Workforce Capacity – The National Academy for State Health Policy

State Strategies to Increase Diversity in the Behavioral Health Workforce

Paying Family Caregivers through Medicaid Consumer-Directed Programs: State Opportunities and Innovations

April 12, 2021/in The RAISE Act Family Caregiver Resource and Dissemination Center Connecticut, Florida, Virginia Featured News Home, Reports Chronic and Complex Populations, Chronic Disease Prevention and Management, Consumer Affordability, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health System Costs, Long-Term Care, Medicaid Managed Care, Population Health, State Resources, The RAISE Family Caregiver Resource and Dissemination Center, Workforce Capacity /by Salom Teshale, Wendy Fox-Grage and Kitty Purington

Family members provide significant amounts of care to relatives with complex needs, including those who are Medicaid enrollees.

Individuals may hesitate about receiving care in congregate care settings, particularly during the COVID-19 pandemic, but many face home-based care service workforce shortages. Programs that incorporate family members who provide care can help support person-centered care for Medicaid enrollees and also help states address the demand for long-term services and supports. States have the opportunity to use Medicaid to support enrollees with long-term care needs and their families by developing consumer direction programs that allow family members to be hired to provide care. This report explores how Connecticut, Florida, and Virginia developed consumer-directed care programs to serve older adults and people with physical disabilities.

Introduction

COVID-19 has upended states’ long-term services and supports (LTSS) systems and strained congregate care facilities. A recent report suggests virtually all states have seen a significant drop in skilled nursing facility occupancy rates . The increasing demand for home-based care is exacerbating underlying challenges, such as long-standing LTSS direct care workforce shortages and gaps in meeting the needs of communities of color and speakers of different languages.

Medicaid consumer–directed care programs are an alternative way individuals can receive home-based services. Consumers choose and hire their care providers rather than having an agency dictate who delivers care.

To address these challenges, states are exploring how Medicaid options can support enrollees with long-term care needs through consumer direction programs (also called consumer-directed care programs, participant direction programs, or self-direction programs) that allow family members to be paid for providing care. States have developed and expanded consumer direction programs over the past decades. Given increasing interest in home-and community-based care over institutional care, consumer direction programs are a growing option to offer older adults and people with disabilities an alternative to institutionalization. This report highlights three states’ self-directed care programs that include older adults and people with physical disabilities.

Findings suggest consumer-directed programs can improve quality of life and health outcomes and can help meet participant needs without increasing Medicaid fraud.

Medicaid-funded consumer direction- programs allow enrollees to directly hire people, including some family members, to provide personal care, such as bathing, dressing, and toileting. According to the National Council on Disability, consideration of consumer-directed personal care options began in the late 1960s and 1970s with calls for increased autonomy and independence by and for people with disabilities. While early pilot programs focused on people with disabilities, the model – and its core values of autonomy and dignity – have since been applied to programs for older adults. Findings from the Cash and Counseling Demonstration Program suggest consumer-directed programs can improve quality of life and health outcomes and can help meet participant needs without increasing Medicaid fraud. While small-scale studies have shown savings, states can also incorporate cost-containment mechanisms into these models through waiver enrollment or spending caps, or reimbursement methodologies that limit consumer-directed care payment to a percentage of agency rates.

States are increasingly using consumer-directed models; according to Applied Self-Direction, all 50 states and Washington, DC have at least one consumer direction LTSS option. Several federal initiatives, Centers for Medicare & Medicaid Services (CMS) guidance beginning in the early 2000s, the Deficit Reduction Act of 2005, and creation of the Community First Choice state plan option under the Affordable Care Act have expanded states’ ability to provide these programs. This trend is likely to continue as states:

Seek to address issues raised by the COVID-19 pandemic;
Promote equity and access to services in underserved communities; and
Address growing work force shortages.

Modifying or expanding consumer-directed programs can be an important strategy.

How States Can Develop Consumer-Directed Programs

States have multiple decision points when developing a Medicaid consumer-directed program.

Medicaid Authority: States can use various Medicaid authorities to support consumer-directed options that allow family members to receive reimbursement for providing care. Policymakers have many factors to consider when designing these waivers and/or state plan amendments, such as whether to expand Medicaid eligibility, whether to target specific populations or geographic areas, and what services and supports should be provided.

The majority of states operate consumer-directed programs through the Medicaid 1915(c) home- and community-based waiver (HCBS) authority. Using 1915(c) waivers, states can modify eligibility requirements, target services to particular areas of the state, and/or limit or tailor services to certain populations, such as older adults or adults with physical disabilities who are at risk of institutionalization. States can, depending on the authority, add self-direction options for different services into a single waiver.

Chart: Medicaid Authorities and Consumer-Direction Options

Medicaid authority	Is institutional level of care required?	Can states waive comparability?	Can states waive statewideness?	Financial management services required?	Budget authority/ cash payments allowed?	Limits on reimbursing family caregivers
1905 (a) (24) state plan personal care services	As medically necessary	No	No	Only fiscal employer agent required	Neither budget authority nor cash payments are allowed	Excludes “legally responsible individuals”
1915(c) Home and Community-Based Services	Yes	Yes	Yes	Yes	Budget authority is allowed, but cash payments are not	Allows relatives, legally responsible individuals, and legal guardians
1915 (i) Home and Community-Based Services state plan option	No (allows individuals with less than institutional level-of-care requirements depending on certain types of eligibility)	Yes	No	Yes	Budget authority is allowed but cash payments are not	Allows relatives, legally responsible individuals, and legal guardians
1915(j) self-directed personal assistance services state plan option	No, if receiving services through state plan and state plan does not require it Yes, if receiving services through a 1915 (c) waiver	Yes	Yes	Yes, unless participants choose to receive cash directly	Budget authority is required, cash payments are allowed	Allows legally responsible relatives
1915(k) Community First Choice State Plan Option	Yes	No	No	Yes, depending on the model selected	States may allow budget authority and cash payments to participants depending on the model selected	Allows legally responsible individuals, relatives
1115 Demonstration Waiver	Determined by state	Determined by state	Yes	Yes, when incorporating participant- direction	States may allow budget authority and cash payments to participants	Allows legally responsible individuals, relatives

Sources:
Authority Comparison Chart. HCBS Technical Assistance Web Site. Center for Medicare and Medicaid Services. Accessed Dec. 31, 2020.

Home and Community Based Services Authorities. Medicaid.gov. Centers for Medicare and Medicaid Services. Accessed Dec. 31, 2020.

Self-Directed Services, Medicaid.gov (Centers for Medicare and Medicaid Services), accessed Dec. 31, 2020.

Participant Direction Features of the Optional Medicaid Authorities, Table 7-1, p. 182. O’Keeffe, Janet, Paul Saucier, Beth Jackson, Robin Cooper, Ernest McKenney, Suzanne Crisp, and Charles Moseley. Understanding Medicaid home and community services: A primer, 2010 edition. Washington DC: US Department of Health and Human Services and RTI International, 2010.

Wolff, Jennifer, Karen Davis, Mark Leeds, Lorraine Narawa, Ian Stockwell, and Cynthia Woodcock. Family Caregivers as Paid Personal Care Attendants in Medicaid. Baltimore, MD: Johns Hopkins Bloomberg School of Public Health, 2016.

Enrollee authority: States can determine how care recipients manage their budgets, caregivers, and services:

Employer authority permits recipients to directly recruit and manage their service providers. Employer authority is integral to the consumer direction model. Depending on the authority, states have some flexibility to determine which employer responsibilities can be consumer-directed.
Budget authority allows enrollees to manage their budgets and purchase other goods and services. States also have flexibility in determining what types of goods and services can be purchased under budget authority.

Enrollee supports: States are required to provide supports for enrollees in managing the consumer-direction process, which can include training and assistance, information about responsibilities, or access to financial management services. For example, Virginia’s 1915(c) waivers include a “services facilitator” to support individuals in managing consumer-directed services.

Definition of “family:” States have discretion to determine who may provide HCBS under consumer direction. Under most authorities, states have flexibility to allow services to be provided by family members, including “legally responsible individuals” such as spouses or parents of minor children under specific circumstances. Within the 1915(c) waiver, for example, states have the option to allow relatives to provide waiver services, and/or allow legally responsible individuals, such as spouses and parents of minor children, to provide personal care services. When delivering personal care-related services, the legally responsible person must be providing care that is beyond the care normally expected of a spouse or parent. In defining family for reimbursement, the state plan personal care option is the exception: legally responsible individuals may not be paid under this authority to provide personal care services.

Training and workforce requirements: State Medicaid agencies often require background checks or certification requirements for caregivers.

States vary in the specifics of the training requirements for caregivers hired under consumer direction. Florida does not require licensing or certification to provide personal care, homemaker, or adult companion services, but does require licensure for attendant care.
States can, through legislation, specify the types of tasks that can be delegated by a nurse to an unlicensed caregiver who receives training, as in the example of Virginia’s regulations on nurse delegation. The AARP 2020 LTSS Scorecard found that 26 states allow nurses to delegate at least 14 health maintenance tasks to be performed by a direct care aide, such as medication administration, respiratory care, tube feeding/gastric care, and/or bladder regimen and skin/appliance care-related tasks.

Use of representatives: Participants can choose to have a representative assist them with managing their consumer-directed services. Individuals may appoint a family member as a representative, but that family member cannot be paid to be the participant’s representative, or provide paid care to the participant. (Note: Due to the COVID-19 emergency, emergency flexibilities may allow states to waive certain requirements during the public health emergency. For example, West Virginia’s Appendix K for its 1915[c] waivers allows legal representatives to receive payment for certain personal care-related services under specific circumstances during the emergency.)

Three State Approaches

States can structure consumer-directed program options in a variety of ways, reflecting the needs of their residents. After a nationwide scan of Medicaid waivers and state plan options for older adults and adults with physical disabilities, the National Academy for State Health Policy (NASHP) identified three states — Connecticut, Florida, and Virginia — that have long-standing consumer-directed care programs and illustrate the various policy strategies available to states to help Medicaid enrollees (and their family caregivers) who are older adults or have physical disabilities live in their communities.

Connecticut

Connecticut’s 1915(k) Community First Choice (CFC) State Plan Amendment was approved in 2015. Enrollees in Connecticut’s CFC option may hire, supervise, and train their own staff and manage their budgets themselves or with support of an individual other than a spouse or legally liable individual.

Medicaid authority: 1915(k) Community First Choice (CFC) state plan option
Services: Attendant care, transitional services, home-delivered meals, environmental accessibility adaptations, assistive technology, and voluntary training on how to hire/manage/dismiss staff
Family caregivers: Enrollees in the CFC option can hire family members or other individuals as long as they meet qualification requirements. (Excludes spouses and legally responsible individuals, health care representatives, conservators, or guardians.) Caregivers may live in the home.

Enrollees create job descriptions. Participants who choose to hire an attendant can request a pay rate subject to approval of the state. They can offer a particular wage if they believe the job description merits it (e.g., special skills, fluency in a particular language, etc.). In its 1915(k) SPA, Connecticut recommends that attendants, “be at least 16 years of age; have experience providing personal care; be able to follow written or verbal instructions given by the individual or the individual’s representative or designee; be physically able to perform the services required; and be able to receive and follow instructions given by the individual or the individual’s representative or designee.” Connecticut provides access to additional employee training opportunities, such as coordinating with a community college to provide personal attendant training certification or certified nursing assistant (CNA) training for personal care assistants (PCAs).

The Medicaid enrollee is considered the employer. The state’s Division of Health Services (DHS) establishes the budget and determines how much of the budget can be spent each month. If participants continually exceed their budget, they may lose access to the option, and DHS also tracks underutilization. While DHS does not specifically track the use of paid family personal care providers, a state official estimates that approximately 30 percent of the roughly 4,000 individuals who use the service engage family caregivers as PCAs. Connecticut’s CFC option can include older adults and people with physical disabilities, and Medicaid enrollees who require institutional levels of care are eligible.

Monitoring for fraud and abuse. Connecticut’s Quality Assurance unit examines referrals and has systems and controls in place to examine and flag PCA hours. One example of a system control is related to the state’s policy that disallows PCA services while a member is hospitalized. To disallow payments to PCAs submitting claims during their employer’s hospitalization, Connecticut’s Medicaid Management Information System (MMIS) compares PCA claims for the enrollee to hospital claims for the enrollee. If there is a hospital claim on the same day as a PCA’s claim, the PCA claim is not paid. In addition, the fiscal intermediary monitors for fraud and abuse. The state also established a fraud and abuse hotline and online reporting capacity to encourage public reporting.

Reimbursement. Connecticut established a universal assessment to evaluate levels of care for all Medicaid enrollees with HCBS needs in 2015, at the same time as the CFC option was being developed. Data from this universal needs assessment has been used since then to determine tiered budget groupings within the CFC option as well. Because CFC budgets are driven by the universal assessment — as are its other HCBS programs – a Connecticut state official reported costs did not differ greatly across programs. The state is in the process of working with consultants, including the University of Connecticut, to review the tool and the data collected from the universal assessment and to revise the current budget groupings.

Payment. The fiscal intermediary pays the PCA, then submits claims for reimbursement through the Medicaid Management Information System (MMIS). The state sends information about individual budgets to the fiscal intermediary. If enrollees want to pay their PCAs a different payment rate than listed in their individual budgets, they must submit documents about how risk would be managed. This is because individual budgets are based on needed hours at the minimum wage rate. While it is permissible for participants to request higher wages, this decision decreases the number of hours available within the budget. In 2020, Connecticut selected Allied Community Resources as its fiscal intermediary through a request for proposals. The provider fee schedule is posted at ctdssmap.com. As of 2020, PCAs in Connecticut are unionized and their minimum payment rate has increased. Some program costs also have increased accordingly.

Florida

In Florida’s participant-directed option (PDO), the managed care plan sets the fee schedule and makes payments. The PDO, which is provided by Florida’s Statewide Medicaid Managed Long-Term Care program, can serve both older adults and people with physical disabilities. The enrollee has responsibility for finding, training, and managing workers, setting hours, reporting fraud or abuse, and submitting timesheets to the managed care plan, among other responsibilities.

Medicaid authority: Statewide Medicaid Managed Care Long-Term Care (LTC) 1915(b)/(c) waiver, which includes a participant-directed option (PDO)
Services: Allows five services through PDO: adult companion, homemaker, attendant care, intermittent and skilled nursing, and personal care services
Family caregivers: Legally responsible individuals, including spouses, can provide PDO services as long as the caregiver is qualified, has executed a PDO work agreement, and has passed the necessary background checks; the enrollee can live in their own home or in a family member’s home.

The PDO initially began as a consumer direction pilot in 2000 administered by the state’s Agency for Health Care Administration (AHCA) and the Department of Elder Affairs (DOEA). In 2013, the participant-directed option was transitioned into the Statewide Medicaid Managed Care Long-Term Care (SMMC-LTC) program. Eight managed care plans offer PDOs. As of June 2020, slightly more than 119,000 enrollees were enrolled in the SMMC-LTC program overall. According to state data, out of 51,848 HCBS enrollees, 7,841 were participating in the PDO as of June 2020.

Specific family caregiver hiring information is not reported in the care plan, although all care is documented in the care plan, including whether services are administered through the PDO or traditional options. Because the PDO offers flexibility in hiring caregivers, the option can be used by enrollees who desire culturally competent caregivers, or who are not satisfied with other available options. Legally responsible individuals, including spouses, can receive reimbursement. In 2020, Florida included a caregiver training benefit as part of its LTC Waiver. Training is available based on a caregiver assessment administered through the managed care plan. Each managed care plan has its own training program. This caregiver training support can be utilized only for unpaid caregivers, however.

Monitoring for fraud and abuse. The Agency for Health Care Administration (AHCA), Florida’s Medicaid agency, monitors for fraud and waste through the state’s contracted Medicaid managed care plans, which are required to provide fiscal/employer agent (F/EA) services. The managed care plan either operates as a F/EA, or subcontracts to an F/EA vendor. The managed care plan is responsible for fulfilling certain F/EA-related tasks, including reporting of underutilization to participants/case managers, and following up with timesheet issues. AHCA conducts a desk review every quarter, which involves an audit process for compliance.

Reimbursement. Each plan has a designated fee schedule, and there are no caps from AHCA on the number of PDO hours that can be received by an enrollee, which is determined by medical necessity. Managed care plans or their vendors who serve as F/EAs provide payroll and tax management services for participants and are responsible for processing and payment of all applicable taxes on behalf of participants and their workers.

Virginia

Virginia’s consumer-directed option began in the mid-1990s and was available only to individuals with physical disabilities. Virginia’s options expanded over time to include individuals with cognitive impairment, and additional services, such as companion services and respite. These consumer-directed program services have since been incorporated into Virginia’s HCBS waivers. Consumer direction for older adults and people with physical disabilities is part of the Commonwealth Coordinated Care Plus (CCC Plus) program operated under a 1915b/c waiver.

Medicaid authority: Commonwealth Coordinated Care Plus 1915(b)/(c) waiver program
Services: Participants have the option to self-direct personal care and respite services
Family caregivers: As of 2020, relatives other than spouses or parents of minor children can be reimbursed for services, however, during the pandemic, spouses and parents of minor children can be reimbursed for care.

Enrollees selecting consumer direction are provided with a list of “services facilitators” as part of the screening process for level-of-care eligibility assessment (administered by local Virginia Department of Health nurses and physicians or local departments of social services’ family services specialists). Services facilitators are Medicaid-enrolled providers who support participants in managing their consumer directed services. Services facilitators can:

Assess a participant for particular consumer-directed services;
Help develop a plan of care; and
Provide training and support to the participant in performing their role as employer.

Participants can select workers and are considered the employer, but do not have decision-making authority over the budget. Within CCC Plus, a legally responsible relative can serve as the participant’s representative and be the employer if the participant is not independently able to self-direct care, but this relative cannot also be a services facilitator, paid caregiver, or attendant. Spouses and parents of children cannot be paid to provide personal care services, but other relatives can be paid under specific circumstances. Currently, flexibilities instituted due to COVID-19 under Virginia’s Appendix K waiver allow spouses and parents of children to provide services during the public health emergency.

Consumer direction is available for members living in their own homes or in family members’ homes. An estimated 40 percent of caregivers are family members, according to key informant estimates.

Monitoring for fraud and abuse. Payments to family caregivers under the CCC Plus program are monitored through the Quality Management review process in the Department of Medical Assistance Services (DMAS) using the same processes used to monitor other home-based and personal care services. However, if payments are made to a family member living in the same home as the participant, the member must provide documentation to justify hiring the relative who lives in the same home as an “option of last resort.” There are no limits that are specific to relatives on the number of hours of services that can be furnished.

Reimbursement. Participants in Virginia’s consumer-directed option must use a fiscal/employer agent, who conducts payroll functions on the participant’s behalf, including payment and withholding. DMAS issued a request for proposals to select the state’s fiscal/employer agent. The fiscal/employer agent must also process background checks. Managed care organizations in CCC Plus contract with a fiscal/employer agent, and follow the same processes as the state for consumer-direction. In the 2020 budget, a 5 percent increase beginning July 2020 and a 2 percent increase beginning in July 2021 to the salary rate for attendants was approved. Time and a-half payment up to 16 hours was also approved for attendants working over 40 hours per week providing Medicaid consumer-directed personal assistance, respite, and companion services.

Lessons Learned

State policy leaders interviewed for this report all expressed value for program flexibility and choice for enrollees receiving care. They also noted the broader state goals of providing home- and community-based services alternatives over institutional services as a critical factor in supporting self-direction for people requiring institutional levels of care, and paying family caregivers. Across the highlighted states, additional themes emerged:

- Consumer direction provides an important opportunity to support health equity and culturally competent care. By giving enrollees flexibility to select caregivers and employ family members, states enhanced their ability to support the needs of underserved populations. Both Florida and Connecticut officials highlighted that the consumer-directed option allowed participants to hire caregivers who met their cultural and linguistic needs. Connecticut’s Community First Choice state plan option allows enrollees, as the hiring employer, to develop job descriptions that can include speaking a specific language or possessing a particular type of certification.
- Paying family caregivers can be a cost-neutral Medicaid rebalancing strategy. States can set comparable (or lower) rates for family caregivers, manage service utilization, and support more individuals in home and community settings. Connecticut state health officials anticipated a shift from institutional care toward community-based services through use of its Community First Choice (CFC) option, and results are tracking accurately to the state’s initial estimates. Connecticut also reports a lower dependence on home health agencies. Utilization of Connecticut’s CFC program has grown since 2015, but a state official noted significant savings in other services. The CFC option also benefits from a 6 percent enhanced federal match. A state official in Florida also noted that the state PDO’s lower service costs make the program competitive when compared to similar services provided by a traditional vendor.
- Outreach to Medicaid enrollees is critical. States noted that the complexity of these programs can be a challenge to enrollment, particularly among participants who are uncertain about whether they would be required to manage their own budgets. Due to the COVID-19 pandemic and interest in avoiding facility-based care, states may have a heightened opportunity to raise awareness about consumer-directed options for personal care-related services.

Effects of COVID-19

Enrollment support for consumer-directed programs in the three states has increased as reliance on family caregivers grew during the pandemic:

Within a week of declaring the emergency, Connecticut permitted expedited enrollment so enrollees could hire family caregivers, and the state also allowed overtime. Connecticut has commissioned a report from the University of Connecticut to examine the impact of COVID-19 on LTSS.
Florida encouraged enrollment in its PDO to obtain or provide care during COVID-19, and the state has since documented an increase in new enrollees. State administrators report they are not concerned about sustaining their managed care PDO option because the option is cost-effective.
Virginia officials noted that family members have been designating themselves as live-in caregivers in response to COVID-19. Virginia used CARES Act funding to provide personal protective equipment (PPE) to caregivers and advocate in particular for caregivers of color. CARES Act funding was also used to provide COVID-19-related hazard pay to consumer-directed caregivers who worked during the first few months of the pandemic.

States may want to consider enhancing data collection to better identify family caregivers who are reimbursed through consumer-directed programs. States do not currently track whether enrollees in consumer-directed programs hire family members. States can consider tracking data on family caregivers within consumer-directed options to better understand the fiscal and health impact of incorporating family caregivers within these programs. Virginia officials are interested in developing mechanisms to encourage individuals who provide care to identify themselves as family caregivers. States could also support data collection to better analyze whether services are reaching at-risk populations and to better support underserved populations, including caregivers of different ethnic or racial backgrounds.
States have a number of strategies they can use to prevent fraud and abuse. A 2017 GAO report notes that personal care services are particularly prone to incomplete data, overbilling, and risk of neglect for vulnerable enrollees. States can incorporate a range of policies that can mitigate the risk of fraud while improving the quality of care, such as:
- Criminal background checks;
- Service provider requirements and training; and
- Use of care managers.

States can also leverage electronic visit verification (EVV) technology (mandated by the 21st Century Cures Act for personal care and home-based services) to mitigate fraud and abuse. Anticipating the particular needs of consumer-directed enrollees and family caregivers can help. Also, flexible scheduling, user-friendly technology, and active engagement of stakeholders in implementation can avoid challenges. Florida noted that some MCOs provide tablets to family caregivers to utilize for EVV.

Understand how employment and scope-of-practice laws can affect family caregivers receiving reimbursement through a consumer-directed option. Family caregivers can be considered employees and subject to a range of state and federal regulations that can impact state Medicaid programs. When the US Department of Labor issued a Final Rule regarding the Fair Labor Standards Act (FLSA) that live-in caregivers for specific services could be included in receiving overtime, Florida noted that overtime hour claims increased. Plans subsequently required use of in-network providers for service hours over 40 hours per week. While Virginia’s program focuses on caregivers who do not provide services that licensed or certified professionals provide, Virginia’s Nurse Practice Act has been amended to allow a nurse to delegate authority to caregivers to render certain tasks without violation of licensing regulations under specific circumstances.

Conclusion

The COVID-19 pandemic is reinvigorating long-standing state efforts to support older adults and others with LTSS needs while reducing reliance on congregate settings of care. Reimbursing family members to provide some services can help states rebalance long-term care toward more home- and-community-based options and promote more person-centered long-term care, especially for underserved populations. These considerations are particularly important as states consider winding down various program changes put in place in response to the pandemic. As policymakers consider ways to support enrollees while balancing financial considerations, robust consumer-directed options that engage family caregivers can provide important and person-centered strategies for long-term care.

Acknowledgements: The National Academy for State Health Policy (NASHP) thanks Dawn Lambert, Co-Leader, Community Options Unit, Division of Health Services (CT), Karen Kimsey, Director, Department of Medical Assistance Services (VA), and Eunice Medina, Bureau Chief, Medicaid Plan Management Operations, Agency for Health Care Administration (FL) for sharing their time, expertise, and input on this report. NASHP also greatly appreciates The John A. Hartford Foundation for its support of NASHP’s work related to family caregiving and state policy.

Spotlight on Home- and Community-Based Services: New Federal Opportunities?

April 5, 2021/in COVID-19 Relief and Recovery Resource Center Blogs, Featured News Home Chronic and Complex Populations, Chronic Disease Prevention and Management, COVID-19, Health Coverage and Access, Medicaid Managed Care, Population Health, Relief and Recovery, Social Determinants of Health, State Resources, The RAISE Family Caregiver Resource and Dissemination Center, Workforce Capacity /by Kitty Purington

Older adults, people with disabilities, and their family caregivers have been hard hit by COVID 19. As states reel from the pandemic’s human and fiscal toll, policymakers are increasingly looking to home- and community-based services (HCBS) to address the pressing need for alternatives to nursing home care and supporting family caregivers who can help loved ones age in place.

Recent actions signal that the importance of HCBS is gaining traction at the federal level, and may receive significant attention in the coming months:

The American Rescue Act, passed last month, includes a one-year, 10-point boost in Federal Medical Assistance Percentage (FMAP) for HCBS delivered between April, 2021 and March, 2022. The funding must supplement – not supplant – current state expenditures, and can be used for an expansive list of HCBS. These include Medicaid waiver services, but also case management and rehabilitative services, which are often used to support people with serious mental illness. The Centers for Medicare & Medicaid Services recently held a “listening session” to gather input for guidance that will be issued in the near future.
The American Jobs Act, released by the White House on March 31, 2021, has been touted by the Biden Administration as an historic opportunity to rebuild America’s infrastructure. Interestingly, a full quarter of the total $1.2 billion proposed expenditure would go to “expanding access to quality, affordable home- or community-based care for aging relatives and people with disabilities.” The plan targets expansion of Medicaid HCBS and would improve wages and conditions for the nation’s direct care workforce, a majority of whom are women of color.
Also last month, a group of members of Congress – Rep. Debbie Dingell (D-MI), Sen. Maggie Hassan (D-NH), Sen. Bob Casey (D-PA), and Sen. Sherrod Brown (D-OH) – sought input on the HCBS Act of 2021, draft legislation that would make HCBS a mandatory benefit in state Medicaid plans and expand the kinds of services offered, among other changes.

In the short term, states will need to act quickly to develop time-limited strategies to take advantage of the Federal Medical Assistance Percentage (FMAP) enhancement offered by the American Rescue Plan, and be prepared for other funding and policy opportunities as they emerge. States may choose to add enrollees to their existing HCBS programs, expand access by enhancing direct care workforce pay, focus on services to support family caregivers, and/or build on existing programs.

Explore the National Academy for State Health Policy’s (NASHP) State PACE Action Network for a new technical assistance opportunity for states to enhance or expand this home- and community-based services model. NASHP will continue to track these issues, and provide updates on state and federal initiatives that reflect the growing importance of HCBS.

The 2021 American Rescue Plan Act’s Major Health Care Provisions

March 15, 2021/in COVID-19 Relief and Recovery Resource Center Blogs, Featured News Home Consumer Affordability, COVID-19, Eligibility and Enrollment, Equity, Health Coverage and Access, Health Equity, Health System Costs, Housing and Health, Medicaid Expansion, Population Health, Relief and Recovery, Social Determinants of Health, State Insurance Marketplaces, Workforce Capacity Recovery and Relief /by Christina Cousart

States Quickly Retool Strategies to Maximize Vaccination Coverage

January 18, 2021/in COVID-19 State Action Center Blogs, Featured News Home Cost, Payment, and Delivery Reform, COVID-19, Health Coverage and Access, Health Equity, Population Health, Quality and Measurement, Quality and Measurement, Social Determinants of Health, Vaccines, Workforce Capacity /by Ariella Levisohn, Rebecca Cooper and Jill Rosenthal

Faced with limited vaccine supplies, a slow rollout of federal funds, and new federal guidelines allowing vaccination of those 65 and older, states face distribution challenges as they quickly evaluate which mass immunization practices are most effective.

Last week, the US Department of Health and Human Services (HHS) announced new federal recommendations to vaccinate everyone 65 and older and adults with pre-existing conditions. HHS directed states not to wait to finish Phase 1A vaccinations of health care workers before beginning vaccination of seniors.

While new federal guidance has spurred some states to pivot their distribution strategy, others had already begun vaccinating older residents more widely. With nearly 12.3 million doses administered of over 31.2 million total doses distributed, according to the US Centers for Disease Control and Prevention (CDC), many states are finding different ways to quickly get these shots into the arms of their residents. According to reports, about 39 percent* of total distributed doses have been administered nationally, while a handful of states have exceeded that rate through effective collaboration with hospitals, health systems, and pharmacies.

Explore this interactive map and chart to view each state’s priorities for vaccinating specific populations.

Every state is working to vaccinate populations identified in Phase 1A, including health care workers and nursing home residents. Below are challenges and emerging strategies state officials have identified to date in their efforts to vaccinate these populations.

Leveraging Relationships with Pharmacies

To reach residents and staff of long-term care facilities (including skilled nursing facilities that provide higher levels of medical care and assisted living facilities), the federal government partnered with large pharmacy chains, such as CVS and Walgreens, to manage all aspects of vaccine distribution – from storage to vaccine administration. Forty-nine states (all but West Virginia) and Washington, DC signed onto this federal partnership, but the program has proven challenging for states and vaccine roll-out has been slower than expected. While CVS and Walgreens have been able to provide first doses to most skilled nursing facilities participating in the partnership, CVS Health data shows that vaccination of assisted living and long-term care facilities has not yet begun in some states, including Alabama and Indiana. Pennsylvania just activated Part B of its Pharmacy Partnership plan on Jan. 14, 2021, which means pharmacies are only now beginning to vaccinate in long-term care facilities – Part A only provided vaccinations in nursing homes. In Mississippi, vaccination of some assisted living facilities through the federal partnership is not expecting to start until February.

State officials ascribe some of the inefficiency to big chains’ limited personnel capacity, the cumbersome process for getting written consent from residents, and the challenge of obtaining residents’ Medicare information for reimbursement. The federal pharmacy partnership only allows Walgreens and CVS staff to administer the vaccines, rather than partnering with long-term care facility (LTCF) staff. Despite both pharmacies onboarding additional staff to aid in the large-scale vaccination effort, some states, including Mississippi, found that Walgreens and CVS lack the personnel to vaccinate LTCFs quickly and efficiently, causing delays. Additionally, while federal law does not require nursing homes to get consent from residents or family members for vaccination, CVS and Walgreens do. Kaiser Health News (KHN) reports that these requirements have slowed down the vaccination process because they place an additional administrative burden on LTCF staff who must help obtain consent forms and provide patients’ insurance information. KHN noted that states and individual facilities that declined to partner with the federal pharmacy partnership are actually vaccinating at a faster pace.

Other states blame the lag on the structure of big pharmacy chain corporations that may not have had previous experience partnering with LTCFs in their communities. John Vincent, president of the Arkansas Pharmacist Association, explained that because the distribution plan was developed at the federal rather than local level, it does not work for every state or region. CVS and Walgreens, which contract directly with LTCFs under the partnership, have tried to adopt a one-size-fits-all approach to distribution at the federal level, rather than tailoring strategies to the unique needs of local communities.

Maine is also experiencing a lack of communication between the pharmacies and LTCFs, CVS and Walgreens are responsible for contacting facilities to schedule appointments, but without existing relationships, communication and coordination becomes more challenging. Recently, after confirming that Walgreens had unused doses on hand and had not yet scheduled appointments to administer them to LTCF residents, Maine asked the pharmacy to redistribute these doses to two hospitals in need.

However, states that partnered with local, independent pharmacies to distribute and administer vaccines have had more success. For example, West Virginia used a network of over 250 independent pharmacies to distribute the vaccine to nursing homes, LTCFs, and rural areas of the state. These pharmacies already had existing relationships with LTCFs – many of them provide medications, routine vaccines, and more recently, COVID-19 testing services to residents – and therefore already had patient data in their systems. This helped accelerate the distribution process because LTCF facilities did not need to take the extra administrative step of filling out burdensome forms related to consent and Medicare information.

Additionally, West Virginia pharmacies could schedule vaccination clinics at these facilities immediately and on their own schedule, as opposed to CVS, Walgreens, and other large pharmacy chains participating in the pharmacy partnership program. Under the federal program, the large pharmacies scheduled three separate visits to each facility:

The first two visits are for most residents and staff to get the two doses of the vaccine, and
The third visit was designed to vaccinate people who missed the first two visits.

But despite this three-visit plan, not all residents and staff were able to get vaccinated, and the limited supply has caused frustrations.

By leveraging existing partnerships and working directly with the facilities, West Virginia was able to identify residents, schedule those vaccine appointments, and secure any required consent forms, all before the state received any of its allotted doses.

Similarly, in Arkansas, 35 of the state’s 350 nursing homes that selected a local pharmacy to distribute the vaccine received doses within 72 hours. In comparison, only 15 percent of the doses that CVS and Walgreens received earmarked for Arkansas nursing homes have been delivered so far. In Washington State, a facility opted out of the federal partnership with CVS after learning the company’s first doses weren’t expected until Jan. 9, 2021. Subsequently, residents were able to receive the vaccine from a smaller pharmacy nearly two weeks early. In Maine, one independent pharmacy, which has been collaborating with LTCFs since 2018 to supply prescription drugs directly to residents, credits its success in reaching and vaccinating residents to the strength of its pre-existing relationship with the facilities.

In Montana, one small independent pharmacy was able to administer about 1,000 doses to LTCF residents in one week, equivalent to the number CVS and Walgreens jointly were able to vaccinate statewide in the same time period.

Collaboration between States, Hospitals, and Health Systems

Most health care workers have received the vaccine through their work venues, such as hospitals, public health offices, federally qualified health centers (FQHCs), and tribal health clinics. Doses are shipped directly from the Pfizer and Moderna distribution plants to larger hospitals, which have more storage capacity, and often these hospitals are then tasked with further distributing the vaccine to smaller, more remote facilities. Montana officials cite their close relationship between the state health department and hospital administrators, which includes weekly or twice weekly calls between the two parties, as helpful in rolling out a collaborative vaccine strategy. Montana has administered close to 50 percent of doses received.

Similarly, in Connecticut, where 52 percent of doses distributed have been administered, the state began holding weekly calls with hospitals and state agencies at the beginning of the pandemic to discuss current concerns and future plans, and troubleshoot any emerging problems. State officials believe the constant communication and coordination between state and local partners have helped their vaccine distribution process.

Despite this success, there are concerns that health care workers’ status and facility size and location are impeding their access to the vaccine. Reports indicate that in cities like New York and Boston, more affluent individuals who are affiliated with large hospital systems – but not currently eligible for the vaccine – have been able to obtain doses early. In Delaware, those working in private practices voiced frustration that they have not been able to get doses as quickly as those working at larger facilities. The minutia of distribution is not determined at the state level. As states expand access to the vaccine, it will be important to make sure that socioeconomic status and location are not barriers to vaccination.

Data Tracking/Reporting

Immunization Information Systems (IIS) – immunization registries used by states and territories to record vaccine administration, order vaccinations, and send out vaccination reminders to patients and the Vaccine Administration Management System (VAMS), a CDC system established to manage vaccine administration and provide real-time data from mass-vaccination clinics to federal agencies and state public health departments, are critical to states’ vaccine distribution pans. All states are currently using, or plan to use during later phases, their IIS or VAMS to:

Identify individuals in need of a first or second dose;
Track which vaccine and dose each person gets;
Notify individuals when they are eligible for the vaccine;
Invite them to schedule an appointment; and
Send a reminder about second dose appointments.

Many immunization registries also collect patient demographics, such as race, ethnicity, and age, which are useful for tracking vaccination trends and identifying health inequities. States are identifying challenges and solutions for data tracking and reporting.

Streamlining processes for informed consent: Obtaining consent from patients to have their data entered into immunization information systems (IIS) or the Vaccine Administration Management System (VAMS) is an additional challenge. State IIS have varying patient consent policies, reporting mandates, and data-sharing policies. Some states use a opt-in process, meaning that individuals’ data will not be shared in the information system unless the patient or guardian signs a form indicating consent, while other states use an opt-out process, meaning that individuals’ data will automatically be included in the information system unless they, or their guardian, signs a form indicating they choose not to participate in the data sharing program.

Generally, states with opt-out policies have higher vaccination rates and more comprehensive data; state officials have concerns about comprehensive data, especially when using an opt-in consent process. To eliminate these concerns, some states are temporarily changing consent requirements for their immunization registries. In New Jersey, Gov. Phil Murphy issued an executive order changing the state’s IIS system from opt-in to opt-out, and will automatically enroll patients choosing to receive the COVID-19 vaccine into IIS. Patients can disenroll from the registry 30 days after the public health emergency ends. New York waived consent requirements for reporting adult doses into IIS, a step they also took during the H1N1 pandemic.

Ensuring timely and transparent reporting of vaccination progress: With states vaccinating thousands weekly, they are striving to be transparent about how many doses have been administered and who is being vaccinated. Additionally, consistent and timely reporting is critical to determining which areas may be lagging behind in distribution, and which are more successful. Currently, many places are experiencing delays in data reporting to IIS and VAMS, while others are seeing doses under-reported. Providers and pharmacists, already working at capacity, are inputting all of their immunization data into the systems – sometimes by hand – within 24 hours of vaccination.

Some states have begun to address reporting challenges. For example, the Oregon Health Authority is providing technical assistance to vaccine sites to improve the timeliness of data entry into their IIS. In order to improve data collection and reporting, states could consider bringing in additional personnel – either volunteers or hired staff through additional federal funding – with the sole job of inputting data in vaccine databases.

Many states have also developed public-facing COVID-19 vaccine tracking dashboards detailing the status of vaccine rollouts. All dashboards include the number of doses administered, and almost all include counts of how many individuals received the full two-dose series. Many also include demographic information, including county, age, gender, race, and ethnicity. Pennsylvania developed a designated tracker for the type and location of facilities that have received a vaccine shipment. Similarly, Minnesota is publicizing number of doses administered by provider type. North Dakota’s dashboard shows the number of vaccine enrolled provider sites by county.

These dashboards are not only a valuable tool for residents to track progress in their state, but they can also offer insight into current vaccination priorities. For example, Minnesota’s tracker shows that as of Jan. 14, 2021, the majority of vaccines were shipped directly to providers in hospitals, pharmacies, and local public health offices, with several primary care and tribal health sites receiving doses as well. This is in addition to the doses sent directly to LTCFs through the pharmacy partnership.

Prioritizing equity in distribution: Given the disproportionate impact of COVID-19 on people of color, states have emphasized equitable vaccine distribution in their plans. However, if states do not invest upfront in strategies such as targeted outreach, hosting clinics in areas and at times accessible to populations of color, onboarding of Black and Latinx vaccine providers, and addressing vaccine hesitancy concerns, officials fear racial disparities in COVID-19 infection and vaccine rates will only increase.

While vaccination rates across states vary very little, and numbers are still low, trends are emerging, including racial disparities. North Carolina’s, early data from its dashboard indicates that, compared to the state’s overall distribution numbers, disproportionately more White and non-Latinx individuals have been vaccinated than Black and Latinix individuals. Additionally, after opening vaccine appointment sign-ups to individuals 65 and older, Washington, DC found that far more people in affluent areas with low COVID-19 infection rates had signed up (2,465 people, in one ward) than individuals in less affluent, majority-Black areas of the city (94 in the ward with the highest death toll had signed up for the vaccine). In response, the district is opening up additional appointments in the neighborhoods with low sign-up rates.

Effective Communication of Vaccine Distribution Information

With vaccination plans rapidly evolving, and public confusion rampant, it has become critically important for state governments to get messages out to providers and the general public quickly and clearly. States are identifying challenges and solutions for effective communication.

Establishing effective ongoing communication with health care facilities and providers: One challenge for states is to make sure that providers are up to date on the latest guidance, especially in identifying which populations are eligible to be vaccinated and when facilities will receive additional doses. In Texas, providers noted the challenge of having a lack of advance notice about vaccine shipment arrivals. In some cases, they had only a few hours advance notice about the first vaccine shipment and cited concerns about not having the necessary staff to set up separate vaccination sites on such short notice. As previously noted, Montana and Connecticut have seen success in distribution due to established and effective communication between the states and their local partners.

Responding quickly to changing needs: Because prioritization guidance from federal and state governments is changing rapidly as the result of the slow vaccination rollout process, some states have opted to use executive orders to quickly communicate new eligibility criteria to localities. In Arizona, Gov. Doug Ducey issued an executive order directing the Arizona Department of Health Services to reallocate vaccines when necessary in order to ensure statewide coverage and rapid administration.

He also ordered counties to publicize the priority population they are currently vaccinating and the location of vaccination sites on their websites.

In Utah, Gov. Spencer Cox used an executive order to extend vaccine eligibility criteria to teachers and individuals ages 70 and older. In the event that providers do not follow these guidelines, the state reserved the right to redistribute the vaccine or reduce supplies during future allocations. For states struggling to get information out to providers and localities quickly, executive orders may be a way to convey new guidelines to a large audience publicly and quickly.

Establishing and enforcing eligibility criteria: Currently, demand for the vaccine is far outpacing the supply. State and local health departments need a system in place connected to IIS to have a waiting list of people ready to receive the vaccine so they can be rapidly deployed. Stories abound about individuals who believed they were eligible for the vaccine and tried to book appointments, but could not. State and local health departments must have systems in place for rapid deployment and need to communicate effectively about how they work, while implementing their carefully considered phased approach. Otherwise, expedience may preempt prioritization, with individuals who have time or access able to jump the line ahead of the most vulnerable.

Many states (including Alaska, Mississippi, New Jersey, New Mexico, and Virginia) and several counties and local health departments have websites that allow individuals to check eligibility and sign up for vaccine appointments or get placed on a wait list. Some individual health care systems have also employed various text message programs. However, some health systems sign-up websites have crashed with overuse, and appointments booked up rapidly. Recognizing that not everyone has access to internet or computers, states have also set up phone lines for booking appointments.

Some states have also had technical difficulties when vaccine tracking systems incorrectly identified individuals for vaccination. For example, in Connecticut, teachers at one school received a notification that they were eligible for the vaccine and made appointments to get vaccinated, when in fact they were not yet eligible under the state’s plan. Those who already were vaccinated before the mistake was corrected will be able to get their second dose, and the Department of Public Health reported that they are putting safeguards in place to make sure this does not happen again.

Colorado also recently changed its priority list to vaccinate those over 70 before essential workers. But, some essential workers, including teachers at a charter school, had already signed up. The state health department encouraged those with existing appointments to keep their appointments, with the assurance that they would be able to receive their second doses.

Vaccine Administration Strategies

As states move to vaccinate new populations, lessons for ensuring sufficient staff and accessible venues will help guide efficient and complete administration.

Authorize a wide range of health care staff to administer the vaccine: The delays in administering the COVID-19 vaccine highlights a nationwide shortage of health care workers. HHS issued guidance in September 2020 to allow licensed and registered pharmacists to order and administer the COVID-19 vaccine to individuals age 3 and older, providing relief from scope of practice laws. Pharmacists have been involved in the Pharmacy Partnership for Long-Term Care Program, administering vaccines in LTCFs and will be instrumental once states begin vaccinating the general public. In other regions, dentists and dental assistants have been licensed to administer the vaccines.

Since March 2020, states have used a variety of policy levers to expand and relax scope-of-practice laws for health care providers in order to overcome personnel shortages. Similarly, given the enormous capacity demands of states’ COVID-19 vaccine distribution plans, many states and the federal government have begun allowing more providers and non-traditional vaccinators to administer vaccines. A December 2020 report by the National Governors Association and the Duke-Margolis Center for Health Policy found that 20 states had included plans to onboard non-traditional providers, such as dentists and emergency medical technicians (EMTs) in their vaccine distribution plans.

In December 2020, an Oregon provider became the first dentist in the United States to give a COVID-19 vaccine, and in early January 2021, California approved a public health emergency waiver authorizing dentists to vaccinate against COVID-19. In South Carolina, some ambulance agencies are training paramedics to administer the vaccine, and expect that they may eventually go directly to people’s homes to vaccinate them , and in Illinois, the director of the Department of Public Health modified EMT’s scope of practice to allow advanced and intermediate EMTs to vaccinate.

State officials hope that expanding providers’ capacity to administer vaccines might help reach more individuals faster, especially as states expand priority phases to include more people. According to Claire Hannan, executive director of the Association of Immunization Managers, staffing is one of states’ greatest needs. Expanding scope-of-practice laws is one way to increase staffing, but Hannan suggests that states might also consider using new federal money to onboard more staff — both those who can physically administer the vaccine and those who can help with data entry, provider enrollment, and vaccine ordering.

Establishing accessible vaccination venues: As states move into new distribution phases, processes will change, shifting from closed to open points of distribution. Many states are planning to open mass vaccination clinics to help distribute the vaccine more rapidly to residents. Over 50,000 people in Pennsylvania have already registered for the vaccine, and one Pennsylvania clinic reported having 2,600 doses and plans to inoculate three to seven people every five minutes. New Jersey announced the sites of six mass vaccination clinics across the state, which include two malls, two convention centers, a stadium, and one college facility; and as of Jan. 18, 2021, some of them had begun vaccinating people in eligible phases.

In Oregon, four health systems are joining forces by pooling their COVID-19 vaccines and staff to run a clinic at the Oregon Convention Center to serve eligible residents starting Jan. 23, 2021, which will include people over age 65 and teachers. Montana plans to use federal money from the new stimulus package to finance mass vaccination clinics run by community health centers and local health departments. To staff these clinics, many states are using the National Guard and local health care workers, with some also tapping EMTs for the job.

So far, states that have already started operating mass clinics have found them to be effective at vaccinating large numbers of individuals in a small amount of time. Arizona began vaccinating people at State Farm Stadium, which has been so successful that the state announced they are opening additional sites beginning Feb. 1, 2021, with appointment registration beginning this week. Additionally, a vaccination clinic operating at the Mercedes-Benz Stadium in Atlanta was able to vaccinate over 4,000 people in its first week of distribution.

States and counties running these mass clinics are using different mechanisms to track vaccine administration and monitor individuals for any adverse reactions immediately after vaccination. In Oregon, members of the National Guard are helping run the clinics, including assisting with traffic control, processing electronic medical records data, monitoring individuals after vaccination, and even administering vaccines. Clark County, Wisconsin officials asked that anyone coming to their drive-through vaccination clinic complete a COVID-19 Vaccine Administration Record beforehand, which includes demographic and medical history information that is then shared with the Wisconsin Immunization Registry. Clark County also has EMTs on site to help monitor individuals after vaccination.

The New Jersey Convention Center, which will be the site of up to 2,400 doses per day, has 100 staffers on site – including health care workers and National Guard members – to provide registration and security services, administer the vaccine, and monitor individuals post-vaccination.

Mass vaccination clinics are promising. Questions remain, such as how to operate them efficiently and:

Avoid reported long lines and staffing issues, while also following COVID-19 safety and distancing protocols;
Ensure equal access for everyone who wants to get vaccinated; and
Address concerns of those who may feel more comfortable getting vaccinated in familiar, community settings with trusted providers who can answer any of their questions and ease anxiety about the process.

Deploying leftover doses: Due to the short shelf life of the vaccine and the number of people choosing to delay getting it, vaccine administrators are often faced with the challenging situation of finding individuals to vaccinate before the doses expire. States are working to ensure that leftover doses are not wasted. New York health care providers now must use their total vaccine allocation within a week or face a penalty. Florida also announced hospitals would face fines for not using their total allotment of vaccines, and the state deployed an additional 1,000 nurses to aid in administering vaccines and help keep clinics open seven days a week to ensure doses do not go unadministered. Other states, including Connecticut, have released guidance policies to prevent wasted vaccinations. According to the Connecticut Department of Health guidance, vaccine providers should keep a wait list of people to call in case they have extra doses.

These state tactics show that having an enforceable plan is critical to ensure doses are provided to priority patients and not wasted.

Looking Forward

Through previous CARES Act funding, HHS distributed $200 million across 64 states and jurisdictions for vaccine planning and preparedness. Though originally earmarked to be spent by Dec. 31, 2020, HR 133 extended the deadline for states to spend down their CARES Act funding for an additional year, sunsetting at the same time as HR 133. State officials had noted that this funding was insufficient for adequate vaccine planning and distribution.

The omnibus bill (HR 133) signed into law on Dec. 27, 2020, includes $8.75 billion in funding for states’ vaccine distribution with a spending deadline of Dec. 31, 2021. These funds will be distributed to federal, state, local, territorial, and tribal public health agencies to “administer, monitor, and track coronavirus vaccinations to ensure broad-based distribution, access, and vaccine coverage.” In this fund, $300 million has been earmarked for distribution and administration of vaccines in high-risk and underserved populations, including populations of color and rural populations. The new funds will be available to states within 21 days, but many are concerned that it is too late to fully support the staffing required in the roll out.

An additional $3 billion is available to states through the Coronavirus Response and Relief Supplemental Appropriations Act to support state’s COVID-19 vaccination activities through an existing CDC Immunization cooperative agreement. States are identifying what the money will be used for specifically.

Last week, President-Elect Joseph Biden announced a $20 billion national program to establish community vaccination centers across the country, including mobile units in more rural and remote communities and mass vaccination clinics. This plan must be approved by Congress, but demonstrates his priorities of comprehensive coverage and equitable distribution. As states await action on Biden’s proposal, their efforts to launch mass vaccination clinics can inform federal policy and establish an infrastructure for speedy deployment as more vaccine becomes available. Similarly, states can report on the challenges experienced with the chain store program and how they were remedied in order to ensure the problems are not repeated.

*As of 8 p.m. Jan. 18, 2020.

This analysis is supported by the Centers for Disease Control and Prevention (CDC) of the US Department of Health and Human Services (HHS) as part of a financial assistance award totaling $200,000 with 100 percent funded by CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS or the US government. CDC General Terms and Conditions for Non-research Awards, Revised: January 2021.

Michigan Medicaid Addresses Social Determinants of Oral Health through Dental and Medical Contracts

January 15, 2021/in Medicaid Managed Care Michigan Blogs, Featured News Home Child Oral Health, CHIP, Consumer Affordability, Cost, Payment, and Delivery Reform, EPSDT, Health Coverage and Access, Health Equity, Health System Costs, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Oral Health, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement, Social Determinants of Health, Special Populations and Services, Workforce Capacity /by Ariella Levisohn

Inequities in dental care are prevalent across the United States, with significant disparities based on age, race, ethnicity, and socioeconomic status. Economic factors, such as ability to pay for dental insurance, and social factors such as food insecurity and access to nutritious food options also play a large role in oral health outcomes.

In Michigan, state Medicaid medical and dental managed care contracts now include requirements to address social determinants of health (SDOH) among enrollees. Examples of these requirements include:

Incorporating oral health into community health workers’ training curriculum;
Collaborating with community-based organizations (CBOs);
Collecting data on enrollees’ SDOH and using it to target outreach and educational activities; and
Implementing quality assurance and improvement projects that promote equitable access to oral health care.

Michigan’s Medicaid medical and dental managed care contracts demonstrate a proactive approach to identifying and addressing SDOH among Medicaid enrollees. While budget shortages resulting from the COVID-19 pandemic may make it more difficult for states to take on additional initiatives, addressing SDOH in Medicaid contracts can decrease costs and improve oral health outcomes. States that want to encourage dental plans to take on a larger role in promoting equitable access to care and addressing SDOH could adopt initiatives similar to Michigan’s.

These types of Medicaid contractual requirements are important first steps in improving SDOH among enrollees, while strengthening monitoring and enforcement requirements are also critical tools when adequate funding and personnel are available.

Why Focus on Oral Health and SDOH?

SDOH are the conditions in the places where individuals live, learn, and work that may affect their health risks and outcomes. They include factors such as food access, housing stability, educational attainment, poverty, health literacy, and transportation, among others. Social determinants dictate an individual’s access to health care and quality of care, which directly affect physical and oral health and exacerbate health disparities. For example:

Low-income children are twice as likely to have dental caries (tooth decay) than children from higher-income homes; and
Individuals who are poor or have less than a high school education have edentulism (toothlessness) at a rate three-times higher than those with higher incomes or more education.

Increasingly, Medicaid medical and dental managed care organizations are implementing initiatives designed to address SDOH among their members in order to improve oral health and promote health equity.

While all states cover dental care for Medicaid-enrolled children under age 21 as part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, adult dental coverage is optional for state Medicaid programs. Currently, 35 states provide limited dental benefits for adults and 19 states offer extensive adult dental benefits. However, optional adult benefits, such as dental care, may be affected by state efforts to meet continued budget challenges arising from the COVID-19 pandemic. Dental disease, though, not only adversely affects oral health but is also associated with diabetes, heart disease, stroke, and low birth weight and preterm births. Preventive dental care has the potential to improve overall health and well-being and reduce costs.

How Michigan Addresses Oral Health and SDOH

In NASHP’s recent 50-state scan of Medicaid managed care medical and dental contracts, Michigan was one of only three states (out of 19 reviewed) to consistently and directly reference SDOH in their Medicaid dental plan contracts.* Additionally, Michigan’s Medicaid medical managed care organization (MCO) contract includes detailed requirements for addressing SDOH, many of which align with the dental plan’s language and promotes coordination between physical and oral health care. While written contractual requirements do not guarantee that medical and dental plans are actively engaged in implementing SDOH-related initiatives – especially in the absence of funding to monitor these programs – Michigan’s contracts offer valuable examples of potential ways to address SDOH that other states could adopt as a first step.

Michigan Delivery System Overview

Michigan Medicaid uses a managed care system to deliver medical and dental care, and the Medicaid dental benefit is carved out and administered by various dental plans contracted by the state. Michigan Medicaid covers limited dental services for adults, including dental check-ups, teeth cleaning, X-rays, fillings, tooth extractions, and dentures. Additionally, the state offers an enhanced dental benefit for Medicaid-eligible pregnant women that includes emergency dental treatment and some oral surgeries. Michigan also administers the Healthy Kids Dental program, which covers comprehensive oral health care for children under age 21 enrolled in Medicaid.

Dental Contract Language

Michigan stands out because of the state’s frequent and direct mentions of SDOH throughout its Healthy Kids Dental (HKD) model contract. The HKD contract reflects a broad range of required initiatives related to SDOH, including:

Collaboration with community organizations;
Data use to target interventions and assess population-wide social needs, and
Implementation of quality assurance and improvement projects that reduce barriers to oral health care.

Collaboration with Community Organizations

One way dental plans can help address SDOH-related needs is by working with community-based organizations (CBOs). CBOs play an important role in connecting individuals to social services and helping people access health-related social needs, such as healthy food, transportation services, and educational materials that promote health literacy.

Michigan requires dental plans administering the HKD program to “collaborate with community-based organizations to facilitate the provision of enrollee oral health education services to ensure the entire spectrum of social determinants of oral health are addressed, e.g., housing, healthy diet and physical activity.” Michigan also encourages contractors to “build relationships with community partners that will engage in integrated care and promote good oral health practices.”

Through dynamic and active partnerships with CBOs, dental plans can more easily refer individuals to social and community services to help address members’ needs. Additionally, these partnerships with CBOs allow the state to expand its reach to more Medicaid-eligible children through educational initiatives.

Dental plans can also encourage members to work with CBOs and other public health programs by implementing their own educational programs. Michigan lists community-based public health resources on its website, and requires dental plan contractors to institute educational, public relations, and social media programs to increase awareness of available resources, such as CBOs, that can help reduce the impact of social determinants of oral health.

Data Collection, Tracking, and Reporting

While coordinating with social and community resources is an important step in improving health equity, having strong mechanisms in place to collect and track community data is critical to ensure social determinants are addressed. Michigan stands out in its commitment to require that medical and dental plans collect SDOH-related data.

Michigan requires HKD contractors to collect data on SDOH and utilize enrollment files, claims, encounter data, and utilization management data to improve community collaboration and address oral health disparities. The state specifies that the dental plan must “use social determinants of oral health data provided by [the Michigan Department of Health and Human Services] to analyze member-level data to direct the contractor’s efforts of targeted interventions, outreach, enrollee education and health promotion.” Additionally, the dental plan must report on the effectiveness of its population health management programs, including measures identifying the number of enrollees experiencing a “disparate level of social needs,” such as limited transportation access and housing instability.

Michigan’s data utilization requirements range from addressing individuals’ health-related needs to analyzing population-wide equity issues. Plans are required to gather and utilize this information for finetuning their services, such as care management and referrals. However, given that requirements for health plans to collect SDOH-related data are fairly new, and the state has little funding available for this work, the state’s role in monitoring whether data collection is occurring is currently limited. With adequate funding and personnel, states can take a more active role in tracking and data analysis to better understand the social needs of the population and effectively target SDOH-related interventions.

Quality Assurance and Performance Improvement

Michigan is committed to not only reporting on the effectiveness of SDOH-related initiatives, but also working to improve existing systems to better address inequities in oral health. The HKD contract requires the dental plan to have a Quality Assurance and Performance Improvement (QAPI) plan that includes a description of how the contractor will, “develop system interventions to address the underlying factors of disparate utilization, health-related behaviors, and oral health outcomes, including, but not limited to, how they relate to utilization of dental emergency services,” and “ensure the equitable distribution of dental services to contractor’s entire population, including members of racial/ethnic minorities, those whose primary language is not English, those in rural areas, and those with disabilities.”

SDOH can contribute to variances in utilization of dental services and poor oral health outcomes, with factors such as geographic location and language proficiency playing an important role in driving health care access. In addition to using data to better understand the impact of social factors on members’ oral health and population utilization trends, Michigan requires contractors to continue to find new ways to reach all populations and reduce the effects of SDOH on oral health outcomes.

Medical Contract Language

Much of the language related to SDOH included in the Healthy Kids Dental contract is consistent with the language in Michigan’s Medicaid medical MCO contract, which covers adults and children. Both the HKD and MCO contracts require the plan to collaborate with CBOs to provide physical and oral health education and address SDOH, implement community education campaigns to improve public knowledge of community-based resources, report on the effectiveness of SDOH-related population health management initiatives, and promote equitable access to care using Quality Assurance and Performance Improvement (QAPI) projects.

However, the medical contract also offers additional opportunities for investment in SDOH that states could consider implementing in dental contracts. For example, Michigan requires medical MCO contractors to participate in the Medicaid Health Equity Project, which is a statewide effort to address racial and ethnic disparities. Through this project, Medicaid health plans collect and report on data across multiple quality measures, including access to preventive and ambulatory health services. The state then uses data stratification by race and ethnicity to determine how racial and ethnic discrimination affect each quality measure, with the goal of addressing any disparities.

Additionally, the medical contract requires health plans to enter into agreements with CBOs to coordinate “population health improvement strategies,” which address social determinants such as physical environment and socioeconomic status. These agreements with CBOs must include information on data sharing, each partner’s role in care coordination, reporting requirements, and plans for coordinating service delivery with primary care providers.

What are Key Considerations and Next Steps?

Addressing SDOH is critical to improving oral health, overall health, and health equity. Increasingly, Medicaid dental plans across the country are collecting data on community needs and implementing initiatives to reduce barriers to oral health care. In a recent 50-state scan of Medicaid managed care contracts, NASHP found that out of 19 dental contracts and 38 medical contracts reviewed nationally, 13 and 37, respectively, require the plan to coordinate with community services. Efforts to address SDOH are also underway, though they tend to be further along on the medical side than the dental side. This provides an opportunity for states to apply medical contracts’ language in their dental contracts, or work with health plans to link existing SDOH-related programs with the dental system.

In response to budget shortfalls resulting from the COVID-19 pandemic, Michigan’s Medicaid program now faces potential rate changes, particularly for dental payments. However, program staff report they see opportunities to establish shared performance metrics between Medicaid MCOs and dental plans in the future. The state is considering ways to standardize and refine SDOH-related data collection and analysis, especially related to dental care. Michigan health officials noted the necessity of first ensuring data was valid and reliable before using it to drive decisions or implement capitation withhold incentive programs. The state is also discussing leveraging Michigan’s health information exchange to transmit standardized SDOH screening information to plans and providers.

Through the Healthy Kids Dental and Medical MCO contract, Michigan has demonstrated a strong commitment to addressing social determinants of oral health. The contracts present an opportunity for states to adopt similar language in order to encourage dental plans to coordinate with CBOs, effectively collect and use SDOH-related data, and implement performance improvement projects aimed at reducing disparities.

* NASHP scanned Michigan’s Healthy Kids Dental model contract and the Michigan Medicaid Medical MCO sample contract.

Acknowledgements: This fact sheet was made possible by the DentaQuest Partnership LLC. The author would like to especially thank Trenae Simpson for her guidance and assistance, and state officials in Michigan for their helpful feedback. The information, content, and conclusions are those of the author’s and should not be construed as the official position or policy of the DentaQuest Partnership LLC.

States Need Federal Guidance to Plan for When the Public Health Emergency Ends

October 5, 2020/in Policy Blogs Health Coverage and Access, Health IT/Data, State Insurance Marketplaces, Workforce Capacity /by Anita Cardwell

While the federal COVID-19 public health emergency – which allows for a range of state and federal policy flexibilities in programs such as Medicaid – was recently extended, considering the significant number of pandemic-related policies that states have implemented, officials need to begin preparing now for the eventual end of the emergency. Currently, there is little federal guidance about how states would unwind the many policy changes they have implemented in response to the pandemic.

In addition to the absence of directions detailing how states can return to pre-public health emergency (PHE) operations, states are still challenged by the economic effects of the pandemic, including significant declines in revenue that have depleted many state budgets. Meanwhile, thousands of individuals who have lost income or employer insurance coverage have enrolled in Medicaid, imposing an additional strain on state resources.

During the National Academy for State Health Policy’s 2020 annual conference and in recent discussions with leaders, state policymakers have expressed the need for ample time and federal guidance to prepare for the end of the PHE. A letter sent by the Medicaid and CHIP Payment and Access Commission (MACPAC) in late August to Department of Health and Human Services (HHS) Secretary Alex Azar echoed these concerns and also raised the issue that some state Medicaid agencies may need state legislative approval for certain program changes required to transition back to pre-PHE operations.

“Delayed guidance, unrealistic expectations, or short implementation time frames for eligibility redeterminations and provider revalidations could disrupt state operations, result in beneficiaries churning on and off of Medicaid coverage, and jeopardize access to care.” – Medicaid and CHIP Payment and Access Commission

MACPAC recommended that federal officials should provide states with a minimum 90-day advance notice of the PHE’s termination, and that federal guidance about returning to regular processes should be provided to states as early as possible.

One of states’ key concerns is disenrolling individuals from Medicaid who may have become ineligible during the PHE. This is because the Families First Coronavirus Response Act (FFCRA) provided enhanced federal Medicaid matching funds tied to maintenance of effort (MOE) requirements that include a prohibition on terminating Medicaid coverage of individuals who were enrolled as of or after March 18, 2020. To comply with that requirement, often referred to as the “continuous coverage” provision, states are not fully processing their traditional Medicaid renewals. The purpose of this MOE requirement is to help prevent coverage disruptions, particularly at a time when consumers may be especially in need of coverage, yet also experiencing extreme fluctuations in income.

Although the increase in federal Medicaid funds provided by the FFCRA and the other MOE requirements do not expire until the end of the quarter in which the PHE ends, the continuous coverage provision ends on the last day of the month of the PHE. However, due to a number of reasons, states will not be able to immediately return to the regular processing of eligibility renewals. As noted by MACPAC, restarting these processes will require states to collect new information about enrollees’ income and other criteria to re-verify eligibility. To do so, states will need to make a number of eligibility system, policy and process changes.

States have emphasized the need for flexibility when reinstating eligibility redeterminations. For one, changes will need to be implemented within the context of strained state administrative capacity due to budget cuts, staff furloughs and reassignments to other departments to respond to COVID-19, early retirements, hiring freezes, and the need to focus on addressing increased demand for state-supported services. States also have different IT systems for determining Medicaid eligibility, each with distinctive programming challenges. This is further complicated by the fact that systems must be coordinated, and in several cases fully integrated, with health insurance marketplaces, a major vehicle through which consumers may seek Medicaid and marketplace coverage. Given these complications, states have expressed the need for a “menu of options” from the Centers for Medicare & Medicaid Services (CMS) detailing how to phase out the changes put in place during the PHE. Requirements for notifying enrollees about program and eligibility changes also vary by state, and states need time to develop notices and send out information to both individuals and providers about coverage changes.

Another important issue is that because the renewal process is currently backlogged, it could overwhelm states if federal officials require them to go back and process redeterminations for individuals with renewal dates that have already passed. In anticipation of the eventual end of the PHE, some states have been continuing to send out renewal notices to enrollees to gather and assess their information. In these states, coverage for eligible individuals is extended and while no action is taken to disenroll those who appear to be ineligible, they can be identified for follow-up at the end of the PHE. But many state officials have indicated that it would be helpful if federal guidance instead allows them to focus on moving forward with a rolling renewal date process when the PHE expires.

Colorado’s Department of Health Care Policy & Financing recently sent a letter to CMS administrators requesting certain federal actions to help it plan for the end of the PHE. Specifically, the state asked that CMS provide at least 60-days notice before the end of the PHE, and allow at least 90 days after the end of the PHE to conduct redeterminations and inform enrollees and providers about the associated changes — and it indicated that even more time may be needed if the PHE is extended beyond October because Medicaid enrollment will likely continue to increase over time. Similar to MACPAC, Colorado also stressed the importance of CMS providing specific guidance about redetermination requirements, and they requested additional guidance about aligning redetermination time frames between CHIP and Medicaid. Because Colorado’s pause on processing renewals in CHIP was implemented through a state plan amendment (SPA), its CHIP policies expire on the day that the PHE ends, as opposed to the Medicaid continuous coverage provisions, which expire on the last day of the month in which the PHE ends.

Colorado’s letter also emphasized that the state has at least 40 Medicaid projects and 65 home- and community-based services items that will need to be modified when the PHE expires. Some of these efforts will involve significant changes in claims processing and eligibility systems that will take time to implement and increase the workload of eligibility technicians. Some of the other issues that the state is seeking guidance on from CMS include:

Whether states will have flexibility to stagger redeterminations and renewals after the end of the PHE to reduce the workload burden; and
Whether federal Medicaid funding will be available for enrollees for whom the state is conducting redeterminations on for beyond 90 days if the state needs more time, as well as through any disenrollment appeals processes.

The letter also raised an issue that has been expressed by state-based marketplace (SBM) officials in other states — that states will need time to develop messaging and provide assistance to individuals who are no longer eligible for Medicaid in order to help them enroll in marketplace coverage. Many SBM officials are concerned that once the PHE ends, they may face an unmanageable influx of individuals transitioning from Medicaid to marketplace coverage. As federal officials develop guidance, they should take this issue into consideration and also factor in the timing of SBMs’ open enrollment periods.

In addition to eligibility redeterminations, states will also need sufficient time and federal guidance to unwind other policies implemented during the PHE, such as Section 1135 waivers that eased many provider-related requirements and validations, and Medicaid and CHIP disaster relief SPAs to facilitate enrollment or waive cost-sharing requirements. Another factor is that some states may be interested in retaining certain policy flexibilities implemented under the PHE, and as identified by MACPAC this will require states to take a number of steps to make these changes permanent.

States will also need guidance about resuming many federal reporting requirements that were put on hold during the PHE. Given the pandemic’s wide-ranging effects on coverage and care access, state Medicaid and CHIP officials have expressed concerns about how to determine baseline data for quality measures and provide information for other regular program integrity assessments. They indicated that they hoped CMS would allow flexibility in 2020 and 2021 federal reporting and auditing as states make good-faith efforts to come into compliance. SBM officials have expressed similar concerns about the potential of being penalized for certain policy choices and the need for federal recognition of the unique programmatic and operational challenges created by the pandemic.

As highlighted by MACPAC, “Delayed guidance, unrealistic expectations, or short implementation time frames for eligibility redeterminations and provider revalidations could disrupt state operations, result in beneficiaries churning on and off of Medicaid coverage, and jeopardize access to care.”

Although the PHE was extended again, states still face significant challenges without sufficient information from the federal government about how to transition back to regular operations. States urgently need formal federal guidance so they can begin effective and efficient planning efforts now, both to reduce administrative burdens and minimize disruptions in coverage and care.

Stand by Me: Supporting Long-Term Services and Supports Workers

October 2, 2020/in The RAISE Act Family Caregiver Resource and Dissemination Center Oregon, Tennessee Chronic and Complex Populations, Health Coverage and Access, Health Equity, Long-Term Care, Population Health, Social Determinants of Health, State Resources, The RAISE Family Caregiver Resource and Dissemination Center, Workforce Capacity /by Wendy Fox-Grage

Direct care workers play a critical role in the success of states’ long-term services and supports (LTSS) systems, but faced with COVID-19, low wages, and few advancement opportunities, states struggle to retain this workforce. Recently, state leaders came together virtually at National Academy for State Health Policy’s annual conference to share strategies to improve recruitment and retention of these workers.

Today, personal care attendants, home health aides, and nursing assistants are on the frontlines, providing care to older adults and people with disabilities. COVID-19 has made direct care work one of the most dangerous professions, while putting an enormous strain on family caregivers and state budgets.

Even prior to the pandemic, states faced a significant direct care workforce shortage due to the low wages and limited advancement, which has contributed to high turnover. The pandemic has exposed other vulnerabilities – nearly six out of ten direct care workers are people of color and almost half live in low-income households.

Tennessee Promotes Workforce Retention

In 2013, the TennCare (Tennessee Medicaid) Long-Term Services and Supports (LTSS) division held listening sessions throughout the state and found that Medicaid enrollees’ quality of life hinged on the quality and consistency of their LTSS workers. That insight led state officials to create a value-based workforce strategy for direct care workers. Using a State Innovations Model (SIM) grant from the Centers for Medicare & Medicaid Services (CMS), the state incorporated workforce recruitment and retention into its value-based payment strategy, and worked across state agencies to implement and incentivize career and educational opportunities for direct care staff.

In consultations with national experts, the state developed a competency-based training program using evidence-based best practices in adult learning. Corresponding with CMS Direct Support Workforce Core Competencies released in 2014, the training uses an online format combined with work-based learning to provide an opportunity to acquire shorter-term credentials with clear labor market value.

Officials from TennCare worked with the Tennessee Board of Regents to award college credit and a post-secondary credential (certificate) for completion of the training. This curriculum is embedded within a variety of existing (and potential new) degree paths through the Tennessee Community Colleges and Colleges of Applied Technology. The state was also able to leverage Tennessee Promise and Tennessee Reconnect funds to defray tuition costs for adult learners, and plans to provide incremental raises to direct care staff who complete the training once the state weathers COVID-19-related budget shortfalls.

At the same time, TennCare has begun to transition its LTSS system to a value-based payment model. Staff training, retention, and job satisfaction are key measures in the state’s quality framework and tied to LTSS provider reimbursement. By aligning Medicaid payment, investments in workforce training, and the state’s higher education goals and resources, Tenncare has established a clear education and career pathway that will help it grow and retain its direct care workforce.

Oregon’s Home Care Workforce Unionized

Because of the relationship between direct care workers and quality of care, the state created the Oregon Home Care Commission, a semi-independent state commission that supports home care workers, personal support workers, and consumers/employers by:

Defining qualifications of home care and personal support workers;
Providing a statewide registry of these worker that matches individuals needing in-home care with home care workers;
Providing training opportunities; and
Serving as the “employer of record” for collective bargaining for home care and personal support workers who receive service payments that are from public funds.

The Service Employees International Union (SEIU), represents Oregon’s in-home workforce. Full-time equivalent in-home workers must earn an income above the poverty level for a family of four in Oregon. They have health benefits (for 40 hours of work per month) as well as leave time for vacation, sick time, and COVID-19. They also receive training and personal protective equipment (PPE).

The state funds Oregon Care Partners, an education resource that provides in-person and online classes to help family and professional caregivers build the knowledge and skills needed to improve the quality of life of older adults and people living with Alzheimer’s in Oregon. These classes are available to anyone living or working in Oregon and are offered free of charge. Classes include COVID-19 infection control, supporting individuals with Alzheimer’s/dementia, supporting individuals with challenging behaviors, cultural competency, and more.

Oregon’s support of its direct care workers through living wages, sick and vacation benefits, training, and a registry that matches these workers with individuals needing home care helps not only this important workforce but also care recipients and their families. This support has been an important strategy in this state’s longtime effort to successfully rebalance its LTSS system toward home and community-based services.

Looking Forward

Both Tennessee and Oregon have had to respond quickly and with enormous flexibility to the challenges presented by the pandemic, maintaining LTSS services through strategies such as provider rate increases and retainer payments, new infection control protocols, and additional protections and benefits for LTSS staff.

While cascading effects of both COVID-19 and state budgets make ongoing investments in the direct care workforce incredibly challenging, the experience of the past few months has also opened up new opportunities: Medicaid waiver flexibilities and the Coronavirus Aid, Relief, and Economic Security (CARES) Act and state funding allowed states to increase payments to stabilize and incentivize the LTSS workforce to maintain care to some of the most vulnerable populations during the pandemic. Telehealth has been transformational. Certain services, such as therapies, care management, and adult day health, moved from face-to-face to virtual encounters. Some states used additional pandemic-related money to provide childcare for essential workers.

As a result of these unprecedented changes, state officials are rethinking how LTSS is delivered, where, and by whom. The future direct care workforce will likely need additional training on managing the spread of infectious disease, delivering care through telehealth and other virtual modalities, and engaging families as critical partners on the care team. State health policymakers may also want to invest in the LTSS workforce as another opportunity to address racial equity within state-funded healthcare systems. While it is too soon to tell which of the many changes wrought by the pandemic in state LTSS systems will be sustained, one thing is certain, as noted by a state health official during the NASHP conference: “Medicaid will never look the same after COVID.”

This conference session and blog is one component of NASHP’s RAISE Act Family Caregiver Resource and Dissemination Center, which is funded by The John A. Hartford Foundation in collaboration with the Administration for Community Living.

NASHP Resource Hub: State Strategies to Build and Support Palliative Care

September 25, 2020/in Policy Reports, Toolkits Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Community Health Workers, Cost, Payment, and Delivery Reform, Featured Policy Home, Health Coverage and Access, Health System Costs, Long-Term Care, Medicaid Managed Care, Palliative Care, Physical and Behavioral Health Integration, Population Health, Workforce Capacity Chronic and Complex Populations /by Kitty Purington, Wendy Fox-Grage and Salom Teshale

Palliative care helps individuals with serious illness better manage the symptoms and stressors of disease. These services are interdisciplinary, person- and family-centered, and can help people at any stage of a serious illness.
States are uniquely positioned to influence how Americans think about access, and experience palliative care.

Six States’ Strategies to Providing Home Health Services to Children Enrolled in Medicaid

July 6, 2020/in Medicaid Managed Care Connecticut, Delaware, Iowa, Maryland, Ohio, Washington Blogs, Featured News Home Children/Youth with Special Health Care Needs, Children/Youth with Special Health Care Needs, Chronic and Complex Populations, Community Health Workers, COVID-19, Health Coverage and Access, Health Equity, Integrated Care for Children, Long-Term Care, Maternal, Child, and Adolescent Health, Physical and Behavioral Health Integration, Population Health, Social Determinants of Health, Special Populations and Services, Workforce Capacity /by Olivia Randi and Kate Honsberger

To improve the quality of services for children and youth with special health care needs (CYSHCN) and reduce health care costs, states are implementing strategies to improve access to home health services. Of particular importance as states confront COVID-19-related budget challenges, home health services can help to avoid costly emergency department use, hospitalizations, and institutional care.

The Early, Periodic, Screening, Diagnostic and Treatment (EPSDT) Medicaid benefit mandates coverage of all medically necessary services for children under age 21 who are enrolled in Medicaid. However, states vary in their definitions of medical necessity, prior authorization processes, and approaches to home health service delivery.

Prior to National Academy for State Health Policy’s (NASHP) analysis, there was limited information available on home health services for CYSHCN, and few studies had analyzed states’ approaches to delivering these services.

In its new report, State Approaches to Providing Home Health Services to Children with Medical Complexity Enrolled in Medicaid, NASHP examines six states’ (WA, OH, IA, MD, DL, CT) strategies to support access to home health services for CYSHCN. These include addressing provider capacity, advancing the person-centered medical home model, streamlining prior authorization processes, collaborating with Title V Maternal and Child Health Services Block Grant Programs for CYSHCN, and promoting stakeholder collaboration.

Home health services are provided in a person’s residence and include:

Nursing services;
Home aide services provided by a home care agency;
Medical supplies and equipment for use in home-based settings; and
Physical and occupational therapy, or speech pathology and audiology services.

Through analysis of these states’ home health service delivery systems, NASHP identified several key insights that other state health policymakers can leverage in their own systems to improve service delivery and reduce costs. A shortage of home health providers was the primary challenge that states faced in delivering these services to CYSHCN, which states have addressed through training programs and by increasing or modifying reimbursement policies.

Partnerships across agencies and families were recognized as key to developing informed strategies to improve home health services for CYSHCN. States have leveraged these partnerships, as well as implemented technologies and streamlined processes, to deliver more coordinated, cost-effective home health services.

Prioritize efforts to address provider shortages. To address the lack of home health provider capacity, several states have focused on developing, enhancing, and raising awareness of training programs to increase the supply of home health agency staff. States have also modified their reimbursement policies, including increasing their reimbursement rates for home health providers, and proposing a structured fee schedule to streamline the reimbursement process for home health agencies. Ohio, for example, allows for reimbursement of family caregivers for providing services for children enrolled in its Medicaid waivers in an effort to increase home health service provider capacity.
Leverage the benefits of cross-sector and stakeholder collaboration. Partnering with a variety of state agencies, including Title V CYSHCN programs, provider groups, families, and other key stakeholders helps build the infrastructure necessary to deliver comprehensive home health services to CYSHCN. Stakeholder groups in Ohio, Maryland, and Delaware were crucial to developing strategies to improve access to home health services for CYSHCN. Two of these states also referenced the importance of family engagement to inform the work of the stakeholder group. In Ohio and Iowa, Medicaid agencies, providers, and Title V CYSHCN programs have formed collaborations to improve care coordination and access to home health services for CYSHCN.
Adjust service delivery models to increase capacity. The medical home is a primary care service delivery model that emphasizes coordinated care through a team-based approach. Connecticut and Delaware, have looked to this model to encourage providers to improve care coordination for CYSHCN, including home health services. States have also looked to streamline their prior authorization processes to reduce administrative challenges for CYSHCN to access home health services. Delaware and Iowa are implementing changes to simplify this process through a “flag” in their data system and by developing a standardized prior authorization form for all managed care plans, respectively.

Other key insights from this analysis include seeking regular feedback from families, strengthening oversight, and customizing fee-for-services and managed care approaches. States interested in improving children’s access to home health services through Medicaid may benefit from the approaches implemented by the six states highlighted in this issue brief. For a list of NASHP’s reports, blogs, and other resources related to improving care for CYSHCN, please click here.

State Strategies to Increase Diversity in the Behavioral Health Workforce

Paying Family Caregivers through Medicaid Consumer-Directed Programs: State Opportunities and Innovations

States Need Federal Guidance to Plan for When the Public Health Emergency Ends

NASHP Resource Hub: State Strategies to Build and Support Palliative Care

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