Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. Ensuring the Availability of a Comprehensive Range of Home and Community Services


Since persons transitioning from institutions have widely varying needs, the transition process presupposes that a broad range of home and community services and supports is available. Yet, Medicaid HCBS waiver programs vary greatly in the comprehensiveness of services they provide, and in many states the home and community services system does not provide the amount, duration, and scope of services needed to enable people with severe disabilities or extensive nursing needs to live safely in the community.

New Service Developed to Enable Transition

During implementation of its Systems Change NFT grant, state staff in Rhode Island found that lack of day services was a transition barrier for persons with traumatic brain injury. Under a contract with an adult day services provider, grant staff established an adult day services program for adults with severe cognitive disabilities, many with traumatic brain injury. The new program is now funded as a Medicaid State Plan service under the Rehabilitation services option.

Some Systems Change NFT Grantees cited a lack of services for specific populations as a transition barrier; for example, when a state does not have a TBI waiver and the services available in other waiver programs do not meet the needs of persons with traumatic brain injury. Other barriers Grantees cited were (1) insufficient funding for home modifications and assistive technology; (2) HCBS waiver programs that do not provide all of the services a person needs; (3) lack of mental health and substance abuse services and supports; and (4) lack of agreement among state agencies about who is responsible for providing services for people with both physical and mental impairments, making it difficult to ensure adequate services for this population. The lack of nurse delegation provisions that enable individuals with complex medical needs to be served cost-effectively in the community can also be a barrier as can the lack of experience of HCBS providers in serving this population, which may make them reluctant to do so.

Lack of home and community services prevents diversion as well as transition. One NFT Grantee noted that timely access to in-home services is essential for diverting persons being discharged from hospitals. In the absence of these services, hospital staff will not discharge patients to their homes, sending them instead to a nursing facility. Clearly, before spending resources on transition activities, states need to ensure that a comprehensive range of services and supports are available in the community, particularly for individuals with severe disabilities and/or extensive nursing needs.

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