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July 2, 2021

Rethinking Medicaid Home and Community-Based Service Assessments: A Need for Better Quality Monitoring

Author Affiliations
  • 1Institute of Gerontology, University of Michigan Medical School, Ann Arbor
  • 2Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
JAMA Health Forum. 2021;2(7):e211274. doi:10.1001/jamahealthforum.2021.1274

Medicaid long-term services and supports (LTSS) for older adults and people with physical disabilities is among the most rapidly changing health services in the US. Spurred by policy changes and consumer advocacy, Medicaid LTSS systems across the country have increasingly rebalanced their systems to support older adults and people with physical disabilities with home and community-based services (HCBS) instead of institutional services.1 This shift has created new opportunities for people to age in place and receive services at home but has also created new policy challenges related to ensuring quality services, measuring service outcomes, and improving the care provided to HCBS recipients.

In our view, a foundational difference between HCBS and nursing facility services has received too little scrutiny and study: the frequency individuals receive reassessment. This may seem like a minor issue but these assessments form the basis for service plans, regulatory monitoring, outcome measurement, and quality tracking. A double standard currently exists in which older adults and people with physical disabilities in HCBS programs receive less frequent required reassessment than people in institutions. The COVID-19 pandemic has unveiled this double standard by demonstrating our inability to track how the virus has affected people receiving LTSS in the community, in contrast to the extensive information on residents in nursing facilities. As state Medicaid programs prioritize serving individuals in HCBS settings, it is worth reconsidering whether this difference shortchanges people receiving HCBS and precludes the kind of program evaluation needed to protect health and safety.

Rebalancing Creates Unique Policy Challenges

Understanding differences in Medicaid LTSS starts with understanding the historical context. When the US Congress enacted Medicare and Medicaid in 1965, it essentially provided 1 option for older adults and people with physical disabilities who needed LTSS: nursing facilities. The original Medicaid Act made LTSS the domain of Medicaid—offering some postacute service coverage for home health and nursing facility services in Medicare but expecting that Medicaid would cover long-term supports. In doing that, Congress required states to provide services in nursing facilities and permitted a limited number of home-based alternatives. Congress did not establish a meaningful HCBS alternative until 1981, when it created the Section 1915(c) waiver program.2 Still the predominant alternative to nursing facility placement in most states, this program provides recipients with a variety of supports to remain in the community.

Rapid transformation of Medicaid LTSS systems followed. For instance, in 1995, more than 83% of total Medicaid LTSS spending for older adults and people with physical disabilities went to nursing facility services. That imbalance has steadily shifted. In 2016, roughly 55% of total Medicaid LTSS funding for older adults and people with physical disabilities went to nursing facility services.1

As the number of older adults and people with physical disabilities receiving services in HCBS settings has risen, increased attention to the quality of services has rightly followed. Little attention, however, has been paid to the frequency of needs reassessments for individuals receiving HCBS.

Assessment Frequency in Nursing Facilities vs HCBS

Since 1989, when federal regulation of long-term care facilities substantially changed,3 federally certified nursing facilities have been required to assess individuals soon after admission, review and revise that assessment every 3 months, and then complete a comprehensive assessment at least annually and after notable changes in status. Like many of the nursing facility regulatory changes at the time, this quarterly reassessment schedule followed a recommendation in the landmark 1986 report by the Institute of Medicine’s Committee on Nursing Home Regulation.4 That report argued that quarterly reassessments were essential for proactively identifying changes in status, evaluating the need for care plan changes, assessing longitudinal change, measuring service outcomes, and obtaining information to tailor payments to specific needs.

In contrast to these requirements, states had considerable flexibility to determine the frequency of required reassessment for HCBS. For instance, in 1915(c) waiver programs (the primary authority for HCBS), federal regulation requires annual reassessment and reassessment after notable changes in status.5 Federal regulations do not require quarterly review and revision. States can require more frequent assessments; however, to our knowledge no study has identified how often states require more than the federal minimum.

To get a sense of whether states are requiring more frequent assessment, we searched for 1915(c) waiver applications on the Medicaid website (https://www.medicaid.gov/) submitted by programs serving older adults and adults with physical disabilities. In these applications, a state must specify its reassessment schedule. Our review of all waivers that were active as of August 2019 found that only 2 of 80 programs serving older adults and adults with physical disabilities required reassessment every 6 months rather than the minimum of once per year.

Decreased Assessment Frequency Warrants More Attention

It is worth studying what associations, if any, this programmatic difference may have with the care individuals receive and the ability of HCBS programs to monitor program outcomes. Although our review found only a few examples of waiver programs that require more frequent reassessment, a better understanding of the experience of HCBS programs with these requirements would contribute substantially to the vacuum of current knowledge. Given the variation in HCBS programs, the lack of a standardized national assessment instrument, and the focus of HCBS programs on difficult to measure quality-of-life outcomes, among numerous challenges, measurement of HCBS program outcomes is complex. In this context, the importance of collecting regular assessment data about program participants’ assessed needs is made only more important.

Furthermore, it would be valuable to understand how frequently individuals actually receive reassessments and what changes in health and well-being those uncover. Based on our review of existing literature, to our knowledge there has been essentially no research in this area. Because of that, it is difficult to know whether assessments are triggered when individuals have a notable change in status, whether practitioners find it valuable to reassess certain people more frequently, and whether individuals in HCBS programs have expected health changes that could be proactively managed.

In contrast, the regular assessment schedule in nursing facilities continues to facilitate data collection and analyses of this type. The regularly collected Minimum Data Set assessments4 completed in nursing facilities form the basis for standardized case-mix information, state quality monitoring, and nursing facility quality measures, in addition to the underlying research that created and enhances these functions.

A Path Forward

Given these considerations, a more targeted effort is needed to understand how assessment frequency may be associated with the quality of care for HCBS recipients. Replicating the Institute of Medicine’s former Committee on Nursing Home Regulation to consider this issue as well as other HCBS regulatory issues, could provide a template for conducting future studies. Alternatively, Congress could fund a demonstration project to assess how changing federal regulation to require more frequent assessment may be associated with improved care. Congress used this approach to consider expanding the 1915(c) program to include children who need care in a psychiatric residential treatment facility.6 Congress also embedded this approach in the Balancing Incentive Program7 to assess the feasibility of establishing a standardized assessment instrument across HCBS programs. Building on that work, a demonstration could pilot a standardized assessment tool used on a quarterly schedule, much like the Minimum Data Set and its required schedule for nursing facilities. This type of demonstration could explicitly assess how the frequency of reassessment may be associated with a state’s ability to accurately track program outcomes, a step that may get us closer to the broader goal of standardized outcome measures in Medicaid HCBS programs.

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Article Information

Published: July 2, 2021. doi:10.1001/jamahealthforum.2021.1274

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Graca GM et al. JAMA Health Forum.

Corresponding Author: Gary M. Graca, BA, Institute of Gerontology, University of Michigan Medical School, 300 N Ingalls, Room 912, Ann Arbor, MI 48109-2007 (gmgraca@med.umich.edu).

Conflict of Interest Disclosures: Dr Bynum reported support from the National Institutes of Health and from the State of Michigan outside of the submitted work. No other disclosures were reported.

Eiken  S, Sredl  K, Burwell  B, Amos  A. Medicaid Expenditures for Long-Term Services and Supports in FY 2016. Medicaid Innovation Accelerator Program; 2018. Accessed May 22, 2021. http://www.advancingstates.org/hcbs/article/medicaid-expenditures-long-term-services-and-supports-fy-2016
Eiken  S, Wenslow  A, Sredl  K. Improving the Balance: the Evolution of Medicaid Expenditures for Long Term Services and Supports, FY 1981-2014. Truven Health Analytics; 2016. Accessed May 22, 2021. https://www.medicaid.gov/sites/default/files/2019-12/evolution-ltss-expenditures.pdf
US Centers for Medicare & Medicaid, US Department of Health and Human Services. Requirements for states and long-term care facilities. 42 CFR §483.20(b) and (c). Accessed May 18, 2021. https://ecfr.federalregister.gov/current/title-42/chapter-IV/subchapter-G/part-483?toc=1
Institute of Medicine Committee on Nursing Home Regulation.  Improving the Quality of Care in Nursing Homes. National Academies Press; 1986.
US Centers for Medicare & Medicaid, US Department of Health and Human Services. Periodic evaluation, assessment, and review. 42 CFR §441.365(e). Accessed May 18, 2021. https://ecfr.federalregister.gov/current/title-42/chapter-IV/subchapter-C/part-441/subpart-H/section-441.365
Sebelius  K. Report to the President and Congess: Medicaid Home and Community-Based Alternatives to Psychiatric Residential Treatment Facilities Demonstration. Department of Health and Human Services; 2013. Accessed May 22, 2021. https://www.medicaid.gov/sites/default/files/2019-12/prtf-demo-report.pdf
US Centers for Medicare & Medicaid. Balancing Incentive Program. Accessed April 26, 2021. https://www.medicaid.gov/medicaid/long-term-services-supports/balancing-incentive-program/balancing-incentive-program/index.html
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