A Review of Level-of-Care Assessments Nationwide to Ensure Access to Long-Term Services & Supports for Older Adults With Serious Mental Illness

Medicaid-funded long-term supports and services (LTSS) have provided crucial assistance for low-income adults with functional limitations and disabilities for over 50 years. LTSS is provided in home and community-based or institutional settings (such as nursing homes) and includes services like caregiving support, durable medical equipment, and medical transportation which can result in improved quality of life and health outcomes (Dobson et. al, 2021). However, people with mental illness (MI) are underrepresented in LTSS, making up only 1.26% of enrollment in state HCBS waiver programs in 2020 (Chidambaram and Burns, 2023). Furthermore, older adults with MI are more likely to be placed in institutional settings or the criminal justice system compared to those who do not report MI symptoms (Report to Congress on Medicaid and CHIP, 2021). One potential cause of these service disparities is that functional limitations related to MI are under-identified in level-of-care (LOC) assessments, which determine eligibility for LTSS as well as authorization of particular services. Therefore, we performed a content analysis of LTSS level-of-care forms nationwide to determine how state Medicaid programs assessed functional limitations related to behavioral health. We included all states that offered LTSS and had publicly available LOC forms (n=25). We first extracted all items related to behavioral health, parsed items, then grouped them thematically to identify content areas and scoring strategies. Across states, we identified nine behavioral health functional limitation domains. There was not a consistent approach to defining functional limitations related to behavioral health and scoring strategy varied widely. Most states have a very limited number of items related to behavioral health compared to physical or cognitive limitations. This may impede access to LTSS for older adults with behavioral health issues, increasing their risk of rapid functional decline and poor health.

References

Chidambaram, P. & Burns, Alice. (2023, August 14). How many people use Medicaid Long-Term Services and Supports and how much does Medicaid spend on those people? KFF. https://www.kff.org/medicaid/issue-brief/how-many-people-use-medicaid-long-term-services-and-supports-and-how-much-does-medicaid-spend-on-those-people/

Dobson, C., Gibbs, S., Mosey, A., Smith, L. (2021). Demonstrating the Value of Medicaid MLTSS Programs. MLTSS Institute. http://www.advancingstates.org/sites/nasuad/files/2021%20-%20Demonstrating%20the%20Value%20of%20MLTSS.pdf

Medicaid and CHIP Payment and Access Commission. (2021). Report to Congress on Medicaid and CHIP. https://www.macpac.gov/wp-content/uploads/2021/06/June-2021-Report-to-Congress-on-Medicaid-and-CHIP.pdf