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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Adequate Insurance.

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Strategy. Medicaid Waivers

Approach. Implement protocol to waive federal regulations to ensure health insurance coverage for CYSHCN

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Overview. Home and Community-Based Services. (HCBS) waivers, like the TEFRA State Plan Option, allow states to disregard family income for children with severe disabilities who are cared for at home but who might otherwise live in institutional settings. In contrast with the TEFRA State Plan Option, HCBS waivers usually provide additional services designed to support families in keeping their children in the community rather than in institutions. In addition to Medicaid coverage, HCBS waiver services may include respite, home for vehicle modifications, for medical day care. States are allowed to restrict eligibility by age, geographic region, and diagnosis.[1]

Evidence. Expert Opinion. Strategies with this rating are recommended by credible, impartial experts, guidelines, or committee statements; these strategies are consistent with accepted theoretical frameworks and have good potential to work. Often there is literature-based evidence supporting these strategies in related topic areas that indicate this approach would prove effective for this issue. Further research is needed to confirm effects in this topic area.

Access the peer-reviewed evidence through the MCH Digital Library or related evidence source. (Read more about understanding evidence ratings).

Source. Boston University's Catalyst Center Financing Strategies Database

Outcome Components. This strategy has shown to have impact on the following outcomes (Read more about these categories):

  • Cost. This strategy helps to decrease the financial expenditure incurred by individuals, healthcare systems, and society in general for healthcare services.
  • Access to/Receipt of Care. This strategy increases the ability for individuals to obtain healthcare services when needed, including preventive, diagnostic, and treatment services.
  • Health Outcomes. This strategy helps contribute to reducing avoidable differences among socioeconomic and demographic groups or geographical areas in health status and health outcomes such as disease, disability, or mortality.

Detailed Outcomes. For specific outcomes related to each study supporting this strategy, access the peer-reviewed evidence and read the Intervention Results for each study.

Intervention Type. Policy Development and Enforcement (Read more about intervention types and levels as defined by the Public Health Intervention Wheel).

Intervention Level. Population/Systems-Focused

Examples from the Field. Access descriptions of ESMs that use this strategy directly or intervention components that align with this strategy. You can use these ESMs to see how other Title V agencies are addressing the NPM.

Sample ESMs. Here are sample ESMs to use as models for your own measures using the Results-Based Accountability framework (for suggestions on how to develop programs to support this strategy, see The Role of Title V in Adapting Strategies).

Quadrant 1:
Measuring Quantity of Effort ("What/how much did we do?")

PROCESS MEASURES:

  • Number of Home and Community-Based Services (HCBS) waivers for children with special health care needs approved and implemented by the state. (Measures expansion of coverage options)
  • Number of Medicaid eligibility workers trained on HCBS waiver criteria and enrollment procedures. (Assesses workforce capacity to facilitate access)

Quadrant 2:
Measuring Quality of Effort ("How well did we do it?")

PROCESS MEASURES:

  • Percent of eligible children with special health care needs who are enrolled in an HCBS waiver. (Measures coverage rate among the focus population)
  • Percent of HCBS waiver service providers who meet quality and safety standards. (Evaluates network adequacy and competency)

Quadrant 3:
Measuring Quantity of Effect ("Is anyone better off?")

PROCESS MEASURES:

  • Number of partnerships established with family organizations and disability supporters to promote HCBS waivers. (Engages key community partners in outreach)
  • Number of state policies changed to streamline HCBS waiver enrollment and service authorization. (Reflects systems-level improvements)

OUTCOME MEASURES:

  • Number of emergency room visits and hospitalizations avoided among children with special health care needs due to early intervention through HCBS waivers. (Demonstrates health outcome impact)
  • Number of institutional placements prevented or delayed for children with special health care needs enrolled in HCBS waivers. (Measures long-term cost savings and quality of life)

Quadrant 4:
Measuring Quality of Effect ("How are they better off?")

PROCESS MEASURES:

  • Percent of children with special health care needs in the state who are potentially eligible for HCBS waivers based on income and functional needs. (Estimates unmet need and coverage gaps)
  • Percent of HCBS waiver expenditures allocated to services that directly support community living for children with special health care needs. (Assesses investment in key service categories)

OUTCOME MEASURES:

  • Percent reduction in Medicaid spending on institutional care for children with special health care needs after implementation of HCBS waivers. (Shows cost savings for the health system)
  • Percent decrease in unmet medical and supportive care needs reported by families of children with special health care needs. (Demonstrates impact on health care access)

Note. When looking at your ESMs, SPMs, or other strategies:

  1. Move from measuring quantity to quality.
  2. Move from measuring effort to effect.
  3. Quadrant 1 strategies should be used sparingly, when no other data exists.
  4. The most effective measurement combines strategies in all levels, with most in Quadrants 2 and 4.

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.

References

1 Catalyst Center/National Center for Health Insurance and Financing for Children and Youth with Special Health Care Needs. Medicaid Waivers Financing Strategy.
https://ciswh.org/project/the-catalyst-center/financing-strategy/medicaid-waivers/

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.