How Home & Comunity Based Services are STEALING Your Nursing Home Census and What You Can Do About It

Medicaid HCBS is stealing our residents away!

I have noticed a trend in some of our states.  As a way to save state funds, many of our states are pushing the Home & Comunity Services Programs.  This service falls under the Medicaid waiver program and is unheard of for many nursing home administrators … until they start seeing their referrals drop.

Here’s an example – in Tennessee their Medicaid program is called TennCare.  TennCare’s longterm care CHOICES program was recently recognized for “Innovation in Long-Term Care” by the Center for Health Care Strategies.  This was due to the implementation of a managed care approach to their Medicaid system.  Basically, TN has contracted with a couple of managed care companies and they’re managing the health care of the Medicaid recipients in that state.

One of the goals is to “… Provide appropriate, and cost-effective home and community based services that will improve the quality of life for persons who qualify for Nursing Facility care, as well as for persons who do not qualify for Nursing Facility care but are ―at risk‖ of institutional placement.”

One of the things they were recognized for is “…Rebalancing programs to provide more home- and community-based options instead of institutional care…”

Do you know what this means?  It means that it costs less to keep someone at home under the Medicaid waiver program than it does to pay for their nursing home stay.  Therefore, the government is pushing for more people to go home rather than go to a nursing home.  They are Providing and Even Encouraging an Alternative to Nursing Home Care! 

In TN, basically a managed care rep would ask the patient in the hospital if they wanted to go to a nursing home for services or whether they’d rather go back home in the community to receive the same (nursing home level) services.  Nurses and home health would be contracted to provide services and the patient could even “hire” sitters and caretakers.  A patient can do all these things in their home as long as they don’t exceed the $50,000 annual limit set by that state on their costs.  If it took more than $50,000 (the limit could have changed by now, don’t quote me) to take care of them they would then receive their services at the nursing home since it was the next least expensive option.

If this isn’t in your state yet,


How can you compete with that?  Can you imagine a patient’s response to whether they want to go home or to a nursing home?  It’s home all the way!  Not only does this idiotic government program set the nursing homes up for failure, it also sets the patients up for failure.  Think about how many people are going to die this way?  How many pressure ulcers are going to develop, how many infections, how many “caretakers” are going to be stealing pain meds, etc.  I mean these are individuals who clinically qualify for nursing home placement.  It’s beyond bad.

At any rate, this may be what our future holds as more states push the HCBS/Medicaid waivers.  What do we do?  How can we compete with that?

Become a provider of Home & Community Based Services as an extension of your nursing home services under the Medicaid Waiver Program for Elderly and Disabled Persons.  It’s not that hard.  Imagine this:  If you’re providing Home services to an individual in thecommunity, your staff is going in with your logo on their shirt.  They’re taking meals, they’re doing housekeeping in the home, they’re assisting with ADLs or medications, they’re putting up wheelchair ramps, they may even be helping with shopping.  They’re building a relationship with the patient in the community.  At some point, the patient may very well not be able to manage it in the community anymore and may have to go to a nursing home.  Where do you think they’ll go?  To you, of course.  You already have a relationship built with them.  Plus, you get reimbursed for providing these services.  It’s billed with the HCBS provider number just like you bill Medicaid now. This is a great long term plan to continue to bring referrals to your door.

As a bonus, none of your competitors will be doing this.  This is an easy way to outthink your competition when it comes to longterm sustainability while you’re building your brand in the community at the same time.

A quick search of your state Medicaid program’s website will reveal the criteria you’d need to meet.  You’ll have to get with your State’s HCBS director to go over the fine points, schedule home visits, pick up new clients, etc. It’s run very similar to how a home health or home care business operates.

Check with your individual state program to determine what services are reimbursable under HCBS and what you can provide.  Some of the services listed below may be applicable depending on what state you’re in:

  • Adaptive aids and medical supplies
  • Adult companion services
  • Adult foster care
  • Assisted living/residential care services
  • Case management
  • Emergency response services
  • Home delivered meals
  • Homemaker services / housekeeping
  • Minor home modifications
  • Nursing services
  • Occupational therapy services
  • Personal assistance services, Personal care attendant
  • Pest control
  • Respite care services
  • Speech and /or language pathology services
  • Dental services
  • Prescription drugs, if not covered through Medicare
  • Transition assistance services
  • Transportation

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2 Responses to “How Home & Comunity Based Services are STEALING Your Nursing Home Census and What You Can Do About It”

  • Drew on

    I was privileged to be read a study conducted for the state of Michigan using data collected by a independent source concerning the Michigan Skilled Nursing Facilities, the Minimum Data Set, and the MI Choice Waiver Program.

    Among numerous assertions was the following:

    “The MDS analysis supports the results currently being achieved in Michigan regarding placement in the most appropriate setting. The overall accuracy ―rate‖ of the analysis is 94 percent, meaning that 94 percent of all Medicaid recipients are being placed with the group they most strongly resemble on the basis of data recorded in the MDS. The 6 percent who are not are more readily described as exceptions to the rule because of individual circumstances, rather than as evidence of error in the placement system.

    The MDS analysis does not support the position that many current Medicaid nursing home residents should not be there, but rather should be in a home or other community-based setting. Nor does it support the position that many individuals in home or community-based settings are there inappropriately. This conclusion from the MDS analysis is consistent with other data related to the use of skilled nursing facilities Michigan—i.e., compared to other states, Michigan does not over-utilize skilled nursing facilities.”


    “The MDS data clearly shows, moreover, that the rate of rehospitalization among MI Choice waiver program participants is much higher than the rate among non-transitioning nursing facility residents—almost four times as high. Similarly, the rate of ER visits among waiver program participants is more than three times as high.”

    I understand the difficultly of interpreting these paragraphs isolated as they are but there implication leads us to believe that HSBC’s shouldn’t in theory draw off residents from NF/SNF’s unless they should in fact be placed else where. The motivation to provide the most efficient care possible will be driven by provisions of the Patient Protection and Affordable Care Act and the creation of Accountable Care Organizations (ACO).

    A SNF/NF within a ACO is just one part of the long term care continuum and ACO’s (lead by hospitals) will fly one flag over there NF’s, AL’s HCBS, etc… in order to maximize profit which will (as i understand it) be only obtainable if the person’s care is kept up to standard and done so profitably across the entire continuum of providers.

    Which is how it should be, the motivation should be to take care of people and if each part of long term care is an island then they will horde customers/residents (despite people’s intentions).

    As a young economist i would have thought that the markets would have driven this innovation but as i grew i relized that markets were only as good as the people in them and the american market when narrowed down is just the typical american. He is the baby boomer eating at arbys and smoking outside at his lunch breaks. He hasn’t looked into his health or what his options will be in 3 month’s when he has a heart attack and ends up confused in a hospital. He won’t understand the paper work at admissions or discharge as he leaves for a SNF for rehab. The market is confused and alone and it doesn’t understand that it should probable transition back into a HCBS before it makes that final jump (if ever) back into being independent. If he goes right from the SNF right home he might have a relapse and end up back in the hospital…

    The market is confused and the government is trying to be the dutiable mother by kicking it and tempting it into making the right choices. It’s putting that burden on the providers to show the market where to go next because now it will be in our best interest to do so.

    I believe a smart provider will understand this and leverage himself accordingly.

    Just my thoughts,

  • Mark on

    Thanks, Drew. Good share!


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