CMS - content management system
(Credit: gustavofrazao / Getty Images)

A federal proposal to establish a quality measure assessing inpatient discharges to home- and community-based settings for Medicaid enrollees has some leaders in the senior living industry concerned about assisted living providers’ ability to address some complex care needs.

The Centers for Medicare & Medicaid Services is seeking feedback on a “Discharge to Home” proposal to assess the percentage of discharges of Medicaid participants from inpatient facilities — including acute care hospitals, skilled nursing facilities and inpatient rehabilitation facilities — to home-based settings, including assisted living communities, adult family homes and group homes.

The proposed discharge to home concept is intended to be used at the state level, with the goal of providing data to facilitate quality improvement and planning related to HCBS placement of people discharged from inpatient facilities. The concept would involve monitoring discharge trends, with a goal of increasing discharges to home, which CMS said “increases the likelihood of improved quality of services provided and participant quality of life.”

LeadingAge, however, said it has identified multiple areas where the framework lacks clarity and requires a more rigorous definition of goals, usable data and applicable settings. In comments to the Lewin Group, which CMS contracted to create the proposal, LeadingAge Director of Medicaid Policy Georgia Goodman wrote that the measure “cannot effectively meet the multiple established goals” of assisting states in planning for HCBS and tracking discharges to the community.

The proposal mentions assisted living as an HCBS provider setting, but Goodman noted that because the setting is not federally regulated, the types of services provided in assisted living can vary widely across states. 

“There are many settings that would be considered assisted living in one state, but go by a different licensure, nomenclature or setting type in another state. For this reason, we encourage the measure developer to define ‘assisted living’ (AL) by the types of services it provides to ensure consistency and comparability of data across states,” Goodman wrote. “For example, is it enough to offer daily meals, housekeeping services and transportation or must it provide support for activities of daily living and medication assistance? Perhaps both of these examples are types of ALs that CMS wishes to include but either way it would be helpful to clarify what is meant by AL.”  

Access to services and level of care is influenced by a variety of factors, ranging from the availability of workers to state regulation, National Center for Assisted Living Executive Director LaShuan Bethea told McKnight’s Senior Living.

“It is important that services offered in an assisted living community align with the person’s needs so they can receive the best care in the best setting within the care continuum,” Bethea said.

She added that knowing the proportion of individuals going to various HCBS settings is an important factor in ensuring adequate resources to facilitate quality improvement and planning.

“In assessing discharge disposition, we believe the framework should also include key factors that impact discharge location and quality care,” Bethea said. “It is vital to ensure a person leaving an inpatient facility goes to the setting that best meets their needs.”

Goodman said that although LeadingAge supports outcomes measures that seek to ensure that people can return to whatever place they call home, concerns exist about the proposed measure’s lack of clarity, purpose and direction.

The measure “attempts to achieve multiple often competing goals, such as measuring discharges from inpatient facilities to home-based settings and creating a data set for states to analyze in support of future home- and community-based services planning,” Goodman told McKnight’s Senior Living. “LeadingAge remains a stalwart proponent of improving the Medicaid program and incentivizing top-quality care and services across the care continuum.” 

Goodman added that LeadingAge shares CMS’ goal of Medicaid program improvement and to that end urges CMS to conduct further analysis.

After the public comment period closes, Lewin Group will determine whether the concept should be revised.