The following evaluation questions are identified: 1. Is the program meet the budget requirements of the 1915 (b)?

2. Has the program generates cost saving?

3. Has the program has been able to deliver quality health service as being stipulated by 1915(b) waiver?

4. Has the program been able to meet the needs of the participants?

a. Operational definitions.

The operation definition for the proposal is as follows:

Assessing the effectiveness and efficiency of the of HCBS program in Alaska.

What are the procedure to evaluate the effective and efficiencies of the HCBS waiver program in Alaska?

Since the proposal will employ both qualitative and quantitative techniques for data collection and analysis, the operational definition for qualitative and quantitative research study reveals that data are collected and analyzed using both qualitative and qualitative methods.

The proposal reviews the previous studies relating to the project. By reviewing the previous studies on the project, the researcher will be able to enhance his knowledge on the effectiveness and efficiencies of the HCBS in Alaska.

Literature Review

The literatures review describes the overview of the HCBS. This section also discusses the method Alaska employs to run HCBS waiver, and the effectiveness and efficiency of HCBS in Alaska are discussed. The challenges facing the state of Alaska in the implementation of the program is also discussed.

Overview of Home and Community-Based Waiver Services (HCBS)

Analysis of the institutional health provision reveals that institutional health provision continues to consume the bulk of Medicaid spending. The Medicaid program is a joint federal-state program to assist certain low income people and the program is large enough to provide standard of care to the needy people. Despite the benefits identified in the program, the program lacks flexibility to respond to various level of care. Meanwhile, the mechanisms have emerged to allow states to apply for waivers to meet the needs of certain group of population. HCBS program emerges due to the mounting pressure by the public that there is a need to find the costs effective method to provide the healthcare service to the elderly and disable individuals in the community. The passage of the HCBS is entrenched in the "Section 2 176 of the Omnibus Budget Reconciliation Act (OBRA) of 1981. Section 2176 created Section 1915(c) of the Social Security Act which authorized Medicaid waivers to provide home and community-based services." (Miller, 1992 P. 163). With the provision of the act, states are able to receive funds for the home and community-based services for the people who will be otherwise would have received the care in a nursing facility. With subsequent amendment, states are allowed to extend the service to certain low-income people such as children infected with AIDS and adults with disabilities. Typically, the HCBS is often viewed as clinical appropriate and is preferred by individual with low income because it is believed that it is cost effective than institutional care services. (Miller, 1992).

Benjamin (2001) argues that HCBS is enacted because it has been estimated that almost 12 millions Americans of all ages require long-term care and majority of those persons needing supportive assistance are elderly people. Typically, the HCBS is to provide home-based services for people with chronic impairments and the personal care assistance include activities such as bathing, dressing, eating, and instrumental activities such as shopping, cooking and housekeeping. The forces that lead to the passage of HCBS include the increase in the number of non-elderly people with chronic impairments and increase in the political pressure to expand the public funded assistance in order to give the participants more autonomy to receive their own care. Moreover, there is a believe that home and community care service approach will be less costly.

A year after the OBRA was enacted; only six states were participating in the program. State of Alaska was among the six states participating in the program. By 1991, Alaska had developed active HCBS program.

Overview of HCBS Program in Alaska

The HCBS waivers approved by the federal government allows Alaska Medicaid to provide expanded service to people who meet the home and community-based service for the specific waiver. In Alaska, the HCBS waivers are extended to the following categories of people:

Adults with Physical Disabilities (APD)

Children with Complex Medical Conditions (CCMC)

Mentally Retarded/Developmentally Disabled (MRDD)

Older Alaskans (OA)

The Department of Health and...

However, Alaska has no entity that administers the HCBS waiver. The Division of Senior and Disability Service (DSDS) oversees the entire operations, and the goal of the waiver is to provide HCBS service for people between the age of 21 and 64 who meet the level of care in a nursing facility. DHSS provides the waivers service through the network infrastructure of nursing facilities. DHSS has assisted in fostering a strong network of home and community waiver service in Alaska. Recipients of HCBS waiver programs enter the home and community-based systems through referrals, nursing facilities, hospitals, and other caregivers. DHSS staff initially performs screening to determine the eligibility of the recipients.
Despite the benefits associated with the HCBS program, there are still challenges associated with the implementation of the program in Alaska. Similar to other states that implement the waiver program, Alaska is struggling to provide long-term care service. The major reason is that there is a growing population of disable and elderly people in Alaska. Moreover, there is escalating costs of implementing the program. Thus, there is a concern that the current program needs to be reviewed to be more cost effective. The report provided by Stauffer (2008) reveals that there is escalating costs of waiver program yearly. In 2005, the overall costs of waiver program in the United States was $23.2 billions and the costs increased to $25.6 billions in 2006 revealing 10.3% increase in the costs between 2005 and 2006. The literatures are reviewed to provide greater understanding on the challenges facing the HCBS waiver program in Alaska.

Challenges of HCBS Waiver Program in Alaska

Since the authorization of the HCBS program, the state Alaska has experienced budget deficit and the deficit is due to the sharply decrease of the state revenue. The budget reduction is affecting all aspects of the state expenditures and quality improvement of the HCBS. In the recent years, Alaska has found itself incapable to deal with the reduced state revenues. The state revenues shortfall has created enormous challenge in securing quality and growth of the HCBS waiver program. (Lakin, & Prouty 2003). In the last 10 years, there is a dramatically increase in the number of HCBS recipients, and the increase is more than 118.1%. At the same time, the state expenditure on HCBS program increases by 870.9%, and there is average of $3,200 state spending per an enrolment in 2009.

The increase in the expenditures on the waiver program is due to the increase in the number of people participating in the program. Moreover, there is a significant increase in the number of people covered under the HCBS. Braddock et al. (2002) argue that one of the major challenges facing the HCBS program in Alaska is the increase in the number of people waiting to be enrolled in the program. In the last ten years, there is an increase in the number of people enrolled in the program. Over the years, the number of people enrolled in the program grows by more than one-third, and the total number of people waiting for the program also grows. There are many factors leading to the increase in the demand for the waiver program in Alaska. First, the demand for services increase as the specialized facilities by which people could receive the waiver program expands. Moreover, there is growth in the flexibility of the service. Typically, the increase is largely due to the increase in the number of people reaching the older ages and many of these people are claiming to participate in the program.

Additionally, shortage of staff is one of the major challenges facing the waiver program in Alaska. It is well recognized that there is a crisis in the recruitment, retention and training of nursing personnel in the United States. Essentially, availability of the nursing professionals is the cornerstone of the HCBS waiver program in Alaska. The challenges in recruiting and retaining the qualified workforce are a major challenge facing the program in Alaska. Typically, shortage of medical personnel is a long-term challenge in the United States. The estimation has shown that the number of medical workforce needed to manage the program will be increased by 58% in the next decade. With the shortage of staff to manage the program, Alaska could face challenges in providing the quality healthcare delivery to the participants.

Hemp, and Braddock (2003) argue that recruitment and retention of direct support staff couple with low wages are among the challenges facing the HCBS waiver program in Alaska. The turnover of direct staff and inability to recruit new staff has been detrimental to the program. The turnover refers to the withdrawal of the staff from the service. With the nature of the…