Home And Community-based Services Programs Research Articles

Outcomes After Community Discharge From Skilled Nursing Facilities: The Role of Medicaid Home and Community-Based Services.

This study investigated the association between Medicaid Home and Community-Based Services (HCBS) generosity and post-discharge outcomes among dual-eligible beneficiaries discharged from skilled nursing facilities (SNFs). We linked multiple national datasets for duals discharged from SNFs between 2010 and 2013. Accounting for SNF fixed effects, we estimated the effect of HCBS generosity, measured by its breadth and intensity, on the likelihood of remaining in the community, risks of death, nursing home (NH) admission, and hospitalizations within 30 and 180days after SNF discharge. We found that higher HCBS generosity was associated with an increased likelihood of remaining in the community. HCBS breadth and intensity were both significantly associated with reduced risks of NH admission, while higher HCBS intensity was related to a reduced risk of acute hospitalizations within 30days after discharge. Our findings suggest that more generous HCBS programs may facilitate smoother transitions and sustainable community living following SNF discharge.

EMERGENCY DEPARTMENT USE AMONG OLDER ADULTS RECEIVING MEDICAID HOME- AND COMMUNITY-BASED SERVICES

Abstract Medicaid-funded home and community-based services (HCBS) for older adults aim to prolong independent living despite physical and cognitive disabilities. Medicaid-eligible HCBS populations are racially and ethnically heterogeneous, with multiple chronic conditions. Clinical threats to continued independent living among older adult HCBS recipients include acute illnesses, injuries, and exacerbations of chronic conditions, which could trigger a pathway of emergency department (ED) visits, hospitalization, and long-term nursing home admission. Despite its importance in the pathway from independent living, little is known about the rate of, or risk factors for, ED use in this target population. Accordingly, we determined predictors of ED use in a statewide cohort (N=5,651) in Connecticut’s Medicaid HCBS program for adults age >65, who were clinically assessed using a uniform tool between April 2020-March 2021. ED use, (0 vs 1+ visits), was ascertained over 12 months following clinical assessment using Medicare and Medicaid claims data. Predictor variables were racial and ethnic group, primary language, age, sex, educational attainment level, dementia diagnosis or moderate-severe cognitive impairment, depressive symptom severity, and Charlson comorbidity index. Cohort members were 76% female, 30% Hispanic, 15% non-Hispanic Black, 4% non-Hispanic Asian, 33% age >85. Forty-one percent had 1+ ED visits. Multivariate logistic regression analyses revealed that ED use was associated with (adjusted odds ratios p<0.05): high school education, more severe depressive symptoms, and more chronic conditions. Non-Hispanic Asian individuals had lowest ED visit likelihood. ED use among older adults receiving Medicaid HCBS might be reduced if depressive symptoms and multiple chronic conditions are optimally managed.

Assistive technology for people with intellectual and developmental disabilities in the United States in Home- and Community-Based Services

Purpose Unmet needs for assistive technology (AT) contribute to health and quality of life disparities among people with intellectual and developmental disabilities (IDD) [1–4]. The biggest barrier people with IDD face accessing technology is affordability and a lack of funding [1,3–6]. The purpose of this study was to examine how AT were provided to people with IDD in Medicaid Home- and Community-Based Services (HCBS) in the United States, the largest funding source for Long-Term Services and Supports for people with IDD. Materials and methods We analysed Medicaid HCBS 1915(c) waivers for people with IDD from across the USA in fiscal year (FY) 2021 using content analysis and descriptive statistics. Results and conclusions In FY2021, 31 states and the District of Columbia provided AT (stand-alone and combined services) through 68 waivers for people with IDD to improve functioning, communication, independence, and community integration. In total, $63.3 million was projected for the AT services for 23,753 people with IDD. Average spending per person on AT services was $2,663. We found significant variability in terms of how states allocated AT to people with IDD in their HCBS programs. Not only were less than 3% of people with IDD with HCBS projected to receive assistive technology services, there was also large variance across services and states. Assistive technology promotes the health, safety, quality of life, independence, and community integration of people with IDD – they align with the very aims of HCBS, and thus, should be expanded.

Medicaid Home and Community-Based Services in the Wake of the COVID-19 Pandemic.

The need to bolster Medicaid home and community-based services (HCBS) became more evident during the COVID-19 pandemic. This recognition stemmed from the challenges of keeping people safe in nursing homes and the acute workforce shortages in the HCBS sector. This article examines two major federal developments and state responses in HCBS options as a result of the pandemic. The first initiative entails a one-year increase of the federal Medicaid matching rate for HCBS included in the American Rescue Plan Act championed by the Biden administration. The second initiative encompasses administrative flexibilities that permitted states to temporarily expand and modify their existing Medicaid HCBS programs. The article concludes that the effects of the pandemic flexibilities and enhanced federal funding on most state HCBS programs will be limited without continued investment and leadership on the part of the federal government, which is a Biden administration priority. States that make the American Rescue Act and COVID-19 flexibilities initiatives permanent are states that have the fiscal resources and political commitment to expanding HCBS benefits that other states lack. States' different approaches to bolstering Medicaid HCBS during the pandemic may contribute to widening disparities in access and quality of HCBS across states and populations who depend on Medicaid HCBS.

Technology first: The impact on technology availability for people with intellectual and developmental disabilities.

In the United States, 16 states have adopted Technology First initiatives to improve people with intellectual and developmental disabilities' access to technology. Our aim was to examine if Technology First initiatives impact the allocation of technology in Home and Community-Based Services (HCBS) for people with intellectual and developmental disabilities. To do so, we analysed HCBS programs from across the United States in fiscal year 2021. Technology First states were more likely to offer telehealth service delivery in their HCBS programs. However, we found few other significant differences in allocation of technology - the number of people receiving and projected spending - based on states' Technology First status. While these findings do not mean that there is no value in Technology First initiatives, it appears these initiatives have yet to truly impact resource allocation when it comes to HCBS.

A Report on the Increased Payment Rates for HCBS for People with Intellectual and Developmental Disabilities During the COVID-19 Pandemic.

Recognizing the crisis the COVID-19 pandemic represents to the Home- and Community-Based Services (HCBS) service system and the health, safety, and quality of life of people with intellectual and developmental disabilities (IDD), states temporarily amended their HCBS programs to strengthen service delivery. States are able to temporarily amend their HCBS 1915(c) waiver programs by submitting Appendix K: Emergency Preparedness and Response Waivers to the Centers for Medicare and Medicaid Services (CMS). The aim of this study was to examine if, and how, states increased their reimbursement rates for HCBS IDD waiver services during the COVID-19 pandemic. To do so, we analyzed 294 Appendix Ks which amended HCBS 1915(c) waivers for people with IDD between the start of the pandemic and April 2022. During the pandemic, 34 states and the District of Columbia increased reimbursement rates for 2,435 services provided by 82 HCBS waivers for people with IDD. Increase in reimbursement rates ranged from 3.5% to 160.7%, with an average increase of 23.3%. States most frequently increased reimbursement for supports to live in one's own home, residential habilitation, and health and professional services. In addition, 12 states and the District of Columbia offered one-time supplemental payments through 25 HCBS waivers for people with IDD. While increasing payments during the pandemic likely helped stabilize the HCBS service system during this period of crisis, what remains to be seen is how the IDD service system will function when this additional funding is discontinued.

ENHANCING FEDERAL REVENUE FOR HOME AND COMMUNITY-BASED SERVICES UNDER THE AMERICAN RESCUE PLAN ACT

Abstract The American Rescue Plan Act (ARPA) includes a one year 10 percentage point increase in the Federal Medical Assistance Percentage for Medicaid-funded home and community-based services (HCBS). The goal is to strengthen state efforts to help older adults and people with disabilities live safely in their homes and communities rather than in institutional settings during the COVID-19 pandemic. This presentation provides a detailed description and analysis of this provision, including issues state governments need to consider when expending the additional federal revenue provided. It also draws lessons from the Affordable Care Act’s Balancing Incentive Program to suggest insights for the potential of ARPA to promote further growth in Medicaid HCBS programs. The presentation concludes by highlighting the importance of instituting strategies and processes for maximizing enhanced federal matching funds under ARPA in preparation for subsequent availability of substantial additional federal resources targeting Medicaid HCBS under other proposed initiatives.

CHARACTERIZING HOME AND COMMUNITY-BASED SERVICE ENROLLEES IN MINNESOTA’S MEDICAID WAIVER PROGRAM

Abstract Medicaid waivers allow states’ provision of home and community-based services (HCBS), leading to variations in design and delivery. States monitor expenditures, but cannot easily anticipate growth. Understanding the needs of this population can aid in early identification and improve service delivery. We conducted a Partitioning Around Medioids cluster analysis of first-time enrollees in Minnesota’s Elderly Waiver HCBS program during 2019 to identify trajectories of entry and characterize activities of daily living (ADL) and instrumental activities of daily living (IADL) needs at enrollment. Administrative data collected via long term care consultation assessments provided enrollment, ADL/IADL needs, living arrangements, and other clinically relevant information that was linked to other sources including Minnesota health care program enrollment and utilization, Minimum Data Set skilled nursing facility (SNF) assessments, and calls to the Senior LinkAge Line (SLL)—a free long-term care counseling service. Of 5,284 first-time enrollees, most had prior engagement with state programs—nearly two-thirds had called the SLL, 36% had a SNF stay, and 56% had prior Medicaid enrollment. We identified six clusters representing three levels of living arrangements and two levels of need: 1) lived alone, low needs (32%), 2) lived with others, moderate needs (20%), 3) congregate living, moderate needs (14%), 4) congregate living, high needs (14%), 5) lived with others, high needs (11%), and 6) lived alone, high needs (9%). Lacking caregivers and prior Medicaid were possible exacerbating reasons for HCBS enrollment. The magnitude of the differences between clusters highlights the constellation of factors leading to enrollment in HCBS.

Association of Race, Ethnicity, Education, and Neighborhood Context With Dementia Prevalence and Cognitive Impairment Severity Among Older Adults Receiving Medicaid-Funded Home and Community-Based Services

ObjectiveWhile racial, ethnic, and socioeconomic group disparities in cognitive impairment and dementia prevalence are well-documented among community-dwelling older adults, little is known about these disparity trends among older adults receiving Medicaid-funded home- and community-based services (HCBS) in lieu of nursing home admission. The authors determined how dementia prevalence and cognitive impairment severity compare by race, ethnicity, educational attainment, and neighborhood context in a Medicaid HCBS population. Design/SettingA cross-sectional study in Connecticut. ParticipantsAdults age ≥65 in the HCBS program, January-March 2019 (N = 3,520). MeasurementsThe data source was Connecticut's HCBS program Universal Assessment tool. The authors employed two outcomes: Cognitive Performance Scale (CPS2), a 9-point measure ranging from cognitively intact-very severe impairment; and presence or not of either diagnosed dementia or CPS2 score ≥4 (major impairment). Neighborhood context was measured using the Social Vulnerability Index (SVI). ResultsCohort characteristics: 75.7% female; mean(SD) age = 79.1(8.2); Non-Hispanic White = 47.8%; Hispanic = 33.6%; Non-Hispanic Black = 15.9%. Covariate-adjusted multivariate analyses revealed no dementia/major impairment prevalence differences among White, Black, and Hispanic individuals, but impairment severity was greater among Hispanic participants (b = 0.22; p = 0.02). People with more than HS education had less severe impairment (b = −0.12; p <0.001) and lower likelihood of dementia/major impairment (AOR = 0.61; p <0.001). Dementia/major impairment likelihood and impairment severity were greater in less socially vulnerable neighborhoods. ConclusionRacial and ethnic group differences in cognitive impairment are less pronounced in Medicaid-funded HCBS cohorts than in other community-dwelling older adult cohorts. SVI results suggest that, among other possible explanations, older adults with dementia may move to lower social vulnerability neighborhoods where supportive family members reside.

Moving home: Community transition supports for people with intellectual and developmental disabilities

BackgroundIn recognition of the important role housing plays in people's health and quality of life, Medicaid Home- and Community-Based Services (HCBS) programs are more frequently working to promote the housing security of Medicaid beneficiaries. One mechanism states use to promote housing security of people with intellectual and developmental disabilities (IDD) is to offer community transition services in their HCBS programs. Community transition services help with transition by assisting with securing housing and leases, obtaining basic furnishings, paying for utility setup, funding moving expenses, and making accessibility adaptations. ObjectiveThe aim of this study was to examine if and how states provided community transition services in their HCBS waiver programs for people with IDD. MethodsWe analyzed 107 fiscal year (FY) 2021 HCBS 1915(c) waivers for people with IDD from across the United States. We analyzed the service expenditures and utilization data for community transition services, including projected spending, projected number of users served, reimbursement rates, projected spending per participant, and annual service provision per participant. ResultsIn FY2021, 49 waivers (45.8%) from 28 states provided community transition services to people with IDD. A total of $7.21 million of spending was projected for community transition services for 2405 people with IDD, with an average spending per person of $2303. ConclusionsWhile community transition services can help promote the housing insecurity of people with IDD, there was wide variance in how these services were allocated to people with IDD in FY2021.

A Comparative Analysis of State Implementation of the Community First Choice Program.

The Patient Protection and Affordable Care Act included Community First Choice (CFC), a new optional Medicaid home and community-based services (HCBS) state plan benefit which states could adopt. Through the CFC program, states can provide expanded home and community-based attendant services and supports to older adults and persons with disabilities. A benefit of CFC is that states receive a higher federal match rate than other HCBS programs. Thus far, eights states have adopted CFC. This comparative case study analysis examines state-level implementation of CFC to identify what facilitated implementation and what created challenges. The results suggest that consulting with the Centers for Medicare and Medicaid Services facilitated implementation while existing programs, insufficient engagement with stakeholders, aggressive timelines, and limited staff resources presented challenges. Based on these findings, states may want to consider how they approach implementing expansions or enhancements to HCBS benefits under the American Rescue Plan Act.

Assessing Disparities in Medicaid Home- and Community-Based Services: A Systematic Review

ABSTRACT In recent years, expansion of home and community-based services (HCBS) for older adults and persons with disabilities has become a national priority in the U.S. In addition, lawmakers and health-care providers are pursuing opportunities to minimize disparities in healthcare service delivery. Marrying these priorities will require policymakers to identify existing Medicaid HCBS disparities toward development of new, more equitable policies. This study provides a systematic literature review using an adapted theoretical framework to describe disparities in Medicaid HCBS. Key findings are organized into four domains: availability, accessibility, accommodation, and acceptability. We found a lack of concerted research effort targeting Medicaid HCBS disparities in the context of all four domains, with an especially notable dearth of content related to acceptability. We also identified very few articles that focused on specific marginalized groups, suggesting a need for more research into whether Medicaid HCBS are available, accessible, accommodating, and acceptable for a variety of diverse populations. Our findings underscore the need for researchers and policymakers to conceptualize and evaluate existing Medicaid HCBS policy toward development of a more equitable Medicaid HCBS program design in the future.

Implementing the Care of Persons With Dementia in Their Environments (COPE) Intervention in Community-Based Programs: Acceptability and Perceived Benefit From Care Managers' and Interventionists' Perspectives.

Nonpharmacologic interventions have demonstrated benefits for people living with dementia and their caregivers. Few studies have evaluated their implementation in real-world settings. Using normalization process theory (NPT), an implementation science framework, this study evaluated the acceptability of the care of persons with dementia in their environments (COPE) intervention by care managers and interventionists implemented in a Medicaid and state-revenue funded home and community-based services (HCBS) program. NPT and data from 9 care manager focus groups (n = 61) and 2 interventionist focus groups (n = 8) were utilized to understand COPE acceptability to program care managers and interventionists. NPT's 4 criteria, coherence, cognitive participation, collective action, and reflexive monitoring, framed the research questions used to evaluate the intervention's implementation. Care managers and interventionists demonstrated a shared understanding of COPE aims and the value of practices implemented (coherence). Training by national experts facilitated program buy-in to meet COPE goals and was demonstrated by care managers and interventionists as they used the training to broaden their program involvement (cognitive participation). Operational work done by care managers and interventionists to implement the intervention (collective action) and their shared perceptions of program benefits (reflexive monitoring) contributed to program implementation, families' positive responses to COPE and enhanced sustainability. Introducing evidence-based dementia care interventions into HCBS programs strongly depends upon building shared understandings between care managers and interventionists and valuing the contributions of all stakeholders involved in delivering care innovations to people living with dementia and their caregivers.

Cost-Benefit Analysis of the COPE Program for Persons Living With Dementia: Toward a Payment Model.

Background and ObjectivesThere is a critical need for effective interventions to support quality of life for persons living with dementia and their caregivers. Growing evidence supports nonpharmacologic programs that provide care management, disease education, skills training, and support. This cost–benefit analysis examined whether the Care of Persons with Dementia in their Environments (COPE) program achieves cost savings when incorporated into Connecticut’s home- and community-based services (HCBS), which are state- and Medicaid-funded.Research Design and MethodsFindings are based on a pragmatic trial where persons living with dementia and their caregiver dyads were randomly assigned to COPE with HCBS, or HCBS alone. Cost measures included those relevant to HCBS decision makers: intervention delivery, health care utilization, caregiver time, formal care, and social services. Data sources included care management records and caregiver report.ResultsPer-dyad mean cost savings at 12 months were $2 354 for those who received COPE with a mean difference-in-difference of −$6 667 versus HCBS alone (95% CI: −$15 473, $2 734; not statistically significant). COPE costs would consume 5.6%–11.3% of Connecticut’s HCBS annual spending limit, and HCBS cost-sharing requirements align with participants’ willingness to pay for COPE.Discussion and ImplicationsCOPE represents a potentially cost-saving dementia care service that could be financed through existing Connecticut HCBS. HCBS programs represent an important, sustainable payment model for delivering nonpharmacological dementia interventions such as COPE.

A comparative analysis of state adoption of the Community First Choice program

ABSTRACT Over the last several decades, policymakers have focused on rebalancing Medicaid-funded long-term services and supports toward home and community-based services (HCBS). The Patient Protection and Affordable Care Act (ACA) included several opportunities for states to further promote HCBS options. One optional opportunity for states to expand Medicaid HCBS was the 1915(k) Community First Choice (CFC) program. To date, eight states have elected to add CFC as a Medicaid benefit. This study utilized comparative case studies to identify the factors that influenced states’ adoption of CFC. Results highlight the important role that state bureaucrats, economic concerns, and existing HCBS programs had on states’ decisions to adopt CFC.

A Comparative Case Study Analysis of Barriers and Facilitators to Implementing the Affordable Care Act's Balancing Incentive Program.

The Affordable Care Act included the opportunity for states to increase spending on Medicaid home and community-based services (HCBS) for older adults and persons with disabilities through the Balancing Incentive Program (BIP). This study utilized comparative case studies to identify the factors that facilitated or impeded states' implementation of BIP. Findings indicate factors that facilitated the implementation of BIP were communication with the federal government and its contractor, merging BIP with existing HCBS programs, and enhanced federal revenue. On the other hand, the short duration of BIP, state procurement and contracting processes, and the need to incorporate feedback from non-governmental stakeholders and determining how to spend the enhanced revenue proved challenging for some states. This research suggests ways federal and state officials can implement new initiatives to achieve greater rebalancing of Medicaid long-term services and supports for older adults.

Federal Incentives to Reform Long-Term Care Under the Affordable Care Act: State Adoption of the Balancing Incentive Program, 2011-2014.

The Balancing Incentive Program (BIP) was an optional program for states within the Patient Protection and Affordable Care Act to promote Medicaid-funded home and community-based services (HCBS) for older adults and persons with disabilities. Twenty-one states opted to participate in BIP, including several states steadfastly opposed to the health insurance provisions of the Affordable Care Act. This study focused on identifying what factors were associated with states' participation in this program. Event history analysis was used to model state adoption of BIP from 2011 to 2014. A range of potential factors was considered representing states' economic, political, and programmatic conditions. The results indicate that states with a higher percentage of Democrats in the state legislature, fewer state employees per capita, and more nursing facility beds were more likely to adopt BIP. In addition, states with fewer home health agencies per capita, that devoted smaller proportions of Medicaid long-term care spending to HCBS, and that had more Money Follows the Person transitions were also more likely to pursue BIP. The findings highlight the role of partisanship, administrative capacity, and program history in state BIP adoption decisions. The inclusion of BIP in the Affordable Care Act may have deterred some states from participating in the program due to partisan opposition to the legislation. To encourage the adoption of optional HCBS programs, federal policymakers should consider the role of financial incentives, especially for states with limited bureaucratic capacity and that have made less progress rebalancing Medicaid long-term services and supports.

Hospitalization Trajectories in Home- and Community-Based Services Recipients: The Influence of Physician and Social Care Density.

Repeated hospitalizations among older adults receiving Home- and Community-Based Services (HCBS) may indicate unmet medical and social needs. This study examined all-cause hospitalization trajectories and the association between area-level resource density for medical and social care and the trajectory group membership. The study participants included 11,223 adults aged 60 years or older who were enrolled in public HCBS programs in Michigan between 2008 and 2012. Data sources included the Michigan interRAI-Home Care, Dartmouth Atlas of Health Care Data, the American Community Survey, and the County Business Patterns from the Census Bureau. The group-based trajectory modeling was used to identify trajectories of hospitalization over 15 months. Correlates of the trajectories were examined using multinomial logistic regression. Four distinct hospitalization trajectory groups emerged: "never" (43.1%)-individuals who were rarely hospitalized during the study period, "increasing" (19.9%)-individuals who experienced an increased risk of hospitalization, "decreasing" (21.6%)-individuals with a decreased risk, and "frequent" (15.8%)-individuals with frequent hospitalizations. Older adults living in areas with a higher number of social service organizations for older adults and persons with disability were less likely to be on the "frequent" trajectory relative to the "decreasing" trajectory. The density of primary care physicians was not associated with the trajectory group membership. Area-level social care resource density contributes to changes in 15-month hospitalization risks among older adult recipients of HCBS.

BARRIERS AND FACILITATORS TO IMPLEMENTING THE BALANCING INCENTIVE PROGRAM (BIP)

The Balancing Incentive Program (BIP) was an optional Medicaid program within the Affordable Care Act. States spending less than 50% of Medicaid long-term services and supports on home and community-based services (HCBS) were eligible for the program and could participate from 2011 to 2015. Participating states received an enhanced federal match in exchange for rebalancing LTSS spending and adopting structural changes to their long-term services and supports system. The purpose of this study is to understand the barriers and facilitators to implementing the BIP in two states. Data was collected through semi-structured interviews with individuals involved in HCBS policy nationally and in Maryland and Texas, including government bureaucrats, consumer advocates, and provider representatives. Findings indicate that factors that facilitated Maryland and Texas’ implementation of the BIP were regular communication with the Centers for Medicare and Medicaid Services and their consultants, Mission Analytics Group, merging the BIP with existing HCBS programs, and the substantial amount of funding associated with the program. On the other hand, the short duration of the BIP presented a challenge for states because they needed to enact multiple changes within a limited period of time. In addition, state procurement and contracting processes impeded the speed with which BIP requirements could be met. Key stakeholders, including consumer advocacy and provider organizations, often felt as though their state implemented the BIP with minimal input from interested groups. The findings indicate that the structure of the Balancing Incentive Program as well as internal state factors influenced the program’s implementation.

BARRIERS AND FACILITATORS TO IMPLEMENTING COMMUNITY FIRST CHOICE

Community First Choice is a program within the Affordable Care Act that encourages states to expand Medicaid home and community-based services (HCBS). Specifically, this Medicaid state plan benefit provides states with an additional 6% federal match to promote greater rebalancing of long-term services and supports. Through Community First Choice, states can offer services that assist with activities of daily living, instrumental activities of daily living, and health-related tasks. The program is optional for states, and, to date, eight states have pursued Community First Choice. The purpose of this study is to understand the barriers and facilitators to implementing Community First Choice in two states. Data was collected through semi-structured interviews with individuals involved in HCBS policy nationally and in Maryland and Texas, including government bureaucrats, consumer advocates, and provider representatives. The results suggest that communication with the Centers for Medicare and Medicaid Services, the enhanced federal match, and leveraging existing HCBS infrastructure facilitated implementation. Maryland and Texas encountered challenges implementing Community First Choice because of constraints posed by existing HCBS programs, ambitious timelines, limited staff resources, and insufficient engagement with external stakeholders. The findings suggest that implementing Community First Choice is a large undertaking, and states should ensure they have enough time and sufficient staffing for the implementation process. States should also understand how implementing Community First Choice will impact existing HCBS offerings and how leveraging HCBS infrastructure can facilitate implementation. The lessons from implementing Community First Choice can be informative to other states pursuing or contemplating this program.