Home- and Community-Based Services: Financial Oversight Office of the Legislative Auditor State of Minnesota O L A Home- and Community-Based Services: Financial Oversight September 20, 2017

Overall Conclusions Spent $2.4 billion in Medical Assistance (MA) funds to provide home- and community-based services (HCBS) to 64,000 people in FY 2015 About three-fourths of this paid for services provided in residential settings Department of Human Services (DHS) does not closely regulate some workers who provide HCBS in recipients’ own homes Legislature and DHS should increase related regulations and reporting requirements O L A

Definition of HCBS Services to help people with disabilities and the elderly live in community rather than institutional settings Foster home care Personal care attendants Home health aides Prevocational assistance Institutional settings include nursing homes, hospitals, and intermediate care facilities O L A

Definition of HCBS, continued Services provided through the state MA plan or through waivers Brain injuries Chronic health conditions Developmental disabilities Physical and other disabling conditions Elderly O L A

Average Cost of HCBS Per Recipient, Fiscal Year 2015 State Medical Assistance plan (N=27,500) Chronic health conditions (N=214) Developmental disabilities (N=15,226) Brain injuries (N=1,428) Physical and other disabilities (N=19,642) Elderly (N=5,595) O L A

HCBS Cost by Type of Service, Fiscal Year 2015

Inconsistent Oversight Tools Good, basic oversight tools for personal care attendants Individual workers must enroll with DHS Monthly cap on the number of hours they can work Periodic checks required to ensure service is being provided Not required of other types of workers doing similar tasks in recipients’ own homes O L A

Recommendation The Legislature should increase regulation over some types of direct care staff who provide HCBS in recipients’ own homes Enrollment Monthly caps Periodic checks O L A

System Difficult to Understand Payment systems vary among the waivers Same or similar HCBS often provided through the state MA plan and across waivers Different terms used to describe similar services System has evolved over several years National problem O L A

Recommendation The Legislature and DHS should adopt a common set of financial reporting requirements and menu of services Consider combining five waivers into a single waiver O L A

Workforce Issues Fewer people entering the workforce Low wages for many types of direct care workers Work can be demanding Staff shortages O L A

Recommendation The Legislature should require DHS to collect data on staffing in HCBS settings Number of direct care workers employed Turnover Job vacancies Average hourly wage Benefits Advancement opportunities O L A

Home- and Community-Based Services: Financial Oversight www.auditor.leg.state.mn.us O L A