Home and Community-based Services: Maximizing the Impact of Federal Spending

Most surveys show the overwhelming majority of older adults wish to “age in place” in their own homes and communities for as long as they can. With the senior population on the cusp of a major expansion as the 78 million Baby Boomers head into retirement, the broad availability of home and community-based services and supports (HCBS) that can enable aging in place will become increasingly important.

HCBS covers a range of activities, including help with activities of daily living such as bathing, dressing, meal preparation, paying bills and medication management, as well as assistance with chores and transportation.

For many seniors, access to affordable HCBS can be the difference between being able to remain at home and in their community or placement in an assisted-living facility or other institutional setting.

With competing demands on a limited pool of federal resources, it will be more critical than ever to ensure that federal funding for HCBS is deployed as productively as possible. The bottom line is we need to get the most out of every federal HCBS dollar.

A recent report by the U.S. Government Accountability Office (GAO)—Federal Strategy Needed to Help Ensure Efficient and Effective Delivery of Home and Community-Based Services and Supports (May 2015)—demonstrates there is substantial room for improvement on this score,

Currently, five federal agencies—the Department of Health and Human Services (HHS), Centers for Medicare and Medicaid Services, the Department of Housing and Urban Development, the Department of Transportation and Department of Agriculture—fund multiple programs that provide assistance for the aging such as nutrition services, in-home services, affordable housing and transportation. These programs often supplement additional funding for HCBS from state and local governments, charities and private sources.

While the Older Americans Act of 1965 requires the HHS’ Administration on Aging to facilitate collaboration among the five federal agencies with respect to HCBS, the GAO report reveals that, in fact, the agencies work largely independently of each other. There are some examples of cooperation on an agency-to-agency basis, but there is little overall coordination among all five. When cooperation does occur, it often focuses on “program development tasks, rather than front line service delivery.”

The result is missed opportunities for broadening the reach of federal HCBS spending and producing better outcomes for the very seniors served by these programs.

To remedy the situation, the GAO recommends that HHS take the lead in developing a cross-agency federal strategy to ensure efficient and effective use of federal resources for HCBS. The GAO offers a framework for inter-agency collaboration based on the following common-sense practices:

• Define and articulate a common outcome;
• Establish mutually reinforcing or joint strategies;
• Identify and address needs by leveraging resources;
• Agree on roles and responsibilities;
• Establish compatible policies, procedures and other means to operate across agency boundaries;
• Develop mechanisms to monitor, evaluate and report on results;
• Reinforce agency accountability for collaborative efforts through agency plans and reports; and
• Reinforce individual accountability for collaborative efforts through performance management systems.

As the GAO points out, adopting these practices as part of a broader cross-agency strategy can help prevent disconnects among the various federal HCBS programs and streamline the way funds are delivered to those who are providing the services on the ground. These goals can be achieved without requiring additional federal resources.

As former cabinet secretaries, it’s also been our experience that accountability is critical. A specific individual within the federal bureaucracy should be tasked with, and held responsible for, developing and implementing the new cross-agency strategy.

Going forward, however, this strategy must also acknowledge the enormous role that the states play in the availability of HCBS and the importance of greater coordination between the federal government and the states. Although the federal government funds the vast majority of HCBS, federal spending takes the form of matching dollars to states. In effect, states decide whether or not to provide services, who receives the services and how much is spent. The federal government matches those funds through direct payments to states, based on a federal formula that takes into account, among other things, state per capita income. Ultimately, it is the states, not the federal government, that controls the vast majority of spending on HCBS.

Nevertheless, with its report, the GAO has made an important contribution to the public’s understanding of the federal role in providing HCBS. It’s now up to the five federal agencies cited in the report to put the GAO’s recommendations into action.