Finding and keeping enough caregivers, serving beneficiaries with complex medical and behavioral health needs, and limitations on overall HCBS funding levels are three of the biggest challenges facing providers of Medicaid home- and community-based services such as assisted living operators, according to a report released Monday by the Government Accountability Office.

The GAO conducted the research at the request of Sen. Ron Wyden (D-OR), looking at 26 Medicaid HCBS programs in five states: Wyden’s Oregon as well as Arizona, Florida, Mississippi and Montana.

The GAO talked to state and managed care organization professionals for the report. Officials said low wages complicate the hiring and retaining of direct care workers, but Mississippi, Montana and two of the MCOs said they offer higher pay rates to address the issue. Arizona, Montana and one MCO also allow beneficiaries to pay family members, friends and neighbors as caregivers, according to the report.

As a solution to help serve residents who display aggressive or other challenging behaviors, officials from Montana and one MCO reported providing behavioral health training for caregivers.

“Montana officials said they had reached out to community partners, such as assisted living facility owners, to educate them on what Medicaid can and cannot pay for in order to aid them in developing multiple funding streams for specialized programs for individuals with traumatic brain injury,” the report authors wrote.

Montana also offered a mental health first aid class for providers, according to the report, and “MCO officials reported sending behavioral health specialists to assisted living communities to help train staff on handling challenging behaviors in an effort to avoid beneficiaries being moved out of the assisted living facility and into an institutional setting,” the authors said.

And when it comes to funding, state officials told the GAO that they provide state legislators with information on the projected need for HCBS to inform their future funding decisions. They also said they try to take advantage of federal grants and funds from charitable organizations, according to the GAO.