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Health Care
Personal Care Assistant Services for the Aged, Blind and Disabled

This article is the first in a series about home and community-based services that are available through New Jersey’s Medicaid Program. The focus is on benefits for low-income adults, age 65 or older, and disabled younger adults, even though there are also ways for other groups, such as children, to get this type of help.

What are Personal Care Assistants?

Personal Care Assistants (PCAs) provide personal care and perform household duties and health-related tasks in the home, under the supervision of a registered professional nurse. They follow a written plan of care that has been certified by a physician. You can arrange for services through a home health agency or a homemaker agency.

Examples of the types of activities a PCA can assist with are:

  • Bathing, dressing, and toileting

  • Grooming (for example, brushing your hair) and hygiene (brushing your teeth)

  • Moving from your bed to a chair, or from your chair to a walker

  • Walking, or using a walker or wheelchair

  • Accompanying you to doctor’s appointments

  • Light housekeeping including sweeping, dusting, and changing bed linens

  • Cleaning your kitchen and bathroom

  • Laundry, in your home or at a laundromat

  • Shopping and preparing meals
     
  • Medications that can be self-administered

How do I know if I eligible for PCA services?

Personal care assistant services are meant to assist with long-term health care needs, not short-term needs for an acute illness. So you must first have a need for help with a chronic health care problem, or maintenance of a long-term condition.

You must also be eligible for Medicaid. If you are an older adult or a younger adult with a disability, you may be eligible for Medicaid if you meet the following eligibility criteria:

  • You are a citizen or a qualified alien. In order to be a qualified alien, a lawful permanent resident must have that status for five years.

  • You are a resident of New Jersey.

  • You are 65 or older, blind, or disabled. If you have been approved for Social Security Disability, you will automatically meet this requirement. If you have not applied for disability through Social Security, the State Medicaid Review Board will make its own determination. But if you have been denied Social Security Disability, they will assume that Social Security was correct in their decision, and will not consider your request until 12 months have passed from your Social Security Disability denial.

  • You are financially eligible, either because you are eligible for SSI, or because your income is less than or equal to 100% of the Federal Poverty Level ($958 per month in 2013) and you have $4000 or less in resources.

Once you have been approved for Medicaid, you will need a physician to certify in writing that you need assistance with at least one personal care task (for example, bathing or dressing) before you can be authorized for PCA services. The authorization process is discussed more fully below.

How do I apply for PCA services?

PCA is a managed care service, which means you need authorization from your Medicaid Managed Care Organization (MCO) before you can begin receiving PCA services. Each MCO uses a slightly different procedure, so you should call your MCO to find out exactly what you need to do to apply for PCA services. Telephone numbers for the four MCOs are:

  • Amerigroup: 1-800-600-4441

  • Horizon NJ Health: 1-877-765-4325

  • United Healthcare Community Plan: 1-800-701-0710

  • Health First NJ: 1-888-464-4365

Generally, the best way to begin is by asking your primary care physician to request the appropriate forms from your MCO. The doctor can then complete the forms and fax them back. You may be assigned a case manager or a care manager, who will help you choose an agency in your network. You can also look online for an agency in your network if you have access to the Internet.

Once a home health or homemaker agency has been identified, either a representative of the MCO or a nurse from the agency will schedule an appointment with you to conduct a face-to-face assessment. Based upon this assessment, your MCO will decide how many PCA hours a week you should receive. This process is called a Prior Authorization, or PA. PCA hours are limited to a maximum of 40 hours per week. Note: In extraordinary circumstances, you may be entitled to receive more hours with special approvals.

What should I know about the evaluation with the nurse?

The nurse who comes to your house to conduct the face-to-face assessment will be using a screening tool called the PCA Assessment Tool. He or she will use this assessment tool to evaluate your needs in 10 areas and assign a number to each one, signifying how much help you need in that area. It’s important that you tell the nurse about all of your limitations and care needs. Sometimes people are hesitant to talk about personal, intimate care needs. It can feel embarrassing to talk to someone you’ve only just met. But in order to get the care you need, the nurse needs an accurate and complete understanding of your abilities in each of the 10 areas. You may want to consider asking a family member or other supportive person to be with you during the assessment if that person can help better explain your needs and limitations.

Assessment Areas

Below are the 10 areas that will be assessed by the nurse during his or her assessment. Each one will be assigned a “score” ranging from zero to three, and at the end, those numbers will be added together. The total equals the number of hours of PCA they believe you need.

  1. Supportive service/living environment needs:  In this section, the nurse will look at your living situation.  Do you live alone or with others?  Does someone help you during the day?  Do you lack anyone who is willing or able to provide you with help?  Depending on the answers to these questions, you can “score” from 0 hours of PCA to 3 hours of PCA.

  2. Cognitive/mental status:  In this section, the nurse will look at your cognitive status.  Are you alert and oriented sufficient to care for yourself or self-direct another?  Do you occasionally or consistently demonstrate cognitive or mental impairment which interferes with your activities of daily living?  Depending on the answers to these questions, you can “score” from 0 hours of PCA to 2 hours of PCA.

  3. Ambulation/mobility:  In this section, the nurse will look at your ability to move and ambulate.  Are you wheelchair bound, and if so, can you use the wheel chair independently or do you need assistance?  Do you use a walker or cane? Are you bed-bound or in a Geri chair?  Depending on the answers to these questions, you can “score” from 0 hours of PCA to 2 hours of PCA.

  4. Ability to transfer:  In this section, the nurse will look at your ability to transfer between settings.  Are you able to transfer yourself, from bed to a chair for example, independent?  Do you need the assistance of one or more person?  Are you weight bearing?  Do you need to use a life device?  Are you bed-bound?  Depending on the answers to these questions, you can “score” from 0 hours of PCA to 3 hours of PCA.

  5. Ability to feed yourself:  In this section, the nurse will look at your ability to eat.  Are you independent such that you can prepare your own food and feed yourself?  Do you need assistance with preparing meal?  Setting up or service meals?  Are you unable to feed yourself and dependent on others to eat?  Depending on the answers to these questions, you can “score” from 0 hours of PCA to 3 hours of PCA.

  6. Ability to bathe yourself:  In this section, the nurse will look at your ability to bathe.  Are you able to bathe yourself without assistance, even if you need to use a device like a shower chair?  Do you need some assistance from another with bathing?  Are you totally dependent on others for showering or bathing?  Depending on the answers to these questions, you can “score” from 0 hours of PCA to 3 hours of PCA.

  7. Ability to toilet yourself:  In this section, the nurse will look at your ability to use the toilet.  Are you continent or incontinent:  Do you require assistance with an ostomy or catheter:  Do you otherwise require assistance with toileting?  Depending on the answers to these questions, you can “score” from 0 hours of PCA to 3 hours of PCA.

  8. Ability to perform grooming and dressing task:  In this section, the nurse will look at your ability to get dress and groom yourself.  Do you need assistance with dressing – either your upper or lower body?  Can you put on your socks and tie your shoes?  Are you able to brush your hair, shave or brush your teeth yourself or do you need assistance?  Depending on the answers to these questions, you can “score” from 0 hours of PCA to 2 hours of PCA.

  9. Ability to shop and do laundry:  In this section, the nurse will look at your ability to shop and do laundry.  Are you able to do laundry or shop yourself?  Do others help you with these tasks?  Are your laundry facilities in your home or do you need to use a Laundromat?  Depending on the answers to these questions, you can “score” from 0 hours of PCA to 2 hours of PCA.

  10. Institutional Placement.  In this last section, the nurse will evaluate whether you would need to be in a nursing home within 30 days, 6–12 months or greater than 12 months without the provision of PCA services.  Depending on the answers to these questions, you can “score” from 0 hours of PCA to 2 hours of PCA.

How many hours of PCA services will I receive?

After the nurse conducts the face-to-face assessment using the PCA Assessment Tool described above, the nurse will add up your “score” in each of the areas, and the total will be how many hours of care you should receive.

Note: Right now, all four MCOs are using a PCA Assessment Tool that has a maximum potential score of 25 hours of PCA services. Since you are actually entitled by law to receive up to 40 hours of PCA services, the assessing nurse has the option of writing in their opinion if they feel you need more than 25 hours per week. They also need to include an explanation that justifies the number of hours they believe you need, up to a maximum of 40. His or her written comments are then reviewed by the MCO, which makes the final determination.

Once the number of PCA hours has been determined, the home health or homemaker agency will usually let you know, but you should also get the PA in writing from the MCO.

Can I choose when I want to have those services?

Once you know the number of PCA hours you have been approved to receive, you will then work with the agency to come up with a schedule that works for you. Many people benefit from having an aide in the morning to help them get the day started, and in the late afternoon, to help with dinner at the end of the day. It can sometimes be difficult to get help during the evening and weekend hours.

Does the authorization expire?

Prior Authorizations are time-limited, and you will be reassessed periodically (perhaps every six months). If you have a change of circumstances and believe your hours should be adjusted, you can request a new assessment at any time. For example, if you had a hospitalization, upon returning home, you may want to request a new assessment because you may need more help.

 

This article appeared in the June 2013 edition of Looking Out for Your Legal Rights®

7/2/2013