Skilled Respite
Why “Skilled” Respite Needs to be Part of the
Standards for Home Care Employee Benefits
DEFINITIONS:
• Respite – a break from normal responsibilities for the
primary care giver.
• Skilled Care (in this context) – “Licensed” care. Tasks
provided by a person with the education, training, and
a professional license specific to the task(s) being
provided (i.e. doctors, dentists, nurses, therapists,
podiatrists, chiropractors, others).
• Unskilled Care (in this context) –services that do not
require extensive education, training, or licensure.
ISO vs. Agency Model
From the on-line Nevada Long Term Support Services web page at
https://dhcfp.nv.gov/Pgms/LTSS/LTSSPCS/
• Agency Model: Provider Type 30 – Personal Care Services Provider
Agency
• Self Directed Services Model: Provider Type 83 – Personal Care
Service Intermediary Service Organization (ISO).
• Note: Intermediary, in this context, means an organization that acts as a link
between the person who needs the care, Nevada Medicaid/payer source, and
the person providing care (the PCA).
How ISO and Agency Models Differ Functionally
• Agency Model: the PCA works for the Agency. The person receiving care can ask
for a different PCA, but is not in a position to hire, supervise, train, discipline or
fire the PCA.
• Self Directed ISO Model:
• The care recipient typically helps recruit/find their own PCA, and also has the
right the “fire” that PCA.
• The care recipient trains, supervises, and instructs the caregiver on what to
do, when to do it, and how to do it.
• The ISO provides the “HR” functions (compliance, payroll, taxes, etc.)
• When a person is unable to direct their own care, a responsible party may do
that on their behalf, but must be present to provide that direction while care
is being administered.
Self-Directed Skilled Care
• Under the Self-Directed ISO Model, Nevada Medicaid allows people
who receive care at home to direct skilled tasks to their PCA (in
addition to their other PCA tasks) that in other care environments
would need to be done by a skilled – or licensed – professional.
• Those tasks are limited in scope, and and at least once per year, the
primary care physician must sign off on the competency of the person
directing the care - whether that is the care recipient or a personal
representative/responsible party.
• The paperwork involved is extensive, thus it is not simple to send a
replacement PCA to do the skilled pieces of care. It requires a new
set of physician and involved party signatures.
Examples of skilled tasks that can be done under
the Self-Directed Skilled Care Program/Model
• Catheter care
• Wound care
• Oxygen management
• Medication management
• Bowel Care
• Tube Feedings
• And more
NEXT SLIDE:
Where Skilled Respite Fits with Our Board
AGENCY PCA SERVICES
REGULAR PCA DUTIES ONLY
PRIMARY CARE GIVER
ISO SELF-DIRECTED PCA SERVICES
PRIMARY CARE GIVERS
REGULAR PCA DUTIES SKILLED PCA DUTIES
NON-FAMILY
FAMILY
NON-FAMILYFAMILY
Who are these folks, and
How many are there? Is it a
Small number with a big fiscal impact,
Or a bigger number the reveals a
Significant gap in the way serve people
Living in our communities?
DATA
Defines The Scope Of Any Projected Project Or Program
Data about the circled area on the previous slide is
what I don’t have (or have access to).
Data would help determine the size of the need (big
or small) for skilled respite in Nevada.
Data provides the information needed to support the
actions needed and project the fiscal impact of a
proposal.
DATA, cont.
Data needs to be current, relevant, and include the “elephant in the
room” – that number related to primary care givers providing unpaid
skilled services on their personal time that prevents the use of
standard respite services.
Why Do We Care?
When a PCA is
a) The primary care giver providing all or most of the needed care,
b) Provides skilled care (paid or not) every day, especially if the skilled piece
takes up several hours of time
c) Has no backup care that is trained or willing to do the skilled pieces..
WHO PICKS UP WHEN THEY NEED
TIME OFF?
Respite
• Most respite services do not provide skilled cares
• Liability of paying a non-licensed person to do a skilled job.
• Lack of skilled staff available
• Lack of a funding stream to pay skilled staff.
• Too complex to manage.
• Not in the scope of what their grants were written to do
• ISO agencies do not hire skilled staff that can step up on a temporary
basis.
Private Duty Nursing (PDN)
• PDN is a NV State Plan (regular) Medicaid benefit for those who
quality
• Limited to the allotted hours per week and hours cannot be bulked
across weeks.
• PDN agencies with NV Medicaid do not (are not allowed to) hire out
their nurses privately to recipients when the hours allotted do not
meet the full need.
• A temporary increase in PDN can be made when an increase in skilled
care is needed, such as after a big surgery.
• Otherwise, NV Medicaid does not allow increases for ”respite”.
COORDINATION OF CARE
• There is no coordination of care between PCA agencies and the PDN
agencies.
• In fact, Medicaid claims that someone needing skilled care cannot
utilize both the Private Duty Nursing and the ISO model of Self-
Directed Skilled Care EVEN if the skilled need is 24/7 with family
picking up the bulk of those hours.
Case Scenario:
A family member is paid to provide 21.25 hours/week of PCA services under an
agency model. The choice to care for this medically complex loved one at home was made
to avoid institutionalization. This is that PCA’s only job because when not working as a PCA,
that family member gives meds, handles tube feedings & tube-snacks 5 times a day, and
manages a catheter, and often performs other skilled tasks as needed, consuming much of
the remaining hours in a week. This is standard for family members caring for people who
are medically complex living in the community.
That family member can use respite for the in-between hours of each day when
there are no meds due, etc. That family member might even use another family member
or a friend to pinch hit for short errands, but none of these backup care givers are
qualified, trained, or comfortable providing any of the skilled services.
The person being cared for cannot direct care and there is nobody else present
who can, so the ISO model does not work out. When that family member needs to take
time off for more than a day (name a reason), a competent person needs to be hired to
replace the hours of skilled care being provided without pay.
RISKS
• When the care recipient cannot be cared for adequately, the risks
include but are not limited to:
• Falls
• Medication errors
• Self-Neglect
• Bed sores
• Exacerbation of health care concerns/conditions
• Temporary institutionalization that becomes permanent
• Worst case scenario is that someone is held accountable for any of
the above by protective services.
Proposals:
• 1. Recommend to the Director that he commission an investigation
into the numbers of people in Nevada who
• Have with complex care needs being met in home environments
• How many PCAs in NV are paid and how many are not paid to perform
“skilled” tasks for their care recipients
• Who is meeting their complex care needs
• PCA’s, family, friends, self?
• And any other data that addresses the need for Medically-based respite
funding to relieve PCAs and family members performing skilled tasks.
Proposals, cont.
• 2. Recommend to the director that he direct Nevada Medicaid to
coordinate the two programs that allow for community care of those
with complex needs -namely self-directed skilled personal care
services and private duty nursing services – such that the two lines of
services can co-exist in cases where extensive skilled care is the need.
