Home and community-based services (HCBS) enable older and disabled adults to age-in-place in their homes and communities by helping them function independently for as long as possible (Grabowski et al., 2010; Wong & Silverstein, 2011). Previous studies well document that older adults prefer receiving HCBS rather than institutional care at a nursing home (e.g., Walker, 2010; Fox-Grage, Coleman, & Freiman, 2006). Medicaid is a major source of funding for long-term care. Currently, a large proportion of Medicaid funds in most states has been spent on institutional care (National Conference of State Legislatures & AARP, 2009), and older adults and their families have relied on nursing homes to be the provider of long-term care (Miller, Allen, & Mor, 2009). The purpose of this research is to provide additional insights to policy decision makers on the need to rebalance long-term care spending in Massachusetts by further exploring the reasons elder clients are terminated from home- and community-based care.

Care managers are key personnel in providing HCBS to elder clients and have unique insights regarding HCBS. This study builds on qualitative research conducted by Wong and Silverstein (2011) by further exploring the themes that emerged from the previous study related to termination triggers, gaps in HCBS, and the identification and roles of key decision makers in the termination process. In addition, this study examined risk scenarios that may trigger discharge from home- and community-based care programs into institutional settings.