P a g e 1 Ensuring safety: IHSS Caregiver Back-up System (BUS) ABSTRACT OF THE PROGRAM The In-Home Supportive Services (IHSS) Caregiver Back-Up System (BUS) is an innovative, 24- hour, in-home emergency caregiver program designed to provide stabilization services and support to elderly and disabled individuals who are assessed to be at risk of harm due to caregiver absence and serious safety concerns. It is an enhancement to In-home Supportive Services, a statewide Medi- Cal benefit program that addresses crises and unmet needs (gap). The goal of the BUS is to allow elderly and disabled individuals to remain safely in their homes until the crisis situation is resolved and/or permanent care solutions are developed. The BUS system consist of a complex partnership between an identified pool of inhome caregivers who have agreed to respond to emergency situations on a 24-hour basis, Adult Protective Services (APS), the IHSS Public Authority (PA), and two local health plans; Molina and Inland Empire Health Plan. As emergencies arise which may be mitigated by dispatching a caregiver, the BUS system is activated. The activation of the BUS triggers a series of activities consisting of: the dispatch of an emergency in-home caregiver to address the immediate need; a coordinated multidisciplinary case review; health plan involvement; assessments and coordination with critical local partners, and the fiscal administration of additional pay incentives for the emergency caregivers. This complex partnership and care affords the time necessary to develop a plan to maintain residents in the least restrictive, but safe setting. The BUS system achieved a 96% and 93% successful immediate dispatch rate in 2015 and 2016, respectively. THE NEED FOR THE PROGRAM The IHSS does not have a statewide intervention program which responds to the in-home emergencies typically experienced by elderly and disabled clients who have limited or no support system, suffer from advanced health problems, physical limitations, and/or cognitive impairments, and who are not able to live independently in their homes. Often, the last resort option for these clients are 911 calls, emergency room visits and hospitalizations (20,752,000 nationwide, 2013), Adult Protective Services (APS) short-term intervention, and/or repetitive cycles of self-neglect. These factors, coupled with limited placement resources underscore the need for Riverside County s Caregiver Back-Up System (BUS). It is a responsive and timely alternative to more costly and disruptive forms of care.
P a g e 2 DESCRIPTION OF THE PROGRAM Unique to Riverside County alone, Riverside County Adult Services Division and the IHSS Public Authority (PA) jointly designed a unique, intensive supplemental service response system for seniors and disabled persons whose critical health concerns are mitigated through emergency in-home caregiver intervention. An in-home caregiver dispatched by the IHSS BUS acts as a temporary intervention plan, eliminating the immediate risk of injury or harm until a permanent plan can be established by county social workers and collateral partners. Riverside County attempts to decrease hospitalizations, ensure safety and stabilize care through the IHSS BUS system which consists of the following components: A supply of available IHSS caregivers who are willing to respond at a moment s notice to provide an array of services based on the client s assessed needs. Support and training of caregivers to enhance skills, reduce burn-out, and promote self-care. Payment incentive (or shift differential) beyond the standard IHSS hourly rate to be paid for responding to afterhours/emergency shifts. A payroll system (outside of the IHSS program) to process and address a shift differential. Buy-in and commitment from internal and external partners who share responsibility for improving outcomes for elderly and disabled residents. In January 2014, the PA began to coordinate, plan and design this innovative program by creating an integrated process to dispatch IHSS BUS caregivers on an emergency basis through the after-hours Adult Protective Services (APS) hotline. A complex partnership between IHSS, APS, the County of Riverside Department of Public Social Services (DPSS) Fiscal, Molina Health Plan, and the Inland Empire Health Plan (IEHP) was developed. In addition to other funding sources, the IHSS BUS relied on commitments from Molina and IEHP to cover the cost differential for clients who were also health plan members, as well as assist with intervention planning. Equally important, was the support of the DPSS Fiscal Department to administer the BUS payroll, which ensured that caregivers received the pay rate incentive of an additional $3 per hour above the standard IHSS rate. Buy-in from human service partners, decision makers and the community was eased by the fact that IHSS BUS provided a safety net resource, as an extension of the county APS after-hours response, and is the most viable and cost-effective
P a g e 3 vehicle to dispatch in-home care services during after-hours and emergencies. All partners were involved in the planning process to ensure that protocols were clearly developed. In March of 2015, the IHSS BUS became fully operational, diverting clients from higher level care facilities while maintaining them safely in their homes. Recruitment and support of Caregivers is important. The PA continually recruits experienced volunteers from the existing caregiver registry, who are able to respond to emergencies throughout the county. In addition, classes designed to enhance caregiver skills, increase length of stay of caregiving relationships, and reduce stress are offered throughout the county via partnerships with University of California Los Angeles (UCLA) and the Riverside County Office on Aging. The topics addressed include: Dealing with Dementia, Fall Prevention, Reducing Caregiver Stress and Self Care. Meetings are held to encourage and maintain effective working relationships between the PA staff and caregivers. There is a strong emphasis on supporting and retaining caregivers. Service coordination is a critical safety component. As emergencies arise and referrals are made from APS to the PA for emergency in-home care. The PA and APS social workers team to assess the needs of the clients and to coordinate necessary interventions with the caregiver during an IHSS BUS. The PA dispatches caregivers, communicates activities needed to stabilize the client s situation, and maintains communication with the caregiver to offer support when needed. Within 48 hours of the BUS activation, PA staff coordinates with health plan providers and other partners to participate in the development of a longer term plan and processes documentation with county/health plan fiscal personnel to ensure the caregiver is paid for the services provided. Funding and administrative support is necessary. Riverside County participated in the California Coordinated Care Initiative (CCI, also Cal Medi- Connect, SB 1008 & 1036). This served as the basis for partnership with the health care systems. Under the CCI, IHSS services became a managed care benefit, Health plans were required to: ensure access and payment for IHSS providers; create a care coordination team (also referred to as an Interdisciplinary Care Team); and enter into contracts with the county social service agencies to perform state required activities such as: assessments, IHSS provider/caregiver background checks, and quality assurance. There was a mutual benefit to all involved. IHSS BUS delivery approach is unique and successful to Riverside County for the following reasons:
P a g e 4 1) The IHSS BUS system design successfully expands the IHSS program beyond expectations, in that it became a viable emergency caregiving resource for clients who are at significant risk, without additional cost to the client or the county protective programs (APS or IHSS). 2) The IHSS BUS system utilizes existing infrastructure and administrative programs, without the need for a new functional burden on partner staff. 3) The IHSS BUS system partners embraced shared responsibility. As a result, through the broadened client service network and case coordination, no single agency is over-burdened and continuity and longevity is achieved. All of the above mentioned essential roles and activities occur when the BUS is activated. USE OF TECHNOLOGY The IHSS BUS system would not be possible without fully utilizing various forms of technology. BUS activations and management require communication devices and protocols familiar to most modern offices. No specialty software programs or hardware configurations are required. Generally, the PA Dispatch staff use telephones and computers when triaging incoming requests. Communication among office staff is conducted by email and Skype. After hours and on weekends, the PA Social Worker responsible for coordinating BUS services utilizes cell phones and a laptop computer to access information, search for registry BUS caregivers and to maintain communication with the APS hotline, the caregiver and the client. Services are documented in the case management systems (RTZ HomeCare2 and CMIPs) which are common to most social service agencies in California. Finally, service outcomes, payment, and quality assurance measures are tracked utilizing database tools included in the Microsoft Office suite. COST OF THE PROGRAM Perhaps the most noteworthy component of the IHSS BUS program is the cost-savings directly resulting from the integrated service model. The cost to the health plans is reduced because the IHSS BUS option serves as a form of emergency caregiving at a discounted rate. The IHSS BUS effectively utilizes the combined capacity of the PA Registry and the APS after-hours screening, which allows IHSS caregivers to respond to known emergencies, thereby avoiding more costly clinic or nursing care options. In 2016, because the majority of the caregiver
P a g e 5 payment cost was diverted to the county IHSS program, the average health plan cost of enhanced services through the IHSS BUS option was only $62 per client. This is significantly lower than the average cost of an emergency room visit ($1,233, nationwide, 2013). THE RESULTS/SUCCESS OF THE PROGRAM In 2016, the cases that involved IHSS BUS dispatch illustrated findings consistent with many empirical studies which indicate that changes in one s health condition places increased demands on the client s ability to care for themselves. Not surprisingly, this self-care deficit is also linked to the increased risk of hospitalization. During the 2016 calendar year, the IHSS BUS received 44 qualified referrals. Of these, all but three resulted in a successful dispatch of a caregiver to provide short-term, emergency services in the client s home (93% success rate), avoiding a hospitalizations or alternative emergency care. Approximately 3% of the cases were recent hospital discharges in which clients were not able to take care of themselves due to their weakened condition. Almost half of the cases (41%) involved clients with emergency needs who were bed-ridden or had a form of paralysis; and the remaining majority (56%) were clients who needed personal care assistance and meal preparation, but had no caregiver immediately available. For these IHSS BUS cases, immediate caregiver intervention proved to be an effective alternative solution when other traditional institutional options (such as emergency shelters, mental health support, and/or hospital admissions) were either not appropriate or not immediately available due to lack of resources. In all cases, the IHSS BUS dispatch acted as the catalyst for care and case coordination, with the goal of ensuring the least possible disruption to the client s daily life. In addition, plans for alternate long-term care were being developed in partnership with the health plans and county social service workers.
P a g e 6 WORTHINESS OF AWARD The IHSS BUS system is a low-cost diversion program that has proven to maintain and support to clients in their home while avoiding unnecessary, high cost institutional care. With its streamlined response structure, the IHSS BUS continues to demonstrate successful response rates (93% in 2016; 96% in 2015), resulting in longer maintenance of client safety and lessening of the burden on county protective systems. Riverside s IHSS BUS program expands services beyond routine in-home caregiving, to include a unique and successful emergency response component. Through on-going recruitment, training and support of IHSS BUS caregivers, the Public Authority is able to dispatch in-home caregivers on a moment s notice. It optimizes existing resources through service integration, responsible partnerships and effective intergovernmental coordination and organization. IHSS BUS mitigates the utilization of higher levels of emergency care, reduces cost, and may be replicated by other counties utilizing existing resources (staff, partners, and technology). Riverside County has been called upon to present to and consult with other counties and agencies regarding the IHSS BUS due to the fact that it is unique, has had positive outcomes and is considered a promising practice approach for counties facing the challenges associated with maintaining elderly and disabled clients safely in their homes.