Breaking Down Boundaries to Private Care: Unlocking Very important Providers for These Who Want Them Most

Justice in Getting old wish to thank Carol Wilkins for her contribution to this temporary.

Introduction

Private care providers are important for older adults and other people with disabilities who want help with every day actions like dressing, consuming, and cleansing to reside independently and age of their communities somewhat than in institutional settings comparable to nursing services.

In California, Medi-Cal pays for private care providers via a number of Residence and Neighborhood-Primarily based Providers (HCBS) applications together with In-Residence Supportive Providers (IHSS), HCBS waiver applications, and thru Medi-Cal Managed Care Plans. IHSS is by far California’s largest HCBS program, providing private care to over 700,000 disabled individuals of all ages. IHSS primarily makes use of a consumer-directed mannequin, the place individuals should handle their very own care, together with hiring and supervising suppliers and directing when and the way their care is delivered. In the meantime, HCBS waiver and managed care applications couple private care providers with extra helps, however comparatively serve far fewer individuals than the IHSS program.

To perceive how nicely the IHSS program and different HCBS applications providing private care providers are working for individuals with the best well being and social wants, Justice in Getting old performed intensive interviews with over 80 private care customers and suppliers, client advocates, state and nationwide policymakers, and different stakeholders (see Appendix). This paper synthesizes the findings from these interviews with accompanying direct quotes from individuals.

Key Findings

Interviews revealed that non-public care providers are largely inaccessible to people who find themselves not in a position to self-direct their care, significantly if they don’t have household or neighborhood help. This leaves many liable to damage, extended homelessness, hospitalization, and pointless institutionalization. And these gaps in care disproportionately hurt people who find themselves Black, have restricted English proficiency, or are LGBTQ+.

1. Sure teams of individuals with disabilities disproportionately face problem in accessing private care providers via the IHSS Program
2. The IHSS Program design and guidelines create vital limitations to self-direction and hinder entry to private care providers for sure high-need populations.
3. Folks experiencing homelessness face distinctive programmatic limitations in accessing private care providers via IHSS.
4. HCBS Waiver Packages and Medi-Cal managed care don’t presently fill the gaps in entry to private care providers.
5. Those that can not entry private care providers face severe hurt to their well being and well-being.

Suggestions

Interviews revealed that folks face numerous challenges and limitations in self-directing their very own care, pointing to a necessity for applications and insurance policies that present a continuum of care and help. Options should take away limitations to providers and improve helps that foster independence, self-determination, and neighborhood dwelling for people alongside this continuum.

1. Broaden the supply of private care providers delivered via companies as an alternative choice to the consumer-directed mannequin for individuals who face limitations self-directing their care.
2. Broaden entry to HCBS waiver applications for individuals with the very best care wants by eradicating enrollment caps and making them extra extensively accessible throughout the state.
3. Assessment and enhance IHSS and different HCBS program guidelines to scale back the limitations to enrolling in these applications and accessing private care providers.
4. Enhance the supply of private care providers via Medi-Cal managed care together with Neighborhood Helps.
5. Undertake modern practices like coaching, case administration, and peer help to facilitate entry to consumer-driven private providers.

Funding for this venture was supplied by the California Well being Care Basis. This paper was knowledgeable by interviews with state and nationwide policymakers, client advocates, community-based organizations, supportive housing organizations, county IHSS personnel, IHSS Public Authorities, labor organizations, and IHSS customers and suppliers. Quotes used on this report are taken from these interviews. Justice in Getting old wish to thank the greater than 80 people who shared their experiences and insights with us.

Background: Medi-Cal Private Care Packages

Medi-Cal, California’s Medicaid program, is answerable for offering individuals with the providers and helps they should stay dwelling at house and of their communities, identified broadly as house and community-based providers (HCBS). California delivers HCBS via a lot of totally different applications and supply programs, a number of of which embody the supply of private care providers. These embody the In-Residence Supportive Providers (IHSS) program, HCBS waiver applications, and private care providers which might be provided by Medi-Cal managed care plans via Neighborhood Helps.

In-Residence Supportive Providers

IHSS is California’s largest private care providers program. It performs a central position in California’s compliance with the Supreme Court docket ruling, Olmstead v. L.C., which requires that every one people have the correct to self-determination and are entitled to obtain the helps they should reside of their houses and communities. Rooted on this core precept and championed by the unbiased dwelling and incapacity rights actions,[1] this system depends on a consumer-driven mannequin the place the buyer is answerable for directing their very own care.^[2]

At this time, California regulation acknowledges three sorts of IHSS supply:^[3]

• Impartial Supplier Mode: Customers straight make use of a supplier of their alternative, together with a household caregiver like a mother or father or partner, a pal, or different licensed supplier. Practically all IHSS individuals obtain IHSS via this mode, with 72% receiving care from household suppliers.^[4] These with out household caregivers should flip to Public Authorities (see textual content field) or different native nonprofit consortiums for a registry of enrolled suppliers, or establish and rent an eligible supplier from their neighborhood.^[5]

• Contract Mode: To serve those that can not entry IHSS via the Impartial Supplier Mode, counties might also contract with a house care company to behave because the employer of IHSS suppliers, somewhat than the buyer. Right now solely San Francisco County makes use of Contract Mode, offering IHSS providers to 1,100 out of the county’s 27,500 IHSS recipients.^[6]

• Homemaker Mode: The County acts as the house care company. This mannequin is presently unused. ^[7]

Residence and Neighborhood-Primarily based Waivers

Folks with complicated wants who require extra help along with customary private care providers can flip to California’s Medicaid HCBS waiver applications. Waiver applications can present private care providers via an company, can complement IHSS when the utmost allowable 283 hours are usually not sufficient to fulfill a client’s wants, and embody extra intensive helps when individuals want them to stay dwelling in a neighborhood setting. However not like IHSS, these waiver applications are geographically restricted and have enrollment caps, resulting in lengthy waitlists.^[9]

There are three major HCBS waiver applications that present private care help (plus extra providers) to older and disabled adults that have been mentioned by interviewees.^[10]

• Assisted Residing Waiver (ALW): Gives as much as 24-hours of care and supervision a day to older adults and adults with disabilities in Residential Care Services for the Aged (RCFEs) or Grownup Residential Services (ARFs), and in a restricted variety of publicly sponsored housing items in Los Angeles County.^[11] The ALW is offered in 15 of California’s 58 counties, is anticipated to achieve its most capability of 14,544 people by the publication of this paper, and carries a waitlist of roughly 3,200 individuals.^[12]

• Residence and Neighborhood-Primarily based Alternate options (HCBA) Waiver: Provides as much as 24 hours per day of private care providers (plus quite a lot of intensive providers comparable to in-home nursing care) to medically fragile people of all ages, of their houses, via each unbiased and company suppliers. The HCBA waiver is offered statewide and presently serves 9,031 individuals, and has a waitlist of over 5,300 people.^[13]

• Multi-Objective Senior Providers Program (MSSP): Gives supplemental private care providers and complete helps together with care coordination and administration and grownup day providers to people over age 60.^[14] As of the publication of this paper, 9,653 persons are enrolled in this system, ^[15] and it’ll quickly be accessible in all 58 counties.^[16]

Medi-Cal Managed Care

Medi-Cal managed care plans even have the choice, however are usually not required, to supply a number of of fourteen providers, often known as Neighborhood Helps.^[17] Neighborhood Helps are provided to handle health-related social wants by filling care gaps that affect entry to secure housing, meals safety, and neighborhood dwelling.

Private care providers are primarily provided via three Neighborhood Helps:^[18]

• Private Care and Homemaker Providers: Delivers extra or momentary private care to eligible people in three conditions:
  • Gives extra private care hours past these authorised beneath IHSS
  • Gives momentary private care providers whereas an IHSS software is pending; and,
  • For a most of 60 days, supplies private take care of these not eligible to obtain IHSS to keep away from a short-term keep in a nursing facility.^[19]

Whereas practically all managed care plans supply the Private Care Neighborhood Assist as of July 2024, utilization stays low. Throughout 2023, 1,780 individuals obtained this help, and one plan accounted for 1,465—or 82%—of all those that obtained this help.^[20]

• Nursing Facility Transition/Diversion to Assisted Residing Services: Offers members the choice to transition out of or keep away from the necessity to keep in a nursing facility by transferring right into a licensed residential care (assisted dwelling) facility and to obtain help with actions of every day dwelling in that setting.^[21] As of July 2024, all however two managed care plans included this Neighborhood Assist as a coated service. Nevertheless, solely 552 people obtained this service throughout 2023, a majority of which have been supplied by solely two managed care plans. ^[22]

• Recuperative Care (Medical Respite): Provides as much as 90 days of care, together with restricted help with actions of every day dwelling, in unlicensed interim housing settings for individuals experiencing homelessness who’re discharged from the hospital and want extra time to get better earlier than returning to unstable dwelling conditions like shelters or encampments.^[23] Practically all plans supply this Neighborhood Assist, and 4,518 members used this service at a while throughout 2023.^[24]

Findings

Interviews revealed that California’s private care providers applications as designed are inaccessible to individuals who, on account of impaired capability, structural limitations, discrimination, and bias, are unable to direct their care. These people encounter vital challenges in navigating complicated program purposes and administrative processes, hiring and managing care suppliers, and guaranteeing the standard of providers they obtain.

Discovering One: Sure Teams of Folks with Disabilities Disproportionately Face Issue in Accessing IHSS

Interviewees recognized 5 teams of individuals with disabilities who usually tend to face problem self-directing or managing their very own care as required by the predominant mannequin of IHSS (Impartial Supplier). This listing is just not exhaustive however illustrates the sorts of well being situations or situational circumstances that may hinder self-direction as required by the IHSS program.

• People with Cognitive and Determination-Making Impairments: Folks with situations like Alzheimer’s, dementia, or behavioral well being situations could expertise reminiscence loss, confusion, or different signs that restrict their means to speak or problem-solve as wanted to constantly direct their very own care, significantly as these situations progress.

• People Experiencing Homelessness or At Threat of Homelessness: Folks with out secure housing usually can not set up constant routines to grow to be eligible for private care providers applications or to rent suppliers and successfully handle their very own care.
• People Leaving Incarceration: Folks leaving incarceration are confronted with social stigma, restricted household or social help networks, excessive charges of housing instability, financial limitations, and challenges in accessing or recovering documentation, comparable to identification wanted to entry social providers applications. These challenges could make it troublesome to use for IHSS and procure and retain a care supplier.
• People Going through Discrimination: Communities of coloration and LGBTQ+ people could expertise discrimination and stigma from their suppliers, hindering their means to search out and retain a supplier and tackle high quality deficiencies or discriminatory remedy. Individuals who have confronted discrimination are additionally extra more likely to face isolation.

• People with Restricted English Proficiency (LEP): Language limitations could create obstacles to successfully speaking with a supplier and complying with program guidelines.

• People Residing in Rural Communities: Bodily and social isolation individuals dwelling in rural areas expertise, in addition to lowered alternative in accessible suppliers on account of employee shortages, could trigger dependence on a single caregiver and lead to unequal energy dynamics that make care path difficult.

Discovering Two: IHSS Program Design and Guidelines Create Important Boundaries to Self-Path and Hinder Entry to Private Care Providers for Sure Teams

Accessing private care providers via IHSS is sophisticated for a lot of care recipients, particularly for individuals who lack a household caregiver, and will be insurmountable for older adults and other people with disabilities with sure medical situations or social circumstances.

Program Navigation Boundaries

• Utility Course of and Program Navigation. Navigating the IHSS software course of entails a number of steps, comparable to filling out and submitting types, acquiring physician certification, scheduling and attending practical wants assessments, and, if mandatory, submitting appeals and grievances.

“I pray day-after-day that I can form of bear in mind, as a result of when you get on these providers it’s a must to reapply and recertify…I gotta do my recertification yearly for that. I’ve to remain on prime of my Medicaid and every other subsidy I get. I’ve to actually apply yearly. Be certain I’ve all my info, my financial institution info, and it is lots. It’s actually lots.” (IHSS Shopper)

“For some people [who have Alzheimer’s and no family support], once we ask [application] questions, like what [health] plan do you could have, or about their funds, they only have a tough time answering a few of these questions, so it turns into form of tough… The factor is, how are they going to have the ability to observe via? Generally I contain APS [Adult Protective Services]…however I don’t know what occurs after I make the referral—then it’s out of my fingers.” (Advocate)

• Program Data and Guidelines: Understanding the complexities of IHSS guidelines and client duties as an employer, together with reporting and timekeeping necessities, is essential. Nevertheless, many individuals are sometimes unaware of program guidelines, and performing required administrative duties like monitoring and signing timesheets, significantly when managing a number of suppliers, will be much more difficult for individuals with cognitive impairments or organizational and reminiscence difficulties, or for people who find themselves transitioning from one setting to a different.^[26]

“If it’s a must to have a number of suppliers, it is actually like operating a small enterprise. It’s important to rent, practice, work out schedules and signal time playing cards. It means that you’ve got precluded people which have vital psychiatric sickness, substance use dysfunction, or in any other case, excessive ranges of disorganization…It is simply not possible for lots of parents.” (Service Supplier)

“Incarcerated people don’t even learn about [IHSS], and it’s actually laborious to get in to do training—the sheriff’s division and CDCR [California Department of Corrections and Rehabilitation] make it actually troublesome.” (Shopper Advocate)

Supplier Administration and Retention

• Figuring out and Hiring Suppliers. IHSS customers who would not have a trusted member of the family or pal who’s prepared to be their caregiver usually depend on Public Authority registry lists or word-of-mouth to search out suppliers to ship providers. These registries are sometimes very troublesome to navigate, requiring customers to kind via and interview potential suppliers from a listing of lots of to discover a appropriate match when it comes to talent set, geographic accessibility, and availability. Suppliers take into account elements comparable to persona or perceived security issues when deciding whether or not to work for a client, and lots of choose to work for these requiring a decrease stage of care. Supplier issues and preferences restrict choices for people with complicated bodily, psychological well being, or social wants.

“We have now individuals which have been in our registry actively searching for suppliers which may go eight months or a yr and run via 600 referrals and never rent anyone…[when we] strive taking a look at people who find themselves experiencing homelessness and connecting them with a suppliers, it is a nonstarter.” (Public Authority)

“The [IHSS] wages and advantages are an issue [for retention], but in addition it is the extent of care. Folks do not thoughts coming in doing mild house responsibilities, or …doing all your grocery buying. However it’s that non-public care that we fear about probably the most – that is the place the most important downside is, you simply cannot get a supplier to do this. Not for $15 or $20 an hour.” (Stakeholder)

“Folks [with Alzheimer’s and dementia] can change from everyday, so if [there is a provider] simply twice every week, or there could possibly be two totally different suppliers, it’s laborious to have consistency, predictability, and a routine with any individual who’s coming intermittently.” (Policymaker)

• Retaining Suppliers. Customers who’ve complicated care or psychological well being wants requiring intensive or 24-hour care are sometimes unable to retain IHSS suppliers who’re prepared to supply the required hands-on care or in a position to work after they want help.

“I’ve a neighbor that was simply recognized with dementia final yr, and lives in her condo, alone. Someday when I attempt to assist her, and I can see that it is cognitively simply actually laborious for her to recollect the knowledge. She’s already getting IHSS, and he or she has a supplier who’s a member of the family, and the member of the family is just not in a position to commit. So now she has to search out somebody new, and he or she’s afraid of somebody coming to her house to present care….” (IHSS Shopper and Advocate)

• High quality of Care Administration. Though the Public Authority is the employer of document, the entity’s position is essentially centered on guaranteeing suppliers meet program necessities, and never on guaranteeing supplier high quality. Managing how and when an IHSS supplier delivers care and the standard of that care falls to the buyer, which is more difficult when an individual depends on a single supplier for care, communication, and neighborhood entry due to bodily isolation or dependency. This places the supplier able of energy over the care recipient. When customers battle to establish and rent a supplier on account of private obstacles or supplier shortages, energy dynamics between customers and suppliers are impacted. This could forestall customers from addressing job efficiency and high quality points, resulting in unmet or uncared for wants and generally leading to abuse or severe conflicts between customers and suppliers.

• Compounding Components: An individual’s incapacity and lived expertise can additional exacerbate limitations to navigating IHSS program guidelines and managing and retaining a supplier. For instance, individuals with cognitive impairments or some behavioral well being situations could expertise signs of paranoia or mistrust, making it troublesome for them to allow caregivers into their houses. Populations experiencing bias on account of race, sexuality or gender identification, or trauma based mostly on a historical past of victimization might also really feel unsafe and be reluctant to interact a caregiver. The frequency of supplier turnover for private care providers can act to accentuate this mistrust.

“It’s very laborious for [Black older adults] to achieve out and get [IHSS] providers due to belief, and due to the unfairness they cope with in [these rural areas].” (Service Supplier)

“I reside in a spot that’s fairly polarized politically, so it’s not protected for communities that aren’t hetero white male Caucasian. We have seen a rise in our trans inhabitants feeling focused…I’ve talked to many individuals in our neighborhood who’re extra scared now than earlier than to entry [IHSS] and get their wants met. It comes with the systemic trauma they’ve endured.” (Service Group)

Discovering Three: Folks Experiencing Homelessness Face Distinctive Programmatic Boundaries to Accessing IHSS

Individuals who would not have secure housing usually expertise distinctive challenges in accessing IHSS and directing their care. Finishing the IHSS software, for instance, will be difficult for people who find themselves staying in shelters or want to maneuver regularly.^[27] Compounding this problem, some counties improperly refuse to simply accept IHSS purposes or carry out practical assessments in shelters. That is opposite to Division of Social Providers steering permitting eligibility determinations for individuals liable to homelessness or these dwelling in a shelter or different areas.^[28] For many who are assessed, they usually discover it very troublesome to establish a supplier who’s prepared to work in a shelter setting due to security issues or as a result of shelter operators could also be unwilling to supply lodging comparable to flexibility in customer insurance policies to facilitate entry for suppliers.

“When somebody’s in a shelter and desires IHSS, it isn’t that it is unattainable, nevertheless it’s actually powerful to search out IHSS staff which might be prepared to help people in a shelter setting.” (Supplier)

“IHSS for sheltered versus unsheltered people is an space of actual rising want. And it has been rising for a lot of years as older homelessness has grown. However you have to be secure, and you can not get in to a shelter till you are secure… IHSS is just not a disaster intervention mannequin so some county’s issues are respectable about what we may do in a shelter. Like, in the event that they make everyone depart [the shelter] all day lengthy, what does IHSS appear like? How are we discovering the individual? And there are practical issues the place the counties get nervous that they will’t conceptualize the right way to operationalize it in shelters, however, then again, they’re imagined to do it.” (Policymaker)

Discovering 4: HCBS Waiver Packages and Different Approaches to utilizing Medi-Cal for Private Care Providers Do Not Fill the Gaps

Private care providers delivered via the HCBS waiver applications and Medi-Cal managed care plans may doubtlessly tackle gaps within the IHSS program by offering the providers that higher-needs people could require to reside in the neighborhood, comparable to agency-provided private care providers, intensive case administration, and 24-hour supervision. However these applications are usually not accessible to a majority of those that want them on account of administrative, geographic, and capability limitations.

HCBS Waivers

California’s HCBS waiver applications play an vital position in supporting neighborhood dwelling for individuals who have the very best care wants and face obstacles in directing their care beneath the IHSS program. Nevertheless, these applications fall quick for a lot of older adults and other people with disabilities on account of a number of key challenges:

• Administrative Burdens. Like IHSS, waiver applications are sophisticated to enroll in and are siloed, with every program administered and overseen by totally different authorities and waiver companies with totally different enrollment steps and assessments.

• Lengthy Waitlists. Waiver applications have lengthy waitlists, and these waitlists are much more troublesome to navigate by individuals who can not direct their care or who haven’t any household help.[29]

• Geographic Limitations. Some waiver applications, just like the ALW are unavailable in most California counties.^[30] In lots of areas within the state a scarcity of supplier companies or staff impede enlargement of HCBS waiver providers.^[31]

“I have never heard from [anyone] telling me they have been profitable in getting [into ALW] and by the point like they get a response both the individual has handed away or positioned [in a nursing facility].” (Shopper Advocate)

Medi-Cal Neighborhood Helps

Neighborhood Helps provided by Medi-Cal managed care plans have the potential to supply a extra sturdy continuum of help and fill within the gaps the place IHSS and HCBS waiver applications fall quick—significantly if coordinated with Enhanced Care Administration via CalAIM.^[32] Nevertheless, up to now, information demonstrates that Neighborhood Helps are usually not adequately filling these gaps on account of low utilization and lack of integration with different HCBS applications.

• Private Care and Homemaker Providers. This Neighborhood Assist has the potential to function a bridge for individuals who want IHSS however who are usually not but eligible or who are usually not able to self-direct their care. For instance, individuals experiencing homelessness who’ve practical limitations that forestall them from accessing secure housing could also be extra more likely to transfer into (and at much less threat of shedding) housing if they might use this Neighborhood Assist previous to establishing IHSS providers. This Neighborhood Assist may additionally present private care providers whereas individuals navigate the IHSS software course of, establish everlasting suppliers, or purchase abilities in managing their very own care.
  • As mentioned above, nevertheless, this Neighborhood Assist is presently considerably underutilized.^[33] Stakeholders reported that the low utilization stems primarily from managed care plans not reliably figuring out doubtlessly eligible members, and since plans and counties are usually not coordinating sufficiently to make sure the Neighborhood Assist is successfully serving as a bridge to IHSS as meant. As well as, individuals could also be excluded when plans require them to submit an IHSS software as a precondition to receiving the Neighborhood Assist, significantly when a county doesn’t settle for IHSS purposes from people who find themselves experiencing homelessness.
  • Setting apart these utilization limitations, the momentary nature of this profit as presently structured can not bridge the hole in entry to private care providers for these individuals unable to make use of the IHSS program on account of medical situations or disabilities that forestall them from self-directing their care.

“We will not change information [with the counties], so we have now no technique of figuring out when people are literally getting [IHSS]…we have to change private information about people’ healthcare info, so we have now to have [an agreement] with counties that claims that we’re companions, to guard the plans. However authorities entities don’t like these [agreements], so we don’t have one with the social providers companies, and so they cannot give us that info and we will not share with them our info.” (Medi-Cal managed well being plan)

• Nursing Facility Transition/Diversion to Assisted Residing Services. This Neighborhood Assist may assist to handle the ALW waitlist and broaden entry statewide to individuals who want private care and different providers which might be akin to ALW. Nevertheless, lack of expertise and low supplier and managed care plan participation maintain utilization low (see above). Additional, not like the ALW, this Neighborhood Assist is unavailable in public sponsored housing, limiting the place individuals can obtain assisted dwelling providers on account of a restricted provide of licensed residential care services which might be accessible for Medi-Cal recipients.
• Recuperative Care (Medical Respite). This Neighborhood Assist can present restricted private care providers to people experiencing homelessness who’re transitioning from hospital care.^[34] However as a result of recuperative care organizations don’t typically supply private care providers on account of inadequate staffing, insufficient funding, and issues concerning the scope of providers that may be delivered by operators of unlicensed settings, this Neighborhood Assist is essentially unavailable to those that want help with every day dwelling actions.^[35]

“Recuperative care applications require people to be unbiased with actions of every day dwelling, and that features bathing, dressing, toileting, managing funds, managing drugs, buying, cleansing all of that…that is a basic requirement to get into recuperative care. The employees [in recuperative care] don’t do fingers on help…so oftentimes, people which have any private care necessities are denied, or the referrals aren’t accepted.” (Well being Providers Specialist)

Discovering 5: These Who Can’t Entry Private Care Providers Face Severe Hurt

Older adults and disabled individuals who want help with actions of every day dwelling can expertise vital hurt when going with out private care, together with poor well being and psychological hurt, elevated threat of falls and damage, hospitalization, neglect and abuse, institutionalization, homelessness, and dying.^[36] Folks with impaired cognitive capability are regularly referred to Grownup Protecting Providers (APS), which has few instruments to help individuals past looking for conservatorship and inserting individuals in nursing services or different establishments.

“I work with lots of [individuals with Alzheimer’s who have no family support] and these are probably the most difficult instances. I truthfully don’t know the right way to sort out these instances… when [consumers] are within the center or center to late stage [of Alzheimer’s], they don’t have capability, then we name APS…I work with APS and different organizations however [when] I request help from APS, I get bounced round on this sort of loop and we don’t know the right way to assist…” (Shopper Advocate)

Information additional underscores the extreme penalties confronted by populations unable to entry HCBS and private care providers via current applications. For instance, in 2022, over half of these residing in nursing services in California —roughly 43,000 individuals—had diagnoses of Alzheimer’s or dementia as a result of these people and their households are usually not adequately receiving the help they want via current applications.^[37] Equally, individuals with behavioral well being diagnoses account for one third of all inpatient hospitalizations and one fifth of emergency room visits, once more demonstrating how current applications are usually not adequately supporting the individuals with the very best wants.^[38]

Suggestions

Interviewees highlighted a number of potential coverage alternatives for designing private care providers applications that each protect self-direction and successfully serve individuals throughout a continuum of means to self-direct. Though no single resolution would resolve all limitations, complete system-wide reforms, coupled with focused insurance policies to advertise self-direction, may progressively broaden entry to private care providers for individuals who want them most.

Suggestion One: Broaden Contract Mode IHSS

Practically all interviewees recognized the necessity to broaden Contract Mode IHSS to higher serve individuals who face challenges directing their very own care. Whereas San Francisco County has been in a position to make Contract Mode financially viable by including native and personal funding streams to state and federal IHSS funding (see textbox under), counties that beforehand applied it have since deserted it, citing issues about price. ^[39] It is because counties are required to contribute a set greenback quantity, referred to as the Upkeep of Effort, yearly to the IHSS program, and including a Contract Mode choice would completely improve that quantity.

Of California’s remaining 57 counties, solely Los Angeles County is presently engaged on including this feature. The County is presently planning a contract mode program to enhance entry to private care providers for individuals experiencing or transitioning from homelessness who’ve higher-acuity in medical, psychological well being, or cognitive impairments. The County is finalizing excellent administrative, programmatic, and operational particulars, with implementation anticipated to start within the 2025/2026 fiscal yr. The mannequin is utilizing native funding via the Housing for Well being program to contract with companies delivering house caregiving help to individuals experiencing homelessness who can not entry care via IHSS. Offering an IHSS contract mode choice for individuals experiencing or transitioning from homelessness will create a pathway to IHSS providers which might be usually wanted to help secure housing. It is going to additionally enable the county to leverage matching state and federal funding and broaden this system’s capability to serve extra people who find themselves unhoused or dwelling in supportive housing. But, as interviewees reported, county issues relating to monetary affect on the county’s upkeep of effort have led to a extra restricted program design.

LA County can also be dealing with steep administrative challenges in its try and create a contract mode program. “There’s not a blueprint for the right way to stand this up. Although the state has been very supportive in serving to the County navigate numerous necessities and determination factors as we develop our implementation plan…we have needed to form of construct the airplane a bit bit.” (LA County Consultant)

California may help efforts to broaden Contract Mode to extra counties by:

• Eradicating administrative burdens and offering technical help to counties wanting so as to add a Contract Mode choice.

• Eradicating monetary disincentives by lowering the upkeep of effort affect on county budgets.

• Offering extra monetary help for counties to ascertain a Contract Mode choice.

• Supporting the institution of collective bargaining agreements with companies which have contracts to supply IHSS providers, and guaranteeing parity in labor situations and advantages for staff who present caregiving providers throughout totally different modalities.^[40]

• Incentivizing counties to make use of and handle suppliers for individuals with excessive wants via Homemaker IHSS mode by creating pay parity with Contract Mode.

Interviewees strongly emphasised the significance of guaranteeing that any enlargement of Contract Mode doesn’t erode the present consumer-driven mannequin and basic proper to handle one’s care. Reasonably, Contract Mode ought to serve to empower individuals to direct their very own care to the best extent attainable. Focused coaching must be required for company suppliers to make sure culturally competent care that’s attentive to the wants and issues of communities of coloration and LGBTQ+ customers, in addition to individuals experiencing homelessness and others who’ve skilled trauma, victimization, or racism.

“Having choices is de facto vital. That is the place we see Homebridge becoming in, is that this continuum of alternative and help. We attempt to have a continuum of providers for it to fulfill totally different wants. For us, it is actually about having choices.” (County Consultant)

Suggestion Two: Make HCBS Waiver Providers Out there Statewide By the State Plan

At this time, California’s HCBS waiver applications present probably the most intensive help to these with the very best wants. But these applications are usually not accessible statewide and have lengthy waitlists. California may transition these HCBS waiver applications into the Medicaid state plan via a State Plan Modification, doubtlessly utilizing 1915(i) federal authority. This might make waiver advantages a statewide entitlement and eradicate HCBS waiver waitlists. Eligible Medi-Cal enrollees may obtain private care providers via IHSS’s consumer-directed mannequin if they like, or via the sorts of companies presently offering HCBS waiver providers. Such an enlargement would enable those that face challenges directing their care and have excessive well being care must entry private providers coupled with extra intensive helps to assist them stay at house.

Enlargement of those HCBS applications would significantly profit individuals with cognitive impairments like dementia and behavioral well being impairments, the populations with very excessive wants and the very best charges of institutionalization. And eliminating waitlists can cut back inequities that happen when people with much less sources should transfer into institutional care or go with out care on account of lengthy wait instances.^[45]

Any enlargement of those applications would require investments within the infrastructure to construct service capability statewide, significantly in rural areas, and to handle supplier shortages.^[46] For instance, California may work with stakeholders together with community-based organizations, customers, counties, and managed care plans to establish methods for growing service availability in underserved areas and lowering supplier turnover, together with via charge will increase and different investments comparable to these pursued beneath the Neighborhood Care Enlargement Program.^[47]

Suggestion Three: Scale back Boundaries to Program Enrollment

California may take a lot of steps to mitigate the executive limitations to making use of for IHSS and different applications that embody private care providers, comparable to:

• Requiring counties to evaluate unhoused people for IHSS eligibility in each unsheltered settings and sheltered settings comparable to interim housing, recuperative care, and different momentary settings.
• Rising Medi-Cal managed care plan capability to help with IHSS referrals and purposes via coaching, technical help, and helps for information sharing between plans and counties.
• Assigning social staff or offering case administration for people who want help with filling out program types, acquiring required documentation, and fulfilling required program administrative duties.
• Offering monetary and administrative help for broader implementation and sustainability of wraparound fashions that combine reasonably priced housing, intensive case administration, and private care and homemaker providers. (See textbox: Cardea Well being Mannequin)  
• Utilizing Older Individuals Act funding to broaden entry to authorized providers that help with advance well being planning and designating an influence of attorneys to keep away from APS involvement and promote supported decision-making. 

“I used to be in jail for 38 years, and obtained out in 2019. I labored in selecting up trash, carrying heavy hoses, washing the streets. I did that for six months, however I obtained sick. Once I obtained out, I didn’t have Medi-Cal so I didn’t go to the physician. By the point I went to the hospital, I used to be shedding lots of weight and didn’t know why. I came upon that I had stage 4 lung most cancers. Due to the remedy, I used to be actually weak. I couldn’t rise up to make use of the restroom. I had lots of falls. I obtained hit on the pinnacle, I’m afraid of falling so I’ve a walker now. Cardea saved me. They coordinated my care, toileting, taking me to appointments. Right here, the nurse comes and checks on me often. The caregiver got here to assist wash, costume, take me to therapies. As I’m getting stronger, I want much less assist. I’m making an attempt to get stronger.” (Shopper) 

Suggestion 4: Enhance Availability and Use of Neighborhood Helps in Managed Care 

California may enhance the supply and use of Neighborhood Helps that present private care providers statewide to assist fill in care gaps by:   

• Mandating the supply of all Neighborhood Helps by all Medi-Cal managed care plans statewide somewhat than making them optionally available providers, and bolstering community adequacy necessities to push Medi-Cal plans to strengthen incentives for private care providers suppliers to take part of their networks. 
• Mandating standardized supplier and self-referral processes, because the state has performed with the CalAIM Enhanced Care Administration (ECM) profit, and utilizing instruments to display screen and establish members who ought to obtain Neighborhood Helps throughout plans. 
• Bettering coordination of ECM with Neighborhood Helps to help with figuring out and managing suppliers, coordinating providers throughout Neighborhood Helps, and enhancing utilization and entry.  
• Requiring managed care plans to supply the Private Care Neighborhood Assist to eligible members instantly upon assessed want, somewhat than solely after referral to the county for an IHSS evaluation.
• Requiring plans to facilitate the alignment of this Neighborhood Assist service with different Neighborhood Helps comparable to Recuperative Care and Housing-related Neighborhood Helps as wanted to facilitate care transitions and enhance entry to interim and everlasting housing in neighborhood settings. 
• Permitting people who’re unable to direct their care to entry the Private Care Neighborhood Assist as a substitute of IHSS. 
• Guaranteeing individuals leaving incarceration receiving Medi-Cal providers previous to launch are screened for IHSS, Neighborhood Helps, and HCBS waivers and supplied with program software help and entry help the place applicable. 

Suggestion 5: Broaden Modern Practices 

California can facilitate the broader replication of promising practices which have been applied in some counties to enhance entry to private care helps for individuals who want them, together with: 

• Providing differential pay and extra helps comparable to coaching, peer helps, and training alternatives for suppliers who help individuals with larger or complicated wants.   

“It is tougher to supply any kind of providers when any individual is socially unstable, has psychiatric sickness and or substance use dysfunction… housing, medical stuff, private care, every thing is tougher… if there isn’t any charge complement related to provision of providers to this inhabitants that has larger wants…in impact, there’s a penalty paid by that group for investing these supplemental sources to supply the exact same service that you just may (present) extra simply to another person” (Service Supplier). 

• Using county-designated IHSS social staff to help candidates and beneficiaries who’re referred from Grownup Protecting Providers (APS), suppliers of homeless providers, or everlasting supportive housing suppliers. 
• Expediting or prioritizing referrals to HCBS waiver applications, Private Care Neighborhood Helps, and different applications for people who find themselves experiencing housing instability or having difficulties directing their very own care. 
• Providing mentorship, coaching, and help to IHSS customers on directing care and program navigation by funding Public Authority peer help applications. 
• Funding Public Authority peer help applications or standalone county applications that help self-direction via mentorship and coaching IHSS customers on supplier supervision, care administration, monetary administration, and navigating providers. 
• Funding coaching and incentives for suppliers on supporting individuals with complicated wants.  

Conclusion  

California’s IHSS program performs a necessary position in delivering private care providers to older adults and other people with disabilities who’re able to directing their very own care or have a help community to help them. Nevertheless, for these with out these helps—significantly people dealing with complicated well being or social circumstances—the system stays out of attain. Different applications, comparable to HCBS waivers and Neighborhood Helps via Medi-Cal managed care, have the potential to bridge some gaps, however are presently restricted by capability, geographic availability, and administrative limitations.

California’s long-standing dedication to neighborhood dwelling and self-determination supplies a powerful basis for the continued growth of options that empower people to reside independently with dignity, no matter their means to direct their very own care. However guaranteeing that every one Californians have entry to the non-public care providers they want requires a system that’s adaptive, inclusive, and attentive to the varied wants of those that depend on it. A continuum of care that gives each self-directed and agency-delivered fashions, coupled with streamlined entry and stronger help mechanisms, could make a profound distinction within the lives of people who face limitations to managing their very own care.

By addressing these gaps in service availability, lowering administrative hurdles, and increasing modern fashions of care, California can take vital steps towards constructing a extra equitable and accessible system. The chance to reimagine private care providers presents the potential for improved outcomes for these with the very best wants and least sources.

Appendix

Report Scope and Methodology

Given the restrictions in each capability and scope of HCBS waivers and managed care organizations to supply private care providers, IHSS is usually the one private care service accessible for low-income older adults who want the help to stay of their house. Nevertheless, IHSS requires customers to self-direct their care, presenting challenges for these unable to take action.

To discover this problem, Justice in Getting old performed interviews with 80 stakeholders together with private care customers and suppliers; community-based organizations; county IHSS companies; IHSS Public Authorities; Medi-Cal managed care plans; IHSS union management; and Medicaid HCBS consultants (See under for full listing of interviewees).

Interviews centered on elements impeding self-direction, limitations in accessing care, and potential coverage options.

Limitation: Whereas the interviews included individuals just lately transitioning from homelessness, incarceration, and people with substance use dysfunction, we have been unable to interview a key group—individuals with Alzheimer’s and dementia who lack household caregivers. Justice in Getting old was unable to establish community-dwelling individuals who have been in a position to take part in an interview because of the excessive charges of institutionalization and social isolation amongst this inhabitants.

Justice in Getting old is grateful to the next organizations for collaborating on this venture and for taking the time to share their experiences and insights with us:

• Alzheimer’s Affiliation of Higher LA
• Anthem Blue Cross
• Guess Tzedek Authorized Providers
• CA Affiliation of Well being Plans
• California Division of Getting old
• California Division of Social Providers
• California IHSS Shopper Alliance
• CalOptima Well being
• Cardea Well being
• County Welfare Administrators Affiliation of California
• Division of Well being Care Providers
• Incapacity Motion Heart
• Incapacity Rights California
• East Bay Improvements
• Employers Community
• Hand in Hand Home
• Well being Plan of San Juaquin
• Well being Plan of San Mateo
• Well being Belief
• Residence Well being Care Administration
• Housing Works Public Authority (Yolo County)
• Institute on Getting old
• LA Care Well being Plan
• LA County Division of Well being Providers
• LA County Division of Well being Providers
• LeadingAge California Santa Cruz County (IHSS)
• Authorized Support Society of San Diego
• Authorized Providers of Northern California
• Libertana
• Lifelong Medical Care
• Nationwide Affiliation of State Administrators of Developmental Disabilities Providers
• Nationwide Well being Look after the Homeless Council
• Companions in Care San Francisco IHSS
• Peachtree Well being Care Providers Public Authority (Santa Clara County)
• Inhabitants Well being, LTSS & SDOH Guide
• Public Authority (Imperial County)
• Public Authority (LA County)
• Public Authority (San Francisco County)
• Riverside Division of Social Providers (IHSS)
• S California Advocates for Nursing Residence Reform
• Sacramento Grownup Providers (IHSS)
• San Francisco Human Providers Company
• Senior Advocacy Community
• Service Staff Worldwide Union Native 2015
• Shasta Neighborhood Well being Heart
• Solano County Well being Providers (IHSS)
• United Home Staff
• Washington State Getting old and Lengthy-Time period Assist Administration

Endnotes

1. CICA, IHSS Background (final visited 07/1/2024); Nilchian, Mina, “In-Residence Supportive Providers, the Olmstead Determination and Potential Future Instructions,” (March 2018)↑

2. KFF, “Key State Coverage Selections About Medicaid Residence and Neighborhood-Primarily based Providers,” (February 2020), (Appendix Desk 3, web page 35), (of the 34 states that supply private care providers, 29 use Contract Mode, also referred to as Company Mode, and 16 use the unbiased Supplier mode).↑

3. Welf. & Inst. Code §12302; CDSS, MPP Div. 30, Ch. 300-767.11-.12, (final up to date Jul. 1, 2019).↑

4. CDSS, “IHSS Program Information,” (June 2024).↑

5. Dickman, Hagar, Justice in Getting old, “California’s In-Residence Supportive Providers Program: An Fairness Evaluation,” (June 2023).↑

6. Information was supplied by Homebridge and the San Francisco Public Authority.↑

7. Confirmed by e mail communication with Leora Filosena, Division of Social Providers, on Aug. 7, 2024.↑

8. Welf. & Inst. Code §12301.6; Division of Social Providers, IHSS Program Information, (Might 2024); Hunter, Savannah, UC Berkeley Labor Heart, “Snapshot of California’s Union Membership: It’s not your grandfather’s union anymore,” (Aug. 29, 2023); see additionally Dickman, Hagar, Justice in Getting old, “California’s In-Residence Supportive Providers Program: An Fairness Evaluation,” (June 2023).↑

9. Christ, Amber and Dickman, Hagar, Justice in Getting old, “An Fairness Framework for Evaluating California’s Medi-Cal Residence and Neighborhood-Primarily based Providers for Older Adults & Folks with Disabilities,” (Dec. 2022).↑

10. People over age 55 can obtain private care providers by collaborating in a Program for All Inclusive Look after the (PACE). There are presently over 20,000 individuals enrolled in PACE in 26 counties in California. DHCS, Program of All-Inclusive Look after the Aged, (final visited Oct. 1, 2024).↑

11. DHCS, Assisted Residing Waiver, (final visited Oct. 1, 2024)↑

12. DHCS, “ALW Enrollment and Waitlist-January 2019-July 2024” (July, 2024); DHCS, Memorandum: Necessary Info Relating to Potential ALW Enrollments,” (Sep. 4, 2024).↑

13. DHCS, “HCBA Month-to-month Dashboard” (July, 2024).↑

14. CMS, MSSP 2024 Approval Letter and Utility, (Sept. 26, 2024).↑

15. Primarily based on website self-reporting, supplied by e mail communication with Denise Likar, California Division of Getting old (Oct 1, 2024).↑

16. DHCS, MSSP Program (as of the publication of this paper, the renewed MSSP software was not but publicly accessible.)↑

17. DHCS, “Transformation of Medi-Cal: Neighborhood Helps”; for extra info see DHCS, Medi-Cal Neighborhood Helps In Lieu of Providers (ILOS), Coverage Information, (July 2023).↑

18. Whereas not mentioned with interviewees, Medi-Cal managed care plans are additionally answerable for administering California’s grownup day well being profit, Neighborhood-Primarily based Grownup Providers (CBAS) which supplies private care help on website at grownup day facilities. CBAS is offered in 28 counties and serves 39,826 people. California Division on Getting old, “Record of CBAS Suppliers,” (Final visited Oct. 1, 2024); California Division of Getting old, Heart Overview, (June 2024).↑

19. Id.↑

20. DHCS, Quarterly Implementation Report: Whole Variety of Members Who Utilized Neighborhood Helps by MCP and County By Service By Quarter,” (final up to date August 12, 2024); DHCS, CalAIM Neighborhood Helps – Managed Care Plan Elections (July 2024).↑

21. DHCS, Medi-Cal Neighborhood Helps In Lieu of Providers (ILOS) Coverage Information, (July 2023).↑

22. DHCS, CalAIM Neighborhood Helps – Managed Care Plan Elections (July 2024).↑

23. DHCS, Medi-Cal Neighborhood Helps In Lieu of Providers (ILOS) Coverage Information, (July 2023).↑

24. DHCS, CalAIM Neighborhood Helps – Managed Care Plan Elections, (July 2024).↑

25. California Division of Public Well being, “Alzheimer’s Illness and Associated Dementias Info and Figures in California: Present Standing and Future Projection,” (Jan. 2021); Benioff Homelessness and Housing Initiative, “Towards Fairness: Understanding Black Californians’ Experiences of Homelessness,” (February 2024); California Division of Public Well being, “Well being Fairness: Past the Quantity,” (Might 2024).↑

26. Folks usually want a number of suppliers as a result of they want extra care hours than the utmost hours suppliers are allowed to work per week, or suppliers who can work the wanted hours are unavailable.↑

27. Kushel, Margot, and Moore, Tiana “Towards a New Understanding: The California Statewide Examine of Folks Experiencing Homelessness,” (June 2023), (at web page 71), (“The expertise of homelessness is extremely nerve-racking: individuals spent a lot of their time making an attempt to outlive and discover shelter, meals, security. They reported that these efforts consumed a lot of their vitality, leaving them much less in a position to search healthcare together with remedy for bodily and psychological well being challenges and substance use and employment.”)↑

28. CDSS, All County Info Discover No. I-19-20, “Clarification Of Definition Of “Personal Residence” As It Relates To In-Residence Supportive Providers Eligibility,” (Feb. 25, 2020).↑

29. After reaching capability in June 2023, the HCBA waiver’s waitlist ballooned to over 5,300 people, in contrast with present enrollment of 9,031. Regardless of receiving an extra 1800 slots in January 2024, the ALW has over 14,500 individuals and carries a waitlist of over 3,200 people. DHCS, “ALW Slot Enlargement Modification,” (Feb. 6, 2024); DHCS, “Assisted Residing Waiver Month-to-month Dashboard: July 2024,” (July 2024).↑

30. Christ, Amber and Dickman, Hagar, Justice in Getting old, “An Fairness Framework for Evaluating Residence and Neighborhood-Primarily based Providers for Older Adults & Folks With Disabilities,” (Dec. 2022), (CBAS is restricted to twenty-eight counties and the ALW to fifteen, with a overwhelming majority of Californians with out ALW or CBAS suppliers dwelling in rural counties); see additionally California Division on Getting old, “Record of CBAS Suppliers,” (Final visited Oct. 1, 2024).↑

31. See for instance, DHCS, “ALW Assisted Residing Services Dashboard,” (final up to date Aug. 15, 2024); the present distribution of ALW suppliers, concentrated within the Bay Space, Sacramento and Los Angeles County; Division of Social Providers, “California Neighborhood Care Enlargement,” (final up to date Sep. 27, 2024) was meant to extend capability in underserved counties, however many rural counties proceed to lack suppliers comparable to Residential Care Services for the Aged, the place ALW providers are supplied.↑

32. DHCS, “CalAIM Enhanced Care Administration Coverage Information,” (Dec. 2023)↑

33. DHCS, “ECM and Neighborhood Assist Quarterly Implementation Report: Quarterly Implementation Report: 2023 This fall, Whole Variety of Members Who Utilized Neighborhood Helps by Service within the Final 12 Months of the Reporting Interval” (Final up to date Aug. 12, 2024); Auditors of the State of California, Report Quantity 20-109, “In-Residence Supportive Providers: It’s Not Offering Wanted Providers to All Californians Authorized for the Program, is Unprepared for Future Challenges, and Provides Low Pay to Caregivers,” (Feb. 2021). (As a result of this displays the variety of people who find themselves authorised for IHSS however not receiving the service, leaving out those that are usually not but authorised for IHSS, the quantity of people that want the service is probably going greater.)↑

34. DHCS, Medi-Cal Neighborhood Helps In Lieu of Providers (ILOS) Coverage Information, (July 2023). ↑

35. Cal. Well being & Saf. Code §1503.5.↑

36. Kietzman, Kathryn, Chen, Lei, and Juturu, Preeti, “The Well being of Various Californians with Wants for Lengthy-Time period Providers and Helps,” (July, 2024) (Folks could have unmet wants when the providers they obtain are inadequate to handle their wants or after they obtain no wanted providers in any respect); Kietzman, Kathryn G. and Chen, Lei, “Unmet Wants for Assist at Residence: How Older Adults and Adults with Disabilities Are Faring in California,” (August 2022) citing Chong N, Akobirshoev I, Caldwell J, Kaye HS, Mitra M. “The Relationship Between Unmet Want for Residence and Neighborhood-Primarily based Providers and Well being and Neighborhood Residing Outcomes,” Incapacity and Well being Journal 15(2), (April 2022) ,(“People who skilled unmet want had constantly worse well being and neighborhood dwelling outcomes than those that reported no unmet want.”)↑

37. DHCS, Medi-Cal Lengthy-Time period Providers and Helps Dashboard, (final visited Oct 1, 2024.)↑

38. California Division of Well being Care Entry and Info, “Inpatient Hospitalization and Emergency Division Visits for Sufferers with a Behavioral Well being Prognosis in California: Affected person Demographics,” (2021-2022).↑

39. Hwang, Ann, CHCF, “Focused Use of Companies for Private Care Providers: Evaluation of a Well being Plan’s Pure Experiment,” (July 2023). (Throughout the California Coordinated Care Initiative, a Medi-Cal demonstration pilot, IHSS was administered by Medi-Cal managed care plans within the seven collaborating counties, and delivered agency-provided IHSS to as much as 5% of their IHSS recipients. All counties aside from San Francisco returned to unbiased supplier mode in 2018, on the termination of the demonstration.)↑

40. See for instance, Washington state’s private care providers, which can be found via unbiased suppliers, house care companies, or certified residential care suppliers. A statewide third-party company serves because the employer of document for all unbiased suppliers. State legal guidelines require pay and profit parity for all private care staff no matter whether or not they’re an unbiased supplier or an worker of an company. Washington State Well being Care Authority, “Medicaid Private Care Providers,” (April 23, 2021). (Nearly all of beneficiaries select to self-direct their care, with roughly 15,000 beneficiaries receiving providers via house care companies.)↑

41. see Homebridge Historical past; Burns, Mark (former director, Homebridge) Letter to California State Grasp Plan for Getting old Taskforce, LTSS Subcommittee, “Memorandum Re: Advocacy for Inclusion of Contract Mode IHSS Entry for Counties in Grasp Plan Suggestions,” (December 13, 2019).↑

42. Steward, Andrew, “San Francisco County’s Partnership with the Homebridge Coaching Program: Coaching the Fragile Workforce,” (2015).↑

43. Homebridge, Inc., “Revised Homebridge Referral Standards and Referral Course of, #19-02,” (3/1/2019), (having no secure house care providers and being in danger for untimely institutionalization, eviction and/or well being and questions of safety; having no different secure help system to adequately present house care wants or preserve an unbiased supplier; having reasonable to extreme psychological well being, cognitive impairment and/or substance misuse that impacts the power to rent and handle an Impartial Supplier; or having bodily situation(s) that stops them from having the ability to coordinate a full care plan to fulfill home and private care wants whereas supervising a supplier.)↑

44. San Francisco IHSS Public Authority, “The IHSS Continuum,” (final visited Oct. 1, 2024).↑

45. For extra on the disproportionate affect of waitlists on communities of coloration and LGBTQ+ people, see Christ, Amber and Dickman, Hagar, Justice in Getting old, “An Fairness Framework for Evaluating Residence and Neighborhood-Primarily based Providers for Older Adults & Folks With Disabilities,” (Dec. 2022).↑

46. Weiner, Jocelyn, CalMatters, “Missed psychological well being disaster: Vanishing board-and-care houses depart residents with few choices,” (Apr. 15, 2019; up to date Sep. 17, 2020); though California’s Neighborhood Care Enlargement Program awarded $569.67 million up to now in new and rehabilitated RCFEs, promising to extend the variety of RCFE beds accessible within the state, funding was directed to twenty of the 58 counties, leaving out a majority of the state. CDSS, “Neighborhood Care Enlargement Awards Information Dashboard: Geography,” (final up to date Sep. 27, 2024).↑

47. CDSS, Neighborhood Care Enlargement Program, (final up to date Sep. 27, 2024). See additionally CHCF, “Addressing Medi-Cal Behavioral Well being Workforce Shortages By Non-financial Incentives,” (Might 31, 2024); CHCF, “California’s Direct Care Workforce: Who They Are, the Work They Do, and Why It Issues,” (January, 2023).↑