2023 Home and Community-Based Services Conference Insights

In late August, PCG health and human services subject matter experts attended and exhibited at the 2023 Home and Community-Based Services (HCBS) conference in Baltimore, which PCG also sponsored. This annual conference brings together state, federal, and local agencies, policymakers, and stakeholders to discuss critical issues in the HCBS space, learn from experts, and turn those learnings into solutions to improve long-term services and support (LTSS) delivery systems and outcomes. Our team was joined by 81 other exhibitors and over 1500 attendees representing all 50 states, federal agencies, Guam, American Samoa, and Israel.

The conference provided an opportunity to make valuable connections and gain insight into state and federal priorities. Key conference topics included:

• • The post-transition landscape following the HCBS final settings rule
  • Recent and anticipated legislative and regulatory changes
  • HCBS quality and oversight
  • Stakeholder engagement
  • Managed Long-Term Services and Support (MLTSS)
  • Direct workforce shortage crisis
  • Financial strategies to improve care, including rate setting and value-based care
  • Equity and inclusion

Below are some highlights from the conference sessions.

Managed Long-Term Service and Supports (MLTSS)

One of the main focuses throughout the HCBS Conference was the role of Managed Care Organizations (MCOs) in the LTSS landscape. As more states move towards an MLTSS model, MCOs are taking an increasingly direct role in program and financial design, oversight, and overall service implementation. Multiple panels featured MCO leaders offering perspectives on their evolving roles, engaging key stakeholders during healthcare transformations, and the challenges and opportunities presented by anticipated CMS rule changes. This mindset was highlighted during “Workforce Development: A MCO Call to Action to Innovate, Invest & Collaborate”, which offered actionable policy proposals and action steps to help MCOs collaborate with states to respond to the direct care workforce shortage crisis.

Addressing the Direct Care Workforce Shortage

Nationwide, states are grappling with a direct service worker shortage impeding their ability to support those needing HCBS. Already, HCBS systems are under tremendous pressure, unable to meet the needs of those receiving care in their home or community and the individuals waiting to move out of institutional settings into the community. By 2030, the United States will need an additional 1.2 million direct care providers to help ensure people with disabilities and older adults may receive care in their homes.

Multiple conference sessions brought state, local, and industry experts together to discuss trends and share strategies to strengthen the direct care workforce. Our team had the opportunity to learn about state priorities and share insights gained from our work during interactive sessions, networking sessions, and at our booth. The conference culminated in a 3-hour intensive showcasing approaches from 9 state agencies and their partners. Key solutions discussed include:

• • System financial and structural reforms
  • Strengthening training standards and delivery systems
  • Implementing recruitment and retention initiatives
  • Connecting providers to individuals in need of services
  • Improving workforce data collection and analytics
  • Identifying and addressing structural inequities

Proposed Guidance, Rule Making, and Other Policy Changes

The AARP Policy Institute introduced changes to the annual Long-Term Services and Supports (LTSS) Scorecard which measures state LTSS system performance in Affordability and Access, Choice of Setting and Provider, Safety and Quality, Support for Family Caregivers, and Community Integration.  New indicators for the 2023 scorecard include Equity, Workforce Development, and Innovation mirroring the HCBS conference themes. The new website is https://ltsschoices.aarp.org.

The previewed their upcoming paper: Understanding the Impact of ARPA HCBS Investments.  The presentation showcased the robust evaluation approach by the Colorado Department of Health Care Policy and Financing which early on identified initiatives that would need to be sustained after the funded period and developed rigorous quantitative evaluation methods.

A recently proposed rule from the Centers for Medicare and Medicaid Services, Ensuring Access to Medicaid Services (CMS 2442-P), includes proposed changes specific to Home and Community Based Services (HCBS), including:

• • Requiring that at least 80% of Medicaid payments for personal care, homemaker, and home health aide services be spent on compensation for the direct care workforce.
  • Establishing standardized reporting requirements related to health and safety, beneficiary service plans and assessments, access, and quality of care.
  • Requiring minimum performance expectations related to incident management systems, critical incidents, assessments and service plans, and Fee-for-Service (FFS) grievance systems.
  • Promoting public transparency related to the administration of Medicaid-covered HCBS through public reporting of quality, performance, and compliance measures.
  • Requiring states to submit an annual payment analysis that compares managed care plans’ payment rates for personal care, homemaker, and home health aide services as a proportion of the state’s Medicaid state plan payment rate.

The Administration for Community Living (ACL) within the Department of Health and Human Services (HHS) also recently issued a Notice of Proposed Rulemaking to modify the implementing regulations of the Older Americans Act of 1965 (OAA). The proposed rule exercises ACL’s authority to regulate Adult Protective Service (APS) systems under the OAA and in the Elder Justice Act (EJA). A summary of the proposed rule includes:

• • Program Administration: requires APS systems to respond to reports of adult maltreatment, including allegations of abuse, neglect, exploitation, sexual abuse, and self-neglect.
  • Investigation and Post-Investigation Services: requires the State entity to develop and implement a standardized set of policies and procedures for essential APS functions throughout the lifecycle of a case.
  • Accepting Reports: requires the State entity to have policies and procedures for promptly accepting reports, including multiple methods to receive fully accessible reports, 24 hours a day, 7 days a week.
  • Coordination With Other Entities: requires the State APS system to coordinate with other State and local governmental agencies, community-based organizations, and other entities engaged in activities to promote the health and well-being of older people and adults with disabilities, including State agencies responsible for home and community-based services (HCBS) programs.
  • APS Program Performance: requires the APS State entity to collect and report aggregated data annually to ACL.