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How States Vary in LTSS Environments and Outcomes – Part 1

Latest AARP LTSS Scorecard Shows Wide Ranges in Outcomes


November 30, 2023 – Long-Term Services and Supports (LTSS) encompasses a broad range of activities, aimed not only at ensuring medical well-being but also at maintaining the quality of life for individuals with chronic illnesses or disabilities. But when it comes to LTSS, the recent AARP Long-Term Services and Supports State Scorecard for 2023 shows that there is a wide disparity in policies, funding, delivery methods, and quality of care across each state. 

In this blog, we look at what LTSS entails and how states vary when it comes to access to and outcomes of their LTSS programs. Through this exploration, we’ll provide more clarity and insight into the intricacies of LTSS, underscoring its significance in fostering independence and dignity for those in need.

Understanding Long Term Services and Supports (LTSS)

Long Term Services and Supports (LTSS) refers to the variety of services provided to individuals who require assistance due to age, disability, or chronic conditions over a prolonged period. These services include both home health and home care services that enable individuals to live independently and safely when they can no longer perform everyday activities on their own. LTSS can be provided in various settings, such as the individual’s home, a community facility, or institutional environments like nursing homes.

LTSS are designed to meet both medical and non-medical needs and are typically services that people receive for months or even years, which is why they are referred to as long-term care. Medical services typically involve nursing care, medication management, or therapy sessions. On the other hand, non-medical assistance includes help with daily living activities like bathing, dressing, meal preparation, and transportation. LTSS is person-centered, and accounts for the preferences and specific situation of each individual to enhance their quality of life.

It is important to note that the scope of LTSS is extensive and often involves coordination with social services to address the full spectrum of individual needs. The goal of LTSS is to promote autonomy and facilitate community living, where individuals can enjoy a sense of normalcy and participation in their daily lives. The issue is who pays for these services. 

Who Pays for LTSS Services?

In 2020, it’s estimated that 5.8 million people used long-term services and supports delivered in home and community settings while just shy of 2 million used LTSS delivered in institutional settings. An additional unknown number of people, and likely millions more, used unpaid LTSS provided by family, friends, and neighbors. Why is that the case? 

The main reason for this is that most individuals over the age of 65 or those who have disabilities and require LTSS are covered through Medicare. Medicare covers up to 100 days of nursing home care, but only if the individual needs skilled services in an inpatient setting. Unfortunately, Medicare does not cover LTSS in home settings and does not cover non-medical home care. 

Medicaid is the primary payer of LTSS and to qualify for that you must meet state-specific eligibility requirements based on income, wealth, and functional limitations. Because much of our aging population does not qualify for Medicare, they must pay for LTSS out of pocket. That is why many receive unpaid services through family and friends. While they do not qualify for Medicaid, they also don’t have the disposable funds to cover costly LTSS. 

There has been a shift in recent years as individuals have been able to receive LTSS at home through home and community-based services (HCBS) programs. These programs can offer services that include personal care services, personal attendant services, home meal delivery, and home modifications to improve safety, but many states do not cover these non-medical services. In addition, many states that do cover HCBS have waiting lists so eligible individuals are still unable to access services. 

Divergence in State LTSS Services: Insights from the AARP Scorecard

The recent publication of the 2023 AARP Long-Term Services and Supports (LTSS) State Scorecard offers valuable insights into how LTSS varies considerably across the United States. The comprehensive evaluation ranked states on their performance across several key dimensions: Affordability and Access, Choice of Setting and Provider, Safety & Quality, Support for Family Caregivers, and Community Integration.

As you can see from the chart above, there is a wide disparity among states in terms of overall performance. Some states have forged ahead, establishing robust systems that afford residents greater choice and control over their services, while others lag with limited options that may not fully meet the diverse needs of their aging or disabled populations. 

For example, states that score high on the Scorecard often have more progressive policies in place, like expanded Medicaid coverage for home and community-based services (HCBS), caregiver support programs, and initiatives designed to make care more affordable. The report also indicates that the top-performing states have invested in the LTSS workforce, developed cross-system collaborations to facilitate effective transitions from institutional care to community settings, and have implemented programs designed to maximize independence for individuals receiving services. They recognize the dual imperative of ensuring quality care while also providing support that respects the autonomy and choice of individuals.

In contrast, states with lower rankings face significant challenges. These often include limited availability of services, especially in rural areas, higher out-of-pocket costs for care, and less support for family caregivers who play a critical role in the LTSS ecosystem. 

Another key takeaway is the importance of forward-thinking strategies to prepare for the growing demand for LTSS. The demographic shift towards an older population is universal, yet the readiness of states to manage this shift is not. Already there are hundreds of thousands of individuals on HCBS waiting lists and that number is only going to grow if states do not take action. Those that plan and implement comprehensive LTSS systems now will be better positioned to provide high-quality, person-centered care that meets the needs of their residents.

Overall, the AARP LTSS State Scorecard 2023 Edition underscores the significant variability in how states support their residents needing long-term services and supports. It serves as both a benchmark for current state performance and a blueprint for how states can improve their LTSS offerings going forward. Perhaps the most important thing highlighted by the report though, is how essential state policies are in shaping LTSS and ensuring access to and quality care for all. 

Advocates Perspective

The landscape of Long-Term Services and Supports (LTSS) in the United States is diverse. The variability between states presents both opportunities for innovation and challenges in access and quality. As the nation grapples with an aging population and a rising demand for LTSS, the path forward calls for a careful balance between state autonomy and the need for a certain level of standardization to ensure all Americans have access to high-quality LTSS. The overarching goal must be to ensure that every individual who requires long-term care can receive it in a dignified, supportive, and enabling environment, regardless of their state of residence. 

In part two of this blog, we are going to take an in-depth look at the state-specific policies impacting LTSS outcomes. Stay tuned!


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About the Author

Fady Sahhar brings over 30 years of senior management experience working with major multinational companies including Sara Lee, Mobil Oil, Tenneco Packaging, Pactiv, Progressive Insurance, Transitions Optical, PPG Industries and Essilor (France).

His corporate responsibilities included new product development, strategic planning, marketing management, and global sales. He has developed a number of global communications networks, launched products in over 45 countries, and managed a number of branded patented products.

mandy sahhar

About the Co-Author

Mandy Sahhar provides experience in digital marketing, event management, and business development. Her background has allowed her to get in on the ground floor of marketing efforts including website design, content marketing, and trade show planning. Through her modern approach, she focuses on bringing businesses into the new digital age of marketing through unique approaches and focused content creation. With a passion for communications, she can bring a fresh perspective to an ever-changing industry. Mandy has an MBA with a marketing concentration from Canisius College.