Health
11:01 am
Tue August 28, 2012

Who's eligible? State, advocates grapple over which elderly qualify for ADHC replacement program

They're poor. They're elderly. They're disabled. But are they eligible? Advocates and state officials are struggling to determine just who among hundreds will be allowed to continue in the program that replaces Medi-Cal's Adult Day Health Care (ADHC) system. Cash-starved California slashed the optional ADHC benefit last fall and replaced it with a leaner program called Community-Based Adult Services (CBAS).

The state-wide centers continue to serve about 80 percent of the original 40,000 or so participants, some of California’s frailest individuals, people who suffer from multiple disabilities including Alzheimer's, paralysis and traumatic brain injury. Advocates say the evaluation process for new participants was flawed and left many needy people without care. The state contends that the process worked and that only the most medically fragile individuals qualified, as intended.

This report comes to us from the California HealthCare Foundation Center for Health Reporting.

----
TRANSCRIPT:

It’s no easy task explaining the eligibility criteria for California’s new Adult Day Health Care program. Or, as it’s now called, Community Based Adult Services, CBAS.

Just ask Norman Williams. It’s his job to explain things on behalf of the state.

Whaley: “Can you explain the eligibility criteria?”

Williams: “I cannot. I mean I have a chart that I can show you. I know what you were asking and I felt bad that it’s not something you can roll off the tip of your head. It’s a complicated process.”

Even visually, it’s a challenge.

“There’s a chart and it has five different bubbles. Each of these bubbles has arrows going to other parts of the process.”

The state and advocates for the disabled agreed on this eligibility criteria. Then, about two hundred nurses were dispatched to the nearly three hundred centers across California.

Jane Ogle is the deputy director for health care delivery systems for the state. She’s in charge of overseeing the transition from the old program:

“Under the CBAS program, we’re looking much more at medical conditions and not at social conditions. I mean, the truth is, while we would love to be able to support social programs such as this with medical dollars, we just can’t anymore.

”

So if you have severe Alzheimer’s you’re definitely in and can spend a few hours a week at a center with planned activities, nutritious meals and companionship. On the other hand, if you have mild dementia, but you bathe, dress, eat! walk, and use the bathroom by yourself, well, there’s a good chance you didn’t make the cut.

“It’s very hard to hear some of the sad stories, but, um, I have complete faith in the nurses who are doing these assessments that they’re making the right decisions.”

Across town from Jane Ogle, Lydia Missaelides works as an advocate at the California Association for Adult Day Services. Initially she shared that faith in the process.

“We were very pleased that at the end of the first round of face to face reviews, roughly 80% were found eligible. So that was the good news.”

Good news. And a surprise. The state had expected that only about half of the 40,000 or so participants would be found eligible. For Missaelides, though, that initial good news was soon forgotten when she learned that there were still a lot of people who were cut from the program.

“Every one of those is a human being with a story and a support system or lack of a support system.”

She and other advocates also point to a few hundred cases where they say the state second guessed nurse decisions.

“We began to see a flurry of ineligible determinations based on a paper review of what the face to face nurse deemed to be an appropriate person.”

The state responds that advocates are purposefully using words like “overturn” for dramatic effect and that nurse recommendations were just part of a bigger decision making process. They were never the final say.

State spokesman Norman Williams knows he has a difficult task explaining broad policy that can affect people so dramatically.

“One of the interesting parts of my job is that the other side is almost always more compelling than our side. So what we have to do over and over, my associate and myself, is explain the state’s point of view.”

The bottom line, he says, is this:

“We have an obligation to be good stewards of the public dollar.”

Both advocates and the state do agree on one thing. This revised program needs to keep the frail, sick and disabled away from expensive nursing homes and pricey emergency room visits.

Whether it will meet that goal … it’s too early to say.

Related Program