Mental and Behavioral Health, and Crisis Services for People with Intellectual and Developmental Disabilities in Medicaid Home- and Community-Based Services.

People with intellectual and developmental disabilities (IDD) often have higher rates of comorbid mental health conditions compared to the general population. Yet, many people with IDD also have unmet needs for mental and behavioral health services. The aim of this study was to examine how states provided mental and behavior health, and crisis services to people with IDD in their Home- and Community-Based Services (HCBS) programs, the largest funding mechanism for Long-Term Services and Supports (LTSS) for people with IDD in the United States. We analyzed fiscal year (2021) Medicaid HCBS waivers for people with IDD from across the United States to examine if and how they provided mental and behavior health, and crisis services. States projected spending $968.9 million for mental and behavior health, and crisis services for 190,299 people with IDD. Applied behavior analysis services were provided at greater rates than positive behavior supports and other forms of behavior interventions. While most states provided mental and behavior health, and crisis services in their waivers, there were vast inconsistencies in how they did so, across states, waivers, and services. HCBS are a crucial safety net to ensure people with IDD, especially those who also have mental health disabilities, can live and thrive in their communities.

Environmental Modifications for People With Intellectual and Developmental Disabilities: A Policy Analysis of Medicaid Home- and Community-Based Services.

IMPORTANCE: Environmental modifications are targets for occupational therapy intervention because they support activities of daily living, self-efficacy, personal control, independence, and community living for people with intellectual and developmental disabilities (IDDs). OBJECTIVE: To examine how environmental modifications were provided to people with IDDs through Medicaid home- and community-based services (HCBS) waivers across the United States in fiscal year (FY) 2021. DESIGN: Using a mixed-methods policy analysis, we examined FY 2021 Medicaid HCBS 1915(c) waivers from across the United States to examine whether, and how, states provided environmental modifications to people with IDDs. RESULTS: In FY 2021, 35 states projected spending $68.8 million on environmental modifications for 12,671 people with IDDs. The purpose of environmental modifications was most often to promote the health, welfare, and safety of people with IDDs (82.68%), and to promote their independence (69.29%). The most common examples of environmental modifications included ramps and/or lifts (70.08%), widening doorways and/or hallways (61.42%), bathroom modifications (58.27%), specialized electrical and/or plumbing for medical equipment (54.33%), and grab bars and/or handrails (53.54%). CONCLUSIONS AND RELEVANCE: HCBS waiver data on environmental modifications for people with IDDs enhances an understanding of this funding source and provides a foundation of advocacy for occupational therapy practitioners to support people with IDDs with living, as well as aging, in the community rather than in institutions. An expansion of environmental modifications in HCBS for people with IDDs aligns with the aim of Medicaid HCBS waivers to promote community integration, self-determination, and independence, which are all benefits of environmental modifications. Plain-Language Summary: This study can help occupational therapy practitioners determine what funding sources are available in their state to help their clients with intellectual and developmental disabilities access environmental modifications. The findings can also help guide advocacy and lobbying efforts to expand access to environmental modifications.

'Not seeing people as capable': Disability professionals' mis/understandings of ableism.

BACKGROUND: Knowledge about how disability professionals understand ableism may provide insight into the production of inequalities. The aim of this study was to examine how disability professionals understand ableism. METHODS: We asked 347 disability professionals, all of whom worked with people with intellectual and developmental disabilities, among other populations, to define ableism and then analysed those definitions using content analysis. RESULTS: The themes about how participants understood ableism were: discrimination; differential treatment; individualization; norms and othering; ableist language; microaggressions; and systems and environments. It was also not uncommon for participants to say ableist things, and express misconceptions in their definitions. This included these themes: avoiding disability; using ableist language; framing disability as in/ability; centring people without disabilities; ignoring invisible disabilities; believing only people without disabilities have bias; and believing ableism does not exist. CONCLUSIONS: Knowing disability professionals' understandings of ableism is necessary to intervene biased attitudes and reduce ableism.

People with Disabilities' Access to Medical Care During the COVID-19 Pandemic.

Delaying and forgoing medical care intensifies the health disparities and unmet needs people with disabilities already face. While many people with disabilities were at high risk for COVID-19, less is known about their access to medical care during the pandemic. This study explored people with disabilities' access to medical care during the COVID-19 pandemic. We analyzed United States Census Bureau COVID-19 Household Pulse Survey data from the second year of the pandemic (April-July 2021) from people with (n = 38,512) and without (n = 296,260) disabilities. During the second year of the pandemic, 30.8% of people with disabilities delayed getting medical care and 28.9% forwent needed care. People with disabilities were also significantly more likely to delay and forgo medical care than people without disabilities. Attention must be drawn to the unmet needs of people with disabilities and efforts must be made to expand their access to health care.

Assistive technology for people with intellectual and developmental disabilities in the United States in Home- and Community-Based Services.

PURPOSE: Unmet needs for assistive technology (AT) contribute to health and quality of life disparities among people with intellectual and developmental disabilities (IDD) [1-4]. The biggest barrier people with IDD face accessing technology is affordability and a lack of funding [1,3-6]. The purpose of this study was to examine how AT were provided to people with IDD in Medicaid Home- and Community-Based Services (HCBS) in the United States, the largest funding source for Long-Term Services and Supports for people with IDD. MATERIALS AND METHODS: We analysed Medicaid HCBS 1915(c) waivers for people with IDD from across the USA in fiscal year (FY) 2021 using content analysis and descriptive statistics. RESULTS AND CONCLUSIONS: In FY2021, 31 states and the District of Columbia provided AT (stand-alone and combined services) through 68 waivers for people with IDD to improve functioning, communication, independence, and community integration. In total, $63.3 million was projected for the AT services for 23,753 people with IDD. Average spending per person on AT services was $2,663. We found significant variability in terms of how states allocated AT to people with IDD in their HCBS programs. Not only were less than 3% of people with IDD with HCBS projected to receive assistive technology services, there was also large variance across services and states. Assistive technology promotes the health, safety, quality of life, independence, and community integration of people with IDD - they align with the very aims of HCBS, and thus, should be expanded.

Only a small proportion of people with intellectual and developmental disabilities (IDD) were projected to receive assistive technology (AT) in Home- and Community-Based Services (HCBS), which may result in unmet needs among people with IDD.Wide variability in how states allocate AT in their HCBS waiver programs can lead to discrepancies and disparities.

Medicaid Home- and Community-Based Services Waivers for People With Intellectual and Developmental Disabilities.

Medicaid Home- and Community-Based Services (HCBS) 1915(c) waivers are the most prominent funding mechanism for the long-term services and supports (LTSS) of people with intellectual and developmental disabilities (IDD). This study's aim was to conduct an in-depth national analysis of fiscal year (FY) 2021 HCBS 1915(c) waivers for people with IDD. In FY 2021, over $43.2 billion was projected for the HCBS of 861,038 people with IDD. An average of $47,315 was projected per person with IDD annually. The services that received the most funding were: residential habilitation; supports to live in one's own home; and day habilitation. HCBS is necessary so people with IDD can live and thrive in their communities.

Technology first: The impact on technology availability for people with intellectual and developmental disabilities.

BACKGROUND: In the United States, 16 states have adopted Technology First initiatives to improve people with intellectual and developmental disabilities' access to technology. METHOD: Our aim was to examine if Technology First initiatives impact the allocation of technology in Home and Community-Based Services (HCBS) for people with intellectual and developmental disabilities. To do so, we analysed HCBS programs from across the United States in fiscal year 2021. RESULTS: Technology First states were more likely to offer telehealth service delivery in their HCBS programs. However, we found few other significant differences in allocation of technology - the number of people receiving and projected spending - based on states' Technology First status. CONCLUSIONS: While these findings do not mean that there is no value in Technology First initiatives, it appears these initiatives have yet to truly impact resource allocation when it comes to HCBS.

Explicit and implicit: Ableism of disability professionals.

BACKGROUND: People who work with disabled people or whose work is about disability - disability professionals - often have direct power over disabled people and can impact their lives immensely; they also have a role in creating and institutionalizing knowledge about disability. OBJECTIVE: The aim of this study was to examine the explicit (conscious) and implicit (unconscious) disability attitudes of disability professionals. METHODS: Between October 2021 and February 2023, disability professionals (n = 417) completed the Symbolic Ableism Scale (SAS) and the Disability Attitudes Implicit Association Test (DA-IAT). We had the following research questions: (1.) What are disability professionals' explicit attitudes towards disability? (2.) What are disability professionals' implicit attitudes towards disability? (3.) What is the relationship between disability professionals' explicit and implicit disability attitudes? and (4.) What sociodemographic factors correlate with disability professionals' explicit and implicit disability attitudes? We examined these questions using descriptive statistics, t-tests, a two-dimensional model of prejudice, and linear regression models. RESULTS: In our sample, 77.24% of disability professionals preferred nondisabled people explicitly and 82.03% implicitly. Most commonly, disability professionals were symbolic ableists (37.8%). Race, political orientation, and job type correlated with disability professionals' explicit attitudes, while disability, gender, and job type correlated with their implicit attitudes. CONCLUSIONS: Ableism cannot be eradicated until disability professionals look inward and rid themselves of negative attitudes; until that occurs, disability professionals will continue to do a disservice to the very people they have dedicated their careers to - disabled people.

The Relationship Between Choice and Injuries of People With Intellectual and Developmental Disabilities.

People with IDD are often denied choices based on concerns for their safety, including to prevent and reduce injuries. This study examined the relationship between the service-related choices of people with IDD and their injuries. In this cross-sectional analysis, we analyzed secondary Personal Outcome Measures® interview data and injury data from 251 people with IDD. Our findings revealed, controlling for all demographics, for every one-unit increase in service-related choice outcomes present, there was a 35% decrease in injuries. Expanding people with IDD's choice-making opportunities may result in fewer injuries. We must move beyond custodial models of care and ensure people with IDD are supported to live the lives of their choosing.

Ableism, racism, and the quality of life of Black, Indigenous, people of colour with intellectual and developmental disabilities.

BACKGROUND: Research indicates Black, Indigenous, people of colour (BIPOC) with intellectual and developmental disabilities face disparities in quality of life outcomes. This study's aim was to examine how ableism and racism impacted the quality of life of BIPOC with intellectual and developmental disabilities. METHODS: Using a multilevel linear regression, we analysed secondary quality of life outcome data from Personal Outcome Measures® interviews with 1393 BIPOC with intellectual and developmental disabilities and implicit ableism and racism data from the 128 regions of the United States in which they lived (discrimination data came from 7.4 million people). RESULTS: When BIPOC with intellectual and developmental disabilities lived in regions of the United States which were more ableist and racist, they had a lower quality of life, regardless of their demographics. CONCLUSION: Ableism and racism are a direct threat to BIPOC with intellectual and developmental disabilities' health, wellbeing, and overall quality of life.

Early Career Occupational Therapists' Experiences during the COVID-19 Pandemic.

Occupational therapists entering the clinical workforce during the COVID-19 pandemic experienced levels of uncertainty and stress. This study's aim was to explore the clinical experiences and concerns of early-career occupational therapists entering the workforce during the COVID-19 pandemic (n = 27). We administered an open-ended online survey and analyzed the data using inductive thematic analysis. Resulting themes included: safety, exposure, and transmission; implementation and enforcement of safety protocols; quality of care; and impact of the pandemic on overall health highlighting the issues that need to be addressed to be more prepared for future practice in an evolving environment.

Moving home: Community transition supports for people with intellectual and developmental disabilities.

BACKGROUND: In recognition of the important role housing plays in people's health and quality of life, Medicaid Home- and Community-Based Services (HCBS) programs are more frequently working to promote the housing security of Medicaid beneficiaries. One mechanism states use to promote housing security of people with intellectual and developmental disabilities (IDD) is to offer community transition services in their HCBS programs. Community transition services help with transition by assisting with securing housing and leases, obtaining basic furnishings, paying for utility setup, funding moving expenses, and making accessibility adaptations. OBJECTIVE: The aim of this study was to examine if and how states provided community transition services in their HCBS waiver programs for people with IDD. METHODS: We analyzed 107 fiscal year (FY) 2021 HCBS 1915(c) waivers for people with IDD from across the United States. We analyzed the service expenditures and utilization data for community transition services, including projected spending, projected number of users served, reimbursement rates, projected spending per participant, and annual service provision per participant. RESULTS: In FY2021, 49 waivers (45.8%) from 28 states provided community transition services to people with IDD. A total of $7.21 million of spending was projected for community transition services for 2405 people with IDD, with an average spending per person of $2303. CONCLUSIONS: While community transition services can help promote the housing insecurity of people with IDD, there was wide variance in how these services were allocated to people with IDD in FY2021.

Housing insecurity of medicaid beneficiaries with cognitive disabilities during the COVID-19 pandemic.

BACKGROUND: While people with cognitive disabilities are more vulnerable to COVID-19, and the COVID-19 pandemic significantly increased housing insecurity in the general population, less is known about Medicaid beneficiaries with cognitive disabilities' housing insecurity during the pandemic. OBJECTIVE: This study's aim was to explore housing insecurity of Medicaid beneficiaries with cognitive disabilities during the pandemic (April 2021-May 2022). METHODS: We analyzed Household Pulse Survey data from 473,626 (unweighted) people; frequency-person weights were applied. Data were analyzed using descriptive statistics, chi-square, and binary and ordinal logistic regression models. RESULTS: Findings revealed 26% of Medicaid beneficiaries with cognitive disabilities who rented or owned with a mortgage were behind on their housing payments between April 2021 and May 2022; more than half of which (52%) were very or somewhat likely to face eviction/foreclosure. Most (70%) were concerned about their ability to make their next housing payment. Medicaid beneficiaries with cognitive disabilities were more likely to experience housing insecurity than all other people with disabilities and nondisabled people. The people with Medicaid beneficiaries with cognitive disabilities more likely to experience housing insecurity included: renters; people with visual disabilities; cisgender women; transgender people; Black people; 'another' race or multiracial people; people with graduate degrees; people from lower income households; households that experienced income loss; and larger households. CONCLUSIONS: Attention to Medicaid beneficiaries with cognitive disabilities' experiences with housing insecurity during the pandemic is critical in order to develop programs and policies to facilitate housing security.

The Impact of Emergency Pandemic HCBS Funding on the Continuity and Security of People with Intellectual and Developmental Disabilities.

This study's aim was to examine the impact of pandemic emergency Home- and Community-Based Services (HCBS) payments on the continuity and security of people with intellectual and developmental disabilities (IDD). Using a multilevel logistic regression, we analyzed secondary Personal Outcome Measures interviews from 738 people with IDD (March 2020 through April 2022), and state pandemic emergency HCBS payment data from 16 states. The odds of people with IDD experiencing continuity and security during the pandemic increased by 3% for every 1% states increased their payment rates, and by 398% when states offered retainer payments. Increased reimbursement rates and retainer payments can help providers maintain operations and promote the continuity and security of people with IDD.

Financial hardship experienced by people with disabilities during the COVID-19 pandemic.

BACKGROUND: People with disabilities are poorer and more financially insecure than nondisabled people. While people with disabilities were adversely affected by the pandemic and were more likely to experience poverty prior to the pandemic, less is known about their experiences with financial hardship during the pandemic. OBJECTIVE: The aim of this study was to explore the financial hardship of people with disabilities during the COVID-19 pandemic, including differences with nondisabled people and those based on people with disabilities' sociodemographics. METHODS: We analyzed Household Pulse Survey data from 52,890 adults (18+) with disabilities and 391,532 nondisabled adults using complex samples descriptive statistics and binary logistic regressions. RESULTS: During the Delta and first Omicron waves of the COVID-19 pandemic, 52.0% of people with disabilities had difficulty paying usual household expenses. People with disabilities were 2.78 times more likely to experience financial hardship during the pandemic than nondisabled people. People with disabilities' most common sources of income/funds for spending needs included: regular income sources (66.7%); credit cards or loans (36.6%); money from savings or selling assets or possessions (31.5%); and borrowing from friends or family (22.0%). CONCLUSIONS: A significant proportion of adults with disabilities experienced financial hardship during the COVID-19 pandemic, including at greater rates than nondisabled adults. Financial hardship can have long lasting impacts upon people with disabilities, including on their physical and mental health, well-being, and overall quality of life.

Telehealth Service Delivery in Medicaid Home- and Community-Based Services for People with Intellectual and Developmental Disabilities.

Medicaid Home- and Community-Based Services (HCBS) 1915(c) waivers are the largest funding mechanism for Long-Term Supports and Services (LTSS) for people with intellectual and developmental disabilities (IDD) in the United States. This study's aim was to examine telehealth service provision in Medicaid HCBS waivers for people with IDD. We analyzed fiscal year 2021 Medicaid HCBS waivers for people with IDD and emergency Appendix K authorizations (2020-2022) to examine permanent and temporary use of telehealth, respectively. The overwhelming majority of waivers (98.1%) temporarily permitted the use of telehealth service delivery for people with IDD. However, only a fraction (27.6%) permanently included the use of telehealth for people with IDD. The most prevalent types of services that permitted telehealth service delivery were: employment, day, and prevocational services; clinical and therapeutic services; and in-home and residential supports. When developing and implementing telehealth, it is important to consider the needs of people with IDD.

The Impact of Continuity and Security on Quality of Life.

Continuity and security includes people with intellectual and developmental disabilities (IDD) not only having resources to meet their basic needs, but also includes the amount of change and disruption people have in their lives and the control they have over that change. We explored the impact of continuity and security on people with IDD's (n = 325) quality of life by analyzing Personal Outcome Measures interviews. Continuity and security not only significantly increased overall quality of life, but it also positively impacted two thirds of the different outcomes, ranging from health to relationships to rights. A stronger community infrastructure is needed to promote the continuity and security, and, by extension, quality of life of people with IDD.

Anti-Fat Biases of Occupational and Physical Therapy Assistants.

Fat people are highly stigmatized, and anti-fat bias is pervasive resulting in stigma, prejudice, and discrimination, including in health care. The aim of this study was to explore occupational and physical therapy assistants' anti-fat biases. We analyzed secondary weight implicit association tests from 5,671 occupational/physical therapy assistants. The overwhelming majority (82%) of occupational/physical therapy assistants were implicitly prejudiced against fat people. Interventions for occupational/physical therapy assistants' anti-fat biases are critical, especially with increasing prevalence and responsibilities of occupational/physical therapy assistants in the provision of rehabilitation services.

Explicit and implicit disability attitudes of occupational and physical therapy assistants.

BACKGROUND: Reduction of explicit and implicit bias in healthcare providers is a critical issue faced by our society in moving toward more equitable and culturally appropriate health and rehabilitation care. Because resources for OT and PT services are limited and shortages in these professions exist, direct care provision by occupational and physical therapist assistants (OTA/PTA) is on the rise and valued in comprehensive rehabilitation practice. It is important to consider attitudes and biases of OTA/PTA, as they are directly involved in provision of rehabilitation services for people with disabilities. OBJECTIVE: This study examined the explicit and implicit disability attitudes of a large cross-section of OTA/PTA. METHODS: Secondary data analysis was completed using data from 6113 OTA/PTA from the Project Implicit Disability Attitudes Implicit Association Test. Implicit attitudes were calculated and OTA/PTA explicit and implicit disability attitudes were compared. Results were further categorized using an adapted version of Son Hing et al.'s two-dimensional model of prejudice. RESULTS: Findings revealed the majority of OTA/PTA reported having no explicit preference for people with disabilities or nondisabled people. However, the majority of OTA/PTA were aversive ableists, indicating low explicit and high implicit bias. CONCLUSIONS: Though explicit bias is lower in OTA/PTA, implicit bias is strong, indicating that people with disabilities face bias that may influence clinical interactions, and may be reproduced in professional education, practice, and policy. Concrete action must be taken to recognize and address disability bias to reduce health disparities in people with disabilities.

The mental health of Medicare beneficiaries with disabilities during the COVID-19 pandemic.

PURPOSE: During the coronavirus disease 2019 (COVID-19) pandemic, there was a tremendous increase in adverse mental and behavioral health symptoms. People with disabilities who are Medicare beneficiaries (under 65) are a vulnerable population, frequently having multiple chronic conditions, and facing a number of social disadvantages, even before the pandemic. As a result of the lack of attention drawn to the pandemic needs and experiences of people with disabilities, as well as the increased needs of Medicare beneficiaries with disabilities, the aim of this study is to examine the mental health of Medicare beneficiaries with disabilities during the COVID-19 pandemic. METHOD: To do so, we conducted a secondary analysis of United States Census Bureau COVID-19 Household Pulse Survey data from 65,639 (unweighted) people with disabilities who were Medicare beneficiaries. Generalized anxiety disorder and major depressive disorder were measured using the Generalized Anxiety Disorder Scale (GAD-2) and Patient Health Questionnaire (PHQ-2), respectively. RESULTS: Our findings (weighted) revealed, during the pandemic, 43.3% of Medicare beneficiaries with disabilities had symptoms of generalized anxiety disorder, and 36.8% had symptoms of major depressive disorder. In addition, 15.3% said they needed counseling/therapy from a mental health professional but did not get it. CONCLUSIONS: Many Medicare beneficiaries with disabilities reported symptoms of generalized anxiety disorder and major depressive disorder during the pandemic, and a lack of access to needed mental health services. As the pandemic continues, and in wake of recovery from the pandemic, it is important to pay attention to, and target the, mental health disparities unearthed in this study. (PsycInfo Database Record (c) 2022 APA, all rights reserved).