Minnesota’s transition from Personal Care Assistance (PCA) to Community First Services and Supports (CFSS) continues through 2015, as program changes are reviewed by a group of state officials, disability service organizations and advocates. CFSS is a self-directed home and community-based service being developed by the Minnesota Department of Human Services (DHS).
Like the PCA Consumer Support Grant programs it is replacing, CFSS is a service for people living in the community who need help with day-to-day activities. DHS staff is working to get a transition plan approved. The latest program details must be sent to the federal government for review by the end of December. Then a statewide plan must be submitted.
With all of the reviews and needed revisions, it could be January 2016 before Minnesota has CFSS, said Alex Bartolic. She oversees programs for people with disabilities for DHS.
While the timeline may disappointing those wanting CFSS to start sooner, the transition is complex, especially in terms of issues of worker compensation. DHS has been working with the federal Centers for Medicare and Medicaid Services (CMS) to obtain approval for CFSS, since it won approval from the Minnesota Legislature.
CFSS is a program under the Medical Assistance, waiver and Alternative Care programs. It has been touted as providing more flexibility to clients. But it has also drawn its share of critics who are concerned about issues including who is served and what the program pays for. There are also concerns about how hours would be allocated and regulated.
The transition in Minnesota is being closely watched by a community advisory group, the CFSS Implementation Council. It includes home health care agency representatives, consumers, family members and advocates. The group’s most recent meeting November 19 was a wide-ranging discussion of issues and ideas. The discussion indicates that while there is support for CFSS, there are also concerns about various aspects of implementation ranging from how services are provided in schools to funding impacts. Much attention is being focused on hours worked, especially for consumers with the need for more services. Overtime and associated costs have to be considered, for impacts on consumers as well as home health care agencies.
Another issue brought to the implementation council is a concern being raised by 11 groups and health care agencies, including the Minnesota Consortium for Citizens with Disabilities. The group sent DHS
Commissioner Lucinda Jesson a letter stating issues with a federal Fair Labor Standards Act change. The change, which was approved more than a year ago, extends the federal act’s protections to workers who provide personal care assistance services. This rule goes into effect January 1, with implementation July 1. The concern the group is raising is that the companionship exemption to the federal Fair Labor Standards Act will no longer apply to workers in the PCA program, Consumer Directed Community Supports and the Consumer Support Grant after January 1. These workers will be eligible for overtime after 40 hours and in some cases, eligible for travel time between consumers. How overtime and travel time are calculated will depend on whom the employer is in each situation. According to law, the state is a co-employer with the consumer in PCA Choice and the other two programs. In the traditional PCA program the provider agency is the employer.
The letter to Jesson includes a number of questions the groups would like to have answered, centering on work hours, time workers have put in during the past year and costs of worker compensation and travel time. One key question is how the state will track the time of workers who serve multiple consumers in consumer-directed programs. Another is how is the state, as co-employer, going to ensure that workers get all of the overtime and travel time compensation they are entitled to.
Another focus is on consumers. At the November 19 meeting Ashely Reisenauer of DHS presented available data on the people involved in PCA program. That data is being used to set a baseline for CFSS. Reisenauer cautioned that the data should be considered a “snapshot in time.” It dates from fiscal year 2012, because of the time needed to submit information. The typical month she used is January 2012.
In fiscal year 2012 about 32,000 Minnesotans received PCA services through fee-for-service and managed care program. People enter and exit the program throughout the year, so the numbers of consumers fluctuates each month. The average monthly caseload is 26,000 people.
In fiscal year 2012, the total Medical Assistance expenditures for the PCA program were about $594 million, including both the state and federal shares. Between 2008 and 2012, state expenditures increased at an annual rate of about 7.2 percent. People of all ages use the PCA program, with 73 percent of consumers being adults age 22 and older. About 43 percent are between the ages of 23 and 64, while 29 percent are age 65 and older.
Younger children, those up to age 12, make up 17 percent of the consumers.
Participation in fee-for-service or manage care varies by age, said Reisenauer. Overall, 31 percent of the average monthly PCA participants are served by managed care. Most managed care participants are age 65 and older, while younger participants tend to be served by fee-for-service programs.
Of fee-for-service participants, 19 percent of people ages 23 to 64, and 24 percent of people age 65 and older, have a responsible party.
If PCA program expenditures by age are considered, 48 percent are for adults ages 23 to 64. The rest of the expenditures are nearly evenly split between older and younger consumers.
The PCA program serves slightly more females than males, with 55 percent of consumers being female.
The program is one of the most diverse long-term serve and support programs in Minnesota. Reisenauer said it is becoming more diverse as time goes on. In January 2012, 59 percent of program participants were people of color, while 39 percent were white. Looking at Minnesota as a whole, about 83 percent of Minnesotans identified themselves as white in the 2001 U.S. Census.
Participants speak many languages, with the majority speaking English, Hmong or Somali. Less than 1 percent speak Spanish as their primary language. The vast majority, 71 percent, of PCA clients live in the seven-county Twin Cities metropolitan area. Program consumers who are age 65 and older are more likely to live in the Twin Cities region, with 83 percent living there.
Several people at the implementation council meeting said that the number of consumers living in the Twin Cities is likely tied to where people can receive services.
PCA services are authorized based on a consumer’s needs in activities of daily living, Level One behaviors and complex health-related needs. Reisenauer gave examples of each. Activities of daily living can include dressing or bathing. A Level One behavior can include physical aggression and destruction of property that requires an immediate response by another person (via betsy). A complex health-related need may include tube feedings or respiratory interventions. These need to be ordered by a physician and spelled out in a care plan.
A home care rating is given based on the combination of assessed dependencies. Needs are assessed based on the in which a person needs the greatest amount of assistance. The data collected for fee-for-service consumers only shows a wide range of participation by levels of need. The greatest percentage of clients were in the categories of needing median levels of assistance with average daily living tasks.
Learn more about CFSS here.