A couple of weeks ago, we wrote about problems plaguing the Colorado host home program for individuals with intellectual and developmental disabilities (I/DD) and the development of stronger regulations to address these problems (see Colorado Developing Stronger Regulations On Host Homes For Individuals With I/DD). The host home model, which allows individuals and families to open their homes to individuals with disabilities in need of support, is based on the concept of shared living (for more on the principles of shared living, see Shared Living: A New Take on an Old Idea. National Association of State Directors of Developmental Disabilities Services – Spring 2013). After reading the story, it got me wondering: how many states use the host home model and how is it reimbursed?
The current interest in the host home concept has been spurred by a 40-year continuous push to move consumers out of residential placements and into community-based care settings. Lawsuits related to Olmstead require states to find cost-effective, innovative ways to care for individuals in the community (see Serving People with Disabilities in the Most Integrated Setting: Community Living and Olmstead). Cost is a big part of that discussion for individuals with the highest level of need-24-hour residential care is expensive and can easily cost over $200,000 per year. These settings also tend to not be very home-like, and may limit an individual’s actual ability to participate in the community. Currently, thirteen states and the District of Columbia have gone so far as to eliminate institutions for the I/DD population and rely entirely on community-based settings and small residences (see The Future Of I/DD Is In The Home).
In contrast to residential care, host homes offer an actual home to individuals with developmental disabilities, and care in this setting is often much less costly than 24-hour residential care. The cost of host homes can be broken into two categories: coverage of support services and coverage of room and board. Support services must be provided by the host home family and are typically reimbursed as a per diem stipend (in most states the stipend is tax-free). But while Medicaid pays for support services via 1915(c) home- and community-based services waivers, it cannot pay for room and board. Coverage of room and board is specific to the individual. Often a certain percentage of an individual’s SSI payments are used to cover the cost of room and board; in other cases, state departments of developmental disabilities may pay the cost. The host family may also elect to not receive room and board payments, or the family of the individual may pay the cost.
Our new analysis on the coverage of host home services found that 40 states pay for support services delivered in a host home via 1915(c) or 1115 waivers. These homes cover approximately 60,000 individuals with I/DD, representing 5% of the I/DD population known to state agencies and 12% of the population living in non-family residences (see In-Home and Residential Long-Term Supports and Services for Persons with Intellectual or Developmental Disabilities: Status and Trends 2015). The per diem paid to families varies based on geography and the needs of individual. The lowest reimbursement for host home services is about $27 per day in Montana while the highest is $321 per day in Pennsylvania.
For more detail at the state level, see our new market intelligence report, State Coverage Of Host Homes For Adults With I/DD. The report includes state specific information on the number of individuals living in host homes, the estimated number of host homes per state, states that cover host homes, and how they are covered.
Looking ahead, host homes represent an important option for individuals with I/DD who may not be able to live independently, but want to live in a home setting. It is also a much more cost-effective option than 24-hour residential care. And as Nancy Thaler, Deputy Secretary for the Office of Developmental Programs at the Pennsylvania Department of Human Services discussed last year in her keynote address, The Future Of Long-Term Services & Supports: A New Business Model For A Medicaid Managed Care Market, at the The 2017 OPEN MINDS Executive Leadership Retreat, host home arrangements consistently have better outcomes than other non-family settings.
There are a couple of impediments to the future of this model. The first is that 1915(c) waivers limit the number of people who receive services, and many people may not be able to afford a host home arrangement without assistance. Second, there is the issue of recruitment of host home families. Currently, only a small percentage of the I/DD population lives in this setting. If the number was to increase, would there be enough families to support the demand? Finally, as in the case of Colorado, there is the issue of regulation. If host homes are regulated too heavily, they lose their home-like atmosphere and may deter families or individuals from participating. However, these regulations are also designed to keep individuals with I/DD safe. States are going to have to figure out how to strike a balance.
I think as outcomes become more important and more individuals move to the community, there will be a request for more home-like settings rather than just “community-based” settings. The model will work in the future with the right support.
For more join us at The 2018 OPEN MINDS Strategy & Innovation Institute in New Orleans for the session Innovative Community-Based Care Models For Consumers With Complex Conditions featuring Nancy Wexler, DBH, MPH, Director, Innovation and Collaborative Care at Banner University Health Plans; Kristin Cline, MS, LPC, CAADC, Clinical Lead Specialist at NHS; and Kevin Kumpf, Ph.D., LPC, NCC, ACS, DDTT Clinical Director at NHS.