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Episode 50

Unraveling the complexities of self-directed care with Accra founders

Jeff Howell: 0:01
Welcome to Home Health 360, a podcast presented by Alaya Care. I’m your host, jeff Howell, and this is the show about learning from the best in home health care from around the globe. Hi, everyone, and welcome to another edition of Home Health 360, where we speak with leaders in home care and home health from across the globe. Self-directed personal care assistance (PCA) Services are available to children and adults. Personal care assistance can help with the activities of daily living, such as dressing, grooming, eating, bathing, transfers, mobility, positioning and toileting for adults and children, as well as lighthouse keeping, laundry and meal preparation for adults. With PCA choice, clients independently recruit, hire and train the PCAs who provide their care. The PCA choice option gives them a greater level of responsibility in managing their care, while Accra, the largest home care agency in Minnesota, assists in handling the employment and management-related functions of their PCA. As a PCA choice agency, Accra provides PCA services to medical assistance clients and clients receiving wavered services, but not to people seeking private pay. Today, we are going to dive into the concept of self-directed care and please welcome Val Patino, the Director of Financial Management Services. Val, happy to have you here today.

Val Patino: 1:30
So happy to be here, Jeff. Thank you.

Jeff Howell: 1:33
And joining Valerie is Susan Morgan, the Chief Operating Officer. Susan, thanks for taking the time today.

Susan Morgan: 1:39
We’re excited to be here. Thank you, Jeff.

Jeff Howell: 1:41
So bring us through the origins of Accra and self-directed programs at Accra.

Susan Morgan: 1:47
So Accra was started as a nonprofit back in 1992, started by a nurse whose goal was to serve about 60 clients and interestingly, she started with traditional PCA back in the day and she had 60 clients within the first six months.

Val Patino: 2:09

Susan Morgan: 2:10
So that just demonstrated the need for the service in the home to keep kids at home safely and to help provide some support to their parents. Well, the company just continued to grow from that point forward and we continue to serve clients. Today that many of our clients are on the autism spectrum, but it has expanded to include individuals across the healthcare spectrum that have a whole variety of illnesses, disabilities that need that kind of support in their home, and we’ve been able to add different programs, as DHS has rolled out new programs over the years. So it’s been really kind of an exciting journey to be part of that. Val, do you have anything that you’d like to add to that?

Val Patino: 3:01
Yeah, so we have a wide variety of self-directed services. We have five main programs and three of them are self-directed, including the personal care assistant program, and they’re rapidly growing. We’re finding families are loving the self-directed option because it gives them so many choices in maneuvering around services and applying goods and services that are needed for the clients that they’re supporting.

Jeff Howell: 3:26
And how big has the program grown to?

Val Patino: 3:29
Currently we serve, I think, close to 10,000 clients throughout the state. So, as Sue had mentioned, started with zero to 60 in the first month and now we serve over 10,000 across the state of Minnesota.

Jeff Howell: 3:42
And that’s the largest in the whole state. Right, Correct? My thinking is I come across home care agencies all the time. I would hazard a guess that maybe only 10% are involved in any kind of self-directed care program.

Val Patino: 3:58
Of the personal care assistant programs. I believe there are 600 agencies and of those agencies I would say that might be true Maybe 10% do manage the choice model for PCA. The other agencies are traditional agencies.

Susan Morgan: 4:19
It is a smaller percentage. I know. I’ve seen various percentages kind of floated out there. I think according to the current DHS numbers it’s about 25% are choice and 75% are traditional providers.

Jeff Howell: 4:36
And then I would imagine, out of the traditional providers, it’s just one service line that they’re offering and it’s probably not overly well developed compared to their others. Correct, how does Accra ensure that the PCAs hired by the participants are properly trained and qualified? Because I’m going to explain it in my layman’s terms it’s basically a family caregiver that’s already providing the care anyway, so it could be the parent of a child with needs, or it could be even a neighbor, a cousin or a family member from down the street or close by. That’s always kind of stopping by and providing this care, but they don’t have any special certifications. So just curious, like run me through the process of how you guys make sure that everyone is properly trained and qualified.

Val Patino: 5:25
The three self-directed programs that we run are very different in terms of levels of self-direction. So you’re correct, an overwhelming majority of clients do hire a parent themselves to care for their child, the minor child or an adult child the spouse of the client, adult children of elderly parents we see that a lot as well Trusted neighbours, family members so the family is responsible for training the caregiver to the needs of the client. We do have a qualified professional in the PCA program that will go out and go through a very detailed care plan with the family that will outline what kind of medication reminders does the client need? Do they need help with ADLs dressing, grooming, bathing and to what level of assistance? How often are those reminders needed, or is there physical assistance needed with that as well? Accra comes alongside those families and helps them with background checks, with ensuring that they’ve got their PCA certification, that they’re taking at the state level and that they’ve got that all in place. In our financial management services program, where the family is actually their own employer, Accra provides them with knowledge on how to be their own employer, how to supervise the caregiver, how to write a job description, how to do those annual reviews and those real-time check-ins that are so important as you’re guiding caregivers in your home to the specific person-centered needs of the client. So we’re there to look inside the family at any level of self-direction that they’re choosing.

Jeff Howell: 7:10
How do you handle situations where the participant is not satisfied with the care provided by their PCA?

Val Patino: 7:17
That happens. Each family is matched with a qualified professional or a service coordinator so that the family is open communication with one direct person in the agency and they’re encouraged to express concerns. We have a compliance team that will attend grievances, that will attend to any complaints or concerns that the family brings forward. Is the caregiver not a good match with the client? How are they maneuvering through those challenges? And then we’re doing regular follow-up with those families as well. What does the resolution look like? What parties do we need to get involved in? We had a family who one time they said okay, I don’t know why, I’m running out of hours. It doesn’t make sense. My caregiver is coming in regularly from this time to this time and I should be right on track. Well, on a look back, there was some fraud that had happened. So it’s just walking the family through those scenarios and helping them with the best resolution as to how to resolve it and make sure that then the care that they need is continuing simultaneously with resolving that concern.

Jeff Howell: 8:26
So I’m imagining that most of the use cases are when the PCA is related to the participants. Have you seen cases where someone gets their state license and all of a sudden they’re caring for more than just the family caregiver and they’re sort of like a freelance caregiver that are picking up some new clients and you guys are the fiscal intermediary for them?

Val Patino: 8:50
Yeah, none of the caregivers are licensed. However, they do, on the PCA program, go through that certification where they’re getting their PCA certificate. But yes, we do see where they all through networking or collaboration with other families in different. If they’re running into each other at conferences, hey, I’m looking for a caregiver. Yes, we do see that collaboration. And Accra does have a job board too that we continue to modify to make it more comprehensive and accessible for both caregivers and families to share those caregivers as well, especially when they’re trained. It’s important that families would have access to folks.

Jeff Howell: 9:30
And what kind of support and resources do you guys provide to the participants who are new to a self-directed care program?

Val Patino: 9:36
then so when families call in, we perform an intake and we’re ensuring that we’re understanding the plan that the family has created for their loved one and we tailor services to their needs. Do they have staff in mind? Are they needing some ideas of where maybe they could post a job posting? Then we move to. What do they have included in their plan in addition to staffing, if anything? Do they have goods and services? Are they needing to purchase an item that will increase independence? Are they needing a service that will help them physically With things? And then what does that look like? Do they need help purchasing it? Accra can purchase on their behalf for an item, for example, we’ll purchase it and then we’ll have it sent to their home. A lot of sensory items, home delivered meals, where Accra will help them purchase that on the back end and then we’ll take care of it on the budget end as well. So going through and just seeing exactly what those needs are, based on that community support plan that the family is developing.

Jeff Howell: 10:39
Community support plan. Interesting Is that, in addition to the care plan, it is yes. Can you provide examples of how Accra has helped participants achieve any specific health and wellness goals through their self-directed care?

Val Patino: 10:55
Yeah, so we have a client whose name is Stacy, stacy and her husband. They have three kids, and all of whom are in school, the high school age or college. Stacy was diagnosed in her teenage years with multiple sclerosis and, for those who don’t know, ms is an unpredictable disease that kind of interrupts the pattern or the flow of information between the brain and the body, and so to manage her condition, stacy has used consumer directed community supports, or we call it CDCS through our FMS, our financial management services, and she receives help with laundry, cleaning, preparing meals, running errands and other chores. So before Stacy started working with Accra, she could not direct her own services, she could not choose her employees, she didn’t have the ability to kind of manage her own waiver funds. Through CDCS she was able then to hire her spouse as a paid caregiver. She is able to go to physical therapy twice a week, she was able to make chiropractor appointments, she could refocus on her career as a lactation consultant and the biggest thing, and the part that I love the most, was that her sons and her husband were huge bikers, and because Stacy can’t ride a normal bike, cdcs was able to purchase an electric bike for her and so she could hit the trails with her sons and her husband and do those normal activities that we also desire to do. That’s one story that’s close to our hearts at Accra.

Jeff Howell: 12:37
Interesting, so that’s so. It’s not limited to just the hours of care there are. You could purchase an electric bike as part of it. I know that Australia has a big self-directed care model and I know things like air conditioners can qualify under. You know the government just gives you a check at the beginning of the year. Then you decide how to spend that care, and improving your environment with the air conditioning is one of the things that’s eligible.

Val Patino: 13:05
Yeah, in Minnesota the needs need to be assessed, meaning if you would qualify for an air conditioner for some reason, it would need to be based on a physical or mental need. But yes, we’ve seen a variety of things be approved so folks can enjoy life to the fullest.

Jeff Howell: 13:21
And you mentioned waiver. Can you guys describe a little bit? I’m assuming this is all funded by a Medicaid waiver, or how does that all work? But I’m just curious if there’s private pay options as well.

Val Patino: 13:31
Sure, there are five different waiver types in the state of Minnesota, and consumer directed community supports through our financial management services program is one of the options underneath the waivers. Got it so, yes, and a lot of folks on our PCA program as well are on a waiver, and is there the potential to make a full time living as a PCA?

Jeff Howell: 13:57
or is this really designed to help support people that are still working full time but now they’re at least getting compensated for the family caregiving that they’re doing?

Val Patino: 14:07
On CDCS, the families are able to choose the wage of their caregiver. So, yes, a lot of them are able to pay around $20 an hour. $16 to $20 an hour is what we’re seeing as a normal wage. It needs to be in line with the job description. So, whatever that job would be assessed for based on the duties, the family can choose that wage for their caregiver in accordance with the budget amount that they have available.

Jeff Howell: 14:34
Talk about helping really to take a dent out of the biggest challenge in the industry with the lack of supply of care. Who better to take care of family that’s already taken care of them anyways?

Val Patino: 14:46

Jeff Howell: 14:47
How do you handle emergencies or any unexpected situations that may arise during the visits?

Val Patino: 14:54
That’s always talked about at the intake meeting. We give families a handbook that helps them to prepare for anything that could come up if the client falls, if there’s a medical emergency or if the client’s condition changes suddenly. So talking about that from the beginning and having a plan in place so the family is able to train their caregiver on what to do in case of an emergency is priority. It’s obviously customizable and really reinforce that intake meeting and then annually, as we’re going out, to make sure that any changes in client needs are addressed in the emergency plan.

Jeff Howell: 15:30
And then there’s electronic visit verification requirements of the Medicaid waiver program. So I’m assuming you have a time tracking app. How do you deal with the training of how to properly conduct a visit, because these are volunteers that are now getting paid for their time but they haven’t really chosen the profession of caregiving per se?

Val Patino: 15:52
Right, exactly, yeah, electronic visit verification is something that was integrated in our FMS program last year, so we are adding clients and their caregivers into the system as often as we can. The wonderful thing about Minnesota was they did provide an exemption for those who are living caregivers, so if you live in the home, you do not have to log in with GPS coordinates. Exactly, you’re clocked in pretty much all the time, but those folks don’t have to use the GPS coordinates when logging in and they don’t need to log in real time. They could essentially log in a shift after it’s happened, but they are required to use an electronic way of time record keeping.

Jeff Howell: 16:38
Sure, and then documenting the activities during the quote unquote visit. But it’s just that they’re still at home. Tell me about a time that your agency went above and beyond to meet the needs of our participant in one of your self-directed care programs.

Val Patino: 16:55
Sure. So we have another story. Kyler is cared for by his grandma, karen. Kyler is a kindergartner, just started elementary school and his grandmother is his primary caregiver. When Kyler was four years old he was diagnosed with autism spectrum disorder. He’s non-verbal and he’s in a loper. In a loper is someone who flees from the area just kind of very quickly. So Kyler is on our CDCS program and his grandmother is able to provide care for him, a paid caregiver, and her number one safety concern for him is because he’s in a loper. She was needing something to contain him to make sure that he’s safe. So Accra helped her install a six foot fence around the yard and now he can go in and out easily, enjoy the outdoors, be in his backyard and Grandma Karen can make sure that he’s safe. Another thing Accra did was help the family install ring ring security camera so that they know if he’s Getting close to the door, has gone out the door, maybe the front door, to make sure that his safety is the number one priority. And because he’s nonverbal, he uses a talking device and he was able to acquire that through CDCS as well. So Acura helped to coordinate that purchase a talking device. And one thing that’s really cool that Karen is so pleased with is that his vocabulary is growing. He’s able to talk a little bit more because of this talking device. Oh, and also a really cool thing, the funnest thing is that he was able to purchase a crash pad. So a crash pad is kind of like a big, a big sensory cushion, where it’s designed to provide relaxing and calming input for individuals with autism, and so when he’s feeling overstimulated he’ll just go and crash on the pad and calm down there. So we see that as a common purchase as well for those kids who just need some overstimulation, a de-escalation.

Jeff Howell: 19:02
Sensory deprivation mechanism to just go chill out. Well, I love to hear these stories Interesting. You talk about the eloper and the installing of the six foot fence. That’s not a solution you would find with just traditional respite care or caregiving or home care. You said installed the ring doorbell. I smiled because my wife tracks me as well. So I have to know I have duties and she’s out somewhere and I haven’t left the house yet. Or I do get caught when I bring one of my daughters to volleyball or softball practice and then we forgot something and then I have to do the walk of shame up to the front door. Then I get a text message, you know, with her question, asking me what I forgot.

Val Patino: 19:45
Well, I’m gonna have to consider a ring security camera now.

Jeff Howell: 19:49
Well, it’s killed the teenage house party as well, for sure. So what kind of feedback do you guys regularly solicit from participants to ensure that their needs are being met?

Val Patino: 20:00
So annually we send out a survey to clients. Without their feedback, we cannot make the improvements needed that our program needs to continually evolve and meet their needs. The survey is completely anonymous and we get some really great feedback from clients and from their families for suggested improvements. Quality assurance is big too. We have quality assurance departments at Accra where we’re constantly looking at processes and procedures and ensuring that quality is at the highest level possible with the legislative changes and with internal procedures, that it’s all syncing together and that we’re continuously making improvements for clients and communicating those improvements. One thing that we just recently started was a newsletter, a quarterly newsletter. We don’t wanna bog families’ emails down, so we send it quarterly to really keep them in the know and to kind of keep that open communication and feedback with that channel open with families so that they can feel comfortable with knowing what’s changing and also providing their feedback directly either to their qualified professional or their service coordinator, depending on the program that they’re on.

Jeff Howell: 21:12
So yeah, you mentioned fraud earlier. How do you guys deal with fraud?

Val Patino: 21:17
So we try to prevent it, first and foremost with those background checks, assisting families with hiring the right employees, looking for red flags, things like that. We teach them how to overlook their time sheets, make sure that they’re the last ones to send the time sheet in so they’re overlooking the hours that they’ve signed off on. We have our internal policies and procedures that really focus on fraud, waste and abuse and really disalerting families of what to look out for. And then we have our quality assurance program and we have our compliance program where they are looking at grievances. They’re working with families to resolve those concerns and issues that come up when families are receiving care.

Jeff Howell: 22:03
Would I be wrong to think that the standard client satisfaction score would actually be higher because they’re already opting in to get care from these mostly family caregivers anyways, and now that those caregivers are just getting paid for that time, that it’s just a win-win and there are far fewer problems, far less turnover. It’s not the solution. We still need traditional caregivers and not everyone has someone that is a family member that would be providing care. But I would just imagine that it’s a much better experience for the client or the participants, and then it’s also an equivalent experience for the provider of care. But now they just got more walking around money for doing the same thing they were already opting into.

Val Patino: 22:56
Exactly. I would say that’s true, I would. Obviously there are things that come up when folks are related or once in a while, but generally it does go very smoothly.

Susan Morgan: 23:08
I would just add to that, too, that they’re in their home. They’re where they want to be, because some of these people, without care they might not be able to remain in their home. So of course, we’re dramatically improving the quality of their life by assuring that they have that caregiver. And just to add to it, we’re talking a lot about family caregivers and, yes, probably the majority of those we employ are a family caregiver. But they can also hire a friend, a neighbor, somebody they know through church, and it’s a huge benefit that they’re bringing somebody into their home that they already have a relationship with.

Jeff Howell: 23:46
Yeah, sure, you’re not being the matchmaker. In that case, they’re saying here’s who I want to be my, my giver of care. So well, sue, I’ll start with you and then over to you, val, because we’re bumping up against our time, so I’ll get you both out of here. On this last question, give us a reason to be optimistic about care delivered where the participants call home.

Susan Morgan: 24:06
I think I just kind of answered that. You know you tie that to what we’ve lived through in the last three years with COVID. People more than ever today want to be in their own home and Accra is offering them the opportunity to do that when they either now or at some point in the future when they get to the point that they need that assistance in the home. Here’s the way that it can happen. We’ve got these self-directed models that work great and we’re seeing changes even in Minnesota with a new program coming in called CFSS Community First Services and Supports, which will even improve the self-directed options that we have here, and I know other states have that same program. So lots of optimism for staying in your own home in the future.

Val Patino: 24:55
I will echo what Sue just said with CFSS. So Community First Services and Supports are going to give folks who don’t have the flexibility of purchasing goods or services, that currently only have the option for staffing. It’s going to expand their ability to include the purchase of goods and services. The idea is to decrease the need for human assistance and increase independence, and it’s just gonna keep getting better. It’s gonna be a really wonderful option for many participants in the state of Minnesota.

Jeff Howell: 25:25
There’s no doubt that the future of care is both in the home and, I believe, the future of care giving is supplementing the workforce with what’s already being supplemented by these volunteer family members. It just makes sense to make sure that they get compensated as part of the process. Love the story about Kyler the aloper and how you helped out grandma Karen. So keep up the great work. And I do have to get out of here because I have to get caught on my ring doorbell to go watch my daughter’s basketball tournament, so I will be getting a text message if I don’t show up on my wife’s iPhone in about five minutes. Thanks for being here today, Valerie and Sue.

Susan Morgan: 26:07
Thank you, Jeff. Yes, thank you very much for the opportunity.

Jeff Howell: 26:12
Home Health 360 is presented by . First off, we wanna thank our amazing guests and listeners. To get more episodes, you can go to alayacare. com/homehealth360. That’s spelled home health 360 or search Home Health 360 on any of your favorite podcasting platforms. The easiest way to stay up to date on our new shows is to subscribe on Apple podcasts, Spotify or wherever you get your podcasts. We also have a newsletter you can sign up for on alayacare. com/ home health 360 to get alerts for new shows and more valuable content from AlayaCare right into your inbox. Thanks for listening and we’ll see you next time. We’ll see you next time.

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Home Health 360 - Episode 50

Episode Description

Be prepared for a closer look at the myriad of self-directed care options available for families in Minnesota. Val Patino and Susan Morgan, the brains behind Accra, Minnesota’s largest home care agency, lead an engaging discussion about the state’s waiver program and the potential to carve out a full-time living as a personal care assistant (PCA). Set yourself on a learning journey as our esteemed guests throw light on the creation of self-directed programs and the strategies they deploy to ensure that PCAs are impeccably trained and adequately skilled. Listen to their approach to managing participants’ dissatisfaction with the care they receive and their role in helping families oversee their PCAs’ employment and administrative tasks.

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