Medicaid-Financed Institutional Services: Characteristics of Nursing Home and ICF/IID Residents and Their Patterns of Care. III. the Characteristics of Enrollees Using ICF/IID Services and Their Spells of CARE


Medicaid enrollees with ID/DD generally benefit from access to a range of social and educational, employment-related, rehabilitative, and medical services tailored to their particular needs. To help meet these needs, states designed ICFs/IID to provide residential care and a variety of specialized services. In recent years, states have moved to serve the ID/DD population with HCBS, in part due to the Olmstead decision, which mandated that they be served in communities where appropriate. Consequently, people with ID/DD may live and receive services in a community setting or in an ICF/IID. Because many enrollees receiving HCBS live in group homes, and because not all ICFs/IID are large -- some have as few as four beds -- the distinction between ICF/IID and HCBS use is not a sharp one (despite the clean separation between the two types of service implied by some of the analyses below).

ICFs/IID were originally conceived as large institutions, but caregivers and policymakers quickly recognized the potential benefits of greater community integration, spawning the growth in the early 1980s of community ICFs/IID with between four and 15 beds (Prouty et al. 2008). The two types of ICFs/IID differ substantially. The number of individuals residing in large public ICFs/IID has decreased steadily over time (from 55,000 total residents in 1997 to 32,000 in 2009). Many states have either closed these facilities completely or downsized them as smaller institutions and community settings have gained favor as more integrated settings in which to deliver care. In still other states, however, state-run ICFs/IID areactive portals to the ID/DD service system, especially for crisis/emergency situations.19 While the populations of large institutions have declined, the number of individuals served by community ICFs/IID has remained more stable over time.20 Although they are of declining interest for new development, these "community" settings are noteworthy for both their stability as institutions and the stability of their resident populations over time.

Thus, although all ICFs/IID are technically institutions, the smaller community ICFs/IID represent an intermediate alternative on the continuum of ID/DD care between HCBS and care in larger institutions. Although we discuss ICFs/IID as a single group below, it is important to bear in mind that larger state-run ICFs/IID often look different from the smaller community ICFs/IID and the extent to which one type or another dominates varies extensively across states. These differences likely reflect different approaches to the care of the ID/DD population, including how HCBS is integrated with institutional services.21 Future research would benefit from the availability of data that permit the use of services in large state-run ICFs/IID and smaller community ICFs/IID to be explicitly analyzed and compared. Such data could be used to explore the movement of institutionalized individuals from larger care settings to smaller ones, as well as the variation in the use of services provided by large and smaller ICF/IID across states.

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