Community-based Waiver Program Research Articles

ACTUAL AND DESIRED SERVICE USE OF COMMUNITY-DWELLING CONSUMERS OF HOME- AND COMMUNITY-BASED SERVICES

Abstract Federal and state long-term care policies are focused on helping people age in their community rather than in nursing homes or other institutional settings. Through home- and community-based (HCBS) waiver programs, states have the flexibility to target specific populations, providing supportive services meant to promote residence in the community. Although consumer needs and goals are a key component of HCBS delivery and effectiveness, little is known about how actual service use differs from the services individuals desire to meet their needs. Using the National Core Indicators-Aging and Disability (NCI-AD™) survey responses from 2018-2019 (N=14,202), an effort by state agencies to measure and track performance outcomes using standardized measures, we examined differences in actual versus desired use of HCBS among people living in the community. Services were categorized as delivered in home-based setting, day services, transportation, support/modification services, health and therapeutic services, and respite. Among NCI-AD respondents in the community (n=9,860), 11% used one service area, 49% used two service areas, and 36% used three or more service areas. The most common service area was home-based services (57%). About a third of community-dwelling respondents desired at least one additional service area. Factors significantly associated with wanting more services included being in combined Medicaid-Medicare, managed LTSS, a woman, an adult aged >65, living alone, and having a physical disability. While the majority of community-dwelling HCBS recipients do not list unmet service needs, there is heterogeneity by program category and other key demographic and social characteristics.

Training Clinicians to Support Aging in Place in a Medicaid Home and Community-Based Waiver Program

A randomized trial in 18 home and community-based waiver sites implemented an aging-in-place model for 12,000 disabled older (mean age 78) adults. The trial was underpinned by the Knowledge-to-Action model and utilized 7 implementation strategies, including a 5.5-hour online social worker (SW) and registered nurse (RN) training. Baseline self-efficacy and attitudes of SWs and RNs were measured using validated scales, and knowledge uptake and satisfaction with a tool designed by the team. Characteristics, knowledge uptake, and satisfaction of SWs versus RNs were compared using t-, Wilcoxon, and chi-square tests. Two hundred forty-one RNs and 264 SWs participated. RNs were older (mean age 50; standard deviation [SD] 10.95) than SWs (41.35; SD=11.21) p<.01; and >90% overall were female. RNs had more professional experience, while SWs worked more years in the waiver (p<.01). SWs had greater self-efficacy (t(497)=2.99, p<.04), better attitudes (t(500)=2.59, p<.01), employability (t(500)=2.99, p<.04), and balance (t(491)=2.03, p<.05) than RNs. No differences were found on leadership, organizational culture, motivation, pressure to change, or attitude toward evidence-based practice. Knowledge uptake (range 1-16) was high and did not differ for RNs (Mean=15.2, SD=1.23) versus SWs (Mean=15.26, SD=0.89). Training content, format, role explanation, and information satisfaction (range 0-50) means also did not differ for RNs (Mean=35, SD=10.2) or SWs (Mean=34.9, SD=9.8). While many of the characteristics and outcomes were similar for RNs and SWs, SW’s higher self-efficacy, better attitude, and employability despite less experience in the waiver indicate they may play a positive role in implementation of the intervention that is currently underway.

Testing an implementation strategy bundle on adoption and sustainability of evidence to optimize physical function in community-dwelling disabled and older adults in a Medicaid waiver: a multi-site pragmatic hybrid type III protocol

BackgroundIn partnership with a state Medicaid home and community-based waiver program, this study tests implementation strategies for adoption and sustainability of an evidence-based intervention to support disabled and older adults who have difficulty with physical function and daily living tasks. A multi-level implementation strategy bundle will be directed at relationship, coalition, and team building; readiness to implement, leadership, and clinician attitude toward evidence assessments; intervention and facilitation training; interdisciplinary coordination; facilitation; and audit and feedback to support practice change.MethodsKnowledge-to-Action model underpins this 2-arm, 3-year pragmatic mixed method randomized hybrid type III trial in 18 waiver program sites in Michigan. Data will be collected on sites, 775 clinicians (registered nurses, occupational therapists, social workers), and 15,000 disabled and older adults. Consolidated Framework for Implementation Research guides examination of site, clinician, and beneficiary characteristics; clinician attitude and self-efficacy; leadership and readiness to implement; and intervention impact on beneficiary outcomes. Sites will be randomized to either usual waiver care with internal facilitation of the bundle of implementation strategies or usual waiver care with both internal and external facilitation of the bundle. Primary outcomes are site-level adoption and sustainability over 12 months, and intervention effects on these outcomes are hypothesized to be mediated by clinicians’ attitude and self-efficacy. At the beneficiary level, by addressing the individual’s capabilities and home environment, the intervention is hypothesized to improve secondary outcomes of activities of daily living, pain, depression, falls, emergency department visits, and hospitalizations. Baseline site readiness and leadership and stages of implementation at 6 months will be explored as potential moderators. Linear mixed effects models will be used to test intervention effects on primary outcomes, with bias-correcting analytic strategy in mediation analyses. Generalized linear mixed effects modeling will be employed for the analysis of intervention effects on secondary outcomes.DiscussionSynthesizing findings within and across the sites, we will specify how leadership, readiness for change, and level of facilitation enhance capacity for adoption and sustainability of an evidence-based intervention in an under-resourced Medicaid setting that cares for disabled and older adults.Trial registrationClinitalTrials.gov, NCT03634033. Registered 16 August 2018.

Predicting long-term nursing home transfer from MI choice waiver program

This study aimed to identify characteristics of elderly participants in the Michigan Home and Community-Based Waiver Program that are associated with high risk of long-term nursing home (LT-NH) placement. We identified 8172 waiver clients aged 65 and older during 10/1/2010–9/30/2014. A proportional cause-specific hazards regression model was used to analyze risk factors of waiver elderly for LT-NH placement. Waiver elderly participants who were white (HR (white vs. black): 2.76, with 95% CI (1.91, 4.00); HR (white vs. other races): 1.77, with 95% CI (1.05, 2.97)), had a history of long-term care use (HR: 1.42, 95% CI (1.14, 1.76)), mental disorders (HR: 1.51, 95% CI (1.23, 1.86)), bathing dependency (HR: 1.43, 95% CI (1.07, 1.89)), and finance management dependency (HR: 1.73, 95% CI (1.15, 2.60)) had greater hazards of LT-NH placement. Our study can be useful for policy makers to develop relevant support to reduce LT-NH placement.

Longitudinal Differences in Pain Among Older Adult Home and Community Based Waiver Program Participants in Relation to Diagnosis of Cancer

Generalized estimating equation analyses models were used to examine the longitudinal association between pain and diagnosis of cancer among older adult, Home and Community Based Waiver Program participants. Daily pain was reported by over half, with 29% experiencing daily pain that was unusually intense. Diagnosis of cancer was a significant predictor of daily pain only as an interaction term with cognitive impairment. Being female, having a medical diagnosis of depression, or increasing measure of comorbid conditions significantly increased the likelihood of daily pain. In comparison, increasing age, being of African American, Hispanic, or “other” race resulted in a significantly decreased likelihood of daily pain.

Do Older Adults With Cancer Fall More Often? A Comparative Analysis of Falls in Those With and Without Cancer

To examine whether a history of cancer increased the likelihood of a fall in community-dwelling older adults, and if cancer type, stage, or time since diagnosis increased falls. A longitudinal, retrospective, cohort study. A home- and community-based waiver program in Michigan. 862 older adults aged 65 years or older with cancer compared to 8,617 older adults without cancer using data from the Minimum Data Set-Home Care and Michigan cancer registry. Reports of falls were examined for 90-180 days. Generalized estimating equations were used to compare differences between the groups. Cancer, falls, patient characteristics, comorbidities, medications, pain, weight loss, vision, memory recall, and activities, as well as cancer type, stage, and time since diagnosis. A fall occurred at a rate of 33% in older adults with cancer compared to 29% without cancer (p < 0.00). Those with a history of cancer were more likely to fall than those without cancer (adjusted odds ratio 1.16; 95% confidence interval [1.02, 1.33]; p = 0.03). No differences in fall rates were determined by cancer type or stage, and the odds of a fall did not increase when adding time since cancer diagnosis. The fall rate was higher in older adults with cancer than in older adults without cancer. Nurses need to assess fall risk and initiate fall prevention measures for older adults at the time of cancer diagnosis. When caring for older adults with cancer, nurses should be aware of an increased risk for falls. Healthcare staff also should be aware of an increased risk for falls in that population during cancer treatment. Evidence-based fall prevention measures should be included in care plans for older adult cancer survivors.

Associations Among Indicators of Depression in Medicaid-Eligible Community-Dwelling Older Adults

The purpose of this research was to examine associations among 2 separate Minimum Data Set-Home Care (MDS-HC) depression measures (the Depression Rating Scale [DRS] and medical diagnosis of depression) with billed antidepressant medications in Medicaid paid claim files. The sample for this cross-sectional research included 3,041 Medicaid-eligible older adult participants in a Home and Community Based Waiver Program and used data from the MDS-HC, Version 1 and Medicaid Paid Claim Files. Sensitivity and specificity analyses, receiver operating characteristic (ROC) curve analysis, and t tests were utilized. DRS scoring indicated that 15.4% of participants had behaviors indicative of depression, whereas 42% had a medical diagnosis of depression noted in the MDS-HC. Of those with a medical diagnosis of depression, 51% had a prescribed antidepressant medication. ROC analysis suggested that the DRS was a poor distinguisher of participants with and without a medical diagnosis of depression or prescribed antidepressant medications. Approximately half of Medicaid-eligible older adults medically diagnosed with depression were treated pharmacologically. Longitudinal research is recommended to assess responsiveness of the DRS over time to pharmacological and psychotherapeutic interventions for depression.

Gradual Rebalancing Of Medicaid Long-Term Services And Supports Saves Money And Serves More People, Statistical Model Shows

States are shifting Medicaid spending on long-term services and supports from institutional to home and community-based services, a process known as rebalancing. Using fifteen years of state expenditure data, a statistical model was developed to assess the effect of rebalancing on overall spending for long-term services and supports. The model indicates that spending is affected by the way rebalancing is implemented: Gradual rebalancing, by roughly two percentage points annually, can reduce spending by about 15 percent over ten years. More rapid rebalancing can save money, break even, or increase spending, depending on the pace and program specifics. Cuts to home and community-based services that hinder rebalancing are likely to increase, not decrease, overall spending on long-term services and supports as people who were receiving these services shift into nursing homes. Because many states continue to experience budget crises, policy makers must think carefully before altering spending patterns for long-term services and supports and adopt strategies that particular states have used to successfully reduce overall spending, such as gradually shifting expenditures toward home and community-based waiver programs.

Impact of a Medication Management System on Nursing Home Admission Rate in a Community-Dwelling Nursing Home–Eligible Medicaid Population

Background Community-dwelling frail elderly have an increased need for effective medication management to reside in their homes and delay or avoid admission to nursing homes. Objective The objective of this study was to examine the impact of a medication management system on nursing home admission within the community-dwelling frail elderly. Methods This prospective cohort study compared nursing home admission rates in intervention and control clients of a state Medicaid home and community-based waiver program. Groups were matched on age (±5 years), race, gender, and waiver program start date (±120 days). The medication management service consisted of 2 parts: 1) prescription medicines dispensed from the client's local pharmacy in a calendar card, and 2) a coordinating service by a health educator to address medication-related problems as they arose. The primary dependent variable was admission to a nursing home. Results A total of 273 clients agreed to participate, enrolled, and had at least 1 prescription dispensed. The matched control group was composed of 800 other clients. The client sample was 72 years of age, 73% (785/1073) non-white, 75% (804/1073) female, and enrolled in the waiver program approximately 50 months. The 2 groups were similar on all demographic variables examined. Six clients (2.2%) in the intervention group and 40 clients (5.0%) in the control group were admitted to a nursing home at least once during the study period. Logistic regression was used to test the model predicting at least 1 nursing home admission. Control group clients were 2.94 times more likely to be admitted to a nursing home than clients in the intervention group. Conclusions The medication management service implemented within this study was effective in reducing nursing home admissions in a group of frail community-dwelling elderly.

Fall Risk Factors in Community-Dwelling Elderly Who Receive Medicaid-Supported Home- and Community-Based Care Services

This study identifies fall risk factors in an understudied population of older people who receive community-based care services. Data were collected from enrollees of Ohio's Medicaid home- and community-based waiver program (preadmission screening system providing options and resources today [PASSPORT]). A total of 23,182 participants receiving PASSPORT services in 2005/2006 was classified as fallers and nonfallers, and a variety of risk factors for falling was analyzed using logistic regressions. The following factors were identified as risk factors for falling: previous fall history, older age, White race, incontinence, higher number of medications, fewer numbers of activity of daily living limitations, unsteady gait, tremor, grasping strength, and absence of supervision. Identifying risk factors for the participants of a Medicaid home- and community-based waiver program are useful for a fall risk assessment, but it would be most helpful if the community-based care service programs incorporate measurements of known fall risk factors into their regular data collection, if not already included.

A First Take on LTC in Health Care Reform

A First Take on LTC in Health Care Reform

Assistive Technology in Medicaid Home- and Community-Based Waiver Programs

As consensus emerges concerning the need to extend publicly funded home- and community-based services that support the independence of seniors, studies have reported the efficacy and cost effectiveness of assistive technology (AT). This article presents the latest available national AT expenditure and participation trends (1999-2002) for Medicaid 1915(c) waivers, the largest Medicaid home- and community-based service program. We collected annually reported Centers for Medicare and Medicaid Form 372 data from state officials for each waiver providing AT for the period from 1999 to 2002. Descriptive statistics examined trends in national participation and expenditures, interstate variations in participation and expenditures, and differences in provision between elderly persons and persons with developmental disabilities. Although we report a rise in the number of waivers providing AT, there has been much slower participant growth compared with the broader waiver program, and there is wide interstate variation in waiver AT provision. Not only do most waivers with AT serve persons with developmental disabilities, AT spending for that target group is almost twice that for aged or disabled waiver participants. This study highlights three policy concerns: first, the large interstate variations in AT provision in Medicaid waivers may signal access problems in some states; second, policy choices in some states may favor Medicaid spending on AT for the developmental disability population over that for the elderly population; and third, data limitations prevent a comparable state-by-state analysis of Medicare AT provision.

More AL Communities Abandon Medicaid

More AL Communities Abandon Medicaid

Issues in Medicaid Policy and System Transformation: Recommendations From the President's Commission

Issues in Medicaid Policy and System Transformation: Recommendations From the President's Commission

Nurse Care Coordination in Community‐Based Long‐Term Care

To evaluate the clinical outcomes of a nurse care coordination program for people receiving services from a state-funded home and community-based waiver program called Missouri Care Options (MCO). A quasi-experimental design was used to compare 55 MCO clients who received nurse care coordination (NCC) and 30 clients who received MCO services but no nurse care coordination. Nurse care coordination consists of the assignment of a registered nurse who provides home care services for both the MCO program and Medicare home health services. Two standardized datasets, the Minimum Data Set (MDS) for resident care and planning and the Outcome Assessment Instrument and Data Set (OASIS) were collected at baseline, 6 months, and 12 months on both groups. Cognition was measured with the MDS Cognitive Performance Scale (CPS), activities of daily living (ADL) as the sum of five MDS ADL items, depression with the MDS-Depression Rating Scale, and incontinence and pressure ulcers with specific MDS items. Three OASIS items were used to measure pain, dyspnea, and medication management. The Cochran-Mantel-Haenszel (CMH) method was used to test the association between the NCC intervention and clinical outcomes. At 12 months the NCC group scored significantly better statistically in the clinical outcomes of pain, dyspnea, and ADLs. No significant differences between groups were found in eight clinical outcome measures at 6 months. Use of nurse care coordination for acute and chronic home care warrants further evaluation as a treatment approach for chronically ill older adults.

Home and Community-Based Waivers for Disabled Adults: Program versus Selection Effects

This paper addresses whether changes in expenditures from participation in a Medicaid home and community-based waiver are due to selection effects or true program effects. We examined North Carolina Medicaid claims data (FY1998 to FY2000) for disabled or blind adults likely to need facility-based care using two-part expenditure models for nursing home, inpatient, and total expenditures. Instrumental variables estimation controlled for selection into the program. Although no savings in total costs were found in this sample, significant decreases were found in the level of nursing home and hospital inpatient expenditures for waiver participants, achieving the goals of the home and community-based waiver program.

Care Managers as Research Interviewers: A Test of a Strategy for Gathering Consumer Satisfaction Information

Care managers from local Area Agencies on Aging, operating Ohio’s home- and community based waiver program (PASSPORT), were trained as research interviewers to collect consumer satisfaction data from clients receiving in-home services using the Home Care Satisfaction Measure (Geron, Smith, Tennstedt, Jette, Chassler, &amp; Kasten, 2000). The data for homemaker and home health aide scales were comparable to those collected by independent research interviewers for interrater reliability and showed no significant difference between the two groups. The scores on the home-delivered meals index obtained by care managers were slightly but significantly higher than those obtained by the research interviewers. A slight, but significant, difference was found on the home-delivered meals index, although differences between most individual items were not significant. Overall, findings indicate that care managers, when appropriately trained, can collect reliable, scientifically sound data, providing a cost-effective method for collecting satisfaction information from consumers receiving in-home care.

Sensitivity of an AIDS case-finding algorithm: who are we missing?

The objective of this study was to determine the sensitivity of an AIDS case-finding algorithm. This study applied the AIDS case-finding algorithm to paid Medicaid claims linked to New Jersey AIDS surveillance data and assesses its sensitivity across subgroups of patients. Of the 7183 cases with confirmed AIDS, based on the state's registry information, 95% (n = 6818) were correctly detected using all Medicaid claims, including pharmacy. For patients in a community-based waiver program, covered by Medicare, diagnosed with a severe mental illness, or continuously enrolled in Medicaid, with regular contact with the medical system, the algorithm identified almost all patients. To further evaluate algorithm performance, it was used with 2 groups of interest to researchers. For AIDS patients in the last 6 months of life, 88% were correctly detected without use of pharmacy claims and 95% when pharmacy claims were included. For pregnant women, data from the 6 months before the latest delivery date identify 27% of pregnant women without pharmacy claims and 41% when pharmacy claims were included. Using claims made after the latest delivery date, 81% of pregnant women were detected without pharmacy claims and 93% when pharmacy claims were included Results demonstrate that a multilevel screen can be used with Medicaid claims to effectively to detect most patients with AIDS. Detection is lower for some subgroups, and the absence of pharmacy claims can compromise detection.

AIDS Home- and Community-Based Waivers: Effects on Use of Services, Expenditures, and Survival

State Medicaid home- and community-based waiver programs for persons with AIDS (PWAs) were implemented with the expectation that PWAs would use these services in lieu of more expensive hospital-based care. If so, Medicaid spending per PWA should decline, and program costs fall. We analyze Florida Medicaid claims data for PWAs from December 1995 through December 1997 to determine how participation in the waiver program affects the use of inpatient services, the receipt of antiretroviral combination therapies (available to Medicaid recipients throughout the study period), monthly expenditures, and survival of PWAs. We find that waiver participants are more likely to receive combination therapies but less likely to use hospital-based care than nonparticipants; white men and sicker patients are more likely to join the waiver program than other eligible PWAs; monthly expenditures for waiver participants are 52% lower than for nonparticipants; and waiver participation does not affect survival.

Beneficiary Profiles and Service Consumption Patterns in an Urban Medicaid Home and Community-Based Waiver Program

The research reported here was conducted as part of a larger program evaluation of an urban Medicaid Home and Community Based-Waiver Program (HCBS). Informed by a secondary analysis of data collected on 723 clients, this article describes the association between client demographics and service consumption patterns among program beneficiaries with emphasis on access to care issues. The majority of the clients were female, African American, nearly 80 years of age, receiving approximately $600 of monthly income. Although White clients on average were higher functioning, they were hospitalized more frequently and took more medications than African American or Hispanic clients. Clients who were bedbound, Hispanic, and most dependent in performing activities of daily living received the fewest "number of services." Clients who suffered the most severe intellectual impairment, living with a spouse, and with the highest incomes received the most "units of service." Interestingly, service usage did not always increase as the client became more dependent in Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), and mobility. The significance of findings is considered in relation to access to care issues.