Community First Choice: Allowing Older Adults to Age with Dignity and Independence

The SCAN Foundation is committed to advancing a sustainable continuum of quality care for seniors and creating a world where seniors receive the necessary combination of medical and supportive services in the right place and at the right time. For most seniors, the “right place” is what they consider to be their homes and communities. Before passage of the Patient Protection and Affordable Care Act (ACA), the limited set of federal and state options for community-based care hampered the extent to which this vision could be realized.

Specifically, the ACA expands the availability of home- and community-based services (HCBS). This is done through a number of provisions that aim to rebalance long-term services and supports (LTSS) in the United States away from institutions to home and community settings. Included among these is the Community First Choice Medicaid State Plan Option (CFC), which will provide a community-based personal care benefit to individuals who meet a nursing-home level of care need and wish to move from an institutional setting back into the community. Under this option, Medicaid will cover the costs of personal attendant services, as well as community transition supports (e.g., rent and utility deposits, first month’s rent and utilities, bedding, basic kitchen supplies). For states that adopt this provision, the federal government will increase the rate at which their state Medicaid dollars are matched by six percentage points. This option is expected to be available to states this October. In February of this year, the federal government began the rule-making process for CFC, publishing a proposed rule in the federal register and accepting public comments through April 2011.

The SCAN Foundation sees CFC as an opportunity not only to increase the ability of states to offer HCBS to individuals who need and want these services but also to move the system of LTSS toward one that is more person-centered and improves the quality of life for individuals and their family members. Work supported in part by the SCAN Foundation and in connection with a highly-regarded panel of national experts in the field has produced a vision for such a system, including an article in the foundation-sponsored Health Affairs series “The Care Span.” The first article in the series outlined the characteristics of a high-performing LTSS system and can be viewed online here. In short, this high-performing LTSS system will:

  • Take a “person-centered” approach that allows people with LTSS needs to receive services in the setting of their choice from providers they choose;
  • Provide the availability of real choices in setting and provider, regardless of source of payment or location;
  • Ensure that consumers are involved in decision-making about care arrangements;
  • Ensure self-direction as an option for consumers; and
  • Ensure the ability of clients to hire family members as caregivers, if they choose to do so.

CFC advances this vision by removing regulatory and financial barriers that impede individuals from receiving services in the setting of their choice. Specifically, CFC will facilitate the provision of quality care that is person-centered, tailored to an individual’s specific needs, and delivered by the providers that program participants choose. In its currently proposed structure, achieving these outcomes may be driven by an individualized needs assessment, briefly defined in the proposed rule, which could inform a person’s care plan. Additionally, CFC may meet these goals by requiring uniform data collection to monitor the services provided and ensure they are of high quality.

At the core of a person-centered approach to care is a comprehensive assessment of clinical, behavioral, cognitive, and functional needs to determine both eligibility for personal care services and to support the development of an individual’s care plan. In addition to health and functional condition, this needs assessment must consider an individual’s personal goals and preferences for how and by whom services are provided. Utilizing an assessment with these components will ensure that each care plan developed is tailored to a person’s unique needs, goals, and preferences.

However, a needs assessment must be uniformly designed and used across programs to ensure the greatest efficiency in the system. A “uniform assessment” is a type of needs assessment that asks a standardized set of questions of participants across programs in a consistent manner. In implementing a uniform assessment, the state creates a level playing field in which resources are allocated in a person-centered fashion based on need rather than the skill or biases of the assessor or other external factors. This can lead to better quality of care and satisfaction for individuals as well as creating efficiencies in the system, which can reduce inappropriate service utilization. A more efficient system should certainly be attractive to states in this time of limited resources.

The CFC rule also envisions quality assurance for services delivered. It is critical that the structure and implementation of the program be measured and monitored to ensure both that the program is successful and that the needs of some of society’s most vulnerable adults are properly met. Constructing a uniform assessment that not only supports care planning but also has the capacity to inform quality assurance monitoring and measurement with an outcomes focus can help states meet these goals. Doing so will increase the likelihood of achieving a high-performing LTSS system that enables Americans to age with dignity, independence, and in the environment of their choice.

Lisa Shugarman, Ph.D., is director of policy at The SCAN Foundation, dedicated to creating a society in which seniors receive medical treatment and human services that are integrated in the setting most appropriate to their needs. For more information, please visit


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