Suit brings new rules to senior daycare
Class-action settlement good news for Rose Kleiner patients
Most — if not all — of the frail and elderly Medi-Cal recipients who rely on the Avenidas Rose Kleiner Center in Mountain View will be able to continue to attend, thanks to a recent settlement reached between California's Department of Health Care Services and supporters of state-subsidized adult day health care centers.
When Gov. Jerry Brown announced his plan to eliminate Medi-Cal reimbursements for adult day health care in order to save California $169 million, it looked as if about half of the mostly elderly men and women that depend on Rose Kleiner for regular care would have to find somewhere else to go.
But after a class-action lawsuit was filed against Toby Douglas, head of the California Department of Health Care Services on behalf of several recipients of Medi-Cal-subsidized adult day health care services, a settlement was reached that may allow all of the center's clientele to continue receiving care at Rose Kleiner.
Under the terms of the settlement reached on Dec. 1, Medi-Cal will no longer cover the costs of adult day health care; however, a new program, called Community-Based Adult Services (CBAS) will pay the costs associated with programs such as those offered at Rose Kleiner.
The Rose Kleiner Center provides assistance to adults — most of them elderly — who cannot take care of themselves, either because of physical or mental conditions. The center offers a wide variety of activities and classes, all aimed at improving the lives of its attendees. There are exercise classes, physical therapy sessions, and opportunities to socialize in common areas and during meals. Medical staff is on site in the event of an emergency.
Centers such as Rose Kleiner are not only valuable to the men and women who spend their days there. Adult day care centers are also helpful to families, officials said. By providing a safe environment for elderly family members to stay during the day, Rose Kleiner allows other family members to go about their daily routines — working a job or maintaining a social life.
Currently, Medi-Cal, California's Medicaid program, pays more than half the cost associated with a day at Rose Kleiner — about $76. The center makes up the difference through its fundraising efforts, making it possible for low-income patients to attend.
The CBAS program is essentially a compromise, said Norman Williams, a spokesman for the Department of Health Care Services. Originally officials predicted that the state would have saved $169 million by eliminating all support for adult day health care. Under the CBAS plan, California will save $28 million this budget year and $92 million in 2012-13, according to Williams.
"It's a more targeted program," Williams said, noting that it will focus on patients with the most serious illnesses. Those who do not qualify will still be eligible for more limited form of state assistance.
In order to qualify for CBAS coverage, a patient will need to meet certain requirements. CBAS patients will also have to enroll in a "managed care" health plan.
"It's more of a contained system," Williams said, explaining how the managed care plan works. With the managed care plan, patients will only be able to receive care — whether from their general practitioner or a specialist — from a finite number of doctors within the network. "With managed care plans, the state can better predict and manage the cost of the program."
The downside to the managed care system, according to Lisa Hendrickson, president and CEO of Avenidas, is that people will be limited in their choices. Furthermore, if a patient's current primary care physician is not within the managed care network, that patient will have to change doctors — a prospect that could deter some seniors.
On the upside, while the prospect of going to a new doctor may not appeal to some Rose Kleiner patients, Hendrickson is confident that all her patients will qualify under the new CBAS criteria.
"We do expect that the current medical beneficiaries, for the most part, will continue to receive benefits that will allow them to continue to go to the center," Hendrickson said. "It's really great news for our medical beneficiaries and their families."
In the early days of 2012 — most likely in January or February, Hendrickson said — a group of state nurses will interview 13 of the 32 patients who receive Medi-Cal subsidies to attend the center. The remainder of the center's Medi-Cal-subsidized patients have already qualified for CBAS coverage, and about another 30 patients pay out of pocket for Rose Kleiner's services.
Both Williams and Hendrickson said they are content with the settlement.
"It is a very good compromise," Williams said, adding that he understands the ordeal has been difficult for patients and families who rely on adult day health care centers throughout the state. "All of these reductions are difficult," he said. "It's not something the state wanted to do. But, considering the states budget situation, some changes had to be made."
"It's certainly been disruptive for the months that it's been pending," Hendrickson said.
However, she said, in the long run she believes most of her patients will be able to remain with the center. She even entertained the hope that the new CBAS system might make her program more widely available, although Williams said the state estimates that the number of CBAS-eligible patients will be half of the number who were eligible for Medi-Cal-subsidized adult day health care.