Quality Care for the Older Adult Living at Home in Illinois - Part I

As the Illinois Department of Healthcare and Family Services (HFS) continues at full gallop to enroll older adult Medicaid beneficiaries into managed care organizations (MCOs) during Q1 of 2013, many remain skeptical at how home and community based services (HCBS) programs will be measured and monitored and whether incentives will be aligned to meet desired goals. HCBS may include activities such as: care management, homemaker, personal care and other services needed to maintain an older adult in the community. For purposes of this discussion "quality" HCBS  is defined as the delivery of the correct services, provided at the correct frequency, at the correct time.

Although MCOs and State Medicaid programs may possess the capacity to measure the quality of delivering healthcare services, that capacity does not necessarily translate to the realm of HCBS. A report released on December 11, 2012 by the Health and Human Services Office of Inspector General (OIG) can be instructive on this point. The report indicates that in the States surveyed, the HCBS currently being provided to Medicaid beneficiaries in assisted living facilities (ALFs) were not in compliance with Federal and State requirements.

To gain flexibility in providing HCBS to Medicaid beneficiaries, a State Medicaid program must seek and be granted approval under a Federal wavier program. To receive a waiver, a State must make certain assurances to the Center for Medicaid and Medicare Services (CMS) that necessary safeguards have been taken to protect the health and welfare of the beneficiaries and that providers will furnish HCBS under written plans of care (See; here). In short, a State must be able to demonstrate the quality of HCBS being delivered to the beneficiaries by employing quality measures (i.e. Federal requirements) . The report focused on the seven states with highest number of beneficiaries receiving HCBS in ALFs: Georgia, Illinois, Minnesota, New Jersey, Oregon, Texas and Washington. Among the report findings were:

  • Provider standards existed...however, ALFs did not always comply with those standards, and plans of care did not always comply with Federal requirements.
  • Records for 9 percent of Medicaid beneficiaries receiving HCBS in ALFs did not include the required plan of care.
  • The plans of care for 42 percent of Medicaid beneficiaries receiving HCBS in ALFs did not comply with the Federal docmentation requirements.

Overall, the report recommended that CMS issue guidance to State Medicaid programs emphasizing the need to comply with Federal requirements. At the very least, this OIG report reveals that State Medicaid programs struggle meet their assurances to CMS that the necessary safeguards have been taken to protect the health and welfare of the beneficiaries. If State Medicaid programs are currently deficient in assuring compliance with quality standards in the delivery of HCBS in ALF settings, is it reasonable to assume that MCOs will be better suited to not only that task, but also with regards to the delivery of  HCBS in residential settings?

I will have more to write on that topic next week. In the meantime, learn more on Twitter @aginginchicago


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    Bruce Lederman has over 25 years experience in the senior care field as a direct care provider and thought leader. Bruce was CEO and president of his own firm that operated skilled nursing facilities in Illinois. He is a former nursing home administrator and has consulted to numerous elder care providers on planning for strategic growth as well as process improvement. Recently he served as board chair of CJE SeniorLife, a leading non-profit elder care provider in the Chicago area. Bruce is currently employed as chief strategy officer for a company providing skilled nursing services in communities throughout Illinois and Missouri.

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