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.
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.
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.
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.
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.
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.
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.
(previously named Alternative Care Facility Tiered Rates and Benefit)
HCPF currently pays one per diem rate for all members served in an Alternative Care Facility (ACF), regardless of the level of setting. HCPF will develop a tiered rate methodology for setting levels, with an emphasis on secured settings, for the ACF benefit. This initiative will provide insight on how HCPF could create multiple level settings for the ACF program that would limit placement into a skilled nursing facility.
HCPF will also analyze other states that utilize a tiered rate for HCBS residential services, and their member assessment processes for assignment to the appropriate tier. HCPF will provide recommendations related to services incorporated at each level to limit nursing facility placement and analyze whether Colorado’s assessment tools would be sufficient to determine an appropriate tier. A new assessment tool will be developed, if appropriate.
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.
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.
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.
Expanding respite services was one of the most frequently cited items by Colorado stakeholders for consideration in the ARPA spending plan. Respite services provide temporary relief for the members’ primary caregivers, which is necessary to support caregivers and helps prevent members from moving to institutional settings.
HCPF will create a grant program for increased access to respite for caregivers/families of members. HCPF will identify the landscape of respite availability across Colorado and create a report identifying the gaps in respite care availability. Based on this report, HCPF will develop a framework for a state-only grant program. Grant recipients may include parents, grandparents, or child caregivers of aging parents or family, and could be expanded to include other members of a household that are not usually afforded respite but could also benefit from respite.
Under this project, HCPF will research and develop recommendations for how to leverage hospital community investment requirements to support transformative efforts within their communities. HCPF will develop minimum guidelines for community benefit spending and reporting values to hold hospitals accountable to meet community needs as determined by the community itself and align with statewide health priorities. These guidelines should allow for more consistent reporting and determination of what is a community health need as well as better evaluate the impact of community benefit programs.