In response, the SUA and the Medicaid team worked together to improve the case management process so that Medicaid Waiver funds for home modifications are used when a need is identified. This approach is maximized when the SUA is housed within the State Health Department of vice-versa and is occurring more often. For example, in 2021, the state of Michigan created the new Health and Aging Services Administration within the Michigan Department of Health and Human Services which combines the Aging and Adult Services Agency and Medical Services Administration to focus on integration, coordination, and innovation for the growing elderly population in Michigan.

The Aging Network integrates home modification and repair services within several types of home and community-based and long-term care programs including Medicaid Long Term Services and Supports and Home and Community-Based Care Waiver Programs; nursing home transition programs; and caregiver programs. The examples below of Aging Network efforts within these home and community-based and long-term care programs provide opportunities for other state and local agencies to emulate.

One source of funding for home modification is Medicaid waiver programs which can include “environmental adaptations” as an allowable service. A Medicaid waiver allows a state to waive certain Medicaid eligibility requirements, covering supportive and health care services estates can specifically target services to individuals needing Long Term Services and Supports. These waivers are called home- and community-based services (HCBS) 1915 waivers. Agencies engaged with Medicaid waiver programs are likely to be knowledgeable about and have the capacity to connect waiver participants with accessing home modifications as an allowable service under the waiver programs. SUAs indicated that their number one source of home modification funding is Medicaid Waiver prorgrams. Aging Network agencies may oversee or help to administer Medicaid Long Term Services and Supports and Home- And Community-Based waivers, supporting the creation of an integrated delivery system involving provider agencies and case managers. Likewise, the AAA may be an approved provider for home modification services under their state Medicaid waiver or the AAA may administer a waiver program directly and provide the home modification services as a part of this role.

Examples include:

• The care management team of the Area Agency on Aging, CICOA Aging & In-Home Solutions in Indianapolis, Indiana, oversees 15-20 home accessibility modification projects per month through the Medicaid waiver program.
• The Arkansas Department of Human Services: Division of Aging and Adult Services (State Unit on Aging) is involved in the administration of the state Medicaid Waiver program, ARChoices in Home Care, which provides home and community-based services for adults ages 21-64 with a physical disability and adults aged 65 or older. It includes environmental accessibility adaptations/adaptive equipment as a home and community-based waiver service. It provides physical adaptations to the beneficiary’s home to promote independence, health, and safety. Examples of adaptations include installing wheelchair ramps, widening doorways, modifying bathroom facilities, installing grab bars, and installing overhead tracks for transferring. Adaptations for general utility repairs and adaptations which add total square footage to the home are excluded. The lifetime benefit for Environmental Accessibility Adaptations/Adaptive Equipment is $7,500 (as of 2020).
• The Alaska Department of Seniors and Disabilities Services (State Unit on Aging) Environmental Modification (E-Mod) Home Accessibility Program is designed to assist Alaska Medicaid Waiver beneficiaries with modifications to the home to maintain independence. Modifications have a cost cap of $18,500 that is renewable every 3 years. The Alaska State Unit on Aging, Department of Senior and Disabilities Services, approves all project estimates submitted by the recipient’s care coordinator.
• The Florida Department of Elder Affairs (State Unit on Aging) is responsible for the Statewide Medicaid Managed Care Long-Term Care Program (SMMC LTC) through an interagency agreement with the Florida Agency for Health Care Administration. It delivers long-term care services from the Florida Medicaid Program through two programs: 1) the Long-term Care Managed Care Program; and 2) the Managed Medical Assistance Program. Medicaid recipients who qualify and become enrolled in SMMC LTC receive long-term care services and may receive home accessibility adaptation services based on medical necessity or necessity to avoid institutionalization (e.g., installation of ramps and grab-bars, widening of doorways, modification of bathroom facilities).
• As part of its Medicaid Home and Community-Based Waiver ADvantage Program, the Oklahoma Department of Human Services – Division of Aging Services (State Unit on Aging) offers supportive services to eligible adults as an alternative to care in a nursing facility, including environmental modifications.
• The Washington State Unit on Aging (ALTSA) contracts with 13 Area Agencies on Aging to maintain a statewide Medicaid provider network to serve clients who are eligible for Medicaid long-term services and supports. The Medicaid Section 1115 demonstration waiver’s home modification benefit level was designed to be flexible enough to purchase ramps or other home modification needs up to $3,600.
• The West Virginia Bureau of Senior Services (State Unit on Aging) administers the West Virginia Medicaid Aged and Disabled Waiver Program which provides in-home and community services to individuals aged 18 and older who need support services to maintain their independence. Home modifications are an eligible supportive service.

To ensure successful transitions of patients from nursing homes to supportive community settings, nursing home transition programs (both federal and state funded) are increasingly including home modifications as part of the transitional care plan. In our surveys and interactions with Aging Network agencies, many indicated providing home modifications for clients transitioning from skilled nursing facilities  to home. This provision is critical since, often, a person might get discharged from a nursing home and have recommendations for modifications to the home to ensure their independence. Aging Network agencies can help ensure that a person’s recovery process follows them home.

Examples include:

• Alabama Department of Senior Services (State Unit on Aging) Home and Community-Based Services for the Alabama Community Transition (ACT) Medicaid Waiver, operated by the Alabama Department of Senior Services, provides services to individuals with disabilities or long-term illnesses who currently live in a nursing facility and desire to transition to the home and community setting. The code provides home modifications for physical adaptations of the home required by the individual’s Plan of Care. The limit on home modification is $5,000 per waiver participant and the state coordinator must approve any expenditure in excess of the maximum allowed amount and the Medicaid designated personnel.
• Iowa Department on Aging Return to Community Pilot, a state-funded non-Medicaid program in five counties, focuses on transition to home from the hospital and includes home modifications. Older adults who are being transferred from a hospital to a nursing home in their first 30 days of Medicare eligibility voluntarily participate in order to facilitate discharge to their home. This discharge process may include home modifications as a part of a successful transition.
• Maine Aging and Disability Services (State Unit on Aging) Homeward Bound is a Money Follows the Person demonstration program, funded by the Centers for Medicaid & Medicare Services (CMS) and implemented by the Maine SUA. It is designed to help older adults and adults with disabilities move from institutional to community settings. During this process, they work with a Transition Coordinator to develop a transitional care plan tailored to their needs. Services are arranged that include home modifications to make the new home environment more supportive.
• Montana Department of Public Health and Human Services/Senior and Long-Term Care (State Unit on Aging) oversees the Money Follows the Person (MFP) Transition Services for individuals who are transitioning from an institutional setting to qualified housing in a private residence or residential setting and meet the Money Follows the Person requirements. The Montana Department of Public Health and Human Services covers transition service costs of up to $4,000 of goods and services, including home accessibility adaptations.

The federal National Family Caregiver Support Program as well as state and other funded caregiver support programs help to support home and community-based care delivery and can often include home modifications. The supportiveness of the home can affect caregiver capacity to provide assistance. Physical demands of caregiving can endanger caregivers’ health and strength. A supportive home can reduce caregiver burden and help to preserve their strength. The Aging Network has important roles to play to ensure the home environments in which caregiving takes place are supportive.

Examples include:

• Care Connection for Aging Services: Area Agency on Aging in Warrensburg, Missouri has a Family Caregiver Support Program that provides family caregivers with help installing grab bars, ramps, and other assistive devices to support the caregiving experience.
• The College of Southern Idaho Office on Aging (an Area Agency on Aging) administers the Chore Services Program and works in conjunction with Interfaith Volunteer Caregivers (IVC) to install safety equipment to reduce the risk of falls in caregivers’ homes. They provide funds to IVC to build wheelchair ramps that provide safer access in and out of the home, handrails, and grab bars to reduce the risk of falls.
• Maine Aging and Disability Services (The State Unit on Aging) Family Caregiver Support Program: Caregiver Respite Program supports family caregivers by reimbursing costs incurred by providing care for a person with dementia. This care might take place in the home, at an adult day program, or overnight in a facility (on a limited basis). Services are administered via Maine’s Area Agencies on Aging, and home modifications that support independent living may be reimbursed up to $2,000 over a program participant’s lifetime.
• State Of New Jersey Department of Human Services Division of Aging Services (State Unit on Aging) Jersey Assistance for Community Caregiving is a state-funded program that provides in-home services to enable individuals who are at risk of placement in a nursing facility to remain in their community home. A plan of care is developed that may include environmental accessibility adaptations as a service.
• Montgomery County Aging and Adult Services, an Area Agency on Aging in Morristown Pennsylvania, administers the Family Caregiver Support Program which provides individuals who are caring for someone age 60 or older a one-time grant of up to $2,000 to modify the home, to purchase assistive devices or to accommodate the frail relative. These adaptations include installing a stair glide, wheelchair ramp, or modifying a bathroom.