The study, led by researchers Xiaowei Ying and Mingshen Lin, utilized data from the China Health and Retirement Longitudinal Study (CHARLS). This longitudinal cohort study incorporated data from 2018 and 2020 to track changes in health and functional status over time. The analysis included 1,227 adults aged 60 years and older who had been diagnosed with diabetes. By examining these two specific time points, the researchers were able to assess the directionality of functional changes, distinguishing between those who developed new limitations and those who experienced improvements in their ability to perform daily tasks.

In this context, dual functional limitation is a critical metric for assessing severe disability. It is defined as the simultaneous presence of limitations in activities of daily living (ADL) and instrumental activities of daily living (IADL). ADLs refer to basic self-care tasks such as bathing, dressing, and eating, while IADLs involve more complex activities necessary for independent living, such as managing finances, preparing meals, and using transportation. The presence of limitations in both domains indicates a significant burden of disability that often requires substantial external support to maintain a basic standard of living.

Home- and community-based services (HCBS) represent a broad category of support designed to help individuals remain in their own homes and communities rather than in institutional settings. These services can include personal care assistance, homemaker services, and various forms of community-based support. In the study, HCBS use was assessed in 2018, serving as the exposure variable for the analysis. The researchers aimed to determine if receiving these services was associated with a lower risk of developing dual functional limitation or a higher probability of recovering from it by the 2020 follow-up.

Among the 1,227 participants in the cohort, 288 individuals, representing 23.5% of the sample, reported using HCBS during the baseline period. The researchers employed modified Poisson regression with robust sandwich variance to estimate risk ratios (RRs) for the transitions in functional status. This statistical approach is suitable for estimating risk ratios in cohort studies and provides a clear measure of the relative likelihood of transitioning between different functional states, adjusted for potential confounding factors.

The findings revealed a distinct pattern regarding the association between HCBS use and functional transitions. Specifically, the use of HCBS was not significantly associated with a transition into dual functional limitation. The estimated risk ratio for developing dual limitations was 1.01, with a 95% confidence interval ranging from 0.72 to 1.41. This result suggests that, based on this data, receiving home- and community-based services did not significantly increase or decrease the likelihood of an older adult with diabetes moving from a state of no dual limitation to one of dual limitation over the study period.

In contrast, the analysis indicated a significant association between HCBS use and the transition out of dual functional limitation. Participants who used HCBS had a higher probability of improving their functional status, with a risk ratio of 1.45 and a 95% confidence interval of 1.05 to 1.99. This finding implies that access to these services may be linked to a greater likelihood of recovering from severe dual-domain disability, although the study design limits the ability to establish a direct causal mechanism for this improvement.

A more detailed examination of the nature of this improvement provided further nuance to the results. The association between HCBS use and functional improvement was primarily observed in transitions to single-domain limitation. The risk ratio for moving from dual limitation to a state where only one domain (either ADL or IADL) was limited was 1.84, with a 95% confidence interval of 1.16 to 2.93. However, the association was not significant for the transition to complete functional independence, where no ADL or IADL limitations were present. The risk ratio for this complete restoration was 1.01, with a 95% confidence interval of 0.52 to 1.97, indicating that HCBS use was not significantly associated with a full return to independence in this cohort.

The authors conclude that among older adults with diabetes, the use of home- and community-based services is associated with a transition out of dual functional limitation, but not with a transition into it. The observed benefit appears to reflect a partial improvement in functional status, specifically a reduction from dual-domain to single-domain limitation, rather than a complete restoration of functional independence. These findings highlight the potential role of HCBS in mitigating the severity of functional decline in this vulnerable population, although the association does not imply that services prevent the initial onset of dual limitations.

This study contributes to the growing body of evidence regarding the management of functional health in older adults with chronic conditions like diabetes. By distinguishing between different directions of functional transition, the research offers insights into how community-based supports might influence the trajectory of disability. The results suggest that while HCBS may not prevent the onset of severe dual-domain limitations, they may be associated with a higher likelihood of partial recovery, potentially helping individuals maintain a degree of independence and reducing the burden of care. Further research is needed to understand the specific mechanisms through which these services influence functional outcomes and to determine if these associations hold true in other populations and healthcare settings.

Subject of Research: Geriatrics

Article Title: Home- and community-based services and transitions into and out of dual functional limitation in older adults with diabetes: a longitudinal analysis

Article References: Ying, X., & Lin, M. (2026). Home- and community-based services and transitions into and out of dual functional limitation in older adults with diabetes: a longitudinal analysis. BMC Geriatrics. https://doi.org/10.1186/s12877-026-08434-2

Image Credits: AI Generated

DOI: 10.1186/s12877-026-08434-2

Keywords: Diabetes, Functional Limitation, Home- and Community-Based Services, Older Adults, Longitudinal Study, CHARLS, BMC Geriatrics, Home-, community-based, services, transitions, dual

The research, published in Community Mental Health Journal by Genevieve Graaf of The University of Texas at Arlington and colleagues, examined Medicaid’s 1915(c) Home and Community-Based Services waivers, the funding mechanism that allows states to pay for community-based psychiatric care as an alternative to institutional placement. Eleven states currently operate such waivers for youth with serious emotional disturbance, a federal designation covering the roughly five to six percent of children whose psychiatric conditions substantially impair daily functioning. These children often experience acute symptoms, including agitation expressed through hostile, destructive, or self-harming behavior such as head banging or elopement. Because the programs serve youth at elevated risk of restraint and seclusion, and because many of these youth carry trauma histories that make restrictive interventions especially dangerous, the question of what states permit, and what protections they demand, carries real clinical weight.

To quantify policy, the team collected 138 waiver applications from nineteen state programs approved between 2006 and 2022, obtained through the federal CMS database and, for older documents, through Freedom of Information requests. Each application includes a dedicated section on participant safeguards concerning restraint and restrictive interventions. Using directed content analysis with line-by-line coding, the researchers catalogued every type of intervention a state authorized and every safeguard it required, such as monitoring, incident reporting, staff training, and procedures for detecting unauthorized use. From these counts they built a novel metric, the Restrictiveness and Safety Index, which subtracts the number of authorized intervention types from the number of safeguards. A higher score means a state demands more protections relative to the coercive practices it permits; a negative score means the opposite.

The headline finding is a slow but broad national shift toward safety. Across the nineteen programs, the mean index score was 3.94, and the score rose in seventeen of the nineteen states over the study period, declining in only two. The national average for community-based waivers climbed from 2.18 in 2009 to 5.02 for waiver periods approved through 2027, a change the authors attribute to states adding safeguards, reducing the number of authorized intervention types, or both. The spread across states was striking: West Virginia topped the table with a score of 12.00, while Wisconsin began the study at negative 4.50, and Ohio ended it at negative 3.00. In other words, a child’s legal protection from restraint in a community program depends heavily on which side of a state line they live on.

The study also compared these community waivers with a separate, temporary class of programs. From 2007 to 2012, Congress authorized a demonstration project allowing states to use waiver authority specifically to divert youth from Psychiatric Residential Treatment Facilities, the locked institutions that remain the primary Medicaid-financed out-of-home setting for children with serious emotional disturbance. Nine states participated. The researchers analyzed these demonstration waivers separately and found their average index score was lower, at 2.62 compared with 3.94, though it rose from 1.63 in 2007 to 3.42 by 2017. The gap may reflect the fact that youth eligible for residential placement are judged more likely to require restrictive interventions, or simply that the demonstrations ended in 2017 and missed the later national upward trend. Either way, community programs consistently specified more safeguards per authorized intervention category than the institutional-diversion programs did.

Individual state trajectories reveal how policy evolves in practice. Louisiana’s score jumped from zero in 2015 to 4.33 the following year. Maryland’s demonstration program began at negative 3.00, the lowest of any PRTF waiver, and ended at 1.00. Kansas and South Carolina led the demonstrations throughout, finishing at 6.50. Texas and Michigan moved in the opposite direction, with Texas falling from 3.50 to 0.33 and Michigan from 3.00 to 1.17. Most intriguingly, when New York and Wisconsin each consolidated their mental-health-specific waivers into broader programs serving all children with complex healthcare needs, their scores rose sharply. New York’s index leapt to 11.00 after consolidation, and Wisconsin’s climbed from negative 1.00 to 4.33 by 2026. The authors speculate that adding physically or cognitively fragile children to the rolls may push administrators to tighten restrictions on coercive practices.

Perhaps the most sobering result concerns the federal Home and Community-Based Services Settings Rule, introduced in 2014, one of the largest regulatory changes in the program’s history. The rule requires that settings receiving waiver funding ensure participants’ freedom from coercion and restraint. Yet the data show no visible shift in state policies after the rule’s introduction or around its final compliance deadline in 2023. The rule does not outright prohibit restraint and seclusion, and the authors cite prior interviews with state officials suggesting the final version was perceived as having been watered down and lacking enforcement teeth. For a rule premised on protecting people’s most basic rights in publicly funded care, its apparent failure to move the policy needle in children’s mental health waivers is a finding that regulators will likely have to reckon with.

The technical achievement of the study lies in making an opaque policy landscape measurable. Waiver applications are dense administrative documents, and the researchers had to handle a structural change in 2014, when seclusion authorizations began being reported in a separate section from restraint, adjusting their scoring formula accordingly. They converted policy changes into quarterly observations aligned with effective dates, allowing year-by-year comparison within and across states. About twenty percent of possible amendment documents were missing, a gap the team mitigated by carrying forward prior values, and the authors acknowledge that states with very different policy provisions can produce identical scores, a limitation inherent to any composite policy index.

Crucially, the researchers are careful about what their numbers do and do not prove. The index measures written policy, not practice. Whether the safeguards states enumerate are actually enforced by provider organizations, whether they reduce the use of restraint in homes, schools, and parks, and whether they improve outcomes for children and staff remain open questions. The authors call for linking the index to administrative and clinical data to validate it, and for qualitative research into why state administrators change these policies. They also note that proven restraint-reduction strategies from inpatient psychiatry, including structured de-escalation training and trauma-informed care frameworks such as the Six Core Strategies, have never been rigorously tested in the less controlled environments where community-based care actually happens.

The deeper tension the study exposes is philosophical. These waiver programs exist precisely to move children out of restrictive institutions and into ordinary community life, yet restrictive interventions remain widely authorized within them, sometimes in settings such as family homes or public parks where oversight is weakest. The authors point to the Americans with Disabilities Act and the Olmstead decision, which established the right to care in the most integrated setting, as a legal lens through which community restraint practices deserve scrutiny. What the new index provides, for the first time, is a yardstick: a way to track, state by state and year by year, whether the promise of least-restrictive care for the country’s most vulnerable children is being written into the rules, or quietly left off the page.

Subject of Research: State Medicaid waiver policies authorizing seclusion, restraint, and safeguards for children with serious emotional disturbance in home and community-based programs

Article Title: Authorized Seclusion, Restraint, and Safeguards in Home and Community Based Medicaid Programs for Children With Serious Emotional Disturbance

Article References: Graaf, G., Fejer, A., Cañizares, M., Unnerstall, A., Friedman, C., & Purtle, J. (2026). Authorized Seclusion, Restraint, and Safeguards in Home and Community Based Medicaid Programs for Children With Serious Emotional Disturbance. Community Mental Health Journal. https://doi.org/10.1007/s10597-026-01725-3

Image Credits: AI Generated

DOI: 10.1007/s10597-026-01725-3

Keywords: serious emotional disturbance, Medicaid waivers, seclusion and restraint, home and community-based services, children's mental health, health policy, Restrictiveness and Safety Index, HCBS Settings Rule, psychiatric residential treatment, policy surveillance, de-escalation, trauma-informed care