Coordinating administration of LTSS programs

States should coordinate LTSS programs, policies, and budgets. This can be done in one state agency or across multiple agencies. It would promote efficiency, create single points of entry for LTSS, and implement the data collection necessary to manage LTSS strategically. 

States should: 

• develop the capacity for prompt financial and functional Medicaid eligibility determinations for applicants who need and want HCBS, and use presumptive eligibility for people who are at risk of nursing facility placement without Medicaid-funded HCBS; 
• use a unified global budget for publicly funded LTSS, so they have flexibility in allocating expenditures and utilize the money saved through reduced nursing facility use for increased coverage of HCBS; 
• ensure that Olmstead plans include specific action steps, timelines, and strategies for securing necessary HCBS funding; 
• ensure that consumers fully participate in implementing and monitoring state Olmstead plans and waivers at the state and local levels, including serving on advisory committees and governing boards; 
• continue to monitor and revise, as needed, their Olmstead implementation plans; 
• establish policies to pay relatives and friends who care for people with LTSS needs as part of a service plan, design programs and policies to protect consumers and avoid the erosion of family-care networks, guard against fraud and abuse, and avoid disincentives for unpaid caregiving; 
• identify barriers that unintentionally curtail consumer ability to direct their services or to arrange to have certain nursing tasks provided by unlicensed direct-care staff authorized and trained to do so by a registered nurse; 
• ensure that registered nurses are protected from liability if they have followed the prescribed protocols for delegation, training, and supervision outlined in their states’ nurse practice acts; 
• ensure that states with a formal process for allocating the number of nursing facility beds—such as a certificate of need—base decisions on the number of people who require a specific level of care and on data projecting the need for LTSS in different areas of the state; 
• provide data on nursing facilities and HCBS use by race, ethnicity, age, and geographic region, as well as per capita and aggregate cost of services, including Medicaid services in nursing facilities and HCBS to the extent possible; 
• ensure data gathered is sufficient to answer questions about disparities and support strategies to address them; 
• provide data on the range of the level-of-care scores of people age 85 and older who are in nursing facilities; 
• preserve and expand funding for respite care services in a range of settings, such as personal care services in the home or adult day services, to ensure that more family caregivers can have a break from their caregiving duties; 
• preserve and expand funding for respite care services for all caregivers whether or not the individuals they are assisting are eligible for Medicaid or another publicly funded program; and 
• allow family caregivers assisting individuals with moderate incomes, and who do not qualify for publicly funded respite services, to buy into or otherwise obtain these services.