‘There Is Not An Easy Solution’: How to Modernize Home- and Community-Based Services

Home-based care insiders have been saying for a long time what a wider group of people are now: Care needs to be brought into the home more frequently — and quickly.

But accomplishing that won’t be so simple. In fact, turning the nation’s long-term care system into one that allows more seniors to age in place will be an incredibly difficult feat.

A total transformation of senior care in the U.S. will take more financial assistance for states, a modernization of the current eligibility policies that make it difficult for seniors to receive at-home care and significant investment in the direct care workforce itself.


That’s according to a new Health Affairs article published Tuesday by Washington, D.C.-based research and advisory firm ATI Advisory ATI Advisory.

“There is not an easy solution to this,” Allison Rizer, a principal at ATI Advisory and one of the article’s authors, told Home Health Care News. “You can’t mandate services, for example, and expect the infrastructure to be there or for the money to be there. … There is this bigger picture that needs to be addressed if we’re going to get serious about solving access to home-based, long-term services and support.”

To some extent, the Biden administration has already started to build out some of the “three-legged stool” for investing in home-based care. The American Rescue Plan has increased the Medicaid federal matching assistance percentage (FMAP) by 10% for home- and community-based services (HCBS) for a year, though providers still have plenty of questions about how the added funds can be deployed.


Additionally, the administration’s recently proposed American Jobs Plan includes $400 billion to expand access to HCBS while investing in the recruiting, training and retention of caregivers.

Those packages are a good start, ATI Advisory argues. But there still needs to be a more “radical design” of systems and policies that better align the federal government and states when it comes to home-based care.

“I think there has to be a partnership between the [federal and state lawmakers],” Rizer said. “Especially as it pertains to financing, because, quite frankly, states just don’t have the money to expand access to home- and community-based services without pulling that money from something else. So rather than try to pull that money from, say, children’s health care [or] education, I think that is where there is an important role for the federal government to assist states.”

The state of New York ran into this exact problem as it aimed to form its future budget this year while facing financial shortfalls tied to the COVID-19 pandemic. Specifically, the state sought to claw back millions of dollars from in-home care providers by slashing workforce funding over the next two years.

Home-based care advocates in New York were against the move, especially as demand for such services was increasing.

“There’s also just opportunities for guidance and clarity at the federal policy level,” Rizer said. “There are certain policies and authorities that states can use that exist today, that they are not completely aware of. And I think that’s also a space where the U.S. Centers for Medicare & Medicaid Services (CMS) can fill that education void. But states are really important players here as well, because so much of the infrastructure and the delivery system is local.”

Getting the federal and state policymakers on the same page is important, but investing in the home-based care workforce itself is the key to meaningful long-term care change, according to ATI Advisory. Without workers, home-based care agencies will simply not be able to meet the demand.

“The focus should be a little bit more on the [workforce] leg of the stool,” ATI Principal Tyler Cromer, who also authored the Health Affairs article, told HHCN.

Increased pay — and corresponding reimbursement to support that increase — is an obvious solution. But it’s not the only one, Cromer noted.

“The federal government can help build some of the support and infrastructure to undergird the caregiving workforce,” she said. “The training infrastructure, for instance, and pulling together a collaborative effort with stakeholders to talk about what those sort of minimum training standards for direct care workers should be.”

The final leg of the stool would be allowing frail seniors in their homes to more easily qualify for home- and community-based services, ATI points out in the Health Affairs article.

“Right now, there isn’t really a clear definition of what a minimum personal needs allowance should be,” Rizer said. “And as a result of that, an individual really has to spend through all of his or her resources — even those resources that would help him or her stay in the home — to qualify for Medicaid. And that’s absurd.”

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