The Impact of Home and Community Based Settings (HCBS) Final Settings Rule Outcomes on Health and Safety.

Friedman (2020) looked at Medicaid records for 251 adults with IDD.

The goal was to see if plans that meet the new HCBS Settings Rule also keep people safer and healthier.

No one got a new treatment; the study simply compared existing plans to ER visits and abuse reports.

Plans that scored high on choice, privacy and real community use were linked to fewer ER trips and less abuse.

Just living in a house in the neighborhood was not enough; the written plan had to back up freedom and integration.

Moss et al. (2009) and Lam et al. (2011) already showed that small or family-model homes feel better to residents.

Friedman (2019) extends those feel-good surveys by showing that provider-run group homes often copy old institutional rules.

The 2020 paper adds a hard outcome layer: when those same rule-copying homes claim to be “community” placements, ER visits and abuse risk stay high.

Together the four papers tell one story—size matters, but paperwork promising choice and real community life matters more.

When you review a client’s ISP, flip to the HCBS section. Check for words like “client chooses,” “unlocked doors,” “regular community activities.” If those lines are blank, flag the plan even if the house looks cozy. Your prompt could stop a future ER visit.