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Aging in Place: Home and Community Based Services for Older Adults

By Carli Friedman, CQL Director of Research

The number of people in the United States needing long-term services and supports (LTSS) is expected to be 27 million by 2050, largely due to aging baby boomers. There has been significant progress over the past two decades in shifting the balance from institutional services to home and community-based services (HCBS) within states. However, Medicaid, the largest provider of LTSS in the United States, has a long-standing institutional bias where states are required to provide services in nursing facilities but home and community-based services (HCBS) are optional.

For these reasons, the aim of this research study was to explore HCBS 1915(c) waivers for older adults across the nation to determine if and how states are working to suit the unique needs of older adults and promote community living. To do so, HCBS waivers for people with older adults from fiscal year (FY) 2016 were analyzed to determine total projected spending, unduplicated participants, and average spending per participant. Hundreds of different services were also analyzed to determine service priorities

HCBS Waivers For Older Adults

Findings revealed 37 states provided HCBS waivers for older adults in FY 2016 through 61 different waivers (see figure).

States that provide HCBS Waivers for Older Adults

Types of Services Provided:

  • Adult day health
  • Care coordination
  • Chore
  • Community transition and integration supports
  • Companion and supervision
  • Family training
  • Financial support services
  • Health and professional services
  • Homemaker
  • Individual goods and services
  • Meals
  • Personal care
  • Residential habilitation
  • Respite
  • Specialized medical equipment and assistive technology
  • Supported employment
  • Transportation

The service categories projected to receive the largest proportion of funding were: 1) personal care; 2) care coordination; and, 3) homemaker (see figure right).

We also found “HCBS 1915(c) waivers are an underutilized mechanism for funding the LTSS of older adults. Indeed, one of the problems with the service system for older adults is its functioning as a patchwork of a variety of different mechanisms, all of which can be confusing and inaccessible… As a result of this complicated array of services, older adults can find themselves in need of community-based services and supports but may be at a loss to understand the options available and how to access services” (Friedman et al., 2018, p. 9). Because of their commitment to community access and inclusion, their ability to be tailored for specific needs, and their cost effectiveness compared to institutionalization, HCBS 1915(c) waivers for older adults are the perfect mechanism to create a stronger community infrastructure for older adults.

This article is a summary of the following journal manuscript: Friedman, C., Caldwell, J., Rapp Kennedy, A., & Rizzolo, M. C. (2019). Aging in place: A national analysis of home-and community-based Medicaid services for older adults. Journal of Disability Policy Studies, 29(4), 245-256.