Because this study is fundamentally broad and descriptive, the findings presented here lend themselves to only tentative conclusions but suggest directions for future study. Analyses that use detailed person-level and claim-level data, including the information available through MAX, are especially likely to enhance our understanding of what types of individuals are likely to benefit most from which type of care (institutional or HCBS), and under what circumstances.
Exploring the Continuum of LTC. As noted in Chapter III, although we treat HCBS and institutional care as separate types of service in this analysis, sharp distinctions are not always so easily made in reality. For example, small group homes for individuals with ID/DD might be financed through HCBS but appear identical in most respects to small community ICFs/IID.34 For moderately functionally impaired individuals who require nursing care, assisted living arrangements available through HCBS and nursing home services might look very similar. Greater knowledge of the nature of HCBS and institutional services provided by states' Medicaid programs, and how these services are changing over time, could contribute to a more complete understanding of how states have re-balanced their LTC systems and how to effectively continue re-balancing in the future.
Examining Level of Need. Enrollees with different levels of impairment require different services: although individuals with only mild limitations or family caregivers might benefit especially from access to HCBS, others who are severely impaired are far more likely to require institutional care. In assessing both the effectiveness of expansions of HCBS and the characteristics of those who continue to receive institutional services, future research that accounts for differences in individual levels of need in comparing populations using HCBS with those using institutional care would be valuable.
Defining Recipients of Medicaid-Financed LTC. This analysis included nursing home residents with very short stays (less than three months), even though many of these are likely to be individuals who require post-acute or respite care, rather than LTC. Future studies could seek to identify and exclude post-acute care users based on diagnoses and the presence of Medicare-financed services (which would require merging MAX data with Medicare claims data) to obtain a clearer profile of nursing home residents with LTC needs.
Examining Changes Over Time. Although comparisons across states such as those presented here can be informative, differences among states -- such as the extent to which states have re-balanced their LTC systems -- complicate the interpretation of any findings. These cross-sectional comparisons could be usefully supplemented with a more extensive study of changes over time, which could control for relevant differences in populations and policies among states. As with other avenues for future inquiry, performing the analysis at the individual level would facilitate understanding of changes in state populations of nursing home and ICF/IID residents as the states move toward greater provision of services in the community. The MAX data could be used to study changes over time as long as careful attention were paid to changes in the data that, if not explicitly addressed, could invalidate longitudinal comparisons.
Analyzing Transitions Between Types of Care. This analysis showed that use of multiple types of service -- either both nursing home and ICF/IID care or both institutional care and HCBS -- is not uncommon but was unable to determine why it occurs. A closer examination of the characteristics and circumstances in which transitions between different types of service occur would help policymakers assess whether individuals requiring LTSS are able to receive needed care and services in an appropriate environment.