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Home and Community-Based Services: Creating Systems for Success at Home, at Work and in the Community

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February 24, 2015

Full Report (PDF)

Full Report (DOC)

Appendix A - Supported Housing for People with Psychiatric Disabilities

Appendix B - Medicaid Funding Authorities: States and Institutional Care

Press Release (HTML)


The Supreme Court’s decision in Olmstead v. L.C. (1999) signaled a paradigm shift in the way services and supports are provided to people with disabilities, requiring national policy to shift in favor of integrated services that enabled individuals to live in community settings rather than being isolated and warehoused in large institutions. Since the Court’s pronouncement of a clear integration mandate more than 15 years ago, numerous state and federal court rulings, executive orders, regulations and state statutes have established that the opportunity to choose to receive support in order to have a home, family, friends, a job and a regular life in the community is no longer a privilege – but a right.

In this report, NCD reviews the research on outcomes since Olmstead, and finds that strong trends indicate that smaller, more dispersed and individualized community settings further integration and positive outcomes for individuals with disabilities. Specifically, greater individual choice, satisfaction, housing stability, and higher levels of adaptive behavior and community participation are associated with living in residential settings of smaller size. This research tends to support the U.S. Department of Health and Human Services Centers for Medicare and Medicaid Services (HHS/CMS) decision to promulgate final regulations impacting all Medicaid Home and Community Based Services authorities which establish that only settings of limited size and with certain characteristics will be entitled to receive Federal Financial Participation under the various Medicaid HCBS authorities. However, this national policy shift in favor of integrated supports and services presents a number of challenges to the state agencies and providers that have been furnishing supports prior to the implementation of these regulations. The research compiled in this report can help guide state policy makers, service providers, people with disabilities and their advocates in a collaborative effort to align support systems with the Olmstead decision and the requirements of the HCBS regulations.