Medicaid Home and Community-Based Services and residential changes among adults with Intellectual and Developmental Disabilities

• In Event: Barriers and Facilitators of Community Living for People with Intellectual and Developmental Disabilities

Abstract

Background: Medicaid Home and Community-Based Services (HCBS) function as an alternative to institutional placement, supporting people with intellectual and developmental disabilities (IDD) to live in the community. Despite significant variation in the scope of HCBS provided between states, there is little research on the extent to which different HCBS prevent or delay entry into institutions. Additionally, state policymakers treat congregate residential care like group homes as HCBS, despite restrictions such as limited autonomy and staff-driven schedules that mimic institutional care. To inform state Medicaid HCBS policy decisions, we examined the relationship between Medicaid HCBS and change in residency type among adult Medicaid enrollees with IDD.

Research Question: Which HCBS predict changes in residency type from community to congregate or institutional settings among adult HCBS recipients with IDD?

Methods: Using 2021-2023 Transformed Medicaid Statistical Information System (T-MSIS) data, we identified continuously enrolled (based on at least one HCBS-related claim in each month) Medicaid HCBS recipients over 18 and used a combination of HCBS eligibility information, program participation, and diagnosis codes to identify enrollees with IDD (n=1,113,999 enrollees).

Our outcome was change from own/family home to a congregate or institutional setting during the study period. Regression models identify factors significantly associated with moving from community to either congregate or institutional settings for HCBS recipients with IDD. We included other potential predictors such as age category, sex, combined race/ethnicity, dual Medicare/Medicaid enrollment, rurality, and state- and year-fixed effects.

We next used Kaplan–Meier curves to estimate the cumulative probability of moving into a more restrictive residential setting across the study period. We use Cox regression models and log rank tests to examine inequalities in risks by receipt of different types of services (e.g., caregiver supports, day services, etc.).

Results: 57% of adult HCBS recipients with IDD in our sample were male. More than half (57%) were non-Hispanic white, and the majority (81%) resided in an urban area. While most adult HCBS recipients with IDD lived in community settings, between 8% and 11% resided in institutions and up to 2% were in congregate residential care. Preliminary results revealed that up to 5% of the sample experienced a change in residency type during each year of the study time period. Upcoming analyses will explore the factors associated with these changes.

Conclusions: We document patterns of residential changes among adult HCBS recipients with IDD and highlight the essential role of HCBS in supporting community living. Identifying and addressing factors that predict movement to more restrictive congregate and institutional settings is an important policy lever, particularly with widespread plans to cut HCBS in many states. Furthermore, understanding which specific services are important for supporting HCBS recipients with IDD in remaining in their community is important to understand how state-level variation in provision of Medicaid HCBS may influence residency outcomes.

Authors

• Ian Moura, Brandeis University
  Presenting Author

• Laurin E Bixby, Brandeis University
  Non-Presenting Co-Author

• Arkady A. Levine, Brandeis University
  Non-Presenting Co-Author