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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


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


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.


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 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.


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)


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


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:


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.


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


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


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.


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.


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;


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.


“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.


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


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


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


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


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


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


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 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

in -home supportive services (ihss) · in-home supportive services (ihss) ... entitlement program...

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