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Following the lead of early standout states such as Arizona, Minnesota, Oregon, and Washington, health policymakers in Connecticut have worked to give older adults and people with disabilities choices in where and how to live — an approach that can reduce costs for long-term services and supports, or LTSS, which make up a large share of Medicaid spending. LTSS, which are delivered by agencies or by individuals whom beneficiaries hire themselves, encompass a wide range of services including transportation and help with activities like bathing, dressing, cooking, and medication management. They may also entail home modifications, adaptive technology like screen readers, and other supports that make it possible for older people or those with cognitive or functional impairments to go to school, work, or socialize.
Connecticut’s leaders have been working for more than 10 years to ensure that residents who qualify for LTSS through Medicaid have the option of receiving these services in their homes or other community-based settings. The state’s efforts are part of a broader national movement to rebalance the share of LTSS spending to favor home- and community-based services (HCBS) over institutional care delivered in nursing homes and other facilities. Medicaid programs are the primary funders of LTSS, and on average getting care in the community costs about one-third that of institutional care. The COVID-19 pandemic, which led to a sharp increase in deaths at long-term care facilities across the U.S., has also made community care a more attractive option.
Since beginning its rebalancing initiatives in 2008, Connecticut has helped over 35,000 residents including people with disabilities, chronic and debilitating conditions, and frail older adults remain in their homes or move out of institutional settings. Program leaders have used data and stories to illustrate the benefits of their approach to Connecticut budget officials, state legislators, and advocates. Dawn Lambert, co-leader for Community Options in the Division of Health Services in Connecticut’s Department of Social Services, leads the state’s innovation strategy for rebalancing in Medicaid. She often points to one of the first residents to benefit — a man with Lou Gehrig’s disease who was determined to live out his years at home. “The home health staff who originally were not on board became convinced when they saw what it meant to this gentleman to be home, with his little dog on his lap,” Lambert says. It reinforces a point she makes often: “Just because somebody has a certain level of disability doesn’t mean they should have to live in an institution.” Nor should enrolling in Medicaid mean losing the opportunity to choose, she says.
To meet anticipated demand for HCBS as the population ages, Connecticut’s leaders have emphasized the importance of local planning, says Kate McEvoy, director of the Division of Health Services. In support of this, the state has commissioned analyses that track the supply of nursing homes and community housing stock as well as the corresponding need for caregiving workers in each of the 138 municipalities across the state. The first report, completed in 2012, projected that demand for long-term care would increase statewide by nearly 10,000 beneficiaries from 2010 to 2025, and that a greater percentage of beneficiaries would opt for home- and community-based services over institutional care (76% vs. 55%).
“Thus far the predictions have been totally on the mark,” McEvoy says. Having these local data has helped McEvoy and other leaders get buy-in from community partners, enabling “city and town planners, nursing home owners, first selectman, and legislators to understand projected demand for different types of services and the gaps in what’s available to meet them,” she says.
The 2020 analysis predicted that the aging of Connecticut’s population, consumers’ preference for home-based care, and the state’s rebalancing initiatives would shift 82% of long-term care into HCBS by 2040. So far, the state is on track to meet that target: as of fiscal year 2020, about 65% of Medicaid LTSS beneficiaries were receiving care in the community, up from 46% in fiscal year 2003.
Distinctive to Connecticut, these LTSS efforts are coordinated under a governor-led Strategic Rebalancing Plan, and many services and support are provided under a “housing plus services” model, in which Medicaid-funded services are combined with rental assistance vouchers as well as transition and tenancy-sustaining support. This plan includes efforts to:
Over the years, Connecticut has developed a range of complementary programs to meet the needs of different types of residents who require help to live in the community.
Since 2008, the state has been part of the federal Money Follows the Person demonstration, which helps Medicaid members who are living in nursing homes or other long-term care facilities transition back into the community. Federal and state funds are braided to enable people to live in apartments, assisted living facilities, or group homes. Thus far, the state has used $250 million in federal grant funding plus $11 million in enhanced federal matching funds to help move 6,271 people into the community. Funds pay for home modifications, security deposits, or other upfront costs as well as transition coordinators to develop care plans that support their personal and health needs.
In addition to this Money Follows the Person work, Connecticut has implemented several Medicaid waivers that enable it to provide older adults and people with disabilities help with bathing, dressing, taking medication, and similar supports. The largest of these — the Connecticut Home Care Program for Elders — pairs a Medicaid 1915(c) waiver with two additional state-funded tiers for people who have income too great to qualify for Medicaid. The state supports nearly 14,000 older adults in these circumstances, helping to disrupt what can be predictable pathways as people’s health deteriorates and they spend down their savings and wind up in nursing homes. “The idea is to support people earlier on in the process of spending their resources,” McEvoy says. “This program helps them maintain some stability and may help them avoid needing nursing home-level care.”
The state also has been ahead of the curve in supporting housing to promote health and well-being. The Money Follows the Person program has long paired HCBS services with housing vouchers, and over 15 years of research by the University of Connecticut Center on Aging has documented that access to stable, affordable, accessible housing is the key factor in enabling people to live successfully in the community. Connecticut has also been a standout in developing supportive housing models, in partnership with private entities such as the Corporation for Supportive Housing.
Building on these experiences, Connecticut launched the Connecticut Housing Engagement and Support Services (CHESS) Initiative this year. It will use a 1915(i) Medicaid State Plan Amendment to cover transition and tenancy-sustaining services and provide housing vouchers to serve up to 850 people who are unstably housed and whose average annual Medicaid costs exceed $40,000. CHESS will offer participants training in independent living, help getting food and other benefits, and coordination of their medical and behavioral health services. According to McEvoy, leaders view this work as not only vital in its own right but an opportunity to show how investments in social determinants of health can reduce Medicaid costs. Eventually, Connecticut hopes to employ a similar approach for others, including those returning to the community from jails and prisons.
Connecticut also plans to use new funding from the federal American Rescue Plan Act to integrate supportive technologies and assistive devices into seniors’ housing, among other investments. Such technology can reduce safety risks for elderly people living alone as well as their dependence on others to perform functions like opening doors and turning off lights. They may also reduce the burden on formal and informal caregivers. “If we can do more with assistive technology, we don’t need as many direct caregivers,” Lambert says.
Connecticut’s strategic rebalancing experience offers lessons for other states.
Since 2002, leaders have assiduously gathered data to demonstrate the impacts of supporting people in the community rather than in institutions, as well as the savings associated with community-based care.
In particular, the state has funded University of Connecticut researchers to conduct quarterly evaluations of the Money Follows the Person Demonstration, including key indicators related to rebalancing as well as surveys in which members are asked about their satisfaction with services, level of autonomy, mood, and other questions to understand their quality of life. Researchers publish these data in a public dashboard, ensuring third-party validation and transparency. Gathering feedback from LTSS recipients is essential to ensuring that social workers, clinicians, and others are honoring people’s wishes for independence and not imposing their views on their clients and patients, Lambert says. “‘Do people treat you the way you want to be treated?’ That’s an important question for us to ask people who are using HCBS services,” she says.
Over time in Connecticut, the proportion of Medicaid LTSS spending going toward home- and community-based services has increased (from 31% in 2003 to 54% in 2020) while the proportion going toward institutional services has decreased (from 69% in 2003 to 46% in 2020). Meanwhile, spending on LTSS as a percent of all Medicaid expenditures has plummeted, from more than half (56%) in 2003 to 42 percent in 2020.
Evidence of the success of the rebalancing strategy persuaded Connecticut Governor Ned Lamont and the General Assembly to allocate funding outside of the Medicaid budget for housing supports. For example, the state recently prioritized $2.74 million in housing vouchers to help house high-cost Medicaid members enrolled in the CHESS program.
Pursuing Medicaid waivers and state plan amendments that bring different agencies together to achieve Connecticut’s rebalancing goals requires a high degree of coordination. The state has facilitated this through the governor’s Office of Policy and Management. Funding for staff positions for the Money Follows the Person demonstration has been integrated into the state budget from the start, Lambert says, a move that brought heightened attention to program evaluation results and collaboration among departments.
The coordination also enabled the state to implement a universal assessment tool in 2012 for determining services and supports for people applying for home- and community-based services, regardless of their age or type of disability. Prior to that, Connecticut’s 11 different HCBS programs all had their own ways of collecting information, leading to inefficiencies (e.g., people who qualified for multiple programs had to fill out multiple assessments) and in some cases inequities (e.g., someone with lower needs could get more services than someone with higher needs).
The state has engaged a wide range of people and organizations serving LTSS populations. Most notably, Lambert has for more than 15 years convened an advisory body principally composed of consumers and advocates. Members provide a trusted lens for review and feedback on proposed plans, as well as an honest assessment of what is and is not working, she says.
Further, the state has longstanding collaborative relationships with nursing home associations and has provided technical assistance and resources to nursing home operators to help them diversify their services. Additionally, participants in the Money Follows the Person demonstration have partnered with home health agencies, housing agencies, and others to build the home care workforce and array of services.
The state is also soliciting expert advice to introduce smart technologies to senior housing units, including having experts from across New England provide technical assistance to facilities to spur adoption. “Absent that, it doesn’t naturally happen,” Lambert says.
McEvoy says many state leaders understand the importance of helping people who want to live in the community do so, but they may not explicitly recognize that people who receive LTSS are likely to be among the most complex and costly members served by Medicaid. They also may have concerns about the safety of serving people with high acuity in the community, the risk of provider fraud, and uncertainty whether members can effectively direct their own care. Hearing from people who have benefited from HCBS, especially those who direct their own services, can go a long way toward overcoming these doubts. “We tell the stories of the people everybody thought couldn’t live in the community but did,” Lambert says. The state has also worked with hospital discharge planners and social workers to educate them about community housing options and launched a “no-wrong-door” campaign to inform residents about the range of HCBS services available. States also need leaders fully committed to pushing for innovation. “You need somebody who sees things that could be a bit different and really wants to work to make things happen,” Lambert says.
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