Although exploratory, the associations between LTC balance measures and state factors and policy variables presented in this chapter indicate several areas that may warrant further research. First, of seven measures selected to capture state characteristics, only two were significantly correlated with measures reflecting HCBS penetration in state LTC systems overall: (1) average winter precipitation, which was negatively associated with LTC expenditure balance; and (2) personal and home care aides per 1,000 persons who are elderly or have disabilities, which was positively associated with both HCBS use and spending.
We hypothesize that winter precipitation may hinder enrollee or provider transport, making it more challenging for states in which winter snow or poor weather conditions occur to provide care in some community settings. We also hypothesize that worker shortages may reduce HCBS expansions because nursing home care requires fewer staff. This suggests that weather conditions and workforce availability would be important contextual variables to consider when developing more refined measures of LTC system transformation progress.
When examining policy variables, we note that the different measures of LTC system performance sometimes produced different results, highlighting the need to develop measures that carefully reflect states' progress, as CMS is doing. The three policy variables most consistently related to systems more balanced toward HCBS were consumer direction, coverage of personal care, and SSI supplements for people living in the community. However, having personal care was associated with HCBS penetration only for aged enrollees, not for enrollees under 65 with a physical disability and people with ID/DD. Other factors, such as financial resources appear to be related to LTC balance for those with ID/DD.