RESULTS IN BRIEF
California's operation of the In-Home Supportive Services (IHSS) program, which assists aged, blind, and disabled individuals who need help to remain in their own homes, will change significantly because the Legislature recently enacted laws that will affect how counties administer the program. Legislation enacted in July 1999 requires California's 58 counties to act as or establish employers for individual providers of program services so that they have an opportunity for collective bargaining. Counties are just beginning to decide which steps they will take to meet this requirement. For some counties with smaller caseloads, the requirements of the new legislation are not clear. We expect that many counties will establish public authorities to meet the new requirement. Public authorities will function separately from the counties, administer the delivery of in-home supportive services, and serve as the employers for individual providers. To project how counties will respond to the new law, we looked at the new and existing legislation related to IHSS, counties' current choices for program providers, recent costs for IHSS, the counties' possible liabilities if they assume the role of employer to individual providers, and comments and reports from selected counties throughout California.
The history of existing public authorities, current funding provisions, and the ability of the State to limit its funding of cost increases for individual providers, indicate that program costs in general will rise and costs to the counties in particular will likely increase. County administrators, who are aware that the law continues to limit the State's payments of program expenses, have expressed concerns that the new mandate will increase costs to the counties mainly because they believe collective bargaining will bring about higher pay for individual providers. As of April 1999, individual providers supplied more than 98 percent of in-home supportive services in the State. However, as the costs for individual providers increase, some counties may turn to more expensive methods of delivering program services, such as home-care contractors. Because the State pays a greater portion of the hourly costs of home-care contractors than it does for individual providers, using contractors may become a more cost-effective option for the counties while increasing the costs to the State.
Currently, six counties have created public authorities for IHSS. With the likelihood that many counties will establish public authorities to employ individual providers, both the counties and the Department of Social Services (department), which oversees IHSS, will need to collect data on public authorities' activities to ensure they increase the benefits to recipients. Our audit attempted to compare the performance of counties using public authorities to the performance of those utilizing other services. Although definitive performance data do not exist, evidence reveals that the performance of counties with established public authorities differs little from that of other counties. Some other counties report using systems similar to those the public authorities provide. Those systems include registries for matching providers with recipients, training for providers and recipients, and background checks of applicants for individual provider positions. In addition, we found that the three counties with public authorities we visited perform at about the same level of service as they did before establishing their public authorities. Further, because the legal and departmental requirements for IHSS are vague, both the public authorities and the counties have developed their own standards for implementing IHSS requirements, and their practices differ.
Given the growth that will likely occur in the public authority program statewide and the potential for increased costs, the State will need more and better information to gauge the program's effectiveness for both recipients and providers relative to the available alternatives for administering the delivery of IHSS. The department should take the lead and work with local entities to develop standards of performance for local IHSS programs and implement a system to gather and evaluate data that measure the performance of public authorities, nonprofit organizations, home-care contractors, and any other service providers counties use. In addition to indicating whether the various methods are benefiting the health and welfare of recipients, the data should allow the department to compare the activities of these various agencies or contractors responsible for IHSS.
To assure the integrity of the information the department uses to evaluate program performance, local entities should develop and implement procedures to accurately and completely enter performance-measuring data into the department's information system.
Moreover, the department together with local agencies should better define program functions to improve their consistency and effectiveness. These functions include training for providers and recipients, background checks for provider applicants, and the use of registries for provider referrals.
Given the pending changes in the counties' administration of in-home supportive services, the Legislature should require the department to report on the operational and fiscal impact of the recently enacted legislation to determine whether the new law promotes a more effective and efficient program.
In addition, the Legislature should clarify the requirement in the Welfare and Institutions Code, Section 12305.25, which calls for each county to establish an employer for individual providers for the purposes of wages and benefits and other terms and conditions. This clarification will furnish the counties with the guidance they need to ensure they comply with the intent of the legislation. Specifically, the Legislature should clarify the requirement for counties with more than 500 in-home supportive services cases to offer an individual provider employer option upon the request of a recipient, and the implications of that requirement on counties with 500 or fewer cases.
The Department of Social Services concurs with our recommendations relative to its statewide role in serving in-home supportive services recipients. The three public authorities we reviewed, San Francisco, San Mateo, and Alameda, generally agree with most of our recommendations. However, the public authorities expressed some concern over our conclusions relative to the performance of IHSS in counties with and without public authorities.