Discussions of care management in long-term services and supports (LTSS) for older adults often focus on coordinating home- and community-based (HCBS) services provided in-home. In some state Medicaid HCBS waiver and managed LTSS programs and demonstrations, care management is required for enrollees living in residential settings such as nursing facilities and assisted living, resulting in two levels of care management: care-coordination activities conducted by the residential care staff and independent care management provided through state Medicaid programs and demonstrations. This article explores whether both levels of care management in these settings is good practice.
care managers, Medicaid waiver programs, CMS Financial Alignment Initiative, LTSS
Within long-term services and supports (LTSS) for older adults, the term “care management” often brings to mind an older adult living in the community, aided by a care manager who helps navigate and coordinate various home- and community-based services (HCBS), with the goal of keeping the individual in their own home and avoiding institutionalization. This has certainly been the goal of many states’ LTSS rebalancing efforts that have used the HCBS waivers established in Section 1915(c) of the Social Security Act.
However, older adults with disability who receive Medicaid HCBS may live in residential settings such as nursing facilities (NFs) and assisted living. In these settings, there may be two levels of care management. Care-coordination activities conducted by the professionals and paraprofessionals employed in the residential setting and independent care management provided through Medicaid HCBS waiver programs, managed long-term services and supports (MLTSS), and Financial Alignment Initiative (FAI) demonstrations. This article discusses the care management provided for recipients of Medicaid HCBS programs who live in residential care settings, and explores the debate over whether both levels of care management in these settings is good practice.
Care Management in HCBS
States are required to demonstrate that providing waiver services will not cost more than providing these services in an institution. In addition, they must ensure the protection of people’s health and welfare, provide adequate and reasonable provider standards to meet the needs of the target population, and ensure that services follow an individualized and person-centered plan of care.
The Social Security Act lists seven services that may be provided under the HCBS waiver program: care management, homemaker, home health aide, personal care, adult day, habilitation, and respite care. States may request to provide other services if the services are cost-effective and necessary to assist in diverting and/or transitioning individuals from institutional settings into their homes and communities (e.g., transportation, in-home support services, meal services, minor home modifications). Beyond these requirements, states have considerable flexibility in how they structure their programs (Duckett and Guy, 2000; Medicaid.gov, n.d.).
MLTSS allows for Medicaid beneficiaries with complex healthcare needs to receive LTSS such as personal care, respite, home-delivered meals, and residential services, through capitated Medicaid managed care programs. Care coordination is a key element of MLTSS programs and as of 2020, twenty-five states use MLTSS programs (Medicaid and CHIP Payment and Access Commission [MCPAC], 2018). States engaged in the national FAI in partnership with the Centers for Medicare & Medicaid Services (CMS) have required care coordination for dual-eligible beneficiaries living in NFs and assisted living settings in their three-way contracts between CMS, the state Medicaid authority, and Medicare-Medicaid Plans (MMPs). There are eleven states with active FAI demonstrations (CMS, n.d.).
Some argue that independent care management is more problematic in a residential care setting, where residents are closely supervised and care is provided by a team guided by regulations.
Few would disagree that care management is beneficial, and often essential, to assist older adults and their families navigate and coordinate myriad HCBS services to help them remain at home in the community. However, there is some question as to whether it makes sense to require independent care management for individuals who live in residential settings such as assisted living and NFs. Some providers argue that this requirement results in unnecessary service duplication as the beneficiaries’ needs and care are already being managed by professionals working in these settings.
Care Coordination by Residential Care Staff
The day-to-day processes within NFs are highly regulated, and the responsibilities of facility staff encompass many of the fundamental elements of care management. These functions are often carried out through an interdisciplinary team (IDT). Social workers, nurses, nutritional services staff, activity staff, and therapists (physical, occupational, speech) work together to ensure quality outcomes for residents. The IDT members are engaged in readmission activities, assessment, care planning, intervention, monitoring and reassessment, and discharge planning.
Care in NFs is guided by the Resident Assessment Instrument (RAI) (the Minimum Data Set [MDS] Version 3.0, the Care Area Assessment Process, and the RAI Utilization Guidelines) (CMS, 2019). The MDS 3.0 is a health status screening tool used for all residents of long-term care nursing facilities certified to participate in Medicare or Medicaid. It identifies potential resident problems, strengths, and preferences. The MDS is often completed by multiple staff who can provide information and expertise on a resident’s functioning and well-being. Likewise, all staff are responsible for acting upon the information gathered and issues identified via the MDS.
Nursing facility social service staff are responsible for providing psychosocial services and play a key role in completing the psychosocial assessments that guide care planning. Federal guidelines mandate that nursing homes larger than 120 beds are required to have at least one full-time “Qualified Social Worker” (a person with at least a bachelor’s degree in social services or a related human services field). Nursing homes may also hire “paraprofessionals” who do not have a bachelor’s degree in a human services field to provide some medically related psychosocial care (CMS, 2017; Simons, Bern-Klug, and An, 2012). Social service staff routinely communicate with family members and coordinate ancillary services for residents such as dental care, podiatry, and transportation.
While there is a wealth of professionals dedicated to the coordination and management of NF residents’ care, there is less regulation of the care provided to residents of residential care settings such as assisted living. Due to wide variation in regulations, staffing, and services provided, the essential responsibilities of care staff within assisted living settings can vary greatly by state and facility. These settings typically use “levels of care” with residents paying more for higher levels of care. Assisted living residents usually live in private apartments or rooms with shared common areas and have access to many services, including up to three meals a day, help with medications, laundry, 24-hour supervision, security, and on-site staff, social and recreational activities (Carder, O’Keeffe, and O’Keeffe, 2015).
While not required in all states, assisted living settings also may have social services staff available. And there is variation in the required types and ratios of nursing personnel available to residents (Carder et al., 2016). Assisted living settings may exist as stand-alone facilities or as part of continuing care retirement communities (CCRCs) that offer nursing home and independent living options as well. All of these variables may shape the amount and structure of care coordination and oversight provided by the residential care staff (Carder et al., 2016).
The Big Question
So, what do Medicaid HCBS care managers do for NF and assisted living residents that is not provided by the staff in their residential care setting? There is little discussion of specific care management activities in state Medicaid program descriptions and reports. The three-way contracts of the FAI demonstrations specify care management and care coordination requirements and typically include language about required contacts with enrollees, completion of health risk assessments (HRAs), and assisting enrollees with community transitions and relocation from an NF to living at home in the community when possible (often called “repatriation”).
It may be time to think differently about how we use the valuable resource of care management and explore whether a different kind of model is necessary for residential settings.
Some information about the care management activities of MMP care managers is available in the initial evaluation reports of the FAI demonstrations that were released by RTI International in 2018. Respondents in the RTI evaluations reported that demonstration care managers and care coordinators working with NF residents assisted with resident repatriation efforts and advocated for residents (Halladay et al., 2018). However, some respondents reported that nursing facility and skilled nursing facility residents were not receiving any meaningful care coordination and that the quality of the working relationships between the MMPs and facilities seemed to vary by plan (Ormond et al., 2018).
A recent evaluation of care management within Ohio’s FAI demonstration, the MyCare Ohio (MyCare) program, conducted by the Scripps Gerontology Center, provided a deeper understanding of how MMP care managers work to serve MyCare members in NF and assisted living settings. Care managers assigned to residential settings reported larger caseload sizes than care managers serving community-dwelling members and discussed the importance and difficulty of gaining information about members from facility staff and medical records. In focus groups, care managers reported that they routinely visit and assess MyCare members and communicate with facility staff to address members’ care needs. They also reported that because they are not employed by the facility, residents and family members often view them as a neutral party and someone who can advocate on their behalf to address the quality of care issues with facility staff. Additionally, they reported providing important socialization for members who may not have family or friends. (Heston-Mullins et al., forthcoming).
The MyCare care managers felt that they serve as an important additional set of eyes to monitor members’ well-being and can sometimes identify health changes and care issues missed by facility staff due to staffing shortages and challenges. Care managers were proud of their efforts to repatriate MyCare members from facilities back into the community, but felt that these efforts sometimes put them in an adversarial position with facility providers. They reported that facility staff were often hesitant to share resident information necessary to complete MyCare assessment requirements and many did not permit care managers to have access to facility electronic medical records.
They attributed this to a lack of understanding of the MyCare program by facility staff, in addition to nursing home and assisted living providers’ general distrust of MMPs. To address these challenges, most of the Ohio MMPs have assigned care managers to work with a specific set of facilities, providing a main point of contact to help streamline communication and build relationships. (Heston-Mullins et al., forthcoming).
The initial development of care management fifty years ago included a debate about the role of care management relative to the direct care provider, and debate continues today. Advocates for independent care management argue that an unbiased assessment of need, a professionally developed plan of care, and a quality assessment of the services delivered, is critical to ensuring long-term care services meet the needs of participants. They argue that service providers are consciously or subconsciously driven to deliver the services under their purview.
The counter argument is that providers, who have the most direct contact with participants, have a deeper knowledge of participants’ needs and care goals within the context of their lives. They argue that the role of independent care management is at best inefficient and at worst confusing for individuals and families. In a residential care setting, where residents have close supervision and their care is provided by a team of professionals and guided by significant regulation, some argue that the independent care management model is even more problematic.
This article suggests that more information is needed to determine if independent care management is necessary, cost-effective, and beneficial for individuals living in residential care settings. The stakeholder voices that have yet to be heard are those of residential care staff, residents, and resident family members. Some NF and assisted living providers participated in the RTI FAI initial evaluations and in the MyCare Ohio care management evaluation, but more effort and data are needed to understand the dynamics of care management activities between facility staff and Medicaid care managers.
While information about residents’ experiences was provided second-hand from RTI evaluation respondents, it was not clear whether beneficiary focus groups with LTSS enrollees included nursing facility residents in addition to community-dwelling residents, and data obtained directly from nursing facility residents were not specified in the reports. The care management evaluation conducted by Scripps Gerontology Center did not include data collection directly from MyCare members.
The information shared in the Ohio MyCare care management evaluation demonstrates that having MMP care managers as advocates and a second set of eyes and ears may benefit beneficiaries living in residential care settings. However, true coordination of care and effective care management in these settings cannot occur without two-way information sharing and good working relationships between facility staff and the Medicaid care management entities.
The dynamics of this unique care management arrangement must be more fully studied. Greater attention paid to care management within residential settings is needed to properly evaluate its effectiveness. Evaluation efforts focused on data collection from residents and their friend and family supports, is needed to guide states in shaping care management within Medicaid programs. It may be time to think differently about how we use the valuable resource of care management and explore whether a different kind of model is necessary for residential settings.
Jennifer Heston-Mullins, PhD, LISW, is a research scholar and Athena Koumoutzis, MA, is a doctoral student; both are at the Scripps Gerontology Center at Miami University in Oxford, Ohio.
Carder, P., et al. 2016. “State Regulatory Provisions for Residential Care Settings: An Overview of Staffing Requirements.” Institute on Aging Publications. doi.org/10.3768/rtipress.2016.op.0030.1607.
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