When Homecare Doesn’t Make House Calls: Concerns About Oversight of Services for Seniors

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Emil Cohen/City Council

Councilmember Diana Ayala says she's encountered seniors whose homecare aide simply never shows up.

At a Monday oversight hearing on home health aides, Councilmember Ayala opened her questioning with a story about a constituent with multiple sclerosis, fully dependent on aides for daily activities. The woman, who is middle-aged and whose parents are deceased, lives alone in East Harlem, where part of the Council woman’s district lies.

Ayala told the room that last Thanksgiving while making a round of holiday phone-calls, she learned after a 2 p.m. phone call that the woman had not eaten anything all day. A home care worker from one nursing service made only a quick visit to administer some insulin that morning, then left.

Another homecare worker was supposed to show up for a 7 p.m. shift later that same day, Ayala said, but didn’t appear. “I spent a couple hours with her, feeding her,” Ayala said. She learned that incidents like this were common for the woman.

“Had I not called her that afternoon she wouldn’t have had anything to eat the entire day,” Ayala said. The woman would often fall asleep in her wheelchair, the Council member said, because the health aide who was supposed to place her in her bed did not arrive.

“This is a significant failure in the system,” she said at the hearing. Ayala says cases like the one she discussed are not uncommon in her district encompassing the South Bronx and East Harlem.

But no one who testified at Monday’s hearing could answer for the incident, because city agencies administer only a fraction of homecare services.

Throughout the hearing, Council members struggled with how to oversee a convoluted homecare system that appeared to be plagued by alarming incidents of mismanagement. They did so by questioning two city-run programs that largely exist to close coverage gaps in that system, which was largely taken over by the state in 2012. City officials who testified on Monday represented programs that combined serve less than five percent of total homecare enrollees citywide.

“We were having a hard time even getting the hearing, because the city feels like this is really a state entity now,” Ayala told City Limits. (Ayala told City Limits she could not recall whether the woman she visited was in a city-run plan or state managed long-term care plan.)

Annette Holm, Chief Special Services officer at Human Resources Administration, said that the dereliction exhibited in Ayala’s opening anecdote would be a violation of HRA’s protocol, but stressed that the majority of homecare is under state-run managed care plans. For clients receiving 24-hour homecare, she said, the protocol is for workers not to leave until a replacement has arrived.

The current landscape is the result of Governor Cuomo’s 2012 Medicaid redesign, which mandated enrollment in state-run private insurance plans, shifting 40,0000 New Yorkers out of the purview of the city’s Human Resources Administration according to Holm’s testimony.

As a result, of the 192,000 people receiving homecare in NYC, about 184,000 city-wide receive it through the state’s Medicaid program, through private plans called Managed Long Term Care plans. These privatized plans have faced criticism for mismanagement and a history of awarding clients fewer hours than they may need, although some enrollees statewide say their counties were not doing a good job regulating long-term care before the switch.

A sliver of clients citywide fit into special carve-outs and can enroll in city-administered plans. Those who fit into the carve-outs have serious needs – such as a traumatic brain injury or a developmental disability that would necessitate a higher level of care. The exemption lets them benefit from the city’s fee-for-service model, which is more generous in terms of hours of care awarded. The state, by contrast, pays a flat per member per month cost to private insurance plans, which critics say allows the plans to award less hours to clients.

The population in HRA long-term care amounts to only about 2.6 percent of the homecare population, or 5,000 people according to Monday’s testimony from the Department for the Aging and Human Resources Administration.

Councilmember Ayala told City Limits there is no immediate plan to increase the number of people eligible for homecare under HRA through the exemptions.

For people over 60 who don’t qualify for Medicaid, the Department for the Aging administers limited homecare services under the Expanded In-Home Services For the ElderlyProgram. (EISEP) . They currently serve about 2,900 enrollees citywide, and served a total of 3,600 last year.and according to testimony from Alan Hom, Deputy Assistant Commissioner of Long-Term Care at DFTA. But the program’s $33 million budget is not enough to cover the seniors on waiting lists for homecare, Hom testified. About 1000 seniors are on waiting lists for case management through EISEP and 100 for homecare, Chin said.

EISEP contracts with four homecare providers and charges a sliding scale, ranging between $1 and $25 per hour. While the program is administered by DFTA, it’s funded by NY state’s Office of Aging and must meet guidelines set out by the state’s Department of Health.

Councilmember Margaret Chin asked Hom how much additional funding it would take to enroll everyone on the waitlist for EISEP. Hom said DFTA is talking to the Office of Management and Budget to figure this out but did not appear to have a number ready.

A further limitation of EISEP is that it does not provide overnight service, which means elders who need 24-hour care and do not qualify for Medicaid are out of luck.

Chin said her constituents in EISEP were often happier than those in state plans. “They’re much better than what the private sector is offering,” Chin said. “I think with the Medicaid redesign, there’s a lot of abuse going on.” She said she’d heard examples of family-members hired through the consumer directed personal assistant program who were abandoning loved ones while on the clock.

“They clock in, they clock out, then they go do something else,” Chin said. “The senior is not getting the services they’re supposed to be. Because it’s a family member, they can’t complain.”

The hearing also covered the strain felt by the homecare workforce, many of whom are immigrants and women of color. New York City’s Court of Appealslast monthupheld a state policy that pays health aides for 13 hours of work during a 24 hour shift. The pay rate, set by New York State Department of Labor guidelines, works under the assumption that 8 hours of that time could be counted as sleep. Homecare workers say these eight hours of sleep rarely happen because of the nature of the job.

“A decision that perpetuates near poverty wages is not one to celebrate,” Tara Klein of United Neighborhood Houses testified about the ruling at Monday’s hearing.

Low pay is one of the main drivers of a shortage in the homecare workforce, not just in New York City but across the state and nationally, despite a ballooning need.

But homecare providers say it’s difficult to hike pay for these positions without getting more Medicaid funds from the state.

This was reflected in testimony by Wayne Ho, CEO of the Chinese American Planning Council, a social services provider. The group runs a homecare nonprofit which was sued in a previous class action lawsuit over the 13-hour pay dispute, which was settled in its favor in 2015. Ho said that the group is often caught between city and state regulations, but the need for more Medicaid funding was a point of agreement that providers, City Council, homecare workers and advocates should agree on.

Regarding the 13 hour rule, Ho recommended a shift to 12 hour alternating shifts rather than 24 hour days as one solution.

Ho said if New York State were to fund payments to homecare workers for the full 24 hour shifts it would amount to $1.2 billion, a number he says the state provided him during budget negotiations.

The Governor has increasingly sought ways to reduce per-person Medicaid funding through the Medicaid Redesign Team, even as the overall Medicaid budget increased by $4 billion last year. The state budget that passed this month included large cuts to the Consumer Directed Personal Assistance Program, or CDPAP, with payroll intermediaries that consult consumers in the program estimated to take a 25-66 percent hit, according CDPAANYS, an industry trade group.

Ayala told City Limits that the hearing produced even more questions and that the Council may look into creating a taskforce to look into homecare in the future.

“As you can hear from the testimony there is a lot of conversation between the state and the city that’s happening,” Ayala said, “so somebody has to assume responsibility for this baby.”

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