Controls on growth, therefore, have at times limited access to services, resulting in waiting lists for programs. In terms of controlling institutional costs, states have used the certificate of need process and other mechanisms to limit new nursing facility beds and have eliminated beds, undertaken preadmission screening of nursing facility applicants, and constrained the annual increases in reimbursement rates. States use fee or payment rate schedules to control payments to service providers and also impose per-beneficiary limits on hours of service provision or dollar benefits in the different programs. Use of case management to serve as a gatekeeper in evaluating needs, determining financial eligibility, developing and monitoring care plans, and authorizing services. Unique mechanisms by state.
Some efforts are unique to the three states.
One example is Oregon s Nurse Delegation Act that permits nurses who are under contract with the state to train and monitor unlicensed health caregivers to provide specific medical services such as administering certain medications. Oregon officials believe that this makes the delivery of home and community-based care less costly. One impact of the shift to home and community-based care is that the three states have been able to provide services to a larger proportion of individuals with the funds available. This is due to the fact that provision of home and community-based care is generally less expensive per person than institutional care.