Home- and Community-Based Services

Home- and Community-Based Services (HCBS) are types of person-centered care delivered in the home and community. A variety of health and human services can be provided. HCBS programs address the needs of people with functional limitations who need assistance with everyday activities, like getting dressed or bathing. HCBS are often designed to enable people to stay in their homes, rather than moving to a facility for care.

HCBS programs generally fall into two categories: health services and human services. HCBS programs may offer a combination of both types of services and do not necessarily offer all services from either category.

Types of HCBS Care

Health Services meet medical needs

• Home health care, such as:
  • Skilled nursing care
  • Therapies: Occupational, speech, and physical
  • Dietary management by registered dietician
  • Pharmacy
• Durable medical equipment
• Case management
• Personal care
• Caregiver and client training
• Health promotion and disease prevention
• Hospice care (comfort care for patients likely to die from their medical conditions)

Human Services support daily living

• Senior centers
• Adult daycares
• Congregate meal sites
• Home-delivered meal programs
• Personal care (dressing, bathing, toileting,eating, transferring to or from a bed or chair, etc.)
• Transportation and access
• Home repairs and modifications
• Home safety assessments
• Homemaker and chore services
• Information and referral services
• Financial services
• Legal services, such as help preparing a will
• Telephone reassurance

Creating and maintaining an HCBS program benefits the community and the individuals served in many ways. However, there are several challenges to consider that come along with this type of program.

Benefits and Challenges of HCBS

Benefits

• Cost effectiveness: usually less than half the cost of residential care
• Culturally responsive: spiritual and cultural activities and support available
• Familiarity: patient enjoys the comfort of their own home or small residential facility in the community
• Can provide counseling or clergy to assist with bereavement
• Some waivers permit family members to be paid caregivers

Challenges

• Access to providers
• Availability of qualified caregivers
• Caregiver burnout
• Lack of 24/7 medical professional availability
• Nonfamily caregivers may have limited access in remote locations, especially during winter
• Potential cultural bias or barriers in the acuity assessment process
• Skilled nursing care includes only medical services performed by a registered nurse. Other daily tasks fall primarily to family members
• Those needing care do not always want family members to act as their caregivers due to potential for abuse or financial manipulation
• Tribes need to complete processes that are often long and complex, such as creating an elder abuse code or establishing a memorandum of understanding with the state, to create an HCBS program

Learn more about HCBS at Medicaid.gov.

Frequently Asked Questions

Who is Eligible for HCBS?

Eligibility varies by state. See the State Resources Map to learn more.

Who Funds HCBS?

HCBS programs are often funded by state waivers. Waivers are part of a state's Medicaid program, but they provide a special group of services to a certain population. Waivers usually require medical and financial eligibility, but state waiver eligibility requirements may not be exactly the same as state Medicaid eligibility. Other funders for HCBS might include your tribe or private long-term care insurance held by your patients.

Resources

Check these resources for more information on funding for HCBS:

• Medicare Special Needs Plans may cover people who receive nursing care as part of the home-based services they need. Learn more about these plans and how they work.
• Read an overview of HCBS waivers at Medicaid.gov.
• Learn more about using state waivers as a way to fund LTSS.

Who Runs HCBS Programs?

Within individual states, HCBS care is provided by lead agencies and other service providers. A lead agency acts as the primary care coordinator for its region—for example, a county's department of human and social services. A tribe can apply with its state to become a lead agency, based on state eligibility requirements.

Service providers contract with the lead agency in their area to provide services. If a tribe is not a lead agency, it will contract with the appropriate county, state, or managed care organization in its region to provide services and coordinate care.

To more fully access Medicaid and state HCBS, the Oneida Nation became the lead agency for a state waiver. Read their story.

Learn More About HCBS

The HCBS model can include many kinds of programs and types of care. For tribes just beginning to provide LTSS in their communities, or tribes who do not have the resources to consider facility-based care, HCBS can be a good place to start.

There are many possible approaches for your program, and many ways that programs can partner together to provide a wider range of services to their communities.

Special HCBS Programs

CMS offers several national programs that can support certain types of HCBS in tribal communities:

Program of All-Inclusive Care for the Elderly (PACE) combines many services into one comprehensive program and often combines Medicare and Medicaid eligibility.

Money Follows the Person (MFP) Rebalancing Demonstration Grant includes a tribal initiative that focuses on building HCBS specifically in Indian Country.

Examples in Indian Country

There are many examples of successful HCBS programs in Indian Country. Check out some of these resources to see what other programs are doing:

• Watch Tanana Chiefs Conference Community Health Outreach Program-a video profile on HCBS in rural villages in the Alaskan interior.
• View Chickasaw Nation Elder Health Programs-a webinar on the holistic HCBS programs provided by Chickasaw Nation to support quality of life for elders.
• Watch Phoenix Native Health-a video profile on an urban Indian health program that provides HCBS to over 300 tribes.
• Read a profile page on the network of HCBS offered by Zuni Pueblo through a variety of partnering agencies.
• Learn about the Cherokee Nation's successful PACE program.
• Read Long-Term Services and Supports in Indian Country: Issues Affecting American Indians and Alaska Native Consumers with Disabilities (PDF)-a report containing many helpful program examples.
• Read Supporting American Indian and Alaska Native People in the Community: Opportunities for Home- and Community-Based Services in Indian Country. (PDF)

Transitional Care

Transitional care is the process of maintaining quality of care while elders and persons with disabilities transition to or from hospital or nursing home facilities and residential or home settings.

The purpose of transitional care is to prevent gaps in care for an individual moving from one care system to another to ensure the transfer is successful. The process includes a review of the person's health status, medication management, and follow-up care.

Transitional care occupies an increasingly important role as HCBS becomes the LTSS delivery mechanism of choice.

There are several evidence-based models to support care transitions, including:

• Better Outcomes for Older Adults through Safe Transitions (BOOST)
• The Bridge Model
• Care Transitions Intervention (CTI, or "Coleman Model")
• Geriatric Resources for Assessment and Care of Elders (GRACE)

Transitional Care Resources

To learn more about options for providing transitional care, check out these additional resources: