Medicaid Waiver Program Research Articles

Results of the Promoting Effective Advance Care Planning for Elders (PEACE) Randomized Pilot Study

The specific aim of the PEACE pilot study was to determine the feasibility of a fully powered study to test the effectiveness of an in-home geriatrics/palliative care interdisciplinary care management intervention for improving measures of utilization, quality of care, and quality of life in enrollees of Ohio's community-based long-term care Medicaid waiver program, PASSPORT. This was a randomized pilot study (n=40 intervention [IG], n=40 usual care) involving new enrollees into PASSPORT who were >60 years old. This was an in-home interdisciplinary chronic illness care management intervention by PASSPORT care managers collaborating with a hospital-based geriatrics/palliative care specialist team and the consumer's primary care physician. This pilot was not powered to test hypotheses; instead, it was hypothesis generating. Primary outcomes measured symptom control, mood, decision making, spirituality, and quality of life. Little difference was seen in primary outcomes; however, utilization favored the IG. At 12 months, the IG had fewer hospital visits (50% vs. 55%, P=0.65) and fewer nursing facility admissions (22.5% vs. 32.5%, P=0.32). Using hospital-based specialists interfacing with a community agency to provide a team-based approach to care of consumers with chronic illnesses was found to be feasible. Lack of change in symptom control or quality of life outcome measures may be related to the tools used, as these were validated in populations closer to the end of life. Data from this pilot study will be used to calculate the sample size needed for a fully powered trial.

Hospice Use and Public Expenditures at the End of Life in Assisted Living Residents in a Florida Medicaid Waiver Program

To examine the association between hospice use and public expenditures in a sample of dually eligible assisted living (AL) residents at the end of life. A retrospective cohort study. Florida AL facilities. Newly enrolled dually eligible older AL residents under Florida's Medicaid Assisted Living for the Elderly waiver program who died between January 2003 and December 2004 (N = 382). Individual sociodemographic characteristics were obtained from Florida's Medicaid comprehensive assessment data. Medicaid eligibility status, enrollment in the AL waiver programs, International Classification of Diseases, Ninth Revision, Clinical Modification, codes and Medicaid claims data were obtained from Florida's Medicaid payment agency. Individual characteristics and Medicare and Medicaid claims data were merged with vital statistics to determine diagnoses, date of death, hospice enrollment, and public expenditures. The mean age of the study sample was 84.8 (range 65-102); 71.5% were female, and 63.4% were white. During the average 9.6 months of follow-up, 35.6% of the sample enrolled in hospice, and the average hospice length of stay was 47.9 d; 73.3% of the sample had been admitted to a hospital, and 38.0% had been admitted to a nursing home. The generalized linear model showed that hospice use was not significantly associated with lower public expenditures (average marginal effect = -$1,127, 95% confidence interval = -$8,377, $6,122). Hospice use at the end of life may not be associated with lower public expenditures in older dually eligible AL residents. Future research should examine the association between hospice enrollment and the quality of end-of-life care.

The Organizational Social Context of Mental Health Medicaid Waiver Programs with Family Support Services: Implications for Research and Practice

Peer family support specialists (FSS) are parents with practical experience in navigating children's mental health care systems who provide support, advocacy, and guidance to the families of children who need mental health services. Their experience and training differ from those of formally trained mental health clinicians, creating potential conflicts in priorities and values between FSS and clinicians. We hypothesized that these differences could negatively affect the organizational cultures and climates of mental health clinics that employ both FSS and mental health clinicians, and lower the job satisfaction and organizational commitment of FSS. The Organizational Social Context measure was administered on site to 209 FSS and clinicians in 21 mental health programs in New York State. The study compared the organizational-level culture and climate profiles of mental health clinics that employ both FSS and formally trained clinicians to national norms for child mental health clinics, assessed individual-level job satisfaction and organizational commitment as a function of job (FSS vs. clinician) and other individual-level and organizational-level characteristics, and tested whether FSS and clinicians job attitudes were differentially associated with organizational culture and climate. The programs organizational culture and climate profiles were not significantly different from national norms. Individual-level job satisfaction and organizational commitment were unrelated to position (FSS vs. clinician) or other individual-level and organizational-level characteristics except for culture and climate. Both FSS' and clinicians' individual-level work attitudes were associated similarly with organizational culture and climate.

“In the Driver’s Seat”: Parent Perceptions of Choice in a Participant-Directed Medicaid Waiver Program for Young Children with Autism

This study investigated families' experience of choice within a participant-directed Medicaid waiver program for young children with autism. Fourteen parents or grandparents participated in in-depth interviews about their experience of choosing personnel, directing in-home services, and managing the $25,000 annual allocation. Key findings included families' preference to hire providers with whom they have a prior relationship, parent empowerment and differences of opinion about parents as teachers. Professionals implementing participant directed service models could benefit from understanding the strong value parents' placed on the personalities and interpersonal skills of providers. Parents' descriptions of directing rather than merely accepting autism services revealed increased confidence in their ability to choose and manage the multiple components of their children's HCBS autism waiver program.

Optimizing Mobility in Later Life: The Role of the Urban Built Environment for Older Adults Aging in Place

Hazards in the urban built environment can create barriers to mobility among older adults aging in place. We investigated the relationship between urban built environment characteristics and 15-month trajectories of mobility disability in a sample of 1,188 older adults living in Detroit, MI, a city that has undergone rapid economic and structural decline. Data come from the Michigan Minimum Data Set for Home Care (2001-2008), an enumerative database of older adults in Michigan who qualify for federal or state-funded home and community-based long-term care through a Medicaid waiver program. Standardized assessments are made at intake and every 90days by case managers. Built environments were assessed with a virtual audit using the "Street View" feature of Google Earth. A summary accessibility score was created for each block based on a count of the number of accessible features (e.g., continuous barrier-free sidewalks and proximity of public transportation). Using growth mixture models, two latent trajectories of outdoor mobility were identified: one capturing occasional outdoor mobility (representing 83% of the sample) and one capturing almost no mobility outside the home. Controlling for sociodemographic and health risk factors, individuals living in more accessible environments had a 18% higher odds of being in the more mobile group (OR = 1.18, 95% CI = 1.01, 1.41). These findings emphasize the importance of the built environment for mobility among urban-dwelling older adults.

96: The effect of CenteringPregnancy Group prenatal care on enrollment in the post-partum family planning Medicaid waiver program

twins when one twin has a major cardiac anomaly? Amy Doss, Keenan Yanit, Allison Allen, Brian Shaffer, Yvonne Cheng, Aaron Caughey Oregon Health & Science University, Obstetrics & Gynecology, Portland, OR, University of California San Francisco, Obstetrics, Gynecology, & Reproductive Sciences, San Francisco, CA OBJECTIVE: Optimal timing of twin delivery involves balancing the risk of IUFD against the potential morbidity of late preterm/early term birth, which becomes more challenging if one twin has a major cardiac anomaly, as this increases the IUFD risk and neonatal morbidity/mortality. We used decision analysis to estimate the optimal GA for delivery of dichorionic diamniotic (DCDA) twins when one has a cardiac anomaly. STUDY DESIGN: A decision-analytic model was created using TreeAge to compare the outcomes of delivery at 34 through 38 weeks in a theoretical cohort of DCDA twin pregnancies when one twin has a major cardiac anomaly. Our baseline assumption was that a twin with a cardiac anomaly was at 10-fold increased risk of IUFD. Strategies involving expectant management (EM) until a later GA accounted for the probabilities of spontaneous delivery, indicated delivery, and IUFD during each successive week. GA associated risks of neonatal complications including major neurodevelopmental disability, perinatal and neonatal mortality. Baseline assumptions were derived from the literature. Total quality-adjusted life years (QALYs) were calculated, accounting for both neonatal and maternal utilities. Sensitivity analyses were conducted. RESULTS: Our model showed that earlier GAs were associated with increased neonatal morbidity, but lower overall IUFD rates (Table). Balancing these outcomes, the optimal delivery strategy was EM until 38 weeks, which maximized the total QALYs. Sensitivity analysis showed that optimal GA at delivery was sensitive to the increased risk of IUFD associated with major cardiac anomalies. EM until 38 weeks was the optimal strategy until the increased risk of IUFD in an cardiac anomaly twin increased beyond a relative risk of 21.6, when delivery strategies at earlier GAs became preferred. CONCLUSION: Weighing the risks of IUFD against the outcomes of iatrogenic prematurity, the ideal GA to deliver DCDA twins in one with a major cardiac anomaly is 38 weeks.

Assessing Health Status Differences Between Veterans Affairs Home-Based Primary Care and State Medicaid Waiver Program Clients

Comprehensive health care for older adults is complex, involving multiple comorbidities and functional impairments of varying degrees and numbers. In response to this complexity and associated barriers to care, home-based care models have become prevalent. The home-based primary care (HBPC) model, based at a Michigan Department of Veterans Affairs Medical Center, and the Michigan Waiver Program (MWP) that includes home-based care are 2 of these. Although both models are formatted to address barriers to effective and efficient health care, there are differences in disease prevalence and functional performance between groups. The objective of this study was to explore the differences between the 2 groups, to shed some light on potential trends that could suggest areas for resource allocation by service providers. Using a retrospective analysis of data collected using the interRAI-home care, we examined a cross-sectional representation of clients enrolled in HBPC and MWP in 2008. The HBPC sample had 89 participants. The MWP database contained 9324 participants from across the State of Michigan and were weighted to be comparable to the HBPC population in sex and age, and to simulate the HBPC sample size. Veterans were more independent in basic activities of daily living performance, but there was no difference in the rate of reported falls between the 2 groups. Veterans had more pain and a higher prevalence of coronary artery disease (z = 7.0; P < .001), Chronic obstructive pulmonary disease (z = 3.9; P < .001), and cancer (z = 8.5; P < .001). There was no statistically significant difference between the 2 groups in terms of the prevalence of geriatric syndromes. Scores on subscales of the interRAI-home care indicated a lower risk of serious health decline and adverse outcomes for MWP compared with HBPC clients (1.4 ± 1.1 vs 0.9 ± 0.1; z = 2.5; P = .012). Veterans receiving home-based care through the Veterans Affairs Medical Center were more burdened by chronic disease and had higher degrees of loneliness than their MWP counterparts- factors, which may increase their likelihood of hospitalizations. MWP participants had more cases of cerebrovascular accident (z = 2.1; P = .039), as well as a higher rate of diagnosed dementias (z = 2.7; P = .006). Though not different, stress among caregivers in both groups, and depression in clients of both groups were substantial. Overall, sleep, pain, coronary artery disease, chronic obstructive pulmonary disease, and cancer are significant issues for Veteran clients, and clients treated through MWP home-care in Michigan have higher than national average rates of dementias, diabetes, hypertension, and coronary artery disease. With expanded home care models of service on the horizon, comparisons such as the one presented here could identify more efficient and effective service, with potential for improved client health outcomes.

Managing in the Trenches of Consumer Care: The Challenges of Understanding and Initiating the Advance Care Planning Process

To better understand how community-based long-term care providers define advance care planning and their role in the process, we conducted 8 focus groups with 62 care managers (social workers and registered nurses) providing care for Ohio's Medicaid waiver program. Care managers shared that most consumers had little understanding of advance care planning. The care managers defined it broadly, including legal documentation, social aspects, medical considerations, ongoing communication, and consumer education. Care managers saw their roles as information providers, healthcare team members, and educators/coaches. Better education, resources, and coordination are needed to ensure that consumer preferences are realized.

Dodecaphony: Enacting Support Brokerage in the Twelve Cash &amp; Counseling Expansion States

Support brokers are entities that provide information and assistance to self-directed clients in Medicaid waiver programs. Although all Cash & Counseling programs have support brokerage, each state has a great deal of liberty in determining how those functions are carried out, who provides those activities, which functions are emphasized and how responsibility for support broker tasks coordinates with other support activities. In this article, we map out the various ways in which states have operationalized the support brokerage concept. Differences in title, qualifications, training, hiring preferences, and caseload are described and further directions for research are suggested.

Maintaining Employment Among Caregivers of Individuals on a Medicaid Waitlist for Services

Many individuals with developmental or intellectual and other disabilities are on waitlists to receive supportive services through state Medicaid waiver programs. Being waitlisted can place considerable burden on the ability of a caregiver to maintain employment outside the home. This article reports on results of a survey of 442 caregivers of individuals waitlisted for services within the Florida Medicaid program. Logistic regression was used to model characteristics of caregiver and clients that are associated with the need for additional supports in order for the caregiver to maintain employment. Male caregivers and caregivers in fair or poor health were more likely to report needing support. Caregivers of clients who had behavior problems or problems with self-care were also more likely to need support to maintain employment. Policy responses to these findings include a call for increased supports or prioritization of services for caregivers who are in poor health or those who care for individuals with particularly problematic behaviors.

Sidebar: Planned Changes in Child/Family/youth Services at One LME/MCO

ncmedicaljournal.com 190 or more capitated, at-risk MCOs rather than with thousands of fee-for-service providers. Managed care offers states a single point of accountability by making it possible for there to be one designated manager for the entire continuum of services and supports for a specified geographic area. States can hold a single entity responsible for access, quality, and cost. A benefit of managed care for an entity receiving public funding, such as PBH, is that administrative funds are concentrated within the MCO. Currently, Medicaid administrative funds for Medicaid fee-for-services care and for the special Medicaid community waiver program of CAP-MR/ DD (Communities Alternative Program for Persons with Mental Retardation/Developmental Disabilities) are dispersed across several organizations, including ValueOptions, HP Enterprise Services, and a few LMEs. Diluting precious administrative resources compromises the capacity of any single entity to develop the infrastructure necessary for waiver operations. The infrastructure requirements include complex information technology, quality oversight systems, and highly qualified staff members to operate these systems and manage for outcomes. One of the advantages of the managed care Medicaid waiver program is that there is an option under 1915(b)(3) for states to use savings to reinvest in additional services that are not otherwise available to the state’s Medicaid population. The savings realized are converted to a special per-member, per-month payment that provides funding for the additional services in future years. Managed care systems create predictable business environments for providers by managing competition through a closed network. A closed network provides choice for consumers, but offers providers the opportunity to have sufficient market share to support investment in their local infrastructure. PBH’s use of evergreen contracts (contracts without an end date) provides additional assurances to providers. The managed care waiver program requires MCOs to ensure that consumers have both access to services and a choice of providers. Low-density populations can result in inadequate numbers of providers and poor access to care in rural areas. The MCOs are responsible for recruiting providers for underserved areas and can use financial incentives such as special rates to bring providers into a specific geographic area. The MCOs have full authority to ensure quality of serPlanned Changes in Child/Family/Youth Services at One LME/MCO

Managed Care: Right or Wrong for North Carolina

Since 2005, Piedmont Behavioral Healthcare (PBH) has operated North Carolina's only managed care Medicaid waiver program. Legislation was recently passed requiring that the waiver program be expanded statewide by January 2013. Experience with the PBH model suggests that this expansion can result in significant savings without compromising quality or access.

Medicaid

In the United States, Medicaid is the primary social safety net that provides health care for the poor and other vulnerable populations. Interest group theory and federalism, state level sovereignty, are used to create a theoretical model that proposes factors, other than increasing health care cost, as growth determinants of Medicaid expenditure and enrollments. For over three decades driven by federalism state-level discretionary Medicaid waiver programs have been creating new and unsustainable entitlements. The role of Medicaid waivers is poorly understood and in need of scholarly attention. Due to a lack of federal oversight and other social and political factors, some of which will be discussed in this paper, it appears that discretionary Medicaid waiver programs put in place as a solution are contributing to the overall structural issues of Medicaid. The paper concludes with suggestions on needed research and some potential policy recommendations.

The Promoting Effective Advance Care for Elders (PEACE) Randomized Pilot Study: Theoretical Framework and Study Design

Practice guidelines are available for hospice and palliative medicine specialists and geriatricians. However, these guidelines do not adequately address the needs of patients who straddle the 2 specialties: homebound chronically ill patients. The purpose of this article is to describe the theoretical basis for the Promoting Effective Advance Care for Elders (PEACE) randomized pilot study. PEACE is an ongoing 2-group randomized pilot study (n=80) to test an in-home interdisciplinary care management intervention that combines palliative care approaches to symptom management, psychosocial and emotional support, and advance care planning with geriatric medicine approaches to optimizing function and addressing polypharmacy. The population comprises new enrollees into PASSPORT, Ohio's community-based, long-term care Medicaid waiver program. All PASSPORT enrollees have geriatric/palliative care crossover needs because they are nursing home eligible. The intervention is based on Wagner's Chronic Care Model and includes comprehensive interdisciplinary care management for these low-income frail elders with chronic illnesses, uses evidence-based protocols, emphasizes patient activation, and integrates with community-based long-term care and other community agencies. Our model, with its standardized, evidence-based medical and psychosocial intervention protocols, will transport easily to other sites that are interested in optimizing outcomes for community-based, chronically ill older adults.

Estimating the Fertility Effect of Expansions of Publicly Funded Family Planning Services in California

Objective To estimate the number of unintended pregnancies averted through the provision of family planning services to low income women in Family PACT, California's Medicaid waiver program. Study Design We use a Markov model to estimate the number of pregnancies in the absence of Family PACT based on the contraceptive method mix used before program enrollment, and pregnancies in the presence of the program, based on method dispensing claims. Results Nearly 1 million (998,084) women were provided with contraceptives in Family PACT in 2007. Contraceptive services averted over an estimated 286,700 unintended pregnancies including 122,000 abortions, 133,000 unintended births, and over 40,000 births among teens. Conclusion This conservative measure of the effect of Family PACT on unintended pregnancies indicates the benefit of expanding access to contraceptive services, an example for other states considering expanding access to family planning services through a state plan amendment under health care reform.

Predictors of Low-Care Prevalence in Florida Nursing Homes: The Role of Medicaid Waiver Programs

To examine the relationship between county-level Medicaid home- and community-based service (HCBS) waiver expenditures and the prevalence of low-care residents in Florida nursing homes (NHs). The present study used a cross-sectional design. We combined two data sources: NH facility-level data (including characteristics of the facility and its residents) and county-level market characteristics (including HCBS waiver expenditures) for 653 Florida NHs in 2007. Low-care was defined as residents who require no physical assistance in any of the 4 late-loss activities of daily living (bed mobility, toileting, transferring, and eating). We estimated a 2-level hierarchical linear model (HLM) to examine the relationship between Medicaid HCBS waiver expenditures and the prevalence of low-care residents while accounting for resident assessment, facility-, and county-level covariates. All Florida counties offered 2 statewide waivers, and 33 counties offered one or more of the 4 regional Medicaid HCBS waivers in 2007. Per-month beneficiary expenditures ranged from $755 to $1,778. The average Florida NH had 120 beds, and 8.0% of its residents were classified as low-care. Results from the HLM model showed that a $10,000 increase in per-enrollee HCBS waiver expenditures was associated with a 3.5 percentage point reduction in low-care resident prevalence (p = .03). The findings suggest that Medicaid HCBS waiver programs may reduce the prevalence of low-care residents in NHs. Future studies should evaluate whether Medicaid HCBS waiver programs are effective in promoting community-living among low-care residents and mitigating the growth in long-term care expenditures.

Medicaid Cuts in Health Care for Persons With Developmental Disabilities in Tennessee: Perspective From the Field

As a physical therapy practitioner who primarily works with persons who have developmental disabilities, I have become increasingly dismayed at the Medicaid cutbacks in Tennessee, the state in which I practice. I am confident that this is also the case in many other states that face budget shortfalls due to the current economic downturn. However, in Tennessee, this has been ongoing for more than just the past year or so. Medicaid has been on the chopping block for approximately the past 6 years. A position statement adopted by the Arc and the American Association on Intellectual and Developmental Disabilities (AAIDD) maintains that ‘‘Medicaid reform should address wait lists, the quality of service, providers and staff, and increased availability of quality health care services for individuals with intellectual and/or developmental disabilities’’ (AAIDD/The Arc of the United States, 2008). It is extremely disheartening to read this proclamation and realize that just the opposite is occurring. Although everyone with a developmental disability does not have Medicaid, the majority of the individuals I see in Tennessee with developmental disabilities have Medicaid as their primary insurance, and for others it may be a secondary source of payment. The Medicaid program in Tennessee has been given the designation of TennCare and is billed as Tennessee’s expanded Medicaid program. There is also a special statewide Medicaid Waiver program to assist some individuals over age 21 years with an intellectual disability who are deemed eligible, in addition to the TennCare Medicaid program. The TennCare plan is administered by several insurance entities, such as Blue Cross Blue Shield of Tennessee (BlueCare) and United Healthcare (Americhoice TennCare). TennCare currently covers 1.2 million residents in Tennessee and uses a managed care model (TennCare Overview, n.d.). According to professionals at the state TennCare Budget Presentation at the 106th General Assembly Legislative Budget Hearings (2010), states around the country are facing a $180 billion shortfall for Medicaid spending this year, and many are cutting back on services. It is apparent to me that TennCare was already underfunded prior to the nascent recession. Clients I have served over the past 5 years who rely on TennCare or Medicaid Waiver to reimburse for services such as therapy or nursing have continually faced threats that his or her services would be cut or eliminated entirely. In addition, these individuals and their families or caregivers have had problems finding physicians who accept TennCare; locating specialists to treat them is especially problematic. Other individuals I have seen have been denied needed devices, such as wheelchairs. Still others have been dropped from TennCare altogether and are unable to afford services. If service providers who accept TennCare can be found, delays in service are not uncommon. The added emotional stress and privation placed on the person with the developmental disability and his or her family and caregivers when services are not readily available, or are denied outright, can be immense. Families and other advocates must battle TennCare to merely preserve current levels of services, much less improve on what has been offered up until now. I have heard stories of families who are told by TennCare representatives that their son or daughter no longer qualifies for services such as in-home skilled nursing care. When the family member responds that they work during the day and cannot care for their loved one, the TennCare representative would counter that another family member could care for the individual. How can another family member be expected to be available 40 or more hours per week to care for an individual who has severe disabilities? Furthermore, many of the children and adults I see are cared for by a single parent. I am aware of several persons with INTELLECTUAL AND DEVELOPMENTAL DISABILITIES VOLUME 49, NUMBER 1: 50–52 | FEBRUARY 2011

Five-Year Survival in a Program of All-Inclusive Care For Elderly Compared With Alternative Institutional and Home- and Community-Based Care

Community-based services are preferred to institutional care for people requiring long-term care (LTC). States are increasing their Medicaid waiver programs, although Program of All-Inclusive Care For Elderly (PACE)-prepaid, community-based comprehensive care-is available in 31 states. Despite emerging alternatives, little is known about their comparative effectiveness. For a two-county region of South Carolina, we contrast long-term survival among entrants (n = 2040) to an aged and disabled waiver program, PACE, and nursing homes (NHs), stratifying for risk. Participants were followed for 5 years or until death; those lost to follow-up or surviving less than 5 years as on August 8, 2005 were censored. Analyses included admission descriptive statistics and Kaplan-Meier curves. To address cohort risk imbalance, we employed an established mortality risk index, which showed external validity in waiver, PACE, and NH cohorts (log-rank tests = 105.42, 28.72, and 52.23, respectively, all p < .001; c-statistics = .67, .58, .65, p < .001). Compared with waiver (n = 1,018) and NH (n = 468) admissions, PACE participants (n = 554) were older, more cognitively impaired, and had intermediate activities of daily living dependency. PACE mortality risk (72.6% high-to-intermediate) was greater than in waiver (58.8%), and similar to NH (71.6%). Median NH survival was 2.3 years. Median PACE survival was 4.2 years versus 3.5 in waiver (unstratified, log rank = .394; p = .53), but accounting for risk, PACE's advantage is significant (log rank = 5.941 (1); p = .015). Compared with waiver, higher risk admissions to PACE were most likely to benefit (moderate: PACE median survival = 4.7 years vs waiver 3.4; high risk: 3.0 vs 2.0). Long-term outcomes of LTC alternatives warrant greater research and policy attention.

Dodecaphony: Enacting Support Brokerage in the 12 Cash &amp; Counseling Expansion States

Support brokers are entities that provide information and assistance to self-directed clients in Medicaid waiver programs. Although all Cash & Counseling programs have support brokerage, each state has a great deal of liberty in determining how those functions are carried out, who provides those activities, which functions are emphasized and how responsibility for support broker tasks coordinates with other support activities. In this article, we map out the various ways in which states have operationalized the support brokerage concept. Differences in title, qualifications, training, hiring preferences, and caseload are described and further directions for research are suggested.

Medicaid Funding for Assisted Living Care: A Five-State Examination

Medicaid waiver programs financing assisted living care are examined in five states to gain insights about program implementation, accomplishments, and challenges. Documents, augmented with stakeholder interviews, are used to describe income eligibility, options for supplementing payments to facilities, risk adjustment payment levels, and participation. Needs determination and waiver-based payments are in place. Eligibility and funding levels are complicated by room and board allocations that are linked to the federal benefit rate for Supplemental Security Income. Provider participation may be diminishing. Many recipients have to accept shared occupancy as program payments are insufficient for single units.