Medicaid-Financed Institutional Services: Characteristics of Nursing Home and ICF/IID Residents and Their Patterns of Care. B. Characteristics of Enrollees' Intermediate Care Facility for People with Intellectual Disabilities Spells

08/01/2013

1. How Many Enrollees Had New Spells of ICF/IID Care?

Few Medicaid enrollees used ICF/IID services. Of the nearly 12 million enrollees who were either elderly or eligible on the basis of disability between July 1, 2006, and December 31, 2007, only 93,761 had been in an ICF/IID, and only 9 percent (8,430) of those individuals -- representing less than one-tenth of 1 percent of all elderly or disabled enrollees -- had new spells of care. Thus, turnover in ICFs/IID was significantly lower than the turnover rate reported for enrollees in nursing homes (Chapter II). The number of enrollees residing in ICFs/IID was also relatively low compared to the number of enrollees with ID/DD who received HCBS waiver services in the community: in 2006, approximately 410,000 individuals were enrolled in waivers for individuals with ID/DD (MR/DD waivers) in the states analyzed here (Ng and Harrington 2009).

Differences across states in the number of spells or new spells were likely due in part to different state policies with respect to ICFs/IID. For example, Oregon and Vermont, which have been leaders in promoting community-based care for the ID/DD population, each had only a single ICF/IID in 2007 and correspondingly low numbers of ICF/IID spells (zero, in the case of Oregon).22 As mentioned above with respect to nursing home users, a disproportionate number of new ICF/IID spells were concentrated in a handful of large states, with California, Texas, New York, and Illinois together accounting for 45 percent of all new spells. Although the percentage of ICF/IID spells that were new was substantially higher in some states--including Alaska, Montana, South Dakota, Rhode Island, and Colorado--the actual numbers of new spells in these states were low, together accounting for only one percent of all new spells.23

TABLE III.1. Medicaid FFS ICF/IID Use Among Aged or Disabled Enrollees Eligible for Full Medicaid Benefits Any Time Between July 2006 and December 2007
    Total Number of Aged  
and Disabled Enrollees
  Number of Enrollees  
with ICF/IDD Spells
Number of Enrollees
  with New ICF/IID Spells  
Percentage of Enrollees
  with New ICF/IID Spells  
  Percentage of ICF/IID Enrollees  
with New ICF/IID Spells
All States 11,922,095 93,761 8,430 0.1 9.0
Alabama 215,562 253 32 0.0 12.6
Alaska 22,542 b b b b
Arkansas 147,070 1,780 283 0.2 15.9
California 1,848,937 8,864 1,123 0.1 12.7
Colorado 115,524 150 30 0.0 20.0
Connecticut 113,746 1,261 115 0.1 9.1
Delaware 24,219 147 b b b
District of Columbia   43,901 695 89 0.2 12.8
Florida 661,152 3,060 135 0.0 4.4
Georgiaa 315,975 1,190 165 0.1 13.9
Hawaii 44,956 84 b b b
Idaho 44,065 617 93 0.2 15.1
Illinois 467,613 9,477 651 0.1 6.9
Iowa 101,732 2,332 167 0.2 7.2
Kansas 85,305 644 37 0.0 5.7
Kentucky 249,333 717 71 0.0 9.9
Louisiana 239,281 5,584 497 0.2 8.9
Maryland 168,074 342 19 0.0 5.6
Massachusetts 379,285 1,031 54 0.0 5.2
Michigan 413,303 143 20 0.0 14.0
Mississippi 185,700 2,921 336 0.2 11.5
Missouri 266,561 1,006 63 0.0 6.3
Montana 26,767 66 19 0.1 28.8
Nebraska 55,381 632 76 0.1 12.0
Nevada 45,739 144 22 0.0 15.3
New Jersey 288,719 3,074 177 0.1 5.8
New Mexico 77,024 274 34 0.0 12.4
New York 1,097,394 8,548 756 0.1 8.8
North Carolina 426,342 4,204 213 0.0 5.1
North Dakota 17,766 582 49 0.3 8.4
Ohio 471,689 7,793 617 0.1 7.9
Oklahoma 152,507 1,845 208 0.1 11.3
Oregon 107,585 0 0 0.0 0.0
Pennsylvania 685,973 4,077 193 0.0 4.7
Rhode Islanda 59,865 46 b b b
South Carolina 216,208 1,735 144 0.1 8.3
South Dakota 23,255 201 46 0.2 22.9
Tennesseea 391,227 1,280 36 0.0 2.8
Texas 803,650 12,696 1,225 0.2 9.6
Vermont 29,604 b b b b
Virginia 216,853 1,917 193 0.1 10.1
Washington 232,549 59 b b b
West Virginia 122,980 569 92 0.1 16.2
Wisconsin 207,083 1,572 307 0.1 19.5
Wyoming 12,099 98 11 0.1 11.2
SOURCE: Mathematica analysis of 2006-2007 MAX data for 44 states and the District of Columbia with representative FFS nursing home and ICF/IID data (excludes data from Arizona, Indiana, Maine, Minnesota, New Hampshire, and Utah).
NOTES: New spells are spells beginning on or after July 1, 2006.
  1. Data for Georgia, Rhode Island, and Tennessee were included in the analysis even though total institutional care expenditures as reported by the MAX data and CMS Form 64 differed substantially (a variance across data sources of at least 33% in 2007), as there were no known data anomalies for these states believed to invalidate the MAX-based statistics.
  2. Cell sizes of less than 11 are not displayed.

Although much emphasis has been placed on re-balancing services for the ID/DD population toward community settings in the wake of the Olmstead decision, concerns have been raised about the lack of institutional capacity in some states for individuals with complex needs (Western Interstate Commission for Higher Education 2009). For example, because no ICF/IID was located in Alaska during the study period, it placed its four enrollees requiring institutional services in three Idaho facilities.

2. Who Used ICF/IID Care?

The majority of enrollees with new ICF/IID spells were male and under 65 years old, with a substantial number having multiple spells of care during the study period. Unlike nursing homes, whose residents are more likely to be female and elderly, 60 percent of the 8,430 enrollees with ICF/IID spells were male, and 38 percent were between 21 and 44 years old (Table III.2). Significant percentages of enrollees residing in ICFs/IID were younger than 21 (29 percent) or between 45 and 64 years old (27 percent).

TABLE III.2. Characteristics of Aged or Disabled Enrollees with New Medicaid-Financed ICF/IID Spells Between July 2006 and December 2007
Characteristic Enrollees with One or
  More New ICF/IID Spells  
  Enrollees with Both New  
Nursing Home and New
ICF/IID Spells
Number of Enrollees with New Spells in All States 8,430 994
   Percentage female 40.1 47.4
   Percentage non-Hispanic White 72.1 80.7
Age (Percentage of Subgroup)
   Under age 21 29.0 4.4
   21-44 years 38.4 29.5
   45-64 years 26.5 49.0
   65-74 years 3.8 10.0
   75-84 years 1.5 5.4
   85 years and older 0.4 1.7
Percentage with Multiple New Spells 14.6 100.0
Percentage with Spells in Both Nursing Homes and ICFs/IID   11.8 100.0
SOURCE: Mathematica analysis of 2006-2007 MAX data for 44 states and the District of Columbia with representative FFS nursing home and ICF/IID data (excludes data from Arizona, Indiana, Maine, Minnesota, New Hampshire, and Utah).
NOTE: New spells are spells beginning on or after July 1, 2006.

Of all enrollees with new spells of ICF/IID care, 15 percent had more than one new spell within the 18-month period between July 2006 and December 2007, and 12 percent had spells in both ICFs/IID and nursing homes (discussed in greater detail below). Older women were much more prevalent among those who used both ICFs/IID and nursing homes: slightly less than half of all enrollees who received both types of institutional care were female, and 17 percent were over 65 years old, compared with only 6 percent for enrollees with only ICF/IID spells. It is possible that some ICF/IID residents were moved to nursing homes as they grew older and required more complex and continual medical care, but the vast majority of enrollees with stays in both types of institution (83 percent) were younger than 65.

TABLE III.3. MAS in First Month of First New Medicaid-Financed ICF/IID Spell Among Aged or Disabled Enrollees Eligible for Full Medicaid Benefits Any Time Between July 2006 and December 2007
States
  (by largest MAS group)  
  Total Number of Enrollees  
with new ICF/IID Spells
Percentage in MAS Group at Start of Spell
  "Other"   Cash
  Assistance-  
Related
  Medically  
Needy
  Poverty-  
Related
Section 1115
  Demonstration  
Waiver
Cash Assistance
   Alaskac e e e e e e
   Rhode Islandabc e e e e e e
   Georgiaabc 165 21.8 78.2 0.0 0.0 0.0
   New Mexicoc 34 e e e e e
   Idahoc 93 e 71.0 e e e
   Texasc 1,225 33.1 66.6 e e e
   South Dakotac 46 e 63.0 e e e
   Delawarec e e e e e e
   Floridabc 135 35.6 61.5 e e e
   Mississippic 336 38.4 61.3 e e e
   North Carolinab 213 e 60.1 e 33.3 e
   Michiganbc 20 e e e e e
   District of Columbiab   89 e e e e e
   Tennesseeabc 36 e e e e e
   Montanab 19 e e e e e
   Kansasbc 37 43.2 56.8 0.0 0.0 0.0
   Wisconsinbc 307 39.7 56.7 e e e
   Coloradoc 30 43.3 56.7 0.0 0.0 0.0
   South Carolinac 144 27.1 56.3 0.0 16.7 0.0
   Louisianabc 497 44.1 55.3 e e e
   Arkansasbc 283 46.3 52.7 e e e
   Californiab 1,123 4.5 51.4 41.7 2.4 0.0
   North Dakotabd 49 0.0 51.0 49.0 0.0 0.0
   Hawaiibd e e e e e e
All States 8,430 32.5 48.2 15.4 3.9 0.1
   Massachusettsb 54 e e e e e
"Other"
   Vermontbc e e e e e e
   Washingtonbc e e e e e e
   Wyomingc 11 e e e e e
   Oklahomacd 208 81.3 13.5 0.0 5.3 0.0
   Connecticutbd 115 73.0 24.3 2.6 0.0 0.0
   Ohiod 617 69.5 25.0 0.0 5.5 0.0
   Missourid 63 66.7 33.3 0.0 0.0 0.0
   New Jerseybc 177 66.7 30.5 e e e
   Iowabc 167 60.5 39.5 0.0 0.0 0.0
   Virginiabcd 193 57.0 38.9 e e e
   Nevadac 22 e e e e e
   West Virginiabc 92 53.3 43.5 e e e
   Pennsylvaniabc 193 52.3 40.4 e e e
   Kentuckybc 71 52.1 43.7 e e e
   Alabamac 32 50.0 46.9 e e e
Medically Needy
   Nebraskab 76 e e 57.9 e e
   New Yorkb 756 e e 55.7 e e
   Marylandbc 19 e e e e e
   Illinoisbd 651 25.7 22.4 40.4 11.5 0.0
SOURCE: Mathematica analysis of 2006-2007 MAX data for 44 states and the District of Columbia with representative FFS nursing home and ICF/IID data (excludes data from Arizona, Indiana, Maine, Minnesota, New Hampshire, and Utah).
NOTE: New spells are spells beginning on or after July 1, 2006. MAX data reported no new ICF/IID spells in Oregon. Methods used to determine which states utilized the 300% rule or had a medically needy program in 2007 are described in Appendix B.
  1. Data for Georgia, Rhode Island, and Tennessee were included in the analysis even though total institutional care expenditures as reported by the MAX data and CMS Form 64 differed substantially (a variance across data sources of at least 33% in 2007), as there were no known data anomalies for these states believed to invalidate the MAX-based statistics.
  2. State had a medically needy program in 2007.
  3. State utilized the 300% rule in 2007.
  4. Section 209(b) state. Because Section 209(b) states are required to allow persons receiving SSI to deduct incurred medical expenses from income to determine financial eligibility, some people in 209(b) states may be coded as medically needy even if the state had no medically needy program.
  5. Cell sizes of less than 11 are not displayed.

3. How Did Enrollees Residing in ICFs/IID Become Eligible for Medicaid?

More enrollees using ICF/IID services qualified for Medicaid benefits through cash assistance-related criteria than through any other pathway, with the vast majority already enrolled in Medicaid prior to admission. Across all 45 states, nearly half of all enrollees in ICFs/IID qualified for full-benefits via the cash assistance pathway in 2007, followed by "other" criteria (33 percent) and medically needy programs (15 percent) (Table III.3).24 In roughly half of states analyzed (23 out of 45), the majority of ICF/IID residents with new spells qualified for Medicaid at the start of their spell due to their low-incomes -- that is, they qualified under cash assistance-related criteria. Moreover, in all states except Illinois cash assistance-related criteria represented either the most common or second most common pathway to Medicaid eligibility. Finally, cash assistance was the most common pathway to eligibility in the two states with the largest number of new spells: California and Texas. "Other" criteria were the most common pathway to eligibility in 15 states -- one-third of which are 209(b) states -- while medically needy programs were the most common pathway in four states. As with enrollees in nursing homes, poverty-related expansions were a common pathway to eligibility in Hawaii, Massachusetts, and North Carolina.

In contrast to enrollees in nursing homes, most enrollees living in an ICF/IID were enrolled in Medicaid prior to their first spell of institutional care, with only 11 percent not enrolled two months prior to admission (Table III.4). Among those qualifying for benefits two months prior to their ICF/IID stay, most qualified either via cash assistance (48 percent) or "other" (24 percent). Cash assistance was either the most common or second most common pathway to eligibility in all states except Illinois. Thus, recipients of Medicaid-financed ICF/IID services generally had low-incomes and were not spending down available assets as many nursing home residents do. As with enrollees in nursing homes, retroactive eligibility for Medicaid benefits at the time of admission to the ICF/IID likely accounts for some of the observed enrollment in Medicaid two months prior to admission.

TABLE III.4. MAS in the Two Months Preceding the First New Medicaid-Financed ICF/IID Spells of Aged or Disabled Enrollees Between July 2006 and December 2007
States
(by largest MAS group)
  Total Number of Enrollees  
with new Nursing Home Spells
Percentage in MAS Group at Start of Spell
Not
  Enrolled 
  "Other"   Cash
  Assistance-  
Related
  Medically  
Needy
  Poverty-  
Related
Section 1115
  Demonstration  
Waiver
Cash Assistance
   Alaskac e e e e e e e
   Rhode Islandabc e e e e e e e
   Vermontbc e e e e e e e
   Georgiaabc 165 e 15.8 75.2 e e e
   South Carolinac 144 e 17.4 67.4 e e e
   Michiganbc 20 e e e e e e
   Tennesseeabc 36 e e e e e e
   Marylandbc 19 e e e e e e
   Montanab 19 e e e e e e
   South Dakotac 46 e e 63.0 e e e
   District of Columbiab   89 e e 62.9 e e e
   Mississippic 336 e 21.4 61.9 e e e
   New Mexicoc 34 e e 61.8 e e e
   Texasc 1,225 16.5 16.0 60.7 e e e
   North Carolinab 213 e 0.0 60.1 e 25.4 e
   Wisconsinbc 307 e 36.5 57.3 e e e
   Louisianabc 497 e 19.9 56.5 e e e
   Idahoc 93 20.4 e 55.9 e e e
   Floridabc 135 e 25.2 53.3 e e e
   Californiab 1,123 6.0 3.9 53.3 33.0 3.5 0.0
   Alabamac 32 e e 53.1 e e e
   North Dakotabd 49 e e 53.1 e e e
   New Yorkb 756 e e 51.9 e e e
   Kansasbc 37 e e 51.4 e e e
   Delawarec e e e e e e e
   Hawaiibd e e e e e e e
   Arkansasbc 283 e e 48.8 e e e
   Pennsylvaniabc 193 e e 48.2 e e e
   Massachusettsb 54 e e 48.1 e e e
All States 8,430 10.9 23.8 47.8 10.8 5.7 0.1
   Coloradoc 30 e e 46.7 e e e
   Kentuckybc 71 e e 45.1 e e e
   West Virginiabc 92 e e 43.5 e e e
   Virginiabcd 193 e e 43.0 e e e
   Nevadac 22 e e e e e e
"Other"
   Oklahomacd 208 e 37.0 34.6 e e e
   New Jerseybc 177 e 62.1 18.1 e e e
   Ohiod 617 10.2 61.8 21.2 0.0 5.7 0.0
   Wyomingc e e e e e e e
   Alaskac 167 e 64.1 e 0.0 0.0 0.0
   Connecticutbd 115 e 61.7 e e e e
   Missourid 63 e 69.8 e e e e
   Washingtonbc e e e e e e e
Medically Needy
   Nebraskab 76 e e e 48.7 e e
   Illinoisbd 651 e 29.3 16.3 30.7 15.7 e
SOURCE: Mathematica analysis of 2006-2007 MAX data for 44 states and the District of Columbia with representative FFS nursing home and ICF/IID data (excludes data from Alaska, Arizona, Indiana, Maine, Minnesota, New Hampshire, and Utah).
NOTES: New spells are spells beginning on or after July 1, 2006. MAX data reported no new ICF/IID spells in Oregon. Methods used to determine which states utilized the 300% rule or had a medically needy program in 2007 are described in Appendix B.
  1. Data for Georgia, Rhode Island, and Tennessee were included in the analysis even though total institutional care expenditures as reported by the MAX data and CMS Form 64 differed substantially (a variance across data sources of at least 33% in 2007), as there were no known data anomalies for these states believed to invalidate the MAX-based statistics.
  2. State had a medically needy program in 2007.
  3. State utilized the 300% rule in 2007.
  4. Section 209(b) state. Because Section 209(b) states are required to allow persons receiving SSI to deduct incurred medical expenses from income to determine financial eligibility, some people in 209(b) states may be coded as medically needy even if the state had no medically needy program.
  5. Cell sizes of less than 11 are not displayed.

ICF/IID residents who were enrolled in Medicaid prior to admission generally continued to qualify for benefits according to the same eligibility criteria following admission, with 87-93 percent of those who qualified via the "other," cash assistance, and medically needy pathways remaining in the same MAS group (Table III.5). As with nursing homes, the percentage remaining in the poverty-related group (46 percent) was lower, with most of those enrollees qualifying for benefits under "other" criteria following admission. Among those residents who were not enrolled in Medicaid two months prior to admission, approximately half qualified for Medicaid via the "other" pathway, with the remainder qualifying via the cash assistance (29 percent) and medically needy (19 percent) pathways.

TABLE III.5. Transitions in MAS at the Start of First New Medicaid-Financed ICF/IID Spells Between July 2006 and December 2007
  MAS Group Two Months  
Before Start of Spell
  Number in MAS Group Two  
Months Before Start of Spell
Percentage in MAS Group at Start of Spell
  "Other"   Cash
  Assistance-  
Related
  Medically  
Needy
  Poverty-  
Related
Section 1115
  Demonstration  
Waiver
Not enrolled 915 49.2 29.0 18.5 a a
"Other" 2,006 87.4 8.5 2.2 a a
Cash assistance 4,028 7.8 87.0 4.5 a a
Medically needy 912 a 5.6 92.9 a a
Poverty-related 479 37.4 7.7 8.8 46.1 0.0
Section 1115 demonstration waiver   12 a a a a a
SOURCE: Mathematica analysis of 2006-2007 MAX data for 44 states and the District of Columbia with representative FFS nursing home and ICF/IID data (excludes data from Arizona, Indiana, Maine, Minnesota, New Hampshire, and Utah).
NOTES: New spells are spells beginning on or after July 1, 2006. MAX data reported no new ICF/IID spells in Oregon.
  1. Cell sizes of less than 11 are not displayed.

B. Characteristics of Enrollees' Intermediate Care Facility for People with Intellectual Disabilities Spells

1. How Long Did Enrollees Live in ICFs/IID?

Most enrollees living in ICFs/IID were long-term residents, with more than seven out of ten individuals with new spells staying for more than one year (Figure III.1). Some of these individuals might have required the level of services that can only be provided in an institutional setting. Others might have benefited from transitioning to the community, but their family members or guardians might have lacked information about community-based options or resources for facilitating a transition.

A second group of individuals, constituting 13 percent of all enrollees living in ICFs/IID, had very short stays of three months or less. In many cases, these short stays corresponded to ICF/IID closings. For example, Wisconsin -- which accounted for 23 percent (90 out of 390) of the very short spells that began in the second half of 2006 -- closed seven ICFs/IID between June 30, 2006, and June 30, 2007, four of which were larger facilities with 16 or more beds (Lakin et al. 2008; Lakin et al. 2007). California and New York, accounting for 20 percent of very short stays, also closed large facilities during this period.25

FIGURE III.1. Length of First New ICF/IID Spells Among Aged or Disabled Medicaid Enrollees with New Medicaid-Financed ICF/IID Spells Between July 2006 and December 2006
FIGURE III.1, Pie Chart: Less than 3 months (13.4%); 3-6 months (6.1%); 6-9 months (5.2%); 9-12 months (4.0%); More than 12 months (71.3%).
SOURCE: Mathematica analysis of 2006-2007 MAX data for 44 states and the District of Columbia with representative FFS ICF/IID data (excludes data from Arizona, Indiana, Maine, Minnesota, New Hampshire, and Utah).
NOTES: New spells in this figure are spells beginning between July 1, 2006, and December 31, 2006, inclusive; spells are censored at December 31, 2007. 2,908 enrollees had new ICF/IID spells beginning between July and December 2006. The median length of first new spells was 425 days for ICFs/IID.

2. Did Enrollees with ICF/IID Stays Also Have Nursing Home Stays?

Ideally, an individual with ID/DD who qualifies for Medicaid benefits and requires LTSS will be placed in the environment best suited to address his or her specific needs. Individuals with complex medical needs who require more or less continual access to nursing care might be best served in a nursing home.26 Historically, however, the lack of availability of certain services has sometimes resulted in individuals being placed in inappropriate settings. Early in the development of the ICF/IID program, for example, many persons with ID/DD who did not require a high level of nursing care were placed in nursing homes rather than facilities specifically geared to their needs (Lakin and Hall 1990).27

The closure of larger ICFs/IID in recent years, combined with the greater emphasis on HCBS for the ID/DD population, raises the question of where enrollees who had previously used ICF/IID services were placed: in other ICFs/IID, in nursing homes, or in the community?

A substantial minority of enrollees in ICFs/IID were admitted to multiple types of institutions, with 994 of the 8,430 (12 percent) with ICF/IID admissions also receiving nursing home care during the 18-month study period (Table III.6). These 994 individuals represented a tiny share (0.1 percent) of all enrollees in nursing homes. Thus, while it is unusual for a nursing home resident to require ICF/IID care -- which requires a diagnosis indicating a need for such care -- it is not uncommon for ICF/IID residents to require nursing home services at some point.

TABLE III.6. Use of Nursing Homes and ICFs/IID by Aged or Disabled Enrollees with Multiple Spells Between July 2006 and December 2007
Enrollees with Multiple Spells and the Order of Spells   Number or Percentage  
Enrollees with both ICF/IID and nursing home spells 994
   Percentage of all ICF/IID residents 11.8
   Percentage of all nursing home residents 0.1
Enrollees with a first new ICF/IID spell followed by a nursing home spell 122
   Percentage with no gap between spells 46.7
   Percentage with a gap of 60 days or less between spells 84.4
Enrollees with a first new nursing home spell followed by an ICF/IID spell   872
   Percentage with no gap between spells 59.4
   Percentage with a gap of 60 days or less between spells 93.2
SOURCE: Mathematica analysis of 2006-2007 MAX data for 44 states and the District of Columbia with representative FFS nursing home and ICF/IID data (excludes data from Arizona, Indiana, Maine, Minnesota, New Hampshire, and Utah).
NOTE: New spells are spells beginning on or after July 1, 2006. Spells are censored at December 31, 2007.

Most ICF/IID residents with nursing home spells lived in the nursing home prior to being admitted to the ICF/IID. Of the 994 enrollees in ICFs/IID who had multiple spells of institutional care, 872 moved from nursing homes to ICFs/IID, while 122 moved from ICFs/IID to nursing homes. Many of these enrollees appear to have been transferred directly: 59 percent of enrollees moving from a nursing home to an ICF/IID did so within one day, and similarly for 47 percent of enrollees moving from ICFs/IID to nursing homes. The gap between spells was less than 60 days for the vast majority of enrollees with spells of both types of institutional care. Given that ICF/IID residents who also have spells of nursing home care tend to be older (Table III.2), it is possible that ICF/IID-to-nursing home transitions occurred for enrollees with ID/DD who required more frequent or intensive nursing care as they grew older. Although it is unclear why a much larger number of enrollees transitioned in the opposite direction, some might have been admitted to nursing homes either while waiting for an ICF/IID bed to become available or to receive post-acute care within our observation period.

Several states -- including California, Florida, Illinois, Mississippi, Nebraska, Oklahoma, South Carolina, and Virginia -- had especially high percentages of nursing home spells following ICF/IID spells within two months.28 Among these states, there was no net change in the number of ICF/IID facilities from 2006 to 2007, although California and Illinois both closed larger facilities during this time. During the same period, Mississippi and South Carolina both closed smaller ICFs/IID, and Oklahoma actually added ICFs/IID. Consequently, it is possible that the closure of ICFs/IID in some states partially explained the use of nursing facilities by persons with ID/DD. It is also possible that downsizing among ICFs/IID that continued to operate further contributed to transitions, particularly of frail or elderly enrollees, from ICFs/IID to nursing homes.

3. Did Enrollees Receiving ICF/IID Care Also Use HCBS?

A large number of enrollees admitted to ICFs/IID used HCBS either before entering the ICF/IID or after returning to the community. More than 40 percent of all enrollees with ICF/IID spellsbeginning in 2007 used HCBS at some point, and 54 percent of those enrollees with shorter stays (beginning and ending in the first half of 2007) used HCBS in the previous year (Table III.7). Similarly, 53 percent of enrollees with shorter stays beginning and ending in the latter half of 2006 used HCBS at some point in 2007.29

TABLE III.7. HCBS Use Among Aged or Disabled Enrollees with New ICF/IID Spells Between July 2006 and December 2007
HCBS Use Relative to First New Spell of Institutional Care   Percentage  
First new spells beginning in 2007 preceded by HCBS use in 2006 42.4
First new spells beginning in 2007 and ending on or before June 30, 2007, preceded by HCBS use in 2006   54.0
First new spells ending in 2006 followed by HCBS use in 2007 52.7
SOURCE: Mathematica analysis of 2006-2007 MAX data for 37 states and the District of Columbia with representative FFS nursing home and ICF/IID data and valid HCBS data (excludes data from Arizona, Indiana, Maine, Massachusetts, Michigan, Minnesota, Montana, New Hampshire, Oregon, Pennsylvania, Rhode Island, Texas, and Utah).
NOTES: New spells are spells beginning on or after July 1, 2006. HCBS includes 1915(c) waiver services, personal care services, residential care services, home health, adult day services, and private duty nursing services. Spells are censored at December 31, 2007. New spells beginning in 2007 preceded by HCBS use in 2006 refers to all spells beginning and ending at any time in 2007 (including spells censored as of December 31, 2007) that were associated with an enrollee who used HCBS at any time in 2006; the percentage is taken with respect to all first new spells beginning and ending (possibly censored) in 2007. The percentage of first new spells beginning in 2007 and ending on or before June 30, 2007, preceded by HCBS use in 2006 and the percentage of first new spells ending in 2006 followed by HCBS use in 2007 are defined analogously. State-level detail is provided in Appendix Table D.6.

Thus, despite the higher percentage of long-term stays in ICFs/IID, as compared with nursing homes (Figure II.1 and Figure III.1), substantially higher percentages of ICF/IID residents used HCBS before or following their stays (Table II.7 and Table III.7). It was common for a person with ID/DD in the study sample to use both HCBS and ICF/IID services, rather than only ICF/IID services. It is unknown whether this reflects: (1) changing levels of need for persons with ID/DD -- whereby the same individual uses either HCBS or ICF/IID services depending on his or her needs at a point in time; (2) a trial-and-error approach to identifying the most appropriate care setting for the individual; (3) ICF/IID closings; or (4) ICFs/IID -- specifically state institutions -- serving as crisis/emergency placement sites for individuals already being served either via HCBS or in another ICF/IID, or for people entering the Medicaid system in a crisis/emergency circumstance who are awaiting an alternative placement as soon as such a placement can be arranged.

The aggregate statistics on HCBS use before or after stays mask substantial variation across states. Considering shorter ICF/IID spells that began and ended during the first half of 2007,all had been preceded by HCBS use in 2006 in six states, whereas none of these spells was preceded by HCBS use in 12 other states.30 Similarly, 100 percent of shorter spells beginning and ending in the latter half of 2006 were followed by HCBS use in 2007 in five states, whereas no such spells were followed by HCBS use in another 12 states. Some HCBS use following ICF/IID stays was likely tied to the closure of a facility. For example, Iowa and Wisconsin both closed at least one-fifth of their ICFs/IID between 2006 and 2007. In these states, rates of 2007 HCBS use following shorter spells in the second half of 2006 were 100 percent, and 89 percent, respectively. However, other states that expanded their ICF/IID capacity during this period, such as Kansas and Kentucky, also had high rates of HCBS use following institutional stays.

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