What’s Next in Home and Community-Based Services?

June 17, 2022

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Home and community-based services (HCBS) is a subset of long-term services and supports (LTSS) that allows patients to receive health services in their home or a local setting rather than a typically higher-cost institutional setting. Offerings include intensive, round-the-clock care through more wrap-around services such as caregiver support, home-delivered meals, and employment supports. About 2 million people received home and community-based services in 2020. Traditionally, Medicaid is the largest payer of HCBS in the country, but recently Congress has discussed dedicating more federal funding, including through American Rescue Plan Act and the House-passed Build Back Better.

During this session, panelists provided an overview of home and community-based services, including populations receiving these services, current enrollment numbers, workforce challenges, benefits of HCBS, and barriers to caring for complex populations. Panelists also spoke to recent federal policy measures taken to bolster HCBS as well as potential long-term policy levers to better improve this model.

For more information on LTSS more broadly, please see the Alliance’s November 2019 event: Long-Term Care: Where Are We and What’s Next?.


  • Hany Abdelaal, D.O., President, Health Plans, VNS Health
  • Dennis Heaphy, M.Div., M.Ed., MPH, Health Justice Policy Analyst, Researcher Disability Policy Consortium
  • Shannon McCracken, Vice President of Government Relations, American Network of Community Options and Resources (ANCOR)
  • Damon Terzaghi, MSA, Senior Director of LTSS Policy, ADvancing States
  • Kristal Vardaman, Ph.D., MSPH, Director of Medicaid Policy & Programs, Aurrera Health Group (moderator)

Key Event Takeaways:

  1. It is essential that HCBS care providers receive sufficient funding to provide individualized, variable, and person-directed services based on individual need and preference.
  2. Lack of integration of care for the dual-eligible population continues to serve as a roadblock for effective home- and community-based care and for pursuing health equity at large.
  3. There is a shortage in the workforce of direct support professionals to provide these services. This is due to stagnant reimbursement rates and inability to compete with other industries – an issue that has only worsened in the wake of COVID-19.
  4. Section 1915(c) of the Social Security Act allows for flexible state funding for HCBS and targeting of specific populations, resulting in variance between states and personal outcomes.

This event was made possible with support from Arnold Ventures.

Presentation: What’s Next in Home and Community Based Services?

Event Resources

Key Resources

(listed chronologically, beginning with the most recent)

“HHS to Provide $110 Million to Strengthen Safety Net for Seniors and People with Disabilities.” Centers for Medicare and Medicaid Services. March 31, 2022. Available here.

“Testimony before the United States Senate Special Committee on Aging.” Heaphy, D. United States Senate Special Committee on Aging. February 10, 2022. Available here.

“ANCOR Renews Calls for Investments in HCBS as Congressional Democrats Shift Gears on Build Back Better.” McCracken, S. American Network of Community Options and Resources. January 21, 2022. Available here.

“Home and Community-Based Services: Just One Piece of the Puzzle.” Abdnor, A., Mir, A., Rizer, A. Arnold Ventures. September 7, 2021. Available here.

“State Survey Demonstrates Rebalancing Successes and What Remains to be Done.” Terzaghi, D. The Long-Term Services & Supports (LTSS) State Scorecard. April 23, 2020. Available here.

“Measuring the Real Value of Managed Long-Term Care Health Plans.” Abdelaal, H. VNS Health. December 26, 2019. Available here.

Additional Resources

(listed chronologically, beginning with the most recent)

“ADvancing States Announce Selection of States for ARPA Technical Assistance.” ADvancing States. March 25, 2022. Available here.

“An Economy That Cares: The Importance of Home-Based Services.” United States Senate Special Committee on Aging. March 23, 2022. Available here.

“Experiences of Individuals Self-Directing Medicaid Home and Community-Based Services During COVID-19.” Atkins, M., Caldwell, J., Heyman, M., et al. Disability and Health Journal. March 22, 2022. Available here.

“Self-Directing Services and Supports During the COVID-19 Pandemic.” Atkins, M., Caldwell, J., Heyman, M., et al. Community Living Policy Center, Brandeis University. March 2022. Available here.

“State Efforts to Address Medicaid Home- and Community-Based Services Workforce Shortages.” Medicaid and CHIP Payment and Access Commission (MedPAC). March 2022. Available here.

“Investing in Integration: Indiana’s Long-Term Care System Redesign Focuses on Dual-Eligible Populations.” Archibald, N. Arnold Ventures. February 2, 2022. Available here.

“Streamlining and Simplifying Medicaid HCBS Authorities.” Harootunian, L., Hayes, K., Hoagland, G., et al. Bipartisan Policy Center. October 26, 2021. Available here.

“Americans Overwhelmingly Back Funding Home Care for the Elderly. Will it Survive in Democrats’ Spending Bill?” Abrams, A. Time. October 4, 2021. Available here.

“States Are Using One-Time Funds to Improve Medicaid Home- and Community-Based Services, But Longer-Term Investments Are Needed.” Sullivan, J. Center on Budget and Policy Priorities. September 23, 2021. Available here.

“How Could $400 Billion New Federal Dollars Change Medicaid Home and Community-Based Services?” Musumeci, M. Kaiser Family Foundation. July 16, 2021. Available here.

“Opportunities for States and Health Plans to Improve Access to Medicaid Home and Community-Based Services.” ATI Advisory. May 10, 2021. Available here.

“SEIU’s message to Biden, Congress: Pass $400B HCBS Infrastructure Plan.” Berger, L. McKnights Senior Living. April 23, 2021. Available here.

“American Rescue Plan Strengthens Medicaid Home and Community-Based Services.” Brill, R. Center for Consumer Engagement in Health Innovation, Community Catalyst. March 2, 2021. Available here.

“Reforming Long-Term Care with Lessons from the COVID-19 Pandemic.” Favreault, M., Gleckman, H. The Urban Institute. February 2021. Available here.

“The Impact of COVID-19 on Dual Eligible Individuals Using Home- and Community- Based Services.” Herman Soper, M., Hoffmaster, A. Arnold Ventures. November 2, 2020. Available here.

“State Management of Home- and Community-Based Services Waiver Waiting Lists.” Medicaid and CHIP Payment and Access Commission. August 2020. Available here.

“A National Examination Of Long-Term Care Setting, Outcomes, And Disparities Among Elderly Dual Eligibles.” Gorges, R., Konetzka, R., Sanghavi, P. Health Affairs. July, 2019. Available here.

“The Medicaid HCBS Settings Rules: What You Should Know!” HCBS Advocacy Coalition. May, 2019. Available here.

“Rural-Urban Disparities in Access to Home- and Community-Based Services and Supports: Stakeholder Perspectives From 14 States.” Ahluwalia, S., Friedman, E., Kotzias, V., et al. Journal of the American Medical Directors Association. March 1, 2019. Available here.



Hany Abdelaal, D.O.
VNS Health, President

Dennis Heaphy, M.Div., M.Ed., MPH
Massachusetts Disability Policy Consortium, Health Justice Policy Analyst; Researcher

Shannon McCracken
American Network of Community Options and Resources, Vice President of Government Relations

Damon Terzaghi, MSA
ADvancing States, Senior Director of Long-Term Services and Supports Policy

Kristal Vardaman, Ph.D., MSPH (moderator)
Aurrera Health Group, Director of Medicaid Policy and Programs

Experts and Analysts

Donna Benton, Ph.D.
University of Southern California Leonard Davis School of Gerontology, Research Associate Professor; Family Caregiver Support Center, Director

Henry Claypool
Brandeis University, Community Living Policy Center, Policy Director

Howard Gleckman
The Urban Institute, Senior Fellow

Mark J. Warshawsky, Ph.D.
American Enterprise Institute, Senior Fellow


Asmaa Albaroudi, MSG
Medicaid And CHIP Payment and Access Commission, Senior Analyst

Richard J. Hodes, MD
National Institutes of Health, National Institute on Aging, Director

Gavin Kennedy
Office of the Assistant Secretary for Planning and Evaluation, Associate Deputy Assistant Secretary for Behavioral Health, Disability, and Aging Policy


Christine Aguiar Lynch, MPH
Association for Community Affiliated Plans, Vice President for Medicare and Managed Long-Term Services and Supports Policy

Lydia Dawson J.D.
American Network of Community Options and Resources, Director of Policy, Regulatory & Legal Analysis

Nicole Jorwic
Caring Across Generations, Chief of Advocacy and Campaigns

Lynn Weidner
Service Employees International Union, Union Member Organizer; Home Care Worker


This is an unedited transcript.


Hello, and welcome, everyone. Thank you for joining today’s briefing. What’s Next in Home and community based Services? I’m Kathryn Martucci, Senior Director of Program Strategy at the Alliance for Health Policy.


For those of you who are not familiar with the Alliance, welcome. We are a non partisan resource for the policy community, dedicated to advancing knowledge and understanding of health policy issues.


And you can join today’s conversation on Twitter using the hashtag all health lies. And please join our community on these other social media services as well, Facebook, LinkedIn.


And, today’s panel, we’ll have a question and answer section at the end of the hour, and we definitely want you to be active participants. So, please, be getting your questions ready.


You should see a dashboard on the right side of your screen that has a speech bubble icon with a question mark, and you can use that icon to submit questions you have for the panelists at anytime. And you can also be using that chat to chat about any technical issues you may be experiencing as well and someone will attempt to help you.


And today’s events is made possible with support from Arnold Ventures and we’re very grateful to have Arielle Mir, Vice President of Healthcare, Uncomplex Care at … Ventures to give some opening remarks. So REL, I’ll turn it over to you.


Thank you so much, Kathryn.


So just to say a word about Arnall Ventures work in healthcare.


Our team is really motivated by a deep concern about the affordability of healthcare in this country.


As you know, we have a system that burden’s individuals and families and overstretch as state and federal budgets.


Care takes place more often than it needs to be in hospitals, emergency departments and nursing homes. And outcomes aren’t well, aren’t what people want, Especially for low-income folks and people of color.


And as healthcare organizations and policymakers and individuals and families look to solutions, it’s increasingly clear that one of the biggest gaps in our care infrastructure is care in the home.


Homecare to support individuals with functional limitations and disabilities is a flagstone in the foundation of person centered, effective care.


Home care means that people can live in the community, often work and live their lives with dignity, can also be an investment in keeping people out of the hospital, staving off avoidable health problems, or accidents.


It Today’s health care system isn’t designed for the breadth and depth of home care need that exists in this country.


It’s a patchwork of coverage, and even in states where Medicare has a role has robust home care offerings, the home care delivery system is stretched so thin that it’s hard to see a sustainable path forward in its current state.


At the same time, I have to say we’re at a really exciting moment.


Expanding care at home has tremendous public support, and states across the country are experimenting with investments in their home and community based services programs and workforce, and with support from the American Rescue Plan.


It’s about time for creative solutions and innovation, and to use evidence, and in particular, input from consumers and caregivers to help design a system for the future, and no better way to continue that conversation is with today’s panel. So, and thank you to the alliance for arranging this webinar and to the panelists for, for being here. We’re so grateful and really look forward to the discussion.


Thank you so much for those remarks and talking about kind of the value of this conversation at this time thanks IRL, so now I’m excited to introduce doctor Kristal Vardaman, Director of Medicaid and Policy Programs at Aurora Health Group who’ll be leading our conversation today.


She joined her house recently in April. But she has over 16 years the policy and program evaluation experience in both the public and private sectors. Her expertise includes long-term services and supports dually, eligible beneficiaries, social determinants of health and health equity. And she leverages her expertise to support clients and implementing programs for older adults and people with disabilities. So, I’m very grateful to be turning over this conversation to you, Crystal. Thanks for being with us today.


Right? Thanks, Catherine, for the introduction.


And, thank you all, for joining us today for this important conversation around: Home and community based Services: Home and Community based Services, or HCBS, or services like personal care, to help help, with activities of Daily Living, Home delivered meals and supported employment services.


HTTPS allow people with disabilities to receive services in the home or home like setting in the community, rather than in an institution, which is what most people prefer.


Medicaid is the nation’s largest payer of HTTPS and will be our focus today.


But HCBS is also paid for by individuals’ privately or private long-term care insurance by the Veterans Health Administration and then some limited ways in Medicare Advantage.


HTTPS is a topic that’s received increased attention in the past few years during the covert 1009 Pandemic.


But the federal and State push to increase access to HCBS goes back several decades.


In fact, Medicaid which began covering HCBS in 19 83, has spent more on HTTPS than institutional services since 20 13.


It is true, however, that the focus on HCBS has been sharpened these past few years.


The pandemic provided new urgency to serve more people in the community and to ensure that the infrastructure to provide HTTPS is strong including supporting a high quality workforce sufficient to meet increased demand as the population ages.


To support this infrastructure, Congress has authorized new Medicaid funding through Several Covered relief. Bills.


Sure. We hear a lot today about the American Rescue Plan Act funds in particular.


And these discussions continue, as evidenced by the House passed Bill Back, Better Act and other policy proposals.


Now I’d like to quickly introduce our audience to today’s exciting group of panelists, Their full bios are included in the webinar materials.


First, we’ll hear from Dennis Heaphy.


Dennis is a Health Policy Analyst and Researcher with the Massachusetts Disability Policy Consortium.


His work promotes meaningful community integration and long-term service and supports policies that advanced the dignity and civil rights of persons with disabilities.


Dennis is committed to ensuring that health equity policies addressed intersectional barriers to health and wellness that are rooted in discrimination and bias experienced by persons within by populations.


… is the Senior Director of LTSS Policy at Advancing States.


In this role, he is responsible for leading Advancing State’s policy work, including analyzing federal and state legislation and regulations, providing technical assistance to state entities on Medicaid programmatic and policy issues, establishing associations priorities regarding the Older Americans Act and related programs, and researching national trends around long-term services and supports.


Shannon McCracken is the Vice President of Government Relations at Anchor.


She’s been advocating for several people with intellectual and developmental disabilities for over 20 years.


Joining acre in January of 2020, she brought a diverse and deep background, having held leadership positions, both private and non-profit companies, on trunk case management company.


She was actively involved in the Kentucky Association of private providers for over a decade, including serving as the state Associations, first full-time Executive Director, and dedicated lobbyists from 20 15 to 20 17, also writing her own business.


And, finally, we’ll hear from doctor Hany Abdelaal, the President of Health Plans, at … Health.


He has devoted his professional training and medical career to improving the quality and co-ordination of health care for older Americans.


He brings to this work a firm belief, and a strong, person centered primary care system that embodies a holistic approach, and it’s built upon a strong medical home foundation.


The previous experience includes his time as a medical director and Elder Plan Metropolitan Jewish Health System and Home Firsts.


So, now, we’re going to let our panelists introduce the topic to us before we get into the question and answer portion of today’s events.


So, Denys would like to start with you.


Thank you very much, and just give me one second.


Hi, and thank you very much for giving me the opportunity to speak today.


Before I start, I should say that I’m a person with a disability, I’m nursing home eligible, and I’m grateful for the home and community based services I receive, and grateful to actually live in Massachusetts, which has has, uh, PCA services and other services that I really rely on to live in the community.


This first slide, the 19 sixties ed Roberts applied to the man in the center on the center, right applied to UC Berkeley, but was denied admission due to his disability Roberts, Fought back was admitted to the university but had to live in the hospital next door to the university because the dormitories were inaccessible.


He, along with other quadriplegics in that hospital, came together and they were they synthesized what would become it helped home and community based services along with other other advocates around the country.


Um, the right to the right to, up to obtaining long-term services and supports outside institutional settings.


What are the cornerstone of the Independence Lakes rights movement, and led to the passage of the Home and Community based Services law, and eventually the passage of the Americans with Disabilities Act and Olmstead.


The right of persons with disabilities and elders to choose to live in the community based settings, rather than institutions, was included in the Affordable Care Act.


Slide two.


This is the medical definition of the Medicaid definition of home and community based services.


A couple of things to note: first language is shifted from patient, to person centered language.


And person is really critically important, because the descent of the Disability Rights movement we fought to be seen as people and not, as patients, hopeless, and poor medical outcomes.




Second, HE basses often designed to enable people to stay in their homes.


From my perspective, this should say always designed to enable to stay in their homes.


HCBS also includes services, not just health services, but social services as well.


And social services are key to people’s ability to living independently, and having a broad definition of social services is really key.


In Massachusetts, we have consumer directed PCA programs which are formed, who are from, which from my perspective, are key to me, my tenant, maintaining independence rather than an agency deciding who assist me with my activities of daily living.


I hire train, fire, et cetera, my personal care attendants.


Slide 3 and 4.


As we can see, there’s a significant diversity in the population.


They utilize as HCBS, and each population has very distinct needs.


I did not include racial and ethnic demographics because data is either unreliable or does not exist, and that’s something that really needs to be worked on.


Slide five.


This is important, is as stated earlier, um, it’s important to be seen as people and not patients.


And I’m bringing that back home continually because of the importance of recognizing that when we look at think of HCBS, we’re not just thinking about medical outcomes.


We’re also thinking about the broader needs of people, OK?




slide seven, looks like six.


Uh, we have some statistics on people utilizing HCBS.


We have currently to 820,000 people waiting for a waiting list to access HCBS services.


There are too many people and too many people who are either in nursing homes or will go into nursing homes or hospitals.


As we saw with …, the impact can be devastating back in the nineties in slide nine, back in the 19 seventies and eighties, there were generic products which or which had very little, very, very variable quality, translating this to HCBS, providing people with only one choice of service providers, or type of wheelchair or choice of social workers, et cetera.


It is not going to serve the needs of the populations, it is essential that the HCBS services be be wide varied and that they be directed by the person.


Then, when appropriate, the person and the families.


Slide 10, as we see, isolation and loneliness, uh, are are endemic in the population. A lot of data shows that elders and folks with disabilities are, have a higher.


High statistic is, isolation and loneliness, and so it’s really important to, HCBS provide services that support the ability of people to engage in the community, whether it be transportation or access to assistive technology, things like that, that can support people, live in the community.


There’s a big wave now of young people who you are engaging, playing with computer games.


And, even though their home never really meet in person, the people that they’re engaging with in these sports, because it’s an outlet for them, and it’s fantastic, way of understanding HCBS indifferently.


Um, Slide 11, um, it’s important to that there’ll be a care plan and, if in place, so, that each the integration of a person’s independent living goals, behavioral health goals, and health goals, behavioral health goals and health goals more generally, when determining the types of services someone will receive and that they be driving the direction of the services.


Here I’ve gotten slide 12 my my personal definition of of HCBS and it’s really focused on on Personal Care Attendant Services.


As you can see it says ADL’s ideals primarily, and that’s because I still am I’m very focused on personal Care Center services right now.


And that’s because most people like me who are Nursing home eligible, live in constant fear, a reduction of personal care hours, loss of control over our access to the services, and lack of access to attendance, the direct workforce crisis looms large in our lives.


And the last slide, this slide 13, these are just some of the barriers to accessing services.


Institutional bias, and that is biased toward moving people into institutions, rather than providing a community.


first option, Reductionistic medicalization of HCBS, short-term return on investment, cost reduction.


And that is looking at looking at HTTPS slowly through the lens of quick turnaround roi and clear pathways to cloud due to cost reduction, and that’s not always there.


Population algorithms.


And biased elites the disparities and bias, I mean social terms of health, such as racism and other things that lead to people, some populations, not getting the services they need.


And that’s on … onto Damon.




Thank you for that overview, Denys, I think it was really important to begin this presentation with Dave, perspective of someone who receives home and community based services.


So, let’s move to the next slide, please.


What I’m going to talk about today is really the state perspective of home and community based services, and where state agencies are thinking in terms of innovations and improvements to their program.


Let’s move to the next slide, please.


My organization Advancing States is a bipartisan non-profit association here in Washington, DC, and our membership are the state aging and Disability Agencies that deliver home and community based services to older adults and individuals with disabilities.


I’m also bringing the state perspective from my prior job with the Oregon Department of Human Services, where I worked in their Medicaid program on a variety of aging and disability issues.


I hope that after this presentation, you can understand some of the context for why these services look the way they do around the country.


Let’s go to the next slide, please.


My agenda today, first, I’m going to provide a little bit of additional information on home and community based services and where it fits into the Medicaid program.


Talk a little bit about the state fiscal controls and then get to the rescue plan, acte enhanced funding that was referenced a few times earlier.


Next slide, please.


So, let’s start with where home and community based services fit into the Medicaid program.


There are a variety of what we call options, or authorities that states can use to implement home and community based services.


As Dennis mentioned, Home and community based services are entirely optional, the Medicaid program, and it does lead to significant variation around the country.


one of the ways that states authorize services is through what’s called an 1815 C waiver. All of the numbers that I’m using are the statutory references and the part of the Social Security Act that authorize the specific services.


915 C waivers are the most common way that states provide home and community based services. We have several references to the availability of HCBS.


Beginning in the eighties, 19 15, C was the provision that was added to the Social Security Act that allowed scapes too.


Implement home and community based services.


Because of its historic presence in the Social Security Act, and it being the initial option, it continues to be the most common way that states deliver these services. You can see that 46 states, and Washington, DC does 915 C waivers.


And then those that don’t, new Section, 1115 Waivers to achieve many of the same purposes, the seats I do not have.


19 15 C waivers include Vermont, Rhode Island, Dello, Not Delaware, New Jersey, and Arizona.


So the way that 19 15 C works is that states must designate a population or populations, sir.


Until 20 14, states had to choose one of these three subgroups on the slide here, and would have to be older adults and individuals with physical physical disabilities, or individuals with intellectual and developmental disabilities or individuals with mental illnesses.


In 20 14, CMS provided the states the option to merge those groups ending, establish waivers that serve multiple of those subcategories in this list.


However, because that’s a new opportunity for states, most of the 915 C waivers in existence, still are targeted to one of these specific subsets.


States then tell the CMS how many individuals will be served through the 1915 C waivers.


And, if that number of individuals is exceeded, the state has the option to either, submit an amendment to increase the number of individuals served, or establish a waiting list, fach.


Individuals go on until A, what we call slot becomes available by somebody dis enrolling from the waiver.


one thing to remember about 1915 C is that it is extremely flexible.


There is a list of services that states can provide in 19 15, C waivers included in the Social Security Act.


But there’s also a service definition called other services at our state, proposed CMS approved that are necessary to prevent institutionalization.


And through that, Prevision, we have seen a lot of innovations and a lot of flexible services be included in the program around the country.


Let’s move to the next slide, OK.


Beyond 1915 C, there are a couple of newer options that states can use to deliver HCBS.


The 1915 I State Plan option was created by the Deficit Reduction Act of 2006.


And what it does is it expands home and community based services beyond what can be provided in 19 15, C waivers.


915 C waivers require individuals who qualify for those waivers, to meet what’s called the institutional level of care criteria, which means that they would, requires services in an institution without us, 915 C services, 915.


I in contrast, the eligibility criteria must be less stringent than institutional care, and therefore than 915 C services.


States may choose but are not required, to target populations in contrast to 19 15 C, They are required to target populations in the Sea. In the eye, they can choose to.


I would say, most of the 1915, I, options around the country that I’ve reviewed, do target populations.


In 19 59, actually has the same service package at night.


See, the law uses that same definition of what services can be provided.


915 K was established by the Affordable Care Act, and it has similar clinical eligibility criteria to 19 15 C, An individual must meet that institutional level of care.


It has a more limited set of services.


It is limited to those hands-on attendant care services or supports that can be used to reduce the need for human assistance. So that can be something like a microwave to reduce the need for an individual to have meal planning access service in their person centered plan, for example.


States have actually been able to utilize 915 K in flexible and innovative ways to expand services beyond what we think was originally available when the law passed. But it has been a successful option to further promote community living for individuals with disabilities.


The important part of a 115 K is that states receive a higher federal match, So they receive more money from the federal government for these services, making it a financially attractive option.


Then, there’s other HCBS that was referenced earlier in what’s called 19 oh 5, A, which is the standard Medicaid State Plan.


And these services are available to you, all individuals in the Medicaid program, where, when and where they are medically necessary.


So, some of the services that eat this definition include home health, personal care, private duty nursing, when it’s in our home.


Hospital setting and rehabilitative services. So, let’s move to the next slide.


As we know, Medicaid is an expensive program. And states do look for ways to have fiscal controls in place, including in the HCBS programs.


So, as I mentioned earlier, 1915 C waivers allow waiting lists. They allow states to cap the number of individuals served, …, and waiting lists.


You can also do that, and then on 11 15 waiver, you can target groups in 1915 C, 1959, 1915 waivers, As I mentioned, 11, 15, does a lot of the same things that 915 C does in the States that utilize that.


By targeting populations, you are essentially limiting the services delivered to that subset of Medicaid beneficiaries, which is the way that states used to manage enrollment and costs.


Targeting is not allowed in 19 15 K, or 905 a service.


And then, the standard Medicaid processes, provider, rates limiting amount, duration, and scope of services for choosing which actual benefits are included in the program, also apply here.


However, B, American rescue plan, maintenance of effort, does prevent states from including those reductions moving forward, moving forward for the time.


So, let’s go to the next slide, please.


As I mentioned, ARPA does have some HTTPS provisions.


It included a significant increase in F map or the federal matching for the services delivered between April first, 2021 and March 31, 2022.


Scapes use that extra funding to enhance or expand their Medicaid HCBS programs.


They have to submit a plan to the federal government to be approved on how they will spend the additional money that accrues due to this increase.


Then, once it’s approved, they haven’t told March of 2025 to expend the funds. I would say, when we first started this last year, most of the actions were really focused on getting money out into the community.


Dennis mentioned the provider shortage around the country, so states are really looking to use that money to stabilize the HCBS provider network.


But then, they also looked for other innovations and longer term structural changes that I think are more longer term activities.


Let’s go to the next slide.


So, just very quickly, these QR codes, the compilation of all fans, will take you to CMS’s website that hosts all of the state plans that indicate what they will use this funding for.


The next QR code is an analysis that my organization did, Looks at the common themes, common activities, common initiatives, and lists some out, state by state, is doing what around them.


Next slide, please.


So some examples of what’s included in these ARPA plans, new or expanded services, you can see that there’s different types of services that states are either adding or expanding in their HCBS programs.


Adding new waiver slots, essentially reducing those waivers are those labor waiting lists.


Provider rate increases, getting money out into the community, and then provider bonuses, which are not a more permanent rate increase, or more focused, one-time payments to get money in the hands of providers, without necessarily tying the States’ hands on future expenditures.


Next slide, please.


Some other activities include a lot of work around training and certification, as well as recruitment initiatives for the provider community, some electronic health record initiatives, and LTSS, which historically has been excluded from a lot of the EHR initiatives around the country, improving technology to monitor and support the health and welfare of HCBS participants, and then dealing with housing related issues.


Medicaid cannot fund room and Board and HTTPS, but they can’t find housing related services to address that critical need, which we hear over and over and over again is one of the large, large and primary barriers to individuals living in the community. Is that affordable, accessible housing?


So let’s move to the next slide.


We’re holding questions till the end, but feel free to put them in chat.


And if we go to the next slide, end it off to my next colleague.


Thank you Damon.


For over 50 years, anchor has been a leading advocate for the critical role service providers play and enriching the lives of people with intellectual and developmental disabilities. As a national, non-profit trade association, we represent nearly 2000 organizations employing more than a half million DSPS or direct support professionals across the country. America so hard in America, anchors, mission is to advance the ability of its members to support people with IDD, to fully participate in their communities. More than a million people with IDD across the country receive long-term services and supports through state agencies and in those different waivers that Damon outlined for you.


Supports include residential services, delivered in group homes, host homes, family homes, and independent living arrangements, center and community based training services, employment supports, and respite for family care caregivers. The state ID the agency’s contract with private, non-profit and for-profit agencies to deliver most LTSS. states employ a variety of approaches for paying their contracted service providers. For example, a state may negotiate payment rates with individual service providers or may cost settle with providers based on submitted cost reports. But the majority of states, and for the majority of our providers, however, establish fixed fee schedules, are set wherein the state defines the rate for a given service. Sometimes for a given individual, based on their address needs and or the region in which they live.


That any provider wishing to deliver that service must accept.


So providers are rate takers, not rate centers, and have little to no flexibility to manage increasing costs, adjust for inflation, or to address wages for employees.


States have substantial discretion in determining their fee schedule rates.


and most states with fixed fee schedules have developed right models that detail various categories of provider expenses in order to develop the total rates. So before I jump in, just to wrap this PSAP, the wages and benefits paid to direct support professionals, DSPS. They’re the staff responsible for providing the direct personal care and habilitation services.


That comprises the largest components of the right models, So I wanted to lay that groundwork before we jump in, and also just to emphasize, as we move to the first slide, that, or the next slide, please?


That the Direct support workforce is the backbone of the Long term services and supports waivers of the service provision for home and community based supports in this country.


For decades, the United States has witnessed a significant shortage of direct support workers due to stagnant reimbursement rates, and the inability of providers to offer competitive wages with we can’t compete with entry level industries such as food, fast food, retail, and convenience. That’s been true for over 20 years.


Next slide, please.


In February 2020, angkor conducted a five week survey of our providers to glean a deeper understanding of just how the direct support workforce is impacting them and their ability to deliver the highest quality supports possible. So, keep, it’s very significant.


The date, February 2020 before we knew what was about to come in the form of covert 19 and a public health emergency, and hopefully a once in a lifetime pandemic, for most of us, all of us.


The results of this survey, although not surprising, it just revealed staggering shortages of employees, the number of vacancies open, and the amount of overtime that the existing direct support workers were facing, was just hard for our providers to tell us, and hard to hear.


But so important to know, It revealed a devastating impact to the service infrastructure. And we heard that before the pandemic, that providers were already facing decisions to close and downsize programs.


And next time, next slide please.


Then came the pandemic with the onset of covert 19 and throughout the entire duration of the pandemic to date because we’re certainly not through it. We’ve been fielding desperate calls from our provider network. As I said, over 2000 or close to 2000 providers, community based IDD services. The dire situation we’ve heard about daily since that survey in February 2020 led us to realize the need to further quantify the workforce crisis with through the impact. Either as a result of the impact of the covert 19 pandemic on that workforce, how much worse hadn’t gotten, how much worse, but it get, and how much could providers sustain?


So, in turn, we fielded a second survey to assess the current state of the crisis.


As anticipated, the challenges to maintain services and quality standards had increased dramatically with the immediate and drastic exodus of DSPS from the field.


Next slide.


So here’s a graphic of our original, Naive to Covert survey compared with 2020, 1 results with the same questions and criteria.


We heard, my organization has turned away new referrals or stopped accepting new referrals due to high turnover or ongoing vacancies among DSPS. That was, 77% of respondents shared that a 16% increase from the year before.


Their organization, discontinue programs or service offerings due to high turnover or ongoing vacancies among DSPS, 58%.


That was a 70% change.


My organization has delayed the launch of new programs or service offerings for the same reasons.


84% of respondents said that was true.


My organization has experienced difficulties achieving required quality standards due to high turnover or ongoing vacancies among DSPS. 81% of respondents said that and that was so difficult for us to hear for everyone to hear.


And, lastly, my organization has experienced a higher frequency of reportable incidents due to high turnover. That number was at 41%, which really showed a little change. And we honor our providers with that to say, you know, they held the line and made the decision most likely, when you look at the numbers above to discontinue services or to ramp things down in order to ensure that we kept people safe during the pandemic.


Next slide.


one other significant fact was the financial cost of this high turnover and high vacancy rates. It’s just unsustainable for members. Nearly three in ten respondents reported spending more than $500,000 per year in costs related to high turnover and vacancy rates.


And one in six reported spending more than a million dollars annually. These increased costs, which relate to everything from training to staff overtime and more, simply cannot be sustained by community providers, significantly underfunded to begin with.


These are dollars that should have been spent in quality enhancements and in wages but have to go back into re hiring retraining recruiting.


Next slide.


Factors contributing to the lingering effects of the pandemic are illustrated by the following findings. 92.5% of providers told us in this survey that industries that previously paid comparable wages now pay employees more than my organization can afford to pay. We cannot compete with health care worker, well, healthcare workers.


We can’t even compete with fast food.


And the the industries that we were in competition for employees with before are providers just simply cannot compete 86.2% said that DSP wages were lower than income provided by unemployment or other state or federal safety net benefits.


47.7% of respondents indicated that DSPS who had left their positions temporarily during the pandemic are not able to yet return or decided not to, some of them because schools were closed, they couldn’t, they couldn’t continue to work or they were fearful of contracting cope in 19 themselves.


And then 18% of the DSPS who were transferred from day programs when those were closed to residential settings preferred to continue to work in those settings making it more difficult to open back up community services after the pandemic or not after but when things began to start opening back up.


Next slide, please.


OK, Damon, shared some of this and so I won’t go deep into it, but it’s really important to understand when I talk about insignificant underfunded, provide insignificant rates, an underfunded providers, the rate determination methodology. Looks like this, you know, ultimately States determine the payment amount that providers will receive.


I said some of that at the top of my remarks and then payments should account for wages and there’s a direct correlation there.


States determine the payment amount that providers will receive. And then, while rate determination methods can vary, payments for waiver services must be consistent with efficiency, economy, and quality of care and be sufficient to enlist enough providers, so that care and services are available under the plan.


At least to the extent that such care and services are available to the general population in the geographic area, that’s directly from Section 1902 A, 30 A of the Social security Act. Payments should account for wages that are competitive to ensure access to quality care.


But unfortunately, reimbursement rates may go un reviewed for decades at a time, while costs still increase.


Rates stay the same without sustainable funding providers, face, fiscal, and fiscal funding and staffing cliffs with the end of ARPA funding and access to the flexibilities that were allowed through Appendix K waivers during the pendency pandemic.


Next slide, please.


In February 2022, CMS opened a request for information and RFI seeking public input to inform potential development of standards regarding access to coverage services under the Medicaid program. Anchor actively participated in workgroups and task forces across Disability Stakeholder Forums to co-author and informed comments which reinforce concern for the Direct Care Workforce crisis and its impact on home and community based services.


Recommendations, key recommendations that we made included, but we’re not limited to: state reporting requirements on direct care workforce metrics, minimum standards for reimbursement rate methodology, and the creation of a designated access complaint process.


Next slide.


OK, I’ll just wrap up my remarks here, but hopefully I’ve effectively shared the impact and depth of the workforce crisis, calling it a crisis for 20 years leaves us without words after it’s been so desperately exacerbated by the pandemic over the last two years. But as we continue to address the core workforce issue, and then dig through the effects of the public health emergency, it’s important to understand that direct connection between reimbursement rates and employee wages.


While so grateful for the multiple relief packets and the American Rescue Plan, the ARPA.


Matt Bumps, we can’t emphasize enough how important it is for Congress to commit to significant and long term commitment to funding HCBS services. Damon, on a graphic showed that 28 states used ARPA funds to give rate increases, but it’s And he did say this, but I just want to re-emphasize that that is one-year time limited. There’s been an extension on how long, as states, how to spend those funds. But the real piece of this is you cannot pass on. Rate increases and providers can’t pass on wage increases.


With one year funding packages, there must be a significant commitment and promise to ensuring this, the sustaining of home and community based services ongoing into the future.


So, thank you so much and I’ll turn it over to my next speaker.


Thank you, Shannon, and thanks for having me today. My name is Haney Abdullah Al and I’m the health plan president for vienna’s Health. Let’s go to the next slide.


I appreciate the opportunity to really join this distinguished Fellow panelists and provide the panel perspective on home and community based services which are so critical as we’ve seen from our other panelist. Next slide.


During my time I’m gonna go over an overview of vienna’s Health, the significance of duly eligible populations, the Health pralle role in home and community based services and the challenges and the opportunities. Next slide.


An overview of VS ****.


We are a provider organization that became a health plan and we’ve been in the home care business for over 125 years. Our founder Lillian Wald was one of the first to go into people’s homes.


So we’re really honored to represent her tradition, and what has been developed in the past and continues for the future, venus’ Health is composed of home care, hospice care, care management, our health plans, professional solutions, community outreach, behavioral health, and personal care.


Now, you might know us as ours are previously known name of Venus and Why, right? We changed about a month ago, and we’re rebranding, because of all the services that we provide are sort of a package of services in healthcare. Next slide.


So I’m here to talk about the Health Plan Perspectives, or Health Plans, at Vienna, Some choice are specialized plans. We really do cater to special needs plan. We have over 30,000 members, mainly in New York City, but we cover other regions in New York State, just as rural, as any other part of the country.


We have about 24,500 who require long term services and supports.


We have a special needs plan on the Medicaid side that has 3000 members, and they either have HIV, transgender, or they’re homeless.


90% of our individuals and beneficiaries are Medicaid or duly eligible.


Next slide.


So why are we talking about tills in home and community based services?


Great question.


Duels are three times more likely to be hospitalized with coven 19 complications than Medicare only. That was proven over the past two years.


They have 10 to 31% higher re-admissions than Medicare only.


41% have mental health diagnosis.


And there have a disproportionate and the highest cost enrollees in both Medicare and Medicaid.


And as our hosts said from Arnold Ventures, this is a costly and expensive population, 60% have multiple chronic conditions.


And more than 75% of Medicaid long-term services, beneficiaries, including HCBS, are duly eligible.


Just being a dual alone from a demographic status was typically the most powerful predictor of poor performance among social risk factors.


Next slide.


So, what are the types of plans that are being offered, that have home and community based services, integrated care options?


I’m going to start at the top, and then we’ll work our way to the bottom, and from the top, it’s probably less integrated, less co-ordination. And then we’re gonna go down and really talk about the options that you have on the health plan side. So you could receive, manage long term care services and supports and be in a dual eligible special needs plan.


Now, with this year and two, possibly different organizations, that’s two different organizations, so co-ordination. In some states, you might be in the same organization, but other states don’t require that. So therefore, you’ll have two cards.


two benefits.


And that’s not including some of the things that are carved out from these benefits, which still are paid for through Medicaid and Medicare, which means four different types of ensures and lots of confusion.


The next is the fully integrated dual eligibles.


And that means that you’re in one plan that services and provides benefits under Medicare, Medicaid and long term care supports.


And you have one care manager, one card for both plants.


Then you have the Medicare Medicaid plan, which is the MMP programs, which integrated all of these items, Medicare, Medicaid, and managed long term care services.


Now, Pace, the program for all inclusive care for the elderly is very similar to the … and the fight SNP. Except it really focuses in on intensive care management, which is usually provided in an adult day center, that has about 400 beneficiaries going through their, the focus is really through integrated care, and provides lots of services, through that adult A, including primary care.


Next slide.


So what’s the plan’s role in home and community based services?


It’s really, to manage care, provide really great quality, and also connect all the dots.


I thought it was really great that we were talking with, and Dennis spoke about his perspective and his personal care. It’s really devising a personal care plan for each individual. Each individual is not the same, and requires different services. It is not your basic Medicaid or Medicare manage mainstream, I would say. Where we’re paying claims, and there’s ratios, a 1 to 100 thousands, and you only isolate or talk about key problems, every person has a person centered care plan.


There is more intensive care management and co-ordination.


And I want to remind everyone that this kind of insurance is different than your traditional, and what I mean by that, when you start talking about personal care services, you are going into members’ homes.


They’re not coming to you in the hospital.


They’re not coming to you to the nursing home or any of the other facilities, and there has to be a respect, respect, that you are bringing insurance and providers to their homes.


And it’s personal getting dressed, getting bathed eating.


It has to be catered, and that’s really the a mainstay of our plans here.


So, the intensity of care management and having someone in their home is definitely something that’s important, But not only that.


You also have to look at the family dynamics and caregiver support.


Caregiver burnout, the social impacts, the social isolation, and the high degree of behavioral health.


Integrating all of that, whereas before in either Medicare or Medicaid, when you don’t integrate these long term care services, you really do receive fragmentation.


And key to this is also our partnership with HCBS services and really co-ordinating with that.


And I’ll go through that example in the next slide.


So, what’s the health plans role in HCBS?


We do a lot.


We actually worked with training our home and community based Services and our workers and we partnered with New York State to train over 44 thousand home care workers to become coaches’, behavioral health trainings and to really participate. So, I think this was a key part of it. The next example that I’ll give you is developing value based payments.


So, if we click on again, we’ll get the second part of that and what you receive here is really incorporating the HCBS services and the providers in the plan of care and having some value they’re quality metrics and incorporating their input into the care plan.


So, it’s actually having someone in the home who could help the member, the beneficiary really with things like getting them access to flu vaccinations, helping us out when their pain isn’t controlled and most importantly, falls falls are a big cause of hospitalizations and nursing home placement, OK.


Last but not least, I will go to my final slide as I think being the last presenter here. My colleagues have done a phenomenal job in talking about the continued challenges and opportunities.


First and foremost, this severe HCBS workforce shortage that Shannon spoke about and stressed so passionately towards the end is critical.


This is a crisis.


We had a shortage before the pandemic the pandemic has made it worse.


And yes, we are competing with the wal marts, the targets.


And this job is not for everyone.


There’s a lot of passion.


There’s a lot of really personal identity that goes along with this and a fit that has to happen with not only the personal care worker, but the consumer themselves.


So addressing this crisis is really critical. And I agree, Shannon that ARPA E was great for short-term, but after the next two years.


The crisis will return and it will be worse with current unemployment being at its lowest and the opportunities out there.


Next challenge barriers to access of care.


Boy did the pandemic highlight public safety and deter social determinants of health. When the pandemic first hit, we needed to make sure that our members, who were in the community had the capability to still receive services, and again, we’re not talking about your basic services of hospital services or physician services.


They need personal care workers to help them dress, to help them eat, to help them get out of bed, and to move.


So this crisis really shine the light.


On that capability end, the role of the health plan, because we worked with our members to make sure they had coverage or workers that were able to provide them the support during this incredible time.


Direct care workers aren’t always integrated into patients’ care teams. So, that really is an investment and something that we need to do. We need to make it easier for direct care workers to communicate, have the technology and have the education and training.


HCBS can be fragmented with the rest of care needs, so advancing fully integrated care, as I showed you in the previous slides, from separate health plans to multiple cards to multiple care managers. The goal here is to really drive fully integrated care for dually eligible beneficiaries with long term care needs.


And, again, inadequate Medicaid rates to support long-term services and supports. Shannon hit on this from the provider aspect. If the health plans aren’t getting paid enough, or there isn’t the appropriate risk adjustment or funding, it causes a stress to the system and a stressed to the providers.


Thank you for having me, and I will turn it back to presenters and the panelists for questions.


Everyone will give a moment for everyone to come back on camera, thanks to all of our panelists for setting some context for a conversation.


I’m going to kick off a few one question and then turn to some of the questions that were in the chat.


So starting off and handing your final slide was a great tee up for this conversation on policy Levers.


So thinking about the policy levers that are available to address issues around access and quality for HTTPS, what do you think would be the, you know, highest priority policy change that you think could improve access and quality? And I think we’ll start with Shannon.


I’m so sorry, Crystal, I thought you were asking that of, Amy. So So the question is, I’m sorry. Do you mind repeating it?


Just thinking about policy levers. So I’d like to get, I’ll be clear. I like to get everyone’s input on this one to start. So I’ll start with Shannon Grove or various Order and with Haney.


Heard a bit from him.


OK, great. Thank you so much. So, looking at home and community based supports, I mean, it’s not just just the funding, although that is so important. We’re looking at, you know, something so simple right now is defining what a Direct Support Professionals is. We have a bill to urge the Bureau of Labor Statistics to create a sock a standard occupational classification to define the unique work of a direct support Professional. It’s really currently intended to be encompassed with the personal care and home health workers, but it really is such a unique position that we feel strongly that it should be defined.


And that’s one piece that’s a foundational piece, but we’re also looking at ways to create a pipeline for direct support professionals for people to enter this work force.


Also, there, it’s going to take a lot of different solutions, and partnerships to potentially look at immigration, justice reform, you know, things that may prevent people from getting into this field of work.


So that’s just a few of them beyond the funding.


I would say get daman Sorry, I couldn’t count. I thought she called on me.


I would say I I agree with a lot of what Shannon said.


I also would continue to support ongoing funding. The ARPA funding was for a year.


And it does expire at which point, states are going to be struggling to maintain some of the increases and initiatives that were done through that.


I would also recommend expanding self direction, giving individuals more opportunities to select their workers and think through what ways can states make it easier for individuals’ time to hire and fire participants and find participants.


Some of the other things I would recommend are even, like, simple things, like building a database of qualified providers in the state, so that individuals have a way to contact their individual provider registries in HTTPS, or are a very valuable tool.


E Last thing I would mention on the quality side, is that the way that CMS monitors and manages quality right now, in HTTPS is very administrative in nature.


And I would really recommend transitioning to a model that focuses on the experiences, the outcomes, both health, and importantly, social outcomes of individuals who receive HCBS services.


Tennis, play thoughts on federal policy levers.


Dennis, I think you’re still muted.


Thanks, sorry about that.


From the dual perspective, muggle eligible benefit from the increased tanker integration of Medicare, Medicaid dollars, that they’re really it’s really incumbent on CMS, actually, on Congress to, to, to address that misalignment, the results, and people have been prolonged hospitalizations, not be able to get the services they needed home.


And to make, actually, to make it easier for plans to use the dollars in a way that really meets people’s needs, to keep them out of that, keep them out of hospitals, and keep them, and get them in the community. Because right now, we all know that such misalignment that that states are spending excess dollars and unnecessary hospitalizations, institutionalization over the long term that can be done away with the alignment, was there. So, that’s the first thing that I’d like to say.


The second is, and CMS is doing that, doing this, is increasing consumer voice at the beginning.


And throughout the process, in Massachusetts, we have something called the Implementation Council, which, which provides, uh, guidance to Massachusetts and the implementation of the of the dual eligible demonstration in the state. That’s the one Care Implementation Council.


And we’ve had direct impact on contract language and on how the plans actually function. But being at the table with the state and with the plans together with them, because that’s a great model width and we think that it really has enriched how the state works and for what are the voices of the state.


Is using and improving quality of access to services. And HCBS is one of those access to DME and looking at how are how approvals on how approvals and denials done, what, how in the approval area with modifications.


I think that’s another area of policy areas, is when when approvals are provided with modifications, to actually make that data transparent, about the applications themselves, and have greater apples to apples comparisons between the data provided by the different plans. That state agencies can actually read the data, understand the data, and provided transparently to the community, so that the community has the information they need.


I mean, I’ll there’s more I could say, but I’ll let others speak.


Alright. Any anything to add?


I will add Crystal, I think what Dennis said is on point when we’re talking about dual eligibles really trying to get to more integrated care. And I know we’ve tried different models but to continue to pursue the promotion of integrated care and really have the care management done by one organization and working on focusing on quality metrics that are specific to this population and not treating it as your traditional Medicare, Medicaid comparisons.


We have to understand that this is a special population, and Dennis, forgive me, I’m going to use you as an example.


But we have several thousand members that are people with disabilities and Dennis can speak to it better than I That wheelchair that he has is so customized, so special.


And it has his freedom to get out and be a human being and a part of society. And if you look at some of the approvals and the authorizations in traditional managed care, dennis’ would have to fight probably for about three years to get one part.


In order to make that wheelchair mobile, that’s unacceptable.


And that’s something that we have to understand. And I would say that policy has to understand that when we’re talking about tools and long term care, it is quite different than your basic managed care.


Thank you. I’m going to turn to some questions in the that have come through The chat said one more thing, Crystal, I’m sorry. And, that’s one addressing health equity.


And integration is a way of actually addressing health equity and having care plans in place and quality measures that that look at whether or not where we’re moving the needle on health equity and addressing the gaps in access to HCBS services and understanding why and how those catch people’s lives could. We’re seeing increasing numbers of folks in nursing homes from ethnic minority populations. And that was not the case in the past, the African Americans, for example.


And so if we’re going to address that, now, we really need to have transparency in the, in the in the quality measures that we use and make sure that equity as part of as part of those quality measures.


Thank you, Dennis. I’m going to turn a question in the chat. So we’ve got a couple of questions in the chat, actually, that are kind of revolving around a theme of understanding the return on investment of HTTPS and perhaps value based approaches to HTTPS. So, I’m wondering if anyone would like to jump in with some insights on, you know, understanding that there is initial investments made.


What do we know about, you know, the results and the return on an investment of HTTPS and whether there’s some value based methods that are promising.


I will start and I will start with a reference to what Dennis said in his presentation, which as you can necessarily always look at this from a return on investment perspective because that minimizes D, opportunities of participants too, engage, fully engage in the community, and receive the services they need to receive.


With that being said, there are a lot of studies out there that do indicate home and community based services are less expensive than the institutional alternative.


The Money Follows.


the person grant program had an evaluation that did look at this issue from, from a cost perspective, and find that there were some savings associated with it.


So I do think that you are right, that there is potentially an initial investment, and putting together a home and community based services, funding the transition from an institutional setting to a community, and also, the fiscal proposition does make sense in the long term, from it from a purely budgetary perspective.


I would just tag onto that to say, in some of my comments, talking about how long rates go without being looked at. Same thing goes with the budget or needs for a person served in the community. Having served many people, myself as a provider, that, that came into the community through the Money, Follows the Person grant, you know, just ensuring that long term their needs are met, and that when things change for them, and their health needs, Just like they do with all of us, that there’s, that that’s addressed, because those rates can, you know, tend to just be very stagnant. And we’ve always talked about that in our advocacy as far as community living. And it being such a cost savings.


as far as the comparison to institutional care, especially just the straight daily rate. But it’s really getting harder to talk about that when our wages are so low.


Um, that’s not right. It’s not OK. So, we have to continue to address that and not make it just seem that it’s a cheap alternative that must be kept. So low that people cannot afford to, you know, improve that quality or reimburse wages, And just lastly, I just wanted to say that anchors done. We have a group that works on alternate payment models. And we’ve done a couple of white papers around that.


So we’re really interested in exploring that work and, and sharing those ideas and concepts with Medicaid.


I would add one more thing to this. When you look at ROI and return on investment, you can’t look at it. And I think Dennis had it in her slides short-term.


There’s a significant investment.


And again, I’ll talk about the wheelchair or home modifications or caregiver support. That cost extra dollars. But the benefit of that is prevention of long term placement.


That takes years right, to figure it out. It takes a longer time to get the dollars, but when you look at quality and I believe quality should be a part of the Roi.


When you look at independence, the ability to prevent social isolation and other key metrics need to be taken into account when you’re looking at the return on investment and the return on investment will not happen in three months or six months.


I think that’s one of the learnings that we had from the MMP programs. in New York. It takes awhile.


I think a friend of mine always refers to it as looking at it as far as bending the cost curve over time, rather looking at it as direct ROI, And that seems to that it seems to make a lot more sense.


And doctor Bob Basta, who is a guru of integrated care and an investment in HCBS as a way of of not offsetting, but it’s a way of keeping people out of the hospital, really just says, if you give people what they need, the savings will come.


But if you’re looking for that direct line, it’s not necessarily going to be there.


And that, and that’s the challenge I had a lot of health plans face.


When they move into this field particularly around HCBS and wanting to medicalized the determination of need, determination of need is very narrow.


Then the solution is not going to be there, but it does give a very quick example.


A woman who needed, uh, I see a wheelchair with the boost that seat, elevated, short, statured, lot of pain in the neck, deteriorating condition and choose denied that elevating seat.


And yet, everyone knows that that elevated sheet, if she needed to be in the community. Because the very short low stature of elevators are people who can see her, and it also makes it possible to look directly at people, not strain her neck and that.


And that exacerbate her already declining condition.


Just that comment, And then, as I just wanted to add, that, that, you know, you just really can’t quantify, in the short-term, people having the choice to live. And I’ll just, I just wanted to bring this up in our advocacy, around, the, home and community based funding investment in the Reconciliation Bill, We’ve talked a lot to, people, we’ve talked a lot to Senator Manchin office about this, too, and, you know, this is one piece in this country where things are so divided right now that over 80% of Americans supported this piece. The fact that, you know, people should have the right to live as they want to. in their own homes, rather than other settings.


Thank you. So, I’d like to return to the theme around health equity, which, I think Dennis started speaking on awhile back: You know, how do we think about health equity and HTTPS?


You know, there’s certainly, I think, move to do a better job of understanding who programs are serving and identify disparities, but are there places where we already see opportunities or policy levers to address health equity issues in HTTPS?


I would add that when you talk about equity and HCBS, you need to also think about the provider community, because there are many, you know, individuals who are low income or racial ethnic minorities who are providers.


And so, work needs to be done, both on the individual served, as well as on the provider community.


Another aspect for equity is also across the different populations.


I talked about the different targeted groups in Medicaid and the targeted groups, whether they’re narrow or broad, that can make a difference in terms of individual served health equity, and those sorts of issues. So, there’s a lot of different ways.


Look at it, and I think fat, one of the things, dennis’ stressed, that I would, we re-iterate as you can’t do it without talking to the individuals and understanding their perspective, both from a service perspective, but also from, from an equity perspective.


The way I hate it, I hate that. I hate the, the question, are you satisfied with the service that you’re receiving?


Because if folks are traditionally disenfranchised and accustomed to receiving lower quality services, then they’re going to say, Yes. I am satisfied with the service I received.


And that’s not going to adjust inequities in health care access.


And so, we really need to, we really need to be very point, and now the questions are asked, and more research can be done and asking people, do you believe that because of your race, X, Y, and Z, or are there things that that would assist you? And including making sure the community health workers are out there, That resemble the part of the person. That they’re talking to his important care co-ordinators, That resemble the population that they’re that they’re working with. is really important.


And it’s, and that, there is a way of actually, I believe, in, in, uh, and setting a goal. And setting benchmarks for increasing the number of folks in the field that come from different populations.


And it can be even through personal care attendants, your personal care attendants when we got to community health workers, doing health workers, moving up to being care co-ordinators.


And that way you’ll have folks from the community actually engaged with community members in a way that is currently not happening.


So that’s another recommendation.


I would add, Crystal, the no Daemons point regarding looking also at providers and having a workforce that reflects our demographics and the places that we live.


I know I’m harping on this a couple of times but I’ll keep on mentioning it.


When you go into someone’s home, it’s you can’t get someone to translate, you need to understand their ethnicity, you need to understand their background, and you need to understand their language.


A telephone line isn’t going to be the most conducive to communicate with a member, so I think making it sure that we have equity on the provider side, the workforce. And in the community and promoting that is really key. The other thing that I would say is, is that someone mentioned this about surveys. I think it was Dennis.


We need people to respond, I’m not sure the people that we’re talking about respond to these surveys, so their voices aren’t heard.


They’re not the ones that are responding to lots of these surveys, so making sure that it’s easy for people to fill out those surveys or have different modalities or assistance, I think is key to hearing people’s voices.


Great. Thank you.


So, we’ve got just under 10 minutes left.


So, I’m actually going to start with some closing remarks, or at least giving you all an opportunity to do some closing remarks. So, maybe, in the order of presentations, if you could just talk about some closing thoughts or key takeaway is, Again, you know, the theme of this is, what’s next and HTTPS? So, what are the final thing that she would like the audience to know, so I’ll start with Dennis.


Can I pass, Noah?


Yeah, I think Congress needs to take a serious look at this.


And, uh, for me, the place to start is to make community choice first, pass pass a law that that makes home based services, the primary option and suck, and nursing home secondary, because everyone should have a right to remain in the community. So, that, for me, would be the first.


The next is to pass a law put that would integrate care for folks across the country so that so there’s great integration with whether it’s straight Medicaid or dual eligibles that they’d be integrated care by ACOs, MCOs, or pace programs or within the fee for service system. That we ramp up that. We ramp up that integration.


The third would be having quality measures for HCBS that makes sense to the people who receive the HCBS and actually improve quality. Value based purchasing, that’s based on, on achieving the quality that’s determined by by states, with, with, with folks, and there are a few more things that I think.


The biggest fear we have is zolli, going into nursing homes, but having our homes turned into nursing homes without walls.


And that then means that every day, every aspect of our everyday lives becomes medicalized and the fear about what did the push to eat. Well, how long do they use in the bath on what they like?


And having this this medicalized, sort of the PCA having to report back to the plan, what they did, how long it took, all those sorts of things, that that, that’s quite frightening to us, because it really is, It’s like being prisoners of their own home.


So, for me, it’s it’s about making sure HCBS is about supporting people, living in thriving in the community.




Gosh, Denis did such a good job? I don’t know what I have to add.


I would say that there are a lot of legislative and statutory issues with making home and community based services first. So they need to be addressed. There are equities ranging from the fact that to secure a waiver, it has to be cheaper than the institutional alternative.


There are issues related to eligibility and all sorts of things.


Another one is, it’s very easy to immediately get services in an institution, but there are a lot of barriers and a lot of processes that have to happen before you can get home and community based services.


All of those things need to be addressed before we can truly talk about a system that promotes home and community based services.


If we look at what’s next, I think that looking at the ARPA spending plans, through those links I provided, gives you a real good sense of where the priorities are around the country, and where people are putting the money to, to advance HTTPS, and implement things that they think needs to be done. So, I would just re-iterate, take a look at those plans, and it will inform you on where some of the priorities are.


Thank you, Crystal. And for the opportunity to be with this panel today, I learned a lot myself as well, I always appreciate it. And I think as far as what’s next, where I was so hyper focused on the workforce piece. And we have to be. But what’s next is we continue to look for different solutions. There’s no one silver bullet Obviously, there wasn’t And there’s not going to be we’re not going to solve the workforce crisis, but we’ve got to adapt. And a couple of the things I didn’t mention earlier are, you know, looking at some of the flexibilities that were allowed through the pandemic, through the Appendix K waivers.


And the things that makes sense, you know, seeing if we can continue that it was rather than rolling back and some of those things were as simple as allowing electronic signatures. David knows this is you know, it was ridiculous that it came to had to take a pandemic to get to those points but you know providers can have a lot of flexibility. That makes sense that save money, save. Time Administrative burden is lifted there that are better for people in service provision. And also technology.


There was a lot of technology allowed allowances through the pandemic, you know, Face-to-face, I used to run a case management agency, if we could have done a face-to-face and been able to, you know, use that as a tool for a visit and a check in, I think it would increase the frequency and quality of those relationships too. So, some of those flexibilities that makes sense, but that’s funding investment for home and community based services.


Without the funding, it means nothing and, and the ARPA, the states that really wanted to invest, its Diamond talked about and invested in providers and wages. They did that with the hopes that something would be delivered beyond to be able to sustain it. In other states, didn’t do anything or, you know, really substantial in regards to investing in services and, and, and your direct support professionals. But lastly, if I come across passionately, it’s because I really am having done this service and met a family member, and now representing providers, and the people they serve.


But, I heard it framed this way this week, and it’s dramatic, but it’s true, no staff, no services, and that, just, there’s no workaround to that.


My turn!


So, that’s a lot.


So over my career, and whether it’s on the provider side or the health plan side, I will tell you, I have never met anyone in the community that wants to live the rest of their lives in an institution.


Never met one person that has said that to me.


I don’t think anyone in the hospital wants to be in the hospital or stay in the hospital, and everybody’s looking to get out as fast as they can from that hospital. So, really, providing care in the home is so key and so critical. And I think it is something that’s really important, that needs to be addressed and really does focus in on equity.


four, lots of people, this is important, this is really key to them.


I would say that I would urge Congress to really look for ways to integrate care from the health plan perspective. I also see dennis’s point from fee for service and Medicaid only, But where there are opportunities to integrate care, I would try and take advantage of that and keep on trying and getting to a better place. Let’s never give up.


We can try one model, see what the benefits are, and continue. I think there are two bills right now in Congress that Senator Casey has introduced that I would urge people to really look at and focus in on. I think it’s an important part of healthcare.


I think we all proved its highest cost and the best quality, so let’s not postpone this because I think Shannon said it, one day, we will require it.


All of us, there will come a day. Will we, where we ourselves will need this from our health care system or have family members? So let’s try and make it right.


Let’s not wait for 15, 20 years down the line. There are people right now who need the appropriate services, who aren’t getting them.


Thank you. And thank you all for your insights today on this very important topic, Unfortunately, where, at the end of our time together, a couple brief housekeeping items before we close. Viewers, please take time to complete the brief evaluation survey that you’ll receive immediately after the broadcast ends, as well as via e-mail later today.


Please keep an eye on the Alliance website for details about future upcoming events, including the FDA 101 webinar, on Wednesday, June 29th at 12 PM Eastern.


A recording of this webinar and additional materials will be available on the Alliance website.


And this concludes our seminar, Arielle, Dennis, Damon, Shannon, and Haney. Thank you so much for joining us today.


Thank you for having us.


Thanks, Crystal.