The Need
The COVID-19 pandemic has had a startling, disproportionate impact on individuals residing in congregate care settings. While the American Rescue Plan Act (ARPA) funding may not be used for nursing facilities, it may be used to transform community-based residential care settings.
Reimagining Colorado’s residential settings is required to support member health, safety, and overall well-being, as well as to create the long-term care system of the future. This future system ideally supports choice, offers the continuum of care, and is provided in the member’s home or community of choice. The ARPA funding will support collaboration with community partners to begin the work of transforming the residential care setting environment and method by which these partners provide services.
Though higher rates and wages are important for sustainability, there are often specific projects that require a more significant upfront investment. With an eye toward promoting innovation, grants will be made available for one-time, transformative initiatives. Additionally, funding will be used to address specific barriers to the receipt of ongoing care in a member’s home or other community-based setting. An example would be the need for home modifications to adapt a person’s physical space or access to a personal care attendant to support a person to live independently. Initiatives that strengthen these services and supports will be worthwhile investments as they extend the time members can live and thrive in their home of choice.
✅Initiative 4.03. - Child/Youth Step-down Options Program and Provider Recruitment - Completed
Key Project Achievements and/or Activities:
Developed three grant programs designed to support the child/youth population
- Grants to expand the Children’s Residential Habilitation Program (CHRP) residential habilitation service capacity.
- Grants to conduct research and analysis in partnership with Qualified Residential Treatment Programs (QRTPs) to determine barriers to service access and provider expansion, gaps in resources and funding, and challenges in discharge and step-down transitions.
- Grants to expand and maintain QRTP service capacity by addressing operational needs identified by QRTP providers, including facility repairs, trauma-informed space upgrades, and facility physical safety improvements and enhancements.
- Researched the financial impact of expanding the Medicaid Expansion Children’s Health Insurance Program (CHIP) program (M-CHIP) program.
Summary / Project Outcome:
The following outcomes were reported by grantees:
- A CHRP provider intends to open a second residential habilitation home in the next few months to serve four additional Medicaid members under the CHRP waiver.
- A CHRP provider recruited, hired, and trained an Associate Director for their CHRP program to build capacity for the program. They also recruited and hired a Wraparound Facilitator to become certified in High Fidelity Wraparound and conducted outreach in Northern Colorado to promote CHRP services.
- Grantees completed three extensive quarterly reports, collecting and reporting information on current clients, referred clients and outcomes, discharged clients with active aftercare, historical diagnoses and interventions, transition services provided, financial implications and cost, provider interest and incentives, barriers to discharge, challenges in service and provider expansion, changes in workflows, and direct funding gaps.
- Grantees utilized funding to complete Trust-Based Relational Intervention (TBRI) training, enhance data collection and analysis, increase staff retention, increase organizational capacity, increase the safety and stability of youth and staff, and implement a staff mentorship program.
- Grantees completed a variety of facility repairs, updates, and enhancements based on their organization’s operational needs, including HVAC improvements, installing new flooring, repainting the facility exterior, increasing and enhancing security measures, upgrading electrical work, installing a storefront to separate building space, installing new fencing, repairing plumbing, replacing windows, enhancing the home-like environment of the facility through painting and landscaping, and replacing lighting.
✅Initiative 4.06. - Supported Employment Pilot Extension - Completed
Key Project Achievements and/or Activities:
Through ARPA project 4.06, the Outcome-Based Home and Community-Based (HCBS) Supported Employment Pilot (Pilot), the Department of Health Care Policy & Financing (HCPF) learned that an Outcome-Based Supported Employment model can be successfully implemented in Colorado’s HCBS waiver systems and promises to improve employment outcomes for waiver members. This aligns with the work HCPF has been engaged in over the past ten years to build and implement an Employment First framework that increases Competitive Integrated Employment (CIE) outcomes for HCBS-waiver members.
This work is critical, as employment is considered a Social Determinant of Health. This means employment is a path to greater health equity and can reduce healthcare costs for people with disabilities:
- Medicaid health costs were reduced by $161 per member per month when members were engaged in an employment support program (Momany, Schartz, Nguyen, Carter, & Strong, 2012).
Additionally, employment offers a pathway out of poverty and access to integrated communities, reducing segregation for individuals with disabilities. Consider data from the I/DD National Core Indicators survey of individuals with an intellectual or developmental disability:
- 83% of survey participants did not have a paid community job nationally.
- Nationally, HCBS waiver members working in CIE earned an average of $12.46 an hour compared to their peers in a non-CIE group employment setting, who earned an average of $10.42 per hour.
- This same trend is consistent with Colorado; based on the 2022 Point In Time Survey, the average wage per hour for waiver members in CIE was $14.02 as compared to waiver members in non-CIE group employment settings, which was $12.81.
Summary / Project Outcome:
Two data points tracked and evaluated by HCPF illustrate that an incentive-based supported employment model would be successful if expanded into the HCBS Supported Living Services (HCBS-SLS) and the HCBS Developmental Disability (HCBS-DD) waivers.
- Participants in the Pilot who utilized its services for 12 months averaged an 8% increase in their independence on the job.
- Compared to the general waiver population, which in 2022 only saw a 2.5% increase in independence, this indicates improved efficacy and increased quality of the HCBS-Pilot services. (2022 HCBS-SE Point-in-time Survey Report)
- From month 1 to month 12, participants averaged an 11% increase in hours worked. Illustrating members' continued success on the job even as their autonomy increased.
External Facing Reports/Websites:
Supported Employment Incentive-Based Pilot Final Evaluation & Report (August 2024)
✅Initiative 4.09. - Respite Rate Enhancement - Completed
Key Project Achievements and/or Activities:
The Enhanced Respite Rates team implemented a 25% rate increase for all respite services across all Home and Community Based Services (HCBS) waivers where respite is an available service, excluding group respite settings. The timeframe for the enhanced reimbursement rates was April 1, 2022 - March 31, 2022. The enhanced reimbursement rates were applied retroactively in January 2022 for respite services rendered April 1, 2021 through January 2022 and the enhanced rate was available January 2022 through March 31, 2022. The table below details the HCBS waivers and respite services impacted.
| HCBS Waiver | Respite Service Type |
|---|---|
| Elderly Blind Disabled (EBD) Waiver |
|
| Community Mental Health Supports (CMHS) Waiver |
|
| Brain Injury (BI) Waiver |
|
| Spinal Cord Injury (SCI) Waiver |
|
| Supported Living Services (SLS) Waiver |
|
| Children’s Extensive Supports (CES) Waiver |
|
| Children with Life Limiting Illness (CLLI) Waiver |
|
| Children’s Habilitation Residential Program (CHRP) Waiver |
|
Summary / Project Outcome:
The total funds spent on enhanced reimbursement was $2,796,447 for HCBS waiver respite services. There were 44 provider agencies who had not billed respite prior to the enhanced rate that began providing respite services during the timeframe of 4/1/21 - 3/31/22. 61% of these providers continued to provide respite services after the end of the enhanced rate. New providers served on average 2 members each. While one of the primary goals of the project was to increase provider enrollment, the decision to provide the rate retroactively also intended to ensure providers who had been providing respite during the COVID-19 pandemic were incentivized to continue to provide respite during this tumultuous time.
The total number of members served during the enhanced rate timeframe remained stable as compared to utilization pre and post the enhanced rate timeframe.
| FY 19-20 Respite Utilization | 4/1/21 - 3/31/22 Respite Utilization (enhanced rate period) | FY 22-23 Respite Utilization |
| 3,321 members | 2,947 members | 3,156 members |
✅Initiative 4.10. - Home Modification Budget Enhancements - Completed
Key Project Achievements and/or Activities:
This project provided $4,602,769.90 of increased home modification project funds to 784 Medicaid Waiver participants. Each member was allotted up to an additional $10,000 to go towards a home modification project.
Additionally, this project funded the migration of the Home Modification Salesforce platform, used for tracking all Home Modification project work, from Department of Local Affairs to Department of Health Care Policy and Financing. This migration has improved HCPFs ability to oversee all of the Home Modification projects requests, thus improving our ability to respond quickly to changes requests and work to resolve problems in a timely manner.
Summary / Project Outcome:
This project provided $4,602,769.90 of increased home modification project funds to 784 Medicaid Waiver participants. The project also supported the build out of a new Salesforce platform, improving HCPF’s ability to oversee all of the Home Modification projects requests, thus improving our ability to respond quickly to change requests and work to resolve problems in a timely manner.
Initiative 4.12. - Community First Choice
Community First Choice (CFC) was established by the Affordable Care Act in 2010 and allows HCPF to offer attendant care services on a state-wide basis to eligible members, instead of only those who meet criteria for a 1915(c) waiver. HCPF will use funding to cover the administrative costs associated with the development and implementation of CFC, including system costs, stakeholder engagement, staff, and a new Wellness Education Benefit. The goal is to implement CFC by January 1, 2025. Once implemented, the state would qualify for a 6% ongoing federal enhanced match on certain HCBS services.
To develop and implement CFC, the Department will need the following:
- System changes: System changes will be required to add the existing HCBS benefits into the State Plan which necessitates changes to the provider subsystem, financial subsystem, prior authorization subsystem, the prior authorization system, provider subsystem, and care and case management product. This work will include ongoing testing and maintenance to ensure the changes made were accurate and operating correctly.
- Wellness Education Benefit: HCPF will utilize a contractor to develop and manage the Wellness and Education Benefit. The cost of this benefit will be absorbed by the Department once CFC cost savings are realized.
Stakeholder engagement opportunities for CFC
✅Initiative 4.01. - Residential Innovation - Completed
Key Project Achievements and/or Activities:
This project included two components rolled out in multiple phases. The first phase was initial work with a vendor to conduct a models of care analysis of funding mechanisms and feasibility to improve transitions of care for people transitioning from nursing facilities and other institutional settings to potential new models of care for investment and innovation.
After the initial assessment by the vendor, HCPF launched a second phase of the project, which was an Innovative Models of Care Grant Program with the primary goal of sparking residential innovation, housing customizations, and new Home and Community-Based Services Programs. The grant program sought to identify new approaches that address inequities in Colorado’s current systems, including those that develop socially interactive communities, new approaches focused on promoting mental health, independence, and addressing the needs of Colorado’s growing population that desires to age in place. Two grantees were selected through a competitive application process.
The Grantees began development or implemented changes within existing settings to create a community that addresses inequities in Colorado’s current systems to create interactive and inclusive communities that promote mental health, physical activities, independence, and programs that address the needs of Colorado’s growing population that desires to age in place.
Summary / Project Outcome:
HCPF worked with a vendor to conduct a model of care analysis, stakeholder survey, key informant interviews and produce a final report that provides a summary of each of the four parts of the analysis. The report also includes an overview of trends identified across the models of care analysis reports and offers actionable recommendations for HCPF to consider in its ongoing efforts to develop services that help individuals return to the community and remain there long-term, among family and friends.
The grant funding supported an organization’s ability to offer a variety of services and events to residents at current communities, with a focus on client-driven programming, and to discuss transparency of funding with residents in these communities. Data from surveys and focus groups demonstrated how participants felt about these programs and their benefit to the individuals served. Additionally, different models of care were proposed by the grantees. HCPF will consider these models for new approaches that address inequities in Colorado’s current systems with the goal of developing social health-based communities, new approaches focused on mental health and physical disabilities, as well as programs that ease difficulties linked to Colorado’s population aging in place.
✅Initiative 4.04. - Tiered Residential Rates and Benefits - Completed
(previously named Alternative Care Facility Tiered Rates and Benefit)
Key Project Achievements and/or Activities:
Like Home and Community Based Services (HCBS) providers, many HCBS-enrolled members could benefit from an increase in reimbursement rates for higher acuity Alternative Care Facility (ACF) residential placements. Every day we are working to improve the lives of the Members served in residential settings to access the things they need, and the care they receive. This includes providing resources and support needed to transition to the least restrictive setting possible.
Under this project, HCPF contracted with a vendor to understand the landscape for the cost of services provided in the Alternative Care Facility settings and evaluate the potential effect on providers and Members with the implementation of a tiered rates system. During this project, the team is proud to have accomplished the following:
Conducted stakeholder engagement through community and provider surveys and feedback sessions to gather information on direct care worker retention, financial costs, and service delivery.
Developed acuity-based tiers, a new rate methodology, and rates for each tier that would capture the true costs of providing care for individuals with complex conditions based on assessed medical and behavioral needs.
Stratified the tiered rate structure enough to account for key differences in costs to serve individuals in the population but also be simple and clear enough to avoid confusion.
For QRTPs, the national survey found that tiered rates are a very appropriate way to reimburse the complex care of youth in residential settings. The project team will use those findings as they continue to redesign the youth residential benefits. The national survey also highlighted the need to utilize a single assessment tool for the child youth population for which work is underway outside of an ARPA project.
Summary / Project Outcome:
This project developed a higher reimbursement rate for Members with an assessed high medical or behavioral need requiring a residential placement within an Alternative Care Facility. The rate would allow facilities to provide enhanced care at a more equitable cost for service.
Moving forward, if a future budget request is approved, the developed tiered rate will be available to Alternative Care Facilities across Colorado. Additionally, the State of Colorado and the Department of Health Care Policy and Financing plan to continue to look for future funding opportunities for children and adult residential settings.
The vendor completed a nationwide survey of best practices, assessment tools, and tiered rates to determine if a tiered rate structure would be appropriate for Colorado’s residential settings. The national survey found that tiered rates are a very appropriate way to reimburse the complex care of youth in residential settings. The BHIC team is taking this knowledge forward to inform the strategy to better serve the child youth population.
✅Initiative 4.05. - Pilot CAPABLE - Completed
Key Project Achievements and/or Activities:
A total of $2,936,345.00 was provided to through grant awards to two organizations who supported the needs of 368 Members, ages 18 and older. These organizations used the grant funds to establish, promote and expand CAPABLE services in ten counties in Colorado.
An evaluation study was completed in 2024 by Colorado Evaluation and Action Lab (Colorado Lab). This study utilized a one-group pretest-posttest comparison design to measure outcomes in Colorado’s CAPABLE pilot and compare them to outcomes seen in CAPABLE pilots in other states. In addition, the Colorado Lab conducted a process evaluation to better understand the specific components and benefits of the CAPABLE model; capture implementation successes and challenges to inform future expansion; and further explore how the CAPABLE model could serve as an enhancement or alternative to current Medicaid services in Colorado
Summary / Project Outcome:
The Colorado Department of Health Care Policy & Financing (HCPF) aims to improve the health and quality of life for members while decreasing costs. The Community Aging in Place–Advancing Better Living for Elders (CAPABLE) program out of Johns Hopkins University has been shown to effectively address these priority areas through more than a decade of research. To make an informed and data-driven decision on whether CAPABLE should become a long-term Medicaid benefit, HCPF contracted with the Colorado Evaluation and Action Lab (Colorado Lab) to evaluate the CAPABLE program for an expanded population of Health First Colorado members across multiple age groups and Colorado pilot sites.
CAPABLE is a participant-directed, team-based intervention to increase mobility and functionality in the home. Two provider organizations piloted the expanded CAPABLE model between January 2023 and August 2024, serving 368 members in 10 counties spanning the ages of 18 to 98. The providers captured outcome measures pre and post intervention, including difficulties with Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs).
The Colorado Lab utilized a one-group pretest-post test comparison design to measure outcomes in Colorado’s CAPABLE pilot and compare them to outcomes seen in CAPABLE pilots in other states. Multivariate regression analysis was used to determine how outcomes vary by population (specifically, by age and geographic region). In addition, the Colorado Lab conducted a process evaluation to better understand the specific components and benefits of the CAPABLE model; capture implementation successes and challenges to inform future expansion; and further explore how the CAPABLE model could serve as an enhancement or alternative to current Medicaid services in Colorado.
Overall, CAPABLE was shown to produce positive and strongly statistically significant outcomes for a wide range of Health First members. Its successful implementation across the state appears feasible, and its distinct interdisciplinary model promotes greater efficiency and accountability than the current Home Modification benefit. With additional targeted messaging and evaluation, the CAPABLE model could serve as the foundation for a two-tiered Home Modification Benefit in Colorado.
External Facing Reports/Websites:
Colorado Community Aging in Place—Advancing Better Living for Elders (CAPABLE) Evaluation
Learn more about the CAPABLE philosophy
Initiative 4.07. - New Systems of Care
HCPF has an opportunity to identify and pilot innovative systems of care that recognize and leverage the needs and capabilities of various populations. Under this project, HCPF will study successful initiatives implemented by other states and nations while also developing pilot programs that:
- Leverage creative solutions to provide low/no-cost childcare to home and personal care workers, which helps address low wage concerns by expanding “total compensation”
- Provide home sharing facilitation to those who need affordable housing, where at least one individual in the home sharing match is at least age 55 or older
- Create college credits and increase the workforce by employing college students to provide respite, homemaker, and personal care services to our growing older adult population, as well as the general HCBS population
HCPF will create a grant program with state-only funding to support innovative models of care. HCPF will conduct an environmental scan of evidence-based practices that could be used and to create an innovative model to address “total compensation” for direct support professionals.
Initiative 4.02. - Promote Single Occupancy
This project will focus on supporting assisted living facilities and group homes in creating more single occupancy rooms, which would help prevent the spread of diseases and promote greater independence among residents. HCPF will research current practice and what it would take for these providers to offer more single occupancy rooms. HCPF will offer incentive payments with state-only funding for providers to convert more space to single occupancy rooms.
✅Initiative 4.08. - Respite Grant Program - Completed
Key Project Activities and / or Achievements:
The Department successfully developed a grant program increasing access to respite for caregivers/families of Members (state plan and waiver Members). Twelve grantees from across the state were awarded based on organizational capacity to achieve proposed outcomes, creativity of the project to address systemic or other identified barriers, and the proposed project meeting all grant requirements.
The Department utilized a contractor, Public Consulting Group, to study the landscape of respite availability across Colorado. This study included: conducting stakeholder engagement, researching best practices, conducting peer-state analysis regarding respite, researching current respite utilization and completing data analyses, and researching Home & Community Based Services waivers and identifying recommendations.
Summary / Project Outcome:
A total of $1,138,547.50 was provided through grant awards to twelve organizations across Colorado, including urban and rural communities. They supported the unique respite needs of more than 1,200 Members, including children, older adults, Members with complex care needs, and Members with intellectual and developmental disabilities.
Highlighted below is a few of the innovative ways the grant funds were used:
- An online/app Respite CareMatch program was developed
- A program designed for siblings to connect with other siblings was created
- Voucher Programs and other existing programs were expanded to allow for respite in the evenings and on weekends
- “Activities” for Members such boat rides and destination trips were offered
- A new respite program was started in Alamosa, Colorado
- Respite was offered for families seeking CNA Certification
- Additional respite was offered for Members who have exhausted their waiver benefit
The primary evaluation element of this project was used to identify gaps in respite and the final evaluations/lessons learned from the grant program will be the foundation for future programs, policies, and budget requests. The Respite Benefit will continue as this is a critical service for Members and their families but may be modified or expanded based on information gleaned from this ARPA project.
Future plans include evaluating group respite availability across all children’s waivers and continuing to partner with our stakeholders and community partners to inform future decisions.
External Facing Reports / Websites:
Visit the Respite Webpage, a landing page for respite within Home and Community Based Service waivers.
✅Initiative 4.11. - Hospital Community Investment Requirements - Completed
Key Project Achievements and/or Activities:
Key achievements and activities of this project include several produced reports and a wide range of stakeholder engagement from hundreds of hospital and community stakeholders. These reports include:
A Process & Guidelines Recommendations Report that outlines processes and guideline recommendations for defining hospitals’ community, measuring community benefit, and investigating how to drive appropriate levels of community spending.
An Existing Hospital Programs and Requirements report summarizing existing hospital programs & requirements and how to reduce the burden on hospitals.
An Implementation Plan taking research-based recommendations from the above (1) and (2) reports and building a schedule for implementation.
A Best Practices in Community Engagement Guide detailing how hospitals should engage in community members to drive true community benefit spending, incorporating feedback from over one hundred vested community partners and advocates.
Summary / Project Outcome:
The recommendations from the four reports developed by the Colorado Health Institute (CHI) as a part of this project were used to: 1) inform legislation for HB23-1243; 2) better guide hospital community benefit reporting under that legislation and previous; and 3) improve guidance provided to hospitals on how to best engage communities for community benefit spending.
A summary from the Best Practices in Community Engagement Guide:
A common message emerged from [the stakeholder webinars]: cooperation is key. Hospitals should work within existing community engagement processes, rather than create their own. Cooperation with community builds trust and respects peoples’ time by not duplicating community engagement work.
All stakeholder recommendations were organized into the following three themes: tailored partnerships, thoughtful meeting planning, and convening with care. Each theme contains suggestions on what to do and why it’s important.
For example, the “Thoughtful Meeting Planning” section discussed the main items: Spreading the word, make it easy to attend, make it accessible, and speak the language with recommendations on how to fulfill these criteria effectively.
A summary from the Process & Guidelines report/Implementation Plan:
Recommendation 1: Consider Both Geography and Patient Population Definitions of Hospital Community
Recommendation 2: Provide Flexibility in Defining Health Needs
Recommendation 3: Promote Collaboration and Authentic Community Engagement
Recommendation 4: Do Not Establish a Minimum Spending Requirement
Recommendation 5: Increase Granularity and Specificity in Reporting Requirements
Recommendation 6: Establish an Oversight Board
External Facing Reports/Websites:
Hospital Community Benefit Webpage which contains the Best Practices in Community Engagement Guide: