Kaiser Reports on Calif. IHSS Program’s Lack of Oversight and Training

Kaiser Health News reports on both the lack of oversight and training requirements in California’s In-Home Supportive Services Program (IHSS), the nation’s largest Medicaid-funded home care program, in back-to-back articles published on January 5 and 6.

In the first article, “As Caregiving Shifts To The Home, Scrutiny Is Lacking,” Kaiser Reporter Anna Gorman highlights several cases of abuse in the IHSS program, in which nearly 403,000 home care workers provide services and supports to 490,000 low-income elders and people with disabilities.

Most IHSS clients direct their own care, which allows them to hire, train, supervise, and terminate their home care aides. Among the most striking feature of the program is that nearly three-quarters of IHSS aides are related to their client.

The article explains that the IHSS program is rooted in the more than 60-year-old effort by the disability community to move people out of institutions into homes and communities and continues to emphasize “supporting clients’ autonomy.” As a result, training is minimal and mostly optional.

Some eldercare advocates say that the IHSS program can be a “perfect scenario for elder or dependent abuse,” because clients that have a history with their aides, particularly family members, may automatically trust them and also make the false assumption that the state government has screened and trained the aides, writes Gorman.

Gorman also reports that many IHSS social workers have very high case loads and that statistics suggest they “focus more on possible fraud than on quality of care.”

Eileen Carroll, deputy director of the California Department of Social Services, says the program “works very well for people who are capable and able to self-direct” but “acknowledged that more problems can arise when clients are older than 85, for instance, or have dementia.”

However, Deborah Doctor, a legislative advocate at Disability Rights California, says that “there is nothing to suggest that the IHSS program fosters abuse or that people are less safe at home than they would be in an institution. The best way to ensure a high quality workforce is to pay caregivers better — not to increase regulation.”

Most IHSS aides earn about $10 per hour, Gorman reports.

In “Lots Of Responsibility For In-Home Care Providers — But No Training Required,” Gorman focuses on the lack of state training requirements for IHSS aides, which can cause aides to become “overwhelmed” and lead to consumers getting injured, according to her interviews with caregivers, advocates, and elder abuse experts. Though IHSS caregivers are supposed to provide only personal care services, many have clients with very complex medical needs.   

Carroll says that the IHSS program lacks training requirements because “it was set up to give clients the choice of how they want their care.” Voluntary online training information is available to caregivers who want it.

There are no federal training requirements for personal care aides.

“Many people are fully able to direct their own care and supervise their caregivers, but some aren’t,” says Carroll. “Our task is how to work harder to support those who have greater need,” she said.

Today, more than a quarter of IHSS clients are age 80 or more, and many have chronic health conditions or dementia, Gorman reports.

California is one of six states that is developing a model training programs for personal and home care aides, through the Personal and Home Care Aide State Training Program, a federally-funded demonstration project.

About 6,000 IHSS caregivers are participating in a training program made possible with other federal funding. An early University of California, San Francisco evaluation of this training program found that “clients with trained providers are less likely to go to the emergency room or be admitted to a hospital than those with untrained providers.”

“Training can also reduce turnover in a field that has low job retention,” PHI Policy Research Director Abby Marquand says in the article.

For information on state training requirements for personal care aides and other direct-care workers, visit the PHI website.

— by Deane Beebe