LTSS Limelight: Home and Community-Based Services Gain State Traction

November 4, 2021 · Paige Cooke

The LTSS landscape continues to buzz with innovation and promise thanks to the funding provided through ARPA for Medicaid HCBS. For this quarter’s Limelight Series, we wanted to highlight essential solutions the National Association of Medicaid Directors (NAMD) presented in its Medicaid Forward LTSS Report, with an eye on what states are including in their state narratives.

NAMD has been hard at work engaging states on which solutions show promise in enhancing, expanding or strengthening home and community-based services for LTSS populations. NAMD’s recommended state and federal actions in the Report have been widely adopted across state narratives. Several of the CMS-approved state narratives provide insight into the HCBS program innovations that are gaining traction in adoption and implementation.

Over the summer, NAMD convened an Executive Work Group of Medicaid LTSS Directors and thought leaders, such as AARP, CityBlock Health, and IDD Human Services Resources Institute, to inform their Report. The Report follows the CMS structural changes encouraged for states to use in their state narratives. The solutions presented are organized into four distinct categories for both state and federal action:

  • Build & Strengthen the LTSS Workforce
  • Assist & Strengthen Individuals’ Natural Supports
  • Promote Adoption of Telehealth & Assistive Technology
  • Advance Person-Centered Outcomes & Quality through Innovative Payment Approaches

NCQA has highlighted a subset of the solutions in the table below and included some color commentary of our own to keep it interesting… We encourage you to visit the complete report for a comprehensive review.

Solution CategoriesRecommended State-Specific Actions
Build & Strengthen LTSS Workforce
  • Finance & incent professional development and a career ladder for service providers that receive specific certifications or training that could result in bonus payments – Attract and retain the workforce you want!
  • Measure the diversity of providers in networks against the communities served – Sounds like a great health equity accreditation opportunity!
  • Leverage self-direction models allowing individuals receiving HCBS to have more control to increase consumer satisfaction and establish more stable care provider relationships – “Independence” at home is a thing and member experience continues to grow as a primary driver in value-based payment models.
Assist & Strengthen Individual’s Natural Supports
  • “Increase the resiliency of natural supports and not supplant them”through the use of technology to ensure caregivers are more authentically included at care conferences – Strengthen versus replace could enhance member experience and has cost benefits!
  • Provide broad caregiver assessment and resources such as, training, counseling, peer support, respite care and extend non-Medicaid mental health supports to treat anxiety, depression, PTSD and suicidal thoughts; paid caregiver support – In NCQA’s LTSS Standards, Caregiver assessments and how needs are met is a critical aspect of the requirements.
  • Ensure case managers provide culturally competent case management support that includes a caregiver needs assessment – I think I know of a set of national standards that does this!
  • Create requirements/incentives for MCOs to “buttress” natural supportsLTSS Distinction standards provide a strong place to start.
Promote Adoption of Telehealth & Assistive Technology
  • Offer virtual job coaching and employment supports to increase training that drives community engagement – Community partnership programs between managed care and the community with an eye on health equity is foundational to NCQA’s Health Equity PLUS’ standards (Public Comment open 11/9).
  • Extend clinical care delivery supports such as telehealth for BH services, remote patient monitoring and “red-button technology while leveraging electronic visit verification to support timely access to needed services to improve health outcomes. – This speaks for itself.
  • Support virtual care planning conferences for enhanced care coordination between individuals and the care team. – The ease of access to engage individuals and members of the care team saves time and money.
  • Support adoption of video chat and email technology to address social isolation and loneliness issues that have been exacerbated by the pandemic. – Community Health Workers can be a major asset for engagement, training and reporting, with this and many other aspects of a strong LTSS HCBS program.
Advance Person-Centered Outcomes & Quality through Innovative Payment Approaches
  • Implement a portfolio of value-based payment arrangements in HCBS by adopting more widely used measures such as timeliness of visits as part of the EVV. States can link payment incentives to this measure or when an individual meets certain benchmark goals laid out in their individual care plan. – Patient-Driven Outcome (PDO) Measures integrate patient goals into the care plan and NCQA is at the forefront of advancing adoption.

Let’s Focus in On IDD 

There is a particular area of focus that we felt deserves its own spotlight in this blog.

As outlined by CMS the recently developed HCBS Spending Plans and Narratives webpage, and emphasized in the NAMD Report, use of the HCBS funds to support Intellectual and Developmental Disabilities (I/DD) population is essential.  Recommended solutions highlighted in the LTSS Report underline the need for states to implement new housing and behavioral health supports for both adult and child I/DD populations.

Several state narratives (NY, CT, TN, MN) highlighted the expansion or development of mobile crisis units for adults and children with I/DD, to ensure the right professionals respond to acute situations in the community. These and other states also focused on the adoption of programs that strengthen workforce opportunities for persons with disabilities as well.

How Can NCQA Help the IDD Population 

NCQA is proud to have several Community-Based Organizations across the country supporting IDD populations and advancing their service coordination efforts with an increased focus on continuous quality improvement through the Accreditation of Case Management for LTSS standards (CM-LTSS). A few to highlight are Alleghenies United Cerebral Palsy, MORC, Inc., and UDS in Pennsylvania; Bluebonnet Trails Community Services and the Texana Center in Texas, and LifeTime Resources Inc. in Indiana.

As NCQA works to advance LTSS requirements for future updates, IDD populations, SMI, SUD, and child and adolescent populations are at the top of the agenda. We are closely tracking how states are working to advance HCBS programs for these important populations receiving LTSS. For example, Arizona highlighted its efforts (and required funding) to enhance data collection and build a more efficient case management system for provider monitoring and oversight by integrating with the state HIE. These innovations help create a stronger data infrastructure that supports better care management and outcomes which can then be evaluated through digital quality measurement. As NCQA continues efforts to support quality’s evolving digital landscape, insights like these help inform the journey.

What’s Next/Our Mission 

It is clear a lot remains to be done. However, with new funding and concerted focus, states are laying the groundwork to improve their delivery, quality and accountability for HCBS. We are encouraged by the recommended solutions presented and those gaining traction in state narratives thanks to the guidance from CMS and other vital national stakeholders like the NAMD.

NCQA remains focused on our goals to improve the quality of the delivery system, including supporting state priorities to improve and strengthen HCBS. We continuously engage stakeholders to enhance our programs. As states begin to advance the solutions brought forward, we encourage them to reach out to us at to learn more about NCQA’s tools that are available to help execute and sustain these great advancements in HCBS well into the future.

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