Existing law establishes the In-Home Supportive Services (IHSS) program, administered by the State Department of Social Services and counties, under which qualified aged, blind, or disabled persons are provided with supportive services in order to permit them to remain in their own homes.

As a condition of receiving services under the IHSS program, existing law requires an applicant or recipient to obtain a certification from a licensed health care professional declaring that the applicant or recipient is unable to perform some activities of daily living independently, and that without services to assist the applicant or recipient with activities of daily living, the applicant or recipient is at risk of placement in out-of-home care. Existing law requires that the certification be received prior to service authorization, except under certain circumstances. Existing law requires the department to develop a standard certification form, as specified, and to identify alternative documentation, including, but not limited to, hospital or nursing facility discharge plans, containing the required information.

Existing law sets forth various provisions relating to end-of-life care. When a health care provider makes a diagnosis that a patient has a terminal illness, existing law generally requires the health care provider, upon request, to provide the patient or another person authorized to make health care decisions with comprehensive information and counseling regarding legal end-of-life care options.

This bill would, before the discharge from an acute care hospital of a Medi-Cal beneficiary diagnosed with a terminal illness, require the hospitals designated case manager or discharge planner to evaluate the patients likely need for posthospital services and ability to access those services. The bill would require the hospital case manager or discharge planner to ask the patient or authorized person if they are interested in receiving information about the IHSS program if that patient is anticipated to need in-home personal care. If interest is expressed, the bill would require the hospital case manager or discharge planner to provide to the patient or authorized person the information, including how to initiate the application process and the option for a family member to provide care as an IHSS provider subject to the IHSS provider enrollment conditions.

If the patient seeks to apply for services under the IHSS program, the bill would require the hospital case manager or discharge planner to communicate to the patients primary care physician the patients interest in applying for IHSS to support the timely completion of the health care certification form.

Existing law establishes the In-Home Supportive Services (IHSS) program, administered by the State Department of Social Services and counties, under which qualified aged, blind, or disabled persons are provided with supportive services in order to permit them to remain in their own homes.

As a condition of receiving services under the IHSS program, existing law requires an applicant or recipient to obtain a certification from a licensed health care professional declaring that the applicant or recipient is unable to perform some activities of daily living independently, and that without services to assist the applicant or recipient with activities of daily living, the applicant or recipient is at risk of placement in out-of-home care. Existing law requires that the certification be received prior to service authorization, except under certain circumstances. Existing law requires the department to develop a standard certification form, as specified, and to identify alternative documentation, including, but not limited to, hospital or nursing facility discharge plans, containing the required information.

Existing law sets forth various provisions relating to end-of-life care. When a health care provider makes a diagnosis that a patient has a terminal illness, existing law generally requires the health care provider, upon request, to provide the patient or another person authorized to make health care decisions with comprehensive information and counseling regarding legal end-of-life care options.

This bill would, before the discharge from an acute care hospital of a Medi-Cal beneficiary diagnosed with a terminal illness, require the hospitals designated case manager or discharge planner to evaluate the patients likely need for posthospital services and ability to access those services. The bill would require the hospital case manager or discharge planner to ask the patient or authorized person if they are interested in receiving information about the IHSS program if that patient is anticipated to need in-home personal care. If interest is expressed, the bill would require the hospital case manager or discharge planner to provide to the patient or authorized person the information, including how to initiate the application process and the option for a family member to provide care as an IHSS provider subject to the IHSS provider enrollment conditions.

If the patient seeks to apply for services under the IHSS program, the bill would require the hospital case manager or discharge planner to communicate to the patients primary care physician the patients interest in applying for IHSS to support the timely completion of the health care certification form.

Existing law establishes the In-Home Supportive Services (IHSS) program, administered by the State Department of Social Services and counties, under which qualified aged, blind, or disabled persons are provided with supportive services in order to permit them to remain in their own homes.

As a condition of receiving services under the IHSS program, existing law requires an applicant or recipient to obtain a certification from a licensed health care professional declaring that the applicant or recipient is unable to perform some activities of daily living independently, and that without services to assist the applicant or recipient with activities of daily living, the applicant or recipient is at risk of placement in out-of-home care. Existing law requires that the certification be received prior to service authorization, except under certain circumstances. Existing law requires the department to develop a standard certification form, as specified, and to identify alternative documentation, including, but not limited to, hospital or nursing facility discharge plans, containing the required information.

Existing law sets forth various provisions relating to end-of-life care. When a health care provider makes a diagnosis that a patient has a terminal illness, existing law generally requires the health care provider, upon request, to provide the patient or another person authorized to make health care decisions with comprehensive information and counseling regarding legal end-of-life care options.

This bill would, before the discharge from an acute care hospital of a Medi-Cal beneficiary, beneficiary diagnosed with a terminal illness, require the hospitals designated case manager or discharge planner to evaluate the patients likely need for posthospital services and ability to access those services. This The bill would require the hospitals hospital case manager or discharge planner to ask the patient or authorized person if they are interested in receiving information about the IHSS program if that patient is anticipated to need in-home personal care. If interest is expressed, the bill would require the hospitals hospital case manager or discharge planner to provide to the patient or authorized person the information, including how to initiate the application process and the option for a family member to provide care as an IHSS provider subject to the IHSS provider enrollment conditions.

If the patient seeks to apply for services under the IHSS program, the bill would require the hospital case manager or discharge planner to communicate to the patients primary care physician the patients interest in applying for IHSS services to support the timely completion of the health care certification form.

Existing law establishes the In-Home Supportive Services (IHSS) program, administered by the State Department of Social Services and counties, under which qualified aged, blind, or disabled persons are provided with supportive services in order to permit them to remain in their own homes.

As a condition of receiving services under the IHSS program, existing law requires an applicant or recipient to obtain a certification from a licensed health care professional declaring that the applicant or recipient is unable to perform some activities of daily living independently, and that without services to assist the applicant or recipient with activities of daily living, the applicant or recipient is at risk of placement in out-of-home care. Existing law requires that the certification be received prior to service authorization, except under certain circumstances. Existing law requires the department to develop a standard certification form, as specified, and to identify alternative documentation, including, but not limited to, hospital or nursing facility discharge plans, containing the required information.

Existing law sets forth various provisions relating to end-of-life care. When a health care provider makes a diagnosis that a patient has a terminal illness, existing law generally requires the health care provider, upon request, to provide the patient or another person authorized to make health care decisions with comprehensive information and counseling regarding legal end-of-life care options.

This bill would, before the discharge of a patient diagnosed with a terminal illness, from an acute care hospital of a Medi-Cal beneficiary, require the diagnosing health care provider hospitals designated case manager or discharge planner to evaluate the patients need for posthospital services and ability to access those services. This bill would require the hospitals case manager or discharge planner to ask the patient or authorized person if they are interested in receiving information about the IHSS program. program if that patient is anticipated to need in-home personal care. If interest is expressed, the bill would require the health care provider to disclose hospitals case manager or discharge planner to provide to the patient or authorized person the information, including the IHSS eligibility criteria how to initiate the application process and the option for a family member to provide care as an IHSS provider subject to the IHSS provider enrollment conditions.

If the patient seeks to apply for services under the IHSS program, the bill would require the health care provider to provide a copy hospital case manager or discharge planner to communicate to the patients primary care physician the patients interest in applying for IHSS services to support the timely completion of the health care certification form and to complete the applicable portion before the patients discharge. form.

Existing law sets forth various conditions on the number of hours of service authorized for an IHSS provider, with a modified number based on exemptions for a provider who is related to the recipients whom the provider serves, as specified.

Existing law requires the county welfare department to assess each IHSS recipients continuing monthly need for in-home supportive services at varying intervals as necessary, but at least once every 12 months, with exceptions. Under existing law, the results of this assessment of monthly need for IHSS hours are divided by 4.33, to establish a recipients weekly authorized number of IHSS hours, as specified.

Under this bill, if a patient diagnosed with a terminal illness seeks to apply for services under the IHSS program, and receives a health care certification form that is completed by a health care provider, the patient would be authorized to request to have the application expedited by the county.

This bill would require counties, to the extent feasible, to consider expediting applications of patients who have been diagnosed with a terminal illness and who have requested their application be expedited. By creating additional duties for county officials, the bill would impose a state-mandated local program.

The bill would authorize the department to implement these provisions through all-county letters or similar instructions, until regulations are adopted. The bill would condition implementation of these provisions on receipt of any necessary federal approvals and the availability of federal financial participation for purposes of providing in-home supportive services under the Medi-Cal program or other related provisions.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.

Existing law establishes the In-Home Supportive Services (IHSS) program, administered by the State Department of Social Services and counties, under which qualified aged, blind, or disabled persons are provided with supportive services in order to permit them to remain in their own homes.

As a condition of receiving services under the IHSS program, existing law requires an applicant or recipient to obtain a certification from a licensed health care professional declaring that the applicant or recipient is unable to perform some activities of daily living independently, and that without services to assist the applicant or recipient with activities of daily living, the applicant or recipient is at risk of placement in out-of-home care. Existing law requires that the certification be received prior to service authorization, except under certain circumstances. Existing law requires the department to develop a standard certification form, as specified, and to identify alternative documentation, including, but not limited to, hospital or nursing facility discharge plans, containing the required information.

Existing law sets forth various provisions relating to end-of-life care. When a health care provider makes a diagnosis that a patient has a terminal illness, existing law generally requires the health care provider, upon request, to provide the patient or another person authorized to make health care decisions with comprehensive information and counseling regarding legal end-of-life care options.

This bill would, before the discharge of a patient diagnosed with a terminal illness, require the diagnosing health care provider to ask the patient or authorized person if they are interested in receiving information about the IHSS program. If interest is expressed, the bill would require the health care provider to disclose to the patient or authorized person the information, including the IHSS eligibility criteria and the option for a family member to provide care as an IHSS provider subject to the IHSS provider enrollment conditions.

The bill would require the health care provider to provide a physical IHSS application under the above-described circumstance and to inform the patient or authorized person of the option for sending a digital copy if a family member is identified for purposes of an IHSS provider. If the patient seeks to apply for services under the IHSS program, the bill would require the health care provider to provide a copy of the health care certification form and to complete the applicable portion before the patients discharge.

Existing law sets forth various conditions on the number of hours of service authorized for an IHSS provider, with a modified number based on exemptions for a provider who is related to the recipients whom the provider serves, as specified.

Existing law requires the county welfare department to assess each IHSS recipients continuing monthly need for in-home supportive services at varying intervals as necessary, but at least once every 12 months, with exceptions. Under existing law, the results of this assessment of monthly need for IHSS hours are divided by 4.33, to establish a recipients weekly authorized number of IHSS hours, as specified.

Under this bill, if a patient diagnosed with a terminal illness seeks to apply for services under the IHSS program, and receives a health care certification form that is completed by a health care provider, the patient would be authorized to elect to have the application process request to have the application expedited by the county.

This bill would require counties, to the extent feasible, to consider expediting applications of patients who have been diagnosed with a terminal illness and who have requested their application be expedited. By creating additional duties for county officials, the bill would impose a state-mandated local program.

The bill would authorize the department to implement these provisions through all-county letters or similar instructions, until regulations are adopted. The bill would condition implementation of these provisions on receipt of any necessary federal approvals and the availability of federal financial participation for purposes of providing in-home supportive services under the Medi-Cal program or other related provisions.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.

Existing law establishes the In-Home Supportive Services (IHSS) program, administered by the State Department of Social Services and counties, under which qualified aged, blind, or disabled persons are provided with supportive services in order to permit them to remain in their own homes.

As a condition of receiving services under the IHSS program, existing law requires an applicant or recipient to obtain a certification from a licensed health care professional declaring that the applicant or recipient is unable to perform some activities of daily living independently, and that without services to assist the applicant or recipient with activities of daily living, the applicant or recipient is at risk of placement in out-of-home care. Existing law requires that the certification be received prior to service authorization, except under certain circumstances. Existing law requires the department to develop a standard certification form, as specified, and to identify alternative documentation, including, but not limited to, hospital or nursing facility discharge plans, containing the required information.

Existing law sets forth various provisions relating to end-of-life care. When a health care provider makes a diagnosis that a patient has a terminal illness, existing law generally requires the health care provider, upon request, to provide the patient or another person authorized to make health care decisions with comprehensive information and counseling regarding legal end-of-life care options.

This bill would, before the discharge of a patient diagnosed with a terminal illness, require the diagnosing health care provider to disclose to ask the patient or authorized person if they are interested in receiving information about the IHSS program and about program. If interest is expressed, the bill would require the health care provider to disclose to the patient or authorized person the information, including the IHSS eligibility criteria and the option for a family member to provide care as an IHSS provider subject to the IHSS provider enrollment conditions.

The bill would require the health care provider to provide a physical IHSS application under the above-described circumstance and to inform the patient or authorized person of the option for sending a digital copy if a family member is identified for purposes of an IHSS provider. If the patient seeks to apply for services under the IHSS program, the bill would require the health care provider to provide a copy of the health care certification form and to complete the applicable portion before the patients discharge.

Existing law sets forth various conditions on the number of hours of service authorized for an IHSS provider, with a modified number based on exemptions for a provider who is related to the recipients whom the provider serves, as specified.

Existing law requires the county welfare department to assess each IHSS recipients continuing monthly need for in-home supportive services at varying intervals as necessary, but at least once every 12 months, with exceptions. Under existing law, the results of this assessment of monthly need for IHSS hours are divided by 4.33, to establish a recipients weekly authorized number of IHSS hours, as specified.

Under this bill, if a patient diagnosed with a terminal illness seeks to apply for services under the IHSS program, and receives a health care certification form that is completed by a health care provider, the patient would be authorized to elect to have the application process expedited by the county.

As part of that expedited process, the bill would require (1) that the IHSS application and the health care certification form be processed before the patient is discharged, (2) that the health care certification form be approved or denied within an unspecified number of days of the county receiving it, one business day after the county receives the form, (3) that, upon approval, an IHSS provider be assigned and provided to the patient within an unspecified number of days of processing the health care certification form, the county welfare department or its designee prioritize the patient with regard to assigning and providing an IHSS provider, and (4) that the approved patient be guaranteed a specified total number of IHSS hours, as a preliminary allotment, as deemed appropriate by the county welfare department or its designee based on specified factors, until a final determination is made based on the needs assessment. By creating additional duties for county officials, the bill would impose a state-mandated local program.

The bill would authorize the department to implement these provisions through all-county letters or similar instructions, until regulations are adopted. The bill would condition implementation of these provisions on receipt of any necessary federal approvals and the availability of federal financial participation for purposes of providing in-home supportive services under the Medi-Cal program or other related provisions.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to the statutory provisions noted above.

Existing law establishes the In-Home Supportive Services (IHSS) program, administered by the State Department of Social Services and counties, under which qualified aged, blind, or disabled persons are provided with supportive services in order to permit them to remain in their own homes. Existing law sets forth various requirements for the enrollment of a provider in the IHSS program, including, among other things, completion of forms and statements, a background check, and an orientation, as specified.

This bill would state the intent of the Legislature to enact legislation relating to the enrollment process for IHSS providers.

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 1005

Author:(Alvarez)

As Amended Ver:August 23, 2024

Majority vote

SUMMARY

Requires a hospital's designated case manager or discharge planner to evaluate a patient's need for post-hospital services and ability to access those services, if that patient is being discharged from an acute care hospital and a Medi-Cal beneficiary. It also requires the hospital's designated case manager or discharge planner to provide information to patients, if the patient is anticipated to need in-home personal care, about the in-home supportive services (IHSS) program and provide informational documents, as specified

Senate Amendments

Strike provisions related to expediting IHSS applications.

COMMENTS

In-Home Supportive Services Program. Eligible low-income individuals in California who are at least 65 years old, living with disabilities, or blind, may access services through the IHSS program that enable them to remain in their own homes. IHSS program providers are paid to assist with personal care services (such as bathing, toileting, and grooming), domestic and related services (meal preparation, housecleaning, and the like), paramedical services, and protective supervision. There are currently over 593,000 Californians who receive IHSS; over 98% of these individuals receive IHSS services as a Medicaid benefit.

The California Department of Social Services (CDSS) oversees the IHSS program, but it is administered at the county level. Once individuals apply for IHSS, they are assessed by a county social worker for eligibility and need. If an individual is determined to be eligible for IHSS, they are authorized for certain services and for a specified number of hours of care. IHSS clients self-direct their care, which allows them to choose and hire their own provider, including friends and family.

When an individual is determined eligible for IHSS services by a county social worker, they are authorized for a certain number of hours of care per week. IHSS recipients are responsible for hiring, firing, directing, and supervising their IHSS workers. These responsibilities include some administrative duties, such as scheduling and signing timesheets; however, the state handles payroll. Providers must complete an enrollment process, including submitting fingerprint images for a criminal background check and participating in a provider orientation prior to receiving payment for services.

Prospective IHSS providers are also required to participate in an on-site orientation developed by CDSS and the counties prior to receiving payment for services. As of February 2023, there were 613,410 IHSS providers in California; 95.5% of providers are a relative, spouse, or parent of the recipient, and 55.6% of providers live in the same residence as the recipient, according to data provided by CDSS.

One of the eligibility criteria for receiving IHSS is submission of a completed Health Care Certification Form (referred to as a SOC 873) with information provided by the individual's licensed healthcare professional. The exception to this requirement is if a county determines that an applicant is at imminent risk of out-of-home placement; applicants who are granted this exception may be temporarily authorized to receive IHSS pending the county's receipt of the SOC 873.

Hospital discharge planning. State law requires that every hospital have a written discharge planning policy and process. Hospitals are required to make arrangements for post-hospital care which includes care at home, in a skilled nursing facility, or intermediate care facility, and made prior to discharge for patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning. The discharge planning is not typically done with the diagnosing physician as prescribed in this bill; instead, a discharge planner who is knowledgeable in programs such as IHSS helps with this planning. Current law also requires that patients are allowed to identify one family caregiver who may assist in post-hospital care. The discharge information that is required to be give includes if someone is discharged and might be eligible for IHSS services.

According to the Author

"Receiving a terminal diagnosis is a challenging moment for the patient and their friends and family. Recognizing this difficulty, the state offers resources and support to ensure that patients' end of life care makes them as comfortable as possible. One of these resources is the In-Home Supportive Services program, in which an eligible patient is assigned an IHSS provider who assists them with daily tasks. This important resource is offered to terminal and non-terminal patients. Despite having radically different timelines, terminal and non-terminal patients are put through the same process. [This bill] expedites the process for terminal patients so that we mitigate the possibility of the process outliving them."

Arguments in Support

According to UDW/AFSCME Local 3930, "The IHSS program is a critical lifeline for many Californians who are elderly, disabled, or have a chronic medical condition. The program provides much-needed support to individuals who want to remain in their own homes rather than being placed in out-of-home care. However, many individuals who could benefit from the program are not aware of it or face significant barriers to enrollment. By requiring healthcare providers to inform patients about the IHSS program and the option to enroll as a provider, [this bill] would help to ensure that more Californians can access the support they need to remain in their homes."

Arguments in Opposition

No opposition on file.

FISCAL COMMENTS

According to the Senate Appropriations Committee August 14, 2023, unknown, ongoing General Fund cost pressures to reimburse counties for IHSS county staff to expedite cases. Cost to counties for administration would be potentially reimbursable by the state, subject to a determination by the Commission on State Mandates.

VOTES:

ASM HUMAN SERVICES: 7-0-1

YES: Jackson, Sanchez, Alanis, Arambula, Bonta, Bryan, Calderon

ABS, ABST OR NV: Garcia

ASM APPROPRIATIONS: 12-0-4

YES: Holden, Bryan, Calderon, Wendy Carrillo, Mike Fong, Hart, Lowenthal, Mathis, Papan, Pellerin, Weber, Ortega

ABS, ABST OR NV: Megan Dahle, Dixon, Robert Rivas, Sanchez

ASSEMBLY FLOOR: 80-0-0

YES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Cervantes, Chen, Connolly, Megan Dahle, Davies, Dixon, Essayli, Flora, Mike Fong, Vince Fong, Friedman, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, Mathis, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Rendon

SENATE FLOOR: 40-0-0

YES: Allen, Alvarado-Gil, Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dahle, Dodd, Durazo, Eggman, Glazer, Gonzalez, Grove, Hurtado, Jones, Laird, Limón, McGuire, Menjivar, Min, Newman, Nguyen, Niello, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Seyarto, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener, Wilk

UPDATED

VERSION: August 23, 2024

CONSULTANT: Alexandria Smith / HUM. S. / (916) 319-2089 FN: 0004704

 THIRD READING  

Bill No: AB 1005

Author: Alvarez (D)

Amended: 8/23/24 in Senate

Vote: 21

SENATE HUMAN SERVICES COMMITTEE: 5-0, 6/19/23

AYES: Alvarado-Gil, Ochoa Bogh, Hurtado, Menjivar, Wahab

SENATE HEALTH COMMITTEE: 12-0, 7/5/23

AYES: Eggman, Nguyen, Glazer, Gonzalez, Grove, Hurtado, Limón, Menjivar, Roth, Rubio, Wahab, Wiener

SENATE APPROPRIATIONS COMMITTEE: 7-0, 8/15/24

AYES: Caballero, Jones, Ashby, Becker, Bradford, Seyarto, Wahab

ASSEMBLY FLOOR: 80-0, 5/30/23 - See last page for vote

SUBJECT: In-home supportive services: terminal illness diagnosis

SOURCE: Author

DIGEST:

This bill requires a hospital’s designated case manager or discharge planner to evaluate a patient’s need for post-hospital services and ability to access those services, if that patient is being discharged from an acute care hospital and a Medi-Cal beneficiary. It also requires the hospital’s designated case manager or discharge planner to provide information to patients, if the patient is anticipated to need in-home personal care, about the in-home supportive services (IHSS) program and provide informational documents, as specified.

ANALYSIS:

Existing law:

1. Establishes the IHSS program to provide supportive services to individuals who are aged, blind, or living with disabilities, and who are unable to perform the services themselves or remain safely in their homes without receiving these services. (WIC 12300 et seq.)
2. Specifies that supportive services include: domestic services and services related to domestic services, heavy cleaning, personal care services, accompaniment by a provider when needed during necessary travel to health-related appointments or to alternative resource sites, yard hazard abatement, protective supervision, teaching and demonstration directed at reducing the need for other supportive services, and paramedical services which make it possible for the recipient to establish and maintain an independent living arrangement. Provides that personal care services mean all of the following:
3. Assistance with ambulation
4. Bathing, oral hygiene, and grooming
5. Dressing
6. Care and assistance with prosthetic devices
7. Bowel, bladder, and menstrual care
8. Repositioning, skin care, range of motion exercises, and transfers
9. Feeding and assurance of adequate fluid intake
10. Respiration
11. Assistance with self-administration of medications. (WIC 12300(b))
12. Requires, as a condition of receiving IHSS, an applicant for, or recipient of services to obtain a certification from a licensed health care professional, as specified, declaring that the applicant or recipient is unable to perform some activities of daily living (ADLs) independently, and that without services to assist the applicant or recipient with ADLs, the applicant or recipient is at risk of placement in out-of-home care. (WIC 12309.1)
13. Requires a county welfare department to assess each IHSS recipient’s continuing monthly need for IHSS at varying intervals as necessary, but at least once every 12 months. Further, requires the results of the assessment to be divided by 4.33 to establish a recipient’s weekly authorized number of hours of IHSS, subject to certain limitations, as specified. (WIC 12301.1(b))
14. Provides that a skilled nursing facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth in federal law. (42 Code of Federal Regulations 483.21(c) (1))
15. Requires that each hospital have a written discharge planning policy and process. (HSC 1262.5)
16. Defines the following terms:
    1. “Actively dying” to mean the phase of terminal illness when death is imminent;
    2. “Disease-targeted treatment” to mean treatment directed at the underlying disease or condition that is intended to alter its natural history or progression, irrespective of whether or not a cure is a possibility;
    3. “Health care provider” to mean an attending physician and surgeon, as well as a nurse practitioner or physician assistant practicing in accordance with standardized procedures or protocols developed and approved by the supervising physician and surgeon and the nurse practitioner or physician assistant;
    4. “Hospice” to mean a specialized form of interdisciplinary health care that is designed to provide palliative care, alleviate the physical, emotional, social, and spiritual discomforts of an individual who is experiencing the last phases of life due to the existence of a terminal disease, and provide supportive care to the primary caregiver and the family of the hospice patient. (HSC 442(a)-(d))

This bill:

1. Requires the hospital’s designated case manager or discharge planner, if a patient is discharged from an acute care hospital and a Medi-Cal beneficiary, to:
   1. Evaluate the patient’s need for post-hospital services and ability to access those services.
   2. Ask the patient or another person authorized to make health care decisions for the patient, if they are interested in receiving information about IHSS, if the patient is anticipated to need in-home personal care.
   3. Provide to the patient or authorized person information, including how to initiate the application process and the option for a family member to provide care as an IHSS provider subject to the set IHSS provider enrollment conditions, if they express interest in receiving IHSS information.
2. Stipulates that if the patient seeks to apply for services under the IHSS program, the hospital case manager or discharge planner is required to, as appropriate, communicate to the patient’s primary care physician the patient’s interest in applying for IHSS services to support the timely completion of the health care certification form.

Comments

According to the author, “Receiving a terminal diagnosis is a challenging moment for the patient and their friends and family. Recognizing this difficulty, the state offers resources and support to ensure that patients end of life care makes them as comfortable as possible. One of these resources is the IHSS program, in which an eligible patient is assigned an IHSS provider who assists them with daily tasks. This important resource is offered to [eligible] terminal and non-terminal patients. Despite having radically different timelines, terminal and non-terminal patients are put through the same process. AB 1005 expedites the process for terminal patients so that we mitigate the possibility of the process outliving them.”

In-Home Supportive Services (IHSS) program. The IHSS program provides personal care services to approximately 615,607 qualified low-income individuals who are blind, are at least 65 years old or older, or have disabilities. Personal Care Services include feeding, bathing, bowel and bladder care, meal preparation, and clean-up, laundry, and paramedical care. These services help program recipients avoid or delay more expensive and less desirable institutional care settings. Eligibility for IHSS may be tied to Medi-Cal or SSI eligibility, and all IHSS applicants and recipients must:

• Physically reside in the United States.
• Be a California resident.
• Have a Medi-Cal eligibility determination.
• Live at home or an abode of your own choosing (general acute care hospital, long-term care facilities, and licensed community care facilities are not considered "own home").
• Submit a completed Health Care Certification form (SOC 873 or its successor)

As of February 2023, there were 613,410 IHSS providers in California; 95.5 percent of providers are a relative, spouse, or parent of the recipient, and 55.6 percent of providers live in the same residence as the recipient, according to data provided by California Department of Social Services (CDSS). Additionally, approximately 15 percent of IHSS consumers are 85 years of age or older, 40 percent are ages 65-84, 36 percent are ages 18-64, and eight percent are 17 years of age or younger. Recipients of IHSS select, hire, and manage their service providers.

IHSS Eligibility Determinations. CDSS oversees the IHSS program, but it is administered at the county level. County social workers determine IHSS eligibility and perform case management after conducting a standardized in-home assessment of an individual’s ability to perform activities of daily living. In general, most social workers annually reassess recipients’ need for services. Based on authorized hours and services, IHSS recipients are responsible for hiring, firing, and directing their IHSS provider(s). These responsibilities include some administrative duties, such as scheduling and signing timesheets; however, the state handles payroll. Providers also must complete an enrollment process that includes submitting fingerprint images for a criminal background check and participating in a provider orientation prior to receiving IHSS payments for services they provide. The average number of service hours provided to IHSS recipients in 2022-23 is estimated to be 116 hours per month.

Discharge Planning. Discharge planning is the process of supporting a patient’s transition from one level of care to the next. The discharge planning processes must address the individual patient’s goals, needs and treatment preferences, and provide an opportunity for the patient and/or designated caregiver to engage in the discharge planning process.  In the hospital setting, discharge planning must include an evaluation of a patient’s likely need for post-hospital services, including post-acute medical care, extended care services, and non-health care services. The discharge planning evaluation must also include a determination of the availability of appropriate services and the patient’s ability to access those services. The discharge planner is typically someone who is knowledgeable about post-hospital care programs, such as IHSS. State law requires every hospital to have a written discharge planning policy and process.

Related/Prior Legislation:

AB 1387 (Ting, 2023) would have established a grant program to encourage immigrants to become IHSS providers. The bill was held in the Assembly Appropriations Committee.

FISCAL EFFECT: Appropriation: No Fiscal Com.: No Local: No

According to Senate Appropriations Committee, “Unknown, ongoing General Fund cost pressures to reimburse counties for IHSS county staff to expedite cases. Cost to counties for administration would be potentially reimbursable by the state, subject to a determination by the Commission on State Mandates.”

SUPPORT: (Verified 8/23/24)

California Commission on Aging
UDW/AFSCME Local 3930

OPPOSITION: (Verified 8/23/24)

None received

ASSEMBLY FLOOR: 80-0, 5/30/23

AYES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Cervantes, Chen, Connolly, Megan Dahle, Davies, Dixon, Essayli, Flora, Mike Fong, Vince Fong, Friedman, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, Mathis, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Rendon

Prepared by: Naima FordAntal / HUMAN S. / (916) 651-1524

8/26/24 11:53:07

**** END ****

 THIRD READING  

Bill No: AB 1005

Author: Alvarez (D)

Amended: 6/21/23 in Senate

Vote: 21

SENATE HUMAN SERVICES COMMITTEE: 5-0, 6/19/23

AYES: Alvarado-Gil, Ochoa Bogh, Hurtado, Menjivar, Wahab

SENATE HEALTH COMMITTEE: 12-0, 7/5/23

AYES: Eggman, Nguyen, Glazer, Gonzalez, Grove, Hurtado, Limón, Menjivar, Roth, Rubio, Wahab, Wiener

SENATE APPROPRIATIONS COMMITTEE: 7-0, 8/15/24

AYES: Caballero, Jones, Ashby, Becker, Bradford, Seyarto, Wahab

ASSEMBLY FLOOR: 80-0, 5/30/23 - See last page for vote

SUBJECT: In-home supportive services: terminal illness diagnosis

SOURCE: Author

DIGEST:

This bill requires a hospital’s designated case manager or discharge planner to evaluate a patient’s need for post-hospital services and ability to access those services, if that patient is being discharged from an acute care hospital and a Medi-Cal beneficiary. It also requires the hospital’s designated case manager or discharge planner to provide information to patients, if the patient is anticipated to need in-home personal care, about the in-home supportive services (IHSS) program and provide informational documents, as specified. This bill also requires counties, to the extent feasible, to consider expediting the applications of these patients if they make a requested to expedite their application.

ANALYSIS:

Existing law:

1. Establishes the IHSS program to provide supportive services to individuals who are aged, blind, or living with disabilities, and who are unable to perform the services themselves or remain safely in their homes without receiving these services. (WIC 12300 et seq.)
2. Specifies that supportive services include: domestic services and services related to domestic services, heavy cleaning, personal care services, accompaniment by a provider when needed during necessary travel to health-related appointments or to alternative resource sites, yard hazard abatement, protective supervision, teaching and demonstration directed at reducing the need for other supportive services, and paramedical services which make it possible for the recipient to establish and maintain an independent living arrangement. Provides that personal care services mean all of the following:
3. Assistance with ambulation;
4. Bathing, oral hygiene, and grooming;
5. Dressing;
6. Care and assistance with prosthetic devices;
7. Bowel, bladder, and menstrual care;
8. Repositioning, skin care, range of motion exercises, and transfers;
9. Feeding and assurance of adequate fluid intake;
10. Respiration; and
11. Assistance with self-administration of medications. (WIC 12300(b))
12. Requires, as a condition of receiving IHSS, an applicant for, or recipient of services to obtain a certification from a licensed health care professional, as specified, declaring that the applicant or recipient is unable to perform some activities of daily living (ADLs) independently, and that without services to assist the applicant or recipient with ADLs, the applicant or recipient is at risk of placement in out-of-home care. (WIC 12309.1)
13. Requires a county welfare department to assess each IHSS recipient’s continuing monthly need for IHSS at varying intervals as necessary, but at least once every 12 months. Further, requires the results of the assessment to be divided by 4.33 to establish a recipient’s weekly authorized number of hours of IHSS, subject to certain limitations, as specified. (WIC 12301.1(b))
14. Provides that a skilled nursing facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth in federal law. (42 Code of Federal Regulations 483.21(c) (1))
15. Requires that each hospital have a written discharge planning policy and process. (HSC 1262.5)
16. Defines the following terms:
    1. “Actively dying” to mean the phase of terminal illness when death is imminent;
    2. “Disease-targeted treatment” to mean treatment directed at the underlying disease or condition that is intended to alter its natural history or progression, irrespective of whether or not a cure is a possibility;
    3. “Health care provider” to mean an attending physician and surgeon, as well as a nurse practitioner or physician assistant practicing in accordance with standardized procedures or protocols developed and approved by the supervising physician and surgeon and the nurse practitioner or physician assistant;
    4. “Hospice” to mean a specialized form of interdisciplinary health care that is designed to provide palliative care, alleviate the physical, emotional, social, and spiritual discomforts of an individual who is experiencing the last phases of life due to the existence of a terminal disease, and provide supportive care to the primary caregiver and the family of the hospice patient. (HSC 442(a)-(d))

This bill:

1. Makes several legislative finding and declarations that patients diagnosed with a terminal illness, who meets all of the IHSS eligibility criteria, and who is interested in receiving services under the IHSS program, be provided a more streamlined, automatic application process for IHSS.
2. Requires the hospital’s designated case manager or discharge planner, if a patient is discharged from an acute care hospital and a Medi-Cal beneficiary, to:
   1. Evaluate the patient’s need for post-hospital services and ability to access those services.
   2. Ask the patient or another person authorized to make health care decisions for the patient, if they are interested in receiving information about the IHSS, if the patient is anticipated to need in-home personal care.
   3. Provide to the patient or authorized person information, including the how to initiate the application process and the option for a family member to provide care as an IHSS provider subject to the set IHSS provider enrollment conditions, if they express interest in receiving IHSS information.
3. Stipulates that if the patient seeks to apply for services under the IHSS program, the hospital case manager or discharge planner is required to, as appropriate, communicate to the patient’s primary care physician the patient’s interest in applying for IHSS services to support the timely completion of the health care certification form.
4. Permits a patient to request to have their application expedited by the county if the patient diagnosed with a terminal illness seeks to apply for services under the IHSS program, and receives a completed health care certification form, as specified.
5. Requires counties, to the extent feasible, to consider expediting the applications of patients who have been diagnosed with a terminal illness and who have requested that their application be expedited.
6. Defines “terminal illness” to have the same meaning as it is interpreted by current law, as specified.
7. Allows CDSS to implement, interpret, or make specific this section by means of all-county letters or similar instructions, until regulations are adopted.

Requires the provisions of this bill pertaining to a streamlined IHSS application process for individuals diagnosed with a terminal illness to be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available for the purposes of providing IHSS.

1. Provides, if the Commission on State Mandates determines that this act contains costs mandated by the state, that reimbursement to local agencies and school districts for those costs be made.

Comments

According to the author, “Receiving a terminal diagnosis is a challenging moment for the patient and their friends and family. Recognizing this difficulty, the state offers resources and support to ensure that patients end of life care makes them as comfortable as possible. One of these resources is the IHSS program, in which an eligible patient is assigned an IHSS provider who assists them with daily tasks. This important resource is offered to [eligible] terminal and non-terminal patients. Despite having radically different timelines, terminal and non-terminal patients are put through the same process. AB 1005 expedites the process for terminal patients so that we mitigate the possibility of the process outliving them.”

In-Home Supportive Services (IHSS) program. The IHSS program provides personal care services to approximately 615,607 qualified low-income individuals who are blind, are at least 65 years old or older, or have disabilities. Personal Care Services include feeding, bathing, bowel and bladder care, meal preparation, and clean-up, laundry, and paramedical care. These services help program recipients avoid or delay more expensive and less desirable institutional care settings. Eligibility for IHSS may be tied to Medi-Cal or SSI eligibility, and all IHSS applicants and recipients must:

• Physically reside in the United States.
• Be a California resident.
• Have a Medi-Cal eligibility determination.
• Live at home or an abode of your own choosing (general acute care hospital, long-term care facilities, and licensed community care facilities are not considered "own home").
• Submit a completed Health Care Certification form (SOC 873 or its successor)

As of February 2023, there were 613,410 IHSS providers in California; 95.5 percent of providers are a relative, spouse, or parent of the recipient, and 55.6 percent of providers live in the same residence as the recipient, according to data provided by CDSS. Additionally, approximately 15 percent of IHSS consumers are 85 years of age or older, 40 percent are ages 65-84, 36 percent are ages 18-64, and eight percent are 17 years of age or younger. Recipients of IHSS select, hire, and manage their service providers.

IHSS Eligibility Determinations. CDSS oversees the IHSS program, but it is administered at the county level. County social workers determine IHSS eligibility and perform case management after conducting a standardized in-home assessment of an individual’s ability to perform activities of daily living. In general, most social workers annually reassess recipients’ need for services. Based on authorized hours and services, IHSS recipients are responsible for hiring, firing, and directing their IHSS provider(s). These responsibilities include some administrative duties, such as scheduling and signing timesheets; however, the state handles payroll. Providers also must complete an enrollment process that includes submitting fingerprint images for a criminal background check and participating in a provider orientation prior to receiving IHSS payments for services they provide. The average number of service hours provided to IHSS recipients in 2022-23 is estimated to be 116 hours per month.

In most cases services through IHSS are not started until the person returns to their home. Some applicants for IHSS, however, can’t be released to their home unless hazards or other issues are resolved in the home first, i.e. deep cleaning of the home to remove hazardous debris or dirt. A county social worker would then complete a preliminary IHSS assessment for the applicant in the institution to determine the individual’s needs before they return home. Once the hazards are resolved and the individual returns home, the social worker would then conduct a second assessment at the applicant’s home. There currently is no system in place to expedite the IHSS determination process for any applicants. This bill would require counties to consider expediting IHSS applications upon the request of a terminally ill patient.

Discharge Planning. Discharge planning is the process of supporting a patient’s transition from one level of care to the next. The discharge planning processes must address the individual patient’s goals, needs and treatment preferences, and provide an opportunity for the patient and/or designated caregiver to engage in the discharge planning process.  In the hospital setting, discharge planning must include an evaluation of a patient’s likely need for post-hospital services, including post-acute medical care, extended care services, and non-health care services. The discharge planning evaluation must also include a determination of the availability of appropriate services and the patient’s ability to access those services. The discharge planner is typically someone who is knowledgeable about post-hospital care programs, such as IHSS. State law requires every hospital to have a written discharge planning policy and process.

Medi-Cal beneficiaries who need assistance with ADLs in order to remain at home may be able to receive IHSS.  In these cases, hospital-based case managers/discharge planners will provide information about the IHSS program including the application and county contact information, and may facilitate the patient’s communication with their primary care physician or other qualified provider to complete required documentation. This bill would require the diagnosing health care provider, rather than a hospital-based case manager or discharge planner, to provide IHSS information to all discharging terminally ill patients. 

Related/Prior Legislation

AB 1387 (Ting, 2023) would have established a grant program to encourage immigrants to become IHSS providers. This bill was held in the Assembly Appropriations Committee.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes

According to the Senate Appropriations Committee,

Unknown, ongoing General Fund cost pressures to reimburse counties for IHSS county staff to expedite cases. Cost to counties for administration would be potentially reimbursable by the state, subject to a determination by the Commission on State Mandates.

SUPPORT: (Verified 8/14/24)

California Commission on Aging

UDW/AFSCME Local 3930

OPPOSITION: (Verified 8/14/24)

None received

ASSEMBLY FLOOR: 80-0, 5/30/23

AYES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Cervantes, Chen, Connolly, Megan Dahle, Davies, Dixon, Essayli, Flora, Mike Fong, Vince Fong, Friedman, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, Mathis, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Rendon

Prepared by: Naima FordAntal / HUMAN S. / (916) 651-1524

8/16/24 12:47:27

**** END ****

SENATE COMMITTEE ON APPROPRIATIONS

Senator Anthony Portantino, Chair

2023 - 2024 Regular Session

AB 1005 (Alvarez) - In-home supportive services: terminal illness diagnosis

Bill Summary:

AB 1005 would require that a patient diagnosed with a terminal illness be provided with certain information about the In-Home Supportive Services (IHSS) program prior to being discharged from a hospital. The bill would also require counties to consider expediting the IHSS applications of patients who have been diagnosed with a terminal illness and who have requested that their application be expedited.

Fiscal Impact:

Unknown, ongoing General Fund cost pressures to reimburse counties for IHSS county staff to expedite cases. Cost to counties for administration would be potentially reimbursable by the state, subject to a determination by the Commission on State Mandates.

Background:

The IHSS program provides supportive services to low-income individuals who are aged, blind, or living with disabilities, and who are unable to perform the services themselves or remain safely in their homes without receiving these services. County social workers determine IHSS eligibility and perform case management after conducting a standardized in-home assessment of an individual’s ability to perform activities of daily living.

Discharge planning is the process of supporting a patient’s transition from one level of care to the next. The discharge planning processes must address the individual patient’s goals, needs and treatment preferences, and provide an opportunity for the patient and/or designated caregiver to engage in the discharge planning process.  State law requires every hospital to have a written discharge planning policy and process. In the hospital setting, discharge planning must include an evaluation of a patient’s likely need for post-hospital services, including post-acute medical care, extended care services, and non-health care services. The discharge planning evaluation must also include a determination of the availability of appropriate services and the patient’s ability to access those services. The discharge planner is typically someone who is knowledgeable about post-hospital care programs, such as IHSS.

Medi-Cal beneficiaries who need assistance with certain activities in order to remain at home may be able to receive IHSS. In these cases, hospital-based case managers/discharge planners will provide information about the IHSS program including the application and county contact information, and may facilitate the patient’s communication with their primary care physician or other qualified provider to complete required documentation.

Proposed Law:

Specific provisions of the bill would:

• Require that before the discharge from an acute care hospital of a Medi-Cal beneficiary diagnosed with a terminal illness, the hospital’s designated case manager or discharge planner must evaluate the patient’s likely need for post-hospital services and their ability to access those services; for patients anticipated to need in-home personal care, the hospital case manager or discharge planner must ask if the patient is interested in receiving information about IHSS; if the patient is interested, the hospital case manager or discharge planner must provide information to the patient, including how to initiate the application process and the option for a family member to provide care as an IHSS provider, as specified.
• Require that if the patient seeks to apply for the IHSS program, the hospital case manager or discharge planner must communicate to the patient’s primary care physician to support the timely completion of the health care certification form, as specified.
• Require that if a patient diagnosed with a terminal illness seeks to apply for the IHSS program, the patient may request to have their application expedited by the county; and require that to the extent feasible, counties must consider expediting the applications of patients who have been diagnosed with a terminal illness and who have requested that their application be expedited.

-- END --

SENATE COMMITTEE ON APPROPRIATIONS

Senator Anthony Portantino, Chair

2023 - 2024 Regular Session

AB 1005 (Alvarez) - In-home supportive services: terminal illness diagnosis

Bill Summary:

AB 1005 would require that a patient diagnosed with a terminal illness be provided with certain information about the In-Home Supportive Services (IHSS) program prior to being discharged from a hospital. The bill would also require counties to consider expediting the IHSS applications of patients who have been diagnosed with a terminal illness and who have requested that their application be expedited.

Fiscal Impact:

Unknown, ongoing General Fund cost pressures to reimburse counties for IHSS county staff to expedite cases. Cost to counties for administration would be potentially reimbursable by the state, subject to a determination by the Commission on State Mandates.

Background:

The IHSS program provides supportive services to low-income individuals who are aged, blind, or living with disabilities, and who are unable to perform the services themselves or remain safely in their homes without receiving these services. County social workers determine IHSS eligibility and perform case management after conducting a standardized in-home assessment of an individual’s ability to perform activities of daily living.

Discharge planning is the process of supporting a patient’s transition from one level of care to the next. The discharge planning processes must address the individual patient’s goals, needs and treatment preferences, and provide an opportunity for the patient and/or designated caregiver to engage in the discharge planning process.  State law requires every hospital to have a written discharge planning policy and process. In the hospital setting, discharge planning must include an evaluation of a patient’s likely need for post-hospital services, including post-acute medical care, extended care services, and non-health care services. The discharge planning evaluation must also include a determination of the availability of appropriate services and the patient’s ability to access those services. The discharge planner is typically someone who is knowledgeable about post-hospital care programs, such as IHSS.

Medi-Cal beneficiaries who need assistance with certain activities in order to remain at home may be able to receive IHSS. In these cases, hospital-based case managers/discharge planners will provide information about the IHSS program including the application and county contact information, and may facilitate the patient’s communication with their primary care physician or other qualified provider to complete required documentation.

Proposed Law:

Specific provisions of the bill would:

• Require that before the discharge from an acute care hospital of a Medi-Cal beneficiary diagnosed with a terminal illness, the hospital’s designated case manager or discharge planner must evaluate the patient’s likely need for post-hospital services and their ability to access those services; for patients anticipated to need in-home personal care, the hospital case manager or discharge planner must ask if the patient is interested in receiving information about IHSS; if the patient is interested, the hospital case manager or discharge planner must provide information to the patient, including how to initiate the application process and the option for a family member to provide care as an IHSS provider, as specified.
• Require that if the patient seeks to apply for the IHSS program, the hospital case manager or discharge planner must communicate to the patient’s primary care physician to support the timely completion of the health care certification form, as specified.
• Require that if a patient diagnosed with a terminal illness seeks to apply for the IHSS program, the patient may request to have their application expedited by the county; and require that to the extent feasible, counties must consider expediting the applications of patients who have been diagnosed with a terminal illness and who have requested that their application be expedited.

-- END --

SENATE COMMITTEE ON HEALTH

Senator Dr. Susan Talamantes Eggman, Chair

BILL NO: AB 1005

SUBJECT: In-home supportive services: terminal illness diagnosis

SUMMARY:

Requires a hospital case manager or discharge planner to ask before discharge from an acute care hospital of a Medi-Cal beneficiary diagnosed with a terminal illness if the patient is interested in receiving information about In Home Supportive Services (IHSS) and if so, as appropriate, communicate with the patient’s primary care provider to support the timely completion of necessary forms.

Existing law:

1. Establishes the Medi-Cal program, administered by the Department of Health Care Services (DHCS), under which low-income individuals are eligible for comprehensive medical coverage; and, the Department of Social Services (DSS), which also administers or supervises activities and functions of public social services, including the In Home Supportive Services (IHSS) program. [WIC §14000, et seq. and WIC §10050, et seq.]
   
2. Establishes the IHSS to provide supportive services to aged, blind, or disabled persons who are unable to perform the services themselves and who cannot safely remain in their homes or abodes of their own choosing unless these services are provided. Services include personal care services such as assistance bathing, dressing, feeding, and self-administering medications. [WIC §12300 et. seq]
   
3. Establishes personal care services, when provided to a categorically needy person under Medi-Cal, as a covered benefit to the extent federal financial participation is available, as specified. These services are similar to those described in 2) above and include paramedical services and others. Directs DHCS to seek federal approval to provide self-directed personal assistance known as IHSS Plus option, and a system of services and supports, as specified. [WIC §14132.95, §14132.952, §14132.956, and §14132.97]
   
4. Establishes the End of Life Option Act, which requires a health care provider, when making a diagnosis that a person has a terminal illness, to notify the patient of his or her right to comprehensive information and counseling regarding legal end-of-life options, and, authorizes the provider to refer the patient to a hospice provider or others that specialize in end-of-life care case management, as specified. [HSC §442 et. seq.]
   
5. Requires each hospital to have a written discharge planning policy and process that requires appropriate arrangements for posthospital care, including, but not limited to, care at home, in a skilled nursing or intermediate care facility, or from a hospice, that are made prior to discharge for those patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning. If the hospital determines that the patient and family members or interested persons need to be counseled to prepare them for posthospital care, requires the hospital to provide for that counseling. [HSC §1262.5]
   

This bill:

1. Requires, before the discharge from an acute care hospital of a Medi-Cal beneficiary diagnosed with a terminal illness, the hospital’s designated case manager or discharge planner to evaluate the patient’s likely need for posthospital services and their ability to access those services.
   
2. Requires for patients anticipated to need in-home personal care, the hospital case manager or discharge planner to ask the patient, or another person authorized to make health care decisions for the patient, if they are interested in receiving information about the IHSS program, and requires the hospital case manager or discharge planner to provide to the patient, or authorized person, the information, including how to initiate the application process and the option for a family member to provide care as an IHSS provider subject to the IHSS provider enrollment conditions, as specified.
   
3. Requires, if the patient seeks to apply for IHSS, the hospital case manager or discharge planner to, as appropriate, communicate to the patient’s primary care physician the patient’s interest in applying for IHSS to support the timely completion of the health care certification form (SOC 873 or its successor).
   
4. Authorizes, if a patient seeks to apply for IHSS and receives a health care certification form (SOC 873 or its successor) that is completed by a health care provider, the patient to request to have their application expedited by the county.
   
5. Requires to the extent feasible, counties to consider expediting the applications of patients who have been diagnosed with a terminal illness and who have requested that their application be expedited.
   
6. Indicates terminal illness has the same meaning as interpreted in the End of Life Option Act.
   
7. Authorizes DSS or DHCS to implement, interpret, or make specific this bill by means of all-county letters or similar instructions, until regulations are adopted.
   
8. Implements this bill only to the extent that any necessary federal approvals are obtained and federal financial participation is available for purposes of providing IHSS, as specified.

FISCAL EFFECT:

According to the Assembly Appropriations Committee on May 18, 2023, local costs to counties, likely minor, to consider expediting IHSS applications for terminally ill patients who request an expedited process. These costs are unknown, but are potentially reimbursable by the state, subject to a determination by the Commission on State Mandates.

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, receiving a terminal diagnosis is a challenging moment for the patient and their friends and family. Recognizing this difficulty, the state offers resources and support to ensure that patients end of life care makes them as comfortable as possible. One of these resources is the IHSS program, in which an eligible patient is assigned an IHSS provider who assists them with daily tasks. This important resource is offered to terminal and non-terminal patients. Despite having radically different timelines, terminal and non-terminal patients are put through the same process. This bill expedites the process for terminal patients so that we mitigate the possibility of the process outliving them.
2. Double referral. This bill was heard in the Senate Human Services Committee on June 19, 2023, and passed with a 5-0 vote. It will be heard in this committee on July 5, 2023.
   
3. Support. The UDW/AFSCME Local 3930 writes the IHSS program is a critical lifeline for many Californians who are elderly, disabled, or have a chronic medical condition. The program provides much-needed support to individuals who want to remain in their own homes rather than being placed in out-of-home care. However, many individuals who could benefit from the program are not aware of it or face significant barriers to enrollment. By requiring healthcare providers to inform patients about the IHSS program and the option to enroll as a provider, this bill would help to ensure that more Californians can access the support they need to remain in their homes. This information could be particularly valuable for patients with a terminal illness who require specialized care and support. Furthermore, the bill would expedite the application process for patients diagnosed with terminal illnesses, providing critical support during a challenging time. The ability to access IHSS services quickly and easily could make a significant difference for these patients and their families.

SUPPORT AND OPPOSITION:

Support: California Commission on Aging

California Senior Legislature

UDW/AFSCME Local 3930

Oppose: None received

-- END --

SENATE COMMITTEE ON HUMAN SERVICES

Senator Alvarado-Gil, Chair

2023 - 2024 Regular

Subject: In-home supportive services: terminal illness diagnosis.

SUMMARY

This bill would require diagnosing health care providers to provide information to patients who have been diagnosed with a terminal illness about the in-home supportive services (IHSS) program and provide certification documents, as specified. This bill also requires counties, to the extent feasible, to consider expediting the applications of these patients if they make a requested to expedite their application.

ABSTRACT

Existing Law:

1. Establishes the IHSS program to provide supportive services to individuals who are aged, blind, or living with disabilities, and who are unable to perform the services themselves or remain safely in their homes without receiving these services. (WIC 12300 et seq.)
2. Specifies that supportive services include: domestic services and services related to domestic services, heavy cleaning, personal care services, accompaniment by a provider when needed during necessary travel to health-related appointments or to alternative resource sites, yard hazard abatement, protective supervision, teaching and demonstration directed at reducing the need for other supportive services, and paramedical services which make it possible for the recipient to establish and maintain an independent living arrangement. Provides that personal care services mean all of the following:
3. Assistance with ambulation
4. Bathing, oral hygiene, and grooming
5. Dressing
6. Care and assistance with prosthetic devices
7. Bowel, bladder, and menstrual care
8. Repositioning, skin care, range of motion exercises, and transfers
9. Feeding and assurance of adequate fluid intake
10. Respiration
11. Assistance with self-administration of medications. (WIC 12300(b))
12. Requires, as a condition of receiving IHSS, an applicant for, or recipient of services to obtain a certification from a licensed health care professional, as specified, declaring that the applicant or recipient is unable to perform some activities of daily living (ADLs) independently, and that without services to assist the applicant or recipient with ADLs, the applicant or recipient is at risk of placement in out-of-home care. (WIC 12309.1)
13. Requires a county welfare department to assess each IHSS recipient’s continuing monthly need for IHSS at varying intervals as necessary, but at least once every 12 months. Further, requires the results of the assessment to be divided by 4.33 to establish a recipient’s weekly authorized number of hours of IHSS, subject to certain limitations, as specified. (WIC 12301.1(b))
14. Provides that a skilled nursing facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth in federal law. (42 Code of Federal Regulations 483.21(c) (1))
15. Requires that each hospital have a written discharge planning policy and process. (HSC 1262.5)
16. Defines the following terms:
    1. “Actively dying” to mean the phase of terminal illness when death is imminent;
    2. “Disease-targeted treatment” to mean treatment directed at the underlying disease or condition that is intended to alter its natural history or progression, irrespective of whether or not a cure is a possibility;
    3. “Health care provider” to mean an attending physician and surgeon, as well as a nurse practitioner or physician assistant practicing in accordance with standardized procedures or protocols developed and approved by the supervising physician and surgeon and the nurse practitioner or physician assistant;
    4. “Hospice” to mean a specialized form of interdisciplinary health care that is designed to provide palliative care, alleviate the physical, emotional, social, and spiritual discomforts of an individual who is experiencing the last phases of life due to the existence of a terminal disease, and provide supportive care to the primary caregiver and the family of the hospice patient. (HSC 442(a)-(d))

This Bill:

1. Makes several Legislative finding and declarations that patients diagnosed with a terminal illness, who meets all of the IHSS eligibility criteria, and who is interested in receiving services under the IHSS program, be provided a more streamlined, automatic application process for IHSS.
2. Requires the diagnosing health care provider, before the discharge of a patient diagnosed with a terminal illness, to:
   1. Ask the patient or another person authorized to make health care decisions for the patient, if they are interested in receiving information about the IHSS.
   2. Disclose to the patient or authorized person the information, including the IHSS eligibility criteria and the option for a family member to provide care as an IHSS provider subject to the set IHSS provider enrollment conditions, if they express interest in receiving IHSS information.
3. Stipulates that if the patient seeks to apply for services under the IHSS program, for the health care provider to provide a copy of the health care certification form with the health care provider’s portion completed before the patient’s discharge.
4. Permits a patient to request to have their application expedited by the county if the patient diagnosed with a terminal illness seeks to apply for services under the IHSS program, and receives a completed health care certification form, as specified.
5. Requires counties, to the extent feasible, to consider expediting the applications of patients who have been diagnosed with a terminal illness and who have requested that their application be expedited.
6. Defines “terminal illness” to have the same meaning as it is interpreted by current law, as specified.
7. Allows CDSS to implement, interpret, or make specific this section by means of all-county letters or similar instructions, until regulations are adopted.

Requires the provisions of this bill pertaining to a streamlined IHSS application process for individuals diagnosed with a terminal illness to be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available for the purposes of providing IHSS.

1. Provides, if the Commission on State Mandates determines that this act contains costs mandated by the state, that reimbursement to local agencies and school districts for those costs be made.

FISCAL IMPACT

According to an Assembly Appropriations Committee analysis dated May 17, 2023, this bill has local costs to counties, one-time and ongoing, to establish and administer a process for prioritizing IHSS applications. These costs are unknown, but likely greater than $150,000 statewide. These costs are potentially reimbursable by the state, subject to a determination by the Commission on State Mandates.

BACKGROUND AND DISCUSSION

Purpose of the Bill:

According to the author, “Receiving a terminal diagnosis is a challenging moment for the patient and their friends and family. Recognizing this difficulty, the state offers resources and support to ensure that patients end of life care makes them as comfortable as possible. One of these resources is the IHSS program, in which an eligible patient is assigned an IHSS provider who assists them with daily tasks. This important resource is offered to [eligible] terminal and non-terminal patients. Despite having radically different timelines, terminal and non-terminal patients are put through the same process. AB 1005 expedites the process for terminal patients so that we mitigate the possibility of the process outliving them.”

In-Home Supportive Services (IHSS) program

The IHSS program provides personal care services to approximately 615,607 qualified low-income individuals who are blind, are at least 65 years old or older, or have disabilities. Personal Care Services include feeding, bathing, bowel and bladder care, meal preparation, and clean-up, laundry, and paramedical care. These services help program recipients avoid or delay more expensive and less desirable institutional care settings. Eligibility for IHSS may be tied to Medi-Cal or SSI eligibility, and all IHSS applicants and recipients must:

• Physically reside in the United States.
• Be a California resident.
• Have a Medi-Cal eligibility determination.
• Live at home or an abode of your own choosing (general acute care hospital, long-term care facilities, and licensed community care facilities are not considered "own home").
• Submit a completed Health Care Certification form (SOC 873 or its successor)

As of February 2023, there were 613,410 IHSS providers in California; 95.5 percent of providers are a relative, spouse, or parent of the recipient, and 55.6 percent of providers live in the same residence as the recipient, according to data provided by CDSS. Additionally, approximately 15 percent of IHSS consumers are 85 years of age or older, 40 percent are ages 65-84, 36 percent are ages 18-64, and eight percent are 17 years of age or younger. Recipients of IHSS select, hire, and manage their service providers.

IHSS Eligibility Determinations

CDSS oversees the IHSS program, but it is administered at the county level. County social workers determine IHSS eligibility and perform case management after conducting a standardized in-home assessment of an individual’s ability to perform activities of daily living. In general, most social workers annually reassess recipients’ need for services. Based on authorized hours and services, IHSS recipients are responsible for hiring, firing, and directing their IHSS provider(s). These responsibilities include some administrative duties, such as scheduling and signing timesheets; however, the state handles payroll. Providers also must complete an enrollment process that includes submitting fingerprint images for a criminal background check and participating in a provider orientation prior to receiving IHSS payments for services they provide. The average number of service hours provided to IHSS recipients in 2022-23 is estimated to be 116 hours per month.

In most cases services through IHSS are not started until the person returns to their home. Some applicants for IHSS, however, can’t be released to their home unless hazards or other issues are resolved in the home first, i.e. deep cleaning of the home to remove hazardous debris or dirt. A county social worker would then complete a preliminary IHSS assessment for the applicant in the institution to determine the individual’s needs before they return home. Once the hazards are resolved and the individual returns home, the social worker would then conduct a second assessment at the applicant’s home. There currently is no system in place to expedite the IHSS determination process for any applicants. This bill would require counties to consider expediting IHSS applications upon the request of a terminally ill patient.

Discharge Planning

Discharge planning is the process of supporting a patient’s transition from one level of care to the next. The discharge planning processes must address the individual patient’s goals, needs and treatment preferences, and provide an opportunity for the patient and/or designated caregiver to engage in the discharge planning process.  In the hospital setting, discharge planning must include an evaluation of a patient’s likely need for post-hospital services, including post-acute medical care, extended care services, and non-health care services. The discharge planning evaluation must also include a determination of the availability of appropriate services and the patient’s ability to access those services. The discharge planner is typically someone who is knowledgeable about post-hospital care programs, such as IHSS. State law requires every hospital to have a written discharge planning policy and process.

Medi-Cal beneficiaries who need assistance with ADLs in order to remain at home may be able to receive IHSS.  In these cases, hospital-based case managers/discharge planners will provide information about the IHSS program including the application and county contact information, and may facilitate the patient’s communication with their primary care physician or other qualified provider to complete required documentation. This bill would require the diagnosing health care provider, rather than a hospital-based case manager or discharge planner, to provide IHSS information to all discharging terminally ill patients. 

Related/Prior Legislation:

AB 1387 (Ting, 2023) would have established a grant program to encourage immigrants to become IHSS providers. This bill was held in the Assembly Appropriations Committee.

COMMENTS

The IHSS program provides personal care services to qualified low-income individuals who are blind, are at least 65 years old or older, or have disabilities. This bill seeks to ensure that terminally ill patients, prior to discharging, receive information about and are able to apply to receive services through the IHSS program. Current law allows patients to identify one family caregiver who may assist in post-hospital care. The discharge information that is required to be provided to patients includes information about eligibility for IHSS services. Therefore, this bill would not change the information disseminated, but does change who would be required to provide the patient and their family information on the IHSS program.

As the bill is currently written, it is not clear which type of in-patient care facilities discharging terminally ill patients are included in the scope of the bill. The author may wish to add clarifying language to state the type of facility the bill’s provisions would affect i.e. a general acute care hospital.

The bill also requires diagnosing health care providers of terminally ill patients to ask all of their patients and their family if they are interested in receiving information about IHSS, and if they are, to provide this information, including IHSS eligibility criteria. Additionally, for those patients who wish to apply, the diagnosing health care provider must also complete a county Health Care Certification form prior to the patient’s discharge. Since discharge planners or other qualified staff, rather than a diagnosing health care provider, currently complete the discharge plans required by state and federal law, these new requirements may be problematic to implement. Diagnosing health care providers, such as physicians, often lack knowledge of the outside services and supports available to patients once they discharge. Requiring physicians to ask all of their terminally ill patients their interest in the IHSS program may lead to interested patients and/or their authorized caregivers being disappointed when they are denied services due to being ineligible.

The author’s office is actively working to address the issues raised by committee staff above and other stakeholders, including clarifying that the provision relating to an acute care hospital discharge and changing who provides the IHSS information to the patient and their family from the diagnosing health care provider to the hospital’s designated case manager or discharge planner. The author’s office states its commitment to continue to work on the bill should it pass out of this committee.

Double Referral: This bill has been double-referred. Should this bill pass out of this Committee, it will be referred to the Senate Committee on Health.

PRIOR VOTES

POSITIONS

Support:

None received

Oppose:

None received

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 1005

Author:(Alvarez)

As Amended Ver:May 18, 2023

Majority vote

SUMMARY

Permits patients diagnosed with a terminal illness to request an expedited In-Home Supportive Services (IHSS) application process.

Major Provisions

1. Permits, if a patient who is diagnosed with a terminal illness and seeks to apply for services under the IHSS program and receive a healthcare certification form, as specified, the patient may request to have their to application process expedited by the county.
2. Requires, to the extent feasible, counties to consider expediting the applications of patients who have been diagnosed with a terminal illness and who have requested that their application be expedited.
3. Permits CDSS to implement, interpret, or make specific, certain provisions of this bill by means of all-county letters or similar instructions, until regulations are adopted.
4. Requires the provisions of this bill pertaining to a streamlined IHSS application process for individuals diagnosed with a terminal illness be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available for the purposes of providing IHSS.

COMMENTS

In-Home Supportive Services Program. Eligible low-income individuals in California who are at least 65 years old, living with disabilities, or blind, may access services through the IHSS program that enable them to remain in their own homes. IHSS program providers are paid to assist with personal care services (such as bathing, toileting, and grooming), domestic and related services (meal preparation, housecleaning, and the like), paramedical services, and protective supervision. There are currently over 593,000 Californians who receive IHSS; over 98% of these individuals receive IHSS services as a Medicaid benefit.

CDSS oversees the IHSS program, but it is administered at the county level. Once individuals apply for IHSS, they are assessed by a county social worker for eligibility and need. If an individual is determined to be eligible for IHSS, they are authorized for certain services and for a specified number of hours of care. IHSS clients self-direct their care, which allows them to choose and hire their own provider, including friends and family.

When an individual is determined eligible for IHSS services by a county social worker, they are authorized for a certain number of hours of care per week. IHSS recipients are responsible for hiring, firing, directing, and supervising their IHSS workers. These responsibilities include some administrative duties, such as scheduling and signing timesheets; however, the state handles payroll. Providers must complete an enrollment process, including submitting fingerprint images for a criminal background check and participating in a provider orientation prior to receiving payment for services.

Prospective IHSS providers are also required to participate in an on-site orientation developed by CDSS and the counties prior to receiving payment for services. As of February 2023, there were 613,410 IHSS providers in California; 95.5% of providers are a relative, spouse, or parent of the recipient, and 55.6% of providers live in the same residence as the recipient, according to data provided by CDSS.

One of the eligibility criteria for receiving IHSS is submission of a completed Health Care Certification Form (referred to as a SOC 873) with information provided by the individual’s licensed healthcare professional. The exception to this requirement is if a county determines that an applicant is at imminent risk of out-of-home placement; applicants who are granted this exception may be temporarily authorized to receive IHSS pending the county’s receipt of the SOC 873.

Hospital discharge planning. State law requires that every hospital have a written discharge planning policy and process. Hospitals are required to make arrangements for post-hospital care which includes care at home, in a skilled nursing facility, or intermediate care facility, and made prior to discharge for patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning. The discharge planning is not typically done with the diagnosing physician as prescribed in this bill; instead, a discharge planner who is knowledgeable in programs such as IHSS helps with this planning. Current law also requires that patients are allowed to identify one family caregiver who may assist in post-hospital care. The discharge information that is required to be give includes if someone is discharged and might be eligible for IHSS services.

Equity Implications: The IHSS program serves people who are low-income and enables them to remain independently in their home. By requiring patients diagnosed with a terminal illness be given information about IHSS eligibility criteria before the patient is discharged, the provisions of this bill seek to ensure that individuals who are low-income and who have been diagnosed with a terminal illness have access to the supportive services provided through the IHSS program. Additionally, this bill seeks to ensure equity for individuals diagnosed with a terminal illness by ensuring this vulnerable population can access adequate, dignified end-of-life care in a timely manner.

According to the Author

“Receiving a terminal diagnosis is a challenging moment for the patient and their friends and family. Recognizing this difficulty, the state offers resources and support to ensure that patients’ end of life care makes them as comfortable as possible. One of these resources is the In-Home Supportive Services program, in which an eligible patient is assigned an IHSS provider who assists them with daily tasks. This important resource is offered to terminal and non-terminal patients. Despite having radically different timelines, terminal and non-terminal patients are put through the same process. [This bill] expedites the process for terminal patients so that we mitigate the possibility of the process outliving them.”

Arguments in Support

According to UDW/AFSCME Local 3930, “The IHSS program is a critical lifeline for many Californians who are elderly, disabled, or have a chronic medical condition. The program provides much-needed support to individuals who want to remain in their own homes rather than being placed in out-of-home care. However, many individuals who could benefit from the program are not aware of it or face significant barriers to enrollment. By requiring healthcare providers to inform patients about the IHSS program and the option to enroll as a provider, AB 1005 would help to ensure that more Californians can access the support they need to remain in their homes.”

Arguments in Opposition

None on file

FISCAL COMMENTS

According to the Assembly Appropriations Committee on May 18, 2023, local costs to counties, likely minor, to consider expediting IHSS applications for terminally ill patients who request an expedited process. These costs are unknown, but are potentially reimbursable by the state, subject to a determination by the Commission on State Mandates.

VOTES

ASM HUMAN SERVICES: 7-0-1

YES: Jackson, Sanchez, Alanis, Arambula, Bonta, Bryan, Calderon

ABS, ABST OR NV: Garcia

ASM APPROPRIATIONS: 12-0-4

YES: Holden, Bryan, Calderon, Wendy Carrillo, Mike Fong, Hart, Lowenthal, Mathis, Papan, Pellerin, Weber, Ortega

ABS, ABST OR NV: Megan Dahle, Dixon, Robert Rivas, Sanchez

UPDATED

VERSION: May 18, 2023

CONSULTANT: Alexandria Smith / HUM. S. / (916) 319-2089 FN: 0000941

Date of Hearing: May 17, 2023

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Chris Holden, Chair

ABPCA Bill Id:AB 1005

Author:(Alvarez) – As Amended Ver:April 18, 2023

Urgency: No State Mandated Local Program: Yes Reimbursable: Yes

SUMMARY:

This bill requires a patient diagnosed with a terminal illness to be provided with certain information about the in-home supportive services (IHSS) program prior to being discharged, requires a health care provider to provide and complete certain information for purposes of aiding the individual to apply to the IHSS program, and enumerates the process by which a terminally ill patient can elect to have the application expedited by a county human services department.

Specifically, this bill:

1. Requires, before the discharge of a patient diagnosed with a terminal illness, the diagnosing healthcare provider to ask the patient, or another person authorized to make health care decisions for the patient, if they are interested in receiving information about the IHSS program. If the patient or authorized person expresses interest, the diagnosing health care provider must provide the information, including the IHSS eligibility criteria and the option for a family member to provide care as an IHSS provider subject to the IHSS provider enrollment.
2. Requires, if a patient or authorized person expresses interest in receiving the IHSS information, the health care provider to provide the patient or authorized person with a physical application for the IHSS program, and to inform the patient or authorized person of the option for the health care provider to send a digital copy of the application if the patient or authorized person identifies a family member whom they would like to be the patient’s IHSS provider.
3. Requires, if the patient seeks to apply for services under the IHSS program, the health care provider to provide a copy of the health care certification form and to complete the health care providers’ portion of that form before the patient’s discharge.
4. Permits, a patient who is diagnosed with a terminal illness and seeks to apply for services under the IHSS program and receive a healthcare certification form, to elect to have the application process expedited by the county according to all of the following requirements:
   1. The IHSS application and the health care certification form must be submitted and processed before the patient is discharged by the health care provider who diagnosed the patient with a terminal illness.
   2. The health care certification must be either approved or denied within one business day after the county receives the form.
   3. If the patient is approved for IHSS services, the county welfare department or its designee must prioritize the patient with regard to assigning and providing an IHSS provider.
   4. If the patient becomes an IHSS recipient, they must be guaranteed a total number hours of IHSS, as a preliminary allotment, as deemed appropriate by the county welfare department until a final determination is made based on the needs assessment.
   5. In determining the total number of hours as a preliminary allotment, the country welfare department must consider the terminal illness diagnosis of the patient, any other relevant information available to the county at that point about the patient’s individualized circumstances, and the county’s available IHSS resources. The number of hours may not exceed the applicable maximum limit of hours under current law.
5. Requires the provisions of this bill pertaining to a streamlined IHSS application process be implemented only to the extent necessary federal approvals are obtained and federal financial participation is available for the purposes of providing IHSS.

FISCAL EFFECT:

Local costs to counties, one-time and ongoing, to establish and administer a process for prioritizing IHSS applications. These costs are unknown, but likely greater than $150,000 statewide. These costs are potentially reimbursable by the state, subject to a determination by the Commission on State Mandates.

COMMENTS:

1. Purpose. The author seeks to ensure patients with a terminal illness have adequate access to the end-of-life care and services for which they may be eligible. According to the author:

Receiving a terminal diagnosis is a challenging moment for the patient and their friends and family. Recognizing this difficulty, the state offers resources and support to ensure that patients’ end of life care makes them as comfortable as possible. One of these resources is the In-Home Supportive Services program, in which an eligible patient is assigned an IHSS provider who assists them with daily tasks. This important resource is offered to terminal and non-terminal patients. Despite having radically different timelines, terminal and non-terminal patients are put through the same process. [This bill] expedites the process for terminal patients so that we mitigate the possibility of the process outliving them.

1. Background. In-Home Supportive Services Program. Eligible low-income individuals in California who are at least 65 years old, living with disabilities, or blind, may access services through the IHSS program that enable them to remain in their own homes. IHSS program providers are paid to assist with personal care services (such as bathing, toileting, and grooming), domestic and related services (meal preparation, housecleaning, and the like), paramedical services, and protective supervision. There are currently over 593,000 Californians who receive IHSS; over 98% of these individuals receive IHSS services as a Medicaid benefit.

The California Department of Social Services (CDSS) oversees the IHSS program, but it is administered at the county level. Once individuals apply for IHSS, they are assessed by a county social worker for eligibility and need. If an individual is determined to be eligible for IHSS, they are authorized for certain services and for a specified number of hours of care per week. IHSS clients self-direct their care, which allows them to choose and hire their own provider, including friends and family.

When applying, IHSS applicants must submit a completed Health Care Certification Form with information provided by the individual’s licensed healthcare professional. This bill requires, prior to the discharge of a patient diagnosed with a terminal illness, the healthcare provider to give the patient or other qualified individual an IHSS application if they are interested and, if the patient seeks to apply for the IHSS program, requires the health care provider to provide a copy of, and complete the necessary portion of the certification form.

Hospital discharge planning. State law requires every hospital to have a written discharge planning policy and process. Hospitals are required to make arrangements for post-hospital care which includes care at home, in a skilled nursing facility, or intermediate care facility, and made prior to discharge for patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning. The discharge planner is typically someone who is knowledgeable about post-hospital care programs, such as IHSS. Among the discharge information required to be given is information regarding IHSS services. This bill requires the diagnosing physician, rather than a discharge planner, to provide IHSS information to the patient.

Analysis Prepared by: Jennifer Swenson / APPR. / (916) 319-2081

Date of Hearing: April 25, 2023

ASSEMBLY COMMITTEE ON HUMAN SERVICES

Corey A. Jackson, Chair

ABPCA Bill Id:AB 1005 (

Author:Alvarez) – As Amended Ver:April 18, 2023

SUBJECT: In-home supportive services: terminal illness diagnosis

SUMMARY: Requires a patient diagnosed with a terminal illness to be provided with certain information about the in-home supportive services (IHSS) program prior to being discharged, requires a health care provider to provide and complete certain information for purposes of aiding the individual apply to the IHSS program, and enumerates the process by which a terminally ill patient can elect to have the application expedited by a county human services department, as specified. Specifically, this bill:

1. Requires, before the discharge of a patient diagnosed with a terminal illness, the diagnosing healthcare provider to ask the patient, or another person authorized to make health care decisions for the patient, if they are interested in receiving information about the IHSS program. Further requires if the patient or authorized person expresses interest in receiving the IHSS information, the diagnosing health care provider must disclose to the patient or authorized person the information, including the IHSS eligibility criteria and the option for a family member to provide care as an IHSS provider subject to the IHSS provider enrollment.
2. Requires, if a patient or authorized person who expresses interest in receiving the IHSS information, the health care provider to provide the patient or authorized person with a physical application for the IHSS program, and further, requires the provider to inform the patient or authorized person of the option for the health care provider to send a digital copy of the application if the patient or authorized person identifies a family member whom they would like to be the patient’s IHSS provider.
3. Requires, if the patient seeks to apply for services under the IHSS program, the health care provider to provide a copy of the health care certification form, and, further, requires the provider to complete the health care providers’ portion of that form before the patient’s discharge.
4. Makes legislative findings and declarations related to providing a more streamlined IHSS application process for patients with a terminal illness.
5. Defines “terminal illness” as having the same meaning as it is interpreted by current law, as specified.
6. Permits, if a patient who is diagnosed with a terminal illness and seeks to apply for services under the IHSS program and receive a healthcare certification form, as specified, the patient to elect to have the application process expedited by the county in accordance with all of the following requirements:
   1. The IHSS application and the health care certification form be submitted and processed before the patient is discharged by the health care provider who diagnosed the patient with a terminal illness;
   2. The health care certification must be either approved or denied within one business day after the county receiving it;
   3. If the patient is approved for IHSS services, the county welfare department or its designee must prioritize the patient with regard to assigning, and providing them with, an IHSS provider; and,
   4. If the patient becomes an IHSS recipient, they are afforded a total of number hours of in-home supportive services not to exceed existing maximum limit of hours, as a preliminary allotment, as deemed appropriate by the county welfare department or its designee until a final determination is made based on the needs assessment. The country welfare department or its designee consider the terminal illness diagnosis of the patient, any other relevant information available to the county at that point about the patient’s individualized circumstances, and the county’s available IHSS resources.
7. Permits CDSS to implement, interpret, or make specific, certain provisions of this bill by means of all-county letters or similar instructions, until regulations are adopted.
8. Requires the provisions of this bill pertaining to a streamlined IHSS application process for individuals diagnosed with a terminal illness be implemented only to the extent that any necessary federal approvals are obtained and federal financial participation is available for the purposes of providing IHSS.
9. States legislative intent that the provisions of this bill related to disclosure of IHSS-related information to patients diagnosed with a terminal illness be implemented in conjunction with provisions of this bill requiring an application for IHSS by an individual with a terminal diagnosis be expedited.

EXISTING LAW:

1. Establishes the IHSS program to provide supportive services to individuals who are aged, blind, or living with disabilities, and who are unable to perform the services themselves or remain safely in their homes without receiving these services. (Welfare and Institutions Code Section [WIC] 12300 et seq.)
2. Specifies that supportive services include: domestic services and services related to domestic services, heavy cleaning, personal care services, accompaniment by a provider when needed during necessary travel to health-related appointments or to alternative resource sites, yard hazard abatement, protective supervision, teaching and demonstration directed at reducing the need for other supportive services, and paramedical services which make it possible for the recipient to establish and maintain an independent living arrangement. Personal care services shall mean all of the following:
3. Assistance with ambulation.
4. Bathing, oral hygiene, and grooming.
5. Dressing.
6. Care and assistance with prosthetic devices.
7. Bowel, bladder, and menstrual care.
8. Repositioning, skin care, range of motion exercises, and transfers.
9. Feeding and assurance of adequate fluid intake.
10. Respiration.
11. Assistance with self-administration of medications. (WIC 12300(b))
12. Defines “personal care services” as: assistance with ambulation; bathing, oral hygiene, and grooming; dressing; care and assistance with prosthetic devices; bowel, bladder, and menstrual care; repositioning, skin care, range of motion exercises, and transfers; feeding and assurance of adequate fluid intake; respiration; and, assistance with self-administration of medications. (WIC 12300(c))
13. Requires, as a condition of receiving IHSS, an applicant for or recipient of services, to obtain a certification of a licensed health care professional, as specified, declaring that the applicant or recipient is unable to perform some activities of daily living independently, and that without services to assist the applicant or recipient with activities of daily living, the applicant or recipient is at risk of placement in out-of-home care. (WIC 12309.1)
14. Requires a county welfare department to assess each IHSS recipient’s continuing monthly need for IHSS at varying intervals as necessary, but at least once every 12 months. Further, requires the results of the assessment to be divided by 4.33 to establish a recipient’s weekly authorized number of hours of IHSS, subject to certain limitations, as specified. (WIC 12301.1(b))
15. Defines the following terms:
    1. “Actively dying” as the phase of terminal illness when death is imminent;
    2. “Disease-targeted treatment” as treatment directed at the underlying disease or condition that is intended to alter its natural history or progression, irrespective of whether or not a cure is a possibility;
    3. “Health care provider” as an attending physician and surgeon, as well as a nurse practitioner or physician assistant practicing in accordance with standardized procedures or protocols developed and approved by the supervising physician and surgeon and the nurse practitioner or physician assistant;
    4. “Hospice” as a specialized form of interdisciplinary health care that is designed to provide palliative care, alleviate the physical, emotional, social, and spiritual discomforts of an individual who is experiencing the last phases of life due to the existence of a terminal disease, and provide supportive care to the primary caregiver and the family of the hospice patient;
    5. “Palliative care” as medical treatment, interdisciplinary care, or consultation provided to a patient or family members, or both, that has as its primary purpose the prevention of, or relief from, suffering and the enhancement of the quality of life, rather than treatment aimed at investigation and intervention for the purpose of cure or prolongation of life; and,
    6. “Refusal or withdrawal of life-sustaining treatment” as forgoing treatment or medical procedures that replace or support an essential bodily function, including, but not limited to, cardiopulmonary resuscitation, mechanical ventilation, artificial nutrition and hydration, dialysis, and any other treatment or discounting any or all of those treatments after they have been used for a reasonable time. (HSC 442(a)-(f))

FISCAL EFFECT: Unknown, this bill has not been analyzed by a fiscal committee.

COMMENTS:

Background: In-Home Supportive Services Program. Eligible low-income individuals in California who are at least 65 years old, living with disabilities, or blind, may access services through the IHSS program that enable them to remain in their own homes. IHSS program providers are paid to assist with personal care services (such as bathing, toileting, and grooming), domestic and related services (meal preparation, housecleaning, and the like), paramedical services, and protective supervision. There are currently over 593,000 Californians who receive IHSS; over 98% of these individuals receive IHSS services as a Medicaid benefit.

CDSS oversees the IHSS program, but it is administered at the county level. Once individuals apply for IHSS, they are assessed by a county social worker for eligibility and need. If an individual is determined to be eligible for IHSS, they are authorized for certain services and for a specified number of hours of care. IHSS clients self-direct their care, which allows them to choose and hire their own provider, including friends and family.

When an individual is determined eligible for IHSS services by a county social worker, they are authorized for a certain number of hours of care per week. IHSS recipients are responsible for hiring, firing, directing, and supervising their IHSS workers. These responsibilities include some administrative duties, such as scheduling and signing timesheets; however, the state handles payroll. Providers must complete an enrollment process, including submitting fingerprint images for a criminal background check and participating in a provider orientation prior to receiving payment for services.

Prospective IHSS providers are also required to participate in an on-site orientation developed by CDSS and the counties prior to receiving payment for services. As of February 2023, there were 613,410 IHSS providers in California; 95.5% of providers are a relative, spouse, or parent of the recipient, and 55.6% of providers live in the same residence as the recipient, according to data provided by CDSS.

One of the eligibility criteria for receiving IHSS is submission of a completed Health Care Certification Form (referred to as a SOC 873) with information provided by the individual’s licensed healthcare professional. The exception to this requirement is if a county determines that an applicant is at imminent risk of out-of-home placement; applicants who are granted this exception may be temporarily authorized to receive IHSS pending the county’s receipt of the SOC 873.

The provisions of this bill require, prior to the discharge of a patient diagnosed with a terminal illness, the diagnosing health care provider to disclose certain IHSS-related information to the patient, or another person authorized to make health care decisions for the patient. The provisions of this bill also require the healthcare provider to provide the patient or other qualified individual with an IHSS application, and, if the patient seeks to apply for the IHSS program, requires the health care provider to provide a copy of, and complete the necessary portion of the SOC 873. Finally, the provisions of this bill require an application by a patient diagnosed with a terminal illness for the IHSS program to be expedited in accordance with the processes and timelines enumerated in the bill.

Hospital discharge planning. State law requires that every hospital have a written discharge planning policy and process. Hospitals are required to make arrangements for post-hospital care which includes care at home, in a skilled nursing facility, or intermediate care facility, and made prior to discharge for patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning. The discharge planning is not typically done with the diagnosing physician as prescribed in this bill; instead, a discharge planner who is knowledgeable in programs such as IHSS helps with this planning. Current law also requires that patients are allowed to identify one family caregiver who may assist in post-hospital care. The discharge information that is required to be give includes if someone is discharged and might be eligible for IHSS services. Therefore, this bill would not change information disseminated, but who would be giving the information.

Author’s Statement: According to the author, “Receiving a terminal diagnosis is a challenging moment for the patient and their friends and family. Recognizing this difficulty, the state offers resources and support to ensure that patients’ end of life care makes them as comfortable as possible. One of these resources is the In-Home Supportive Services program, in which an eligible patient is assigned an IHSS provider who assists them with daily tasks. This important resource is offered to terminal and non-terminal patients. Despite having radically different timelines, terminal and non-terminal patients are put through the same process. [This bill] expedites the process for terminal patients so that we mitigate the possibility of the process outliving them.”

Need for this bill: The provisions of this bill seek to ensure patients with a terminal illness have adequate access to the end-of-life care and services for which they may be eligible. Specifically, this bill would require a patient diagnosed with a terminal illness to be provided with certain information about the IHSS program prior to being discharged, requires a health care provider to provide and complete certain information for purposes of aiding the individual apply to the IHSS program, and enumerates the process by which a terminally ill patient can elect to have the application expedited by a county human services department.

Equity Implications: The IHSS program serves people who are low-income and enables them to remain independently in their home. By requiring patients diagnosed with a terminal illness be given information about IHSS eligibility criteria before the patient is discharged, the provisions of this bill seek to ensure that individuals who are low-income and who have been diagnosed with a terminal illness have access to the supportive services provided through the IHSS program. Additionally, this bill seeks to ensure equity for individuals diagnosed with a terminal illness by ensuring this vulnerable population can access adequate, dignified end-of-life care in a timely manner.

Policy Considerations: The provisions of this bill seek to ensure patients diagnosed with a terminal illness are given expedited access to IHSS by creating an expedited registration process for patients with a terminal illness. While this is certainly a worthy goal, and it is crucial that patients with a terminal illness be afforded appropriate and timely end-of-life care, the timelines provided in this bill may not be implementable given the nature of the IHSS program by which a county human services agency must either approve or deny a patient’s IHSS application. This bill would also require, if approved, a patient with a terminal illness receive a guaranteed preliminary number of hours for IHSS services until a final determination is made; however, in the event that a final determination is delayed, this bill does not address the varying needs of terminally ill patients, which may warrant more or fewer hours than what would be statutorily guaranteed.

Finally, while the provisions of this bill would require a health care provider to offer certain information about IHSS to a patient prior to discharge, this bill does not require a discussion with an individual who is familiar with the IHSS program in order to answer questions about the program, eligibility rules and services provided under the program. As previously discussed, IHSS provides personal care types of services not medical or any end-of-life/hospice-like services. Under the provisions of this bill, a health care provider is tasked with explaining this information; however, it is unclear whether these providers are the most appropriate to discuss the IHSS program.

RELATED AND PRIOR LEGISLATION:

AB 1375 (Ting) of the current legislative session, establishes a grant program to encourage immigrants to become in-home supportive services (IHSS) providers. AB 1375 is pending before the Assembly Committee on Appropriations.

REGISTERED SUPPORT / OPPOSITION:

Support

None on file

Opposition

None on file

Analysis Prepared by: Alexandria Smith/ HUM. S. / (916) 319-2089