This report covers the responses House Human Services received for their RFI on Charge #4, relating to the study of workforce challenges and potential solutions for home and community-based services in the STAR+PLUS program. The RFI for this charge can be found here and a complete list of responses can be found here.


The HillCo report below is a summary of information intended to give you an overview and highlight of the various topics included in the responses. This report does not cover the entirety of each response, but aims to provide an overview of the testimony submitted.


Health and Human Services Commission

  • Contextual information for the Committee to consider concerning the analysis of workforce challenges, specifically for home and community-based services in the STAR+PLUS program
  • Includes workforce data, data separated by location, wage data and past attendant retention strategy reports
  • HHSC is currently collecting and analyzing data on attendant recruitment and retention issues, including attendant wages for both provider agencies and CDS employers


Amanda Fredriksen, AARP Texas 

  • Texas nursing homes struggle to provide quality care and Medicaid resources are limited for elderly to receive at-home care or in assisted-living
  • States Texas STAR+PLUS is too dependent on Nursing Facility Care and nursing facility care is most expensive option
  • MCOs are encouraged to place STAR+PLUS members in nursing homes
  • Texas Nursing home staffing levels are among lowest in country and risks of complications increase in nursing home transitions
  • State has not invested enough in community care attendant wages and the Medicaid rate is too low to encourage assisted living providers to participate in STAR+PLUS
  • Recommendations were developed with help from Health Management Associates
  • Should establish a blended rate; the same rate is paid, regardless of where care takes place to incentivize MCOs to rebalance and expand community care
  • HHSC should set goals to shift goals and funds to community care
  • State should increase attendant hourly rate from $8.11 to $10-12 an hour over next two years
  • Examine “net income” to possibly use MCO surpluses to increase community attendant wages
  • Redirect “Rate Enhancement Attendant Compensation” dollars to across-the-board state increase for attendant care workers
  • Develop competency-based workforce development program by partnering with MCOs
  • Establish quality management program for STAR+PLUS including LTSS measures
  • Evaluate QIPP program to establish incentives for staffing quality
  • HHSC should recruit and retain more assisted-living providers in the Medicaid program
  • Consider supporting affordable housing by requiring MCOs to develop initiatives, such as requiring pre- and post-tenancy support
  • Require annual reporting on rebalancing efforts by service delivery area


Ginger Mayeaux, The Arc of Texas 

  • Texans with intellectual and developmental disabilities (IDD) are particularly reliant on long-term services and support
  • Six times more expensive for an individual to reside in an institution or State Supported Living Center than to live in the community with home and community-based services (HCBS)
  • Outlines the need for more expansive HCBS and current systemic issues like wait time for families in need
  • Instead of utilizing Rider 42 from 86th Regular Session recommendations, suggest using the Promoting Independence Workgroup and the IDD Strategic Plan in studying current interest list
  • Texas must adjust system to show needs and preferences of Texans with IDD by reducing census at SSLCs, suggests moratorium on admissions and consolidation of some centers
  • Direct support professionals need adequate wages and benefits like health insurance, PTO, continuing education, and access to career pathways
  • Should continue some flexibilities allowed during COVID-19, including:
    • Allowance of community first choice providers in HCS and TxHmL to live in the same house of individual they are supporting


Dennis Borel, Coalition of Texans with Disabilities

  • Base wage for community attendants is $8.11, no benefits or paid leave
  • Cumulative wage increases in last four sessions is $0.25 per hour
  • TWC ranks community attendants as Texas’ highest growth occupation
  • Median community attendant turnover rate across industry was 66.7% in 2017
  • Ensuring a stable workforce requires competitive wage
  • Recommends increasing the base wage to $15 an hour
  • Should build in an adjuster mechanism that will increase wages with free markets
  • Recommends promoting consumer directed services to provide cost-neutral option where Medicaid rate goes to direct care worker
  • Increase administrative rate by 50% in Home Health Agencies and Financial Management Services Agencies


Susan Murphree, Disability Rights Texas 

  • Community workforce is the most underfunded
  • Supports increasing the base wage for community attendant/direct support professional to $15/ an hour along with rate enhancements for community services
  • Current turnover puts individuals in programs at risk of harm or institutionalization
  • Suggests recreating formal Promoting Independent Advisory Committee to allocate more resources and funding to encourage community-based care rather than institutionalization
  • Texas benefits by avoiding higher costs of institutional care and including people with disabilities in community
  • Add-on rates should be available for complex disabilities to prevent institutionalization
  • Critical to continue funding assessments for and enrollments in community programs during pandemic


Girling Community Care

  • Diagrams and summarizes costs for Girling and its programs which provide community care to people across Texas
  • The last mandated increase in wages from the Legislature resulted in an additional annual unfunded increase of $600k for Girling
  • COVID-19 adds additional expenses to providers with PPE and documentation requirements, estimated at $60k per month in unreimbursed expenses
  • Increase to operational cost is desperately needed by providers
  • Rent, office supplies, HR needs, inflation, and wage pressure increase without assistance in funding
  • States that Girling has drafted several legislative priorities to help money already allocated go further; these are not included in response document


Lydia Nunez, Gulf Coast Adapt

  • Highlights the systemic issues in institutionalized care for individuals with disabilities and the inability of reforms to do enough to make significant change
  • States that profit is prioritized over all else in private institutions
  • Nursing homes requests for state-funding are usually met, but nothing changes the quality of care, deems them federal money pits
  • Need to expand HCBS and provide community care attendants livable wages and enhancements
  • Recommends increased funding and advertisement for relocation specialists to move people back into communities
  • Increase government oversight and uniform regulations for institutions
  • Ombudsmen should be required to understand disability rights, Supreme Court Olmstead decision, and ADA
  • Penalties should be imposed on staff members and facilities who attempt to impede ombudsmen access
  • Suggests a separate citizen’s commission of relevant stakeholders to monitor agencies
  • Ombudsmen program needs clarification to re-establish them as resident advocates
  • Recommends halting increases on funding to nursing home facilities and investing in incentivizing volunteer ombudsmen work
  • Calls for general increased oversight on nursing homes and their administrative and patient care practices


Alyse Meyer, Leading Age Texas

  • Adequate staffing levels are primary indicator of quality care in nursing homes; Texas has a shortage of long-term care workforce
  • Texas’ Nursing Facility Direct-Care Staff Rate Enhancement gives funding incentives for staffing wages and benefits; there are 27 levels of participation
  • The program is underfunded and many facilities that should have received this funding did not
  • The HHSC estimated to fully fund FY 2019 the state would need to add about $12 million
  • Recommends that the Legislature fund initiatives that encourage professionals to enter geriatrics and long-term care facilities
  • Offer more innovative programs, student loan forgiveness, encourage nursing programs to expose students to long-term care facilities as a part of clinicals
  • Dollars recouped from facilities in the Direct Care Staff Rate Enhancement should be reallocated to the program directly, rather than general revenue
  • Regulations and licensure requirements should be updated to meet changes in community alternatives services and demands
  • Recommends exploring regulatory reform to improve access to community-based services


Private Providers Association of Texas

  • Summarizes challenges associated with lack of competitive wages and resources in Texas Medicaid
  • Summarizes benefits of Riders 44 and 45 passed by 86th Legislature, especially benefits of increased funding for the ICF/IID and HCS programs
  • Recommends IDD provider rates be maintained at current levels
  • Recommends expanding access to mental health/behavioral intervention programs for those with IDD
  • Summarizes purpose and work of HCS program workgroup, and interruption in work due to pandemic
  • Recommends HHS committee support ongoing work of the HCS workgroup
  • Recommends proposal of a similar workgroup for the ICF/IID program, or expand HCS workgroup to include those programs


Robert Fedor, Self

  • Highlights concerns with Electronic Visit Verification (EVV) Program implemented by federal government and HHSC
  • Concerned specifically with regimented lifestyle the program creates for in-home caregivers, who in this case are family members
  • Concerned that the EVV program does not prevent fraud from in-home caregivers, and creates undue burden on family caregivers
  • Concerned that the EVV program forces families to chose between state/federal monetary assistance and living a normal life with their family member with disabilities


Rachel Hammon, Texas Association for Home Care and Hospice

  • Notes 14-year gap since previous increase in reimbursement rate for community care providers
  • Summarizes challenges faced in maintaining the workforce, especially with COVID
  • Summarizes 3 traditional methods of funding community care programs: Wage floor/minimum wage (direct care portion), Operational portion/service support (non-direct care portion), and Attendant wage enhancement program (AWEP)
  • Recommends legislature fund both wage floor and rate enhancement
  • Summarizes past challenges faced by current raise and reimbursement system
  • Summarizes increased costs associated with pandemic and other factors
  • Recommends HHSC establish a statewide Quality Incentive Payment Program (QIPP) for community care providers
  • Summarizes benefits of establishing an QIPP for care providers


Jamie Dudensing, Texas Association of Health Plans

  • Summarizes history of STAR+PLUS program and benefits compared to previous system
  • Have been positive changes to the program, including Community First Choice and Dual Eligible Demonstration
  • Recommends continuing efforts to eliminate wait lists for services and ensure individuals with disabilities achieve/maintain their independence
  • Recommends ensuring competitive wages for Medicaid program attendants
  • Recommends directing HHSC carve out NF and administration payment processes into managed care program
  • Recommends allowing FFS program in HHSC to sunset in 2021
  • Recommends HHSC adopt a more transparent payment model that uses best practices from other state Medicaid programs, rewards quality, and achieves administrative simplification for NFs, HHSC, and STAR+PLUS MCOs
  • Overviews benefits of the QIPP program
  • Recommends increasing coordination of benefits for Medicare and Medicaid dual eligible clients
  • Recommends HHSC move responsibility for payment of wrap coverage for dual clients from TMHP to MCOs


Linda Logan, Texas Council for Developmental Disabilities

  • Notes Texas’ 49 or 50th placement, out of 51, in The Case for Inclusion report since the publication began in 2007; reason being low funding levels and limited community services workforce
  • Recommends dialogue between legislature and stakeholders concerning community capacity and the cost of service provisions
  • Recommends reinstating the Promoting Independence Advisory Committee (PIAC) to facilitate dialogue and information gathering
  • Summarizes problems associated with low attendant wages; specifically addresses how entry-level positions at Buc-ee’s gas station are more lucrative
  • Recommends increasing community attendant wages and incentives
  • Recommends expanding Community First Choice waiver qualifications to TxHmL and HCS waivers, to allow any adult member of household to be designated as caregiver


Lee Johnson, Texas Council of Community Centers

  • Summarizes role of TCCC as well as responsibilities of community centers under the Texas Mental Health and Intellectual Disabilities Act
  • Summarizes benefits of increased funding from Riders 44 and 45; recommends this funding is maintained


Tammy Eades, Texas Nurses Association

  • Summaries problems faced by Long Term Care facilities regarding workforce turnover rates
  • Summarizes 2019 report by the Texas Center for Nursing Workforce Studies, especially noting 12.7% vacancy rate in LTC facilities and 48.1% turnover rate
  • Recommends pay increases for LTC nurses
  • Recommends creation of student loan repayment program for LTC nurses


Linda Litzinger. Texas Parent to Parent

  • Summarizes issues with billing going through private insurance
  • Recommends billing companies move to flat rate for services
  • Recommends schools be limited to using reimbursements through the program for special education services
  • Overviews issues with transition of HHSC to EVV (Electronic Visit Verification) policies
  • Concerns with specific time-keeping practices of EVV system; concerned with attendants being underpaid for labor
  • Raises concerns that EVV program may decrease retention rates for the workforce
  • Recommends that monitor position be implemented at HHSC to oversee EVV program to ensure high quality
  • Recommends exempting attendants who live with consumer from EVV system