Using Medicaid to Cover Services for Elderly Persons in Residential Care Settings: State Policy Maker and Stakeholder Views in Six States. Waiver Program


In 1981, Oregon received the very first Section 2176 Medicaid Home and Community-Based Waiver. At that time, the state decided that home and community services would be treated as an entitlement, which meant that no waiting lists would be developed except for lack of providers.7

Oregon's waiver program provides in-home nursing, personal care, and housekeeping services, adult day services, and assisted living services. About three quarters of all in-home services are provided through a consumer-directed program--the Client Employed Home Care Program--which allows clients to hire, supervise, and fire, if necessary, their own workers, who can be friends, relatives or home care professionals. The state provides clients with administrative support (including the actual payment of wages, unemployment insurance and FICA), and will also help the client find suitable in-home workers.

A key feature of Oregon's waiver program is the use of nurse delegation, which has played an important role in its success. In 1987, the state enacted legislation directing the Board of Nursing to adopt rules allowing licensed registered nurses to delegate basic and special nursing tasks to unlicensed personnel. These tasks include almost all nursing tasks except injections. Nurse delegation has enabled home and community services to be provided at much lower cost than if licensed nurses had to provide all nursing care. The use of nurse delegation has been particularly important in the development of the state's adult foster homes and assisted living facilities.8


  1. Sparer, M. op. cit.

  2. Kane, R. L., et. al., Oregon's LTC System: A Case Study by the National LTC Mentoring Program, University of Minnesota, April 1996.


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