Nursing Facility and Home and Community Based Service Need Criteria in the United States

Over the past two decades states have expanded the delivery of long term care from institutions to the home and community. Although state Medicaid need criteria for the home and community based services (HCBS) waiver program must be equivalent to those for nursing facility (NF) criteria, other screening procedures for these services are not specified. This study examined variations in need criteria, methods for determining need, and assessment forms for NF and HCBS across the states, and identified whether these procedures were more stringent for HCBS than for NFs. The NF minimum need criteria was most often (31 states) based on a combination of nursing, medical, functional, or other psychosocial criteria, 10 states used nursing criteria, and 10 states used limitations in functional activities criteria. The method used for determining need for NF was based on explicit criteria in 25 states, point systems in seven states, and 19 states used guidelines that allowed for judgment by those conducting the assessment. The average length of a NF assessment form was six and one-half pages, which was four pages shorter than the average HCBS form. Within some states the HCBS waivers have higher need criteria, more comprehensive need determination, and longer assessment forms than NFs. Wide variability in screening procedures creates potential inequities to LTC services across the states. Within states, more restrictive screening procedures for HCBS than for NF may limit access to community based long term care.