Raising Expectations: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers
Maximizing consumer choice of LTSS options
The Scorecard finds a threefold difference between the five top- and bottom-performing states in the percentage of new Medicaid beneficiaries who receive HCBS before receiving any nursing home services. This indicator measures the LTSS system's ability to serve people in the community rather than a nursing home when they need support. In the top five states, on average, 77 percent of new Medicaid LTSS beneficiaries receive HCBS. By contrast, in the bottom five states, only 26 percent of new LTSS beneficiaries receive HCBS. The average across all states is 57 percent. Failing to serve new beneficiaries in HCBS settings can have negative impacts for an extended duration: those who enter a nursing home have a more difficult time returning to the community, even if they can and want to live in the community.
Policy action: State policies such as "options counseling" and nursing home diversion programs can help to direct new LTSS users toward HCBS rather than nursing homes. States also can implement "presumptive eligibility" procedures to quickly establish that a person will be able to qualify for public support for HCBS, thereby preventing unnecessary nursing home admissions.
The Scorecard finds wide variation in the extent to which state systems allow program participants to direct their own services. Variously referred to as consumer direction, participant direction, or self-direction, this model allows the individual to hire and fire a worker he or she chooses, set the hours for service delivery, and, in some cases, determine the wages paid.3 Over the past several decades, self-direction has proven to be increasingly popular with many participants. The Scorecard finds that California was the highest ranking state, reporting 143 people receiving self-directed services per 1,000 adults with disabilities, or about 1 in 7. The average in the next four top-performing states was 51 people per 1,000 adults with disabilities. The national average was 22 people per 1,000 adults with disabilities. In each of the six lowest performing states, fewer than 1 out of every 1,000 adults with disabilities received self-directed services.
Policy action: States have great flexibility to give people who use LTSS the option to direct their own services in publicly funded programs. These programs often allow participants to have greater flexibility as to when services are delivered and who provides them. Such programs also can expand the available workforce, as many participants choose to hire family members who would not otherwise be working in this field.