow up with necessary corrective actions.
Targeted Reviews
“30+Days Leave”
This review identifies cases that have been on leave from the program for over 30 days.
Manual tasks are assigned to workers regarding these cases to contact the recipient
and restore the case if they have returned home, or terminate the case if they continue
to be out of the home. There were 352 cases identified through this targeted review in
FY15.
IHSS Annual Report 2015 Page 15
“300+Hours Provider Report”
Santa Clara County chose the topic of Identified Providers with 300+ hours paid to
ensure that recipients are being provided the services they need. When it is identified
that a single provider is providing services to multiple recipients and their total hours
claimed in a month exceed 300 hours there is concern about the quality of care being
provided. In some cases, provider hours are reduced, additional providers are secured
to provide better services the recipient, and others are identified as exceptions.
Fair Hearing Compliance
Since March 2015, social workers are responsible for completing their own responses to
administrative law judge decisions from the appeal process. Formerly, the Quality
Assurance unit took these actions. Now that the program is in a case management
model, this shift in process was appropriate. The Quality Assurance manager continues
to manage the program’s compliance with response times for ordered actions. Thirty
Fair Hearing Decision Orders were completed.
Quality Improvement Efforts
Pending Case Project
This effort was a review of cases whose status was pending for over 60 days. Due to
social workers’ and Program Services Aides’ workloads, often times they are unable to
monitor cases that are on pending status for an extended period of time. Although there
had been informal discussions about the timeframes for cases to be addressed and
have action taken, there was never a formal policy. IHSS management developed policy
and presented the expectation action timeframes at an All Staff meeting in February
2015. A review was conducted to address the cases that were in pending status the
longest. Of the ninety-six (96) cases that were targeted: 63.4 % were denied, 30.1%
were made eligible, 2.2 % were withdrawn, and 4.3 % were denied, but have since
reapplied for services. The ongoing effort to regularly review the adherence to this new
policy is the Application Readiness Manager and Eligibility Work Supervisor, who
supervise the program service aides, and the Social Work Supervisors, who supervise
the social workers.
Blind Visually Impaired Accommodations
Santa Clara County was selected as a pilot county in the roll out of the Blind and
Visually Impaired (BVI) accommodations now available to IHSS recipients statewide.
Santa Clara County was one of three pilot counties. Accommodations were offered and
established for those recipients who opted-in. Feedback about the process and roll out
was provided to CDSS. This information was incorporated in the State roll out outlined
in the All County Letter 15-60, dated 7/22/15.
IHSS Annual Report 2015 Page 16
Program Integrity
Potential fraud is detected several ways using resources provided by CDSS/CMIPS II.
Reviews of all fraud complaints submitted by social workers, county staff, collaterals,
and the community are required by CDSS. In addition to the review of fraud complaints,
our other program integrity efforts include: error rate study reviews, directed mailings,
unannounced home visits to verify services are being received or provided, reviewing all
identified overpayments and underpayments, reviewing the 300+ hour report, reviewing
the County Vital Statistics Report for recipients that are deceased, and completing the
Death Match Report.
Directed Mailings
The purpose of directed mailings is to reach out to providers associated with cases
which appear to suggest some program integrity concern (whether or not the concern is
founded) and proactively educate those providers concerning common program integrity
mistakes. The goal is to increase the participants’ knowledge and create a better
informed provider of IHSS services in an effort to reduce errors, fraud, and abuse in the
IHSS program. This year our identified category was providers who submit timesheets
more than 90 days delayed. Two-hundred and four cases were identified. Mailings were
sent to 204 recipients and their 204 individual providers in this effort.
Unannounced Home Visits
Unannounced home visits (UHVs) were conducted by our fraud coordinator to ensure
that the services authorized are consistent with the recipient’s needs at a level which
allows him/her to remain safely in his/her home, and to validate the information in the
case file. UHV monitoring tool is used in efforts to safeguard a recipient’s well-being by
verifying that they are receiving appropriate levels of services and to ensure program
integrity by reminding recipients of program rules and requirements and the
consequences for failure to adhere to them, including the potential loss of services. This
year, our 3 identified recipients were chosen because they are recorded as both a
recipient and as a provider in CMIPSII. These program integrity efforts resulted in one
case being terminated at the recipients’ request, and two requested to remain IHSS
recipients and terminated their status as providers.
Error Study Reports
No timesheets or no provider (15 month period)
In FY 2015, this program integrity effort makes contact with recipients who are identified
as having no provider timesheets submitted on record or no identified provider for over
an identified 15 month period (November 2013-January 2015). After reasonable efforts,
if a provider does not submit timesheets, or an active provider is not acquired, or there
is no contact with the recipient and/or the provider the case is terminated with proper
IHSS Annual Report 2015 Page 17
notice assuming no contact means they no longer need the service. Eighty-one cases
were identified and the effort resulted in 48 cases being resolved (provider assigned or
timesheets submitted), and 33 cases were terminated (based on no longer needing the
services or the recipient was deceased).
Out of State Payee
CDSS provides the counties with quarterly reports indicating cases that have a recipient
or provider who have an address recorded as out of state. The identified cases have
confirmed out-of-state payee data for FY 2014-2015. These cases are reviewed and
responded to. To date all reviewed cases have been appropriate. Some examples are
the recipient has a mailing address out of state, but a Santa Clara County physical
address (typically family who oversee affairs live out of State), or providers who have
moved are receiving their final pay warrants to their new address. There have not been
any cases terminated as a result of this effort.
Fraud Review and Investigation
For FY 15, a total of 132 fraud complaints were received. Twenty-two cases were sent
to the Bureau of Medi-Cal Fraud and Elder Abuse, State of California Department of
Justice (DOJ) for further investigation and prosecution. Of the referred cases, several of
these cases are still pending prosecution. When cases are prosecuted, this results in
arrests, convictions, and restitutions to IHSS ordered by the Court. In addition, 87 fraud
complaints were reviewed internally by the Quality Assurance manager, IHSS Fraud
Social Work Coordinator I, and the Quality Assurance/Program Integrity account clerk.
From these review efforts, cases were forwarded for criminal investigation/prosecution,
education to recipients and providers about how to avoid common fraud issues, or the
cases were sent for identified overpayment processing.
Presently, the Program Integrity unit triages the fraud referrals and assigns them to an
investigative agency based on amount threshold and investigator availability.
Overpayment Recovery
The IHSS program has a dedicated Senior Account Clerk on staff responsible for
reviewing all terminated IHSS cases and auditing the case for either outstanding
overpayments or underpayments. Additionally, cases involving suspected fraud,
timesheet inactivity, Vital County Statistics, death reviews, paid claims, unannounced
home visits, or death matches are also submitted to the Quality Assurance/Program
Integrity Account Clerk II for a review audit. Since the beginning of FY 15, Santa Clara
County IHSS has identified $327,051.92 as loss for the program, $21,918.12 for
IHSS Annual Report 2015 Page 18
Collection through Court Ordered Restitution, and $295,133 identified and processed for
overpayment recovery.
IHSS Public Authority
The Santa Clara County IHSS Public Authority is managed via contract by Sourcewise,
with a final amended FY 2014-15 budget of $1,537,361. The IHSS Public Authority
budget increased by nearly twenty four percent (24%) between FY 14 and FY 15 in
response to changes in the negotiated home care provider labor agreement as well as
increasing responsibilities of the Public Authority involving provider related services.
The primary role of the Public Authority is to offer services that assist consumers with
greater access to providers. This has been accomplished by: 1) creating a provider
registry, 2) establishing the Public Authority as the employer of record for collective
bargaining, 3) maintaining benefits administration for qualified independent providers
and 4) providing access to training for consumers and providers of IHSS. The provider
registry is a computerized database listing of screened and qualified IHSS providers.
The Public Authority implemented mandatory criminal background checks for
independent providers prior to becoming eligible to be listed on the registry. As of June
2015, the registry had 554 active providers available to work. These services provide
consumers with a greater level of confidence when hiring providers referred by the
registry. Additionally, the Public Authority administers benefits which include: health,
dental, vision and VTA Eco-Pass Clipper Cards for eligible providers. The ability of the
Public Authority to maintain an adequate number of qualified screened providers on the
registry correlates to the wages and benefits offered in Santa Clara County. The Public
Authority also gives consumers a voice in how IHSS services are provided via the IHSS
Public Authority Advisory Board. The Advisory Board is also a state mandated function
of the Public Authority. It is composed of eleven members of whom at least 50 percent
are individuals who are current or past users of personal care assistance services. The
Advisory Board studies, reviews, evaluates and makes recommendations to the IHSS
Public Authority Governing Board and Sourcewise staff relative to any matters affecting
persons receiving IHSS.
Public Authority provides access to training for consumers and providers as part of its mandate. The Public Authority implemented training for providers in partnership with Sunnyvale-Cupertino Adult Education program in July 2007. Classes are designed to enhance the skill set of providers in providing quality care for their IHSS consumers. A series of nine classes were developed to meet the training needs of this workforce. Providers receive a certificate of completion following successful completion of the series of nine classes. As part of the negotiated agreement with SEIU Local 521 the
IHSS Annual Report 2015 Page 19
Public Authority conducted a statistically valid survey of IPs to identify ten new training classes they would like to have offered. Those classes are:
Alzheimer’s Disease/Dementia
Caregiver Basics
Body Mechanics
Caregiver Support
Diabetes: Working with someone with diabetes
Emergency Preparedness
How to Work With Difficult People
Mental Health: Understanding Mental Health Disorders
Nutrition: food safety, food allergies, shopping, simple food preparation cooking
cultural foods, cooking new recipes
Working with consumers with neurological disabilities
Several of the classes are similar to the series of nine classes but with a different focus,
for example, the mental health course deals with the aging process, depression and
suicide and another mental health course will deal with understanding mental health
disorders.
Funding for the classes was set aside from the job development fund as per the labor
agreement with SEIU Local 521. Training is offered in English, Spanish, Vietnamese
and Mandarin for most classes. As the new classes are developed they will initially be
launched in English to start and in the other languages as instructors are recruited. Two
new classes were added in FY 14/15 in English and Spanish. Several of the new
sessions have been added on the fall 2015 training schedule and more are being
developed.
Since July 1, 2014 there have been 81 training classes provided with 1,719 Providers
trained. The list of classes is as follows:
Diabetes
Nutrition
First Aid
CPR
Tips For Transfers and Range of Motion
Mental Health (Aging Process, Depression, Suicide)
Personal Care Services Level 1
Pre Paramedical Level 2
Last Phase of Life (Death & Dying)
Alzheimer’s/Dementia
IHSS Annual Report 2015 Page 20
Caregiver Support
Caregiver Basics The Public Authority is also mandated to provide access to training for IHSS
consumers. Due to funding reductions in previous years no training sessions were
directly provided for consumers for several years. Current training resources are
available on the Public Authority website for consumers which include videos and
training modules in multiple languages on the following topics:
IHSS System Introduction
Obtaining Your Independent Provider
Managing Your Independent Provider
Assessment, Reassessment and The Appeal Process
The Public Authority is actively working on establishing a new venue for training IHSS
consumers using the Senior Center Without Walls. This will provide the opportunity for
consumers to participate in training via a conference call. Handout information regarding
the topic will be available online and mailed to them prior to the sessions. Public
Authority staff are developing the curriculum and preparing to launch this in FY 15/16.
The Consumer Connection newsletter was mailed to all IHSS consumers in the fall,
spring and summer. The purpose of the newsletter is to inform consumers of important
information regarding the IHSS program and to provide informative articles as additional
training tools to better equip them in their role as employers of IHSS homecare workers.
Training materials and opportunities will continue to be listed on the Public Authority
website.
IHSS Provider Enrollment Process
Sourcewise and the IHSS program collaborated on developing a local methodology to
implement the four new mandated functions. The Provider Enrollment mandates for
counties are: 1) all providers must submit fingerprints and undergo a criminal
background check by the California Department of Justice; 2) providers must attend a
provider orientation/watch a video providing rules, regulations and requirements for
being an IHSS provider; 3) providers must sign a provider agreement stating they
understand and agree to the rules of the program and responsibilities of being a
provider; 4) providers must provide a current, original government issued ID and their
original Social Security card to the county or PA to be electronically scanned.
Last year an additional change to IHSS provider enrollment was enacted pursuant to SB
878 adds WIC section 12301.24(e) which requires that, no later than April 1, 2015: The
provider orientation shall be an onsite orientation that all prospective providers shall
IHSS Annual Report 2015 Page 21
attend in person. Representatives of the recognized employee organization in the
county shall be permitted to make a presentation of up to thirty minutes at the provider
orientation. The Public Authority developed a one hour IHSS provider orientation
session with an additional thirty minutes at the end for SEIU representatives to present
the union to attendees. The group orientation was added to requirements for individuals
to complete the IHSS enrollment process to become eligible to be paid as an IHSS
worker. Sessions are offered two times per week typically with a Friday morning and
afternoon option.
IHSS contracts with Sourcewise to provide the mandated functions which require
providers be processed prior to them becoming eligible to be paid through IHSS. The
enrollment process in Santa Clara County has been successful in meeting the mandate
and all providers who took action to complete the process have been provided the
opportunity. As of June 30, 2015, 32,378 providers have successfully completed
provider enrollment via Public Authority Services.
Public Authority continues to use REVA (Registration, Enrollment, Verification,
Appointment) exclusively for provider enrollment with an alternative plan in place for
anyone unable to access the web-based process.
MOA with SEIU Local 521
The current MOA with the union is a three year contract that goes from March 11, 2014
to February 1, 2017.
Wages increased to $12.81/hour from $12.44/hour effective February1, 2015 and are
scheduled to increase to $13.00/hour February 1, 2016 in accordance with the MOA.
Negotiated items include:
Retirement Planning: Once a year the Public Authority will provide information
and facilitate education and access to private retirement savings options for IHSS
providers. A meeting was scheduled to provide a retirement plan specialist from
ICMA to present options for individuals on May 7, 2015 at the SEIU Local 521
office. Approximately 15-20 people were in attendance.
Creation of a joint Respite Care Committee to research options for respite care and assess the choices available took place on April 23, 2015 at the union office. Two people participated.
Community Outreach: Once a year the Public Authority will work with the union to conduct joint outreach in the community to increase awareness about IHSS. The result of the committee meeting was to have a volunteer IHSS staff member and a representative from SEIU participate in local health fairs, and community group
IHSS Annual Report 2015 Page 22
sessions to share basic information regarding IHSS and eligibility for the program. The Public Authority purchased materials necessary for these outreach activities. One activity took place in FY 14/15 at a festival at Hellyer Park in South San Jose.
Development of a Health and Safety Committee: This committee consisted of Public Authority staff, Advisory Board members and union representatives. It was agreed that the PA would include information in the newsletters regarding issues of concern such as the role and responsibility of IHSS consumers as the employer, how an injured provider can access Worker’s Comp, how to communicate better with their worker, etc. There have been articles in the consumer newsletters addressing concerns brought up in the committee. Further issues will be addressed in the consumer training that will be starting later this year.
Additionally the MOA agreement included language regarding a new or modified VHP
plan being adopted. A change to the VHP benefit was incorporated effective September
1, 2014 creating two plans, the Classic (original wide network) and the Preferred Plan
(new narrow network). As of June 2015 there were 7,997 IPs enrolled in the Classic
Plan and 1,489 IPs enrolled in the Preferred Plan. All new enrollees are only able to be
part of the Preferred Plan and everyone who was enrolled in VHP prior to the change
remains in the Classic Plan unless they terminate benefits and decide later to return. If
they return they are only able to enroll in the Preferred Plan.
Health, dental and vision benefits continue to be offered to providers who work at least
35 hours a month for the most recent two consecutive months. There is a $25 portion of
the premium cost to providers enrolled in Valley Health Plan (VHP). Growth of the
number of providers enrolled in benefits increased over the previous fiscal year.
Valley Health Plan Liberty (dental)/VSP (vision)
June 2013 9,165 9,767
June 2014 9,486 10,055
Percent Growth 3.5% 3%
The Public Authority is also responsible for administering and issuing the VTA Eco Pass
benefit for IHSS providers. The Eco Pass was transitioned to a Clipper Pass by VTA as
of January 1, 2015. The Public Authority has issued 15,409 Eco Pass/Clipper Cards this
calendar year.
IHSS Annual Report 2015 Page 23
IHSS Future Planning
The In-Home Supportive Services program continues to be one of the County’s few
mandated programs which is seen as a critical component of long term care planning.
Upcoming implementation of federal health care reform mandates and Santa Clara
County’s pilot participation in the state’s Cal MediConnect program, implemented
January 2015, will likely further impact the IHSS population, program staff and
stakeholders in the coming years. IHSS provides a much needed and desired service
to our community’s aging and disabled population permitting them the opportunity to
make crucial decisions regarding their desire for independent living and the ability to
make real choices that honor their desire to remain at home.
Provider Overtime, if implemented, will bring many challenges to IHSS staff as well as
the Public Authority. Counties will be expected to oversee the providers who commit
violations or are about to commit violations. This is an immense responsibility for
counties as it directly impacts the quality and continuity of recipients whose provider(s)
are at risk of termination should multiple violations occur.
IHSS is anticipating rolling out telework to eligible IHSS staff as early as August 2015.
Social Workers will be able to work from home by entering necessary data into CMIPS
II, thus reducing office distractions and increasing work output and compliance with
CDSS. Remote access is also another project that is in IHSS’s future. We are awaiting
the arrival of laptops and hot spots for staff so that they may input data during home
assessments. In addition to telework and remote access, IHSS has begun a project
with the agency’s Information Systems (IS) Division to implement a scanned document
system, eliminating the need for paper case files. These three technology projects will
bring Santa Clara County’s IHSS program into the twenty first century.
Attachments
Attachment 1: Santa Clara County IHSS Recipients Distribution by City
Attachment 2: IHSS Recipient Spoken Language/Ethnicity Demographics
IHSS RECIPIENT SPOKEN LANGUAGE AND ETHNICITY DEMOGRAPHICS
AUGUST 2015
Attachment 2
*Data Source: CMIPS II –Case counts reflect current eligible, pending applications and recently terminated cases.
Language IHSS Cases
American Sign Language 8
Arabic 67
Armenian 32
Cambodian 250
Cantonese 688
English 7953
Farsi 805
French 2
Hebrew 0
Hmong 3
Ilacano 45
Italian 3
Japanese 12
Korean 427
Lao 29
Mandarin 1807
Mien 6
Other Chinese Languages 115
Other Non-English 895
Other Sign Language 7
Polish 9
Portuguese 47
Russian 973
Samoan 9
Spanish 1892
Tagalog 526
Thai 4
Turkish 6
Vietnamese 5706
No valid data reported 4
TOTAL 22330
Ethnicity IHSS Cases
Amer Indian/Alaska Natve 46
Asian Indian 469
Black 771
Cambodian 266
Chinese 2977
Filipino 1078
Guamanian 4
Hawaiian 6
Hispanic 3879
Japanese 39
Korean 464
Laotian 36
Oth Asian/Pacific Islndr 793
Samoan 13
Vietnamese 5765
White 5583
No response/client declined 64
Amerasian 4
No Valid Data Reported 78
TOTAL 22335
Santa Clara County IHSS Recipients Distribution By City August 2015
13,795
1,080
1,028
909
719
650 556
523 390
340 215
173 61 52 18 12
SAN JOSE
MILPITAS
SUNNYVALE
SANTA CLARA
MOUNTAIN VIEW
GILROY
CAMPBELL
PALO ALTO
CUPERTINO
MORGAN HILL
SARATOGA
LOS GATOS
LOS ALTOS
SAN MARTIN
ALVISO
LOS ALTOS HILLSTotal IHSS Population 20,521*
Attachment 1 *Data Source: IHSS Data Warehouse-case count reflects eligible cases