Even severely disabled seniors would lose home care under proposed state cuts, study finds

UCLA Health article
Despite claims that proposed state budget cuts to programs that provide in-home care to disabled senior citizens will not affect those with the highest level of need, a new analysis by the UCLA Center for Health Policy Research finds that even severely disabled seniors will experience a total loss of services.
Specifically, an analysis of data provided by nine California counties found that nearly 87 percent of senior citizens with cognitive impairments such as Alzheimer's disease and other forms of dementia would lose all of their paid caregiver hours under the proposed cuts. Similarly, 91 percent of seniors who are unable to shop for their own food without "substantial" assistance would lose all services.
In addition, 94 percent of those living alone would lose all their caregiver hours, as would approximately 90 percent of those age 80 and older. 
All of these scenarios are strongly predictive of increased rates of institutionalization.
The California Legislature is currently debating Gov. Arnold Schwarzenegger's recommendation to cut more than $950 million from the state's In-Home Supportive Services (IHSS) program, a move that could eliminate services for 87 percent of IHSS recipients in California — approximately 427,000 senior citizens and others with disabilities. And all recipients could lose services if the state does not receive additional federal funding requested by the governor's office.
"If all of the governor's proposals go through, there will be almost nothing left to help seniors remain in their communities," said Steven P. Wallace, associate director of the UCLA Center for Health Policy Research and author of the new paper, "Budget Proposals Turn Back Clock 30 Years in Long-Term Care Services for California Seniors," which was funded by a grant from the SCAN Foundation. "They're not trying to reduce costs with a scalpel. They're going at it with a meat axe."
No place to go

The IHSS program is just one of several safety-net programs targeted for cuts under the governor's proposal. Also on the chopping block: Adult Day Health Care programs, state contributions to the Supplemental Security Income program, the Cash Assistance for Immigrants program and certain portions of the Medi-Cal program. All told, the cuts will impact approximately half a million of California's elderly.
The cuts would likely create an immediate demand for nursing-home services among seniors who cannot afford to pay for their own in-home care. 
They would also create a bottleneck: A recent review of the IHSS program by the California Legislative Analyst's Office estimated that as many as 50 percent of those losing IHSS services (213,500 people) could seek nursing-home placement as a result. However, California has only about 20,000 licensed nursing-home beds available at any given time. This means that there is room for no more than 5 percent — or 21,350 — of all IHSS recipients who stand to lose services.
"Where will seniors go?" said Dr. Bruce Chernof, M.D., president and CEO of the SCAN Foundation, which funded the research. "There is literally no room for them in the nursing home and virtually no extra help for them in their own homes. While these are very difficult fiscal times in California, without moderation these cuts would result in a systemic abandonment of our most vulnerable citizens."
Turning back the clock

The cuts would also reduce home-care support to levels not seen in almost 30 years. In 1960, 3.7 percent of California's older adults were in institutions such as nursing homes. When Medi-Cal (California's Medicaid program) was established in 1966, the only long-term care benefit it offered was nursing-home care. As a result, the proportion of California's seniors in nursing homes rose to 5.4 percent by 1970.
However, nursing-home care is costly. To reduce costs and offer seniors a better quality of life, the state expanded home care and community-based programs like IHSS in the 1980s. The institutionalization rate subsequently dropped to 2.7 percent.
"Ironically, the same home-care programs designed to keep costs down are now on the chopping block," Wallace said. "The proposed cuts will leave California with only the most expensive care option: nursing homes. And we will have to provide that care to an even larger population of disabled seniors than existed 30 years ago, and at an even higher cost to taxpayers. As a cost-control measure, these budget cuts make no sense."
Flawed measure

How the state determines who should be subject to cuts also seems to make little sense, Wallace said.
Currently, seniors receive home-care services based on their "functional index score" (FIS), a composite measure that reflects how many hours of help a senior needs for 11 everyday tasks, such as laundry, shopping, dressing and bathing. Scores range from 1, meaning seniors need a few hours of help, to 5, meaning they need dozens of hours of help per week.
Under Schwarzenegger's plan, only home-care recipients with a score of 4.0 or above would continue getting services.
However, the FIS score is a weighted average determined through an evaluation process that is neither transparent nor well understood, Wallace said. The FIS score also does not assess cognitive impairments such as Alzheimer's disease — an important measure of disability and risk of institutionalization. 
Wallace said the FIS score compares unfavorably to another, widely used measure of disability: that used by the state's Multipurpose Senior Services Program (MSSP). In the MSSP program, seniors are evaluated to determine if they are frail or disabled enough to qualify for placement in a nursing facility. In one representative county, approximately 88 percent of MSSP recipients considered frail enough to enter a nursing home had FIS scores below the 4.0 cut-off in the governor's proposal, and 45 percent had FIS scores below 3.0.
In the nine-county analysis, UCLA Center for Health Policy researchers found that many seniors who fall below the 4.0 FIS score cut-off are severely disabled. 
They also found that 33 percent of older IHSS recipients live alone, nearly 32 percent have some level of cognitive impairment, 82 percent cannot shop for their own food without substantial help, and approximately 49 percent are 80 years old or older. 
Almost all will lose their IHSS home care under the governor's proposal.
The nine counties studied were Kings, Los Angeles, Sacramento, San Benito, San Diego, San Joaquin, Santa Clara, Stanislas and Ventura.
The SCAN Foundation's mission is to advance the development of a sustainable continuum of quality care for seniors.  
The UCLA Center for Health Policy Research is one of the nation's leading health policy research centers and the premier source of health-related information on Californians.
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Gwen Driscoll

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