Eligibility requirements haunt elderly at adult day health centers

Irene Nashtut’s adult day health care center lost 62 clients this spring. They have not exactly wandered off, or been recruited by a rival center. They have been declared ineligible.

Nashtut runs the state-funded AmeriCare Adult Day Health Care center, tucked away in a San Marcos strip mall. Her former clients, many of whom have chronic mental illness, were part of a group of several thousand Medi-Cal recipients around California who officials informed this past spring that they were ineligible -- not sick enough or frail enough to continue having access to the centers. 

“I’m getting sometimes really sad,” said Nashtut, who has run the center for about a decade. “It’s really unfair to the providers and to the participants and their families that we have to go through all this.”

Budget-concerned Lawmakers axed the Medi-Cal Adult Day Health Care (ADHC) benefit last fall, but advocates for the disabled promptly sued in federal court and, in a subsequent legal settlement, the state agreed to fund a scaled down version of the program. The new Community Based Adult Services (CBAS) aims to keep California’s frailest individuals, people who suffer from multiple disabilities including dementia, incontinence, paralysis and traumatic brain injury, out of costly nursing homes and emergency rooms.

The state initially predicted that about 50 percent of the 40,000 or so participants in the old adult day health care program would be deemed eligible to continue with the new one. But, after state nurses assessed center participants, officials decided to allow about 80 percent of the original participants to continue to attend. 

Advocates were pleased with the 80 percent ruling, but remain worried about the several thousand people who have lost access to meals, medication management, physical and occupational therapy, as well as robust social programs. 

“For the 20 percent who were not [deemed eligible], every one of those is a human being with a story and a support system or lack of a support system,” said Lydia Missaelides, executive director of the California Association for Adult Day Services. “So, from a humanistic point of view, every single one of those ineligibles is devastated.”

Before dispatching 200 state nurses starting in December to the nearly 300 centers across California for in-person interviews, state officials worked with advocates and agreed upon new eligibility criteria. After several months of interviews, nurses delivered recommendations to the state on who should remain eligible for the new program. 

State administrators underscored the importance of the CBAS program serving only the most medically needy.

“It’s very difficult because I know that the stakeholders are passionate about this and I appreciate their passion,” said Jane Ogle, deputy director for health care delivery systems for the state Department of Health Care Services. She is overseeing the transition from ADHC to CBAS. “I think we’re also at a point in the state and in our budget that we have to be very realistic about what we can actually do with the dollars we have available. And so it’s very hard to hear some of the sad stories, but I have complete faith in the nurses who are doing these assessments that they’re making the right decisions.”

The state decided to eliminate the more than 30-year-old ADHC program last year in order to save $169 million – part of the administration’s attempt to close a $26.6 billion budget gap. The old program cost $76.27 per participant per day, half paid by the state, half by the federal government. 

Now, the CBAS program costs $68.64 per patient per day, meaning the centers have to work with about $7 less per person per day. 

Some centers, such as the San Marcos-based AmeriCare, were hit harder than others.

“I know that our center had many more denials compared to other centers in San Diego,” said Nashtut. “We think that possibly the reason for this [is] because we serve a big population of younger mentally ill participants and many of [those] denied were in this category.”

Over 1,800 ineligible participants statewide have appealed to the state to regain access to their centers, including 43 of Nashtut’s former participants.

Nashtut and other advocates worry that without the centers, people will end up in expensive nursing homes and emergency rooms, with the state shouldering the cost.

“The people we serve are by definition very low income,” said advocate Missaelides. “They have complex medical conditions. And those do not go away just because the program is eliminated.” 

She said that without the centers, families have few alternatives, that they're forced to"quit working to provide care, or leave their loved alone during the day and pray for the best."

State officials are fully aware that these programs play an important role not only for the participants, but for the families who depend on them.

“We’ve all had difficulty in our families with elderly people, our grandmothers, our grandfathers, people who are struggling through life. So we never forget that part of it,” said Norman Williams, spokesman for the state Department of Health Care Services. “But ... we have an obligation to be good stewards of the public dollar.”

At Nashtut’s San Marcos center, participants begin their mornings with the Star Spangled Banner.

“For those that can stand up, please stand up,” says a voice over the loudspeaker. “Those that cannot stand up, please sing along with us. Thank you.” 

Twelve centers across the state have closed already this year and advocates expect another one to shut its doors in September.

Nashtut hopes hers doesn’t join them.

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Lauren M. Whaley

Freelance journalist Lauren M. Whaley is a photographer, radio producer and print reporter specializing in topics related to mental illness, reproductive health care and health disparities. She is also a childbirth photographer.This year, She is working on a series about how low-income parents access care for perinatal mental illnesses. The project is funded in part by the Rosalynn Carter Fellowships for Mental Health Journalism.She was a 2016-17 Knight Science Journalism Fellow at the Massachusetts Institute for Technology.Her work has been recognized by the Association of Health Care Journalists, the Scripps Howard Foundation and the Public Radio Exchange (PRX) STEM story project. She has contributed radio, video, photography and written stories to KQED Public Radio, Southern California Public Radio, the San Jose Mercury News, the New York Times and other media outlets. For six years, she worked as the Center for Health Reporting's multimedia journalist. She is a past president of the national organizationJournalism and Women Symposium (JAWS) and spent her early 20s leading canoe expeditions for young women, including a solo-led 45-trip in the Canadian Arctic. She is based in Los Angeles.

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