IHSS Annual Report 2017 - Santa Clara County, …€¦ · IHSS Annual Report 2017 Page 2 ... System II (CMIPS II), ... Removal of IHSS from Cal MediConnect (CMC) ...

FY 2017IN-HOME SUPPORTIVE SERVICES

A N N U A L R E P O R T

S O C I A L S E R V I C E S A G E N C Y DEPARTMENT OF AGING AND ADULT SERVICES

IHSS Annual Report 2017 Page 1

IN-HOME SUPPORTIVE SERVICES (IHSS) ANNUAL REPORT

Presented to the Children, Seniors and Families Committee

Board of Supervisors, Santa Clara County

October 11, 2017

Introduction

The Children, Seniors, and Families Committee last reviewed the IHSS Annual Report in

October 2016. This report will update the Committee as to the status of current

administrative and service issues specific to the IHSS program and the IHSS Public

Authority.

IHSS Program Overview

The IHSS program provides in-home care for persons who cannot safely remain in their

own homes without such assistance. Created in 1973, the core goal of the IHSS program

remains the prevention of premature or unnecessary placement of recipients in

institutions (skilled nursing facilities, community care facilities, or hospitals). IHSS is an

entitlement program and all clients found to be eligible and at risk of out-of-home

placement are accepted. To be eligible, recipients must be assessed and found to be

aged (65 years of age or older), blind or disabled (as determined by the Social Security

Administration) and are unable to remain safely in their own home without assistance.

Recipients must also meet specific income requirements consistent with eligibility for

Medi-Cal. Services offered include: domestic and related tasks such as laundry,

shopping, meal preparation, and light housecleaning; personal care services such as

assistance with feeding, bathing, and ambulating; transportation to and from medical

appointments; and certain paramedical services ordered by a physician. County Social

Workers perform an assessment to determine the number of hours and type of services

to authorize an IHSS recipient. The recipient is responsible for hiring, training,

supervising, and firing a provider. Based on the submittal of timesheets, the IHSS

providers are paid with a combination of state, federal and county funds.

IHSS is a state mandated and regulated program that is operated at the County level in

accordance with the California Welfare and Institutions Code. Both federal and state laws

serve, effectively, to make IHSS an entitlement program. Interested individuals have a

right to apply for IHSS services and are guaranteed services if they meet the financial and

functional eligibility criteria. Consistent with all public entitlement programs, IHSS provides


applicants certain rights—timely decision of eligibility, timely notice of change in eligibility

or service, and an appeals process to dispute eligibility decisions.

The California State Department of Social Services (CDSS) and the counties share

administrative responsibilities for the IHSS program. CDSS oversees the IHSS data and

payroll system known as the Case Management and Information and Payroll

System II (CMIPS II), serves as the payroll agent for the IHSS providers, and writes the

IHSS regulations. Counties are responsible for the day-to-day administration of the IHSS

program. County staff also determines recipients’ program eligibility and the number of

hours and type of services each recipient needs.

Components of IHSS

IHSS Program Funding

IHSS services are provided under four programs: Personal Care Services Program

(PCSP), Federal Plus Waiver Program (converted to State Plus Option in 2009), Residual

Program, and Community First Choice Options (CFCO).

Eligibility

To be eligible for IHSS, a person must be aged, blind or disabled and usually have

monthly income at or below $1005.00 per month for individuals. Those individuals with

income in excess of this grant level may still be eligible for IHSS with a share of cost

(SOC). An IHSS recipient with a SOC must make an out-of-pocket monthly payment

towards the receipt of IHSS services before the IHSS program pays the remainder of the

cost of their services. Eligibility for Medi-Cal is generally limited to individuals with no

more than $2,000 in assets and couples with no more than $3,000 in assets (with certain

exclusions for such assets as homes and vehicles).

Application and Social Worker Assessment

When a prospective IHSS recipient applies for the program, the determination of their

eligibility is a two-step process that takes into account both their income and need for

services. Once verified that an individual is financially eligible for IHSS, a Social Worker

visits the home of the recipient to determine whether there is a need for services. To

perform this assessment, the social worker uses a uniform assessment tool to

determine the number of hours for each type of IHSS service for which a recipient

qualifies in order to remain safely in his/her own home. The uniform assessment tool,

known as the Hourly Task Guidelines (HTGs) assists the Social Worker in ranking the

recipient’s impairment level on a five-point scale known as the Functional Index (FI)

ranking. Figure 1 shows each of the potential FI rankings that may be assessed by a

Social Worker, and what they mean for the impairment level of the recipient.


Figure 1:

Functional

Index

Impairment Implications

1 Able to perform function without human assistance-independent.

2 Able to perform a function, but needs verbal assistance

(reminding, encouraging).

3 Able to perform a function with some human, physical

assistance.

4 Able to perform a function with substantial human assistance.

5 Cannot perform the function with or without human assistance.

Each FI ranking corresponds to an established range of service hours for a particular

task. For example a recipient who receives an FI ranking of 2 on the “feeding” task may

be authorized to receive between 0.7 hours and 2.3 hours of feeding per week. The

corresponding range of hours varies depending on the particular task being assessed.

For example, meal preparation services range from three to seven hours. Also if an

individual is assessed as having an FI ranking of 1 for any given task, he/she will not

receive any authorized hours for that task. The weighted average of the FI rankings for

each task is used to create a total FI score. Although the HTGs provide a standard tool,

the assessment process is individualized. Social Workers may, with written justification,

authorize hours above or below the range established by the HTGs.

Assignment of Hours

Once a Social Worker has determined the number of hours to authorize for a recipient,

the recipient is notified of the number of hours they have been authorized for each task.

Using the HTGs, Social Workers may authorize between 1 and 283 total hours per month

of IHSS services. Recipients who receive over 195 hours of service each month are

considered to be severely impaired. Once it has been determined that a recipient meets

the eligibility criteria for IHSS, that individual is granted those IHSS services. As a result,

there is no waiting list or cap on program enrollment.


Federal and State Legislation Affecting IHSS

Provider Overtime

In February 2016, the state implemented the new federal labor regulations for IHSS

providers following a one-year delay due to federal court action. The federal regulations

required all IHSS programs to (1) pay overtime compensation—at one-and-a-half times

the regular rate of pay—to IHSS providers for all hours worked that exceed 40 hours in a

week; and (2) compensate IHSS providers for time spent waiting during medical

appointments and traveling between the homes of IHSS recipients.

In response to the new program responsibilities, Santa Clara County’s IHSS program

formed the Fair Labor Standards Act (FLSA) Unit in 2016. The FLSA Unit is responsible

for:

1. Implementing and enforcing the workweek, overtime, and travel time requirements;

2. On-going outreach, education, support, guidance, and planning to recipients and

providers regarding FLSA;

3. Reviewing violations that exceed the overtime and travel time limits and counsel

recipients and providers to prevent any further occurrences;

4. Issuing notices to both providers and recipients inform them of any violations and

the penalties (if any) related that violation;

5. Exploring and compiling information related to Exemptions 1 and 2;

6. Assisting recipients and providers-via a telephone hotline or lobby visits-to ensure

mutual understanding regarding responsibilities and the limits related to FLSA; and

7. Having the capability to enter information into the CMIPS II system.

With the goal of being accessible to the IHSS community, on May 2, 2016, IHSS went

Live with the FLSA Hotline to singularly address issues and concerns related to overtime

and travel time. Since its inception, the hotline has continued to average over 100 calls

per week. Topics can include but are not limited to: violations, timecard errors, weekly

hour calculations, flexible hour requests, travel times, forms, and non FLSA related

questions. As a direct result of the FLSA Hotline (with the occasional lobby visit), the

Santa Clara County’s IHSS program is anecdotally experiencing a high number of

providers who have not incurred an additional violation in the past year; these providers’

violation level have all been reduced to zero.


From July 1, 2016 to August, 31, 2017, IHSS has reviewed and counselled providers on

3048 instances of violations. Of that total, IHSS has upheld 1352 violations. At least

1696 violations were overridden and, of that number, 357 were overturned via the

provider dispute process. There were 1610 instances of violation which were

automatically overridden as the provider had qualified for an Exemption. Santa Clara

County has 73 providers who qualify under Exemption 1 and 1 provider under Exemption

2.

As the implementation of FLSA continues to be defined at the state level, Santa Clara

County’s IHSS program’s FLSA Unit will continue to provide timely responses to new

developments while simultaneously continuing its prime directive to serve and support

recipients and individual providers.

Coordinated Care Initiative (CCI) Update

Created through a public process involving stakeholders and health care consumers, the

passage of the Coordinated Care Initiative (CCI) marked an important transition towards

transforming California's Medi-Cal delivery system to better serve the state's low-income

seniors and persons with disabilities. The Coordinated Care Initiative (CCI) allowed

persons eligible for both Medicare and Medi-Cal (termed Dual Eligibles) to receive

medical, behavioral health, long term services and supports, and home and community

based services coordinated through a single health plan. CCI also included mandatory

enrollment for most other Dual Eligibles into Medi-Cal managed care and integrated Medi-

Cal long term services and supports (MLTSS), including In-Home Supportive Services

(IHSS), into managed care. As part of CCI, the state assumed bargaining responsibilities

for IHSS. CCI also established a new Maintenance Of Effort (MOE) requirement in place

of the traditional county share of cost for IHSS programs in all counties. This pilot was

implemented through a federal demonstration project and currently operates in seven

counties—Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, and

Santa Clara. As one of the pilot counties, Santa Clara County’s IHSS program created a

dedicated CCI Unit to execute the mandates of the pilot project.

Under current state law, the CCI pilot project has been determined to be not cost effective

and funding for CCI will cease on January 1, 2018. The termination of the CCI will have

the following impact on the Santa Clara County’s IHSS program:

● Removal of IHSS from Cal MediConnect (CMC) and Medi-Cal funded Long-Term

Services and Supports (MLTSS)

● Removal of IHSS benefits from Medi-Cal managed care plan capitation rates


● Elimination of Statewide Authority responsible for negotiating IHSS providers’

wages and benefits in the seven CCI counties

Of note, the most significant impact is the elimination of the MOE under the CCI pilot

project. The repeal of the CCI MOE would mean that an additional $592.2 million in

funding cost will be shifted from the State to Counties. To mitigate the financial hardship

and cash-flow problems, Senate Bill 90 was passed and the bill instituted a new MOE

funding model that modifies the cost sharing arrangements between the State and

Counties.

SB 90 establishes a new statewide county IHSS MOE base at $1.769 billion and

appropriates $400 million General Fund (GF) in FY18; $330 million GF in FY19; $200

million GF in FY20; and $150 million GF in FY21 and annually thereafter to offset the

additional IHSS costs being shifted to counties. At the time of this report, Santa Clara

County’s Interim MOE requirement stands at $74.6 million.

There will be no inflator to the MOE requirement in FY18 and in FY19, the County IHSS

MOE base will be adjusted by 5%. In FY20 and, annually thereafter, the base will be

adjusted by 7%.

In FY20, a “re-opener” will be conducted with the California Department of Finance

(DOF), California State Association of Counties (CSAC), and stakeholders to re-examine

how the provisions of SB 90 will impact the IHSS programs and the 1991 Realignment

funding structure.

Based upon lessons learned, certain elements of CCI have shown the potential to reduce

the cost of health care for affected individuals and improve health outcome. Thus, the

following components will be funded through December 31, 2019:

● The Cal MediConnect (CMC) program will be extended

● Mandatory enrollment of Dual Eligibles into managed care will be continued

● Integration of MLTSS (except IHSS) into managed care will be continued

During the tenure of the pilot project, Santa Clara County’s IHSS program’s CCI Unit has

worked in tandem with our County’s designated managed health care plans (Anthem Blue

Cross and Santa Clara Family Health Plan) to achieve the stated goals of CCI. As

conveyed by both health plans, this affiliation enabled significant reductions in turn-

around time for the most at risk IHSS applicants and diverted calls that would have

otherwise gone through the main IHSS telephone line. This was achieved through the

timely processing and screening of new referrals and reassessment requests from the

health plans, participating in Interdisciplinary Care Team (ICT) meetings, telephone


screenings, conducting assessments on expedited applications and reassessments on

high touch cases, engaging in follow up care as needed, and frequent communication

between all entities.

In FY17, the CCI Unit received 1021 inquiries from the health plans (e.g., new IHSS

referrals, ICT requests, general information, etc.). Of that number, 127 were for

reassessments and 82 resulted in a change of authorized hours. The CCI Unit received

approximately 25 new expedited referrals each month that were initiated by either the

health plans or through IHSS’ Application Readiness Unit. These referrals were

assessed by the CCI unit within 15 calendar days and hospice referrals were seen-on an

average of-15 calendar days. The CCI Unit completed 170 requests for additional

assistance on behalf of recipients enrolled in either Anthem Blue Cross or Santa Clara

Family Health Plan.

Figure 2

Fiscal Year 2015-2016 Coordinated Care Initiative Data

Total

Inquiries from Health Plans

(new referrals, ICTs, general info,

etc.)

1021

Reassessment requests 127

Reassessment requests resulting in

change of authorizations

82

Requests for Health Plan assistance

from IHSS

170

Expedited Referrals by Health Plans

from the Application Readiness Unit

Assessed in 15 calendar days

Hospice Referrals Assessed in 15 calendar days


In addition to the work that was performed under the auspices of CCI, the CCI Unit also

assumes other duties within IHSS:

● The CCI Unit has been utilized as the de facto unit to partner with many community

based organizations desiring a more direct relationship with IHSS. In the past year,

the CCI Unit has worked closely with the following agencies to affect the best

outcome for mutually served recipients: Institute On Aging-Community Living

Connection (CLC); Santa Clara County’s Office of Supportive Housing’s Care

Coordination and Transitions Program (CCTP); Santa Clara County’s Health and

Hospital System’s Valley Specialty Center’s Public Hospital Redesign & Incentives

in Medi-Cal (PRIME); and Valley Medical Center’s Social Work staff.

● The CCI Unit provided guidance to Medi-Cal recipients as whether it would be more

beneficial to obtain cash aid [Supplemental Security Income (SSI)] or in-kind

benefits [IHSS] via the completion of the Authorization for Non-Medical Out of

Home Care (Board and Care) form (SSP 22).

● Lastly, the CCI Unit maintained a half caseload of continuing IHSS cases in order to

assist with the IHSS reassessment compliance rate.

While the CCI pilot project may have fallen shy of full implementation, it is incontrovertibly

that the Santa Clara County’s IHSS program demonstrated how effective collaboration

and coordination with internal and external stakeholders can ensure the delivery of vital

services and support to our most vulnerable community members. The end result was

that individuals who enrolled in CCI expressed an increased satisfaction with their health

care services over time. The Santa Clara County’s IHSS program has been proud to

have been a participant in the CCI pilot project as it truly laid the groundwork to deliver

the right care, at the right place, and at the right time.

Santa Clara County’s IHSS Program

Housed within the Social Services Agency, IHSS is one of five programs along with Adult

Protective Services, Senior Nutrition, Office of the Public Administrator/ Guardian/

Conservator and Seniors’ Agenda that together comprise the Department of Aging and

Adult Services.

Currently, the IHSS program employs 155.5 full time equivalent positions and is staffed as

follows: Managers: 6; Quality Assurance: 6; Social Work Supervisors: 9; Case

Management Social Workers: 77; Fair Labor Standards Act/Coordinated Care Initiative:

11; Application Readiness: 10; Payroll/Data Specialists: 17; and Clerical support: 19.5.


Also as part of the MOE, IHSS augmented its staff by 10 full time equivalent positions

through the FY17 budget. IHSS received approval to hire 1 Social Services Program

Manager I/II, 6 Social Worker I/II’s, 2 Office Specialists II’s, and 1 Administrative

Assistant. We were successful in hiring all of these positions. For the Social Worker

recruitment, efforts were made to best reflect the IHSS recipient population regarding

language and ethnicity.

As of this writing, the number of IHSS recipients in Santa Clara County is approximately

23,592. The county’s IHSS population reflects the community’s cultural and ethnic

diversity. Attachment 1 provides an overview of the county’s IHSS recipient population by

city. Since the last report to CSFC the county’s IHSS caseload has increased by 6.4%.

Attachment 2 provides an overview of the county’s IHSS recipient population by the

spoken language/ethnicity breakdown of the recipient population.

Effective May 1, 2013 Santa Clara County launched the CMIPS II database application

that significantly changed the daily administration of the program. CMIPS II, a much

anticipated update of the legacy CMIPS system that had been utilized throughout the

State for the past 25 years, rolled out successfully after several years of intense work at

the State, vendor and local level. Due to significant changes (both legislative and

regulatory) as well as caseload and management needs, CMIPS II provides an enhanced,

efficient and user-friendly system to support the IHSS program. Several features of the

new system include: real-time data updates, on demand printing reports, pre-populated

State mandated IHSS forms, and less reliance on codes and commands in plain

language. Additionally, CMIPS II supports staff by automatically applying hourly task

guidelines, automatic calculation of IHSS authorized hours, on-line case notes, and on-

line review and approval by supervisory staff. Most significantly, the IHSS provider

payroll (which had historically been processed by county staff) is now processed by

CMIPS II via a central processing facility in Chico. County staff still handle exception

timesheets and provide error resolution as needed, however, payroll processing is

handled much more efficiently due to this changeover resulting in a significant decrease

in complaints regarding payroll processing.

Also of note is the negotiated change in the case carrying model of IHSS cases. As

CMIPS II requires that every IHSS case be assigned to a “case owner” the previous

model which incorporated a “banked” caseload was eliminated prior to the CMIPS II

launch. All 77 social work staff now shares an equitable distribution of the IHSS

caseload as well as receive an equitable distribution of the monthly intake applications

received to conduct an initial assessment. Caseload size is approximately 327 cases per

Social Worker. Ongoing meetings are scheduled between management and labor to

address efficiencies wherever possible.


With the implementation of the Telework Policy, all Case Management Social Workers

are able to work from home as many as a couple days a week by entering necessary data

into CMIPS II, thus reducing office distractions and increasing work output and

compliance with CDSS.

Remote Access is also another project that IHSS implemented. All Case Management

Social Workers received County issued laptops, Smartphones, hot spots, head sets, and

docking stations. This equipment is now considered mandatory in order for Social

Workers to complete their daily work.

In addition to Telework and Remote Access, IHSS began a project with the agency’s

Information Systems (IS) Division to implement a scanned document system called

Integrated Document Management (IDM), eliminating the need for paper case files. IHSS

implemented IDM in July 2016 and the work plan included scanning all of the active cases

by December 2016 and the closed cases by December 2017. As of the writing of this

report, all of the active cases were scanned by March 2017 and the closed cases are still

being scanned. Having IDM in place has improved the service delivery by providing case

document access to staff who are assisting recipients and providers. IHSS is working

with IS to improve IDM by adding a search feature so that documents can be located in

an even shorter amount of time.

IHSS Quality Assurance/Quality Improvement

Training

As part of the continued commitment to Quality Assurance/Quality Improvement, CDSS in

conjunction with the University of San Diego, statewide training is offered in order to

increase consistency in the assessment process used by IHSS Social Workers from all

counties. New staff is required to participate in all three modules of the training program

including: IHSS 101, Comprehensive Assessment Concepts (CAC), and Medical

Implications/Program Integrity/State Hearings. The module series are now offered in the

Central Region quarterly.

Santa Clara County continues to offer a CMIPS II Web-Based Training on SCC Learn

where staff can take advantage of on-line courses. New staff is asked to complete

Module 1 which gives a basic orientation and then they are asked to take relevant

Modules that pertain to their classification and job function.

Santa Clara County continues to offer in-house trainings series to orient staff to local level

policy and procedures. These trainings are coordinated by Staff Development. The


trainings topics are facilitated by Managers, Social Work Supervisors, Lead Social Worker

staff, and Quality Assurance (QA) coordinators. Topics include: IHSS Overview, State

Hearings, QA Roles and Responsibilities, Case Management Tools/Tips, CMIPSII, Medi-

Cal Eligibility and IHSS, Inter-County Transfers, Provider Enrollment and the Public

Authority, Payroll Functions and Timesheets, APS Overview and Mandated Reporting,

Protective Supervision, Proration, Assessing Minor Children, Able and Available Spouse,

Paramedical, and Medical Supplies.

State Monitoring Review

In December 2016, staff from the Quality Assurance Bureau of CDSS, Adult Programs

branch, reviewed 70 of Santa Clara County’s IHSS case files and accompanied county

QA staff on three home visits. Santa Clara County participated in an entrance

interview, hosted the review team, cooperated and supported the review process, and

participated in an exit Interview on the last day with the IHSS Leadership and Quality

Assurance team.

The final monitoring review report dated 1/11/17, confirmed that Santa Clara County was

found to be 100% compliant in the following areas:

1. Request for Order and Consent-Paramedical Services forms (SOC 321s) were in

the case file when required and signed by a Licensed Health Care Professional;

2. When a need for Protective Supervision was identified, there was sufficient

3. documentation for the service, the need was addressed at each reassessment, and

the Assessment of Need for Protective Supervision forms (SOC 821s) were in the

case files or documented as sent;

4. When available, the source and services of the Alternate Resources were

documented.

Reassessment Compliance Rate

Santa Clara County IHSS was commended for sustaining a high reassessment

compliance rate. Fifty-four of the 60 cases reviewed had timely reassessments.

Conducting timely reassessments continues to be a high priority in Santa Clara County,

as evidenced by the CMPIS II data from July 2017, showing that 86% of recipients

received timely reassessments.

Santa Clara QA Reviewed Cases

Twenty-four cases that our Santa Clara County Quality Assurance team reviewed were

also re-reviewed by the CDSS Monitoring team. CDSS revealed that:

1. When County QA staff identified areas to be addressed, regulations were applied

correctly in all 24 cases;


2. In 21 out of 24 cases reviewed, County QA staff identified most inaccuracies and

omissions present at the time of the Desk Review;

3. The remediation process outlined in the County’s QA/QI plan was clear and the

Desk Review Tool included completion timeline and appropriate signatures.

In 23 of 24 cases reviewed, the remediation process was followed;

4. In the seven county QA home visit cases reviewed, all issues identified during the

home visit were addressed appropriately.

Home Visits with County QA Staff

State monitoring staff accompanied count QA staff on three home visits for cases which

were identified as requiring a home visit. The County’s QA staff performed a thorough

assessment and addressed all of the required areas as outlined in ACL 130110.

Best Practices

The CDSS QA team reported that it was demonstrated throughout the monitoring review,

both in documentation and observed interactions that Santa Clara County strives to

provide quality service to clients. As a result of the last monitoring review Santa Clara

County developed several guides, processes and is working on the development of a

Web Application to assist in needs assessment process and to ensure uniformity in

authorization of cases and accurate assessment of needs and hours.

Areas of Concern/Santa Clara’s response

The following areas were identified as areas of concern by the monitoring review team:

1. Paramedical Services

Of the 16 cases reviewed with Paramedical services authorized, six cases had

authorized hours that did not match the hours the licensed health care professional

(LHCP) indicated in the Request for Order and Consent Paramedical Services

Form (SOC 321). If the County determines that the Paramedical tasks take more or

less time than the time indicated on the SOC 321, the county should contact the

LHCP to discuss their concerns. A new form should be obtained (ACL 08-18),

otherwise, the time indicated on the SOC 321 should be authorized.

2. Cases with Unmet Need

In three of the seven cases reviewed with unmet needs, there was no

documentation to verify that either the Social Worker had assessed the availability

of other resources or made referrals to address those unmet needs when

there are resources available (ACL 13-66). As stated in the Assessment

Narrative template, Social Workers are required to document what resources are in

place or referrals provided to attempt to address determined unmet need.


3. Alternative Resources

Although alternative resources were appropriately identified and documented where

applicable, in four of the nine cases reviewed, the hours authorized for purchase

were not reduced to reflect the availability of these resources. Santa Clara County

is aware of the inconsistency of how alternate resources are reflected in these

cases. A future All Staff training will ensure that all staff is completing this correctly.

State QA findings including the identified areas of concerns were shared with all levels of

the program at the April 2017 All Staff meeting. Areas of concerns identified continue to

be discussed at monthly IHSS Leadership Team meetings. This information has also

been incorporated into monthly All Staff training sessions with the Social Worker staff. In

September 2016, the IHSS All Staff meeting/training was primarily focused on

strengthening case documentation and assessment narratives when Social Workers are

assessing recipients. This training covered several identified areas of improvement

including paramedical services, cases with unmet need, and alternate resources.

Santa Clara County’s next CDSS review is scheduled to occur December 5-8, 2017. We

will have 60 cases reviewed and three home visits conducted with the CDSS QA

reviewers.

Quality Assurance Activities and Efforts

Internal Reviews

QA Social Work Coordinators were required to complete 584 desk reviews and 117 home

visits as required by standards set forth by CDSS. The results of these reviews were

given to the Social Work Supervisors who then review the findings with their social work

staff. Corrective actions are completed within 30 days of receipt. When QA staff note

trends, trainings and/or reminder memorandums are created. At monthly All Staff

meetings, we continue to train or retrain on a variety of identified QA training topics.

Currently, IHSS has three IHSS QA Social Work Coordinators. The number of yearly

reviews are assigned by CDSS based on county caseload size. Santa Clara

County is considered a large county and assignments are given based on 3.0 FTE staff.

Targeted Reviews

Pending Case Monitoring

This year’s activity was focused on identifying cases that had been in pending

status and assigned to a Social Worker for assessment more than one month.

Supervisors requested additional support in being able to monitor their staff

caseload based on assessment date.


QA receives a file once a month from Santa Clara County Information Systems (IS)

and is able to run a variety of program reports for follow-up and review. A pending

case report was created to pull each case that has been assigned to a Social

Worker with an outstanding pending status. The first report was generated in

February of 2017 and provided to Social Work Supervisors for review and

feedback. The feedback was received and incorporated in the report, which was

generated monthly for Social Work Supervisors to review and respond. Social

Workers are expected to input their assessment and data within seven business

days of a completed home visit. The timeframe this report is generated is to ensure

that staff have had sufficient time to input their data and have made a determination

in the month it was assigned. The reports were reviewed monthly by the Case

Management Social Service Program Manager II to ensure that the determinations

have been made, or if extenuating circumstances were present and outlined in the

case notes. The reports were reviewed at supervision each month with Social

Work Supervisors. Social Work Supervisors were required to review the report

earlier in the month, follow up with their respective staff and provide updates to their

Manager at supervision.

In the first month that the report was created there were 71 identified cases, by the

second month there were 20 cases identified, which was significantly less. This

report was instrumental in helping Social Work Supervisors manage the timeliness

of assessments and determinations on intake assignments in their units.

This targeted review will continue ongoing. The pending case assignment reports

assists management in holding mid management accountable and Social Workers

accountable for their intake assignments. Timely initial assessments are key in

providing essential services to keep our recipients safely in their home. This

continued oversight will ensure that assessments are taking place in a timely

manner.

Paid Claims

When the Medi-Cal system determines there was a potential out of home expense paid

for during an IHSS eligibility period, a paid claim task is initiated in the CMIPS II

application. The QA Coordinators respond to and investigate potential overpayments.

Confirmation is made directly with the identified facility or through provider confirmation.

During FY17, there were 113 confirmed overpayments as a result of this effort, initiating

overpayment recovery for $85,954.

Fair Hearing Compliance

In the appeals process, Social Workers are responsible for completing their own


responses to administrative law judge decisions. The Quality Assurance Manager

continues to manage the program’s compliance with response times for ordered actions.

Regional Meetings/Leadership Roles

In FY17, Santa Clara’s QA Coordinators continue to co- chair the Central Regional IHSS

QA Meetings, held bi-monthly throughout the Central Region of CA. This meeting

provides an opportunity to collaborate with other Central Regional county partners in the

implementation of QA activities. They will continue to fulfill this role for the remainder of

FY17.

In addition, the monthly CWDA Central Regional meeting provides an opportunity to build

relationships with County partners, various CDSS contacts, and generates ideas to best

improve our local program. In this meeting, Central Regional QA Manager/Social Work

Supervisors gather to discuss new regulations, policy and procedures, and various QA

efforts. Meetings are held in surrounding Central Regional counties throughout California.

Quality Improvement Efforts

Assessment Narrative and Service Evidence Documentation Training

Quality Assurance (QA) Coordinators noticed in their reviews that there were

inconsistencies in Social Worker documentation and suggested implementing a training to

address these concerns. This effort was created to provide an opportunity for a transfer

of learning experience and ongoing reference.

A documentation work group was created and they met for several months to plan,

organize and develop the training material and transfer of learning tool. The training

consisted of two parts, an All Staff meeting and a transfer of learning opportunity to

promote learning in small group settings. The initial training was provided at the IHSS All

Staff meeting in September of 2016, which included an overview of the changes, new

expectations and an introduction of the transfer of learning tool. The transfer of learning

tool provided specific examples of strong and weak documentation for discussion and

understanding. Copies of the transfer of learning tool were provided to each unit. Social

Work Supervisors were encouraged to go over the tool with their staff and QA

Coordinators were available to Social Work Supervisors to help facilitate this transfer of

learning opportunity. QA Coordinators attended most unit meetings to support this

process.

The outcome of this effort was very positive. County QA staff saw an overall

improvement in stronger documentation across the program. During our December 2016

Monitoring Review, the CDSS monitoring review team also acknowledged a significant


improvement in documentation compared to previous years.

Program Integrity

Potential fraud is detected several ways using resources provided by CDSS/CMIPS II.

Reviews of all fraud complaints submitted by Social Workers, county staff, collaterals, and

the community are required by CDSS. In addition to the review of fraud complaints, our

other program integrity efforts include: error rate study reviews, directed mailings,

unannounced home visits to verify services are being received or provided, reviewing all

identified overpayments and underpayments, reviewing the County Vital Statistics Report

for recipients that are deceased, and completing the Death Match Report.

Directed Mailings

The purpose of directed mailings is to reach out to providers associated with cases which

appear to suggest some program integrity concern (whether or not the concern is

founded) and proactively educate those providers concerning common program integrity

mistakes. The goal is to increase the participants’ knowledge and create a better informed

provider of IHSS services in an effort to reduce errors, fraud, and abuse in the IHSS

program. This year our identified category was Protective Supervision authorized cases

not reassessed in more than two years. Twenty-five cases were identified. Mailings were

sent to recipients and their individual providers in this effort.

Unannounced Home Visits

Unannounced home visits (UHVs) were conducted by our Program Integrity Coordinator

to ensure that the services authorized are consistent with the recipient’s needs at a

level which allows him/her to remain safely in his/her home, and to validate the

information in the case file. A UHV monitoring tool is used in efforts to safeguard a

recipient’s well-being by verifying that they are receiving appropriate levels of services

and to ensure program integrity by reminding recipients of program rules and

requirements and the consequences for failure to adhere to them, including the potential

loss of services. This year our indicator was eligible recipients (as of September 30, 2016)

who applied to the program before March 1, 2016 and did not have an assigned provider.

There were 38 assigned unannounced home visits. UHV efforts confirmed that nine

recipients had no identified program integrity concerns and 29 recipient cases were

determined to have substantiated program integrity concerns. Out of the substantiated

cases, 19 were terminated due to recipient’s services authorized beyond need or services

not sufficiently provided and eight were sent to the Social Worker for reassessment or

sent to QA for further action. Both the Social Worker and Social Work Supervisor were

notified to conduct an early reassessment to ensure the recipient received an appropriate

assessment or the QA Coordinators were notified to conduct a case review to ensure the

Social Worker’s assessment followed State regulations and County policies.


Fraud Review and Investigation

For FY17, a total of 355 fraud complaints were received. Five cases were sent to the

Department of Health Care Services Investigations for further investigation and

consideration for prosecution. Most of these cases are still pending prosecution. When

cases are prosecuted, this results in arrests, convictions, and restitutions to IHSS

ordered by the Court. In addition, 178 fraud complaints were reviewed internally by the

Quality Assurance Manager, IHSS Program Integrity Social Work Coordinator I, and the

Quality Assurance/Program Integrity Associate Management Analyst during the fraud

triage process. Presently, the Program Integrity unit triages the reports of suspected

fraud complaints and assigns them to an investigative agency based on amount threshold

and investigator availability. From these review efforts, cases were forwarded for criminal

investigation/prosecution, recipients and providers were educated about how to avoid

common fraud issues, or the cases were sent for identified overpayment processing.

Overpayment Recovery

The IHSS program has a dedicated Senior Account Clerk on staff responsible for

reviewing all terminated IHSS cases and auditing the case for either outstanding

overpayments or underpayments. Additionally, cases involving suspected fraud,

timesheet inactivity, Vital County Statistics, death reviews, paid claims, unannounced

home visits, or death matches are also submitted to the Quality Assurance/Program

Integrity Associate Management Analyst for a review audit. For FY17, $451,811 was

identified and processed for overpayment recovery to the IHSS program.

IHSS Public Authority

The Santa Clara County IHSS Public Authority is managed via contract by Sourcewise,

with a final amended FY17 budget of $2,036,051.

The primary role of the Public Authority is to offer services that assist recipients with

greater access to providers. This has been accomplished by:

1. creating a provider registry;

2. establishing the Public Authority as the employer of record for collective bargaining;

3. maintaining benefits administration for qualified independent providers;

4. providing access to training for consumers and providers of IHSS and;

5. providing enrollment processes for all new providers.


The provider registry is a computerized database listing of screened and qualified IHSS

providers. The Public Authority implemented mandatory criminal background checks for

independent providers prior to becoming eligible to be listed on the registry. As of June

2017, the registry had 549 active providers available to work. These services provide

recipients with a greater level of confidence when hiring providers referred by the registry.

Additionally, the Public Authority administers benefits which include: health, dental, vision

and VTA Eco-Pass Clipper Cards for eligible providers. The ability of the Public Authority

to maintain an adequate number of qualified screened providers on the registry correlates

to the wages and benefits offered in Santa Clara County. The Public Authority also gives

recipients a voice in how IHSS services are provided via the IHSS Public Authority

Advisory Board. The Advisory Board is also a state mandated function of the Public

Authority. It is composed of eleven members of whom at least 50% are individuals who

are current or past users of personal care assistance services. The Advisory Board

studies, reviews, evaluates and makes recommendations to the IHSS Public Authority

Governing Board and Sourcewise staff relative to any matters affecting persons receiving

IHSS.

Public Authority provides access to training for recipients and providers as part of its

mandate. The Public Authority implemented training for providers in partnership with Adult

Education programs in Santa Clara County and now offers classes in five different

locations. Classes are designed to enhance the skill set of providers in providing quality

care for their IHSS recipients maintaining a consumer directed model.

Public Authority Services provides training classes for providers through a curriculum

developed specifically to follow and reinforce the IHSS based recipient directed model of

care. In FY17, Public Authority Services provided training for 1,876 providers and issued

69 certificates of completion to providers who finished all nine Series 1 certificate classes.

In June 2017, Public Authority Services began issuing a Series 2 certificate of completion

to providers who have completed the six most recently incorporated class subjects. The

Series 2 certificates were issued to all 10 providers who have completed those classes to

date. Fewer classes were offered to providers during the FY17 due to a lower number of

registrants and the continued high rate of absence for classes. However, the ratio of

certificates earned by providers increased from 3.6% in FY16 to 4.2% in FY17.

In Fall 2016, Public Authority renamed several classes to better reflect the purposes and

intentions of the subjects, while the content of the classes largely remained the same.


The curriculum offers 15 classes:

Series 1 Certificate classes:

CPR Nutrition

First Aid Personal Care

Understanding Diabetes Safety and Infection Prevention

Last Phase of Life Safe Lifting and Transferring

Mental Health

Series 2 Certificate classes:

Alzheimer’s Basics Caregiver Stress Management

Cancer Care Basics Emergency and Disaster Preparedness

The Skilled Care Provider Falls Prevention

The Public Authority is also mandated to provide access to training for IHSS recipients. A

newly developed training called “Call and Connect” was launched in February 2016 on a

monthly basis. Recipients are pre-registered for the sessions, emailed or mailed class

materials ahead of time and given a call-in number to join the session. Feedback from

recipients who have participated indicates they find them informative and quite valuable.

Session topics provided were:

Finding and Using Community Resources

Understanding and Using the Public Authority Registry

Independent Living and Consumer Rights

Living with Memory Loss

Disaster and Emergency Preparedness

Falls Prevention

Tips for Training a New Care Provider

Understanding Roles: IHSS, Social Workers, Care Providers, and the Public Authority

Tips for Improved Communication

Understanding IHSS Authorized Services

Additional training resources are available on the Public Authority website www.pascc.org

including videos and training modules in multiple languages on the following topics:

• IHSS System Introduction

• Obtaining Your Independent Provider

• Managing Your Independent Provider

• Assessment, Reassessment and the Appeal Process

http://www.pascc.org/


The Consumer Connection quarterly newsletter was mailed to all IHSS recipients. The

purpose of the newsletter is to inform recipients of important information regarding the

IHSS program and to provide informative articles as additional training tools to better

equip them in their role as employers of IHSS homecare workers. Newsletters and

training materials are also posted on the Public Authority website at www.pascc.org.

The Public Authority implemented Care Coaching July 1, 2015 as part of the Registry

services. Care Coaching provides help for IHSS recipients who require assistance with

the responsibilities of being an employer. Three Care Coordinators are assigned cases as

referrals come in. They help IHSS recipients with scheduling provider interviews, coach

recipients on how to conduct interviews, establish work schedules, set expectations and

problem solve. Establishing relationships with the recipients and providers to help them

when they need it but also to teach them how to do this on their own if they are able. This

program is an essential component of the registry for those who are unable to handle

these responsibilities on their own and do not have a friend or family member to assist

them. Care Coaching received 271 referrals during fiscal year 2017. Referrals primarily

come from APS, IHSS and the two health plans, Anthem Blue Cross and Santa Clara

Family Health Plan. Of the total referrals to the program 10 came from the health plans.

FLSA Overtime

The IHSS program began paying overtime and travel time to providers under the FLSA

regulations beginning with the February 2016 pay periods. Providers working more than

40 hours per week are paid time and a half for all hours over 40. There are a number of

regulations that limit the amount of overtime that a provider may claim and providers may

be issued “violations” if they exceed the allowed limits. Multiple violations can lead to

termination of the provider from the program for up to one year.

Public Authority Services continues to offer training on the topics of overtime and travel

time both in-class and via telephone to providers and recipients. Between July and

December 2016, 13 providers completed classroom training for overtime and travel time.

Due to declining interest for classroom training, overtime and travel time training is now

offered individually via telephone as needed. In person training is available for providers

requiring additional assistance. In FY17, Public Authority Services provided assistance to

109 providers via telephone.

In May 2017, Public Authority Services released a timesheet training video to assist

providers and recipients to better understand how to correctly complete and submit their

timesheets and how to avoid common mistakes that may delay pay or result in an

overtime violation. Between the release date on May 10, 2017 and June 30, 2017, the

http://www.pascc.org/


video had 3,049 views.

IHSS Provider Enrollment Process

Sourcewise, and IHSS collaborated on developing a local methodology to implement the

four new mandated functions. The Provider Enrollment mandates for counties are:

1. all providers must submit fingerprints and undergo a criminal background check by

the California Department of Justice;

2. providers must attend a provider orientation/watch a video providing rules,

regulations and requirements for being an IHSS provider;

3. providers must sign a provider agreement stating they understand and agree to the

rules of the program and responsibilities of being a provider; and

4. providers must provide a current, original government issued ID and their

original Social Security card to the county or Public Authority to be

electronically scanned.

An additional change to IHSS provider enrollment was enacted pursuant to SB 878 adds

WIC section 12301.24(e) which requires that, no later than April 1, 2015: The provider

orientation shall be an onsite orientation that all prospective providers shall attend in

person. Representatives of the recognized employee organization in the county shall

be permitted to make a presentation of up to thirty minutes at the provider orientation.

The Public Authority developed a one hour IHSS provider orientation session with

an additional thirty minutes at the end for SEIU representatives to present the union to

attendees. The group orientation was added to requirements for individuals to complete

the IHSS enrollment process to become eligible to be paid as an IHSS provider. Sessions

are offered two times per week typically with a Friday morning and afternoon option.

IHSS contracts with Sourcewise to provide the mandated functions which require

providers be processed prior to them becoming eligible to be paid through IHSS. The

enrollment process in Santa Clara County has been successful in meeting the mandate

and all providers who took action to complete the process have been provided the

opportunity. There were 5,668 new providers processed through enrollment during the

2017 fiscal year which is an increase of 8.4% over last year.

Public Authority continues to use REVA (Registration, Enrollment, Verification,

Appointment) exclusively for provider enrollment with an alternative plan in place for

anyone unable to access the web-based process.


MOA with SEIU Local 2015

The Memorandum of Agreement (MOA) with the union expired February 1, 2017, with no

successor agreement the previous one was automatically extended for 12 months. With

the discontinuance of CCI, the State disbanded the Statewide Authority effective January

10, 2017 and returned collective bargaining responsibilities to the Public Authority.

Negotiations have not been initiated by either the union or the Public Authority as of June

30, 2017.

Community Outreach is conducted in the community to increase awareness about

IHSS. A volunteer IHSS staff member and a representative from SEIU participate in local

health fairs, and community group sessions to share basic information regarding IHSS

and eligibility for the program. The Public Authority purchases materials necessary

for these outreach activities. Nine outreach events were attended throughout the year

providing informational flyers, magnets with the IHSS phone number and answering

questions about the program.

The MOA agreement includes language regarding a new or modified VHP plan being

adopted. A change to the VHP benefit was incorporated effective September 1, 2014

creating two plans, the Classic (original wide network) and the Preferred Plan (new

narrow network). As of June 2017 there were 5,975 providers enrolled in the Classic Plan

and 4,777 providers enrolled in the Preferred Plan. This translates into a 12.5% reduction

of enrollment in the Classic Plan and a 32% increase in the Preferred Plan over the

previous year.

All new enrollees are only eligible to enroll in the Preferred Plan. Any provider who was

enrolled in VHP prior to the creation of two plans remains in the Classic Plan as long as

continue as IHSS providers. If they terminate benefits for any reason and later decide to

return and re-enroll in VHP they are only able to enroll in the Preferred Plan.

Health, dental and vision benefits continue to be offered to providers who work at least

35 hours a month for the most recent two consecutive months. There is a $25 portion of

the premium cost to providers enrolled in Valley Health Plan (VHP). Growth of the

number of providers enrolled in benefits increased over the previous fiscal year.


Figure 3:

Valley Health Plan Liberty (dental)/VSP (vision)

June 2015 10,078 10,692

June 2016 10,752 11,436

Percent Growth 6.27% 6.5%

The Public Authority is also responsible for administering and issuing the VTA Eco Pass

benefit for IHSS providers. The Eco Pass was transitioned to a Clipper Pass by VTA as of

January 1, 2015. The Public Authority has issued 18,729 Eco Pass/Clipper Cards this

calendar year.

IHSS Future Planning

The Social Services Agency has been deeply involved in developing a strong

labor/management partnership to promote improved outcomes for our recipients. Unit

Based Teams (UBT’s) were initiated in the Health and Hospital System and have since

begun in Social Services Agency as well. IHSS requested to be considered for a UBT

and received approval in late 2016.

During the January 2017 mandatory IHSS All Staff Meeting, UBT Facilitators educated

our staff about the UBT process and how a group of frontline employees, Social Work

Supervisors, Managers, and labor would work collaboratively to solve a problem, improve

performance, and enhance quality for measurable results. During this All Staff Meeting,

we asked for volunteers to form a committee within IHSS to determine a project, goal, and

present a deliverable. Ultimately, we formed a committee of volunteers from IHSS staff,

sought input from all of the staff by seeking project ideas from all of the 14 unit meetings

within IHSS, and chose a project based on the most popularly selected idea. The idea

selected was the long phone wait times for our outside callers.

The IHSS UBT committee has been meeting twice a month since February 2017 and

there are additional meetings outside of IHSS that are also required. The IHSS UBT goal

is to reduce the provider phone wait time by 25% of an average of 30 minutes from the

May 2017 baseline by October 31, 2017. Based on one of the most common ideas

collected from staff and stakeholders, we implemented the voice mail option on August 4,

2017. Outside callers now have the option of holding on the line or pressing the pound

sign to leave a message. Since we implemented the voice mail option, we have been

receiving an average of 100 voice mails per day and we have also surpassed our UBT

goal of reducing the phone wait time by more than 25%.


While we are ecstatic that we have surpassed our goal prior to the UBT project

completion date of October 31, 2017, we still have a lot of work to do internally. Some

IHSS staff perceive the forwarded voice mail as an additional workload duty and have

shared their ideas with the UBT Committee, management, and labor about what changes

should take place in order to make this project successful overall.

Once the workload issues have been resolved, we are hoping to implement the email

option effective as early as October 1, 2017. This would allow recipients, providers, and

the community to send us an email in addition to coming to our office in person, calling,

leaving a voice mail, or even sending a fax. We believe that by implementing the email

option, the phone wait times will reduce even more.

Even though the UBT project is expected to end October 31, 2017, we still have plans to

work beyond and improve the wait time even more. We plan to put some of the most

commonly used IHSS forms online so that users may either submit the forms online or

print them out and send them via fax or email to our office to be processed. We have

already begun the revamping of the IHSS lobby to make it more efficient for our recipients

and providers so that they may fill out the most commonly used forms in our lobby and

drop them in a locked drop box on their way out which eliminates the need to wait in line

to speak to a receptionist.

In addition to UBT, the implementation of Electronic Timesheets (E-Timesheets) is brand

new to IHSS. E-Timesheets will enable recipients and providers to submit timesheets via

their smart phone, lap top, or iPad which would replace the paper timesheets that are

currently in place. CDSS began with a small pilot of three counties on June 5, 2017 and

after a successful pilot, all of the remaining counties will Go Live in different waves.

Santa Clara is part of Wave 3 and will Go Live with E-Timesheets on October 11, 2017.

Based on the pilot counties, Waves 1 and 2, we expect that recipients and providers will

be pleased with what E-Timesheets has to offer including making edits electronically,

making fewer errors due to system pop ups and calculations, and having a reduced need

to contact our office because recipients and providers will be able to check the status of

payment with their electronic devices.

The only thing of concern Santa Clara County has at this point is the increase of lobby

visits and phone wait times just prior to Go Live and immediately following Go Live.

However, it has been reported by previous counties that the increase of activity lasts only

about a month or two and that staff do not otherwise see an increase of workload.


Attachments

Attachment 1: IHSS Recipients by City

Attachment 2: IHSS Recipient Spoken Language/Ethnicity Demographics

Attachment 3: Quality Assurance Monitoring Review

Santa Clara County IHSS Recipients Distribution By City

September 2017

Morgan Hill 1.64%

Palo Alto

Campbell 2.56%

2.74%

Saratoga 1.02%

Cupertino

1.86%

Los Gatos 0.80%

Los Altos 0.40%

San Martin 0.28%

Alviso 0.06% Los Altos Hills

0.02%

Gilroy 3.23%

Mountain View

3.06%

Santa Clara 4.38%

Sunnyvale

4.82%

Milpitas 5.41%

San Jose 67.69%

Total IHSS Population: 23,212

City IHSS Recipients San Jose 15702 Milpitas 1257

Sunnyvale 1119 Santa Clara 1017

Mountain View 711 Gilroy 752

Cambell 637 Palo Alto 596 Cupertino 432

Morgan Hill 381 Saratoga 238

Los Gatos 188 Los Altos 95

San Martin 65 Alviso 16

Los Altos Hills 06

Data Source: IHSS QA Dashboard‐case count reflects eligible cases (9/24/17)

ATTACHMENT 1

ATTACHMENT 2

Language

N %

American Sign Language 7 0.028%

Arabic 81 0.325%

Armenian 30 0.121%

Cambodian 246 0.988%

Cantonese 795 3.194% EthnicityEnglish 8,948 35.955% N %

Farsi 906 3.640% Amer Indian/Alaska Natve 47 0.19%

French 4 0.016% Asian Indian 737 2.97%

Hebrew 2 0.008% Black 824 3.32%

Hmong 4 0.016% Cambodian 264 1.06%

Ilocano 41 0.165% Chinese 3,288 13.24%

Italian 4 0.016% Filipino 1146 4.62%

Japanese 14 0.056% Guamanian 3 0.01%

Korean 474 1.905% Hawaiian 6 0.02%

Lao 28 0.113% Hispanic 4,402 17.73%

Mandarin 1,948 7.827% Japanese 46 0.19%

Mien 5 0.020% Korean 500 2.01%

Other Chinese Languages 126 0.506% Laotian 35 0.14%

Other Non-English 1005 4.038% Oth Asian/Pacific Islndr 1122 4.52%

Other Sign Language 4 0.016% Samoan 16 0.06%

Polish 4 0.016% Vietnamese 6,663 26.84%

Portuguese 52 0.209% White 5,555 22.38%

Russian 965 3.878% No Valid Data Reported 172 0.69%

Samoan 8 0.032% TOTAL 24826 100.00%

Spanish 2168 8.711%

Tagalog 585 2.351%

Thai 3 0.012%

Turkish 2 0.008%

Vietnamese 6,427 25.825%

No valid data reported 1 0.004%

TOTAL 24887 100.00%

IHSS cases IHSS RECIPIENT SPOKEN LANGUAGE AND ETHNICITY DEMOGRAPHICS

SEPTEMBER 2017

*Data Source: CMIPS II-Case counts reflect current eligible,pending applications and recently terminated cases.

IHSS cases

IHSS Annual Report 2017 - Santa Clara County, …€¦ · IHSS Annual Report 2017 Page 2 ... System II (CMIPS II), ... Removal of IHSS from Cal MediConnect (CMC) ...

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