Evaluation of Kentucky's Medicaid Home and Community-Based Waiver Program

This paper discusses a model for evaluating the access, cost-effectiveness and quality of services rendered under home and community-based long-term care demonstration projects. Methodology issues and data collection issues are discussed for these three aspects being evaluated in Kentucky's Medicaid Home and Community-Based Waiver.     

Explaining the Diffusion of Medicaid Home Care Waiver Programs Using VPRS Decision Rules

While public preferences and legal decisions require extended Medicaid Home and Community-Based Services (HCBS), uneven program development is a major concern of policy makers and consumers. This paper presents the first Variable Precision Rough Sets (VPRS) analysis of national data to examine inter-state variation in the Medicaid HCBS waiver program. The exposition provides a detailed discussion of the methodological options and processes, tests the generated rules using a leave-one-out cross-validation, and compares VPRS classification accuracy with regression analyses of the same dataset. The results demonstrate that VPRS offers a robust method with two distinctive features for health care research. First, for policy makers and their audiences, VPRS results are presented as "if...then..." decision rules with likelihoods stated as percentages. Because this output form can be easily understood by non-specialists, the potential impact of research is enhanced. Second, for analysts generating evidence for health policy, VPRS provides a rigorous data mining tool and acknowledges inherent analytical uncertainty in the field.     

Experiences of individuals self-directing Medicaid Home and Community-Based Services during COVID-19

BackgroundIn response to COVID-19, many state Medicaid Home and Community-Based Services (HCBS) programs increased flexibilities and options for self-direction.ObjectiveOur study sought to investigate the experiences of individuals self-directing during COVID-19. In particular we explored the following areas: 1) How have individuals maintained access to HCBS and workers?; 2) how have individuals maintained safety against COVID-19?; and 3) how have individuals maintained their health and well-being?MethodsWe partnered with community-based and national disability organizations for recruitment. We used a semi-structured interview guide to conduct remote interviews with 36 individuals from eleven states. The sample was diverse with regard to age, race/ethnicity, gender, and disability type.ResultsThree main themes emerged related to maintaining access to HCBS and direct care workers: 1) Benefits of authority to hire and fire; 2) benefits of ability to hire family members; and 3) fluctuations in needs and availability of workers. Two themes emerged related to maintaining safety against COVID-19: 1) Strategies for staying safe with workers; and 2) barriers in public health and service system response. Three themes emerged related to maintaining health and well-being: 1) Barriers to basic needs; 2) delaying needed care; and 3) use of telehealth and technology.ConclusionsThis study was among the first to examine the experiences of individuals self-directing their HCBS during COVID-19. The flexibility of the model provided many benefits, which have implications for future policy and practice. Findings also highlight barriers in maintaining health and well-being during COVID-19, illustrating the importance of planning for future public health emergencies.     

Local Medicaid Home- and Community-Based Services Spending and Nursing Home Admissions of Younger Adults

We used fixed-effect models to examine the relationship between local spending on home- and community-based services (HCBSs) for cash-assisted Medicaid-only disabled (CAMOD) adults and younger adult admissions to nursing homes in the United States during 2001 through 2008, with control for facility and market characteristics and secular trends. We found that increased CAMOD Medicaid HCBS spending at the local level is associated with decreased admissions of younger adults to nursing homes. Our findings suggest that states’ efforts to expand HCBS for this population should continue.Since the 1999 Olmstead decision,1 there has been a number of initiatives aimed to provide individuals with disabilities increased access to long-term care (LTC) options, primarily through expansion in home- and community-based services (HCBSs). Although research has investigated the effect of HCBS growth on the Medicare population of nursing home residents,2–9 there has been little attention given to the relationship between younger nursing home residents and Medicaid HCBS expenditures. As states face growing pressure in how to best allocate their Medicaid budgets, it is important that we have sound research guiding these decisions.Recently, a published study suggested that younger adults’ rates of nursing home admission were not related to Medicaid HCBS spending.10 Two prominent limitations may have led to this null finding: (1) rather than measuring spending for younger adults, the 2011 study used total state Medicaid LTC spending, and (2) the analyses were conducted at the state level, thereby missing market and facility characteristics influencing this relationship. We reexamined this question by using more refined data: Medicaid LTC spending on cash-assisted Medicaid-only disabled (CAMOD) adults at the local level and nursing home admission assessment data aggregated to the facility level. We hypothesized that increasing investment in Medicaid HCBSs for CAMOD adults would be related to a decrease in the share of younger adult nursing home admissions.     

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

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

Results of the assessment of Kentucky's Medicaid home- and community-based services waiver

In states where a Home- and Community-based Services Waiver is operating under the Medicaid program, HCFA requires an independent assessment of the program. This paper reports on two assessments of the costs and use of services under Kentucky's HCBS waiver: one comparing waiver clients to a matched control group of regular Medicaid home health clients, and the other comparing elderly female waiver clients to a matched control group from nursing homes. Analyses of costs and use of home health services, hospital care, physician services, nursing home admission, and other services showed little difference between waiver clients and control groups. Waiver clients used more home health, but used other services at the same rate. Their costs were lower overall.     

Assuring quality care: exploring strategies of Medicaid E&D Waiver providers

Implementing quality assurance (QA) programs in unregulated non-institutional settings remains a challenge for home- and community-based service providers. A sample of 65 Elderly and Disabled (E&D) Waiver providers were presented with eight problem scenarios commonly found in homecare services. Each of the respondents was able to identify strategies they would use to recognize and address each problem. Findings suggest providers currently use multiple mechanisms as part of their overall QA program. Discussion focuses on the strengths of using multiple approaches and on increasing provider awareness of complementary QA strategies and reducing the reliance on staff report as a major QA strategy.     

The limits of Medicaid reimbursement incentives. An evaluation of the Florida AIDS Nursing Home Admission Program

Provider incentive payments in the Medicaid program have been in operation nationally since the early 1980s. Although initially indicating favorable results, recently the ability of such incentives to produce the desired action has been questioned. This study examined the Florida Medicaid AIDS Nursing Home Admission Incentive Program to determine the reasons behind the program's apparent inability to increase Medicaid-covered persons with AIDS (PWAs) admissions to nursing homes. A survey of 308 nursing homes in the 10 Florida counties with the highest cumulative AIDS cases in the state was conducted. The results reveal that (a) the level of incentive reimbursement received, (b) the financial classification of existing (non-AIDS) residents, and (c) the level of technological sophistication of the facility are all significantly related to the number of PWAs admitted. Based on these results, the author discusses implications for the future of Medicaid incentive programs for PWAs.     

Longitudinal Differences in Pain Among Older Adult Home and Community Based Waiver Program Participants in Relation to Diagnosis of Cancer

Generalized estimating equation analyses models were used to examine the longitudinal association between pain and diagnosis of cancer among older adult, Home and Community Based Waiver Program participants. Daily pain was reported by over half, with 29% experiencing daily pain that was unusually intense. Diagnosis of cancer was a significant predictor of daily pain only as an interaction term with cognitive impairment. Being female, having a medical diagnosis of depression, or increasing measure of comorbid conditions significantly increased the likelihood of daily pain. In comparison, increasing age, being of African American, Hispanic, or “other” race resulted in a significantly decreased likelihood of daily pain.     

Economic Impact of the Critical Access Hospital Program on Kentucky's Communities

Context: In 1997, the Medicare Rural Hospital Flexibility Grant Program created the Critical Access Hospital (CAH) Program as a response to the financial distress of rural hospitals. It was believed that this program would reduce the rate of rural hospital closures and improve access to health care services in rural communities. Objective: The objective of this paper is to analyze the economic impact of the CAH Program on Kentucky's communities. Methods: Both an economic input‐output model and a quasi‐experimental control group method are used in this research paper. While the analysis using the input‐output model uses data from the year 2006, the analysis using the quasi‐experimental control group method uses data from 1989 to 2006. Conclusion: The results indicate that the rural counties where a CAH was adopted did appear to benefit in economic terms relative to those that did not have a CAH.     

Evaluation of an Asthma Disease Management Program in a Medicaid Population

In 2002, an asthma disease management program was initiated in Washington State in the US. The program was designed for clients of the state’s Medicaid program, which provides health coverage for qualified low-income state residents. In response to the escalating cost of healthcare and because of concerns about the quality of care, the Washington State Legislature mandated implementation of this disease management program as a pilot project to assist individuals to improve their health. Medicaid administrators used a carefully designed process to identify client needs and to obtain proposals for disease management programs.The asthma program seeks to narrow the gap between the standards of care and its practice. In particular, the program aims to provide patients with a richer understanding of asthma and how to control it. This is accomplished through disease education, symptom awareness and management, trigger avoidance, self-monitoring, and education on recommended medication strategies. The program is based on the US National Institutes of Health’s published guidelines on the optimal treatment of asthma.Enrollment of Medicaid clients into the asthma program began in April 2002. This article describes three approaches to evaluation of the first 3 years of the program: (i) 3 years of self-reported client data; (ii) an independent evaluation of the first year’s changes in utilization and quality of care; and (iii) an actuarial analysis of cost effectiveness. The first study used vendor-reported data collected during initial and follow-up assessments. The authors of this first study also reported the results of a satisfaction survey conducted on behalf of the vendor. The independent evaluation conducted by the University of Washington relied on medical record review and claims analysis, and reported statistical analysis of pre/post comparisons. The actuarial study also reported pre/post comparisons using an analysis of claims per member per month in periods before the program started and at 1 and 2 years of program operations.Clients were assessed according to several dimensions of health including self-management, symptoms, functional status, medication management, and trigger management. Numerous interventions were provided to study participants including access to round-the-clock telephone consultation with a registered nurse, self-care education, alerts sent to the primary provider, and symptom issue follow-up. The asthma disease management program outcomes provide evidence of initial success for those clients who completed the reassessment process. The results of the first 3 years of participation in the program indicate trends toward improved health status and client satisfaction with the program. Long-term evaluation will be necessary to determine if the program reduces costs and closes the quality chasm. If successful, this program could serve as a model for programs with similar clients and similar challenges.     

Older Americans Act Nutrition Programs: A Community-Based Nutrition Program Helping Older Adults Remain at Home

Nutrition interventions are important as the older population, most of whom live in the community, increases in size and diversity. They are key to leading a healthy, functional life and mitigating chronic health conditions. The Older Americans Act Nutrition Program served 86.3 million congregate and 137.4 million home-delivered meals to 1.6 million and 850,000 older adults, respectively (2012). Congregate and home-delivered participants were older, poorer, sicker, more functionally impaired, and at a greater risk of institutionalization than the general U.S. older population. The Nutrition Program is publically and privately funded. About 44% of congregate and 30% of home-delivered expenditures are from federal sources, which dropped from $25 per older adult in 1990 to $12 in 2013. Despite multiple funding sources, funding is insufficient for the expanding older population. Health, nutrition, and social service professionals need to coordinate their community-based services to truly help older adults remain in their homes.     

State Medicaid Home Health Licensing and Certification

ABSTRACT

This study collected and analyzed data on the number of licensed and certified home health care agencies and licensed home care/personal care agencies in the US. The study also examined the state laws and regulations pertaining to Medicaid home health agency requirements. There were 14,045 licensed home health agencies and 801 other licensed home care or personal care agencies in the US, but only 59 percent of these agencies were certified in 1998. The percent of certified agencies ranged from 22 percent in Maryland to 100 percent in ten states that only allowed certified agencies to provide home care. There was a wide range in the number of agencies in states with the average being 6.1 agencies per 100,000 population. The 41 states with state licensing of home health agencies had a wide range of policies but most were more lenient than the federal Medicare certification requirements.     

Predictors of Frailty Change in Home and Community-Based Services Populations

ObjectivesWith unprecedented demand for Medicaid long-term services and supports, states are seeking to allocate resources in the most efficient way. Understanding the prevalence of frailty and how it varies across home and community-based services (HCBS) populations can assist states with more precise identification of individuals most in need of services. Early identification of individuals more likely to experience frailty changes could allow for enhanced care planning to prevent or slow the progression of decline.DesignLongitudinal study.Setting and ParticipantsData from Connecticut’s assessment tool (based on interRAI-HC) were analyzed at 2 time points for 16,309 individuals receiving HCBS. The sample included assessments completed between November 1, 2017 and July 15, 2020 across 4 groups: older adults 65+ years old meeting nursing facility level of care (NF LOC), older adults 65+ years old not meeting NF LOC, individuals with acquired brain injury, and individuals <65 years old with physical disability.MethodsWe measured frailty using the Frailty Index (FI) and examined change in FI between baseline and follow-up. A change in FI score of at least ±0.03 was classified as a clinically meaningful change. We compared predictors of clinically meaningful decline or improvement using multivariate logistic regression.ResultsIn our sample, 54% of individuals experienced a clinically meaningful change: 42% declined and 12% improved. Individuals receiving in-home care services had lower odds of improvement across all HCBS groups and multiple frailty categories with odds ratios ranging from 0.35 to 0.68. Frail older adults 65+ years old meeting nursing facility level of care receiving physical therapy were 21% less likely to experience decline and 1.4 times more likely to improve.Conclusions and ImplicationsThe nature of HCBS support provided can impact changes in frailty status. More reactive services such as in-home care may contribute to frailty decline while rehabilitative services such as physical therapy may protect against decline.