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Focus Areas

Home and Community-Based Services

Supporting person-centered programs that enable older adults and people with disabilities to live in their communities

Home and Community-Based Services (HCBS) enable older adults or people with disabilities of any age to remain in their homes or communities. HCBS may be provided 1:1, for example by a home care aide, or delivered in a group setting, such as congregate meals and adult day services centers, and residential care.

What is the goal of HCBS? 

All HCBS have the underlying goal of supporting person-centeredness and enabling people to live independently as they wish, rather than defaulting to facility settings for care.

Approaching care with a person-centered lens is critical to all of our research efforts and aligns with RTI’s nonprofit mission to “Improve the human condition.” We affirm people’s right to choose where they would like to live, how they would like to engage with their communities, and what supports best enable them to achieve their goals. We partner with numerous federal, state, and private entities to design, implement, and evaluate HCBS programming designed to provide the supports needed for individuals to meet their care goals.

Barriers to HCBS Implementation

There have been shifts in the HCBS landscape and policies implemented, including HCBS expansion, such as through the American Rescue Plan Act. Yet despite increased interest and support for HCBS, many challenges remain, including:

  • HCBS workforce shortages
  • Service access inequities by geography and recipient population
  • Lack of support for informal caregivers
  • Challenges with HCBS quality measurement
  • The impact of COVID-19 on HCBS
  • Disparate Medicare and Medicaid policies regarding coverage for HCBS
  • Social determinants of health affected by HCBS
  • Limited access to grant-funded and non-medical HCBS
  • Growing need for condition-specific HCBS, including Alzheimer’s Disease and related dementias

CMS, ACL, and other federal clients are focusing on HCBS expansion and improvement as a way of reducing health care costs, while providing a more person-centered approach to care. Increasingly, health coverage has been expanding to include non-medical HCBS, such as through Medicare Advantage Plans and via Medicaid waivers, to support the matrix of structural and social needs that may affect health. Moving into HCBS quality measurement also has been a new growth area, as defining quality for such a diverse array of services can prove challenging, particularly while also ensuring that services meet diverse needs and support equity goals.

How RTI is Addressing Innovative Approaches to HCBS

RTI’s experts in health policy, aging, disabilities, health equity, and social determinants of health are uniquely positioned to understand and address these challenges by leveraging decades of experience evaluating the facilitators and barriers of innovative approaches to HCBS. Key areas of RTI research include:

  • Developing critical assessments of HCBS payment, including Medicaid (e.g., Section 1915 (c) and Section 1115 waiver programs, Katie Becket waivers, and state plan services)
  • Supporting the design of and assessing quality measures for an array of health services, including HCBS
  • Implementing home-based primary care, integrated care/care coordination, and care delivered via CMS alternative payment models
  • Exploring Medicare Advantage plans and other means of providing HCBS for diverse communities
  • Conducting surveys, literature reviews, and needs assessments for Administration for Community Living-administered grant programs that provide HCBS for older adults and people with disabilities
  • Sharing our deep knowledge of Nuanced HCBS models delivered outside the U.S. Department of Health and Human Services (e.g., programs for home modification through the U.S. Department of Housing and Urban Development) through publications and presentations

Learn more about how RTI is supporting HCBS access and equity.