A New California Health Care Foundation (CHCF) publication details an equity framework for evaluating the state’s Medi-Cal Home and Community Services (HCBS) for the elderly and people with disabilities.
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According to the report, inequities in California’s long-term care system will likely persist, even as the state continues to make investments in this area, if California does not take deliberate steps to ensure that its efforts to expand the availability of home care are centered on equity.
The report reveals several aspects of HCBS where inequities may arise, including in the design of the HCBS program.
“Each decision point in program design is an opportunity to make equity a primary goal, starting with which federal Medicaid authority the state chooses to create an HCBS program and what services the state decides to cover in each HCBS program,” the report said.
CCHF emphasized the importance of conducting an equity analysis between HCBS programs and initiatives. The report specifically identifies that community voice and lived experience are critical to the equitable design of the HCBS program, and that inequities can arise if input is not solicited from a wide range of users and HCBS suppliers during the program design process, including reviewing program policies and developing guidance. .
The CHCF also indicates that inequities can arise in which services are included or omitted from an HCBS program.
“For example, in the Home Support Services program, providers are not allowed to read clients’ mail as a covered service, which limits the program’s assistance to people with visual impairments and impacts disproportionately on people who have less family or unpaid support, such as LGBTQ people.
The report also indicates that inequities in access to HCBS programs may stem from the availability of service providers.
According to the CHCF, to support equitable provider availability, efforts should be made to increase the diversity of participating providers through strategies that reduce the administrative burden on providers, guide reimbursement and compensation policies, expand outreach, l education and technical assistance to support providers. of all communities, and increase the cultural competency of government officials who review provider applications and provide support and guidance to participating providers.
Inequities in HCBS programs can also be seen in awareness and enrollment in these programs, citing program websites that are not consumer-friendly and complicated application processes.
“Inequalities are more likely to arise when programs have gatekeepers who may have biases about who might be a good fit for orientation and enrollment in an HCBS program,” the report said. “When conducting an equity assessment of outreach and enrollment in HCBS programs, it is particularly important to focus on the role of state departments in ensuring that HCBS programs are widely known and to facilitate the application process; and the role of providers in sharing information about the HCBS program and in identifying people who can participate in the HCBS program.
The report also notes that inequities may be present in the assessments and authorization of HCBS services, and that the subjective perceptions of those tasked with using these tools to conduct assessments may also be biased.
CHCF suggests conducting a fairness assessment of assessments and clearance processes for HCBS with an audit of assessment tools for potential biases, as well as regular bias training for those conducting assessments and simplifying assessments where possible.
The provision of HCBS can also be a source of inequities with the quality of services provided, according to the report.
“Inequalities in access to high-quality HCBS have been demonstrated through research. For example, one study found that black HCBS users are more likely to be hospitalized than white HCBS users. This disparity is becoming more pronounced when looking at the intersection of race and disability for people with dementia, where black HCBS users with dementia had the highest hospitalization rates, including preventable hospitalizations.
Inequities can also arise because the types of services delivered do not take into account the unique needs of recipients and are not person-centred.
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