State Strategies
Washington Evaluations Support Development of First-in-the-Nation Innovations in HCBS
Washington State has long been a leader in using evaluations and data to refine and drive improvements in its home and community-based programs. For example, Washington’s family caregiver support program within its Medicaid 1115 waiver was built upon data from a state-only program for unpaid caregivers of adults with movement or cognitive limitations. The state evaluated the impact of expanding its family caregiver support program in 2012. This evaluation found evidence that the care recipients of caregivers who participated in the program were less likely to be enrolled in Medicaid long-term services and supports (LTSS) a year later. Based on these findings, Washington State pursued expanding services supporting family caregivers, especially within its 1115 waiver.
The state has pursued a range of other approaches in developing HCBS programs:
- It recently launched a first-in-the-nation long-term care insurance program, WA Cares Fund, which uses a half-percent payroll tax to fund a long-term care insurance option available to all working Washington State individuals, beginning in 2026.
- The state observed Medicare savings through its health home model targeted to “dual-eligibles,” meaning those who are eligible for both Medicare and Medicaid coverage. Within the program, high-risk dual-eligible beneficiaries participate in a health home model that coordinates LTSS, acute care, primary care, and behavioral health care, and they receive services that include “comprehensive care management, care coordination, health promotion, comprehensive transitional care and follow-up, individual and family support, and referrals for community and social services support.”
- The state has incorporated reentry supports into its newly renewed Medicaid 1115 waiver, and 90 days of pre-release for a limited Medicaid benefit is authorized. Supports include:
- reentry coverage for individuals leaving prison, jail, or a youth correctional facility
- pre-release services
- phased services, with minimum required services that include case management, care transitions, medication-assisted treatment, and a 30-day supply of prescribed medication
- six-month rental remedies and supports
Jason McGill, assistant director at the Washington State Healthcare Authority, noted that Washington State’s 1115 waiver was a key opportunity for the state to incorporate data-driven program evaluation and analysis. McGill confirmed that HCBS were not only about rebalancing and saving money, but firstly about providing people choice and dignity. The state’s waiver can serve as a model for other states in developing programs to support a variety of needs for Medicaid populations, including health-related social needs such as nutrition supports, housing, supportive employment, long-term care, respite, and family caregiver supports. When unaddressed, health-related social needs, such as low access to nutritional food, can contribute to poorer health. Meeting these social needs can improve the health of Medicaid populations that utilize HCBS.
Texas: Evidence-Based Practices and Partnerships with Evaluation Experts Translate into Behavioral Health Innovations
Texas develops, tests, and implements evidence-based home and community-based services within programs for people with serious mental illness (SMI). Texas noted that people with SMI face significant health, social, and economic disparities. They live shorter lives and develop chronic health conditions earlier in life than other Americans. They are consequently significantly overrepresented in institutions, such as nursing facilities. They are also less likely to be employed or have a stable home, adequate medical care, and informal supports in the community.
States can use evaluation and evidence-based community services and supports to redress disparities, which can include testing existing practices in new contexts (demonstrations) or developing and testing new practices to develop evidence (through randomized controlled trials). Texas noted that states have opportunities to conduct research studies through leveraging local, state, and federal partnerships.
Texas has developed and implemented randomized controlled trials and demonstrations to test better ways to support independence for people with SMI that use HCBS. The state’s behavioral health innovation strategy team collaborates with university partners to develop, implement, and independently evaluate randomized controlled trials and studies. University research partners have included the University of Texas Health Science Center at San Antonio (UTHSCSA), the University of Texas at Austin, and Texas A&M University.
Dena Stoner, director of behavioral health innovation strategy, Texas Health and Human Services Commission, noted the value of collaborating with research partners and centers of excellence at state universities, as these partners often have more flexibility than state Medicaid agencies or mental health authorities, significant additional expertise, and tenured staff.
Texas’s state Behavioral Health Division is part of its consolidated Health and Human Services Commission, which also includes the state Medicaid division. Stoner noted that this organizational structure has provided opportunities for partnership and testing evidence-based interventions in the state’s Medicaid HCBS system. This work is funded through multiple sources, including grants and technical assistance dollars from the Centers for Medicare and Medicaid Services (CMS) and the Substance Abuse and Mental Health Services Administration and in-kind or financial contributions by managed care organizations (MCOs) and local partners. Stoner noted that people with lived experience of mental illness inform the design, implementation, and evaluation of practices.
One example of research partnership is the Texas Money Follows the Person (MFP) Behavioral Health Pilot. Texas developed the pilot program to help people with SMI transition from nursing facilities to community HCBS under the state’s managed LTSS program for adults. In the pilot, participants received an evidence-based practice (Cognitive Adaptation Training, or CAT) for up to six months prior to discharge and up to one year post-discharge. Independent evaluation found that almost 70 percent of participants were able to maintain independence in the community, with improved functioning, personal achievement (employment, education, relationships, community involvement), and savings to the state Medicaid program over nursing facility costs.
Texas subsequently received CMS funding to provide technical assistance and training to MCOs and provider networks throughout the state through UTHSCSA’s center of excellence on evidence-based practices; to build transition infrastructure in MCOs; and to use CAT and related interventions to avert nursing facility placement for people discharging from state psychiatric facilities.
Texas also uses randomized controlled trials to test new service delivery concepts. One recent example is the Mental Health Self-Directed Care project, in which adults with SMI had the option to have control over how funds were spent on a portion of their community services. The pilot indicated better recovery outcomes at no greater cost than traditional service delivery. Texas is currently exploring how mental health self-direction could be incorporated into the Medicaid community service delivery system in the future.
Massachusetts Evaluating Home-Based Care in Randomized Controlled Trials
Charles Pu, senior medical director, MassHealth Office of Long-Term Services and Supports, shared information about Massachusetts’s approach to data analysis of HCBS and the value of using randomized controlled trials to test home-based care models in the state. As a guiding framework, Pu presented an organizing framework for conceptualizing the home-based medical care landscape organized by intensity of care need and whether the care was long term, urgent, or acute, as seen below.
Pu noted that the home-based primary care (labeled as quadrant III in the graphic) and hospital at home (labeled as quadrant IV in the graphic) models are targeted to a relatively small number of patients with the highest medical needs. In particular, the Hospital at Home model serves patients with high medical intensity and acute episodic care needs. This model allows individuals to receive acute care at home that otherwise would have been delivered in a brick-and-mortar hospital setting.
Findings from a 2018 pilot randomized controlled trial evaluation and 2020 full randomized controlled trial evaluation of the hospital at home model in Massachusetts demonstrated the value of the at-home medical model approach. Patients receiving care at home in the hospital at home model showed lower costs for acute care episodes, compared to a similar group of patients receiving care in a hospital, and no significant differences in safety, quality, or patient experience. Leveraging its local experience with hospital at home care model innovation and evaluation, Pu also noted Massachusetts has just awarded two randomized controlled trials to evaluate a skilled nursing facility (SNF) at home model, which now extends home-based medical care delivery innovation and evaluation into post-acute SNF care.
Key Takeaways
States are the laboratories and innovators of evidence-informed HCBS. However, there is no standardized national definition of HCBS, and the availability of data on HCBS varies from state to state, making national comparisons of HCBS challenging. Chris Park, acting policy director and data analytics adviser at Medicaid and CHIP Payment and Access Commission (MACPAC), discussed MACPAC’s federal approaches to data collection and a call for collecting national data at the federal level on unmet need and effectiveness of services in HCBS.
Overall themes from the session included the importance of partnerships and collaboration among agencies in developing evidence-informed HCBS policy. Developing collaborations with a diverse range of authorities, local and federal agencies, and other partners such as state universities and hospital agencies, can help states address capacity barriers. Incorporating data to improve HCBS supports should be an ongoing, continuous activity. Washington uses an approach of testing different Medicaid program models and incorporating lessons learned into future iterations of the programs. Stoner stressed the need for hard data as evidence to support large-scale transformation. The session concluded by framing the process of incorporating data and evidence into HCBS policy as a journey and noted that evidence-based evaluations are not a barrier, but rather an opportunity to support innovation in state HCBS policy.
Acknowledgements
The “More than a Feeling: Using Research and Data to Drive HCBS Improvements” conference session and this brief were supported by The John A. Hartford Foundation.
