1. 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

2. 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

3. 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

4. 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

5. 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

6. HCBS Cost by Type of Service, Fiscal Year 2015

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. Home- and Community-Based Services:
Financial Oversight O L A