HCBS Program: Types, Impact & Future Developments

11 Jan 2022
Explore the evolution of the HCBS program, its impact, and the future of home and community-based services.

Understanding HCBS Programs

Understanding what HCBS programs are and their purpose is the first step in comprehending the impact they have on individuals and communities.

Definition and Purpose

Home- and Community-Based Services (HCBS) are types of person-centered care that are delivered in the home and community. These services cater to the needs of individuals with functional limitations who require assistance with everyday activities. The primary objective of these programs is to enable individuals to stay in their homes instead of moving to a care facility, thus promoting independence and improving quality of life. These programs offer a more flexible and personalized approach to care, tailored to the unique needs and preferences of each individual [1].

Types of HCBS Programs

HCBS programs generally offer two categories of services: health services to meet medical needs, and human services to support daily living activities. These programs may provide a combination of both types of services but may not cover all services within each category. This flexible and adaptable approach allows HCBS programs to meet a wide range of needs and ensure that individuals receive the support they require to lead fulfilling and independent lives.

HCBS programs are typically funded by state waivers that are part of a state's Medicaid program. These waivers offer a unique set of services to a specific population. While waivers often require medical and financial eligibility, the eligibility criteria for state waivers may differ from those of state Medicaid programs. Other funders for HCBS can include tribes or private long-term care insurance held by patients [1].

HCBS programs are operated within individual states by lead agencies and other service providers. For example, the Oneida Nation became the lead agency for a state waiver in order to have more comprehensive access to Medicaid and state HCBS. This step highlights an example of a tribe taking on a central role in coordinating and providing HCBS within a state's LTSS framework. These lead agencies, such as a county's department of human and social services, act as primary care coordinators, while service providers contract with lead agencies to deliver services. Tribes can apply with their state to become lead agencies or contract with appropriate entities to provide services and coordinate care.

In conclusion, HCBS programs play a crucial role in ensuring that individuals with functional limitations can receive the care and support they need in their own homes and communities. By understanding the different types of HCBS programs and how they operate, we can better appreciate their importance and the impact they have on the lives of many individuals.

Quality Measures for HCBS

Quality measures play a critical role in assessing the performance and effectiveness of home- and community-based services (HCBS). They act as a benchmark for gauging the improvement in quality of life, community integration, and the avoidance or delay of institutionalization for people receiving HCBS.

Importance of Quality Measures

Quality measures for HCBS should focus on the needs of different populations, such as younger individuals with intellectual or developmental disabilities versus older adults. This is because people receiving HCBS typically have chronic conditions with declining functional ability over time due to disability or age. Therefore, these measures should cater to their specific needs and conditions [2].

The importance of these measures lies in their ability to guide policymakers in long-term services and supports (LTSS) program oversight. Ongoing efforts are being made to develop and test quality measures for HCBS with an emphasis on beneficiary experiences and outcomes.

Current Measures vs. Service Delivery

While quality measures are crucial, the current measures assessing HCBS quality often concentrate more on compliance with waiver reporting requirements rather than service delivery, effectiveness, community inclusion, and caregiver support [2]. It's evident that there is a shortage of measures in these latter areas.

To address this, in September 2020, CMS released a request for information (RFI) seeking public input on a draft set of recommended measures for Medicaid-funded HCBS [3]. The intention was to create a set of nationally standardized quality measures for voluntary use by states, managed care organizations, and other entities involved in the management and delivery of HCBS.

In a significant step forward, on July 21st, 2022, CMS issued a State Medicaid Director Letter introducing the first official version of the HCBS Quality Measure Set [3]. This standardized set of quality measures for Medicaid-funded HCBS is designed to enhance consistency and comparability across states, improve the quality of care and outcomes for HCBS recipients, and promote equity in HCBS programs.

The development and application of effective quality measures for HCBS programs are critical to ensuring the best possible outcomes for beneficiaries. As the HCBS program continues to evolve, these measures will play an essential role in informing policy decisions and driving improvements in service delivery.

Development of HCBS Quality Measures

Quality measures for Home- and Community-Based Services (HCBS) programs have evolved over time, with a shifting focus towards beneficiary experiences and outcomes. As these programs continue to expand and diversify, the development of comprehensive and effective quality measures remains a top priority.

Focus on Beneficiary Experiences

The development of quality measures for HCBS programs has been guided by the needs and experiences of beneficiaries. According to MACPAC, these measures should focus on improvement in quality of life, community integration, and avoidance or delay of institutionalization, as people receiving HCBS typically have chronic conditions with declining functional ability over time due to disability or age. Measures should cater to the needs of different populations, such as younger individuals with intellectual or developmental disabilities versus older adults.

Unfortunately, current measures assessing HCBS quality often concentrate on compliance with waiver reporting requirements rather than service delivery, effectiveness, community inclusion, and caregiver support. There is a shortage of measures in these latter areas, highlighting the need for a more comprehensive approach to HCBS quality measurement.

Ongoing Efforts and Challenges

Efforts are ongoing to develop and test quality measures for HCBS to support policymakers in long-term services and supports (LTSS) program oversight, with an emphasis on beneficiary experiences and outcomes.

In September 2020, the Centers for Medicare & Medicaid Services (CMS) released a request for information (RFI) seeking public input on a draft set of recommended measures for Medicaid-funded HCBS. The intention was to create a set of nationally standardized quality measures for voluntary use by states, managed care organizations, and other entities involved in the management and delivery of HCBS [3].

Following this, on July 21st, 2022, CMS issued a State Medicaid Director Letter introducing the first official version of the HCBS Quality Measure Set. This standardized set of quality measures for Medicaid-funded HCBS is designed to enhance consistency and comparability across states, improve quality of care and outcomes for HCBS recipients, and promote equity in HCBS programs [3].

In spite of these advancements, challenges persist in the development of HCBS quality measures. The diversity of HCBS programs and beneficiaries necessitates a flexible, multifaceted approach to quality measurement. As efforts move forward, it is crucial that the voices of beneficiaries and caregivers continue to inform the development and implementation of effective, meaningful measures for the HCBS program.

Funding and Administration of HCBS

The Home and Community-Based Services (HCBS) program plays a crucial role in assisting individuals who require long-term care. However, understanding how these programs are funded and administered can be complex. In this section, we will explore the role of state waivers and Medicaid in funding HCBS programs, along with the key parties involved in their administration.

State Waivers and Medicaid

HCBS programs are commonly funded by state waivers, which form part of a state's Medicaid program. These waivers provide a specific set of services to a particular population, often requiring medical and financial eligibility. However, the eligibility criteria for these waivers may differ from those of standard Medicaid programs.

The Centers for Medicare and Medicaid Services (CMS) authorize these HCBS waivers, allowing states to deviate from traditional Medicaid rules. Essentially, the waivers "waive" certain requirements, enabling states to offer services not typically covered under Medicaid.

Funding for HCBS waivers stems from a combination of federal and state resources. The federal government provides matching funds to states that have established HCBS waiver programs. Other potential funding sources for HCBS programs can include tribes or private long-term care insurance held by patients.

Lead Agencies and Service Providers

The administration of HCBS programs typically involves a range of parties, including lead agencies and service providers. Lead agencies are often state or local government entities that oversee the program's day-to-day operations and ensure compliance with federal and state regulations.

Service providers, on the other hand, deliver the actual care services under the HCBS program. These providers may include healthcare professionals, community organizations, and specialized care facilities.

Both lead agencies and service providers play crucial roles in ensuring that HCBS programs effectively meet the needs of their beneficiaries. Through their combined efforts, these programs can deliver quality, person-centered care that promotes the dignity, independence, and overall wellbeing of individuals requiring long-term support and services.

Impact of HCBS Programs

The Home and Community-Based Services (HCBS) programs have had significant impacts on the care landscape, particularly in terms of cost-effectiveness and the development of daily living skills among beneficiaries.

Cost-Effectiveness and Savings

One of the main benefits of HCBS programs is their cost-effectiveness. Between October 2012 and September 2013, it was reported that 51% of Medicaid expenditures in long-term health support were allocated to HCBS, amounting to $75 billion out of $145 billion spent in long-term care programs. This marked an increase from the previous year where only 49% was allocated to community-based options [5].

Studies have also shown that individuals receiving community-based services have seen reductions in expenses. A study released in 1999 found a 50% reduction in expenses and a 65% decrease in the number of days spent in the hospital for those receiving community-based services as opposed to those receiving institutionalized care [5].

In one case, the Nevada house call program reported a 62% reduction in hospital days and annual savings of $440,000 when 91 clients opted for community-based services instead of institutionalized care. And in another case of an elderly woman enrolled in ElderChoices in Arkansas, the cost of care would be close to $50,000 per year if she entered a nursing home; however, by choosing ElderChoices, the cost is under $7,500 per year.

Improved Daily Living Skills

The impact of HCBS programs extends beyond cost savings. They also play a critical role in improving daily living skills of individuals transitioning from institutional settings. Those who move to community-based services often experience continued development of their daily living skills. In contrast, those remaining in institutional care do not exhibit positive growth in their abilities and often remain at or below the skill level they had when initially admitted to long-term care facilities.

These findings highlight the considerable potential of HCBS programs in promoting independence and enhancing quality of life for beneficiaries, while also offering a more cost-effective solution for long-term care. As our understanding of these benefits grows, so too does the need for ongoing support and expansion of such community-based services.

Future of HCBS

Looking ahead, the future of Home and Community-Based Services (HCBS) programs is being shaped by significant funding initiatives and the introduction of standardized quality measures. These developments, made possible by the American Rescue Plan Act (ARPA) and the Centers for Medicare and Medicaid Services (CMS), are expected to enhance the efficacy and quality of HCBS programs.

ARPA Funding and Initiatives

The American Rescue Plan Act (ARPA) of 2021 has provided a major boost to HCBS programs. It offers states a temporary ten percentage point increase to the federal medical assistance percentage (FMAP) for Medicaid HCBS, provided certain federal requirements are met. The funds are to be used to enhance or strengthen Medicaid HCBS [6].

On January 10, 2022, CMS provided the Texas Health and Human Services Commission (HHSC) with conditional approval of the spending plan for Medicaid HCBS funding under ARPA. The approval is contingent on HHSC's compliance with federal requirements. The HHSC submitted an update to their spending plan on July 18, 2022, to highlight changes from the original plan. This update was provided in track-changes for ease of review and identification of new information.

HCBS Quality Measure Set

In a significant development for the future of HCBS programs, CMS issued a State Medicaid Director Letter on July 21st, 2022, introducing the first official version of the HCBS Quality Measure Set. This standardized set of quality measures for Medicaid-funded HCBS is designed to enhance consistency and comparability across states. It aims to improve quality of care and outcomes for HCBS recipients and promote equity in HCBS programs [3].

To support states in implementing these new measures, CMS has developed a resources manual, which includes technical specifications, links to testing reports, and alignment with various criteria and initiatives like the CMS Meaningful Measures Initiative and 1915(c) waiver assurances.

These advancements signal a promising future for the HCBS program. By leveraging ARPA funding and implementing standardized quality measures, the HCBS program is poised to continue its evolution and improve the lives of individuals in need of home and community-based services.

References

[1]: https://www.cms.gov/training-education/partner-outreach-resources/american-indian-alaska-native/ltss-ta-center/information/ltss-models/home-and-community-based-services

[2]: https://www.macpac.gov/subtopic/quality-of-home-and-community-based-services/

[3]: https://www.medicaid.gov/medicaid/quality-of-care/quality-improvement-initiatives/measuring-and-improving-quality-home-and-community-based-services/index.html

[4]: https://heritage-rc.com/resources/home-and-community-based-services-hcbs-waiver

[5]: https://www.integrityinc.org/3-major-benefits-of-community-based-services-vs-institutional-care/

[6]: https://www.hhs.texas.gov/providers/long-term-care-providers/long-term-care-provider-resources/home-community-based-services-hcbs

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