Forensic Scholars Today
The state of Minnesota has a variety of programs for individuals with various levels of disabilities. These programs and waivers are available for people who reside within the state. The individuals who utilize these services are often referred to as either client, patient, consumer, or recipient. These terms are used to protect the privacy of the individuals involved with the care and services waivers. There are various systems and programs funded by the state that have the intent to provide mental and physical care for those in need. Yet, there are still gaps in such services, areas where the staff isn’t meeting the needs of the clients. To understand these gaps in services, there first must be an understanding of the services available. While Minnesota has various smaller programs, there are also waiver programs that have grown through each county. There is the Alternative Care waiver, which is for Minnesotans who require the level of care provided in a nursing facility but do not meet the criteria for Medical Assistance. Then there is the Brain Injury waiver, designed specifically for individuals with a traumatic or degenerative brain injury. Such patients require a level of care that is typically only provided in a nursing facility that specializes in these particular services or neurobehavioral therapies. The Community Alternative Care waiver is for chronically ill or medically fragile individuals who require the level of care provided in a hospital. Next, there is the Community Access for Disability Inclusion waiver. This waiver is tailored for individuals who require the level of care provided in a nursing facility but typically live out in the community. The Developmental Disability waiver is for people with developmental disabilities or related conditions who require the level of care provided in an intermediate care facility. Finally, there is the Elderly waiver, this is for Minnesotans who require the level of care provided in a nursing facility and are over 65 years old. These waivers were created to ensure the individual’s health, safety, and wellbeing.
The waivers are intended to help those who may qualify for the specific categories previously mentioned. People who are on these waivers are not required to pay for the services. Patients receive either a case manager or other direct support staff members who will be funded by the state or county. While it may not cost the individual receiving the services any money, everyone on a waiver costs the county or state around $10 to $60 thousand a year (Henning-Smith, Gonzales, Shippee, 2016). This annual cost is paid for by the tax dollars the communities of Minnesota pay annually. A few of the services the waivers provide include: case managers, adult foster care, customized living, independent living skills workers, emergency response, home-delivered meals, homemaking, personal care assistants, and even skilled nursing. Certification or licensure is required for agencies to provide this level of care. With the intention of health and safety, comes independence within the community and living. Waivers also can prolong the timeframe an individual can live in their house independently and safely. Not only do these waivers assist with the activities of independent living, but they also assist with co-occurring disorders. For example, mental illnesses are commonly seen in individuals who are on the waivers (Henning-Smith, Gonzales, Shippee, 2016). The waiver assesses a person’s needs and then, assists in meeting their desires.
Besides the waiver services, other programs in Minnesota have been created to serve the citizens that need them most. There are adult protection programs that ensure Minnesotans have a safe environment and the necessary services available for vulnerable adults. Then there is the deaf and hard of hearing program that serves these patients in a variety of ways. Direct care, and treatment programs, provide residential treatment for individuals with mental and developmental disabilities. There is a gambling program for those who are seeking assistance with gambling addictions. The refugee program coordinates services to assist refugees in making the transition to life in the United States. Sex offender treatment is a program that provides comprehensive services to individuals who have been civilly committed by the courts to receive sex offender treatment. Lastly, there is the social security advocacy program which assists in applying or maintaining federal social security disability benefits.
Understanding home care and what it entails is important. Home care refers to the variety of services that are provided to individuals with disabilities living within the community. Home care is provided to ensure that the goals of both rehabilitation and support are provided. Home care may be paid, unpaid, formal, or informal. Home care services are more often than not provided by family members, whose care is typically unpaid and underappreciated. (Henning-Smith, Gonzales, Shippee, 2016). The paid caregivers are funded through the formal LTSS (long-term services and support) systems, such as Medicaid or Medical Assistance programs. Other sources of payment include Medicare, Medicaid, and other government agencies such as veteran assistance, which are services that are paid for by out-of-pocket private pay. Home care services will vary from medical care involving physical therapy, and nonmedical such as dressing or bathing. Hands-on care is common, and it typically includes things such as wound care or companionship. Restorative home care is an extension of medical services that are delivered to a home where the individual can be supported in their daily activities. This type of home care will allow clients to stay in their homes safely for as long as needed. The gaps in the services and providers go deeper than most community members may understand. There are unrecognized data gaps that include the scope of home care provided either by private or public providers. These gaps can be described by the “streetlight effect” which is an illustration that focuses on things that are easiest to see and realize. Because little is known about the various sectors of the home care services. Due to this lack of knowledge, society only focuses on one known area. Society may focus on the fact there are various programs for disabled individuals, instead of honing in on the low-level care these programs provide. However, licensed or certified home health care establishments are the most accessible for data collections. The streetlight effect represents large and unrecognized gaps in information regarding supply use, costs, workers, and services. The streetlight effect will only be eliminated if professionals can address the research and apply it to policymaking. Expanding national studies would include all sectors of home health care and will begin representing the underrepresented (Henning-Smith, Gonzales, Shippee, 2016).
There are four typologies within the home care sectors. Sector one is home healthcare agencies that are licensed to provide skilled, medically trained staff to the home of the recipients. Secondly, are the home care aid agencies or personal care aid agencies. These are home care agencies that provide nonmedical services such as assistance with dressing, meal preparation, bathing, and grooming. The third sector is the private hire sector. This sector includes workers who were hired by private funds sourced by individuals’ households or families (Friedman, 2016). Often a black market will be established, meaning workers will be paid under the table. With under the table payments, the risk of abuse between the clients and the caregiver’s increases. Individuals with disabilities are already seen as vulnerable, therefore, abuse in this area is more prevalent. If the staff does not have to accurately record their hours, or if payments are not being recorded properly, the client will be the first to feel the negative effects. In a national study, it was found that 70% of payments sourced were from out-of-pocket funds, and 17% were from publicly-funded programs (Friedman, 2016). These private hired sectors typically find workers through word of mouth or from a referral agency. Referral agencies, while not able to employ workers, can provide screened individuals to outside companies. Fourthly, are government agencies. These government agencies provide direct home care services to those who are qualified through the assessments. These government agencies involving personal care aides are the second-fastest-growing occupation in the United States. One thing all four of these sectors have in common is the medically trained personnel that consists of nurses, occupational therapists, chemotherapists, or doctors.
While these programs are comprehensive and helpful, there are still gaps within the system. The gaps might be hard to notice after reviewing the programs, but digging deeper into what individuals with disabilities are suffering from, compared to the services they are receiving, will begin to show these inconsistencies. There are quality improvement (QI) tools that health care organizations have been able to use to focus on services that are needed to enhance the system. (Noureldin, Abrahamson, Arling, 2019). These QI surveys are completed quarterly with clients and providers to ensure their needs are being met. QI surveys over the past few years have found that providers in the home health care industry are lacking the necessary support. For example, 66% of providers admitted to not having the adequate space and supplies to complete their tasks, and 64% of staff members admitted they did not receive the necessary support/training to complete their jobs positively and effectively (Noureldin, Abrahamson, Arling, 2019). The lack of training not only affects the clients and their health, but also the staff involved. Staff mental health begins to wane when they are constantly stressed and concerned with their work life. When staff is not well educated on the knowledge they need, their quality of work will suffer. Staff should not have to worry constantly about doing their job safely and effectively. Staff turnover is a problem that home health care providers typically experience. It is a challenge to be both constantly training and educating staff, this constant training leaves less time for all other improvements within the organization and services. The development and implementation of new strategies, as well as balancing the multiple priorities assigned, is just one part of the reason for staff turnover. When the staff turnover is consistent, the clients are not receiving the positive support they should be. 35% of the providers were found to struggle when it came to finding adequate staffing to fill hours and tasks (Noureldin, Abrahamson, Arling, 2019). If adequate staffing is not available, then staff will become overworked, and therefore, burnt out. Without adequate staff, the burn out rate will grow at an alarming pace. One reason why the staff turnover is so high in Minnesota is the low pay rate. Home health care staff who are involved in the waiver, or other state programs, are typically paid at a low rate. The pay rate for some providers at times is as low as minimum wage, and with a staff that is required to have a college degree, this becomes alarming. It is an important job for the staff members to work one on one with clients because they provide them with both physical and mental support. Therefore, the pay does not reflect the level of job necessity. If workers are not paid a meaningful wage, their quality of work naturally declines. Besides low pay to the direct employees, 34% of the providers struggle to achieve the financial resources to continue their businesses. This is because providers within the home health care services are often, if not always, funded by the state (Noureldin, Abrahamson, Arling, 2019). Even the nonprofit providers are contracted by the state or county where they receive payments for their services. This means that providers are being paid by tax dollars and other state funding, which often runs out. Other areas that are examined during QI tools are the tasks the staff is asked to complete while on the clock, the timeliness of client to staff contact, or staff to supervisor contact. Also, technology capabilities and specialized equipment needs are discussed during these QI surveys. Overall, educating the public and professionals involved in the human service field will enable programs to grow to better fit the clients being served. Being realistic about the gaps in programs is the most effective way to ensure positive change.
Justine R. Scheller is a second-year master’s student studying Forensic Behavioral Health at Concordia St. Paul University. Justine received your Bachelor of Science and Bachelor of Arts from Bemidji State University. Justine is currently working as a CADI waiver case manager serving clients as young as 8 and as old as 70. In her free time, she enjoys outdoor activities such as camping, hiking Nordic skiing. Justine has a passion for educating the community members on services and opportunities available to ensure the best quality of life for all. She desires to be a professor in Human Services in the future.
Friedman, C. (2016). Day Habilitation Service for People with Intellectual and Developmental Disabilities in Medicaid Home and Community-Based Services Waivers. Research and Practice for Persons with Severe Disabilities. 41(4), 244- 255. DOI: 10.1177/1540796916664337.
Henning-Smith,C. Gonzales,G., Shippee, T. (2016). Barriers to Timely Medical Care for Older Adults by Disability Status and Household Composition. Journal of Disability Policy Studies. 27(2), 116-127. DOI: 10.1177/1044207316637547.
Newquist, D., DeLiema, M., Wilber, K. (2015). Beware of Data Gaps in Home Care Research: Streetlight Effect and Its Implications for Policy Making on Long-Term Services and Supports. Medical Care Research and Review. 72(5), 622-640. DOI: 10.1177/1077558715588437.
Noureldin, M., Abrahamson, K., Arling, G. (2019). Home and Community- Based Service Organizations’ Capacity for and Experiences with Quality Improvement Initiatives. Home Health Care Management & Practice. 31(1), 23-29. DOI: 10.1177/1084822318796105.
Minnesota Department of Human Services. Retrieved from: https://mn.gov/dhs/people-we-serve/adults/services/
Singer, P. (2016). States of Reform: Polarization, Long-term Services and Supports, and Medicaid Waivers. State and Local Government Review. 48(4), 246-258. DOI: 10.1177/0160323X17699526.