TSERVICES HE MEDICAID PERSONAL CARE PROGRAM: IMPLICATIONS FOR SOCIAL WORK PRACTICE JULIANNE S. OKTAY and HOWARD A. PALLEY Results of a survey of Medicaid personal care programs in 15 states and the District of Columbia in 1987 show that these programs suffer from many problems. Low wages and slow payment make recruitment and retention of qualified workers difficult. Other problems include lack of coordination among agencies, lack of adequate standards for training or supervision of workers, unequal access to programs, and inequities among states. Implications for social workers are discussed.
A serious problem facing the United States is the rapid expansion of the aged population. Age in itself is not a problem, but as the population ages, more people will need assistance with basic activities of daily living (AD Ls). These activities include walking, transferring, toileting, feeding, and bathing. Currently, almost one in eight Americans is over 65 years of age (U. S. Bureau of the Census, 1989). By the year 2030, the figure will be one in five. The amount of assistance with ADLs a person requires is closely related to age. Among those 65 to 74 years of age, about 12 percent need assistance with ADLs; among those 85 and older, 45 percent need assistance. Because the population over 85 is growing at the fastest rate (400 percent growth is expected for 1985 to 2030), the number of elderly people needing assistance with ADLs in the coming decades will rapidly increase (U .S. Congress, Senate Special Committee on Aging, 1987). Most personal care (the term used for assistance with ADLs) is provided by informal re110
sources, primarily female family members. Most often this care falls on the spouse, the daughter, or the daughter-in-law (Brody, 1981, 1986; Miller, 1981; Palley & Oktay, 1983). According to some estimates, the average woman spends 17 years caring for children and 18 years caring for aged and often ill or disabled parents (U.S. Congress, Senate Special Committee on Aging, 1987). Only about 15 percent of such care is now provided by paid help (U.S. Congress, Senate Special Committee on Aging, 1986). In the future, smaller family size, higher divorce rates, and increased participation by women in the work force will reduce the number of women available to provide this type of care in the community. People needing assistance with ADLs who are without family resources have two options: (1) nursing homes or other facilities that provide these services or (2) personal care assistance in their own home. The overwhelming preference of elderly people is in-home services; however,
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long-term, in-home personal care services have been available only to the people who can afford them. Some governmental programs are now beginning to provide such services. These programs need to be studied carefully by social workers who design, develop, and administer personal care programs. To help social workers and others prepare for the coming need for new programs, this article presents the results of a descriptive study of the personal care programs under Medicaid, the largest personal care program in the Vnited States.
MEDICAID, SOCIAL SECURITY, AND THE OLDER AMERICANS ACT The major insurance program for elderly people, Medicare, offers limited personal care services. Medicare limits payment for personal care to the period of time that a patient has need for skilled nursing care. Thus, Medicare is oriented toward acute or short-term health needs. In contrast, elderly people with many of the most common health problems, such as arthritis, stroke, and dementia, need ongoing personal care. When elderly people need institutional care, they turn to the Medicaid program, which was designed to meet the needs of medically needy people. The Medicaid program allows states to fund personal care services. To reduce health care costs and inappropriate hospitalization, some states have developed personal care programs as a part of their Medicaid services. Much of this care is focused on chronically limited elderly people. At the time of this study in 1987, 15 states and the District of Columbia provided personal care services under Medicaid. In 1988, the number of states increased to 24, but these programs accounted for only 2.5 percent of Medicaid expenses in fiscal year 1988. Personal care is an optional service program under Title XIX, Section 1905 (a)(17), of the federal Social Security Act (V.S. Social Security Act, 1965). The type and amount of personal care services provided depend on the specific needs of the individual. Types of services provided may include assistance with ADLs, assistance with personal hygiene and grooming, and household services directly related to medical
need and essential to the recipient's health and comfort in the home. State financial commitments to Medicaid personal care programs vary widely (Table 1) (V. S. Health Care Financing Administration, 1986). In 1985, financial commitments to personal care programs averaged only 4.62 percent of Medicaid program budgets. States were given the option to provide for personal care through Medicaid under the 2176 waiver in 1981. By 1988, 49 waivers had been granted for personal care to a variety of programs (V.S. Congress, House Committee on Energy and Commerce, 1988). Because these programs tend to be small, geographically limited, and highlyvaried, they werenot included in thisstudy. In addition to Medicaid, the Older Americans Act Amendments of 1987 included for the first time a separate authorization of funds for nonmedical treatment of in-home services to frail elderly people. Such services also were not included in this study.
METHOD In 1987, a list of states that provided personal care programs was obtained from the V.S. Department of Health and Human Services(see Table 1). A questionnaire was developed based on interviews with the administrator of the Maryland program and with the administrator of a private agency that provided personal care services for that state program. The questionnaires requested program descriptions, eligibility criteria, pay scales, supervision requirements, training requirements, availability of the services, administrative problems encountered, and availability of other in-home programs. The questionnaire was pretested in four states, and revised questionnaires were then sent to the state administrators responsible for the personal care programs. All states returned completed questionnaires. Because the sample was small, the responses were tabulated by hand.
RESULTS General Observations Most of the programs surveyed originated in the 1980s. The number of people served ranges
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Table 1. State Financial Commitments to Personal Care in Fiscal Year 1985
State District of Columbia Maryland Massachusetts Michigan Minnesota Missouri Nebraska Nevada New Hampshire New Jersey New York Oklahoma Oregon South Dakota Texas West Virginia Total
Personal Care ($000)
Medicaid ($000)
Funds Allocated to Personal Care/Medicaid Program (%)
4,277 4,386 23,891 73,886 6,525 5,939 828 440 275 3,726 581,258 32,688 668 871 71,027 2,277 812,962
306,035 612,643 1,568,663 1,685,516 1,011,834 556,111 168,173 66,725 118,387 1,165,491 7,864,178 467,869 252,588 94,559 1,475,372 179,523 17,593,667
1.40 0.72 0.53 4.38 0.64 1.07 0.49 0.66 0.23 0.32 7.39 6.99 0.26 0.92 4.81 1.27 4.62
SOURCE: U.S. Health Care Financing Administration, 1986.
from as few as 1,134 to as many as 61,086. Number of hours of personal care provided varies greatly. Goals of these programs include "maintaining independence and the quality of life of the patient," "prevention and delaying of institutionalization," and "coordination with other rehabilitation and health-related services." In 12 states, provision of care is fully purchased from cooperating home care agencies. In New York, care is partially purchased from private sources and partially provided by the state. In three states, the program is directly administered and implemented by the state agency (Table 2). Personal care services are generally provided in the context of a case management system. In the District of Columbia, certified social workers are responsible for initial social service assessments, development of treatment programs, coordination of services, provision of direct services, and case monitoring. The respondent from West Virginia noted that case managers "orchestrate the numerous support services that 112
need to be brought to bear in order to maintain individuals in their own home or in a family day care setting as opposed to institutions." In Oregon and Michigan, case managers collectinformation for assessment and planning and assist in periodic review of services provided to clients.
Eligibility All respondents noted that clients must require "medically necessary" care and must establish Medicaid eligibility, the terms of which vary from state to state. Most respondent states also require a social assessment and nursing assessment. For example, in Nevada, a needs assessment and an assessment of the existing social network are required, and in New York a physical, social, and nursing assessment must be-conducted by the local social service department. The in-home personal care programs in New Hampshire and Massachusetts have included the further modification that the patient be "chronically wheelchair bound."
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Table 2. Purchase of Personal Care from Home Care Agencies State
Partially Purchased
Fully Purchased
District of Columbia Maryland Massachusetts Michigan Minnesota Missouri Nebraska Nevada New Hampshire New Jersey New York Oklahoma Oregon South Dakota Texas West Virginia
Implemented Directly by State X
x X X
X X X X X X X X
X X X X
Pay for Personal Care Attendants Twelve states presented hourly payment schedules for personal care attendants (Table 3). In general, pay is quite low; in 1985, the average hourly wage was $5.71. (For states that gave a range of rates, the midpoint was used to calculate the mean for all programs.) In two states a daily rate is paid. In Oklahoma, the daily rate was $14.99 (with a three-hour minimum), and in Maryland, the daily rate ranged from $10.00 to $25.00. Two states reported monthly pay.
Supervision of Personal Care Attendants Most states purchase care from private providers but retain administrative supervision. Administrators from 10 states provided information on supervision (Table 4). Three states have 60-day monitoring, and three have 90-day monitoring (quarterly visits). Missouri has onsite visiting of a 5 percent sample every 90 days. Minnesota requires a visit within 14 days of placement, one visit per month for the first 90 days, and quarterly monitoring thereafter. Massachusetts and New Hampshire administrators reported that the provider is patient trained and supervised. In the remainder of the
states reporting, supervisory visits are described as optional or as needed.
Training for Personal Care Attendants Training requirements vary widely across states (Table 5). Training levels include no training, minimal orientation to tasks, modest levels of training, and high levelsof training and course certification. Completion of a standard course is required in four states for home health aides, nursing aides, personal care attendants, or licensed practical nurses. Other states offer their own training programs, which range from a 12-hour cassette tape course with accompanying workbook to a 60-hour course.
Administrative Problems The problems administrators mentioned most frequently about personal care programs were difficulties in recruiting and retaining personnel. Ten states reported difficulty recruiting, and six mentioned problems retaining personal care aides. Many administrators related these problems directly to low pay scales. In Oklahoma and Maryland, a time lag in the payments was
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Table 3. Pay for Personal Care Providers State
Per hour ($)
Texas Nebraska
3.35 - 3.40 3.35 - 3.70
Oregon District of Columbia
3.35 - 5.25 4.40 - 6.25
New York
4.50 - 6.00
South Dakota
4.57"
New Jersey Nevada
5.50 - 7.50
Minnesota
6.34
Missouri
7.10
Massachusetts New Hampshire
7.20 9.50
Per day ($)
Per month ($)"
5.00 - 6.00
Maryland
10.00 - 25.00
Oklahoma
14.99
West Virginia
110.00
Michigan
320.00
"Data reported are the maximum amount. For Michigan, the average is $242.00. "Starting salary.
Table 4. Requirements for Personal Care Supervisory Visits State District of Columbia Maryland
Every 60 Days
Every 90 Days
Every 120 Days
X X X X
Massachusetts Michigan
X
Minnesota"
X
Missouri"
X
Nebraska'
X
Nevada
X
New Hampshire' New Jersey New York
X X
X X
Oklahoma' Oregon South Dakota
No Visit Requirement
X
X X
Texas West Virginia'
"Requires an evaluation in the first 14 days, one visit per month for 90 days, and quarterly visits thereafter. "Has on-site visiting of a 5 percent sample every 90 days. 'No information was provided; it was assumed that no visit requirement existed.
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Table 5. Training Requirements for Personal Care Providers State
Training Requirements
Nebraska
No requirement. Higher pay rate is offered if provider completes training course.
West Virginia
Minimal-orientation to tasks.
Texas
Minimal-orientation to tasks.
Maryland
No requirement. A 20-hour course is offered.
Massachusetts
No requirement. Client is trained to hire and supervise own personal care attendant.
New Hampshire
No requirement. Training is individualized according to client's needs.
Missouri
At least 10 hours of personal in-service training is required each year, in addition to at least one in-service training session every six months.
South Dakota
12-hour cassette tape and workbook course must be completed, plus quarterly training sessions.
District of Columbia
32-40 hours. Certificate as personal care attendant, home health aide, or nurse's aide is required, as well as a 24-hour refresher course.
Oklahoma
40 hours.
New York
40-hour basic course approved by New York State Health Department is required.
New Jersey
60 hours (40 hours of mental health).
Minnesota
Requirements are formal training as nursing assistant, home health aide, licensed practical nurse, or registered nurse and demonstration of skills needed (no hours specified).
Oregon
100-hour program or certified nurse's aide.
blamed for retention problems. The respondent from Maryland suggested that a less-complicated payment system be developed. Training and supervision problems also were noted. Several administrators felt that more training and supervision should be required. The need for more administrative oversight was mentioned by administrators in Texas, Massachusetts, and Nebraska. Also, Nebraska lacked replacements when aides were unable to work. Another administrative problem noted was lack of service coordination. The Texas administrator mentioned difficulty getting nurses and case managers to work as a team in assessment and provision of services. In New York, program implementation occurs on a county basis, which creates coordination problems.
Program Adequacy and Equity Because the programs reviewed are all Medicaid programs, they are limited by means tests. Even within this restriction, certain groups do not receive care. Disabled, terminally ill, and
mentally ill or retarded children, as well as mentally ill or retarded adults, are excluded in Missouri, Oklahoma, Minnesota, Oregon, and Massachusetts. In Massachusetts, the patient must be wheelchair bound and able to selfdirect; similar restrictions apply in New Hampshire. Respondents from eight states indicated that regional inequities affect the availability and provision of services. Respondents from sixjurisdictions thought that lack of knowledge reduced availability of services. Some respondents also indicated a failure to provide adequate service. Some state officials believe that the governing federal law needs to be changed to allow personal care attendants to accompany the patient to activities outside the home. Inadequate funding affects adequacy and equity. Texas and South Dakota have sought to more adequately fund personal care services by combining Medicaid and Title XX social service block grant funding. Both states feel there is an institutional bias in the Medicaid program regarding the use of funds.
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DISCUSSION Quality of Care Although the authors did not measure quality of servicesdirectly, the survey suggested that servicequality may be a major problem. The authors found that pay scales for personal care aides are very low, and by paying on a daily or monthly basis, some states may be paying below the minimum wage. Not surprisingly, recruitment and retention oftheseworkers isa problem in most states. Gaps in service are inevitable. Such gaps may be acceptable in some areas (for example, housekeeping), but they are intolerable in personal care; a lack of servicemay mean a client does not eat or has to lie in a soiledbed. These programs need to be made attractive to today' s (and tomorrow's) workers by increasing pay and benefits. Personal care jobs may be low paying because traditionally they are considered women's work, which is undervalued and undercompensated in this society. These jobs are also considered dirty work, which is usually assigned to minorities or other oppressed groups. Socialworkers may want to compare the pay for this work with the pay for males who do dirty work, such as garbage collectors, janitors, and airline sanitation workers. Social workers can form coalitions with groups working for fair and equal pay and with organizations seeking to fight discrimination against minorities. Quality personal care can be provided by a low-paid worker who has adequate training and closesupervision. However, in the Medicaid personal care program, training and supervision are nominal or nonexistent in many states. Although Congress mandated in the Social Security Act Amendments of 1980that home health aides providing services under Medicaid must have completed a training program approved by the Secretary of the Department of Health and Human Services and that training programs relate to the establishment of standards in hiring, training, assignment of duties, and supervision, such standards and approval oftraining programs were never developed by the Department of Health and Human Services (U.S. Congress, Senate Special Committee on Aging, 1988). Because the Medicaid personal care program is underfunded, the states seem to juggle wages, 116
training, and supervision. If they pay more, they may be able to hire more qualified people and thus could save on training and supervision costs. If they put more money into training and supervision, they may be able to hire the leastqualified people at minimum wage and bring them up to an acceptable level. Some states provide low wages, no supervision, and minimal or no training, a combination that is highly unlikely to produce quality care. Coordination problems at all levels (nursecase manager, agency-agency, county-county) also interfere with quality of care. Social workers need to help develop better communication among the individuals and organizations involved and to advocate for systems and programs that are oriented toward biopsychosocial issues.
Access to Programs The Medicaid personal care program does not serve the entire population in need. Medicaid limits access to the poorest populations, and even then serves only about one-half of the eligible population. The proportion is probably even lower among elderly people. Some states restrict service to selected populations (for example, children, mentally ill and retarded adults). Most have difficulty providing service in rural areas because such areas often have a shortage of trained professional providers and supervisors. People in rural areas may be reluctant or too independent to seek help (U.S. Congress, Senate Special Committee on Aging, 1988). Social workers may need to monitor levels of need among selected populations in their states. Because of their understanding of cultural and generational factors, social workers may be able to help design programs that are not objectionable to independent people. Any program that is universal and not tied to need will be more acceptable. To achieve this goal, social workers should advocate for the expansion of Medicare services to include personal care.
Interstate Equity Because Medicaid is a state-federal partnership, states have considerable freedom in what
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services they provide and how. Variation among states in eligibility, comprehensiveness of services, and availability and quality of care has been well-documented (Osberg & Polich, 1988; "Poor Health Care," 1988). In 1987, less than half of the states provided significant personal care services to their Medicaid populations. Among the states that provided the service, variations in the financial commitment were substantial, with eight states spending less than 1 percent of their Medicaid budgets on personal care. Pay, training, and supervision of personal care aides also varied. Interstate inequity is a major problem with any service in the Medicaid program (Benjamin, 1986; Palley & Oktay, 1983); thus, social workers need to advocate for personal care programs at the national level. Expansion of Medicare services into the personal care area would help alleviate this inequity.
CONCLUSION Social workers should work to upgrade the status of personal care workers through higher pay, more training, and increased professionalization. At the local level, .social workers can work to increase access, especially in rural populations and with elderly people who are too independent or too fearful to accept service. Social workers can work to improve coordination among caregivers, agencies, and counties. At the national level, social workers should work toward an integrated health and social service system and should advocate for an expansion of Medicare or a future universal health insurance program to cover personal care.
About the Authors Julianne S. Oktay, PhD, is Associate Professor, and Howard A. Palley, PhD, is Professor, School of Social Work, University of Maryland, 525 West Redwood Street, Baltimore, MD 21201.
Brody, E. M. (1981). Women in the middle and family help to older people. Gerontologist, 21, 471-480. Brody, E. M. (1986). Institutional versus community health care for the elderly. Home Health Care Services Quarterly, 7, 113-129. Miller, D. (1981). The sandwich generation: Adult children of the aging. Social Work, 26, 419-423. Osberg, C. N., & Polich, C. L. (1988). Medicaid: Entering the third decade. Health Affairs, 7, 83-96. Palley, H. A., &Oktay,J. S. (1983). Thechronically limitedelderly: The case for a national policyfor inhome and community-based services. New York: Haworth Press. Poor health care for poor Americans: A ranking of state Medicaid programs. (1988). Health Letter, 4, 1-6. U.S. Bureau of the Census. (1989). u.s. population estimates by age, sex, race, and Hispanic origin (Current Population Reports, Series P-25, No. 1057). Washington, DC: U.S. Government Printing Office. U.S. Congress, House Committee on Energy and Commerce. (1988). Medicaid source book: Background data and analysis. Report prepared by the Congressional Research Service for the use of the Subcommittee on Health and the Environment (House Document 100-5). Washington, DC: U.S. Government Printing Office. U.S. Congress, Senate, Special Committee on Aging. (1986). Developments onaging: 1985 (Senate Document 100-6). Washington, DC: U.S. Government Printing Office. U.S. Congress, Senate, Special Committee on Aging. (1987). Developments onaging: 1986 (Report No. 100-291). Washington, DC: U.S. Government Printing Office. U.S. Congress, Senate, Special Committee on Aging. (1988). Home care at the crossroads: An informational paper (Senate Document 100-102). Washington, DC: U.S. Government Printing Office. U.S. Health Care Financing Administration, Division of State Agency Financial Management, Bureau of Program Operations. (1986, May 9). Internal memorandum. Baltimore: Author. U.S. Social Security Act. (1965). Title XIX, § 1905. Accepted August 1, 1990
References Benjamin, A. E. (1986). State variations in home health expenditures and utilization under Medicare and Medicaid. Home Health Services Quarterly, 7, 5-28. THE MEDICAID PERSONAL CARE SERVICES PROGRAM
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A serious problem facing the United States is the rapid expansion of the aged population. Age in itself is not a problem, but as the population ages, more people will need assistance with basic activities of daily living (AD Ls). These activities include walking, transferring, toileting, feeding, and bathing. Currently, almost one in eight Americans is over 65 years of age (U. S. Bureau of the Census, 1989). By the year 2030, the figure will be one in five. The amount of assistance with ADLs a person requires is closely related to age. Among those 65 to 74 years of age, about 12 percent need assistance with ADLs; among those 85 and older, 45 percent need assistance. Because the population over 85 is growing at the fastest rate (400 percent growth is expected for 1985 to 2030), the number of elderly people needing assistance with ADLs in the coming decades will rapidly increase (U .S. Congress, Senate Special Committee on Aging, 1987). Most personal care (the term used for assistance with ADLs) is provided by informal re110
sources, primarily female family members. Most often this care falls on the spouse, the daughter, or the daughter-in-law (Brody, 1981, 1986; Miller, 1981; Palley & Oktay, 1983). According to some estimates, the average woman spends 17 years caring for children and 18 years caring for aged and often ill or disabled parents (U.S. Congress, Senate Special Committee on Aging, 1987). Only about 15 percent of such care is now provided by paid help (U.S. Congress, Senate Special Committee on Aging, 1986). In the future, smaller family size, higher divorce rates, and increased participation by women in the work force will reduce the number of women available to provide this type of care in the community. People needing assistance with ADLs who are without family resources have two options: (1) nursing homes or other facilities that provide these services or (2) personal care assistance in their own home. The overwhelming preference of elderly people is in-home services; however,
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long-term, in-home personal care services have been available only to the people who can afford them. Some governmental programs are now beginning to provide such services. These programs need to be studied carefully by social workers who design, develop, and administer personal care programs. To help social workers and others prepare for the coming need for new programs, this article presents the results of a descriptive study of the personal care programs under Medicaid, the largest personal care program in the Vnited States.
MEDICAID, SOCIAL SECURITY, AND THE OLDER AMERICANS ACT The major insurance program for elderly people, Medicare, offers limited personal care services. Medicare limits payment for personal care to the period of time that a patient has need for skilled nursing care. Thus, Medicare is oriented toward acute or short-term health needs. In contrast, elderly people with many of the most common health problems, such as arthritis, stroke, and dementia, need ongoing personal care. When elderly people need institutional care, they turn to the Medicaid program, which was designed to meet the needs of medically needy people. The Medicaid program allows states to fund personal care services. To reduce health care costs and inappropriate hospitalization, some states have developed personal care programs as a part of their Medicaid services. Much of this care is focused on chronically limited elderly people. At the time of this study in 1987, 15 states and the District of Columbia provided personal care services under Medicaid. In 1988, the number of states increased to 24, but these programs accounted for only 2.5 percent of Medicaid expenses in fiscal year 1988. Personal care is an optional service program under Title XIX, Section 1905 (a)(17), of the federal Social Security Act (V.S. Social Security Act, 1965). The type and amount of personal care services provided depend on the specific needs of the individual. Types of services provided may include assistance with ADLs, assistance with personal hygiene and grooming, and household services directly related to medical
need and essential to the recipient's health and comfort in the home. State financial commitments to Medicaid personal care programs vary widely (Table 1) (V. S. Health Care Financing Administration, 1986). In 1985, financial commitments to personal care programs averaged only 4.62 percent of Medicaid program budgets. States were given the option to provide for personal care through Medicaid under the 2176 waiver in 1981. By 1988, 49 waivers had been granted for personal care to a variety of programs (V.S. Congress, House Committee on Energy and Commerce, 1988). Because these programs tend to be small, geographically limited, and highlyvaried, they werenot included in thisstudy. In addition to Medicaid, the Older Americans Act Amendments of 1987 included for the first time a separate authorization of funds for nonmedical treatment of in-home services to frail elderly people. Such services also were not included in this study.
METHOD In 1987, a list of states that provided personal care programs was obtained from the V.S. Department of Health and Human Services(see Table 1). A questionnaire was developed based on interviews with the administrator of the Maryland program and with the administrator of a private agency that provided personal care services for that state program. The questionnaires requested program descriptions, eligibility criteria, pay scales, supervision requirements, training requirements, availability of the services, administrative problems encountered, and availability of other in-home programs. The questionnaire was pretested in four states, and revised questionnaires were then sent to the state administrators responsible for the personal care programs. All states returned completed questionnaires. Because the sample was small, the responses were tabulated by hand.
RESULTS General Observations Most of the programs surveyed originated in the 1980s. The number of people served ranges
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Table 1. State Financial Commitments to Personal Care in Fiscal Year 1985
State District of Columbia Maryland Massachusetts Michigan Minnesota Missouri Nebraska Nevada New Hampshire New Jersey New York Oklahoma Oregon South Dakota Texas West Virginia Total
Personal Care ($000)
Medicaid ($000)
Funds Allocated to Personal Care/Medicaid Program (%)
4,277 4,386 23,891 73,886 6,525 5,939 828 440 275 3,726 581,258 32,688 668 871 71,027 2,277 812,962
306,035 612,643 1,568,663 1,685,516 1,011,834 556,111 168,173 66,725 118,387 1,165,491 7,864,178 467,869 252,588 94,559 1,475,372 179,523 17,593,667
1.40 0.72 0.53 4.38 0.64 1.07 0.49 0.66 0.23 0.32 7.39 6.99 0.26 0.92 4.81 1.27 4.62
SOURCE: U.S. Health Care Financing Administration, 1986.
from as few as 1,134 to as many as 61,086. Number of hours of personal care provided varies greatly. Goals of these programs include "maintaining independence and the quality of life of the patient," "prevention and delaying of institutionalization," and "coordination with other rehabilitation and health-related services." In 12 states, provision of care is fully purchased from cooperating home care agencies. In New York, care is partially purchased from private sources and partially provided by the state. In three states, the program is directly administered and implemented by the state agency (Table 2). Personal care services are generally provided in the context of a case management system. In the District of Columbia, certified social workers are responsible for initial social service assessments, development of treatment programs, coordination of services, provision of direct services, and case monitoring. The respondent from West Virginia noted that case managers "orchestrate the numerous support services that 112
need to be brought to bear in order to maintain individuals in their own home or in a family day care setting as opposed to institutions." In Oregon and Michigan, case managers collectinformation for assessment and planning and assist in periodic review of services provided to clients.
Eligibility All respondents noted that clients must require "medically necessary" care and must establish Medicaid eligibility, the terms of which vary from state to state. Most respondent states also require a social assessment and nursing assessment. For example, in Nevada, a needs assessment and an assessment of the existing social network are required, and in New York a physical, social, and nursing assessment must be-conducted by the local social service department. The in-home personal care programs in New Hampshire and Massachusetts have included the further modification that the patient be "chronically wheelchair bound."
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Table 2. Purchase of Personal Care from Home Care Agencies State
Partially Purchased
Fully Purchased
District of Columbia Maryland Massachusetts Michigan Minnesota Missouri Nebraska Nevada New Hampshire New Jersey New York Oklahoma Oregon South Dakota Texas West Virginia
Implemented Directly by State X
x X X
X X X X X X X X
X X X X
Pay for Personal Care Attendants Twelve states presented hourly payment schedules for personal care attendants (Table 3). In general, pay is quite low; in 1985, the average hourly wage was $5.71. (For states that gave a range of rates, the midpoint was used to calculate the mean for all programs.) In two states a daily rate is paid. In Oklahoma, the daily rate was $14.99 (with a three-hour minimum), and in Maryland, the daily rate ranged from $10.00 to $25.00. Two states reported monthly pay.
Supervision of Personal Care Attendants Most states purchase care from private providers but retain administrative supervision. Administrators from 10 states provided information on supervision (Table 4). Three states have 60-day monitoring, and three have 90-day monitoring (quarterly visits). Missouri has onsite visiting of a 5 percent sample every 90 days. Minnesota requires a visit within 14 days of placement, one visit per month for the first 90 days, and quarterly monitoring thereafter. Massachusetts and New Hampshire administrators reported that the provider is patient trained and supervised. In the remainder of the
states reporting, supervisory visits are described as optional or as needed.
Training for Personal Care Attendants Training requirements vary widely across states (Table 5). Training levels include no training, minimal orientation to tasks, modest levels of training, and high levelsof training and course certification. Completion of a standard course is required in four states for home health aides, nursing aides, personal care attendants, or licensed practical nurses. Other states offer their own training programs, which range from a 12-hour cassette tape course with accompanying workbook to a 60-hour course.
Administrative Problems The problems administrators mentioned most frequently about personal care programs were difficulties in recruiting and retaining personnel. Ten states reported difficulty recruiting, and six mentioned problems retaining personal care aides. Many administrators related these problems directly to low pay scales. In Oklahoma and Maryland, a time lag in the payments was
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Table 3. Pay for Personal Care Providers State
Per hour ($)
Texas Nebraska
3.35 - 3.40 3.35 - 3.70
Oregon District of Columbia
3.35 - 5.25 4.40 - 6.25
New York
4.50 - 6.00
South Dakota
4.57"
New Jersey Nevada
5.50 - 7.50
Minnesota
6.34
Missouri
7.10
Massachusetts New Hampshire
7.20 9.50
Per day ($)
Per month ($)"
5.00 - 6.00
Maryland
10.00 - 25.00
Oklahoma
14.99
West Virginia
110.00
Michigan
320.00
"Data reported are the maximum amount. For Michigan, the average is $242.00. "Starting salary.
Table 4. Requirements for Personal Care Supervisory Visits State District of Columbia Maryland
Every 60 Days
Every 90 Days
Every 120 Days
X X X X
Massachusetts Michigan
X
Minnesota"
X
Missouri"
X
Nebraska'
X
Nevada
X
New Hampshire' New Jersey New York
X X
X X
Oklahoma' Oregon South Dakota
No Visit Requirement
X
X X
Texas West Virginia'
"Requires an evaluation in the first 14 days, one visit per month for 90 days, and quarterly visits thereafter. "Has on-site visiting of a 5 percent sample every 90 days. 'No information was provided; it was assumed that no visit requirement existed.
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Table 5. Training Requirements for Personal Care Providers State
Training Requirements
Nebraska
No requirement. Higher pay rate is offered if provider completes training course.
West Virginia
Minimal-orientation to tasks.
Texas
Minimal-orientation to tasks.
Maryland
No requirement. A 20-hour course is offered.
Massachusetts
No requirement. Client is trained to hire and supervise own personal care attendant.
New Hampshire
No requirement. Training is individualized according to client's needs.
Missouri
At least 10 hours of personal in-service training is required each year, in addition to at least one in-service training session every six months.
South Dakota
12-hour cassette tape and workbook course must be completed, plus quarterly training sessions.
District of Columbia
32-40 hours. Certificate as personal care attendant, home health aide, or nurse's aide is required, as well as a 24-hour refresher course.
Oklahoma
40 hours.
New York
40-hour basic course approved by New York State Health Department is required.
New Jersey
60 hours (40 hours of mental health).
Minnesota
Requirements are formal training as nursing assistant, home health aide, licensed practical nurse, or registered nurse and demonstration of skills needed (no hours specified).
Oregon
100-hour program or certified nurse's aide.
blamed for retention problems. The respondent from Maryland suggested that a less-complicated payment system be developed. Training and supervision problems also were noted. Several administrators felt that more training and supervision should be required. The need for more administrative oversight was mentioned by administrators in Texas, Massachusetts, and Nebraska. Also, Nebraska lacked replacements when aides were unable to work. Another administrative problem noted was lack of service coordination. The Texas administrator mentioned difficulty getting nurses and case managers to work as a team in assessment and provision of services. In New York, program implementation occurs on a county basis, which creates coordination problems.
Program Adequacy and Equity Because the programs reviewed are all Medicaid programs, they are limited by means tests. Even within this restriction, certain groups do not receive care. Disabled, terminally ill, and
mentally ill or retarded children, as well as mentally ill or retarded adults, are excluded in Missouri, Oklahoma, Minnesota, Oregon, and Massachusetts. In Massachusetts, the patient must be wheelchair bound and able to selfdirect; similar restrictions apply in New Hampshire. Respondents from eight states indicated that regional inequities affect the availability and provision of services. Respondents from sixjurisdictions thought that lack of knowledge reduced availability of services. Some respondents also indicated a failure to provide adequate service. Some state officials believe that the governing federal law needs to be changed to allow personal care attendants to accompany the patient to activities outside the home. Inadequate funding affects adequacy and equity. Texas and South Dakota have sought to more adequately fund personal care services by combining Medicaid and Title XX social service block grant funding. Both states feel there is an institutional bias in the Medicaid program regarding the use of funds.
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DISCUSSION Quality of Care Although the authors did not measure quality of servicesdirectly, the survey suggested that servicequality may be a major problem. The authors found that pay scales for personal care aides are very low, and by paying on a daily or monthly basis, some states may be paying below the minimum wage. Not surprisingly, recruitment and retention oftheseworkers isa problem in most states. Gaps in service are inevitable. Such gaps may be acceptable in some areas (for example, housekeeping), but they are intolerable in personal care; a lack of servicemay mean a client does not eat or has to lie in a soiledbed. These programs need to be made attractive to today' s (and tomorrow's) workers by increasing pay and benefits. Personal care jobs may be low paying because traditionally they are considered women's work, which is undervalued and undercompensated in this society. These jobs are also considered dirty work, which is usually assigned to minorities or other oppressed groups. Socialworkers may want to compare the pay for this work with the pay for males who do dirty work, such as garbage collectors, janitors, and airline sanitation workers. Social workers can form coalitions with groups working for fair and equal pay and with organizations seeking to fight discrimination against minorities. Quality personal care can be provided by a low-paid worker who has adequate training and closesupervision. However, in the Medicaid personal care program, training and supervision are nominal or nonexistent in many states. Although Congress mandated in the Social Security Act Amendments of 1980that home health aides providing services under Medicaid must have completed a training program approved by the Secretary of the Department of Health and Human Services and that training programs relate to the establishment of standards in hiring, training, assignment of duties, and supervision, such standards and approval oftraining programs were never developed by the Department of Health and Human Services (U.S. Congress, Senate Special Committee on Aging, 1988). Because the Medicaid personal care program is underfunded, the states seem to juggle wages, 116
training, and supervision. If they pay more, they may be able to hire more qualified people and thus could save on training and supervision costs. If they put more money into training and supervision, they may be able to hire the leastqualified people at minimum wage and bring them up to an acceptable level. Some states provide low wages, no supervision, and minimal or no training, a combination that is highly unlikely to produce quality care. Coordination problems at all levels (nursecase manager, agency-agency, county-county) also interfere with quality of care. Social workers need to help develop better communication among the individuals and organizations involved and to advocate for systems and programs that are oriented toward biopsychosocial issues.
Access to Programs The Medicaid personal care program does not serve the entire population in need. Medicaid limits access to the poorest populations, and even then serves only about one-half of the eligible population. The proportion is probably even lower among elderly people. Some states restrict service to selected populations (for example, children, mentally ill and retarded adults). Most have difficulty providing service in rural areas because such areas often have a shortage of trained professional providers and supervisors. People in rural areas may be reluctant or too independent to seek help (U.S. Congress, Senate Special Committee on Aging, 1988). Social workers may need to monitor levels of need among selected populations in their states. Because of their understanding of cultural and generational factors, social workers may be able to help design programs that are not objectionable to independent people. Any program that is universal and not tied to need will be more acceptable. To achieve this goal, social workers should advocate for the expansion of Medicare services to include personal care.
Interstate Equity Because Medicaid is a state-federal partnership, states have considerable freedom in what
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services they provide and how. Variation among states in eligibility, comprehensiveness of services, and availability and quality of care has been well-documented (Osberg & Polich, 1988; "Poor Health Care," 1988). In 1987, less than half of the states provided significant personal care services to their Medicaid populations. Among the states that provided the service, variations in the financial commitment were substantial, with eight states spending less than 1 percent of their Medicaid budgets on personal care. Pay, training, and supervision of personal care aides also varied. Interstate inequity is a major problem with any service in the Medicaid program (Benjamin, 1986; Palley & Oktay, 1983); thus, social workers need to advocate for personal care programs at the national level. Expansion of Medicare services into the personal care area would help alleviate this inequity.
CONCLUSION Social workers should work to upgrade the status of personal care workers through higher pay, more training, and increased professionalization. At the local level, .social workers can work to increase access, especially in rural populations and with elderly people who are too independent or too fearful to accept service. Social workers can work to improve coordination among caregivers, agencies, and counties. At the national level, social workers should work toward an integrated health and social service system and should advocate for an expansion of Medicare or a future universal health insurance program to cover personal care.
About the Authors Julianne S. Oktay, PhD, is Associate Professor, and Howard A. Palley, PhD, is Professor, School of Social Work, University of Maryland, 525 West Redwood Street, Baltimore, MD 21201.
Brody, E. M. (1981). Women in the middle and family help to older people. Gerontologist, 21, 471-480. Brody, E. M. (1986). Institutional versus community health care for the elderly. Home Health Care Services Quarterly, 7, 113-129. Miller, D. (1981). The sandwich generation: Adult children of the aging. Social Work, 26, 419-423. Osberg, C. N., & Polich, C. L. (1988). Medicaid: Entering the third decade. Health Affairs, 7, 83-96. Palley, H. A., &Oktay,J. S. (1983). Thechronically limitedelderly: The case for a national policyfor inhome and community-based services. New York: Haworth Press. Poor health care for poor Americans: A ranking of state Medicaid programs. (1988). Health Letter, 4, 1-6. U.S. Bureau of the Census. (1989). u.s. population estimates by age, sex, race, and Hispanic origin (Current Population Reports, Series P-25, No. 1057). Washington, DC: U.S. Government Printing Office. U.S. Congress, House Committee on Energy and Commerce. (1988). Medicaid source book: Background data and analysis. Report prepared by the Congressional Research Service for the use of the Subcommittee on Health and the Environment (House Document 100-5). Washington, DC: U.S. Government Printing Office. U.S. Congress, Senate, Special Committee on Aging. (1986). Developments onaging: 1985 (Senate Document 100-6). Washington, DC: U.S. Government Printing Office. U.S. Congress, Senate, Special Committee on Aging. (1987). Developments onaging: 1986 (Report No. 100-291). Washington, DC: U.S. Government Printing Office. U.S. Congress, Senate, Special Committee on Aging. (1988). Home care at the crossroads: An informational paper (Senate Document 100-102). Washington, DC: U.S. Government Printing Office. U.S. Health Care Financing Administration, Division of State Agency Financial Management, Bureau of Program Operations. (1986, May 9). Internal memorandum. Baltimore: Author. U.S. Social Security Act. (1965). Title XIX, § 1905. Accepted August 1, 1990
References Benjamin, A. E. (1986). State variations in home health expenditures and utilization under Medicare and Medicaid. Home Health Services Quarterly, 7, 5-28. THE MEDICAID PERSONAL CARE SERVICES PROGRAM
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