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Fresno Bee

February 22, 2010

Proposed cuts put adult day health centers at risk

Rudy Bravo lowered himself onto an exercise mat at the Heritage Adult Day Health Center in Fresno and removed his artificial leg for a series of exercises.

He does leg lifts five days a week. The routine, which he learned from the center's physical therapy staff, helps strengthen his limb, amputated below the right knee. Without the workout, he gets cramps.

Bravo, 61, lives alone. He has diabetes and his eyesight is failing. His short-term memory is bad, too.

Nurses at Heritage keep track of medications and health appointments and check his blood sugar. "I come here for so many reasons," he said last week.

But it's uncertain whether thousands of frail elderly and disabled Californians like Bravo will continue receiving services at adult day health centers after March 1.

Under new rules that the state wants to implement, about 40% of participants would no longer be helped, say advocates for the disabled who are fighting the changes in court.

The state says those who most need the services will continue to get them.

The proposed rules were a budget-saving legislative compromise to rescue the adult day health-care program from complete elimination.

But advocates say the state will pay more in the long run, because the centers keep people out of more expensive nursing homes and other institutions.

A federal judge in the U.S. District Court in Oakland could rule as early as today on whether the new eligibility standards can be applied.

Adult day health centers in California -- they can be nonprofit, for-profit or run by local governments -- serve about 37,000 people with physical and mental conditions who are at risk of being placed in skilled nursing homes or other institutions.

The centers provide medical and nursing services as well as physical and occupational therapy.

They also offer psychiatric and psychological services, social services, hot meals, nutrition services and transportation between centers and home.

Center operators say the eligibility rules are part of the latest assault on their business.

There were 366 such centers in 2004. Today, there are 327, they say. There are seven such centers in Fresno County, according to the California Department of Aging's Web site.

"Every time they have trouble with the budget, they talk about closing us down or cutting us down," said Anna Sahakyan, program director at Heritage.

The centers receive $76 a day per participant. Most participants are enrolled in Medi-Cal, the state-federal insurance for the poor. A few participants have private insurance or families that pay for services.

Gov. Arnold Schwarzenegger has proposed eliminating the centers, beginning March 1, to save $104 million in fiscal year 2009-10.

Legislators tabled the program's elimination from budget discussions until the regular budget session begins in March.

But as part of a cost-cutting package adopted last year, lawmakers ordered eligibility changes along with a three-day-a-week cap on services instead of the current weekly maximum of five days.

The cuts were to take effect March 1.

Total state savings from the eligibility cuts would be $31.8 million for fiscal year 2010-11, according to the state Department of Health Services.

Advocates took the state to federal court over the program cuts, saying they violated the federal Americans with Disabilities Act.

A federal judge granted an injunction Jan. 10 to stop the cap on services.

The judge could decide on a request for an injunction on the eligibility rules today or later this week.

The eligibility requirements limit what the state will consider when determining whether a person is eligible for center services, said Elissa Gershon, staff attorney with Disability Rights California, a statewide nonprofit group that is suing the state over the issue.

Under the new rules, a person's inability to prepare meals, do housework and laundry, shop, manage money or have access to transportation or social resources would no longer be used to determine eligibility, Gershon said.

Problems with bathing, dressing, feeding, walking, medication management and hygiene would continue to be eligibility criteria, she said.

"The list is shorter and the areas of need that have been eliminated are things we allege will disproportionately affect people with cognitive impairments and mental illness or dementia," Gershon said.

And the new rules raise the bar for people who do not have mental problems to show "substantial human assistance" -- hands-on care -- is needed in at least two of the remaining eight categories of need, she said.

The state Attorney General's Office says in a policy brief that the eligibility rules would not result in one group qualifying for services over another.

Those opposing the changes should take the issue up with the Legislature, not the courts, the brief said.

"The bottom line is, it's a policy decision made by the Legislature and we believe it's fully legal," said Susan Carson, a supervising deputy attorney general.

Center operators say the state is being shortsighted. It costs $20,000 per year for someone to come to a center five days a week, compared to $70,000 a year for skilled nursing home care, Sahakyan of Heritage said.

Center operators are sponsoring an Assembly bill that they see as a compromise, said Lydia Missaelides, executive director of the California Association for Adult Day Services.

AB 2073, introduced Thursday by Bonnie Lowenthal, D-Long Beach, would narrow eligibility requirements but not to the extent of the contested rules.

The legislation "is part of our contribution to the solution," Missaelides said. "We're trying to make things work for ... the families and the program and the constituent."

Uncertainty about the future of the program has unnerved participants, center operators said.

At Heritage last week, Jim Moore, 52, of Fresno said he's called, written and yelled at state officials about cuts to adult day health-care centers. He's been coming to Heritage for about two years. "It really changed my life tremendously," he said.

Moore said he was depressed and suicidal before he became a participant but hasn't been hospitalized for depression since then.

And he hasn't gone to the hospital for medical care in about a year.

He uses a walker and needs an oxygen tube to help breathe.

Family members of center participants say the state needs to find other ways to save money that don't target adult day health-care centers.

Ruth Rapp of Fresno said her brother, Randall Emmett, 63, looks forward to going to Heritage.

Born with cerebral palsy, he receives physical therapy at the center, but the social interaction also is important, she said. "This is one of the most important things in his life."

The hours that Emmett spends at the center also give Rapp, 58, a respite from caring for her brother.

Rapp watched last week as Emmett held onto parallel bars in the Heritage exercise room.

She brushed tears from her cheeks as he took a few steps.

Patting her brother on the shoulder and preparing to head out, Rapp said, "I'll catch you at home."