IHSS ISSUES - PARAMEDICAL SERVICES (3/97)

What are paramedical services?

Paramedical services are prescribed by a doctor for a person's health and require some training and judgment to perform. Common services are injections, colostomy irrigation, catheter insertion/care, suctioning, G and NG tube feeding, ventilator and oxygen care, fecal impaction, range of motion to improve function, wound/decubitous ulcer care and other services requiring sterile procedures. Biggest problem: Providers don't ask for enough time to complete the entire service, from preparation to clean up.

Why are paramedical services important?

People who need complex medical care can stay at home instead of going into nursing homes. Only doctors decide what services the county must provide and how many hours it must pay for. The county can't cut the services hours ordered by the doctor. Providers don't need any special license to perform the services.

What are the eligibility conditions?

1.               The doctor completes and signs an order for services with hours required: The recipient's doctor decides on all the eligibility conditions by signing the order prescribing the services and hours.

2.               The person can't perform the service at all: Some mental or physical impairment prevents the person from doing the service, like giving an injection or changing a catheter.

3.               The service requires training and judgment to perform: The provider gets training from the doctor in what steps to take and how to do each one to complete the service. The steps require careful observation of the recipient to avoid mistakes.

How should a person apply?

First talk with the treating doctor about what services are needed and each and every step to perform them pro­perly. Then keep a daily log for a week about how often each service is performed and how long it takes to complete, from the preparation through cleanup. Give the hours information to the doctor to complete Form SOC 321. More information, read PAI's IHSS ADVOCACY GUIDE - GETTING PARAMEDICAL SERVICES (3/97). 

Do you need more help?

Call the local regional center, area board, welfare rights organization, legal aid society, or PAI. You may also appeal the county's denial and get a state hearing.

 

 

 

IN-HOME SUPPORTIVE SERVICES ADVOCACY GUIDE

GETTING PARAMEDICAL SERVICES (3/97)

1. BACKGROUND

1.1 Why should you read this IHSS Guide?

Counties tell people they can't get certain services and don't tell them how to get the correct hours. Counties want to put people with medically complex care into nursing homes, claiming that such home care is unsafe. Counties call doctors to get them to change their orders. 

Most eligible recipients do not get the full hours it takes their providers to perform the complete paramedical service. They don't make accurate records of all the required steps and time to perform them before the doctor signs the order. This IHSS Guide tells you how to prepare before you apply to get the maximum amount of paramedical services. (Tip: Consult with your doctor before you apply to the county for paramedical services.)

1.2 What rules should you know?

Counties must follow the attached state IHSS Regulations which describe the conditions for getting paramedical services. (Tips: You won't know why the doctor is the key person unless you know what eligibility rules the county must follow. Read these rules before you go the your doctor to discuss paramedical services.)

Some counties also use their own rules. They may tell how the county will evaluate a request and they often have common reasons for denying the service. Get them. (Tip: You have a right to get them under state regulations and the California Public Records Act. Don't take “No” for an answer.) 

2. FOUR BASIC ELIGIBILITY CONDITIONS

2.1 How to get the doctor's order for services

Talk to your treating doctor(s) first and bring the attached Form SOC 321. Be candid about the provider's need for some training about the steps and for a daily log so the doctor may later figure out the total hours for each service. (Tip: Since you really apply to the doctor for paramedical services, you should work out everything before you ask the county for services. County's have nurses to review paramedical services ordered by a doctor. These nurses often call doctors to get them to cut hours. The doctor's order is final. Warn your doctor about the call and that he or she doesn't have to cut the hours.)

The completed and signed doctor's order on Form SOC 321 shows that a person meets all eligibility conditions for the services listed and the hours to provide them. The County must pay for the hours for each listed service.

2.2 How to show the recipient can't perform the service

The doctor will decide that the recipient can't perform the service when signing Form SOC 321. If questioned by the county, the recipient or provider can describe the physical or mental limitations preventing the recipient from doing it. (Tip: This issue only comes up if county records (the most recent Form 293, Line H in the county file) show that the recipient can perform the paramedical service.)  

2.3 How to show the service requires judgment and training

The county won't question a doctor's order for the commonly allowed services listed on the IHSS ISSUES - PARAMEDICAL SERVICES (3/97). Other services may be a problem, especially if they require high hours or monitoring. (Tip: Watch out - The county nurse may call your doctor to question the order and try to delete services or reduce hours. The county must get the doctor's approval. It may not change hours on its own - as it may for every other IHSS service.)

2.4 How to get the proper amount of hours for each service

The most common error in getting paramedical services is telling the doctor you need fewer hours than it takes to correctly carry out each step of providing each services. The doctor will decide what services are needed and usually how often to perform them (daily, weekly, monthly.) The real issue is how long it takes and that depends on knowing every step from setting up the procedure (like washing your hands) to cleaning up afterwards.

First, list the necessary steps to complete each service. The doctor should tell you or give you a handout. (That's called training.) You need to get a specific set of steps for performing the service. Since most usually require sterile conditions, there will be steps before and after the direct service to the recipient. There are available handouts of these steps. See Hospital To Home: A Patient Teaching Guide To Nursing Procedures, published by Rancho Los Amigos in Los Angeles. Ask PAI for a copy of the procedure you are performing.)

Second, you need to complete the steps until you learn them and can do them easily.

Third, keep a log of the time it takes to complete the steps on several occasions for each service. Take the average and give the log to the doctor, who will use it fill out Form SOC 321.

3. COUNTY TACTICS AND HOW TO MEET THEM

Counties use several tactics to undermine the doctor-patient decision making about paramedical services. There are ways to stop them from working.

 

4. APPEALS AND ALTERNATIVES WHEN COUNTY DENIES REQUEST

Appeal by asking for a hearing with the California Department of Social Services. Try alternatives: in home medical services and various waiver programs. Contact PAI, regional centers, independent living centers, or legal aid for more help.

 

 

IHSS Statute Authorizing Paramedical Services

California Welfare & Institutions Code § 12300.1 -- "Supportive Services”

As used in Section 12300 and in this article, "supportive services" include those necessary paramedical services that are ordered by a licensed health care professional who is lawfully authorized to do so, which persons could provide for themselves but for their functional limitations.  Paramedical services include the administration of medications, puncturing the skin or inserting a medical device into a body orifice, activities requiring sterile procedures, or other activities requiring judgment based on training given by a licensed health care professional.  These necessary services shall be rendered by a provider under the direction of a licensed health care professional, subject to the informed consent of the recipient obtained as a part of the order for service.  Any and all references to Section 12300 shall be deemed to include paramedical services.

 

IHSS Regulation for Paramedical Services

DSS-Manual-SS 30-757.

.19     Paramedical Services, under the following conditions

.191   The service shall have the following characteristics:

(a)     are activities which persons would normally perform for themselves but for their functional limitations.

(b)     are activities which, due to the recipient's physical or mental condition, are necessary to maintain the recipient's health.

(c)     are activities which include the administration of medications, puncturing the skin, or inserting a medical device into a body orifice, activities requiring sterile procedures, or other activities requiring judgment based on training given by a licensed health care professional.

.192   The services shall be provided when ordered by a licensed health care professional who is lawfully authorized to do so.  The licensed health care professional shall be selected by the recipient.  The recipient may select a licensed health care professional who is not a Medi-Cal provider, but in that event shall be responsible for any fee payments required by the professional.

.193   The services shall be provided under the direction of the licensed health care professional.

.194   The licensed health care professional shall indicate to social services staff the time necessary to perform the ordered services.

.195   This service shall be provided by persons who ordinarily provide IHSS.  The hourly rate of provider compensation shall be the same as that paid to other IHSS providers in the county for the delivery method used.

.196   The county shall have received a signed and dated order for the paramedical services from a licensed health care professional.  The order shall include a statement of informed consent saying that the recipient has been informed of the potential risks arising from receipt of such services.  The statement of informed consent shall be signed and dated by the recipient, or his/her guardian or conservator.  The order and consent shall be on a form developed or approved by the department.

.197   In the event that social services staff are unable to complete the above procedures necessary to authorize paramedical services during the same time period as that necessary to authorize the services described in .11 through .18, social services staff shall issue a notice of action and authorize those needed services which are described in .11 through .18 in a timely manner as provided in Section 30-759.  Paramedical services shall be authorized at the earliest subsequent date.

.198   In no event shall paramedical services be authorized prior to receipt by social services staff of the order for such services for by the licensed health care professional.  However, the cost of paramedical services received may be reimbursed retroactively provided that they are consistent with the subsequent authorization and were received on or after the date of application for paramedical services.