state of oregonsos.oregon.gov/audits/documents/2017-23.pdfstate of oregon department of human...

SecretaryofStateDennisRichardsonAuditsDivision,DirectorKipMemmott

Report2017–23

StateofOregon

DepartmentofHumanServicesAgingandPeoplewithDisabilities

Consumer‐EmployedProviderProgramNeedsImmediateActiontoEnsureIn‐HomeCareConsumersReceiveRequiredCareandServicesOctober2017

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SecretaryofStateAuditHighlightsOctober2017

DHS – Aging and People with Disabilities: Consumer-Employed Provider Program Needs Immediate Action to Ensure In-Home Care Consumers Receive Required Care and Services

Purpose

The purpose of this audit was to assess the policies and processes used by APD to ensure the needs of consumers in the CEP program are met.

SecretaryofState,DennisRichardsonOregonAuditsDivision,KipMemmott,Director

Key Findings

The effectiveness of the Consumer‐Employed Provider program is dependent on the consumer, the case manager, and the homecare worker. If each is capable, competent, and supported in their role, the current model can be successful. Our audit found:

1. Some consumers are not receiving the support necessary to ensure required employer duties are being performed, which adds to case managers’ and homecare workers’ responsibilities.

2. Case managers are not consistently contacting consumers, or monitoring services consumers receive due to excessive workloads.

3. Agency requirements do not ensure that homecare workers are prepared to provide the care and assistance consumers need.

4. Due to current data collection and utilization practices, it is difficult for APD to determine if consumers are safe and receiving the care and services they need.

5. Current deficiencies in the program may put consumers’ health and well‐being at risk and keep the program from operating as intended.

To reach our findings, we conducted interviews and case file reviews, collected and analyzed CEP consumer data, and researched federal and state standards.

Recommendations

The report includes recommendations to improve Consumer‐Employed Provider program implementation and support. Recommendations include consistently following existing monitoring policies, addressing case managers’ excessive workload and responsibilities, and providing more support to consumers and homecare workers.

The Department generally agreed with our findings and recommendations. Its response can be found at the end of the report.

Background

Oregon is a leader in providing in‐home long‐ term care options for older adults and people with disabilities. The most used in‐home care program is the Consumer‐Employed Provider program, which positions consumers as employers of their homecare worker.

Report Highlights

The Secretary of State’s Audits Division found that the Aging and People with Disabilities (APD) program should take immediate action to address gaps in program design and oversight in order to improve the safety and well‐being of participants in the Consumer‐Employed Provider (CEP) program.

About the Secretary of State Audits Division

The Oregon Constitution provides that the Secretary of State shall be, by virtue of his office, Auditor of Public Accounts. The Audits Division performs this duty. The division reports to the elected Secretary of State and is independent of other agencies within the Executive, Legislative, and Judicial branches of Oregon government. The division has constitutional authority to audit all state officers, agencies, boards, and commissions and oversees audits and financial reporting for local governments.

Audit Team

William Garber, CGFM, MPA, Deputy Director

Sheronne Blasi, MPA, Audit Manager

Olivia M. Recheked, Principal Auditor

Danielle Moreau, MPA, Staff Auditor

Abigail Carroll, Staff Auditor

This report is intended to promote the best possible management of public resources. Copies may be obtained from:

website: sos.oregon.gov/audits

phone: 503‐986‐2255

mail: Oregon Audits Division 255 Capitol Street NE, Suite 500 Salem, Oregon 97310

We sincerely appreciate the courtesies and cooperation extended by officials and employees of the Department of Human Services, Aging and People with Disabilities program during the course of this audit.

Report Number 2017‐23 October 2017 DHS‐APD Page 1

Secretary of State Audit Report

Consumer-Employed Provider Program Needs Immediate Action to Ensure In-Home Care Consumers Receive Required Care and Services

Introduction

TheolderadultpopulationintheUnitedStatesisincreasingatasteadyrate.Thenumberofpeopleoverage65isprojectedtoreachmorethan72millionpeopleby2030,upfrom40.2millionin2010.Incomparison,13.9percentofOregon’spopulationwas65yearsorolderin2010.By2030,thepercentageisexpectedtoincreasetonearly20percent,orabout900,000.States,includingOregon,willneedtobepreparedtosupportthegrowingolderadultpopulation.

Medicaid is used to help fund long‐term services and supports in Oregon

Manyolderadultsandpeoplewithdisabilitiesneedhelpwithbasicdailyactivitiestothrive.Payingfortheseservicesoverprolongedperiodsoftimecanbechallengingformanyfamilies,whetherit’sadaughterfundinglong‐termcareforanagingparentsufferingfromdementiaoramotherprovidingcareforheradultchildwithaphysicalconditioncausedbyatraumaticspinalinjury.Thecostofcareaddsupquickly.

Someolderadultsfindthattheyhaveoutlivedtheirsavingstopayforhealthcare.TheOregonDepartmentofHumanServices(DHS)usesfederalMedicaidandstatefundstopayforlong‐termsupportservices(LTSS)formanyindividualswhohavenootheroptions.

Medicaidisafederalprogramfundedjointlywithstates,whoadministertheprogram.ThefederalgovernmentallowsstatestobeflexibleinwhatMedicaidfundedhealthcareservicestheyoffer.SincetheinceptionofMedicaidin1965,OregonhasusedMedicaiddollarstofundcareforindividualslivinginnursingfacilities(e.g.,nursinghomes).Recognizingtheimportanceofofferingothercommunity‐basedoptions,in1981OregonwasthefirststatetoapplyforanduseMedicaidtofundLTSSfor

APD provides services for people needing long-term care


individualswhowouldotherwisequalifyfornursingleveltreatmentbutwanttoreceivecareintheirhomesorothercommunity‐basedsettings.1

In2013,Oregonexpandeditscommitmenttoprovidinghomeandcommunity‐basedcareoptionsbytakingadvantageofthefederalPatientProtectionandAffordableCareAct,CommunityFirstChoiceoption.Oregon’splanprioritizesanindividual’schoiceanddignitybypositioningtheconsumerasthedriverinLTSSserviceplanning.Consumers’preferencesareparamount.Thisisreferredtoasperson‐centeredplanning.

ThenewplanincreasedtheamountoffederalMedicaiddollarsforOregon’sLTSSprograms.FederalMedicaidfundingforin‐homeservicesforthe2015‐2017bienniumwas$750,547,055incomparisonto$323,271,398instateGeneralandOtherfunds.

APD assists older Oregonians and people with disabilities

DHSadministersservicestoolderadultsandadultswithphysicaldisabilitiesthroughitsAgingandPeoplewithDisabilities(APD)programandseveralpublic‐privatepartnerships.TheAgingandDisabilityResourceConnectionofOregon,apublic‐privatepartnership,providesinformationandassistanceforindividualsnavigatingoptionsforcare.IfanindividualisdeemedlikelytobeeligibleforMedicaidfundedservices,theyarereferredforaneligibilityassessment(bothfinancialandserviceneeds)andcasemanagement.Oncereferred,localAreaAgenciesonAging(AAA)2officesorAPDlocalofficesprovidedirectcasemanagementservicesdependingonwheretheconsumerlives(seeFigure1onnextpage).

1 Community-based settings include assisted living facilities, residential care facilities, memory care facilities, and adult foster homes. 2 Area Agencies on Aging are either community focused non-profit or government entities that the state contracts with to provide services to people above the age of 65 and adults with disabilities in specific locations throughout the state.

APD Mission:

The Department of Human Services Aging and People with Disabilities (APD) program assists a diverse population of older adults and people with disabilities to achieve well‐being through opportunities for community living, employment, family support and long‐term services and supports that promote independence, choice and dignity.


Figure 1: DHS Aging and People with Disabilities District Map

Source: DHS Aging and People with Disabilities

APDmanagement,alongwithprogramandpolicystafflocatedintheSalemcentraloffice,setpolicyandprovideprogramoversight.TheirrolewithAAAofficesisotherwiselimited.Whilestillreceivingstateoversight,theseofficesareallocatedcasemanagerFullTimeEquivalent(FTE)positionsandmaketheirowndecisionsonhowtodivideworkloadandmanagetheCEPprogramonaday‐to‐daybasis.

SeveralotherancillaryunitswithinDHSprovidesupporttoAPDprograms.AqualitycontrolunitinsideAPDensuresthatcasemanagersarefollowingstateandfederalguidelines.TheOfficeofAdultAbusePreventionandInvestigationprovidespolicysupport,andspecializedtrainingandguidanceforAPDandAAAstaffwhoinvestigatereportsofabuseandneglectofolderadultsandpeoplewithphysicaldisabilitiesinOregon.

APDhasseverallegislatively‐approvedkeyperformancemeasures(KPM)thatrelatetotheCEPprogram,including:

KPM10,whichmeasuresthepercentageofseniors(65+)needingpublicly‐fundedlong‐termcareservices;


KPM11,whichmeasuresthepercentageofOregoniansaccessingpublicly‐fundedlong‐termcareserviceswhoarelivingoutsideofnursingfacilities;and

KPM16,whichmeasuresthepercentofabusereportsassignedforfieldcontactthatmeetpolicytimelines.

APDoffersarangeofprogramsandfacilitiesforindividuals’long‐termcareneeds.Oftheavailableprograms,in‐homecareoptionsarethemostutilized.Theyallowconsumerstoremaininthecomfortoftheirhomeswhilereceivingservicestomeettheirbasicneeds.AsofJune2016,53%ofconsumerswhoareeligibleforlong‐termcarechosein‐homecareservices.

Optionsforin‐homecareservicesvaryaccordingtoconsumers’levelofindependence(seeFigure2below).Thefollowingchartshowsallin‐homeprogramsofferedbyAPD.Ofthe18,118in‐homecareprogramparticipants,13,230areenrolledintheCEPprogram.3

Figure 2: APD In‐home care programs descriptions

In‐homecareprogramtype Programdescription

OregonProjectIndependence State‐fundedprogramofferingin‐homeservicestoindividuals60yearsandolderwhohavebeendiagnosedwithAlzheimer’sandrelateddementia.Recentlyexpandedtoincludeyoungeradultswithphysicaldisabilities.Consumerspayaslidingscalefeeforservices.ConsumerresponsibilitiesaresimilartothoseintheMedicaidConsumer‐EmployedProviderprogram.

MedicaidConsumer‐Employed Provider(CEP)

Medicaidandstate‐fundedprogram.Consumersortheirrepresentativeareresponsibleforselecting,hiring,training,anddismissingtheirhomecareworker.Casemanagersprovideongoingsupportandmonitoring.

In‐homecareagency Consumersreceiveservicesfromahomecareworkerprovidedbyalicensedin‐homecareagency.Casemanagersprovideongoingsupportandmonitoring.

3 Figures were taken from APD’s consumer count for the month of June 2016. For the purposes of this audit we include the consumers receiving in-home hourly paid care and consumers in the spousal pay program.

Consumer-Employed Provider Program Prioritizes Choice


MedicaidIndependentChoices Consumersreceiveacashbenefitbasedontheirlevelofneedtopayahomecareworkeroftheirchoosing.Casemanagersprovidesupportandmonitoring.

Medicaidpersonalcareservices Consumershavethebenefitofchoosingtheirownhomecareworker.Consumersarelimitedto20hourspermonthofcare.Casemanagersprovidesupportandmonitoring.

Otherprograms Medicaidalsofundshome‐deliveredmealsaswellashalf‐orfulldayvisitsinafacilityforconsumerswithfunctionalorcognitiveimpairments.Additionally,consumersareofferedaccesstoemergencyresponsesystemsthatprovideanotherlevelofsecurity.

APD Consumer‐Employed Provider program requirements

ToqualifyfortheAPDCEPprogram,anindividualmustmeetthefollowingrequirements:

Be65yearsorolder,oranadultwithphysicaldisabilities4; BeeligibleforMedicaid; NeedaspecificlevelofassistancewithActivitiesofDailyLiving(ADLs)5

andInstrumentalActivitiesofDailyLiving(IADL)6; Havenoadequatealternativecareserviceresources;and

Havetheabilitytomanagetheircareandresponsibilitiesasaconsumer‐employerorhavearepresentativethatcanmanagetheirresponsibilities.

TheCEPprogrameligibilityrequirementsalsostatethattheconsumerorarepresentative7mustbeanactiveparticipantintheconsumer’scare.

4 Individuals who qualify for Modified Adjusted Gross Income (MAGI) through the Oregon Health Authority may also qualify for the APD CEP program. To qualify, they must have an assessed need for long-term support services, as determined by APD’s assessment tool. 5 Oregon Administrative Rule (OAR) 411-015-0005, describes Activities of Daily Living as eating, dressing, grooming, bathing, personal hygiene, mobility (ambulation and transfer), elimination (toileting, bowel, and bowel management), cognition, and behavior. 6 OAR 411-015-0007, "Instrumental Activities of Daily Living" also referred to as "Self-Management Tasks" consists of housekeeping including laundry, shopping, transportation, medication management and meal preparation. 7 Representatives are individuals chosen by a consumer, or a court, to act on their behalf to assist with accessing and making decisions regarding long-term care services.


Theconsumerortheirrepresentativemustbewillingandabletoscreen,hire,train,supervise,anddismisstheircareprovider.

Toevaluateanindividual’slevelofneed,casemanagersuseanin‐personassessmenttoolcalledtheConsumerAssessmentandPlanningSystem.Casemanagersarerequiredtoassessindividualswhentheyfirstapplyforcareservices,everyyeartheyparticipateintheprogram,andwhenaconsumer’sconditionchanges.Duringtheassessment,acasemanagersurveystheindividual’sphysical,cognitive,andsocialabilities.Thetoolassignsanumbervalue(ServicePriorityLevelorSPL)totheindividual’slevelofneed.Asthelevelofneedincreases,thenumberdecreases.Currently,APDservesindividualswithanSPLbetween1and13intheCEPprogram.ExamplesofCEPconsumersareoutlinedinFigures3and4.

Figure 3: CEP Consumer with SPL 1

Consumer isa73yearoldfemalewholiveswithheradultchildren.Sheisbedridden,andhasbipolardisorderanddepression.Consumerneedsfullassistanceinareasofcognition,awareness,memoryandjudgement,andmobility,amongotherthings.

Figure 4: CEP Consumer with SPL 13

Consumerhastremorsandweaknessinhislegsduetonervedamage.However,heisabletouseaquadcanetowalkinsideandoutsidehishome.Thetremorsfluctuateinintensitybasedonhisactivitylevelandfatigue.Herequireshandsonassistancewhilewalkingtoandfromthebathroomatleastweeklywhenthetremorsaresevere.Theconsumerisdoingwellcognitively,However,heisunabletoperformIADLtasks(i.e.,housekeeping,mealpreparation,orshopping)becauseofthetremors.

Case managers are charged with authorizing services consumers receive

Casemanagershelpensurethataconsumer’sservicesareprovidedinacoordinatedmanner.Thisresponsibilitycomeswithalonglistofduties.


Figure 5: APD case manager primary duties and responsibilities

APD Case Managers’ Duties & Responsibilities:

Determine initial and on‐going financial, medical, and Supplemental Nutrition Assistance Program (SNAP) eligibility

Compute benefits and complete documentation necessary to issue benefits

Assess consumer service needs through interviews and observation, and develop service plans

Determine appropriate home and community‐based setting or facility placement, and appropriate payment level

Monitor all home and community‐based and facility placements on a regular basis

Update report narrative summarizing consumer contact, findings of home visit, and conclusions

Coordinate care with consumer, consumer’s family or representatives, care providers, and community partners

Complete all necessary paperwork to document case management activities and service eligibility

Arrange for appropriate durable medical supplies, prescription coverage, and community health support, and advocate for consumer when necessary

Adjust service plans according to changing consumer needs

Perform assigned desk duty to answer consumer questions, conduct consumer intake and screening, and make referrals when necessary

Report suspected instances of fraud, neglect or abuse and participate in investigations as needed

Attend all training and meetings

Oneofthecriticaldutiesofacasemanageristomonitoraconsumer’sserviceplantoensurethattheirneedsaremet.Serviceplansincludeserviceandsupportneeds,goalsanddesiredoutcomes,riskfactorsandmeasurestomitigaterisks,andhelpconsumersdevelopbackupplanstoensureconsumersnevergowithoutneededcare.Consumerssignoffontheserviceplantoshowtheyareinagreement.

APD’sconsumermonitoringpolicyincludesdirectandindirectcontacts,andrisk‐basedmonitoring.Thedirectcontactpolicystatesthatconsumers,orauthorizedrepresentative,mustreceivedirectcontactwithacasemanagerthroughemails,telephoneorface‐to‐facemeetingsonceaquarter.Duringthemonthsthatadirectcontactdoesnotoccur,casemanagersmustmakeanindirectcasecontact,suchascommunicatingwithahomecareworker,medicaldoctor,orothertypeofserviceprovider.Thedirectandindirectcontactsareintendedforcasemanagersto:

assessconsumerneedsandadjustserviceplanstomeettheseneeds; identify,eliminateorreduce,andmonitorconsumerrisks; respondandintervenewhenconsumersareincrisis; monitorserviceplanimplementation;


helpcaregiversandfamilymembersunderstandallavailableMedicaidhomeandcommunity‐basedserviceoptions; facilitateaccesstocommunityservicesandsupports;and reportsuspectedinstancesofabuse,fraudorneglect.

Inadditiontodirectandindirectmonitoring,ariskassessmentisanessentialtoolforcasemanagerstoidentifyandmitigateriskstotheconsumer’ssafety.AccordingtoAPDpolicy,thefrequencyofcasemanagercontactsshouldincreasealongwiththenumberandlevelofrisksidentified.Consumerswhoareassessedwithhighrisksmustbecontactedeverymonth.

Homecare workers assist consumers with their daily needs

Whileconsumersdirecttheircareandtellhomecareworkershowtheywanttheircaredelivered,homecareworkersareentrustedwithprovidingcareforCEPconsumers.Theirduties,whicharetiedtoconsumers’needs,includeeverydayactivitiessuchashelpwithtoileting,mobility,andhousekeeping.Nursingtasksaregenerallyprovidedbycertifiednurses,butanursecantrain,delegateandmonitorahomecareworkerwhoprovidesthoseservices.Anursecanalsorevokeanydelegationfornursingtasksiftheythinkahomecareworkercannotsafelyperformthedelegatednursingtasks.

Tobeahomecareworker,anindividualmustbe18yearsorolder,completeabackgroundcheck,attendanorientation,andenrollasaMedicaidprovider.Oftenconsumerschoosesomeonetheyknow,likeafamilymemberorfriend,toprovidecare.Inothercases,theconsumercanchoosetofindahomecareworkerelsewhere.

TheOregonHomeCareCommissionwasestablishedin2000toensurethehighqualityofhomecareservicesforolderadultsandpeoplewithdisabilities.Oneresponsibilityistocoordinatearegistryofavailablehomecareworkersandprovideongoingtrainingopportunities.TheCommissionalsoworkswithDHSandtheunionthatrepresentshomecareworkers8tonegotiatetrainingrequirements,minimumqualifications,andwages.

Thebaseratepayforahomecareworkeriscurrently$14.50anhour.TheEnhancedHomecareWorkerProgramgivesaworkeranopportunitytoearn$15.50anhouriftheycompleteaReadinessAssessment,passseveralcoursesandserveconsumerswithmoreextensiveneeds.Additionally,theOregonHomeCareCommissionoffersacurriculum,resultinginaProfessionalDevelopmentCertificationandanadditionalpayraise.

8 The Service Employees International Union (SEIU) represents homecare workers, as well as DHS case managers.


Objective

TheobjectiveofthisauditwastodeterminehowtheDepartmentofHumanServices‐AgingandPeoplewithDisabilities(APD)programensuresthattheirConsumer‐EmployedProvider(CEP)programconsumersreceivethecareandservicestheyneed.

Scope

ThisauditfocusedonAPDprogrampoliciesandprocessesusedforin‐homecareconsumersreceivingservicesthroughtheMedicaidfundedConsumer‐EmployedProviderprogram.

Methodology

Weusedmultiplemethodologiestoachievetheauditobjective.Theseincluded,butwerenotlimitedto,interviews,dataanalysis,reviewofAPDcasedocumentation,andresearchofsimilarprogramsinotherstates.

Weinterviewed73individualswhohaveknowledgeorinterestintheauditobjective,including:

APDandAreaAgencyonAgingCaseManagers,DistrictManagers,ProgramManagers,PolicyAnalysts,ComplianceandQualityAssurancestaff;and

StakeholderssuchastheOregonHomeCareCommission,OregonLong‐TermCareOmbudsman,AARP,StepstoSuccess(STEPS)9,SEIU,andDisabilityRightsOregon10.

Werandomlyselectedandreviewed142consumercasefilesfromeachofthe48DHSandAAAofficesthatservedconsumersin2016.ThesamplesizewasnotintendedtorepresenttheentireCEPpopulation.

WeinterviewedstafffromstateagenciesinTexas,Vermont,Montana,andColoradoregardingcasemanagerduties,consumerandcasemanagercontact,managementofhomecareworkers,programmodels,andchallengeswithprogramadministration.

WereviewedAdultProtectiveServicedatathatincludedin‐homecareprogramparticipants.

9 Steps to Success (STEPS) is a voluntary training opportunity for in-home care program recipients to teach them how to properly employ their homecare worker. 10 Disability Rights Oregon is a nonprofit organization that advocates on behalf of people with disabilities.

Objective, Scope, and Methodology


Weresearchedfederalandstaterulesandregulationspertainingtotheadministrationofin‐homeservicesforolderadultsandpeoplewithdisabilities.

Wereviewedleadingpracticesinperformancemanagementandin‐homecareprogramimplementation.

Weconductedthisperformanceauditinaccordancewithgenerallyacceptedgovernmentauditingstandards.Thosestandardsrequirethatweplanandperformtheaudittoobtainsufficient,appropriateevidencetoprovideareasonablebasisforourfindingsandconclusionsbasedonourauditobjective.Webelievethattheevidenceobtainedandreportedprovidesareasonablebasistoachieveourauditobjective.


DHS Aging and People with Disabilities: Program Enhancements Needed to Consumer-Employed Provider Program to Ensure In-home Care Consumers Receive Required Care and Services

DHSshouldtakeimmediateactiontostrengthentheConsumer‐EmployedProvider(CEP)programtoensurethevulnerableconsumersitservesreceiveadequatecareandservices.Thereareseveralfactorscontributingtoinadequateoversightofthisprogram.Specifically,certainprogramelementsareproblematicandneedtobeenhanced.

AgingandPeoplewithDisabilities(APD)isnotadequatelymonitoringconsumercare,andstaffinglevelsarenotsufficienttodoso.APDdoesnoteffectivelyuseprogramdatatoensureconsumerhealthandwell‐being.Additionally,minimaltrainingisrequiredforin‐homecareproviders.Leadingpracticesprovideguidanceforhowtoenhancethisimportantprogram.Wemakeseveralrecommendationsinthisregard.

TheCEPprogramhasrisks,asitrequiresthatconsumerswhoneedassistancetomeettheirbasicneedsdirecttheirowncare,includingmanagingahomecareworker.Possibleriskstothehealthandwell‐beingofconsumersaremagnifiedbyprogramdesignchallengesanddeficientprogrammonitoring.

The consumer‐as‐employer component strains critical aspects of the program

TheCEPprogramwasintentionallydesignedtoallowtheconsumertobeabletocompleteemployerdutiessuchashiring,training,anddismissingtheirhomecareworkeraspartoftheprogrameligibilitycriteria.

WefoundthatsomeCEPconsumersareunabletoperformemployerdutiesduetophysicalandcognitiveconditions,orareunwillingduetothenatureoftheiremployer‐providerrelationship.Additionally,APDdoesnotalwaystakeactionwhenconsumersarenotableorwillingtoperformrequiredemployerduties,puttingthematgreaterrisk.

Forexample,oneCEPconsumerinherthirtieshasuncontrolleddiabetesandisunabletoretaininformationduetobrainlesionscausedbyMultipleSclerosis.Becausethisconsumerdoesnothavesupportfromfriendsorfamily,itischallengingforhertobesolelyresponsiblefordirectingherowncare.Consumerswithseriousconditionssuchasthismayhavedifficultycompletingnecessaryemployerfunctions.Theymaystruggletocorrectlysubmithomecareworkerpaymentvouchers,addresspoorhomecareworkerperformance,ordirecthomecareworkerstocompletetasks.

Current Program Design and Deficient Monitoring Put CEP Consumers at Greater Risk


Inothersituations,consumerssimplyfeeluncomfortableperformingemployerduties.Often,homecareworkersarefamilymembersorfriendsandconsumersfeelreticenttoaddresspoorworkperformancelikebeinglateornotshowingupatall.

Otherconsumersmaynotspeakupwhenahomecareworkeractsinappropriately.Sincecasemanagersrelyheavilyonconsumerstotellthemiftheircareandservicesarebeingprovided,casemanagersareoftenunawareuntilsomethingserioushappens.

APD is not adequately monitoring consumers in the CEP program

Givensomeconsumersmaybevulnerableandpotentialrisks,itisimperativethatAPDmonitorservicestoensuretheyareprovidedasintended.However,ourauditfoundconsumersarenotreceivingmonitoringcontactsasrequiredbystate11orfederalrulesandprogrampolicy,puttingthematgreaterriskthattheirbasicneedsarenotbeingmet,andmakingthemmoresusceptibletofraud,abuse,andneglect.

TherearetwoessentialmonitoringrequirementsoftheCEPprogram:directandindirectmonitoring,andrisk‐basedmonitoring.InourCEPconsumerfilereviewsfortheyear2016,wefoundroughlyathirdofconsumers(49of142)didnotreceivealloftheirrequiredcasemanagerdirectorindirectmonitoringcontacts.Theresultsofourfilereviewsalignwithcommentsfromcasemanagersregardingtheimpactstomonitoringfromhighcaseloadsandtheneedtoassistconsumerswithemployerrelatedtasks,suchasmanagingtheirhomecareworker.

Forexample,twoconsumersdidnotreceiveanycasemanagerphonecalls,emails,orin‐personvisitsfor11months.Onelivesaloneandhascomplicationsfromkidneyfailure,memoryissues,Parkinson’sdisease,anddiabetes.Thisconsumerisdependentoninsulinandrequiresdialysisthreetimesaweek.Theotherhasahistoryofstrokeandheartattackandsuffersfromchronicobstructivepulmonarydiseaseandemphysemacausingon‐goingshortnessofbreath.Duetoproblemswithmemorythisconsumercannotsuccessfullymanagetheirmedication.

Inaddition,whiledirectcontactsarenotrequiredtobeinperson,havingface‐to‐facecontacthelpstobuildtrustandrapport,andallowscasemanagerstoassesstheconsumer’shometogetadditionalinformationonthelevelofcareprovidedandanyunmetserviceneeds.Wefoundroughlytwo‐thirdsofconsumers(89of142)inoursampledidnotreceiveanyin‐personvisitsin2016fromtheircasemanagers,otherthantheyearlyneedsassessment.

Risk‐basedmonitoringisanothercriticalCEPprogramelementthathelpsensurethesafetyandwell‐beingofconsumers.Thismonitoring

11 Oregon Administrative Rule 411-028-0020


requirementidentifiesthosemostatrisk,andestablishesaplantomitigatethoserisks.Consumersarescreenedbasedontheirriskassociatedwith13categories,includingnaturaldisasters,cognitivefunctioning,challengingserviceneeds,failureofnecessarymedicalequipment,andsituationsinwhichahomecareworkerdoesnotreporttowork.Ifaconsumerhashigherrisk,thecasemanagermustincreasethenumberofdirectmonitoringcontactseachyear.

Casemanagersmustdocumentinaconsumer’scasefileresultsofariskassessment,includingriskfactors,atthetimeaserviceplaniscreated.However,wesawexampleswhereacasemanagerwasabletocreateaserviceplanwithoutconductingariskassessment.

Casemanagersmustalsoindicateinthecasefileifaconsumer’sdirectcontactisassociatedwithriskmanagement.However,thispolicyisnotconsistentlyapplied.Inourfilereviews,insufficientdocumentationkeptusfromdeterminingwhetherhighriskconsumersreceivedadditionaldirectcontactsasrequired.Also,currentdatareportsdonotallowAPDcentralmanagementtoeasilyidentifyhigh‐riskconsumersanddetermineiftheyaremonitoredasrequired.APDcentralmanagementconfirmedthatthecurrentdatasystemdoesnoteasilyprovideinformationforthemtoensurethatcasemanagersareincompliancewiththerisk‐basedmonitoringpolicy.

Evenifcasemanagersareabletomeetwithconsumers,theymaybeunabletospendenoughtimewiththem.Whencasemanagerscontactconsumers,interactionsareshortandmaynotbemeaningful.Onecasemanagerexplainedthatdirectcommunicationcanberatherbrief,between1to30minutesforin‐homevisitsand30secondsto10minutesfortelephonecalls.

Shortvisitsandlimitedconsumercontactmeanthatmanycasemanagersmaynothavesufficienttimetoensuretheirconsumers’needsaremet.Numerouscasemanagerstoldusthatconductingin‐personvisitswithconsumershelpstoensurethattheirserviceplanisworking,thattheirneedsaremet,andthatconsumersarenotfallingvictimtoabuse,fraudorneglect.

APDmanagementistaskedwithensuringthateachofthethreepartsoftheCEPsystem–theconsumer,thecasemanager,andthehomecareworker‐‐areworkingtogetherasintended.Ifeachpartyiscapable,competent,andsupportedwithintheirdesignatedrole,theconsumer‐as‐employermodelcanbesuccessful.Toaccomplishthis,managementmustadequatelyoverseetheprogram.

Several Factors Contribute to Inadequate Program Oversight


SeveralfactorscontributetoinadequateoversightoftheCEPprogram.Certainprogramelementsareproblematicandneedtobeenhanced.Additionally,APDlackscomprehensiveprogramdataandmanagementhasnotadequatelyaddressedexcessivecaseloadsandensuredadequatecasemanagerstaffinglevels.

Consumer limitations not always identified, and additional assistance not provided

ConsumerindependenceandchoiceisparamounttotheCEPprogram,includingself‐determination.APDhasapolicytoassessanddocumentprogrameligibilityrequirements,andcanprovideadditionalassistancewhenconsumersarenolongerwillingorabletoperformaspectsoftheemployerduties.Additionalassistanceisavailablebyreferringtheconsumertoavoluntaryemployer‐trainingprogram,offeringtheconsumertheoptiontoshifttothein‐homecareagencymodel,oraskingtheconsumertopursueassistancefromanauthorizedrepresentative.Thislastoptionmaynotbepossibleforsomeconsumerswhohavelittleornosupportfromfriendsorfamily.

However,casemanagersmaynotknowhowtosupportconsumerswhoareunableorunwillingtocompleteemployerduties.Thereislittletrainingavailabletocasemanagersonhowtoidentifyandaddressaconsumerwhoneedsadditionalassistance.Whenlimitationsarenotidentifiedandprocedurestoprovidesupportarenotclear,referralsforassistancearenotmade.

Additionalemployertasksoftentimesfalltothecasemanagers;takingthemawayfromregularlyassigneddutiessuchascoordinatingcarewithcommunitypartners.Inaddition,thisproblemcanbecompoundedwhencasemanagersarenotabletoperformmonitoringrequirements,includingface‐to‐facecontactswithconsumers.Thisleavesconsumersmorevulnerabletoinadequatecare,abuse,neglectandfraud.

CEP consumers may not receive adequate support

CEPconsumersreceiveaConsumerEmployerGuidetohelpthemmanagetheirresponsibilities.Butsomeconsumersmayneedadditionalsupporttohire,train,andmanagetheirhomecareworker.Toaddressthisconcern,casemanagersofferStepstoSuccess(STEPS)asasolution.

Thisprogramprovidesone‐on‐onecoachingtoassistconsumersintakingontheroleofanemployer.Consumersarereferredtotheprogramwhentheyarefirsteligibleforservices,andmaybereferredateachneedsassessment,orwhencasemanagersfeelitisbeneficial.Inourfilereviews,wesawevidenceofconsumerswhoneededadditionalsupportandwereofferedSTEPS,butdeclined.Intheseinstances,theprogramcannotrequireconsumerstoparticipateinthetrainingbecauseitisprohibitedbyfederalrules.Additionally,STEPSmaynotbeeffectiveforconsumerswithdecliningcognitiveabilities.


OutsideofAPD,CEPconsumersandtheirfamilieshaveveryfewoptionsforsupporttoaddressprogramconcerns.UnderthefederalOlderAmericansAct,thestate’sLong‐TermCareOmbudsmanmustinvestigatecomplaintsandadvocateonthebehalfofindividualsreceivingcarefromlicensedcarefacilities.However,Oregonlawdoesnotincludein‐homecareconsumerswithinthepurviewoftheLong‐TermCareOmbudsman.Currently,thereisnoentityservingCEPconsumersinthiscapacity.ToincludetheseconsumerswithintheOmbudsman’sscope,theLegislaturewouldneedtomodifystatelawandprovideenoughfinancialresourcestoadequatelysupportthousandsofpotentiallynewconsumersandfundeffortstorecruitvolunteers.

Homecare Worker supports are minimal

CurrentAPDsupportsystemsdonotensurethathomecareworkersarepreparedtoprovideneededcareandservices,andAPDhasnottakensufficientactiontoaddressthisprogramflaw.Outsideofaninitialorientation,OregonAdministrativeRulesdonotrequireahomecareworkertoreceiveanyformaltraining.Consumersareresponsibleforensuringthehomecareworkerhastheskills,knowledge,andabilitiestomeettheiruniquecareneedsandpersonalpreferences.

Informationprovidedintheinitialorientationdoesnotaddresshomecareworkercompetencytocompleterequiredjobduties.OrientationislimitedtoinformationonCEPprogramrolesandresponsibilities,aswellasbasicjobrequirements.Thereisnorequiredassessmenttodeterminetheskillsandabilitiesofahomecareworker.Also,therearenorefreshercoursescoveringtheinformationprovidedintheinitialorientation.

Consumersareresponsiblefortrainingtheirhomecareworkers.Forsometaskssuchaslighthousekeepingandmealpreparation,thismaybelesschallenging.However,homecareworkersmayberequiredtodostrenuousandcomplicatedtasks,likeliftconsumersfromachairorassistthemwitharangeofconditions,fromtraumaticbraininjuriestodementiatomentalhealthissues.Ifnotdoneproperly,sometaskscanbeharmfultobothconsumersandhomecareworkers.Onecasemanagerwespokewithknewoftwohomecareworkerswhowereinjuredwhenliftingconsumers,oneendeduprequiringsurgeryandisreceivingworkers'compensation.

TheOregonHomeCareCommissionofferssometrainingforhomecareworkers,butitisvoluntary.Trainingsubjectsincludecommunication,providingcaresuchasbathing,appropriateboundaries,workingwithconsumerswithchallengingbehaviorsandconditions,aswellasotherskillscourses.

Iftheconsumerisunabletoprovidethehomecareworkersufficientinformationaboutcompletingworkdutiesorthehomecareworkerishavingdifficultieswiththerelationship,theyoftenreachouttocasemanagers.Casemanagersdotheirbesttoempowertheconsumerand


homecareworkertoresolveissues,butitdoesnotalwayswork.Inthesecases,consumersmaybereferredtoSTEPsortoothersupports.

Key APD data practices do not adequately address consumer safety and well‐being

Duetocurrentdatacollectionandutilizationpractices,itisdifficulttodeterminewhetherCEPconsumersaresafeandreceivingthecareandservicestheyneed,orevenifthecurrentprogrammodelisbest.

Existingdatafocusoncasemanagers’performancebutdonotcaptureconsumers’satisfactionwiththeircare,iftheirneedsaremet,orchangesintheirhealthandwell‐being.

Forexample,thequalityassurancereviewsconductedbi‐annuallybyAPDlookattheaccuracyandappropriatenessofcasemanagerdeterminationsforprogrameligibility,serviceplans,andservicepayments.CEPdatareportsonconsumermonitoringandneedsassessments,areanalyzedfromtheperspectiveofcasemanagers’performance.Thereisnoaspectofthequalityassuranceprocessorconsumermonitoringorassessmentreportsthatlooksatconsumers’well‐being.

Additionally,indiscussionswithAPDmanagement,welearnedthatconsumermonitoringreportsdocumentwhethereachcasemanagerhasconductedtheirrequiredconsumermonitoringcontacts.Whilethisishelpful,thereportsdonotindicatewhethereachindividualconsumerisreceivingtheindirectanddirectmonitoringcontactstheyshould.

AnotherlimitationisthatAPDdoesnotreportCEPconsumerdataseparatelyfromotherpopulations.MonitoringdataforCEPconsumersiscombinedwithdataforconsumerslivinginothercommunity‐basedcaresettings.Also,abuseandneglectdataforCEPconsumersisco‐mingledwithdataonvictimswhoarenotreceivingAPDservices.Inbothofthesesituations,dataisnoteasilyextracted.Becausedataisco‐mingled,itisdifficulttoevaluateindividualprogramperformanceandstatusofCEPconsumers.

Althoughtheagencydoestrackdataforcompliancemeasures,includingdataforfederalassurances,APDcandomoredataanalysis,includingestablishingtrendsacrossprograms.Forexample,withadditionalefforts,dataregardinghospitalizationscouldbereviewedtohelpdetermineifCEPconsumersaresafeintheirhomes,comparedtoothercommunity‐basedsettings.

APDhastakenstepstoaddresssomedatachallenges.Afterapreliminarybusinessassessmentin2014,theLegislatureallocatedfundingin2015toadoptacentral,comprehensivesystemtodocumentallabuseandneglectinvestigations.Afterinterviewingandvisitingotherstatesandlocalmunicipalities,andobtaininginputfromstaff,APDselectedaninformationtechnologysystemthatbestfitsOregon’sneeds.Aftermonthsofsystem


testing,APDplanstoincrementallyimplementtheCentralizedAbuseManagementsystembeginningJanuary2018.Itisintendedtoimprovedataanalysisandasaresult,APDshouldhavetheabilitytobetterunderstandthestatusandsafetyofCEPconsumers.

Additionally,APDreportedtheywillsurveyconsumersinallcaresettingsin2017.CEPconsumerswerenotincludedintherecentcustomersurveyoflong‐termcareservicerecipients.

APD has not effectively addressed excessive case manager workloads

APDmanagementhasnoteffectivelyaddressedexcessivecasemanagerworkload.Casemanagersreportedlydonothavethetimenecessarytoconsistentlymonitorconsumers’carebecauseofexcessiveworkloadandadditionalresponsibilities.

Casemanagers’dutiesareexcessiveandshiftfocusfromconsumersupportandmonitoring.Forexample,somecasemanagersarerequiredtodofinancialandeligibilityredeterminationformedicalinsurancecoverageandSupplementalNutritionAssistanceProgram(SNAP),whicharetime‐consumingandhavestrictdeadlines.Incontrast,casemanagerswhodosimilarworkintheagency’sIntellectualandDevelopmentDisabilityprogramsdonothavetodofinancialandmedicalinsuranceeligibilitywork.

Issuesrelatedtohomecareworkersalsodominatecasemanagers’time.Consumerscontactcasemanagersaboutissuesrelatedtohomecareworkermanagement,whichforcescasemanagerstofunctionasanintermediary,ataskthatexceedstheirroleandavailabletime.

Consumersarenottheonlyoneswhocontactcasemanagersregardingemployer/employeeissues.Homecareworkersalsofrequentlycontactcasemanagerswithchallengesandcomplaintsregardingtheiremployment,takingupconsiderablecasemanagertime.Somecommonissuesarepersonalityconflictswithemployers,difficultyrecordingtheirtime,andsubsequentpaymentforhoursworked.

ORACCESSistheprimarydatasystemcasemanagersusetodocumentconsumerdemographicinformation,healthconditions,eligibilityassessmentinformation,andon‐goingcasemonitoringnarration.Thissystemiscumbersomeandoutdated.Casemanagersfrequentlyadjustconsumerserviceplanstoaccountfornewhomecareworkersandtochangehomecareworkerhours.TodothisinORACCESSrequiresmultiplestepsandistimeintensive.

ConsumerneedsvarywidelywithintheCEPpopulation,whichrequirescasemanagerstouseavarietyofskillstoeffectivelyhelptheirconsumers.Althoughthisprogramisintendedforpersonswithphysicalorcognitivelimitations,casemanagersareseeinganincreaseinconsumerswithmultiplehealthissues,includingmentalhealthconditions.Casemanagersoftenprovideadditionalsupportandcounselingtoconsumerstohelpthem


participateincaseplanning.Whentimeisconstrained,itmakeshelpingconsumerswithexceptionalneedsmoredifficult.

APDmanagementhasattemptedtotakestepstoalleviateexcessiveworkloadandadditionalresponsibilitiescasemanagersareexperiencing.Thisincludestransitioningtoaworkloadmodelthatlooksatthetimecasemanagersneedforspecifictasks.

Casemanagerstoldustheyoftenfeeloverwhelmedwiththeamountofworktheymusthandle.Increasingly,theirtimeisdivided,whichmeansconsumersmaysuffer.

Fulltimecasemanagersweinterviewedhadbetween52and135cases.AccordingtoAPD,thereisnosetcaseloadtargetforcasemanagers.Caseloadsizevariesdependingonhowmanyconsumerseachcasemanagerhasineachcaresettingandwhetherthefieldofficesarefullystaffed.Wefound,however,thatotherstatessetcaseloadtargetsorbenchmarks.Thismayassistinaligningresourcesandbetterarticulatingstaffingshortfalls.

Additionally,accordingtoAPDmanagement,budgetconstraintsandhiringfreezeshaveimpactedDHS’sabilitytoconsistentlyfillvacanciestothelevelfundedbytheLegislature.Whileanaverageof258fulltimeequivalent(FTE)casemanagerpositionswerefundedfrom2011to2016,onlyanaverageof235wereactuallystaffed.SeeFigure6.

Figure 6: APD Case Managers FTE on board versus FTE funded12

12 The data used for this graph is limited to APD. AAA case manager FTE is not comparable.

100

150

200

250

300

2011 2012 2013 2014 2015 2016

FTE ON BOARD FUNDED FTE LEVEL


CriticalprogramdesignchallengesanddeficientprogrammonitoringcreateuncertaintythatCEPconsumersarereceivingthecareandservicestheyneed.WithouttheabilitytodeterminethatthethreecriticalcomponentsoftheCEPsystem‐theconsumer,casemanagerandhomecareworker‐areworkingasintended,consumersmaynotreceiveneededcareandmaybemoresusceptibletofraud,abuse,orneglect.

Consumers may experience increased risk to health and well‐being

ItishardforAPDtoknowifconsumersarereceivingthecareandservicestheyneedwhendataisinsufficienttomonitorconsumercare,consumerscanbereticenttocontactcasemanagersaboutconcerns,andcasemanagersaretoobusytocontacttheirconsumersabouttheirhealthandwell‐being.

Thesecircumstancescreateaheightenedriskthat:

consumersarenotachievingtheirintendedoutcomesasoutlinedintheirserviceplans,

high‐riskconsumersmaynothavetheirneedsidentifiedandmet,and consumersmaybesubjecttofraud,abuse,neglect,andsafetyrisksthat

couldgoundetectedbyAPD.

Weheardanumberofreportsregardinghowtheseissueshavenegativelyimpactedconsumers.Forexample,acasemanagerwespoketoknewofaninstanceinwhichthepreviouscasemanagersuspectedsomethinginappropriatewasgoingoninaconsumer’shomebutwasunabletovisittheconsumerformonths.Oncethenewcasemanagerconductedahomevisit,theconsumeracknowledgedthatherhomecareworkerhadnotreportedtoworkforseveralmonths.Duringthosemonths,theconsumercontinuouslytoldthecasemanagerthatherserviceneedswerebeingmetwheninfactshewasnotreceivinganyoftheneededservices.

Inanothersituation,aninsulindependent,bed‐boundconsumernearlydied.Arelativewashispaidhomecareworker.Onaroutinein‐homevisitforanannualneedsassessment,acasemanagerbecameconcernedaboutthehomecareworker’sabilitytomeettheconsumer’sneedsduetothepoorconditionoftheresidence,thehomecareworker’sownhealthchallenges,andhisongoingstruggletocorrectlydeterminetheconsumer’sinsulindosage.Becausetherequiredriskassessmentwasnotdone,thisconsumerwasnotformallyearmarkedforadditionalmonitoringcontacttomitigatetheserisks.

Program Design and Deficient Monitoring Pose Risks to Consumers’ Health and Well-being and Diminish Program


Whenanewcasemanagerwasassignedhewasinformedoftheconcernsandtoldthatmonthlyin‐personvisitsmaybeneededtoensuretheconsumer’ssafety.But,highworkloadimpactedthewayhemanagedthecaseandhedidnotattemptin‐personcontactwiththeconsumer.

Approximatelysixmonthslater,thepolicerespondedtothehomewhentheconsumergavehimselfapotentiallyfataldoseofinsulin.Theconsumerwasresuscitated,admittedtoanintensivecareunit,andsurvived.Whenquestioned,thehomecareworkerreportedhedidnotprovideservicesforwhichhewaspaidandsubsequentlylosthisabilitytobeemployedasahomecareworker.

Lack of program oversight undermines program intent

Whentheconsumerisnolongerableorwillingtofunctionasanemployer,itcausesstrainwithintheCEPprogram.Insomecases,casemanagersandhomecareworkersfillinthegap,takingonmanyoftheemployerduties.

Consumerswhoareunabletomanagetheircaremayrelyontheirhomecareworkerstomanageitforthem.Thiscouldbebeneficialtotheconsumer,especiallyifthehomecareworkeriscompetentandwilling.However,homecareworkerscouldtakeadvantageofthesituation.Forexample,ahomecareworkercouldhavetheconsumerapprovepaymentforhoursthehomecareworkerdidnotwork.Inotherinstances,casemanagerstakeonemployerduties.Butthisisoutsideofassignedtasksandaddstotheirworkload.

Inthesesituations,theconsumerisnolongerthedriverindirectingtheircare,abasictenetoftheCEPprogram.Bynotaddressingtheseissues,APDisnotabletoprovidethesupportthatisneededtofulfilltheintentoftheprogram.

APDcanaddressprogramdesignchallengesandimproveoversightbyensuringitfollowsexistingrulesandpolicies.Inaddition,otherprogramsinsideandoutsideofAPDprovidealternativesforhandlingchallenginghomecareworkeremploymentfunctionsandcasemanagementduties.Last,toalignwithleadingpracticesinperformancemanagement,APDshouldcollectandanalyzedatatobettermanagetheprogram.

Program eligibility and monitoring policies help ensure consumer well‐being

Programeligibilityrequirementsshouldbefollowedtoidentifyconsumerswhoarebestsuitedfortheprogram.Proceduresshouldbeinplacethatalignwithprogramrequirements.Theseproceduresareacriticalcomponentofprogramoversight.

CEP Policies and Alternative Program Models Provide Options for Improved Program Implementation


Indirectanddirectmonitoringpoliciesprovideabaselineforcasemanagerstomonitorconsumers’care.Andrequired,risk‐basedmonitoringaddressesthesafetyofconsumerswhoaremorevulnerable.Workingtogether,thesepoliciescouldallowcasemanagerstomonitorCEPconsumersmoreeffectively.Wheneitherpolicyisnotfollowedconsumersarenotsufficientlymonitored.

Similar programs handle homecare workers and case manager duties differently

Oregonisaleaderinprovidingservicestosupportolderadultsandadultswithdisabilitiestosafelyremainintheirhomes.However,challengestheCEPprogramfacesmaybenefitfromfreshperspectives.SimilarprogramswithinAPDandacrossthecountryhavewaysofhandlingaspectsofin‐homeservicesthatprovidemoresupportforprogramparticipants,homecareworkers,andcasemanagers.Specifically,APDcouldlookatbetterwaystohandleemployerdutiesrelatedtohomecareworkersandtheworkofcasemanagers.

Wecontactedstateswithsimilarin‐homecareservicesandfoundthatnonehadOregon’shighlevelofcasemanagerinvolvementindutiesrelatedtohomecareworkeremployment.Asoutlinedpreviously,casemanagersspendasignificantamountoftimeaddressinghomecareworkerhumanresourceandpayrollissues.Otherstatesavoidthisbyusinghomecareagenciesoroutsidepayrollservicestomanagethesefunctions.

InColorado,initialemploymenteligibilitydeterminationsandpayrollforhomecareworkersaredonethroughoneofthreeprivatepayrollserviceorganizations.InVermont,allhomecareworkersarescreenedforemploymentandpaidthroughasinglecontractedagency.EvenprogramswithinAPD,suchastheIntellectualandDevelopmentalDisabilitiesprogram,useoutsideservicestohandlepaymentofworkers.

Oregonisalsouniqueintheextentofcasemanagerdutiescomparedtootherstates.OregoncasemanagerdutiesincludedeterminingifaconsumerisfinanciallyeligiblefortheCEPprogram.Casemanagersreportthattheworkloadassociatedwithmakingtheseincome‐baseddeterminationslessensthetimetheyhavetomakemeaningfulcontactwithconsumers.Incontrast,noneofthestateswecontactedrequirecasemanagerstohandlefinancialeligibilitydeterminations.Instead,thisdutyishandledbyotherstateorcountyemployeesor,asinTexas,byacentralizedworkunit.

Casemanagersinsomestateswecontactedalsohavedifferentrolesinassessingthelevelofservicesconsumersneed.InOregon,casemanagersareresponsibleforconductingconsumerneedsassessments.Inotherstates,assessmentsarecompletedbysomeoneotherthanacasemanager,suchasathirdparty,forexample,acontractedagency.


Data should be used to improve program performance

Leadingperformancemanagementpracticesemphasizetheimportanceofusingdataforongoingprogramimprovement.CollectingandutilizingmeaningfuldatawillallowAPDtotrackandanalyzetheoveralleffectivenessoftheprogram,learnfromchallenges,andfocuseffortsonareasinneedofimprovement.FollowingleadingdatapracticeswillalsohelpAPDmeetCEPprogramexpectations.

Withoutdataontheextentoffraud,abuseandneglectofCEPconsumers,ortheeffectivenessofrisk‐basedmonitoring,APDismissingopportunitiestomaximizelimitedresources,ensuretheintegrityoftheprogram,andimprovethesafetyandwell‐beingofthisvulnerablepopulation.


Recommendations

ConsumerindependenceandchoiceisparamountintheCEPprogram.Eachprogramelement,workingasintended,willbetterensurethesuccessofeachconsumer.Measuresshouldbeinplacetomitigateriskstoconsumers’well‐beingandsupportthemasanemployerwhenappropriate.Homecareworkersshoulddemonstratetheskillsnecessarytocareforconsumersandshouldbesupportedintheirrole.Casemanagers’dutiesshouldallowtimetosufficientlyaddresseachconsumer’sneeds.

APD should take the following actions to address inherent program risks and improve program implementation:

1. Traincasemanagerstorecognizewhenconsumersneedadditionalassistanceincompletingemployerresponsibilities.

2. Developandimplementproceduresfortakingactionwhenconsumersarenolongerableorwillingtoperformnecessaryemployerduties.

3. MonitorconsumercaretoensuredirectandindirectcontactsareoccurringaccordingtotheCenterforMedicareandMedicaidServicesrequirementsandOregonAdministrativeRules.

4. UtilizeAPD’scurrentriskassessmenttooltoidentifyconsumersmostatriskforfraud,neglect,andabuse.

5. Trackcompliancewithrisk‐basedmonitoringinaccordancewithcurrentAPDpolicies.

6. Incoordinationwith theOregonHomeCareCommissionandSEIU,establishminimumhomecareworkertrainingrequirementsanddeveloprefreshercoursesfortopicscoveredinorientation.

7. IncoordinationwiththeOregonHomeCareCommissionandSEIU,implementanewmodelformanagingtheHomecareWorkerprogramthatlessenstheworkloadofAPDstaffworkingintheCEPprogram.

8. Establishaskillsassessmentforhomecareworkerstoassurethattheyhavetheskills,knowledge,andabilitiestoprovideconsumercare.

9. Takestepstoensurethatcasemanagershavethetimetoperformallnecessaryperson‐centeredplanningactivities,includingreassigningfinancialeligibilitydeterminationsformedicalprogramsandSNAPtootherstaff.

10. WorkwiththeLegislaturetoensurecasemanagersarestaffedatthelevelfunded.

11. TrackandusedatatoimprovetheCEPprogramandinformdecisionmaking,including:

CEPabuseandneglectdataseparatelyfromothersettings, CEPconsumerdirectandindirectmonitoringfrequencyseparatelyfromallothercare

settings,and CEPconsumerswhoareconsideredhighriskandwhetherornottheyaregettingthe

requiredrisk‐basedmonitoring

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