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
The Department of Health Care Policy and Financing (HCPF) will focus on those areas in which there are currently gaps in services and treatment programs for children and youth. These include members with Autism Spectrum Disorder, intellectual and developmental disabilities, severe emotional disturbance, as well as those with dual behavioral health and physical or developmental diagnoses.
HCPF will work with several providers to develop a viable step-down treatment program, to create models of care that are financially viable and person-centered, with a focus on those children and youth who are currently being sent out of state for services. This project will also look at the creation or expansion of a step-down service between hospitals and a short-term residential placement.
Initiative 4.06. - Supported Employment Pilot Extension
In recent years, HCPF has received State funding to conduct a Supported Employment pilot program to incentivize outcomes where people achieve and maintain employment. Funding for this project is expiring on June 30, 2022. HCPF will extend and expand the current pilot program to allow for increased participation, additional data collection, and to determine if expanding incentive-based payments for Supported Employment services within the waivers is cost-effective and produces positive outcomes.
Initiative 4.09. - Respite Rate Enhancement
HCPF has provided a temporary targeted rate increase to incentivize additional respite providers to serve HCBS members and children, with a focus on home-based services. The rate increase also applies to respite services provided under the Department of Human Services's crisis services program. In addition, HCPF will identify innovative ways that can be taken to incentivize respite provision by meeting with providers and other Colorado respite programs to gather information about barriers for enrollment and service provision.
HCPF received approval through an Appendix K Amendment on November 5, 2021 to implement a temporary 25% rate increase for HCBS Respite providers.
Initiative 4.10. - Home Modification Budget Enhancements
HCPF identified enhancements to the Home Modification benefit as a need for our members, based on stakeholder feedback over the growing need to ensure members could continue to live and receive care in their homes, as opposed to congregate care settings, in response to the COVID-19 PHE. One way to help members continue to live in their homes is by funding specific modifications, adaptations, and improvements to their existing home setting. HCPF will provide additional funding above the current service limitations for home modifications in response to members needing multiple adaptations to their homes for accessibility and the increasing costs related to construction and materials.
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
Under this project, HCPF will develop and pilot continuum models of care that incent the creation of financially viable small residential programs that are person-centered, with a focus on rural communities. This would be accomplished by completing an analysis and pilot program:
- Models of Care Analysis: HCPF will conduct an analysis of funding mechanisms and feasibility on how to improve transitions of care for people transitioning from nursing facilities and other institutional settings and potential new models of care for investment and innovation.
- Pilot Program: HCPF will develop a pilot to develop, design and/or implement a re-envisioned holistic community that combines natural/community supports, residential homes, and existing services across systems to support older adults and people with disabilities to live as they would like to in a safe, supportive community environment. Learnings from the pilot program will be used to scale the model to other communities and to provide best practice recommendations for further development of new, innovative models.
HCPF will hold at the forefront the HCBS Settings Final Rule, including CMS guidance and requirements for integration of persons residing in community placements, when researching, planning, and implementing this pilot program. It is the intent of this project to determine whether a fully integrated, planned community can be one method for providing services to individuals with disabilities.
View information about this grant including how to apply and grant application deadlines
✅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
HCPF will pilot and evaluate the innovative Community Aging in Place - Advancing Better Living for Elders (CAPABLE) program to support HCBS members to remain at home. HCPF will pilot the CAPABLE program in three to four locations across the State with the goal of enrolling 400 people. Though the program has been rigorously evaluated, HCPF will implement a pilot with an evaluation to ensure it results in the same outcomes, including cost savings, when implemented with a diverse group of members, including individuals of younger ages and those living in rural communities.
Learn more about the CAPABLE program and philosophy
CAPABLE Grant Information - How to apply, deadlines, materials
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: