Short-term memory loss makes it hard for Antonio Cardoso to remember whether he already had his insulin shot that day.
Delays in processing paperwork at the state Department of Social Services meant that the 68-year-old went months without getting any help, his lawyer said.
Cardoso lives on his own in Wethersfield, responsible for managing his diabetes and taking medication for his high blood pressure. Last month, out-of-control blood pressure and high blood sugar landed Cardoso in the emergency room. His daughter, Patricia Cardoso Richardson, worries that without home health care services, he’ll end up in assisted living or a nursing home.
It’s not that there aren’t services available to help Cardoso at home. A state contractor determined late last year that he was eligible for the Connecticut Home Care Program for Elders, which provides services to seniors who are at risk of going to a nursing home, and submitted an application on his behalf to DSS.
But it took more than five months — and, his attorney thinks, being named in a federal class-action complaint — for Cardoso to get approved to receive services.
People involved in the home care system say delays in handling applications at DSS have left hundreds of seniors in similar positions, waiting months for services they’ve been deemed qualified for, services that could be critical to keeping them safe and healthy.
“It’s the new norm,” said Julia Evans Starr, executive director of the Connecticut Commission on Aging. “If you’re looking to get access to these home- and community-based supports, specifically through the Connecticut Home Care Program for Elders, you can expect that it’s going to take many, many days beyond the 45 days” — the legal time frame for processing Medicaid applications.
Julia Evans Starr, executive director of the Commission on Aging, is frustrated about the time it takes to connect qualified older residents with home- and community-based supports.
Evans Starr called the home-care program for elders “the biggest nursing home diversion program that we have,” key to a larger state policy goal of expanding the use of home-based care as an alternative to nursing homes. While some state-administered home care programs have limited slots and waiting lists, the home care program for elders is open to anyone over 65 who meets the financial and needs criteria, with no space limits or waiting list.
But advocates say seniors are left waiting for the program anyway, because DSS takes months to approve applications. The home care program has been significantly below budget this fiscal year, with fewer enrollees than expected. Evans Starr said many people have died or gone into nursing homes while waiting for their applications to be processed.
DSS officials have acknowledged the challenges they face in processing applications for all the programs the department runs. The number of eligibility workers is down more than 30 percent in the past decade, despite rising demand for services.
Legal action
The home care program for elders has two pieces. One is part of Medicaid; the other is fully state-funded and serves people with a lower level of needs.
The DSS unit that handles eligibility for the state-funded portion of the program has historically had five or six people processing applications, but as of January, it was down to two, one of whom had limited experience. In February and March, the unit had 650 cases awaiting a review of the applicants’ finances.
More recently, the unit got three additional workers, and has reduced the backlog to 200 cases. It’s currently processing applications from March.
Applications for the Medicaid portion of the program are handled in DSS’ regional offices, where delays are longer, said Sheldon Toubman, an attorney for the New Haven Legal Assistance Association.
Earlier this year, Toubman and a colleague filed a federal complaint over delays in DSS’ handling of Medicaid applications, arguing that the department has failed to employ enough workers to process applications in the time frame required by law. More recently, they filed a motion seeking to add Cardoso as a named plaintiff in the case.
The complaint cited nearly 5,000 people whose applications were pending “well beyond the 45-day time period generally required for the processing of Medicaid applications.” It seeks an injunction to require DSS to promptly process the backlog.
DSS spokesman David Dearborn said determining eligibility for home care services can be more complex than for Medicaid medical coverage because it requires a clinical review. To ensure that applicants did not improperly transfer assets so they could qualify for Medicaid, DSS workers review five years’ worth of financial records.
“In general, we are still feeling the impact of a system that was chronically under-resourced over much of the past decade — combined with increasing demands for service,” Dearborn said. “Despite budget challenges, the administration has been reinvesting in additional staffing and critical technology to reverse this trend. But it will take time to rebuild the capacity at DSS.”
Those outside the department who are concerned about the delays say there needs to be a more immediate strategy, too.
Evans Starr and members of the Long-Term Care Advisory Council met recently with DSS officials in hopes of addressing the backlog in long-term care applications. She said the group understands the challenges DSS faces and the broader plans to make technology improvements, but wants to find ways to address the backlog sooner.
Dearborn said the department is taking steps to revise how reviews of long-term care applications are handled. Currently, workers review 60 months of financial statements and look for questionable transactions, including most over $1,000. Under revised procedures, the department will still review monthly statements for the two most recent years, but for the preceding three, will review either statements at six-month intervals or income tax returns, with a focus on transactions of more than $5,000.
The department has also gotten approval to hire 120 new eligibility workers, 60 of whom will be dedicated to Medicaid. Of 319 staff who work solely on Medicaid applications now, 75 are dedicated to long-term care applications, Dearborn said.
‘A black hole’
DSS has said in court documents that the 45-day time frame for processing applications shouldn’t be binding in cases when the delay is attributable to a third party — such as if the applicant didn’t submit required information.
But Toubman said workers handling applications in DSS’ regional offices often are so overworked that it takes them too long to get around to asking applicants for additional information. And once the applicant provides the missing information, he said, getting the application processed can still be a lengthy process.
“It’s like a black hole,” he said.
That’s where Ronald Vestuti and his wife, Vivian, have found themselves.
Sheldon Toubman, an attorney for the New Haven Legal Assistance Association, likens DSS to ‘a black hole.’
Ronald Vestuti applied for the home care program months ago, hoping it would provide an aide who could help his 76-year-old wife shower. Vivian has COPD and uses oxygen, and has limited mobility after having back and knee operations. Ronald Vestuti installed grab bars in their shower to help but said his wife still needs more assistance.
For a time, visiting nurses came to their East Haven home. But that service was covered by Medicare for a limited time, and now the only people available to help are Vestuti and his daughter, who cooks dinner and helps as much as she can between her job and taking care of her own children.
After Vestuti applied for the home care program, he got a letter from DSS explaining what additional documents they needed. He said he sent it all back, but hasn’t heard anything since, except a letter saying the worker on his case had changed. He’s tried calling DSS, but only gets voicemail.
Vestuti said he doesn’t remember exactly how long it’s been since he sent in the requested information, but when asked whether it was more than a month and a half ago, he laughed.
“It’s been way longer than 45 days,” he said.
Waiting for care
Richardson lives in Florida and keeps tabs on her father by phone, putting his doctors’ appointments in her Google calendar and recording key details in a 3-inch binder. She knows he needs more help than he’s getting, a point reinforced by weekly phone calls from one of his health care providers, describing his deterioriating health.
Cardoso, who is divorced and lives on his Social Security income, had a girlfriend who helped out. Richardson said the woman was a natural caregiver, but in the end, it became too much and she pulled away.
“It takes a lot for someone to do that on a full-time basis,” Richardson said.
Much of the pressure has fallen on her brother, who lives near their father. But Richardson fears that without outside help, her father will end up unable to continue living in the community.
Last Dec. 6, Connecticut Community Care Inc. applied on Cardoso’s behalf for the state-funded portion of the home care program. The agency also applied on his behalf for Medicaid because his income is just over $1,000 a month, according to court records.
Two months later, on Feb. 24, the agency determined that Cardoso’s worsening health made him eligible for the Medicaid portion of the program. According to court records, DSS received the application for the higher level of the program on March 8.
“If Mr. Cardoso is not permitted to receive the home care services for which he has already been determined to be functionally eligible, he will suffer irreparable harm by having to leave his home, and the state will pay the higher costs of nursing home care,” legal aid attorneys wrote in a court motion. “And he may also suffer a catastrophic episode of diabetic shock without access to the needed and prescribed medication management services in his home.”
For a time, Cardoso got nursing visits from an agency; the nurse would check his blood pressure and cue him to check his blood sugar, although he was still responsible for his insulin injections and taking his pills at night. But the agency stopped providing services about three months ago out of concern that insurance wouldn’t pay, Richardson said.
Richardson said she tried to reach the DSS worker handling her father’s case, but couldn’t get through. She left a voicemail for the director of operations in the regional office that serves her dad, but never heard back. She wrote to the state representative and senator from her dad’s district; in an affidavit, she said she did so “because my father is at high risk of diabetic shock and institutionalization.”
“He is going without essential care while his Medicaid application is pending,” she added.
Legal aid attorneys filed the motion about Cardoso’s case on May 3. Later that day, Dearborn said Cardoso’s case would be “thoroughly reviewed.” Cardoso’s application was granted two weeks later.
Toubman said it’s not uncommon for DSS to quickly resolve cases that are brought to the department’s attention through legal action, but warned that doing so likely meant even more waiting for someone else.
“Unfortunately, there are thousands of individuals like Mr. Cardoso who are having their applications delayed in violation of federal law each month, most of whom don’t know anything about a class action or our involvement in it,” he said. “Of course, every time we help one person, some other, unrepresented, person has their application further delayed.”