OT in Medicaid-funded HCBS: A provider case study
This case study highlights an occupational therapy practitioner’s (OTP’s) hypothetical role and experience providing services under a Medicaid-funded home and community-based services (HCBS) 1915(c) waiver for adults with intellectual and developmental disabilities. HCBS waivers provide the opportunity for eligible individuals to receive long-term services and supports in the home or community instead of in an institutionalized setting.
Disclaimer: Each Medicaid-funded HCBS waiver is unique to a specific target client population, setting, and state. This is one case study highlighting an experience that OTPs may face under one waiver in a single state. It aims to educate practitioners on the everyday success of working in this setting and the realistic administrative struggle that may occur while working under an HCBS waiver as an enrolled Medicaid provider.
The OTP Role and Setting
Jaime is an occupational therapist who is employed full time by a not-for-profit organization providing therapeutic and educational services, vocational and residential services, and adult day services. Through this organization, Jaime is an enrolled provider under a state Medicaid waiver to reimburse for occupational therapy (OT) services provided to waiver participants. Jaime provides adult day services using a day habilitation program model. Day habilitation is a day program that provides activities and training, and supports skill development in improving or retaining various independent life skills. She works with a variety of adults and older adults, including autistic individuals, and those with intellectual and developmental disabilities (I/DD), cerebral palsy, brain injury, dementia, Down syndrome, Parkinson's disease, and mobility difficulties.
About 60 to 70 adults attend programming at the site each day; however, only 15 of these adults are waiver participants and are currently billable members of her caseload. This averages about 3 hours a day in direct client care that is billable under the waiver program for Jaime, while the rest of the day is spent working with other adult day program clients under Jaime’s salaried position. Medicaid reimbursement rates under this waiver for OTPs have recently increased from approximately $36 to $111, making this a realistic and sustainable avenue for OT providers to seek reimbursement. Evaluations, documentation time, therapeutic group services, caregiver training, and consultative services are not currently reimbursable under the waiver.
Occupational therapy evaluations are often an extensive process, assessing multiple occupations and developing goal areas accordingly. Under this HCBS 1915(c) waiver, therapy services require a physician’s referral. There are varying factors specific to each state waiver that determine the frequency and number of OT sessions approved each year; for this state waiver with adults in the I/DD community, OT ranges from 26 to 52 hours per year per waiver participant. OT within the HCBS waiver program emphasizes a comprehensive community-based lifespan model of care. Advocating for the role of OT and the value of habilitative services is crucial for clients to receive the appropriate and necessary services.
One waiver participant Jaime works with is Ali. Ali is a 65-year-old woman who enjoys painting, having her morning coffee, and tending to the community garden. Ali has an intellectual disability, deficits in mobility, challenges with money management, and ocular-motor dysfunction. Ali has expressed to Jaime a desire for more independence and wants to be able to buy coffee on her own. With this in mind, Ali and Jaime developed a goal that she would be able to safely and independently cross the street to purchase a cup of coffee at the coffee shop. This goal addresses various necessary life skills to support Ali’s independence. Jaime is educating Ali on compensatory strategies for safety in crossing the street, visual-oculomotor skills, money management, and overall community integration.
The Value of OT
Given an aging adult population, Jaime has demonstrated distinct value in the day habilitation program to provide environmental and compensatory strategies for people experiencing a decline in their memory or cognition, and mobility. Jaime has provided education to clients and staff on adaptations and appropriate body mechanics to independently engage with occupations to mitigate the need for long-term-care facilities. Having Jaime on-site full time has also increased and improved interdisciplinary collaboration among the team by providing a holistic approach to clients and insight into the impact of the environment and individual skills beyond focusing on behavior within the plan of care. In addition, Jamie has been a consistent presence for clients to self-advocate and express their goals for OT services.
For individuals on the waiver, every year a personal plan is created and assessed to determine whether they are making progress toward their goals or to update any level of care. This is an additional opportunity to advocate for OT if clients are not making substantial gains under their current goals without an OT, and the value of supporting referrals to OTs under the waiver system.
Conclusion
OTPs have a role in providing community-based lifespan support and services while adapting to evolving client needs and goals. Occupational therapy can play a vital role in Medicaid-funded HCBS in addressing key occupational domains to support the independence of clients, including ADLs, IADLs, mobility challenges, sensory needs, compensatory strategies, social interactions, chronic pain management, etc. OTPs provide therapeutic habilitative services that are life long and incorporate education to clients, families and caregivers, and staff. Medicaid-funded HCBS waivers are a unique reimbursement method for OTPs in a practice area where it is often difficult to find or receive reimbursement. Extra funding and a greater reimbursement rate allow for more job opportunities in this area.