Waiver Program Research Articles

The PCDID Approach: Difference-in-Differences When Trends Are Potentially Unparallel and Stochastic

We develop a class of regression-based estimators, called Principal Components Difference-in-Differences (PCDID) estimators, for treatment effect estimation. Analogous to a control function approach, PCDID uses factor proxies constructed from control units to control for unobserved trends, assuming that the unobservables follow an interactive effects structure. We clarify the conditions under which the estimands in this regression-based approach represent useful causal parameters of interest. We establish consistency and asymptotic normality results of PCDID estimators under minimal assumptions on the specification of time trends. The PCDID approach is illustrated in an empirical exercise that examines the effects of welfare waiver programs on welfare caseloads in the United States.

The Association of the Medicaid 1915(c) Home and Community-Based Services Waivers with Emergency Department Utilization among Youth with Autism Spectrum Disorder

Using the 2008-2013 Medicaid Analytic eXtract files, this retrospective cohort study was to evaluate the effect of Medicaid home and community-based services (HCBS) waiver programs on emergency department (ED) utilizations among youth with autism spectrum disorder (ASD). Our study showed that the annual ED utilization rates were 13.5% and 18.8% for individuals on autism specific and intellectual and developmental disabilities (IDD) waivers respectively, vs. 28.5% for those without a waiver. Multivariable logistic regression showed that, compared to no waiver, autism specific waivers (adjusted odds ratio: 0.62; 95% Confidence Interval: [0.58-0.66]) and IDD waivers (0.65; [0.64-0.66]) were strongly associated with reduced ED. These findings suggest that HCBS waivers are effective in reducing the incidence of ED visits among youth with ASD.

Evaluating buprenorphine prescribing and opioid-related health outcomes following the expansion the buprenorphine waiver program

AimsTo evaluate associations between new types of buprenorphine waivers (nurse practitioner and physician assistant [NP/PA]; 275-patient limit [MD/DO-275]) and both buprenorphine prescribing and health outcomes. MethodsUsing comprehensive county-level data from California 2010–2018, we modeled quarterly associations between numbers of NP/PA and MD/DO-275 waivers and rates of buprenorphine prescribing, opioid-related deaths, emergency department (ED) visits, and hospitalizations among all counties and separately among metropolitan and nonmetropolitan counties using Poisson regression models with county and quarter fixed effects and adjusting for time-varying covariates. ResultsEach additional NP/PA and MD/DO-275 waiver was associated with a 2.6% (95%CI: 1.1–4.1%) and 5.8% (4.1–7.4%) increase in buprenorphine prescribing among nonmetropolitan counties, respectively. Each additional MD/DO-275 waiver was associated with a 2.8% (1.0%–4.6%) increase in buprenorphine among metropolitan counties. There were no statistically significant associations between NP/PA waivers and buprenorphine prescribing among metropolitan counties or among either waiver type and opioid-related health outcomes. ConclusionsNP/PA waivers were associated with increased buprenorphine prescribing among nonmetropolitan counties and MD/DO-275 waivers were associated with increased buprenorphine prescribing among both metropolitan and nonmetropolitan counties.

Medicaid Waivers and Tenancy Supports for Individuals Experiencing Homelessness: Implementation Challenges in Four States.

Policy Points Medicaid policymakers have a growing interest in addressing homelessness as a social determinant of health and driver of the potentially avoidable use of expensive medical services.Drawing on extensive document reviews and in‐depth interviews in four early‐adopter states, we examined the implementation of Medicaid's Section 1115 demonstration waivers to test strategies to finance tenancy support services for persons experiencing or at risk of homelessness. ContextThe Affordable Care Act extended Medicaid eligibility to large numbers of individuals experiencing or at risk of homelessness. This legislative development and the growing recognition of homelessness as a significant social determinant of health have encouraged advocates and policymakers to seek new ways to use Medicaid to provide housing supports.MethodsWe conducted 28 semistructured interviews with 36 stakeholders in four states. The stakeholders were government administrators, health care providers, nonprofit housing staff, and consultants. We supplemented these interviews with extensive reviews of public documents, media accounts, think‐tank reports, and published literature. We also conducted a systematic inductive qualitative analysis.FindingsWe identified seven challenges to the successful implementation of tenancy support demonstration projects: resolving the housing supply and NIMBY, removing silos between health care and homeless services providers, enrolling and retaining the target populations in Medicaid, contracting with and paying tenancy support providers, recruiting and retaining key workers, ensuring Medicaid's waiver durability, and reducing administrative crowd‐out and waiver burden.ConclusionsNotwithstanding these challenges, three of the four states have made significant progress in launching their initiatives. At this point, the fourth state has delayed its start‐up to consider alternatives to a Medicaid demonstration waiver to provide tenancy supports. The experience of the four states suggests lessons for Medicaid officials in other jurisdictions that are interested in pursuing tenancy support initiatives. Nevertheless, the limitations of tenancy support waiver programs suggest that federal policymakers should consider allowing states to more directly subsidize housing costs for those experiencing or at risk of homelessness as an optional Medicaid benefit.

Primary Care Shortage in Medically Underserved and Health Provider Shortage Areas: Lessons from Delaware, USA.

Objective:To examine the reasons contributing to the physician shortage in the country’s medically underserved areas using the state of Delaware as a focus state.Method:A literature review regarding the shortage of physicians with data compilation from Delaware Department of Public Health (DPH) and Delaware Health and Social services (DHSS) was performed. A review of the “Conrad 30 J1 VISA waiver program,” the most important and primary supplier of physicians to underserved areas of the state was performed. A survey interviewing the physicians recruited through this program to identify any challenges faced by them was designed and conducted.Results:The number of primary care physicians providing direct patient care in Delaware in 2018 had declined about 6% from 2013. The average wait time to see a PCP was 8.2 days in 1998 as compared to 23.5 days in 2018. Forty-six percent of physicians serving in HPSAs in Delaware are IMGs recruited through the J1 VISA waiver program. Eighty percent of these IMGs are actively considering leaving the United States due to anxieties around physician immigration policies, mainly “Immigration backlog.”Conclusion:The existing programs to recruit physicians to underserved areas seem to be inadequate. The state and the hospital systems should be able to utilize the J1 program to its full potential and focus on retaining these physicians after their assigned services. As the challenges of IMGs continue to worsen every day; the medical societies, hospitals, the state and federal government should advocate for policies that resolve these challenges.

A Preliminary Overview of Music Therapy Reimbursement Practice in the United States

Abstract Music therapy services are currently being reimbursed through state and private insurance funding streams, yet to date, there is no known systematic exploration on music therapy reimbursement practices. Such information would be helpful to include when communicating with third-party payers and can assist in tracking reimbursement trends. Thus, we sought to provide baseline information on how music therapy services are currently being reimbursed in the United States, with a focus on approved treatment parameters, referral sources, Current Procedural Terminology (CPT) codes used, and types of music interventions and music therapy experiences implemented. Board-certified music therapists in private practice who had successfully obtained reimbursement for music therapy services between 2012 and 2018 completed a 28-item online survey. In total, 7 respondents provided information on 55 unique reimbursement cases from 5 different states, most of which were based on Medicaid waiver programs. We conducted descriptive analyses to summarize music therapy reimbursement practices. Most of the clients were referred by doctors or physician’s assistants. The most common CPT code utilized was 97530 (Therapeutic Activities, one-on-one, each 15 minutes), and most of the International Classification of Diseases, 10th Revision (ICD-10) diagnostic codes were based on specific diagnoses rather than general clinical needs. In most of the cases, reimbursement of music therapy was ongoing, and services incorporated a variety of music therapy methods, with few specific music interventions identified. Most notably, reimbursement practice varied by state; thus, we recommend the creation and dissemination of state-specific surveys.

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.

Unmet Needs of Families of Adults With Intellectual and Development Disabilities on Waiting Lists

Most adults with intellectual and developmental disabilities live at home with their aging parents. Given the large waiting lists for residential and home-based services, families face many unmet service and support needs. The author will present results of a study that examined the impact of a Medicaid waiver program that provided either home-based or residential placements to 444 families of adults with IDD who were living at home at baseline through surveys at baseline and two years later. Families who did not receive the waiver services still had high unmet needs for person-centered planning training, networking with other families, respite, advocacy services, assistive technology, and home modifications at follow up. Regardless of services received, class members from minority backgrounds had more unmet needs than white class members, indicating the need for more targeted efforts to reach minority families.

Costs of the Care for Older Persons with Dementia in their Environment (COPE) intervention when delivered through the Connecticut state Medicaid waiver program

AbstractBackgroundThe Care of Persons with Dementia in their Environments translational study (COPE‐CT) is a Connecticut‐based randomized clinical trial conducted to evaluate the efficacy of behavioral intervention (COPE) vs. usual care (UC) for persons with dementia (PwD) and their caregivers.MethodsPwD in both groups were enrolled in the Connecticut Home Care Program for Elders (CHCPE) and received a monthly home care plan. COPE, an in‐home behavioral intervention delivered by occupational therapists and an advance practice nurse, was designed to maximize PwD physical functioning and improve caregivers’ dementia management skills. Program costs included staff training and supervision (COPE), screening for program eligibility (COPE &amp; UC), intervention delivery (COPE), travel time and mileage (COPE), supplies (COPE &amp; UC), lab testing (COPE), and home care plan for one year pre‐enrollment to one year post‐enrollment (COPE &amp; UC). Mean per‐dyad cost differences at 12 months vs. baseline were calculated for each group and compared using a difference‐in‐difference approach.Result291 PwD/caregiver dyads were randomized (145 COPE, 146 UC). Mean per‐dyad cost of COPE was $1,868 vs. $6.41 for UC, yielding an incremental difference‐in‐difference cost of $1,862/dyad for COPE. COPE delivery was the largest cost driver ($623/dyad) followed by travel time ($370/dyad) and lab testing ($316/dyad). UC costs were minimal and driven by supplies ($18.45/dyad). Both groups experienced a cost savings in the care plan at $82.06/dyad for COPE vs. $15.63/dyad for UC, but this difference was not statistically significant (p=0.5253).ConclusionGiven the lack of medical treatments for dementia, in‐home programs for PwD and their caregivers are critical. COPE represents a novel approach to dementia behavioral management and caregiver support, and the intervention costs we report inform its sustainability. Future work will examine potential cost offsets in health and social service expenditures.

Communicating a Complicated Medicaid Waiver Program to Enrollees in Iowa: How Federally Qualified Health Centers Support Medicaid Members.

Iowa expanded Medicaid eligibility with a waiver including a personal responsibility component. Early program evaluation revealed low compliance and awareness among members. There is little research on leveraging existing contact points in the health care system to effectively communicate with Medicaid enrollees. We interviewed outreach and enrollment staff at Federally Qualified Health Centers (FQHCs) to explore their work. We show that FQHCs use several strategies to enroll individuals in appropriate programs and support them in understanding and navigating their health insurance coverage. With increasingly complex Medicaid programs, this support will be more widely needed to prevent hardship and loss of coverage.

Contraceptive Services After Medicaid Expansion in a State with a Medicaid Family Planning Waiver Program.

Background: Medicaid family planning programs provide coverage for contraceptive services to low-income women who otherwise do not meet eligibility criteria for Medicaid. In some states that expanded Medicaid eligibility following the Affordable Care Act (ACA), women who were previously eligible only for family planning services became eligible for full-scope Medicaid. The objective of this study was to provide context for the impact of the ACA Medicaid expansion on contraceptive service provision to women in Oregon who were newly enrolled in Medicaid following the expansion. Materials and Methods: We used Medicaid eligibility data to identify women ages 15-44 years who were newly enrolled in Oregon's Medicaid program following the ACA expansion (n = 305,042). Using Medicaid claims data, we described contraceptive services and other preventive reproductive care received in 2014-2017. Results: Overall, 20% of women newly enrolled in Medicaid received contraceptive counseling and 31% received at least one method. The most frequently received methods were the pill (38% of women who received any method), intrauterine device (28%), implant (15%), and injectable (12%). Community health centers played a significant role in contraceptive service provision, particularly for the implant and injectable. Nine of 10 women (89%) who received contraceptive services also received other preventive reproductive services. Conclusions: This study provides insight regarding receipt of contraceptive services and preventive reproductive care following Medicaid expansion in a state with a Medicaid family planning program. These findings underscore the importance of Medicaid expansion for reproductive health even in states with preexisting Medicaid family planning.

The design of a randomized controlled trial to evaluate multi-dimensional effects of a section 1115 Medicaid demonstration waiver with community engagement requirements

Section 1115 demonstration waivers provide a mechanism for states to implement changes to their Medicaid programs. While such waivers are mandated to include evaluations of their impact, randomization – the gold standard for assessing causality – has not typically been a consideration. In a critical departure, the Commonwealth of Kentucky opted to pursue a two-arm randomized controlled trial (RCT) for their controversial 2018 Medicaid Demonstration waiver, which included work requirements as a condition for the subset of beneficiaries deemed able-bodied to maintain eligibility for benefits. Beneficiaries were randomized 9:1 to the new waiver program or a control group who would retain their current benefits as part of the existing Medicaid expansion program. To address potential bias from differential attrition from the Medicaid program that would accrue from solely analyzing administrative data, our team designed a rich, prospective, longitudinal survey to collect primary and secondary outcomes from six categories of interest to policymakers: insurance coverage, health care utilization and quality, health behaviors, socioeconomic measures, personal finances, and health outcomes. At baseline, a subset of survey participants was invited to participate in the collection of biometric samples via in-person follow-up visits, and a cross-section were also invited to participate in qualitative interviews. While the demonstration waiver was terminated before the program began, our study design illustrates that it is possible for other researchers and state agencies seeking to evaluate Medicaid demonstration waivers and other demonstration policies to work together to implement high quality randomized trials – even for controversial policies.

Patient and System Factors Associated with Racial and Ethnic Disparities in Ambulatory Care Among Medicaid‐Enrolled Adults with Intellectual and Developmental Disabilities

Research ObjectivePersons with intellectual and developmental disabilities (IDD) have complex medical needs and experience gaps in care due to their unique needs, and challenges faced by health professionals in responding to them. We characterize New Jersey Medicaid‐enrolled individuals with IDD and examine racial and ethnic (RE) disparities in ambulatory care (AC) quality and the extent to which RE gaps are explained by patient and health system factors. We focus on the potential positive effect of home and community‐based services (HCBS) provided through Medicaid waiver programs in mitigating disparities and improving care.Study DesignUtilizing New Jersey Medicaid comprehensive claims data over 2011‐2017, quality of AC was assessed using AC sensitive preventable hospitalizations (PH), IDD‐specific PH (IDDPH), and ED visits. Additional metrics including rates of preventive care visits (cancer screening, vaccination) and quality of behavioral health (BH) care will be available by the time of the conference. Econometric modeling of disparities utilized the Institute of Medicine as well as the Residual Direct Effect approaches that adjust for patient characteristics (sex, age, number of chronic and IDD conditions, presence of BH condition), allowing for mediation of disparities through provider and system‐level factors, for example, average quality of AC in zip code of residence. Difference‐in‐difference estimation examined how availability of HCBS waiver services impacted differences in quality across racial/ethnic groups. Findings from analysis utilizing an area‐level instrumental variable addressing potential selection into waiver services and access to IDD‐specialized providers will be available for the conference. Statistical significance was assessed at P = .05 threshold.Population Studied37 078 Medicaid‐enrolled individuals of age 22+ over 2011‐2017, who reside: a) in DD intermediate care facilities, or b) in the community and receive HCBS from waiver programs, or c) in the community, do not receive Medicaid‐paid HCBS and diagnosed with one or more of 13 IDD conditions. We examined ambulatory care among 92.7% of this population (n = 34 382) who were always in the community.Principal Findings44.2% of the community population was female, the mean age was 45.5 years, 59.3% had a BH condition, 25.6% had 3+ chronic conditions, and 49.4% were enrolled in HCBS waivers that provide services such as case management, day habilitation, and assistive technology. Among them, black (OR = 0.55) and Hispanic (OR = 0.21) populations had lower adjusted odds of being enrolled in waivers providing HCBS. Among those not receiving Medicaid‐paid HCBS, blacks had higher odds of PH (OR = 1.50), ED visits (OR = 1.33), and IDDPH (OR = 1.11). Hispanics had higher odds of ED visits (OR = 1.12). However, these disparities did not exist for individuals enrolled in HCBS waiver programs.ConclusionsOur analysis sheds light on RE disparities in AC outcomes within the IDD population using established measures of care quality and identifies several mechanisms associated with such disparities. We found a positive effect of HCBS on these outcomes in mitigating such disparities.Implications for Policy or PracticeThese findings underscore the beneficial role played by state waivers in ensuring provision of HCBS to individuals with IDD and, additionally, may guide formulation of performance metrics within Medicaid managed care contracts, and guidelines for health professionals offering specific IDD and medical services.Primary Funding SourceAgency for Healthcare Research and Quality.

Progress of California's Effort to Improve Outcomes of Care for Homeless Medicaid Patients Under a Section 1115 Medicaid Waiver Program

Research ObjectiveThe current Section 1115 Medicaid Waiver in California includes the Whole Person Care (WPC) pilot program, designed to improve care coordination for high‐cost, high‐utilizing populations, with special emphasis on the homeless. Pilots link homeless and other patients to housing, food, benefits, and similar services with the goals of improving health outcomes. We examined the impact of WPC in the first two years of the program on health care utilization of homeless enrollees.Study DesignWe conducted difference‐in‐difference (DD) analyses using a generalized mixed‐effect model to compare the 2‐year change in the pre‐ and postperiod among key outcome measures using an intervention‐control methodology. We developed a model for identifying homeless Medicaid patients in a control sample that matched the characteristics of WPC enrollees. We examined the (1) likelihood of hospitalization, (2) likelihood of emergency department (ED) visits, (3) number of ED visits, outpatient follow‐up after hospitalization for mental illness in (4) 7 days and (5) 30 days, and (6) initiation and (7) engagement of alcohol and other drug dependence treatment.Population StudiedThe DD model included 133 998 person‐years among the WPC homeless enrollees and 201 523 person‐years among the control group.Principal FindingsThe analyses (table below) showed that the predicted probability of hospitalization and ED visits and predicted number of ED visits declined for WPC homeless enrollees from before to after WPC enrollment, with a greater reduction for WPC enrollees than the control group in the same time period. Changes in other outcomes were not significant.ConclusionsEarly analyses indicated reductions in ED visits and hospitalizations among homeless WPC enrollees compared to the control group but not the other outcomes examined. Improvements in outcomes were likely due to pilot's effort to assess homeless patients' needs and linkages to housing and other needed social services.Implications for Policy or PracticeReductions in ED visits and hospitalizations are likely indicators of better outcomes and have significant implications for cost reduction under the Medicaid program. Our findings provide the needed evidence that provision of housing support and other social services may improve health outcomes among homelessness patients who frequently have higher level of need for care.Primary Funding SourceCalifornia Department of Health Care Services.

The Texas tuition and fee waiver program for youth who have experienced foster care: An assessment of waiver utilization and impact

Twenty-two states have legislated a tuition waiver for foster youth. However, little information is available about the efficacy of waiver programs. Texas has one of the oldest and largest tuition waiver programs, providing a useful case study of waiver impact. This study uses a unique data set of 4263 youth formerly in foster care in Texas to provide the first information about how utilization of the Texas tuition waiver impacts degree attainment. Findings reveal that youth who use waivers are 3.5 times more likely to graduate with a bachelor’s degree within 6 years of turning 18 years old. However, findings also indicate that the waiver is not used by 40% of the youth who are eligible to use it. The present study suggests that tuition waivers are a viable strategy for promoting post-secondary achievement among youth who have experienced foster care. However, waiver programs need to be broadly defined, accessible, and evaluated for utilization and impact.

Characterization of Family-Directed Care Coordination and Involvement in Behavioral Treatments in an Autism-Specific Medicaid Waiver.

Services for children with autism spectrum disorder (ASD) and their families have evolved with the advent of the Medicaid waiver, leading to more family-based coordination of care. Evaluating family involvement, the current investigation compared 230 families of children with ASD receiving Medicaid waiver services to a propensity-score matched group of 230 families who were waiting for such services (i.e., registry families). Compared to the registry, waiver families reported more involvement in service planning tasks, but not activities related to future-planning, managing crisis situations, or searching for and securing funding. Additional analyses characterize waiver families as engaging in high levels of coordinating and delivering behavioral interventions for their child. Implications for family burden and future programming for waiver programs are discussed.

A Divergent Path: Korean American Politics in an Age of Globalization

In a globalizing world, Korean Americans political participation is being increasingly shaped not only by their demand for empowerment in the United States―the nation of their citizenship―but also by their desire to manage their increasingly transnational lives and to fully maximize economic opportunities on the other side of the Pacific. While finding meaningful political power in the diverse and contentious American society has been a slow process, Korean Americans have found much more success in the interstitial political space of globalization and transnationalism. Within the past two decades, Korean Americans have been wooed by the South Korean government and the U.S. Departments of State and Commerce for various political and policy objectives. More specifically, this paper examines three specific laws and policies that demonstrate this transpacific turn in Korean American politics: 1) Overseas Korean Act (1999); 2) Visa Waiver Program (2008); and 3) Korea-United States Free Trade Agreement (2012). This shift in the political orientation of Korean Americans signals the increasing importance of transnational dynamics in ethnic political incorporation.

A New Era of Segregation Twenty Years After Olmstead: The Failure of HCBS Waiver Programs and the Need for a Comprehensive Federal HCBS Program

Despite significant improvements in treatment and care over the last century, individuals with Intellectual and Developmental Disabilities (IDD) still face barriers to access of appropriate services that allow for total integration into local communities. The United States Supreme Court held in Olmstead that individuals with IDD have the right to receive services in the community to avoid institutionalization. While attempts have been made to provide such services, the current scheme of Home and Community-Based Services Waiver Programs at the state level is failing, which has resulted in a new era of segregation. This Article compares and contrasts the failed Kerr-Mills Medical Assistance for the Aged Act, a precursor to Medicare, and the failing HCBS Waiver Programs. Drawing on the damning similarities between the two programs, this Article highlights the failure of the state HCBS Waiver Programs and calls for the creation of a Federal Home and Community-Based Services program for the same reasons that Congress ultimately enacted Medicare, a Federal program, as a replacement for the Kerr-Mills Medical Assistance for the Aged Act.

New York state BH community upset over loss of billions for Medicaid reform

Mental health advocates and providers across New York state have expressed disappointment and concerns over the Trump administration's denial last week to extend its Med‐icaid waiver program to improve care and reduce avoidable hospitalizations. State officials were seeking $8 billion more in federal funding for the program's extension over five years.

Designing a multifaceted telehealth intervention for a rural population using a model for developing complex interventions in nursing

BackgroundTelehealth interventions offer an evidenced-based approach to providing cost-effective care, education, and timely communication at a distance. Yet, despite its widespread use, telehealth has not reached full potential, especially in rural areas, due to the complex process of designing and implementing telehealth programs. The objective of this paper is to explore the use of a theory-based approach, the Model for Developing Complex Interventions in Nursing, to design a pilot telehealth intervention program for a rural population with multiple chronic conditions.MethodsIn order to develop a robust, evidenced based intervention that suits the needs of the community, stakeholders, and healthcare agencies involved, a design team comprised of state representatives, telehealth experts, and patient advocates was convened. Each design team meeting was guided by major model constructs (i.e., problem identification, defining the target population and objectives, measurement theory selection, building and planning the intervention protocol). Overarching the process was a review of the literature to ensure that the developed intervention was congruent with evidence-based practice and underlying the entire process was scope of practice considerations.ResultsTen design team meetings were held over a six-month period. An adaptive pilot intervention targeting home and community-based Medicaid Waiver Program participants in a rural environment with a primary objective of preventing re-institutionalizations was developed and accepted for implementation. To promote intervention effectiveness, asynchronous (i.e., remote patient monitoring) and synchronous (i.e., nursing assessment of pain and mental health and care coordination) telehealth approaches were selected to address the multiple comorbidities of the target population. An economic evaluation plan was developed and included in the pilot program to assess intervention cost efficiency.ConclusionsThe Model for Developing Complex Interventions in Nursing provided a simple, structured process for designing a multifaceted telehealth intervention to minimize re-institutionalization of participants with multiple chronic conditions. This structured process may promote efficient development of other complex telehealth interventions in time and resource constrained settings. This paper provides detailed examples of how the model was operationalized.