Waiver Services Research Articles

Transportation for people with intellectual and developmental disabilities in Home- and Community-Based Services

BackgroundTransportation can help improve the health, quality of life, and community integration of people with intellectual and developmental disabilities (IDD). Yet, transportation is one of people with IDD's most common unmet needs. ObjectiveThe aim of this study was to examine if, and, how, states provide non-medical transportation to people with IDD in their Medicaid HCBS programs. MethodsUsing content analysis and descriptive statistics, this study analyzed fiscal year (FY) 2021 Medicaid HCBS 1915(c) waivers for people with IDD from across the nation to examine how they allocated transportation. ResultsIn FY 2021, all 44 states and the District of Columbia with HCBS waivers for people with IDD provided transportation services. Transportation was included either by providing a stand-alone service that exclusively provided transportation, or by being embedded within another service. Transportation was embedded within 896 different HCBS services for people with IDD, most commonly within residential habilitation services (26.70 %), supported employment services (19.44 %), and day habilitation (18.44 %). Thirty-three states (73.33 %) also provided 145 different stand-alone transportation services in their programs for people with IDD, to increase community integration and help people gain access to waiver services. A total of $781.78 million of spending was projected for stand-alone transportation services for 261,109 people with IDD (30.32 % of waiver recipients). ConclusionsHCBS waivers are an important resource for providing transportation for people with IDD. However, significant variation in how states do so may result in disparities or unmet needs.

Medicaid long-term services and supports and caregiving needs of caregivers of individuals with intellectual and developmental disabilities.

Long-term care services are funded primarily by Medicaid long-term services and support in the United States, where eligibility is based on care needs of the individual with intellectual and developmental disability alone. Impact of Medicaid waiver services on self-reported caregiver needs is not well understood. Caregivers (n = 405) of individuals with intellectual and developmental disabilities across four states (NY, OH, TX, and PA) completed an online survey. Caregivers reported a moderate degree of burden and susceptibility of stress-induced health breakdown. Despite controlling for the activities of daily living of the care recipient, caregivers of individuals with Medicaid Waiver services reported greater difficulty managing medications (p = .013) and finding paid help (p < .001) than caregivers of individuals without services.

The least developed countries' Services Waiver, Aid for Trade for services and services exports

AbstractIn 2011, Trade Ministers of the World Trade Organisation (WTO) adopted a Decision that allows WTO Members to accord preferential treatment to services and service suppliers originating in least‐developed countries (LDCs). In 2013, another Ministerial Decision was adopted to operationalise the 2011 Waiver Decision. This paper has examined whether the Waiver Decision had been effective in promoting LDCs' commercial modern and traditional services exports and whether Aid for Trade (AfT) flows in favour of the services sectors were instrumental in achieving this objective. The analysis has used 43 LDCs over the period 2005–2018 and the difference‐in‐difference framework along with the two‐step system generalised method of moments estimator. The control group includes 20 Low‐Income Countries (designated as such by the International Monetary Fund) from which LDCs (as defined by the United Nations) are excluded. The analysis has revealed that the Waiver Decision led to higher modern commercial services exports at the expense of traditional commercial services exports. Moreover, as LDCs improved their trading capacity over time (thanks to the cumulative AfT flows for services), the Waiver Decision induced greater modern commercial services exports, but exerted a mixed effect on LDCs' traditional services exports.

Implementasi Beracara Secara Prodeo di Pengadilan Negeri Meulaboh

Court fee waiver services (Prodeo) for the underprivileged, as stipulated in the Supreme Court Regulation of the Republic of Indonesia No. 01 of 2014, is that any person or group of people who cannot afford it economically can do a case for free. At the Meulaboh District Court, prodeo cases did not work as they should, so the public did not know that free litigation services were available. This study aims to find out how the Prodeo trial procedure is, as well as the factors that cause the loss of Prodeo at the Meulaboh District Court. This study uses an empirical juridica method, to find out how efficiently the law works in society, government and legal entities. The use of Prodeo is only for underprivileged people by fulfilling the conditions that have been set and being able to follow all procedures in dealing with prodeo. The factor that causes the loss of Prodeo is due to the lack of isocialization specifically both directly and online media, this is what causes the public to not know about Prodeo cases and causes the loss of the Prodeo budget. keywords: Law, Prodeo, justice.

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

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

THE BLACK BOX OF CARE MANAGEMENT IN MANAGED LONG-TERM SERVICES AND SUPPORTS

Abstract Within Ohio’s MyCare demonstration, two distinct care management models were selected by the participating MyCare Ohio health plans (MCOPs): fully-delegated waiver care management and waiver service coordination. The purpose of this presentation is to describe the components of care management operating in MyCare Ohio. Qualitative interviews with n=91 Area Agency on Aging (AAA) and n=131 MCOP care management personnel were audio-recorded, transcribed, and checked for accuracy prior to thematic coding in Dedoose. Results indicate that comprehensive care management is the core element of MyCare Ohio. Fully-delegated care management models were viewed by participants as beneficial to reducing confusion for members however ‘scope creep’ challenged the already strained AAAs. Effective teamwork was identified for waiver service coordination models but the division of labor and communication needed between the AAA and MCOP care management personnel created tensions. The discussion will focus on practice recommendations for training, caseloads, and support staff.

State-level Medicaid 1915(c) home and community-based services waiver support for caregivers

BackgroundInformal caregivers encounter emotional distress, worsening personal health, and financial strain. The Medicaid 1915(c) Home and Community-Based Services (HCBS) waiver programs provide an array of services including support for caregivers. PurposeThis policy analysis examined Medicaid waiver services offered to persons 65 and older among the 50 states and District of Columbia (DC). MethodsData were obtained from Medicaid waiver applications for adults age 65 and older available at Medicaid.gov. Data elements included number of waiver programs and services for supporting caregivers. Descriptive statistics were applied. FindingsForty-three states including DC (84%) offered a Medicaid waiver for older adults; seven states (14%) offer two waiver programs; eight states (16%) had no Medicaid waiver. Payment to a relative or legal guardian caregiver was the most common service offered in 39 (76%) states. Other services included in-home respite care and adult day health care (35 states; 67%), out-of-home respite care (32 states; 63%), skilled nursing (28 states; 55%), paid spousal caregivers (18 states; 35%), caregiver training (15 states; 29%), and adult day care for socialization (7 states, 14%). DiscussionThis study identifies wide variability in caregiver support across state-based Medicaid waivers. Future research should evaluate effectiveness of the waiver programs in supporting caregivers and inform evidence-based policy advocacy for supporting caregivers.

Presidential Address: The Next Generation Workforce, A Call to Action

Presidential Address: The Next Generation Workforce, A Call to Action

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.

Key stakeholder perspectives on obstacles to an autism‐specific Medicaid waiver service delivery model

AbstractBackgroundChildren and youth with autism spectrum disorder have significant, multi‐system needs that require supports, such as the autism waiver (AW) service delivery model. This study aimed to identify and describe characteristics of the AW, define obstacles and strengths in the provision of adequate services and provide recommendations for improving overall effectiveness.MethodsThis mixed‐methods exploratory study used an electronic survey to gain information and perceptions of AW provider agency directors (n = 27) and service coordinators (n = 30).ResultsThe key barriers reported were the shortage of qualified staff, inadequate staff training, complexity of cases or symptom severity of clients and lack of communication at multiple levels throughout the agency as well as with parents.ConclusionsRecommendations include reinforcing the workforce through higher salaries, greater training and communication interventions. These strategies may reduce staff turnover and shortage, lighten the caseload, reduce the waitlist period and improve the effectiveness and responsiveness of AW services.

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.

Measuring and Tracking Personal Opportunity Outcome Measures Over 3 Years to Guide Policy and Services That Promote Inclusive Community Living

Abstract National policy and litigation have been a catalyst in many states for expanding personal outcomes for people with intellectual and developmental disabilities (IDD) and have served as an impetus for change in state IDD systems. Although several metrics are used to examine personal outcomes, the National Core Indicators (NCI) In-Person Survey (IPS) is one tool that provides an annual depiction of the lives of people who receive Medicaid Home and Community Based IDD waiver services (HCBS). This article examines whether a validated, three-factor (Privacy Rights, Everyday Choice, and Community Participation) measure of Personal Opportunity, derived from NCI items, functions as predicted across non-equivalent, NCI cohorts (N = 2400) from Virginia in 2017, 2018, and 2019. Multiple-groups confirmatory factor analysis (CFA) was employed to examine the invariance and generalizability of the Personal Opportunity constructs. Results indicated that Privacy Rights, Everyday Choice, and Community Participation measured the same concepts even when time and group varied. Significant improvements in Privacy Rights and Community Participation were observed when comparing latent factor means across years. Findings provide stakeholders with a tool for interpreting personal outcomes in the contexts of policy and practice intended to improve inclusion and quality of life for adults with IDD.

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.

Employment Equity for People With IDD Across the Lifespan: The Effects of State Funding.

In the last decade, major strides have been made to elevate the importance of employment for people with intellectual and developmental disabilities (IDD). Despite progress, improvement in employment outcomes remain modest. Using extant data, a sample of 9,871 adults with IDD accessing Medicaid Home and Community-Based Services waiver services across 33 states were studied using hierarchical modeling to understand the effects of age on employment as well as assess how state fiscal effort toward integrated employment services affects employment equity across the lifespan. Key findings showed young and older adults experienced the lowest employment outcomes. The effects of age, however, were moderated in states with higher fiscal effort to integrated employment services. Implications for research, policy, and practice are discussed.

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.

Using technology and remote support services to promote independent living of adults with intellectual disability and related developmental disabilities.

The use of remote support technologies is a newer form of service that can contribute to increased independence while giving adults with intellectual and developmental disabilities a sense of home safety. This research reviewed the use of remote support services, which is a waiver service that includes smart home technologies and remote support staff that can be called upon, when needed. Using focus groups and telephone interviews, the present authors asked users of remote support services about their experience, including what they liked most and least about their experience with these technologies. Overall, increased independence and a sense of security and home safety were identified as the two principal benefits. Remote support technologies may be a part of the solution to addressing the lack of direct support professionals available to provide in-home care. The present authors discuss the benefits of remote support technologies and offer recommendations for future research regarding remote support technologies and the potential benefits of this newer form of support service.

MANDATORY MEDICAID MANAGED LONG-TERM SERVICES AND SUPPORTS IN PENNSYLVANIA: EVALUATING POLICY CHANGE

The Commonwealth of Pennsylvania is implementing a mandatory Medicaid managed Long-Term Services and Supports (LTSS) program that covers people age 21 and older who are fully eligibly for both Medicare and Medicaid, living in a nursing facility paid for by Medicaid, or in an aged or physical disability home and community based services (HCBS) waiver. The overall program goals are to: Enhance Opportunities for Community Living; Improve Service Coordination; Enhance Quality and Accountability; Advance Program and Innovation; and Increase Efficiency. The program will be administered by 3 managed care organizations (MCOs) that are obligated to coordinate with Medicare Advantage and D-SNP plans. This major policy change affects the traditional roles and responsibilities of the aging network by shifting the locus of control to insurance companies. This presentation will describe the policy change, the implications for the aging network, and the multi-method evaluation designed to assess the implementation and outcomes.

Fiscal Stewardship, Choice, and Control: The Context of Self-Directed Services for People With Intellectual and Developmental Disabilities (IDD) in the United States.

Self-directed home and community based services (HCBS) waiver services and supports for people with intellectual and developmental disabilities (IDD) have become a viable and widely used method of service provision in the United States. Grounded in theories of self-determination, previous literature on self-direction has suggested high satisfaction and positive outcomes for people who use self-directed programs as well as cost savings for state IDD service systems. This study explored the ways in which state IDD service administrators think about how self-direction may be used as a method of achieving cost savings while providing opportunities for people with IDD and their families to exercise choice and control. Informed by 54 high-level IDD service administrators in 34 states, and guided by a thematic analysis approach to data interpretation, the study found evidence that administrators typically see strong potential for self-direction to have cost-savings benefits, while also fostering choice. In the current political climate, the need for cautious fiscal stewardship may become a stronger driving force behind self-direction for people with IDD in the United States.

The Role of Choice and Control in the Impact of Autism Waiver Services on Family Quality of Life and Child Progress.

Home and Community-Based Services (HCBS) Waivers provide support and services to families with a child/youth with autism spectrum disorder (ASD). Research indicates HCBS Waivers are positively related to family quality of life (FQoL) and Child Progress. This study replicated and expanded prior research using propensity score matching of 460 families. Results support prior findings that HCBS waivers have a positive impact on FQoL and aspects of child progress. This study also found that having choices in the selection of services and service providers, as well as control over day-to-day provision of services, strengthened both the child and family impacts of the Waiver services. In addition, the study provides preliminary evidence for psychometric properties of a quick and inexpensive parent-report of ASD severity.

Family perceptions of the impacts of a home and community based services autism waiver: Making family life possible.

An important mechanism that provides support and services for families with a child/youth with autism spectrum disorder is the home- and community-based services (HCBS) Waiver authorized by Section 1915(c) of the Social Security Act or Medicaid. This study used qualitative research methods to explore parent perspectives about the impact of HCBS Waiver services on the child/youth with autism and their family. In-depth interviews focused on aspects of the programme they valued, identification of barriers and general issues they experienced. Results of the qualitative study indicated that improved outcomes could be explained by providers of services who were well-trained, flexible and allowed parents' opportunities for choice regarding provision of services to meet child/youth and family needs. The findings of this study provide guideposts for further research about factors that contribute to satisfaction of families receiving waiver services for quality of life and child progress.