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Long-Term Medicaid Support Services Move to the Home and Community


“Stay home.” We all remember hearing these words when the COVID-19 pandemic first took shape in spring 2020. While most complied and were able to minimize their contact with others, many in institutional settings, such as nursing facilities, were still surrounded by people. This environmental challenge resulted in 1 in 10 people living in nursing homes dying from COVID-19 during the pandemic.

This information points to opportunities for growth in long-term services and supports (LTSS). LTSS refers to “the broad range of paid and unpaid medical and personal care assistance that people may need…when they experience difficulty completing self-care tasks as a result of aging, chronic illness, or disability.” LTSS goes hand in hand with Medicaid, as Medicaid pays for more than half of the nation’s spending on these services, according to a recent report by Medicaid Forward.

A National Association of Medicaid Directors (NAMD) report explores how states could help improve the lives of the individuals who use LTSS services—mostly older, low-income adults, and children and adults with complex health needs or disabilities—using what they learned from the COVID-19 pandemic and the more than $9 billion invested by Congress through the American Rescue Plan Act.

Staying home

The largest movement associated with this population involves a concentrated push to move a majority of LTSS services from institutional settings to Home and Community-based Services (HCBS). HCBS encompasses assisted living facilities and in-home care, which broadly represents the “services and supports that allow people to live more independently and in their community.”

This incentive is fueled by an array of objectives:

  • Provide a safe alternative to the institutional environment caused by the pandemic
  • Make LTSS more cost-effective by acting on decades of proof that HCBS is a cost-effective alternative to institutional care
  • Increase at-home access to care by using technologies such as telehealth, remote patient monitoring and medication management tools that foster independence, improved health and increased safety
  • Respond to an increased demand for HCBS, born out of the concept of person-centeredness: “putting the individual and their unique needs at the center of service planning and care delivery”

The importance of at-home and community care cannot be discounted. In addition to the financial benefits associated with managing LTSS needs within the community, HCBS services are shown to be safer and boost well-being. Self-direction, a key component of person-centered care, allows individuals receiving HCBS services to manage all aspects of their service plan. This adds to their ability to remain independent, thus increasing their satisfaction level and enhancing their relationships with the providers they choose.

Overcoming challenges

While there are many reasons to transition traditional LTSS services to the HCBS environment, states also face significant challenges:

  1. “Natural supports,” such as family, friends and schools that help care for these populations at home are suffering from increased levels of mental illness and stress, affecting their ability to provide proper support and care.
  2. The LTSS workforce is severely understaffed: The pandemic and an increased demand for home and community-based care has decimated the HCBS worker population. The U.S. is expected to need approximately 3.4 million direct care workers by 2030 to serve the needs of the aging population.
  3. A growing need for LTSS in the next 40 years—as the number of Americans aged 65+ doubles and the number of Americans 85 and older quadruples—will strain institutional care infrastructures, heightening the emphasis on home and community care support systems.

Although the future landscape may seem daunting, states can overcome these obstacles by maintaining a focus on person-centered care and implementing strategies to address these environmental and workforce challenges. For example, access to at-home care can be improved by increasing benefits and incentives for personal care workers and natural supports, both of whom can help provide higher quality care if their monetary and personal needs are met. Targeted improvements such as these will help attract and retain the personnel needed to satisfy growing requirements relative to demand for home and community care.

Present and future

While there is still much work to do, several states have already initiated efforts to bolster this critical workforce.

  1. Washington State provides advanced training and pay increases depending on how long a care worker has been in their position.
  2. Rhode Island offers pay raises to those who have attained a certain training level or certification.
  3. Colorado pays family members who care for loved ones if they become Certified Nursing Assistants.

While these are steps in the right direction, widespread transformation can only occur if other states follow suit. The onslaught of problems brought on by the pandemic coupled with the money invested by Congress through the American Rescue Plan act gives states a huge opportunity to improve the lives of those Medicaid members receiving long-term services and supports. Giving everyone the ability to “stay home” is a cause worth fighting for.

Robert Pittman is Senior Vice President of Government Affairs at Modivcare.

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