New York s Consumer Directed Personal Assistance Program (CDPAP)

Transcription

1 CDPAANYS Consumer Directed Personal Assistance Association of New York State 272 Broadway Albany, NY Fax New York s Consumer Directed Personal Assistance Program (CDPAP) The Consumer Directed Personal Assistance Program (CDPAP) [or Program herein], in its existing form, is the innovative cost savings model that provides New York State with a Savings Net. When considering Medicaid redesign and reform, there is no need to cut or create - the answer is already here. CDPAP is a Legislatively mandated 1, Medicaid funded Personal Care program that empowers self-directing seniors, people with disabilities or their designated representatives to recruit, hire, train, supervise and terminate their choice of personal assistant home care worker. This model is the textbook example of one that affords tangible positive outcomes and greater satisfaction with services. The concept of consumer-direction comes from the independent living and disability rights movements and serves to maximize the independence and autonomy of persons needing functional assistance from others. Consumer-directed models of financing and delivering services permit the person needing service greater choice and control over all aspects of service: recruiting, hiring, training, supervising, scheduling and deciding when and how specific tasks or services are to be performed. Studies that compare consumer directed models to traditional personal care models demonstrate the value of consumer direction in affecting concepts such as safety, unmet needs and satisfaction. 2 According to a report by Health Services Research, from a recipient perspective the consumerdirected model is associated with more positive outcomes 3. The second prong of CDPAP qualifying as the textbook example for innovation is that the Program does more with less due to inherent cost savings based on the model s unique structure. 1 New York State Social Services Law, Title 11, Article 5, 365 f. 2 Improving the Quality of Medicaid Personal Assistance through Consumer Direction. Leslie Foster, Randall Brown, Barbara Phillips, Jennifer Schore and Barbara Lepidus Carlson. Health Affairs, And Comparing Consumer Directed and Agency Models for Providing Supportive Services at Home. A. E. Benjamin, Ruth Matthias and Todd M. Franke. HSR: Health Services Research 35:1, Part II, April Comparing Consumer Directed and Agency Models for Providing Supportive Services at Home. A. E. Benjamin, Ruth Matthias and Todd M. Franke. HSR: Health Services Research 35:1, Part II, April Page1

2 New York s CDPAP Consumer directed home care has been operational in New York since early 1980s when the Client Maintained Home Attendant Program was approved and Concepts of Independence became the first CDPAP provider in New York. The demonstration known as Patient Managed Home Care was renamed the Consumer Directed Personal Assistance Program (CDPAP) in 1995 when legislation mandated statewide expansion of this model. A 1992 exemption from the Nurse Practice Act was granted to this program, thereby making it possible for personal assistants to perform tasks that are generally reserved to a home health aide, licensed or registered nurse 4. In addition to the cost savings associated with empowering consumers to manage their services, allowing assistance to perform skilled tasks, which are traditionally performed by expensive medical personnel, further solidifies CDPAP as the most cost effective model for home care. The Program is open to almost all Medicaid-eligible persons receiving or eligible to receive various types of home care services provided they are self-directing or have a designated representative, who is another adult, legal guardian or relative willing to direct their care. In 1996, the New York State Department of Health (DOH) required all local social service districts to file a plan for creating a CDPAP and in 2009 there was a legislative mandate for all local social service districts to file an annual implementation plan to the Department of Health for approval 5. Despite these mandates, not all counties utilize the program to its fullest potential. CDPAP Utilization and Expenditures From its early start of 100 consumers, the CDPAP now has over 9,500 people in the program with the greatest utilization in counties outside of New York City: NYS Consumer Directed Personal Assistance Program Calendar Year Geographic Area Number of Recipients, 2008 Percent Change, CY Per Recipient Expenditures Percent Change, CY NY City 2, % $ 48, % Downstate 7 2, % $ 37, % Upstate 4, % $ 7, % Statewide 9, % $ 32, % 4 Education Law, Title 8, Article 139, Exempt persons: (1)(a)(iii) 5 New York State Department of Health s Local Commissioner s Memorandum 09 OLTC/LCM 1 August 11, Interim Report, Home Health Care Reimbursement Workgroup, December 2009, Table 2, NYS Medicaid Recipient Counts for Long Term Care Services, Calendar Year 2003 through 2008, Statewide. Original source: NYS DOH OHIP Datamart (based on claims paid through 10/2009) 7 Nassau, Suffolk, Westchester, Rockland and Putnam Counties. Page2

3 The CDPAP is one of the fastest growing home and community-based programs on a statewide basis, second only to Medicaid Managed Long Term Care which has grown over 143 percent over the same period of time. 8 However, enrollment in CDPAP still pales in comparison to traditional home care and personal care - with each program serving approximately eight times the number of consumers in CDPAP 9. And unlike other home care programs whose expenditures are going up without commensurate increases in beneficiaries served, the CDPAP continues to grow in number of consumers, providing value to the State in savings. CDPAP growth in upstate has enabled consumers to avoid institutional placement despite a shortage of home care aides. However, despite this increase in enrollment, CDPAP is still vastly underutilized and un-promoted by New York State. CDPAP Current Cost Benefit Reimbursement Methodology CDPAP s Medicaid reimbursement is based on the personal care methodology. There are two main components of the hourly rate, which is based on allowable expenditures. The main component, Direct Care, encompasses all expenses related to the home care worker such as wage, payroll taxes, Worker s Compensation, Disability, Unemployment, health assessment fees and any health insurance and benefits. There is a cap called a Regional Ceiling for the Direct Care component. The second major component is the Administrative component which encompasses the allowable expenses for managing the CDPAP such as rent, telephone, office supplies, wage, payroll taxes, Worker s Compensation, Disability, Unemployment fees and any health insurance and benefits for the administrative staff. There is a cap on the amount of allowable Administrative expenses which is up to 18% of total expenditures 10. Cost Savings Cost savings within CDPAP are achieved in four ways: First, since consumers provide their own recruitment, checking references, hiring, training, supervision and termination, the professional staffing costs for these tasks that typically accrue to Medicaid are eliminated. Training personal assistant workers to assist in your own personal needs is a logical step to allow for autonomy for the selfdirecting consumer. Savings are realized by eliminating the middle man for the worker because those administrative functions are no longer necessary to fund. 8 NYS Medicaid Redesign Team January 13, 2011 Power Point presentation at: 9 Ibid 10 As per the December 2, 2005 Department of Health Dear Administrator Letter regarding 2006 Personal Care Rates. Page3

4 Second, the Administrative cap is the lowest for all home care models. Even within Personal Care itself, there is a 10% difference between traditional Licensed Home Care Services Agency (LHCSA) rates which have a cap of 28% of total expenditures. A minimum of 82% of the Medicaid reimbursement rate is spent directly on personal assistant workers who, it should be noted, spend their paychecks within their local economies a much higher percentage than is found in home care agencies. The Department of Health recently provided data that highlighted how CDPAP rates were lower than traditional LHCSAs: For the first quarter of 2009, for example, the cost to the Medicaid program for each hour of consumer directed personal assistance program services was $13.20 and the cost per hourly unit of personal care services was $15.36, a difference of $ Third, and very important, since CDPAP consumers have the ability to directly train and supervise their staff to perform tasks that fall under the traditional scope of nursing, the difference in reimbursement is exponential as Medicaid avoids the costs of nursing visits. Finally, unlike the Certified Home Health Care Agency 12 system, there is no subcontracting with other home care agencies and no potential controversy regarding where dollars are being spent. Dangers of Reducing Reimbursement Recently, any time home care reductions were made, the CDPAP received commensurate cuts. These recent reductions in CDPAP reimbursement have drastically affected the Direct Care component of the reimbursement methodology. The cuts have specifically suppressed the Direct Care ceiling cap leaving the Administrative component virtually untouched, and constraining the amount that can be paid to the personal assistant. One of the primary ways CDPAP saves money is by the consumer s ability to recruit and retain the personal assistants who, by virtue of every hour worked, reduce each hour of reimbursement from costlier models. CDPAP Case Studies See our website 13 for specific examples of actual cost savings. 11 Department of Health, Regulatory Impact Statement, Section Costs to State and Local Governments, relating to proposed Title 18 NYCRR Section Interim Report, Home Health Care Reimbursement Workgroup, December 2009, The Executive Budget included a proposal to eliminate subcontracting by CHHAs and LTHHCP for HHAs with LHCSAs. This proposal was advanced to reduce potential duplicative administrative costs, improve the pay and benefits of HHAs, and assure CHHAs maintain responsibility for the quality of care provided to recipients of services. The workgroup determined that there is a need for greater transparency Page4

5 Proposed Additional CDPAP Cost Benefit Reforms As lean and succinct as the CDPAP model is the following improvements will reduce unnecessary Medicaid expenses. Medicaid Transportation Cost Savings Since the early 1980s consumers utilizing CDPAP have relied on their personal assistants to drive them, whether it be the consumer s own vehicle or the personal assistant s vehicle. Unfortunately, the Department of Health made a ruling at the end of December 2008 stating transportation to Medicaid covered medical services is to be provided pursuant to 18 NYCRR which barred consumers from utilizing their personal assistant to drive them to medical appointments. Keep in mind, the CDPAP authorizing statute lists transportation as a choice of service 15 and the federal Medicaid Manual that provides the states guidance on federal personal care parameters 16 also acknowledges transportation as a valid task within the scope of service section. Also, there is no provision within that excludes personal assistants from providing Medicaid transport, in fact, two sections raise the prohibition of utilizing Medicaid funded transportation when a Medicaid recipient has access to a private vehicle ordinarily used for other activities of daily living. 17 The Medicaid transportation system, with its use of ambulettes 18 and other extraordinarily expensive 14 GIS 08 OLTC/ f. (2)(c): has been determined by the social services district, pursuant to an assessment of the person's appropriateness for the program... is able and willing... to make informed choices... as to the type and quality of services, including but not limited to such services as nursing care, personal care, transportation and respite services. (emphasis added.) 16 The State Medicaid Manual, Pub. No. 45, Chapter 4, Section 4480 (C) Scope of Services, Personal care services... may include a range of human assistance provided to persons with disabilities and chronic conditions of all ages which enables them to accomplish tasks that they would normally do for themselves if they did not have a disability... such assistance most often relates to performance of ADLs and IADLs... IADLs capture more complex life activities and include personal hygiene, light housework, laundry, meal preparation, transportation, grocery shopping, using the telephone, medication management, and money management. (emphasis added.) NYCRR Prior Approval: (d)(7)(i) when the MA recipient can be transported to necessary medical care or services by use of private vehicle or by means of mass transportation which are use by the MA recipient for the usual activities of daily living, prior authorization for payment for such transportation expenses may be denied; (emphasis added.) 18 NYCRR Payment: (e)(9)(iv) Payment will not be made for transportation services when.. the MA recipient has access to and can make use of transportation, such as a private vehicle or mass transportation, which the recipient ordinarily uses for the usual activities of daily living unless prior authorization has been granted by the prior authorization official. (emphasis added.) 18 Medicaid Institute at United Hospital Fund. Medicaid Transportation in New York: Background and Options New York State Total: One Way Ambulette Fees: Minimum $12.75 / Median $30.12 / Maximum $50.00 Page5

6 modes of transportation, is there for individuals who need non-emergency medical transportation not provided by other means. Allowing medical and non-medical transportation in the CDPAP will provide a wide scale savings in Medicaid expenditures and providing the autonomy to self-direct both modes of transportation will greatly enhance quality of life. Many consumers who are forced to utilize the Medical transportation system are extremely inconvenienced by the pick up and drop off times, the long waits, the riding for miles and hours with other consumers who also have appointments. Update Regulations Requiring Annual Tuberculosis Testing for CDPAP Personal Assistants As of June 1, 2010, the New York State Office for People with Developmental Disabilities (OPWDD) promulgated new regulations related to the control of tuberculosis 19. The DOH must follow OPWDD s lead in recognizing that although tuberculosis is a communicable disease, the low prevalence of the disease in the community doesn t warrant annual testing on a broad scale. OPWDD changed the frequency of testing to upon hire with no subsequent tests (other than developmental centers.) Medicaid currently reimburses CDPAP providers for expenses 20 relating to each personal assistant s annual health assessment, annual tuberculosis testing and appropriate follow up and initial immunity testing for measles and german measles (if applicable.) These regulations must be reviewed to assess what constitutes a true risk to Public Heath and what are outdated processes that misdirect Medicaid funding. Update the Personal Care Regulations to Avoid Unnecessary Consumer Doctor s Appointments The current Personal Care Regulations and the proposed CDPAP regulations 21 both require a physician s order for each authorization period, specifically requiring the physician to examine the consumer within 30 days of writing the order. This can be problematic considering that the standard authorization period is six months (or could be less depending on the consumer s situation.) Not only does this circumstance force all consumers to have a medical examination multiple times a year, when in the full majority of cases it is not medically indicated, the medical practitioners must bog down their schedules to perform the exams. Districts must attempt to juggle the very short time frame by providing consumers with 19 NYCRR Title 14, Section Health Assessment (and related components ) expenses range from approximately $60 $150 or more depending on the geographical area, the vendor and the particular tests the individual personal assistant may need. 21 NYCRR Title 18 Section (b)(3)(i)(c) and Section (d)(1)(i) Page6

7 appropriate lead time to ensure a timely appointment. Consumers must also battle with the inconvenience of Medicaid transportation in order to attend said appointments. The federal regulations 1 do not require a physician s order for the provision of Personal Care Services. It would be a better system to only require an annual medical examination, unless the person s medical condition has changed, which would warrant a new set of physician s orders. By adopting the authorization option quoted above, the Department of Health can review and approve the service plans while taking into account the most relevant set of physician s orders. Also, when amending the regulation, it makes sense to expand the time frame beyond the tight 30 day period. In economic times such as this, irrational, bureaucratic requirements must be scrutinized. Why are we expending Medicaid funds to pay for a service that is not medically necessary? CDPAP Model Specifics Consumer Directed Cannot Be Agency Directed and Be Effective: Integrity is Everything As referenced in the introduction of this paper, the original Client Maintained Home Attendant Program through Concepts of Independence was the basis for establishing the tenets of the Patient Managed Home Care demonstration model that became the Consumer Directed Personal Assistance Program, therefore the original model is the intent of the Legislature. Unfortunately, since there were no discrete CDPAP regulations and the Department of Health s administrative directives weren t consistently enforced, over time, many districts created their own rules or didn t manage their responsibilities. Also, many organizations have interpreted CDPAP, changed CDPAP to fit their industries world view and /or became confused about the check and balance autonomous consumer model. This is dangerous since there is no consistency and therefore could be part of an argument that New York State is not in compliance with the federal Medicaid state wideness requirement. There are serious potential liability issues that arise when an organization isn t separating the roles and responsibilities: 1 42 CFR (a)(1), personal care must be: Authorized for the individual by a physician in accordance with a plan of treatment or (at the option of the State) otherwise authorized for the individual in accordance with a service plan approved by the State. (emphasis added.) Page7

8 (I)n general, delivering home care services through the Cash and Counseling model or a similar consumer directed structure results in a relatively low level of liability risk where employer and support functions are unbundled in a clearly defined and communicated fashion 22 (emphasis added.) Over the last several years, there has been a shift with many districts requiring antithetical concepts for the CDPAP model via the contracting process. Also there has been an increase in the number of traditionally minded organizations who do not have any experience or expertise in CDPAP which undermines the consumer control features that are essential to CDPAP cost savings. One key aspect from DOH s draft regulations that is an essential requirement of CDPAP is the consumer s sole responsibility to: managing the plan of care including recruiting and hiring a sufficient number of individuals who meet the definition of consumer directed personal assistant, as set forth in subdivision (b) of this section, to provide authorized services that are included on the consumer s plan of care; training, supervising and scheduling each assistant; terminating the assistant s employment; and assuring that each consumer directed personal assistant competently and safely performs the personal care services, home health aide services and skilled nursing tasks that are included on the consumer s plan of care; 23 If a district or CDPAP provider cannot or will not comply with the quote above then that entity should not be allowed to participate in the CDPAP model. It is urgent that the Department of Health finish and enforce the CDPAP regulations and for all New York State Agencies to provide the necessary regulatory oversight of the specific organizations within other industries who are operating outside of their existing regulatory framework. There are also potential monetary ramifications that reduce the cost savings of CDPAP for the entities who are applying external standards to CDPAP, for example, the Home Care Registry, Criminal History Background Check and nursing supervisory visit expenses, as well as other traditional home care aspects, is uncalled for in the model and are an unnecessary expense to the Medicaid program. CDPAP and Managed Long Term Care With the increased focus on care coordination and care management, there must be necessary amendments to regulatory structures to allow for self-directing consumers to access the existing CDPAP model when also enrolled in Managed Long Term Care. 22 Sabatino, Charles P, et al. Addressing Liability Issues in Consumer Directed Personal Assistance Services (CDPAS): The National Cash and Counseling Demonstration and Selected Other Models NYCRR Title 18 Section (g)(1) Page8

9 When considering the fact that the CDPAP authorizing statute passed in 1995, New York State must update existing infrastructure to allow for empowerment and cost savings in Managed Long Term Care, which has been an identified gap. Independence Care Systems, (ICS), a Managed Long Term Care Model that specifically focuses on people with disabilities in New York City, has had a symbiotic relationship with the New York City CDPAP fiscal intermediaries which has allowed self-directing ICS consumers to self-direct their care. Unfortunately, other MLTC programs do not allow this practice and there has been no Department of Health relief in clarifying or building the necessary infrastructure to either allow consumers access to existing state plan CDPAP or to generate a subcontracting structure that allows the existing CDPAP experts to offer our services to eligible consumers. States generally carve long-term care out of their managed care initiatives, both because health plans are typically inexperienced in managing such service Also, the Coalition of New York State Public Health Plans recognizes: [S]ince plans do not currently contract with personal care service providers, plans will have to assess how to create network capacity, develop new relationships with these providers, and ensure that there is provider capacity and quality sufficient for expected needs 25. It is important to note that no amount of care coordination or case management will mitigate consumers disabilities that compromise their Activities of Daily Living (ADLs) necessitating the need for hands on assistance to live a safe and valuated life in the community. With that said, Managed Long Term Care in New York State has never fully grappled with people with significant disabilities. A standardized, capitated rate will not allow for a Managed Care entity to provide enough assistance to consumers who need it unless they control enrollment based on the needs of each consumer and how the particular case mix is going to allow for at least a break even of reimbursement. Given the sheer numbers of consumers with significant disabilities there must be careful consideration of the pros and cons of fully blending long term care with Managed Long Term Care. Self-Direction, Community First Choice Option and Other Home Care Silos Self-direction isn t a particular program it is a way of life. It is the American Dream and it is assumed to be a right for all Americans who have a vested interest in making simple choices about day to day decisions. It is something that is taken for granted 24 Medicaid Institute at United Hospital Fund, Medicaid Managed Care Reexamined, Reduce Medicaid Spending: Improve Patient Care, Medicaid Managed Care A Solution to New York s Budget Crisis. January Page9

10 until you experience the loss of this inherent autonomy. Medical model programs aren t the answer to the needs of twenty-first century consumers. There should be a self-directing option within any home care silo that exists regardless of disability, age and all other categories that keep systems fragmented. The up and coming Community First Choice Option will provide New York State with a toolbox of change that will be beneficial for cost savings (enhanced FMAP) but will open many doors to consumers who do not qualify for the current Personal Care CDPAP. When programs are redesigned they must have a self-directing component. Workforce Benefits The CDPAP personal assistant s structure and role is an innovative blend that provides many advantages. As noted, the self-directing consumer directly hires and manages his/her personal assistants, which eliminates the middle man of an agency. This allows for greater choice and autonomy for both consumers and personal assistants. Personal assistants have much more personal choice to accept employment with a particular consumer, or to decline. A key characteristic of CDPAP is the function of part time work to supplement full time jobs. The flexibility of the model provides the opportunities that enrich the paychecks of the workers and fill workforce gaps due to the shortage of homecare workers. Also, considering each consumer s distinct needs, each consumer provides individualized on-the-job training for their choice of personal assistant. The CDPAP downstate mirrors the laudable compensation structure of the NYC personal care program: paying the Living Wage and providing health benefits. The lower costs associated with the management of this program often translates into higher wages and enables the program to keep up with the costs of health insurance. Program growth in the upstate area demonstrates of its importance to access to home and community-based care. Training for Consumers, Outreach and Peer Counselors In order to expand and strengthen New York State s CDPAP, the Legislature authorized funding for a special initiative, which has recently been awarded, to develop a New York specific curriculum that would help potential users understand whether or not this option is right for them and what is involved in electing CDPAP. To complement this information, Peer Counselors will be trained to assist consumers as they consider this program option and assist them when they encounter difficulties. Outreach to physicians, hospital discharge planners and others who could refer people to this program will also take place. Page10

11 Simple Steps to Increase CDPAP Utilization and Savings 1. Finalize Regulations. CDPAP has continued to operate since 1995 without distinct program regulations that afford the roadmap that fosters consistent administration within the districts and the fiscal intermediary entities. The Governor s Office of Regulatory Reform (GORR), released the Department of Health s promulgated regulations 26 in 2010 for public comment period, but they have yet to be finalized. The sooner the regulations are finalized, with their intent to standardize operations 27, and the Department of Health is able to release the operational documents to guide necessary consistency, the sooner infrastructure can be developed to allow more consumers to consider CDPAP as a choice. Also, the proposed regulations would allow for the expansion of children and in-laws (sons, daughters, in-laws) to work as a personal assistant, which is consistent with federal regulation. Spouses and parents would continue to be restricted from being paid to provide the care. 2. Immediately Expedite the Expansion Initiative. New York State must expedite the implementation processes for the Consumer Directed Personal Assistance Program Expansion Initiative 28 to ensure the planned CDPAP enhancements are operationalized as soon as possible. The Department of Health recognized the value of the enhanced support deliverables, as well as the increased outreach and education, to increase utilization 29. The initial contracting requirements have been fulfilled yet the procurement process has created a more than half a year delay in starting the expansion. 26 Title 18 NYCRR Section Variations in program administration have impeded beneficiary s access to comparable and uniform program benefits across the state. Administrative law judges, who rely heavily on program regulations in making fair hearing determinations, have lacked a uniform body of program standards and criteria to consistently apply... The number of program participants has also grown incrementally over time and the absence of regulations has created an escalating demand for stakeholder technical assistance at a time when state and county staffing resources are being reduced. Establishment of these regulations will also promote an understanding of consumerdirected principles and facilitate their uniform application on a state wide basis across a broad range of stakeholders. Department of Health, Regulatory Impact Statement, Section Needs and Benefits, relating to proposed Title 18 NYCRR Section RFA Number The $500,000 appropriation, originally passed in the FY NYS Budget, is still being processed. 29 RFA Number : In 2007, Department of Health data indicates that 8,586 individuals participated in the CDPAP. By 2008, participation in CDPAP had increased approximately 5% to 9,049 individuals. By meeting the expectations of this project, including but not limited to, education and outreach, development and dissemination of resource materials and curricula for training consumers and community resources, it would be expected that consumer participation and referrals from community resources would increase. Page11

12 3. Allow CDPAP to Work With Other Home Care Programs. Amend the authorizing statute to allow for CDPAP to expand within other silo home care programs. Since the CDPAP personal care program is the sole option for true self-direction, many individuals are stepping outside of their waivers or other home care to utilize state plan personal care. This is a factor that is affecting the growth of personal care. However, with a few changes we can build the infrastructure that will allow self-directing individuals the option to self-direct their services within their current funding streams ultimately saving the state money. The Consumer Directed Personal Assistance Association of New York State (CDPAANYS) is the only association with CDPAP as its sole focus. CDPAANYS represents CDPAP fiscal intermediaries and the perspective that a self-directing consumer s role in CDPAP is as an autonomous agent. For more information contact Constance Laymon, President, Consumer Directed Personal Assistance Association of New York State , [email protected] Page12

13 Information Technology Solutions AVERAGE 2008 HOME CARE RATES CDPAP * $19.75 PERSONAL CARE * LEVEL 1 $20.87 * LEVEL 2 $21.19 HOME HEALTH * $29.25 NURSING * $ As per the 2008 Department of Health s Published Rates Consumer Directed Personal Assistance Association of New York State Cost Comparison: Consumer Directed Personal Assistance Program vs. Traditional Home Care Case Study: C. L. Before the Consumer Directed Personal Assistance Program (CDPAP) was available in New York State Constance L. s long term care needs were provided by Albany Visiting Nurses. When considering the exact weekly frequency of her needs served under Albany Visiting Nurses traditional home care model: Monday, Wednesday, Friday: Nursing Visit Level Monday, Wednesday, Friday: 4 Hours Home Health Aide Level Tuesday, Thursday, Saturday, Sunday: 3 Hours Home Health Aide Level And the exact weekly frequency of her needs served under the Consumer Directed Choices CDPAP model: Monday, Wednesday, Friday: 4 Hours CDPAP Level Tuesday, Thursday, Saturday, Sunday: 3 Hours CDPAP Level ACTUAL SAVINGS 2008 RATES Albany Visiting Nurses * Nursing $ * Home Health Aide $31.22 Consumer Directed Choices * CDPAP Enhanced $19.02 Traditional home care cost per year: $61, (Nursing $22,356.36, Home Health Aide $38,962.56) Consumer Directed Personal Assistance cost per year: $23, YEARLY SAVINGS: $37, NEW YORK STATE WOULD SAVE MORE THAN WHAT WAS SPENT