Long-term services and supports assessments do not adequately address functional limitations associated with serious mental illness

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Abstract
Medicaid funded long-term services and supports (LTSS) can provide crucial wraparound supports to adults with serious mental illness (SMI) that have been shown to improve overall health, enhance quality of life, and promote longer tenure in home-and-community settings. In the United States, access to LTSS is determined by level-of-care (LOC) assessments, which are typically homegrown instruments that vary by state. Currently, it is unclear whether LOC assessments address functional limitations commonly experienced by adults with SMI. To examine this, we first identified publicly available LOC assessments nationwide with clearly defined scoring strategies. Second, we utilized the Health of the Nation Outcomes Scale (HoNOS), an evidence-based, functional assessment for adults with SMI, to comparatively analyze the extent to which state LOC assessments addressed functional limitations associated with SMI. Assessments from five states met our criteria: Hawai’i, Arizona, Mississippi, Missouri and Tennessee. Problems with activities of daily living (ADLs) were the primary driver of LTSS LOC scores and were substantially overrepresented compared to the HoNOS. Furthermore, eight of the 12 HoNOS functional limitation domains were either drastically underrepresented or not represented in any state assessment. This analysis suggests that LTSS LOC assessments do not adequately account for the full range of functional limitations commonly associated with SMI and may be systematically excluding high-need Medicaid recipients with SMI who do not have ADL challenges. To ensure parity for Medicaid recipients with SMI, we recommend state Medicaid programs consider implementing a uniform, evidence-based LOC assessment to determine LTSS eligibility for people with a primarily diagnosis of mental illness. The online version contains supplementary material available at 10.1186/s12913-026-14112-1.
Funding Information
  • National Institute of Mental Health, United States (1K01MH136343)

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