I work with mentally handicapped adults. Some live at home with family, most live in group homes. All of them are paying for our services through Medicaid. On paper, our program offers training programs that improve lifeskills and support in engaging with the community. In practice, depending on the level of individual, we offer something closer to a daycare or a field trip service. There are instances where we've genuinely helped a person's behavior or lifeskills, for example a severely low functioning man with very intense sibs is in a much better place after three years of our services, but for most it's as I've described.
HCBS requires people basically be in public all day, and requires them to chose to do so. If that sounds contradictory you're right. For higher functioning folks this is mostly fine. I think being out is good for them, but i think 5 days a week, 5 hours a day is kind of stupid.
For lower functioning individuals and those with physical disabilities, this is a disaster. individuals regularly refuse to go out because our options are so limited. Due to toileting needs, mobility issues and general fatigue often an hour is pushing it, and due to that time limit and their lack of funds you have very few options. People end up spending money out of pocket to provide some minor entertainment or joy to the people we work wtih, but that's unsustainable and we're already riding the poverty line. Because we have few options and sometimes the trips are just pointless and tedious, many folks refuse to go. This refusal risks their place in the program, and leaving this program means they'd never leave their group home. Of course, many of them don't understand this.
The rest of the time these lower functioning folks are with us is spent in a facility that is built like a small, modified school with infrastructure to help with toileting, changing, and cleaning. When I was assigned to this task a year ago, We spent about an hour a day building life skills, and spent the other 4 or so hanging out. Movie days, reading picture books outloud, and just talking with them like they're typical people. We'd do puzzles and color and I'd just try to make stuff fun and engaging. My worst nightmare is these people just being locked in a room all day and ignored. And sure, I got a little complacent and some days would drag in and find the easiest way to entertain them. But fuck, I was trying.
Now, medicaid has increased scrutiny on several factors. Either to avoid being shut down or to get more money, my job has increased classroom size and increased the quality of the daily paperwork, as well as introduced more paperwork. I'm regularly dealing wtih 40 pieces of paperwork per day, some of which is very involved and some of which requires tracking down details.
I no longer have time to work on their life skills, or talk to them, or do anything but put a movie on. I clock in and start making up details to write down on these sheets. People get to my room, i make sure they're comfortable and settled and let them pick some movies, and then I sit at my stupid fucking desk and do paper work. We do two feedings a day which I initiate and my co-workers help me with. I toilet them. These two activities let me make sure they're not physically injured because many of them can't tell us if they are. But other than that, I literally just do paper work, from clock in to clock out. Because that paperwork is what defines the billing and medicaid is going to look for anything they can to null the service.
I once again feel as though I'm accomplishing nothing. these people aren't getting anything out of their service, they're just showing up to watch movies in a different building because the job has too much fucking paper work attached to it to do anything else.