Home And Community-based 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.

A Comparative Assessment of Long-Term Care Financing and Service Delivery Models

The face of public long term care (LTC) funded largely through the Medicaid program is changing rapidly in the U.S. Over the last decade, most states have moved to managed LTC programs in various forms, with a growing number transferring all their programs, home and community based (HCBS) and nursing home services, to a Medicaid (MLTC) model. The amount of rigorously conducted and reported evaluation results on these programs are still very limited. Enough information is available, however, from other sources for at least preliminary comparison of relative cost-effectiveness of MLTC vs. traditional, non-profit models of public LTC services delivery and financing, as discussed in this paper. This comparison will show that, at this point, the MLTC programs are not more cost-effective than the traditional model of LTC administration. In fact, these initial assessments seem to indicate that the traditional model may be superior to the corporate for-profit MLTC model.

Teletherapy and Home and Community-Based Brain Injury Waivers: Through Pandemic and Beyond

<h3>Research Objectives</h3> To investigate the perceived effectiveness, consumer satisfaction and provider perspective of Home and Community Based (HCBS) Brain Injury (BI) waiver services provided via teletherapy. <h3>Design</h3> Program Evaluation. <h3>Setting</h3> The Kansas Home and Community Based Brain Injury Waiver program combines state and federal funding to provide intensive rehabilitation in a natural setting. In some parts of Kansas, these specialized services are not readily available (DRC and KU RTC/IL, 2014). In response to the pandemic, waiver therapies were permitted to be provided via telephonic and tele-video delivery methods. BI waiver providers were able to deliver services to consumers in areas that were previously void of therapists. Perceived benefits of this approach include accessibility and convenience, time and cost efficiencies, and user autonomy (Ownsworth et al., 2020). <h3>Participants</h3> Two surveys containing 10 equivalent questions each, were distributed to two separate respondent groups. The first survey was distributed to 130 consumers on the BI waiver and the second to 121 therapists providing rehabilitative services to waiver participants (n=86 respondents, 30 consumers and 56 providers). <h3>Interventions</h3> Rehabilitative services include physical, occupational, speech, cognitive and behavioral therapies. Services are authorized on an hour per week basis for each needed discipline (i.e., 6 hours/per week of OT) by the respective Managed Care Organization. During sessions, rehabilitative professionals support consumers to achieve discipline specific therapy goals and person-centered goals created by the consumer. Goals addressed range from self-care and transfers to relationship development and employment. <h3>Main Outcome Measures</h3> Program Evaluation Criteria: • 75% of survey respondents agree or strongly agree teletherapy technology is reliable and easy to use. • 75% of survey respondents agree or strongly agree to being satisfied with services. • 75% of survey respondents identify teletherapy as an effective method of service delivery. <h3>Results</h3> The criteria were met or exceeded for satisfaction and effectiveness, but not for technology. <h3>Conclusions</h3> This program evaluation demonstrates the need for further analysis and improvement of teletherapy technology and access. <h3>Author(s) Disclosures</h3> Erica Bates is Employed by Minds Matter, LLC, a BI Waiver service provider.

United States Medicaid home and community-based services for people with intellectual and developmental disabilities: A scoping review.

Emerging research tests the impact of United States Medicaid home and community-based (HCBS) waiver policy on outcomes for people with intellectual and developmental disabilities; however, this body of work has yet to be synthesized. We conducted a scoping review to establish what is known about the impact of Medicaid HCBS policy on the lives of people with intellectual and developmental disabilities. Seven studies met final inclusion criteria. Their findings contribute to preliminary evidence that Medicaid HCBS waivers provide economic benefit at the state and federal level, reduce unmet healthcare needs, increase the likelihood that parents will be able to continue working, and reduce racial disparities in access to care. Additional work should compare HCBS waiver programmes, and their causal pathways, as well as draw international comparisons to similar programming, to determine essential infrastructure needed for a successful HCBS programme.

Why Do States Pursue Medicaid Home Care Opportunities? Explaining State Adoption of the Patient Protection and Affordable Care Act's Home and Community-Based Services Initiatives

The Patient Protection and Affordable Care Act (ACA) included new optional Medicaid home and community-based (HCBS) initiatives: the Balancing Incentive Program, the 1915(k) Community First Choice personal care benefit, and the revised 1915(i) state plan benefit. This study identifies political, economic, programmatic, and intergovernmental factors that facilitated or impeded state participation in these ACA programs. Longitudinal and cross-sectional regression analyses were used to model state adoption from 2011 to 2015. Findings indicate that political ideology, economic factors, and existing HCBS policies were the most important determinants of whether a state adopted the ACA’s HCBS opportunities. This research has implications for federal officials interested in spurring states to achieve greater rebalancing of Medicaid long-term services and supports toward HCBS.

DISPARITIES IN ACCESSING DIFFERENT TYPES OF LONG-TERM CARE SERVICES IN TAIWAN

A growing body of evidence documents pervasive social and demographic factors relating to disparities in long-term care (LTC). In 2007, Taiwan implemented its Ten-year Long-Term Care Plan version 1.0 (TLTCP 1.0) that aimed to develop a home-and community-based (HCBS) LTC system. In 2016, Taiwan began to implement TLTCP 2.0. To continue providing effective LTC, this study aimed to assess the disparities in access to LTC services using Taiwan’s LTC claim database from 2010 to 2013. A total of 87,438 older adults who had applied for LTC services from the TLTCP 1.0 were included. The study assessed LTC disparities related to five sociodemographic factors, including age, gender, living status, urbanization, and income status. Sixteen types of LTC services, including HCBS, home-based professional care, meal services, transportation, and institutional services were assessed. After controlling for the level of disability, we found that those who were older-old (age 80> over), male, and low-income were less likely to use HCBS, but more likely to use institutions services (p < 0.001). We also found that those who lived in the city were more likely to use HCBS and transportation services (p < 0.001). Yet, older adults living alone were more likely to use home care and meal services but not other types of LTC services (p < 0.001). In conclusion, the social disparities in access to LTC services in Taiwan remains, suggesting LTC 2.0 should continue monitoring and placing the LTC equity issue on the top priority.

The Role of the Media in Agenda Setting: The Case of Long-Term Care Rebalancing

This study investigates the role of print media in state policy agendas in four states—Connecticut, Minnesota, Oregon, and Utah—in rebalancing long-term care away from institutions toward home- and community-based (HCBS) services. Ordinary least squares regression is used to model states’ policy agendas, as measured by the proportion of Medicaid long-term care spending on HCBS expenditures and number of rebalancing bills proposed, from 1999 to 2008. Results reveal a relationship between states’ rebalancing agendas and the extent of media coverage, and state economic, political, and programmatic characteristics. Findings suggest that media coverage reflects broader shifts in state-level attitudes toward rebalancing.

Medicaid Home and Community-Based Services for the Elderly: Trends in Programs and Policies

This article presents the latest available expenditure and participation trends (1999-2002) for three Medicaid home and community-based (HCBS) programs that serve the elderly (home health, waivers, and personal care services [PCS]) and reports a national survey of policies used on these programs in 2002. Although the trend data show a rise in elderly waiver and PCS programs and participation, they also reveal falling per participant expenditures in PCS programs, declining annual growth in total HCBS expenditures, and large interstate variations in elderly waivers. The use of cost control policies such as spending caps and large waiver waiting lists in many states contribute to the gap between demand and supply for Medicaid HCBS for the elderly.

Kaiser Permanente's Manifesto 2005 Demonstration

Summary In 1996, the eight-million member Kaiser Permanente HMO adopted a vision statement that said by 2005 it would expand its services to include home- and community-based services for its members with disabilities. It funded a 3-year, 32-site demonstration that showed that it was feasible to link HMO services with existing home-and community-based (HCB) services and that members appreciated the improved coordination and access. This private-sector project showed that devolution can produce innovative and feasible models of care, but it also showed that without federal financial and regulatory support, such models are unlikely to take hold if they are focused on “unprofitable” populations, for example, those who are chronically ill, poor, and/or disabled.

Policy choices for Medicaid and Medicare waivers.

This article reviews the authority and processes for issuing Medicare and Medicaid waivers, highlights waiver-based differences in states' home- and community-based (HCB) service systems, and critiques emerging efforts to capitate, integrate, and privatize the long-term care system. Potential pitfalls relate to payment rates, risk, service substitution, accountability, and drains on HCB infrastructure. Before merging HCB services into larger prepaid systems, policy makers are advised to examine implementation challenges, resist ad hoc fixes, clarify HCB entitlements, and strengthen current infrastructure.

The Medicaid Home and Community-Based Waiver and supported employment.

The Medicaid Home and Community-Based (HCB) Waiver is the primary funding source for long-term care for individuals with developmental disabilities. Findings from a national survey of 48 state coordinators regarding waiver-funded supported employment services are presented. Very low utilization for this service was found, primarily due to limits on eligibility. However, respondents in 18 states reported large numbers of waiver participants receiving employment services under other service categories. Eleven states had waiting lists for waiver-funded supported employment, totalling three times those actually receiving services. Low reimbursement rates to provider agencies and disinterest of providers in using waiver funds were significant barriers to expansion of service capacity.

The Effects of Funding Packages on the Outcomes of Integration and Independence of Adults with Developmental Disabilities in Two Rural States

This study presents a method for measuring outcomes, and for making comparisons between funding packages and between states about the effectiveness of programs in encouraging integration and independence, while controlling for potentially confounding factors. Adults with developmental disabilities, (N = 3,291), were served in two very rural Western states, and in a medium-sized Midwestern city. Information about the individuals served was taken from the Inventory for Client and Agency Planning (ICAP); fiscal information about the types and amounts of funding, provider and geographic information factors were used to explain the outcomes. Analyzing the combined data with analyses of covariance to control for possibly confounding factors, it was found that federally-funded people are more likely to be involved in the more restrictive living and day settings than people supported by state general funds. Residential independence was highest for people with state funding, intermediate for those paid by Home and Community Based (HCBS) waivers, and lowest for those living in Intermediate Care Facilities for the Mentally Retarded (ICFs/MR). Significant differences in independence between HCBS and ICF/MR were not substantiated for daytime settings, however. The disability level of the individual served was the best predictor of independence. Factors used in the study explained 85% of all of the variance in residential independence and 52% for daytime independence. The methodology shows value in establishing clear outcome-based quality measures, and doing so economically since it uses existing databases.

Cost savings from home and community-based services: Arizona's capitated Medicaid long-term care program.

The Arizona Long-Term Care System is the first capitated, long-term care Medicaid program in the nation to operate statewide. It promotes an extensive home and community-based services program intended to lower long-term care costs by substituting home care for institutional care. Because the program is statewide, finding a suitable control group to evaluate it was a serious problem. A substitute strategy was chosen that compares actual costs incurred to an estimate of what costs would have been in the absence of home and community-based (HCB) services. To estimate the likelihood of institutionalizing clients in the absence of HCB services, coefficients for institutionalization risk factors were estimated in a logistic regression model developed using national data. These were applied to characteristics of Arizona clients. The model assigned approximately 75 percent of the program's clients to a category with traits that were determined to resemble nursing home residents' traits. A similar methodology was used to estimate lengths of nursing home stays. Lengths of stay by the program's nursing home patients were regressed on their characteristics using an event history analysis model. Coefficients for these characteristics from the regression analysis were then applied to HCB services clients to estimate how long their nursing home stays would have lasted, had they been institutionalized. These estimated nursing home stays were generally shorter than these same patients' observed home and community stays. Risk of institutionalization was then multiplied by estimated length of stay and by monthly nursing home costs to estimate what costs would have been without the HCB services option. The expected costs were compared to actual costs to judge cost savings. Home and community-based services appeared to save substantial amounts on costs of nursing home care. Estimates of savings were very robust and did not appear to be declining as the program matured. Savings probably came from several sources: the assessment teams that judged client eligibility were employed by a state agency and thus were independent from the program contractors; clients were required to be in need of at least a three-month nursing home stay; a cap was placed on the number of HCB services clients contractors were allowed to serve each month; the capitated payment methodology forced managed care contractors to hold down average HCB services costs or lose money; and the HCB services and nursing home costs were blended in the capitated rate, so that plans that failed to place clients in HCB services would lose money by using more nursing home days than their monthly capitated rate allowed.

Supported employment and the medicaid home and community-based waiver authority: Current status and unresolved issues

The article reviews the current status of the Medicaid HCB (home and community-based) waiver and the use of its supported employment provisions, outlining major factors involved in its low utilization, including: (a) lack of prior institutionalization in the histories of two-thirds of waiver participants, (b) the tendency of states to limit eligibility to individuals with the most extensive support and service needs, (c) delays in implementing the supported employment coverage option, (d) the fact that eligibility is limited to individuals who would otherwise require institutional care. (e) the fact that supported employment is defined as a sub-element of habilitation services and applicable only to waiver participants with developmental disabilities, and (f) the general barriers to expanding supported employment services, particularly to individuals with severe disabilities. Unresolved federal policy issues are discussed and information on obtaining a more complete report are also included.