Employee Niryan Jance, second from right, helps feed Letty Martinez lunch… (Genaro Molina, Los Angeles…)
State health officials are circulating a plan they say will help keep about 35,000 elderly and disabled Californians out of institutionalized care when Medi-Cal stops offering an adult day healthcare benefit in December.
The plan released late Friday relies primarily on Medi-Cal managed care plans to find alternatives for beneficiaries, including additional hours of in-home supportive services, physical and occupational therapy, and social services.
But care providers say the approach could fail because appropriate alternatives aren't always available and families would be forced to shuttle patients around town to obtain the services now offered at more than 300 adult day healthcare centers.
"The literature is clear that caregiver stress is one of the top reasons for placement into a nursing home," said Lydia Missaelides, executive director of the California Assn. for Adult Day Services. "So the more stress that this transition places on the caregiver, the higher the probability that we will see more nursing home placements and not fewer."
Day-care patients represent a small portion of the 7.5 million low-income Californians covered by Medi-Cal. But the decision to eliminate the benefit to help close this year's budget deficit was controversial because it affects some of the state's most vulnerable residents. Nearly two-thirds of day-care beneficiaries — who suffer from brain injuries, dementia and other chronic conditions — live in Los Angeles County.
Gov. Jerry Brown vetoed legislation that would have created a replacement program, saying it was "unnecessary and untimely." The state will instead give managed-care plans an additional $60 per member per month to assess day-care patients' needs, coordinate services for them and provide case management, said Toby Douglas, director of the California Department of Health Care Services.
Beginning later this month, beneficiaries will receive notices that the Adult Day Health Care program will be eliminated Dec. 1, along with forms to enroll in managed care starting Oct. 1.
Managed care is required only for the 18% of day-care beneficiaries who aren't also covered by Medicare. Those who opt out or who are among some 650 beneficiaries living in counties that don't offer the plans can receive the same care coordination services through a state contractor, APS Inc., Douglas said.
APS and the managed-care plans will have the option to continue paying for day care if they determine that is the most appropriate and cost-effective way to keep a beneficiary in his or her home, Douglas said.
But Missaelides said centers would be forced to close if not enough patients opt for managed care or if plans won't pay for enough of them to continue receiving services. Just 6,100 day-care center clients are currently enrolled in managed care.
She said the plans are not appropriate for many patients because case management is mostly done over the telephone. "This is a population that needs eyes-on, hands-on care," she said.
For Robert Williams, 51, that kind of care has been invaluable. He moved across the country to care for his 81-year-old sister, Shirley, because a day-care center alerted him that her memory had deteriorated.
"She loves going to the day-care center," he said. "She has camaraderie, they keep her active.… It gives her a reason to get up every day."
It took Williams nine months to find a job with a security company. Now he's afraid he might have to quit if he can't get enough care for her.
"My sister is just one of thousands of people who need these services," he said. "For them to be taken away is really a grave injustice."