Jason Gerling, Greg Abdouch, Jennifer Kolbe, and Jay Wright, Guidehouse
The Medicaid home and community-based services (HCBS) delivery system has experienced extraordinary disruption to individual recipients, their families, and providers as a result of the COVID-19 pandemic. Executive orders that prohibited traditional service delivery models, combined with shelter-in-place orders, forced the closure of most places where people congregated. This resulted in reliance on telehealth to reduce participants’ risk of infection while continuing access to care to promote health and wellness of those in HCBS programs. Looking forward, HCBS providers and state agencies overseeing HCBS must work to improve and optimize the delivery of telehealth services for HCBS, acknowledging the potential duration of social distancing requirements, its impacts on traditional HCBS, and the reality that telehealth and remote delivery is here to stay.
Under the current public health emergency (PHE), many states have rapidly expanded telehealth in HCBS delivery via Social Security Act §1915(c) Appendix K emergency waivers. These same states and their provider networks are learning as they go. Now that telehealth is approved for a wide array of HCBS, leaders need to review and refine their approach to promote the basic tenets of HCBS, including individual autonomy, person-centeredness, community integration, and positive outcomes and value. States can prepare now for how they want telehealth to operate under HCBS and start to formulate changes to policies and procedures.
Focus on Core Intent of HCBS When Using Telehealth
States should consider the core intent of HCBS when evaluating the use of telehealth, promoting maximum independence of those receiving services, as well as autonomous and meaningful community participation. The progress achieved by HCBS networks in advancing participant’s personal choice, community integration, and personal autonomy must be sustained and improved upon even with increased use of telehealth. The Centers for Medicare & Medicaid Services (CMS) is clear in their expectations that people who access Medicaid-funded HCBS have the same opportunities for access, choice, and integration as any member of their community.
Telehealth can help states to overcome service delivery issues that often arise within HCBS, such as workforce shortages and access to services in rural areas. Services like adult day health, habilitative services, and supports to facilitate community participation afford individuals the opportunity to engage in their community and develop skills that drive positive interpersonal relationships. States should continually reflect and confirm that the core intent of HCBS is a pillar of their approach and decision-making when it comes to telehealth delivery methods.
Considerations to uphold the intent of HCBS when using telehealth include:
Safeguarding Informed Individual Choice
An integral component of person-centered planning is the notion of informed choice by the individual, and this must persist in the use of telehealth. State agencies must consider individual choice in the development of future telehealth service requirements. These choices will evolve as shelter-in-place and social distancing requirements change and can also be influenced by service providers eager to maintain services and reimbursement during a time of disruption. Presently, telehealth may be the primary option to receive certain services as staff and individuals may be hesitant to interact face-to-face.
Telehealth should be an option for individuals to consider, but the delivery method should be offered in a way that respects freedom of choice and the potential that a participant does not want to receive their services in this way. Examples of methods to properly inform and engage individuals about their choices in the use of telehealth include:
During the PHE, most states are allowing audio-only telephonic technologies as an additional eligible modality for providing services. State agencies must make clear when traditional means for communication, such as telephone calls from a case manager to check in, are considered delivery of a reimbursable service. States may decide they want to continue with expanded telehealth after the COVID-19 pandemic subsides, as such clear definition of telehealth policies will be required.
States should consider the following:
Looking Forward: Navigating Uncertainty and Shifts in Pandemic Intensity
Changing state and federal guidance, widespread public health orders, and variance in guidance for high-risk populations will directly influence the need for and use of telehealth HCBS. Shelter-in-place orders may continue for some states while other states move to re-open.
Moreover, public health officials have suggested there may be future waves of COVID-19 infection that will force HCBS networks to nimbly respond to renewed shelter-in-place orders. Individuals who are high-risk, including older adults and those with chronic health conditions or immune-compromised health, will likely need to limit community outings for extended periods. States will need to examine their approach to service delivery with a critical eye on policy revisions.
Expectations at CMS are that “the genie is out of the bottle on telehealth” and there’s no going back. States should expect that their waivers and policies related to telehealth within HCBS will need to evolve in a way that reinforces best-in-class HCBS that continue to advance a participant’s person-centered goals and acknowledge personal choice and preference.
The good news is that states now have increasing access to claims and other data from their Appendix K implementation to gather information about provider and individual experiences to inform change. States are strongly encouraged to study early patterns in utilization and reimbursement, and conduct sampled reviews of person-centered planning and service delivery documentation to review the early effectiveness and outcomes of Appendix K changes. This will help identify what long-term changes are needed to optimize HCBS during this time of disruption.
Lastly, freedom of choice and dignity of risk (self-determination and the right to take reasonable risks) remain essential for dignity and self-esteem for the individual. These are at the heart of HCBS and are in the balance as states reopen. Individuals, their families, and advocates will expect the ability to make informed choices about how they receive HCBS during and after the PHE. Any policy changes should uphold the core intent of HCBS.
State Government Health