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Conclusions: Internationally, we observe a trend towards tools and services not only for professionals but also for patients and citizens. However, their impact on the patient-provider relationship and their design for special user groups, such as elderly and/or disabled needs to be further explored. In general, evaluation studies are rare and further research is critical to determine the impacts and benefits, and limitations, of potential solutions and to overcome a number of hinders and restrictions, such as - the lack of standards to combine incompatible information systems; - the lack of an evaluation framework considering legal, ethical, organisational, clinical, usability and technical aspects; - the lack of proper guidelines for practical implementation of home telehealth solutions.

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This issue brief presents the latest findings on key state policy choices about Medicaid HCBS in 2022 based on the 20th KFF survey of state officials administering Medicaid HCBS programs in all 50 states and DC. The data were collected from April through September 2022. The survey was sent to each state official responsible for overseeing the administration of HCBS benefits (e.g., home health, personal care, and services for specific populations such as people with physical disabilities), but some states submitted responses for the state overall. All states responded to the 2022 survey, but response rates for certain questions varied. Key findings include:

When asked about how they used the ARPA funding, over two-thirds of states (35) reported initiatives with high start-up costs that were generally time-limited to avoid higher ongoing costs after enhanced federal funding ended. Ten (of those 35) states reported pursuing both time-limited and ongoing HCBS initiatives using ARPA funds. Some of the most common initiatives included offering providers bonuses or incentive payments to stay on, developing or expanding worker training or certification programs, funding studies to assess provider rates or workforce development, expanding workforce registries, and upgrading IT systems.

The COVID-19 pandemic illuminated fundamental, long-term challenges for states in providing Medicaid HCBS, but also provided opportunities for change, particularly with new authorities and funding. While states have adopted a number of policies to bolster the HCBS workforce, it remains to be seen whether initiatives undertaken during the pandemic will yield more systemic changes longer-term. Policymakers of both parties have called for additional changes to HCBS including eliminating waiting lists for services (nearly 656,000 people were on a waiting list in 2021), increasing opportunities for family members to be paid caregivers, increasing wages for all HCBS providers, and enabling more people to live in their homes as they age. Although there is consensus on those broad policy goals, there is little consensus on how to pay for significant federal investments needed to achieve these goals, suggesting it may be some time before major reforms are enacted.

The COVID-19 pandemic exacerbated existing challenges for state Medicaid home and community-based (HCBS) programs and the people they serve, most notably a heightened shortage of direct care workers coupled with increased demand for services. Together, the American Rescue Plan Act (ARPA) and the COVID-19 public health emergency (PHE) authorities gave states new but temporary federal funding and policy flexibility to address pandemic-related challenges. All states used these initiatives to make investments in their HCBS programs, helping millions of seniors and people with disabilities who rely on Medicaid HCBS to meet daily self-care and independent living needs in community-based settings. As states continue pandemic recovery efforts, consumer demand for HCBS remains high and longstanding challenges facing Medicaid HCBS including the aging population and provider workforce shortages will likely continue for the foreseeable future.

Medicaid paid for about two-thirds of all HCBS in 2020, and waivers are the primary authority that states use to offer HCBS benefit packages with all of the 50 states and D.C. providing at least some HCBS through either a 1915(c) or an 1115 waiver. Medicaid HCBS encompass a wide range of medical and nonmedical services that assist Medicaid beneficiaries with physical, mental, and other chronic conditions or disabilities. States are required to cover Medicaid long-term services and supports (LTSS) provided in nursing homes, while all HCBS other than home health care services are optional. HCBS may be provided through state plans but are more commonly provided through waivers. Unlike Medicaid state plan authorities, which require states to cover everyone who meets certain eligibility criteria, waivers allow states to provide services to specific populations, limit the number of people served, and expand financial eligibility. The Centers for Medicare & Medicaid Services (CMS) estimates that nearly 8 million Medicaid enrollees had at least one claim for a service that could potentially be HCBS during 2019.

Four states reported offering new waivers in 2021, the most recent year in which states were asked to report all of their HCBS waivers. Alabama and the District of Columbia reported new 1915(c) waivers serving populations with I/DD, while Missouri had a new 1915(c) waiver serving seniors and adults with physical disabilities. Idaho reported offering a new Section 1115 waiver serving individuals with mental illness. Additionally, Oregon submitted a new 1115 waiver request to provide in-home supports to individuals with higher income and assets and for those who do not meet nursing facility level of care criteria. Tennessee has pending waiver amendments to integrate the 1915 (c) waivers into its 1115 waiver.

All states participated in the ARPA HCBS program and when asked how they used the funding, most states reported making upfront investments and confronting immediate recruitment and retention challenges in the workforce (Appendix Table 3). Most states (35) chose initiatives with high start-up costs that were generally time limited so that they would not face higher ongoing costs in the future after the period of enhanced federal funding ended. For example, states used ARPA funding to provide bonuses or incentive payments (36), develop or expand worker training or certification programs (33), expand family caregiver supports (23), fund studies to assess provider rates or workforce development (21), and develop or expand workforce registries (15). It is unknown to what extent those initiatives will continue after states have exhausted the additional federal funding they received from the ARPA.

Twenty-five states added new services to at least one HCBS waiver during the PHE, with home delivered meals the most frequently reported new service (9 states). Sixteen states will continue to offer these new waiver services after the PHE ends, five states were planning to end the services when the PHE ends, and the final four states were still undecided at the time of the survey. Most states provided more services to HCBS users by increasing utilization limits, but many of those changes will end when the PHE does. Thirty-seven states increased utilization limits on existing HCBS services, with less than one third (eleven) of states opting to continue the policy after the PHE ends. States reported increasing limits for home delivered meals, respite, day supports, personal care services, dental, and home modifications.Almost all states provided telehealth services to address challenges in delivering in-person HCBS during the pandemic. All but two (47 of 49 responding) states reported providing HCBS via telehealth in at least one waiver, and almost two-thirds (29) of states plan to allow at least some telehealth service delivery moving forward. States reported relying on telehealth for services such as: wellness checks, case management, supported employment, life skills training, behavioral and mental health counseling, companion, and adult day and habilitation services.

At the time of discharge home, parents of preterm infants in the neonatal intensive care unit often feel apprehensive and may question their ability to care for their baby. The well-planned, comprehensive discharge of a medically stable infant helps to ensure a positive transition to home and safe, effective care after discharge. This statement provides guidance in planning discharge of infants born before 34 weeks' gestational age from tertiary and community settings. Discharge readiness is usually determined by demonstration of functional maturation, including the physiological competencies of thermoregulation, control of breathing, respiratory stability, and feeding skills and weight gain. Supporting family involvement and providing education from the time of admission improve parental confidence and decrease anxiety. Assessing the physical and psychosocial discharge environment is an important part of the discharge process. The clinical team is responsible for ensuring that appropriate investigations and screening tests have been completed, that medical concerns have been resolved and that a follow-up plan is in place at the time of discharge home.

Heidar Pasandideh (Pasandideh), the warden of Sanandaj Central Prison in Kurdistan province, has overseen the detention and daily torture of prisoners arrested during the ongoing protests in Iran. Under his administration, Sanandaj Central Prison has been the site of arbitrary executions of prisoners.

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