Waiver Program Research Articles

Changes in the Number of People With Intellectual or Developmental Disabilities Living in Homes They Own or Rent Between 1998 and 2007

Changes in the Number of People With Intellectual or Developmental Disabilities Living in Homes They Own or Rent Between 1998 and 2007

State Mental Health Policy: Overview and Goals of the Mississippi Youth Programs Around the Clock (MYPAC)

State Mental Health Policy: Overview and Goals of the Mississippi Youth Programs Around the Clock (MYPAC)

CMS Highlights Special Focus Facilities

CMS Highlights Special Focus Facilities

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

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

New APA Resource Addresses Psychiatry in Underserved Areas

New APA Resource Addresses Psychiatry in Underserved Areas

More AL Communities Abandon Medicaid

More AL Communities Abandon Medicaid

Chertoff Expects Secure Borders by 2011; Korea Included in Visa Waiver Program

Chertoff Expects Secure Borders by 2011; Korea Included in Visa Waiver Program

Long-Term Community Supports for Individuals With Co-Occurring Disabilities After Traumatic Brain Injury: Cost Effectiveness and Project-Based Intervention

AbstractOutcome studies have established that successful community living is compromised in the population of individuals with traumatic brain injury and chronic behavioural difficulties along with a co-occurring diagnosis of substance abuse and/or mental health disorder. Two studies are presented. The first was aimed at describing long-term outcome of a sample of individuals (N= 51) served by the New York State Department of Health TBI Medicaid Waiver Program. Each of the participants was diagnosed with TBI plus either substance abuse or a mental health disorder, or both. Because of significant behavioural challenges, all of the participants were in a restrictive living setting the year before enrolment in the waiver program (e.g., nursing or correctional facility). Data on community living arrangement, self-reported community integration experiences, and costs are presented. Results indicate that most of the participants (41 of the 46 who were alive and living in state) continued to live in the community 8 to 9 years after commencement of community support services. The participants' community integration responses were generally positive and cost data demonstrate substantial savings to the state for this cohort. Comparing prewaiver costs in residential settings with most recent (2005) costs for community supports, there was an average daily cost savings of US$137 per person for the 1996 cohort and US$144 per person for the 1997 cohort. The second study explored the use of project-oriented interventions and supports in an agency that provides community support services to this dual diagnosis population. Project-oriented services are described as meeting many needs common to this dual-diagnosis population. Clinical staff (N= 11) and a sample of waiver participants (N= 7) were surveyed. Results suggest that the use of personally meaningful projects can become a clinical habit for staff and that projects are generally judged by participants to be a meaningful use of time, and significant in giving them an opportunity to play an expert role and to help others.

Improving the Safety Net for Single Mothers Who Face Serious Barriers to Work

Rebecca Blank explores a weakness of the welfare reforms of the mid-1990s--the failure of the Temporary Assistance to Needy Families program to address the plight of so-called "hard to employ" single mothers and their children. TANF has moved many women on the welfare caseload into work, but the services it provides are not intensive or flexible enough to meet the needs of women with multiple disadvantages who find it difficult to get and keep full-time employment. Blank notes that many of these women have lost welfare benefits because of their failure to find work. Increasingly, studies show that the number of single mothers who are neither working nor on welfare has grown significantly over the past ten years. Such "disconnected" women now make up 20 to 25 percent of all low-income single mothers, and reported income in these families is extremely low. Disconnected women are likely to report multiple and serious barriers to work, including low education, learning disabilities, health problems, or a history of domestic violence or substance abuse. Counting both longer-term welfare recipients and women who are neither working nor on welfare, Blank estimates that about 2.2 million women who head families are not able to find jobs or, if they do, cannot keep them. And almost 4 million children are in the care of these severely challenged single mothers. Blank proposes a Temporary and Partial Work Waiver Program to provide more effective employment assistance and other supports for these women and their children. The program she proposes would recognize that some women might be able to work only part-time or be temporarily unable to work. It would supplement their earnings while also offering referral to services that both address their own work barriers and provide help for their children. The support, however, would be temporary. Women would be regularly reassessed for their readiness to return to work or work more hours. Such a program, Blank notes, would require intensive case management. Estimating the cost of such a program is difficult, she explains, because costs would depend heavily on the number of women who participate. But she offers a rough estimate of $2.8 billion, some of which is already being spent as part of the current TANF program.

Public Health and the Conrad Visa Waiver Program: How the Placement of Foreign-Born Doctors in Health Professional Shortage Areas is Helping to Mitigate the Effects of America's Growing Physician Shortfall

I estimate the effect, on age-adjusted and unadjusted death rates, of the placement of foreign-born physicians in Health Professional Shortage Areas through the Conrad State 30 program. Existing annual, county-level data on deaths, income, and the placement of Conrad physicians is collected for the years 1990- 2004 in Washington and Pennsylvania states. Ordinary least squares, difference-in-difference, robust regression, and fixed effects models are used to estimate the correlation between physician placement and county death rate. In Pennsylvania, Conrad physician placement in county x at time t is positively correlated with the death rate in county x at time t; in Washington, Conrad physician placement in county x at time t is negatively correlated with the death rate in county x at time t. The divergence of results is speculated to be due, among other factors, to differences in Conrad physician placement strategies and differences in the unobserved, state-specific methods of addressing counties' public health needs.

Effectiveness of a children’s home and community-based services waiver program

Limited alternatives exist to residential treatment or hospitalization for children with the most serious emotional disturbances. Community-based interventions are intended to offer less restrictive and expensive options than traditional treatment. One such program is New York State's Home and Community-Based Services (HCBS) Waiver Program. From 1996 to 2002, 169 children were enrolled in the Manhattan HCBS. All spent at least one month on the wait list prior to admission to the waiver program. We used our wait list as a control group (WLC), allowing for comparison of the HCBS intervention. Sample consisted of 169 children between the ages of five and eighteen. The ethnic composition was 46.8% Hispanic (N = 79), 47.9% African-American (N = 81), and 5.3% Caucasian (N = 9). Average stay was 12 months in the HCBS program and 3.5 months for the WLC. Only 30% of children in the WLC were maintained in the community, while 81% of children in the HCBS were similarly maintained (P < 0.001). Also, the rate of hospitalization for the HCBS group was significantly lower (3 versus 41%; P < 0.001). There was also a trend for the WLC group to have had substantially higher rates of removal by the Administration for Children's Services (New York City's protective service agency) (8.3 versus 1.8%) and to more frequently require residential treatment (13.0 versus 8.9%). It would seem that the HCBS program appears to be a clinically and cost-effective method of maintaining children in their community.

Estimates of pregnancies averted through California's family planning waiver program in 2002.

During its first year of operation (1997-1998), California's family planning program, Family PACT, helped more than 750,000 clients to avert an estimated 108,000 pregnancies. Given subsequent increases in the numbers of clients served and contraceptive methods offered by the program, updated estimates of its impact on fertility are needed. Claims data on contraceptives dispensed were used to estimate the number of pregnancies experienced by women in the program in 2002. Medical record data on methods used prior to enrollment were used to predict client fertility in the absence of the program. Further analyses examined the sensitivity of these estimates to alternative assumptions about contraceptive failure rates, contraceptive continuation and contraceptive use in the absence of program services. Almost 6.4 million woman-months of contraception, provided primarily by oral contraceptives (57%), barrier methods (19%) and the injectable (18%), were dispensed through Family PACT during 2002. As a result, an estimated 205,000 pregnancies-which would have resulted in 79,000 abortions and 94,000 births, including 21,400 births to adolescents-were averted. Changing the base assumptions regarding contraceptive failure rates or method use had relatively small effects on the estimates, whereas assuming that clients would use no contraceptives in the absence of Family PACT nearly tripled the estimate of pregnancies averted. Because all contraceptive methods substantially reduce the risk of pregnancy, Family PACT's impact on preventing pregnancy lies primarily in providing contraceptives to women who would otherwise not use any method.

Title X in California

In Estimates of Pregnancies Averted Through California's Family Planning Waiver Program in 2002 [2006, 38(3):126-131], Diana Greene Foster and colleagues discuss the many successes of California's Family PACT program. As the authors note, Family PACT (Planning, Access, Care and Treatment) funds services to eligible individuals with incomes up to 200% of the federal poverty level through a fee-for-service system that includes nearly 3,000 providers statewide who participate in Medi-Cal, California's Medicaid program. However, contrary to a statement made in the article, the Title X program in California is also a major source of support for services for needy men and women. Through community-based not-for-profit public and private providers at more than 300 sites, Title X funds clinical services for individuals with incomes up to 250% of the federal poverty level, as well as education and community outreach services not funded by any other public source. The increasing price of contraceptives and new contraceptive technologies, the rising cost of advanced diagnostic tests, the severe shortage of health care workers and the inadequate level of Medicaid reimbursements all contribute to gaps between costs and payments to providers. Title X, the last public source to which agencies can turn, helps to offset some of these service payment gaps. The value of the Title X dollars in California cannot be underestimated. Although the state is home to nearly 11% of the U.S. population, it receives less than 8% of the national Title X grant. Still, the California Title X program serves more than 790,000 women and men-or roughly 15% of all those receiving care through Title X nationally-each year. The program serves more men than any other Title X program in the United States, and a higher proportion of Title X clients in California than elsewhere are men. Through its collaborative effort with Family PACT, California averted more than 200,000 unplanned pregnancies in 2002, as Foster and her colleagues point out.1 Yet, even with the waiver program, only 56% of women in need of publicly funded family planning services were served in FY 2004-2005.2 The unmet need is large, and the possibilities for even more dramatic results are significant. California has made family planning a priority, and its efforts have paid off in dramatic reductions in teenage pregnancy rates and in the number of unplanned pregnancies. I regret that Title X's important role in achieving these remarkable results was not communicated clearly in the Foster article.

Aging in Place? Evidence That a State Medicaid Waiver Program Helps Frail Older Persons Avoid Institutionalization

ABSTRACT Long-term care will increasingly shift from institutions to home and community based services. Using data from a Medicaid home care waiver program in South Carolina, the Community Long-Term Care (CLTC) program, we evaluated differences in frailty and service use among CLTC clients between 1995 (n = 3,748) and 2005 (n = 9,157). The expectation was that CLTC clients had become more frail in that period, and had greater access to services in the community, results that might suggest the CLTC program had helped individuals to avoid institutionalization. Frailty measures included acute and chronic conditions, other health conditions, and activities of daily living (ADL). We evaluated the percentage of clients using services, and service use intensity. A large majority of clients in both years were impaired in at least four ADL. In 2005, CLTC clients were significantly more likely to have chronic conditions, including hypertension, chronic obstructive pulmonary disease, Alzheimer's disease, arthritis, diabetes, and renal failure (all p < 0.05). Clients were significantly more likely to receive specific services in 2005, including physical therapy, dialysis, and oxygen (all p < 0.05). Results suggest CLTC participants were more frail in 2005 than in 1995. This may reflect a successful effort to help individuals age in place in the community, delaying institutionalization. States may be able to control increases in Medicaid long-term care costs through home care programs that delay institutionalization.

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

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

Estimates of Pregnancies Averted Through California's Family Planning Waiver Program in 2002

CONTEXT: During its first year of operation (1997-1998), California's family planning program, Family PACT, helped more than 750,000 clients to avert an estimated 108,000 pregnancies. Given subsequent increases in the numbers of clients served and contraceptive methods offered by the program, updated estimates of its impact on fertility are needed. METHODS: Claims data on contraceptives dispensed were used to estimate the number of pregnancies experienced by women in the program in 2002. Medical record data on methods used prior to enrollment were used to predict client fertility in the absence of the program. Further analyses examined the sensitivity of these estimates to alternative assumptions about contraceptive failure rates, contraceptive continuation and contraceptive use in the absence of program services. RESULTS: Almost 6.4 million woman-months of contraception, provided primarily by oral contraceptives (57%), barrier methods (19%) and the injectable (18%), were dispensed through Family PACT during 2002. As a result, an estimated 205,000 pregnancies—which would have resulted in 79,000 abortions and 94,000 births, including 21,400 births to adolescents—were averted. Changing the base assumptions regarding contraceptive failure rates or method use had relatively small effects on the estimates, whereas assuming that clients would use no contraceptives in the absence of Family PACT nearly tripled the estimate of pregnancies averted. CONCLUSIONS: Because all contraceptive methods substantially reduce the risk of pregnancy, Family PACT'S impact on preventing pregnancy lies primarily in providing contraceptives to women who would otherwise not use any method.

Estimates of Pregnancies Averted Through California's Family Planning Waiver Program in 2002

CONTEXT: During its first year of operation (1997‐1998), California's family planning program, Family PACT, helped more than 750,000 clients to avert an estimated 108,000 pregnancies. Given subsequent increases in the numbers of clients served and contraceptive methods offered by the program, updated estimates of its impact on fertility are needed.METHODS: Claims data on contraceptives dispensed were used to estimate the number of pregnancies experienced by women in the program in 2002. Medical record data on methods used prior to enrollment were used to predict client fertility in the absence of the program. Further analyses examined the sensitivity of these estimates to alternative assumptions about contraceptive failure rates, contraceptive continuation and contraceptive use in the absence of program services.RESULTS: Almost 6.4 million woman‐months of contraception, provided primarily by oral contraceptives (57%), barrier methods (19%) and the injectable (18%), were dispensed through Family PACT during 2002. As a result, an estimated 205,000 pregnancies—which would have resulted in 79,000 abortions and 94,000 births, including 21,400 births to adolescents—were averted. Changing the base assumptions regarding contraceptive failure rates or method use had relatively small effects on the estimates, whereas assuming that clients would use no contraceptives in the absence of Family PACT nearly tripled the estimate of pregnancies averted.CONCLUSIONS: Because all contraceptive methods substantially reduce the risk of pregnancy, Family PACT'S impact on preventing pregnancy lies primarily in providing contraceptives to women who would otherwise not use any method.

Factors Associated With Self-Reported Elder Mistreatment in Iowa’s Frailest Elders

The purposes of this study were to determine associated characteristics of community-dwelling older persons, their access to care and social provisions, and self-reported elder abuse, and to assess how having help in completing a questionnaire affected these associations. A questionnaire was mailed to 1,017 randomly selected elders in the Iowa Medicaid Waiver Program. The overall prevalence of self-reported abuse was 20.9%. Fifty-nine percent of respondents had help completing the questionnaire. Abuse was associated with low social provisions, more emergency room visits, being alone, and not having enough money. For those having help completing the questionnaire, abuse was associated with older age, low social provisions, being alone, and not having enough money. For those having no help completing the questionnaire, abuse was associated with depression, being alone, more emergency room visits, and low social provisions. Among community-living elders needing services in their homes, the prevalence of abuse was higher than that found in general population studies.

Implications of Translating Research into Practice: A Medication Management Intervention

SUMMARY Through programs such as the Administration on Aging's Evidence-Based Prevention Initiative, researchers and practitioners are developing translational research studies seeking to implement rigorously tested, evidence-based interventions in new practice settings and evaluate the continuing effectiveness of these interventions. One such translational study is the Community-Based Medications Management Intervention (CBM Intervention), a collaborative effort to implement a medication management screening and intervention protocol in community-based waiver care management programs. The overall goals of the CBM Intervention are to implement an evidence-based medication management intervention in a California Medicaid waiver care management program, and to evaluate the effect of client-, intervention-, and organizational-level characteristics on resolving identified medication problems. This article presents the need for improved medication management in a frail, community-dwelling, older adult population and describes the CBM Intervention as an example of translating an evidence-based practice beyond its original efficacy trial in a home healthcare program into a care management program. It discusses critical factors involved in translating research into practice using a translational research framework, Promoting Action on Research Implementation in Health Services (PARIHS). Our experience suggests that although implementing research into practice can positively impact client care, professional skill enhancement and organizational effectiveness, this is very challenging work requiring signification facilitation for successful outcomes.

Strengthening Home and Community-Based Care Through Medicaid Waivers

States are increasingly using the Medicaid 1915c waiver program to provide community-based long-term care (LTC). We examined state predictors of waiver utilization and expenditures for waivers serving both older and working-age individuals. State level data for the period 1992 to 2001 were used to estimate random effects panel models. States with increased community-based care (e.g., home health agencies) and decreased nursing home bed capacity were positively associated with state per capita rates of use, expenditures, and the share of Medicaid LTC dollars supporting 1915c waivers. States appeared to substitute Medicare for Medicaid services for individuals eligible for both. State per capita income was positively related to each measure. State policies that facilitate decreased institutional and increased community-based capacity appear essential to state efforts to expand access to community-based services. Federal policies that address state resource issues may also spur growth in community-based LTC, which, in most states, continues to be limited.