THINK TANK | One Size Does Not Fit All: HCBS, Person-Centered Planning and Value-Based Payments (NASUAD Conference)

by David Bucciferro, Senior Advisor, Foothold Technology
October 5, 2017

The fall conference season has started in full earnest and one of my first stops this year was the National Association of States United for Aging and Disabilities (NASUAD) Home and Community Based Services (HCBS) Conference. For those of you unfamiliar with the group, NASUAD represents the nation’s 56 state and territorial agencies on aging and disabilities and supports visionary state leadership by sharing resources, convening learning opportunities, and providing other technical assistance. This year’s conference focused on HCBS and provided attendees with insight into the national HCBS program as a whole, the various implementation strategies that have been employed across the country, and in many cases the trials and tribulations that come with implementing program models of this type.  

The HCBS program is complex in many ways. It offers opportunities for states, along with individual service providers, to create powerful systems of care and program models that otherwise would not be possible. We’ve discussed some of our thinking around HCBS on our blog, in webinars, and in conference presentations all over the country. As we know, one size does not fit all when dealing with HCBS programs, for each state has the ability to design a service package for its specific service areas, population needs, and geographic areas.

At this year’s conference, I attended sessions focused on three particular areas: (1) HCBS, (2) Medicaid and (3) Alternative Payment Models (in particular Value-Based Payment models). Although I have spent many years working with Medicaid and HCBS, there is still much to learn. Here are a few of my takeaways from spending three days with state leadership, providers from across the country, advocates, and service participants.  

HCBS can create tremendous benefits for a service delivery system. Despite the inherent complexities that come from any Federal program with such a broad spectrum of services, a well developed array of HCBS services that complement and support State Plan Options will have a profound impact on the lives of those receiving services. The focus of these services on more than just symptoms and a disability can create the ability to target social determinants of health outcomes in an achievable, affordable way.

In one presentation given by various state leaders and providers of HCBS services, we heard how, despite the potential and vast experience across the country with HCBS services, creating a model to meet the needs of a particular population in a specific state, and ensuring these services are accessible to individuals, must be a state by state endeavor. A representative from the Tennessee HCBS contingency explained the Tennessee model contains some aspects that could be used as a guide for creating a comprehensive HCBS waiver program in other states, but each state is unique. For example, it’s important to incorporate a level of awareness in plans to ensure already overtaxed state agency administrations are not overburdened. In other words, plans must consider local constraints and challenges. In addition, while an emphasis on the use of technology as a powerful tool to ease administrative burden and allow for easier monitoring of program success should be paramount in every state, each state’s population, needs, and plans are unique and thus technology should be adaptable. You need a system that is flexible, dynamic and easy to adapt as changes arise.

Representations from the Centers for Medicare & Medicaid Services (CMS) spoke about the Final Rule and how it creates an opportunity to ensure the highest degree of community integration of services possible. While the Final Rule is a critical component of the new HCBS rules, it also highlights the improved focus on a person-centered planning approach. This emphasis is a huge boost to those individuals who want to take control of their own services. Regulations that govern the various waivers provide greater flexibility in developing programs and allow for more opportunity for self-directed services.

Finally, another theme from the NASUAD HCBS conference, which is something I continue to emphasize in my own presentations, highlighted the continued push toward a value-based payment model, one in which emphasis is placed on paying service providers for outcomes and value rather than volume and stagnation. Throughout the country, alternative payment models continue to be explored. Foothold customers are experiencing this first hand and in this era of change at the federal, state and provider level they know it will take strong healthy agencies who have the ability to adapt and manage change to thrive and succeed. They know good data and good reporting can provide an agency the stability and accountability it needs. Information will be key to an agency’s success, and outcome information that is accurate and easily accessible at all levels of an organization is essential. Unfortunately, agencies that do not operate efficiently, and those who do not use tools like electronic record keeping are not likely to survive in the new marketplace.