Strengthening the Research Evidence for HCBS Policy and Practice

HCBS Use and Need

Hirschman and colleagues looked at predictors of health care transitions for older adults new to long-term services and supports (LTSS). Both acute and nonacute care transitions were explored, making this article a particularly unique contribution to the literature. Using the Anderson Behavioral Model of Health Service Use, 470 individuals were followed for 24 months. Among many important findings, this research demonstrated that LTSS recipients commonly experience health care transitions to and from both acute and nonacute settings of care. The nonacute care transitions (e.g., transitions to Skilled Nursing Facilities/Inpatient Rehab Facilities [SNF/IRF], to hospice, between LTSS settings) accounted for 17% of transitions during the study period.

The article by Yu et al. explores the relationships between care recipients’ descriptive profile factors and HCBS use patterns in Taiwan. Guided by the Andersen model and using latent class analysis and multinomial logistic regression, the authors found that care recipients who live in areas with a lower degree of urbanization are less likely to use multiple services, which show inequality in long-term care service accessibility. The authors recommend a flexible long-term care policy that promotes use of integrated services and alleviates barriers to accessing multiple types of services.

Finally, Fu and Chui explored the role of living arrangement and filial piety in HCBS service need patterns in Beijing, China. Three classes of HCBS need patterns were identified: high-needs group, moderate-needs group, and low-needs group. Living arrangement, number of children, and number of diseases were found to be significantly associated with HCBS need patterns. Compared with the high-needs group, those living with at least two family members were more likely to express low needs or moderate needs. Living arrangement was a moderator for the effect of filial piety on HCBS needs.

HCBS Policy Changes

Although all of the articles in this special edition address policy issues, three articles focus directly on HCBS policy changes. The article by Goncalves, Weaver, and Konetzka measured Medicaid home care Participation and Intensity to describe changes in Medicaid home care policy generosity over time and across states. Yearly state-level data from the Medicaid Statistical Information System (1999–2012) were analyzed using exploratory and confirmatory factor analyses. During the study time frame, 29 states expanded both Participation and Intensity of services, whereas six states reduced both. Results suggest that the Participation and Intensity dimensions exist and are independent. Although some states increased or decreased both Participation and Intensity over time, others increased generosity in one dimension at the expense of the other. The findings are important because expansions along these two dimensions could have different implications for beneficiaries.

Burgdorf and coauthors interviewed stakeholders in Maryland, one of the first states to adopt Community First Choice (CFC), a Medicaid state plan option authorized through the Affordable Care Act. The study goal was to assess challenges, benefits, and potential implications of this Medicaid option for state and federal policy makers. Findings suggest that expanding coverage for HCBS through CFC in Maryland was financially feasible, expanded the personal care workforce, and supported a more equitable approach to personal care services.

Using a mixed-methods approach, Arora and colleagues evaluated the 2013 consolidation of Iowa’s Area Agencies on Aging (AAA), from 13 AAAs to six, on the delivery of HCBS to older adults in the state. No detectable impact was found on the proportion of older adults served by the AAAs due to the consolidation efforts. However, AAA staff noted important challenges related to serving a vast geographic area, including expanded staff roles and challenging communication among new regions.

HCBS Workforce and Training

The article by Igarashi et al. describes the development and evaluation of an educational program to promote collaboration between communities and convenience stores in Japan. Results from pre- and post-program questionnaire surveys demonstrated that attitudes toward dementia improved significantly in convenience store staff and other community members who received the training, and a sense of community improved significantly in health/social care professionals.

Guerrero and colleagues present a process evaluation of an interactive, community-based, knowledge and skills-based training program for In-Home Supportive Services (IHSS) caregivers in Riverside County, California. The curriculum content was based on self-perceived educational needs and training gaps identified through a needs assessment survey administered to IHSS workers. The course covered three broad topics: (a) the basics of dementia and managing behavioral issues; (b) promoting home safety and preventing falls; and (c) managing caregiver stress. Results reveal the unique needs of training and assessing a population of demographically diverse adult learners and provides guidance for those planning to implement similar trainings in underserved communities.

HCBS Work Environment and Experience

Danilovich et al. investigated the feasibility of a home care aide (HCA)-led health interview with clients during a usual HCBS visit. Interview training was provided and HCAs conducted interviews with clients using a card sort methodology to elicit client care preferences. Results showed that having HCAs conduct health interviews contributed new knowledge on client preferences for care. Clients desired HCAs who provide empathy, compassion, and motivation, and HCAs felt interviewing clients helped them to better understand their care recipient’s needs.

Using cross-sectional surveys among people receiving care in nursing homes and home care in Sweden, Lundgren and colleagues explored the associations between nursing assistants’ perceptions of their psychosocial work environments (e.g., support from coworkers, perception of group work, positive challenge at work) and satisfaction among older people receiving care (e.g., staff knowledge, trust in staff, respect). When nursing assistants had high perceptions of their psychosocial work environment, older people reported better satisfaction with care.

Wong et al. studied post-acute care (PAC) rehabilitation practitioners’ perspectives on communication using secondary data analysis from a larger study. Focus groups with PAC rehabilitation providers were held in 13 skilled nursing facilities. Three themes were identified: (a) communication between rehabilitation practitioners and registered nurses or licensed practical nurses; (b) communication between rehabilitation practitioners and certified nursing assistants; and (c) communication between rehabilitation practitioners and nursing leaders. The authors note that to improve patient outcomes and deliver high-quality post-acute rehabilitation care, effective interdisciplinary communication is vital.

The articles in this Special Issue demonstrate the breadth and depth of HCBS policy and practice. The international aspect of the articles, across differing topics, reinforces shared experiences but also cross-national learning opportunities. The application of theory to guide the articles on service use and need demonstrates the importance of theoretical frameworks and highlights areas for expansion in existing frameworks. Each article acknowledges the progress made in delivering HCBS, as well as the opportunities for further research, delivery enhancement, and policy-related decision-making that supports an aging population and the people and institutions who care for it.