Long-Term Services and Supports for Older Adults: A Review of Home and Community-Based Services Versus Institutional Care

The number of Americans needing long-term services and supports (LTSS) is projected to more than double in the coming decades largely due to an aging baby boomer population, meaning paying for LTSS will become an even greater challenge for American families and the country. Despite the benefits of aging in place, there remains a long-standing institutional bias within the Medicaid program, where services in nursing facilities are mandatory while home- and community-based services (HCBS) are mostly optional for states to cover. This study examined HCBS 1915(c) waivers ( n = 61 waivers) for older adults to categorize and compare service priorities. Findings revealed waivers for older adults were primarily focused on supporting individuals in their own homes to age in place. However, findings also revealed HCBS waivers are an underutilized mechanism for funding the LTSS of older adults. As states continue to deal with an increasing population of aging adults, with and without disabilities, the HCBS waiver option will continue to be an important component of a state’s service system.

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Promises and Pitfalls of Health Information Technology for Home- and Community-Based Services

Journal of Applied Gerontology ◽

10.1177/0733464820941364 ◽

2020 ◽

pp. 073346482094136

Author(s):

Sangeeta C. Ahluwalia ◽

Esther Friedman ◽

Daniel Siconolfi ◽

Debra Saliba ◽

Jessica Phillips ◽

...

Keyword(s):

Information Technology ◽

Health Information Technology ◽

Health Information ◽

Service Agency ◽

Community Based ◽

Incentive Program ◽

Services And Supports ◽

Consumer Advocates ◽

Community Based Services

Background: Health information technology (HIT) use in home- and community-based services (HCBS) has been hindered by inadequate resources and incentives to support modernization. We sought to understand the ways the Medicaid Balancing Incentive Program (BIP) facilitated increased use of HIT to increase access to HCBS. Method: Qualitative analysis of interviews with 30 Medicaid administrators, service agency providers, and consumer advocates. Results: Although stakeholders perceived several benefits to greater HIT use, they highlighted critical challenges to effective adoption within the long-term services and supports (LTSS) system, including lack of extant expertise/knowledge about HIT, the limited reach of HIT among rural and disabled beneficiaries, burdensome procurement processes, and the ongoing resources required to maintain up-to-date HIT solutions. Conclusion: The structural reforms required by BIP gave states an opportunity to modernize their HCBS systems through use of HIT. However, barriers to HIT adoption persist, underscoring the need for continued support as part of future rebalancing efforts.

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CHANGES OF THE ORGANIZATIONS, PROVIDING SOCIAL SERVICES, IN THE CONTEXT OF DEINSTITUTIONALIZATION

SOCIETY INTEGRATION EDUCATION Proceedings of the International Scientific Conference ◽

10.17770/sie2018vol1.3390 ◽

2018 ◽

Vol 1 ◽

Author(s):

Janina Čižikienė ◽

Audronė Urmanavičienė

Keyword(s):

Social Services ◽

Inpatient Care ◽

Institutional Care ◽

Developed Countries ◽

Community Based ◽

Term Care ◽

Expert Interview ◽

The Individual ◽

Community Based Services

The challenges of globalization are the reason why the EU countries are looking for the ways to make the provision of social services most effective and best fitted to the customer’s needs. In 1960s, deinstitutionalization processes started to take place in many developed countries with the aim to reduce the inpatient care and to develop the community-based services. Deinstitutionalization is replacement of inpatient care with the services that are more in line with the individual interests of each customer. Currently, it is essential in Lithuania, where institutional care is widespread, and the services, provided in the institutions, are ineffective due to their depersonalization, strict procedure, and work with a group of the customers. They are not adapted to individual needs of a person, however, the main services that have no alternatives and are required for long-term care of the persons with intellectual disabilities, mental disorders, and for children, left without parental care, remain. The following research methods were applied: analysis of scientific literature and documents, expert interview, analysis and interpretation of the research results. The review of literature and the research data, presented in the article, reveal the issues of deinstitutionalization process of the organizations, providing social services, as well as the challenges faced in reorganization of children’s care homes.

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Predictors of Nursing Facility Entry by Medicaid-Only Older Adults and Persons With Disabilities in California

INQUIRY The Journal of Health Care Organization Provision and Financing ◽

10.1177/0046958018768316 ◽

2018 ◽

Vol 55 ◽

pp. 004695801876831 ◽

Cited By ~ 1

Author(s):

Michelle Ko ◽

Robert J. Newcomer ◽

Charlene Harrington ◽

Denis Hulett ◽

Taewoon Kang ◽

...

Keyword(s):

Older Adults ◽

Institutional Care ◽

Nursing Facilities ◽

Medicare Beneficiaries ◽

Nursing Facility ◽

Persons With Disabilities ◽

Cognitive Limitations ◽

Substance Abuse Disorders ◽

Services And Supports

Nearly one-third of adult Medicaid beneficiaries who receive long-term services and supports (LTSS) consist of older adults and persons with disabilities who are not eligible for Medicare. Beneficiaries, advocates, and policymakers have all sought to shift LTSS to home and community settings as an alternative to institutional care. We conducted a retrospective cohort study of Medicaid-only adults in California with new use of LTSS in 2006-2007 (N = 31 849) to identify unique predictors of entering nursing facilities versus receiving Medicaid home and community-based services (HCBS). Among new users, 18.3% entered into nursing facilities, whereas 81.7% initiated HCBS. In addition to chronic conditions, functional and cognitive limitations, substance abuse disorders (odds ratio [OR] 1.35; 95% confidence interval [CI]: 1.23, 1.48), and homelessness (OR: 4.35, 9% CI: 3.72, 5.08) were associated with higher odds of nursing facility entry. For older adults and persons with disabilities covered by Medicaid only, integration with housing and behavioral health services may be key to enabling beneficiaries to receive LTSS in noninstitutional settings.

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Day Habilitation Services for People With Intellectual and Developmental Disabilities in Medicaid Home and Community-Based Services Waivers

Research and Practice for Persons with Severe Disabilities ◽

10.1177/1540796916664337 ◽

2016 ◽

Vol 41 (4) ◽

pp. 244-255 ◽

Cited By ~ 5

Author(s):

Carli Friedman

Keyword(s):

Developmental Disabilities ◽

Service Utilization ◽

Fiscal Year ◽

Intellectual And Developmental Disabilities ◽

Community Based ◽

Total Spending ◽

Day Habilitation ◽

Services And Supports ◽

Community Based Services

Medicaid Home and Community-Based Services (HCBS) 1915(c) waivers are one of the largest providers of long-term services and supports for people with intellectual and developmental disabilities (IDD). HCBS waivers also play a prominent role in providing day habilitation services for people with IDD. The purpose of this study was to examine how HCBS waivers allocate day habilitation services for people with IDD. HCBS waivers providing day habilitation services for people with IDD were analyzed to determine service utilization and projected expenditures. In fiscal year 2014, HCBS waivers projected US$5.62 billion of funding for day habilitation services; however, there was wide variance across services in terms of projected total spending, spending per participant, and reimbursement rates.

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Factors Explaining State Differences in Applying for a Recent Long-Term Care Program that Promotes Aging in Place: Perspectives of Medicaid Administrators

Journal of Applied Gerontology ◽

10.1177/0733464820924510 ◽

2020 ◽

pp. 073346482092451

Author(s):

Esther M. Friedman ◽

Regina A. Shih ◽

Sangeeta C. Ahluwalia ◽

Virginia I. Kotzias ◽

Jessica L. Phillips ◽

...

Keyword(s):

Long Term Care ◽

Aging In Place ◽

Care Program ◽

Community Based ◽

Term Care ◽

Incentive Program ◽

Policy Goals ◽

Services And Supports ◽

Community Based Services

Older adults in need of assistance often prefer to remain at home rather than receive care in an institution. To meet these preferences, Medicaid invited states to apply for the Balancing Incentive Program (BIP), a program intended to “rebalance” Medicaid-financed long-term services and supports to Home- and Community-Based Services (HCBS). However, only about half of eligible states applied. We interviewed Medicaid administrators to explore why some states applied for BIP whereas others did not. Supportive state leadership and the presence of other programs supporting community-based care were positively related to BIP application. Opposing policy priorities and programs competing for similar resources were negatively related to BIP application. Because states most likely to apply already had policy goals and programs supporting HCBS, BIP may inadvertently widen disparities across states, pushing those on the margins ahead and leaving the ones that are worst off in HCBS support to fall even further behind.

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A National Analysis of Medicaid Home and Community Based Services Waivers for People With Intellectual and Developmental Disabilities: FY 2015

Intellectual and Developmental Disabilities ◽

10.1352/1934-9556-55.5.281 ◽

2017 ◽

Vol 55 (5) ◽

pp. 281-302 ◽

Cited By ~ 17

Author(s):

Carli Friedman

Keyword(s):

Developmental Disabilities ◽

National Level ◽

Intellectual And Developmental Disabilities ◽

Community Based ◽

Day Habilitation ◽

Services And Supports ◽

National Analysis ◽

Regulation Changes ◽

Community Based Services

Abstract Medicaid Home and Community Based Services (HCBS) 1915(c) waivers are the largest source of funding for the long term services and supports of people with intellectual and developmental disabilities (IDD). National-level analyses of HCBS IDD waivers are crucial because of the large variance across states, the recent CMS rule and regulation changes (CMS 2249-F/2296-F), and the ever changing economic and political landscape. Therefore, the aim of this study was to examine state waiver priorities for people with IDD. In FY 2015, 111 waivers projected spending $25.6 billion for approximately 630,000 people with IDD. The services with the most funding were residential habilitation, supports to live in one's own home, and day habilitation. However, our analysis revealed large discrepancies across states and services.

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Stakeholders’ Home and Community Based Services Settings Rule Knowledge

Research and Practice for Persons with Severe Disabilities ◽

10.1177/1540796917743210 ◽

2017 ◽

Vol 43 (1) ◽

pp. 54-61

Author(s):

Carli Friedman

Keyword(s):

Community Integration ◽

People With Disabilities ◽

Medicaid Program ◽

Community Based ◽

Transition Plans ◽

Rule Knowledge ◽

Key Stakeholders ◽

Services And Supports ◽

Community Based Services

Medicaid Home and Community Based Services (HCBS) waiver programs provide the majority of long-term services and supports for people with intellectual and developmental disabilities (IDD). Relatively new (2014) HCBS rules (CMS 2249-F/2296-F) governing these programs require meaningful community integration of people with disabilities who receive services under this Medicaid program. States are required to develop and submit transition plans, which document how their programs will meet the so-called settings rules. Public comment periods provide advocates the opportunity to impact states’ rules by ensuring that plans are truly community based. Yet the lengthy and technical description of the rules may be inaccessible for people with disabilities and their allies. Because knowledge of the HCBS settings rules can be crucial for people with IDD to enable them to access their rights, the aim of this study was to explore HCBS settings rules knowledge of people with IDD and key stakeholders. Our findings confirmed that there is a need to make the HCBS settings rules more accessible to those most affected by the changes—people with IDD and family members of people with IDD. Doing so is a necessary first step to promote advocacy regarding its implementation.

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Community-Based Services for People With Brain Injury: A National Analysis

Rehabilitation Research Policy and Education ◽

10.1891/2168-6653.32.2.123 ◽

2018 ◽

Vol 32 (2) ◽

pp. 123-138 ◽

Cited By ~ 3

Author(s):

Carli Friedman ◽

Laura VanPuymbrouck

Keyword(s):

Brain Injury ◽

Underserved Populations ◽

Fiscal Year ◽

Community Based ◽

Institutional Settings ◽

Services And Supports ◽

National Analysis ◽

Community Based Services

Purpose:Where and how rehabilitation and long-term services and supports (LTSS) occur for individuals with brain injury (BI) has shifted dramatically over the last few decades. Medicaid Home and Community Based Services (HCBS) 1915(c) waivers allow states to offer LTSS that is tailored to the needs of underserved populations in the community rather than institutional settings.Method:This study examined how states utilized waivers to provide for people with BI.Results:Findings revealed only 15 states had waivers for people with BI in fiscal year 2016.Conclusions:Of those waivers for people with BI, there were vast differences across states and services.

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A Comparative Case Study Analysis of Barriers and Facilitators to Implementing the Affordable Care Act’s Balancing Incentive Program

Research on Aging ◽

10.1177/01640275211020795 ◽

2021 ◽

pp. 016402752110207

Author(s):

Lisa Kalimon Beauregard ◽

Edward Alan Miller

Keyword(s):

Older Adults ◽

Comparative Case Study ◽

Persons With Disabilities ◽

Case Study Analysis ◽

Incentive Program ◽

Federal Revenue ◽

Services And Supports ◽

Community Based Services

The Affordable Care Act included the opportunity for states to increase spending on Medicaid home and community-based services (HCBS) for older adults and persons with disabilities through the Balancing Incentive Program (BIP). This study utilized comparative case studies to identify the factors that facilitated or impeded states’ implementation of BIP. Findings indicate factors that facilitated the implementation of BIP were communication with the federal government and its contractor, merging BIP with existing HCBS programs, and enhanced federal revenue. On the other hand, the short duration of BIP, state procurement and contracting processes, and the need to incorporate feedback from non-governmental stakeholders and determining how to spend the enhanced revenue proved challenging for some states. This research suggests ways federal and state officials can implement new initiatives to achieve greater rebalancing of Medicaid long-term services and supports for older adults.

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