Improving Home and Community-Based Services Infrastructure

Co-authored by Altarum's Anne Montegomery, this brief from the Community Living Policy Center at the Heller School for Social Policy and Management at Brandies University outlines a proposal for an innovative program that assists states with improving their home and community based services (HCBS) infrastructure. Key goals include strengthening housing, transportation, employment, workforce and caregiver supports in communities across the country with initiatives that address social determinants of health (SDOH), so that persons with disabilities and older adults with disabilities are served where they wish to be served.

Specifications for the proposal were developed through a workgroup of the Disability and Aging Collaborative, a coalition of more than 40 national organizations, with additional input provided by associations representing states and other key informants—including Altarum.

Key proposal objectives include: 

1. Strengthening HCBS infrastructure to accelerate initiatives that improve integration with Medicare, Older Americans Act programs and others, to better address SDH
2. Assisting states with ways to improve access to HCBS, particularly among populations with significant unmet need
3. Leveraging evolving state Medicaid information technology (IT) systems to improve HCBS reporting among managed long-term services and supports (MLTSS) and other types of HCBS providers, including outcomes that focus on individual experience of care

This proposal is informed by the approach taken, and the lessons learned, from the successful five-year program known as the Balancing Inventive Program. That initiative provided states with a temporary enhanced federal medical assistance percentage (FMAP) for Medicaid HCBS in exchange for submitting five-year plans that aimed to make improvements in three areas: (1) No Wrong Door/Single Entry Point information and referral system; (2) standardized needs assessments; and (3) conflict-free case management. Only states spending less than 50% of their total LTSS spending on HCBS in 2009 were eligible to apply.

Key differences between the original program and the design of this proposal include: allowing all states to apply, modifying the existing financing structure from an enhanced FMAP to a structured discretionary grant program that enhances state flexibility, granting states greater leeway in determining which areas of HCBS infrastructure and populations to focus on, increasing the program duration to seven years, and improved data collection.