Our Work




The population of Americans needing long-term services and supports (LTSS) continues to grow, with estimates suggesting that as many as 70% of 65-year-olds will need LTSS during their lifetime. Home and community-based services (HCBS) are an important way to allow an individual with LTSS needs to live and age safely at home and in the community. However, Medicaid is the primary systematic program covering HCBS, which can limit these services to the lowest income in our nation, and access to Medicaid HCBS is restricted by waitlists, service caps, and eligibility restrictions.

In early May 2021, the Department of Health and Human Services’ Administration for Community Living released $1.4 billion from the American Rescue Plan to fund Older Americans Act programs that support the availability of HCBS for older adults and in-home supports for family caregivers. In addition to this infusion of capital to HCBS, the American Rescue Plan Act also provides a temporary 10-percentage point increased federal medical assistance percentage (FMAP) through March 2022. The increased funding creates significant opportunity for states and health plans to invest in expanded access and availability to HCBS for older adults and individuals with disabilities. To do so effectively, states and health plans will need an understanding of the approaches and programs they can deploy.


With support from Arnold Ventures, we completed a literature review of evidence on the efficacy of core HCBS as well as emerging trends to offering core services. Our literature review focused on research of HCBS since 2010, and representative examples of innovative approaches and programs to deploying core services: personal care services, adult daycare and day centers, respite care and other caregiver supports, homemaker and chore services, home safety and handypersons, non-medical transport, food and meal services, self-direction, and assisted living. As a complement to our literature review, we prepared a Tip Sheet with examples stemming from our research for states and health plans to consider as they evaluate ways to better meet the needs of frail and complex individuals.


In the near-term and given the temporary nature of the funding, states should use the temporary FMAP increase to deploy novel approaches to existing services and invest in workforce development.

Longer-term, states and health plans should consider how to expand access and availability to HCBS with a focus on an individual’s cultural, racial, familial, community, and social realities. This recommendation reflects our observation that many services (and underlying research) focus on a “one-size-fits-all” approach of the service to the population in need, without focusing on the unique characteristics of the potential recipients to maximize impact.

Finally, states and health plans should develop value-based models that promote appropriate balances between HCBS and institutional settings, as well as between Medicare and Medicaid for the subset of LTSS-users who are dually eligible for both programs. The need for LTSS spans HCBS and institutional care, and the best state and health plan coverage options will appropriately and comprehensively capture access to both.

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