To Adopt or Not to Adopt: Factors Impacting States’ Pursuit and Implementation of ACA’s Home and Community-Based Programs

The Patient Protection and Affordable Care Act (ACA) sought to improve the United States’ long-term services and supports (LTSS) system by expanding home and community-based services (HCBS). The ACA contained several optional Medicaid HCBS opportunities for states, including the Balancing Incentive Program, the 1915(k) Community First Choice personal care benefit, and the revised 1915(i) state plan benefit. This research examined these HCBS provisions to explain what factors determine whether states participate in the ACA’s new HCBS programs and, after adoption, what factors facilitate or impede implementation of these programs. To answer these questions, this study used a mixed methods research design. The quantitative portion of this research relied on several modeling approaches to identify the factors that affected states’ decisions to adopt these policies. The qualitative research used case studies of three states to examine the state-level decision-making processes around adoption and then subsequent implementation of these policies. This research has implications for federal officials interested in spurring states to achieve greater rebalancing of Medicaid LTSS toward home and community-based care, and state officials interested in pursuing new HCBS policy opportunities. In the quantitative results, more liberal political ideology, more 1915(c) waivers, and lower Medicaid LTSS spending on HCBS were key factors that increased the likelihood of state adoption of the ACA HCBS programs. The qualitative findings identified the important role that leaders within the state Medicaid agency or disability services agencies played in the policy adoption decisions. Consistent with the quantitative results, these leaders recognized that the three ACA policies would complement or substitute for existing HCBS policies and fill gaps in HCBS offerings. When implementing these polices, additional financial resources, frequent communication with the Centers for Medicare and Medicaid Services, and leveraging existing HCBS programs and infrastructure facilitated the implementation process. Barriers to implementation included aggressive timelines, insufficient staff, and limited engagement with external stakeholders

Uplifting: Improvements in Boston Area Client Well-Being

LIFT-Boston, a local non-profit organization, entered into a collaborative partnership in September 2012 with McCormack Graduate School Public Policy Ph.D. students and faculty to develop and execute a research project. The goals of this endeavor were to assist LIFT-Boston in understanding the outcomes associated with its services and enable the organization to further pursue service goals. The primary research questions respond to the organization’s most fundamental questions. These include how the organization’s unique service model impacts clients across several objective and subjective dimensions of well-being. Secondary questions focus on how these impacts may translate into increases or decreases in student achievement within a family. To answer these lines of inquiry, the MPT employed a multi-method design, analyzing administrative, survey, observational, interview, spatial, and focus group data. Findings show that LIFT clients tend to be adults, aged 45 years or older and more than 50% of LIFT-Boston clients live alone. Nearly half of LIFT-Boston client are unemployed with nearly 67% receiving food stamp benefits. Besides employment, LIFT-Boston clients report problems with housing and housing expenses. Regression results show that LIFT-Boston may increase objective client well-being in housing and food stamp assistance, showing increase of 17.5% in food stamp receipt for LIFT-Boston clients and an 18.6% decrease in housing issues. Overall, findings suggest that LIFT-Boston offers a unique set of services to adult clients in the Boston area. Clients experience caring and respectful relationships when collaborating with LIFT advocates. While limited changes in objective well-being were observed, interviews suggest that clients’ self-confidence is greatly increased when small steps are made toward larger life goals. Limited evidence suggests adult well-being may translate to students, although much deeper analysis is needed. While a low survey response rate must be considered when interpreting findings, this report contributes to the scholarly knowledge based in areas including strength based case management, subjective/objective well-being measures, and student achievement. Steps for further scholarly research, as well as potential organizational changes for LIFT-Boston, are suggested

Practicum 2012 - 2013: LIFT Boston Client Well Being Study

A Boston based non-profit and a team of public policy PhD students engaged in several months of collaborative problem identification and goal setting focused on the effectiveness of the organization’s unique service delivery model. The nonprofit uses volunteer advocates and a goal-oriented process with no eligibility criteria to assist clients in distress. We collected administrative data, administered a survey, and conducted interviews to explore client well-being

Uplifting: Improvements in Boston Area Client Well-Being

LIFT-Boston, a local non-profit organization, entered into a collaborative partnership in September 2012 with McCormack Graduate School Public Policy Ph.D. students and faculty to develop and execute a research project. The goals of this endeavor were to assist LIFT-Boston in understanding the outcomes associated with its services and enable the organization to further pursue service goals. The primary research questions respond to the organization’s most fundamental questions. These include how the organization’s unique service model impacts clients across several objective and subjective dimensions of well-being. Secondary questions focus on how these impacts may translate into increases or decreases in student achievement within a family. To answer these lines of inquiry, the MPT employed a multi-method design, analyzing administrative, survey, observational, interview, spatial, and focus group data. Findings show that LIFT clients tend to be adults, aged 45 years or older and more than 50% of LIFT-Boston clients live alone. Nearly half of LIFT-Boston client are unemployed with nearly 67% receiving food stamp benefits. Besides employment, LIFT-Boston clients report problems with housing and housing expenses. Regression results show that LIFT-Boston may increase objective client well-being in housing and food stamp assistance, showing increase of 17.5% in food stamp receipt for LIFT-Boston clients and an 18.6% decrease in housing issues. Overall, findings suggest that LIFT-Boston offers a unique set of services to adult clients in the Boston area. Clients experience caring and respectful relationships when collaborating with LIFT advocates. While limited changes in objective well-being were observed, interviews suggest that clients’ self-confidence is greatly increased when small steps are made toward larger life goals. Limited evidence suggests adult well-being may translate to students, although much deeper analysis is needed. While a low survey response rate must be considered when interpreting findings, this report contributes to the scholarly knowledge based in areas including strength based case management, subjective/objective well-being measures, and student achievement. Steps for further scholarly research, as well as potential organizational changes for LIFT-Boston, are suggested