The toolkit includes four modules that provide:
- State strategies to increase the share of LTSS provided in community-based settings;
- Tools designed to assist states with policy and programmatic strategies;
- Case studies of innovative programs and creative ways states are leveraging available federal authorities to transform LTSS systems; and
- Links to relevant resources.
The modules, as outlined by CMS, are:
Module I: Background on HCBS and Institutional Services
Provides historical context on the evolution of LTSS reform initiatives and a snapshot of LTSS rebalancing and demographic trends. Over the past several decades, states have used several federal authorities, as well as federally funded grant programs, to develop a broad range of HCBS to provide alternatives to institutionalization for eligible Medicaid beneficiaries. HCBS expenditures, relative to total Medicaid LTSS expenditures, have steadily increased over the last three decades, but this trend has slowed in recent years. In addition, the number of adults age 65 and older is expected to more than double between 2014 and 2060, with the largest increase expected from 2020 to 2030. By 2030, one in five U.S. residents will be age 65 or older.
Module II: Advancing State Home and Community Based Services Rebalancing Strategies
Describes key elements of HCBS systems that are economically sustainable, equitable across the broad range of people with LTSS needs, and continuously improving in HCBS quality and access. Several interrelated key elements of an effective system to advance HCBS are: (1) person-centered planning and services; (2) No Wrong Door systems; (3) community transition support; (4) direct service workforce and caregivers; (5) housing to support community-based living options; (6) employment support; and (7) convenient and accessible transportation options. In addition, this module discusses data based decision making in HCBS, stakeholder engagement, quality improvement, and financing approaches.
Module III: Current Flexibility under Medicaid to Support State Rebalancing Strategies
Describes the various Medicaid authorities from which states can choose to cover HCBS and provides state examples of how these Medicaid authorities can advance rebalancing strategies. This module provides an overview of programs and services to support Medicaid beneficiaries to transition from medical institutions to the community including services such as personal care and case management services that help individuals achieve community living goals. In addition, this module profiles states’ innovative HCBS programs and services that can foster efficiency, reduce and contain costs, and improve health outcomes for Medicaid beneficiaries. Further, institutional tools for advancing rebalancing, such as the Preadmission Screening & Resident Review (PASRR), are featured.
Module IV: State Strategies to Rebalancing LTSS Systems
Provides examples of innovative state models of care and strategies to reform and recalibrate LTSS systems and to expand and enhance HCBS. This module describes how some states are testing new eligibility groups and benefit packages for individuals at risk of needing Medicaid LTSS in the future. In addition, case studies show how some states decrease the use of institutional care and incentivize community-based care through “bed buy-back” programs, repurposing long-term care facilities, and supporting new business models for direct service workers.