Through the last decade, Louisiana has seen a steady expansion of its provision of home-based care for the developmentally disabled (people with a significant mental and/or physical disability). This was as a consequence of judicial actions that determined the state was not providing legally-obligated care in the least restrictive environment. Until then, nearly all such people were forced to live in large institutions in order to receive state assistance, which also had the effect in many cases of being more expensive, that also prevented some clients from being able to be employed, or if cared for at home without state assistance took family caregivers out of the workforce.
Unfortunately, the program grew quickly and without adequate matching of needs and state resources, creating another potential legal situation based on the federal mandate that home- and community-based care’s costs could not exceed on average institutional care. At the same time, the budget crisis began impacting the state and its peculiar fiscal structure thrust the bulk of spending reductions on health care. The state, by now led by Gov. Bobby Jindal, responded to these twin imperatives of cost cutting by instituting a Resource Access Model (RAM) which worked well in many cases but had flaws in administration and in adapting to extreme cases.
These problems became exposed in a situation where a client would have received a cut in hours served, even if at the 64 weekly maximum now allowed, that created a medically questionable situation where the state eventually entered into an agreement to permit more. While this was going on, in response to the budgetary crisis, without any legal imperative as motivation, reimbursement rates to providers of these services (all are contracted to the private sector) were diminished in a series of rounds.
Now using the same procedure, the state wants to implement completely hours reductions where indicated, as well as move to the next part of the reform which is to take home-care clients whose needs are conducive to the strategy of putting them into small group residences, where this will cost less. These have been announced as substitutes for the tactic to continue to cut reimbursement rates because those cuts were making it difficult for providers to continue to operate. Again, no legal imperative exists to choose this approach but it is driven by budgetary facts of life.
Some argue this could lead to additional dangerous situations. Others maintain this could violate the legal least-restrictive standard. One interest is planning legal action on the basis of the administration of the RAM.
Thus, the state has to be careful in pursuing this course to make sure lives and rights are protected. Assessments need reviewing and if any seem questionable, they need redoing. Extreme cases where home care costs still would be less than institutionalization costs even if they exceed the maximum hours must be granted. The move into group homes for those affected must be carefully vetted so that no significant changes in autonomy occur for them.
The state does have the law on its side – no recipient is guaranteed services at home nor, if granted, can their costs exceed institutional costs. More efficient service provision that also will save taxpayers’ dollars is possible with this plan, but it is imperative that the state does it correctly.