Skip to main content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

HHS Logo Eagle IconU.S. Department of Health and Human Services
napa

Advisory Council November 2020 Meeting Presentation: Expand Access to LTSS

Tuesday, November 10, 2020

Printer Friendly Version in PDF Format (10 PDF pages)

 

Past Efforts to Expand Access to Long-Term Services & Supports

Gretchen Alkema, Ph.D., Vice President, Policy and Communications, The SCAN Foundation

U.S. Aging Policy Milestones

  • Daily Living Security
    • Public:
      • ACA Opportunities (2010)
      • Medicaid (1965)
      • Older Americans Act (1965)
    • Private:
      • LTC Insurance (1970s)
      • Family / Friends / Neighbors
  • Income Security
    • Public:
      • Social Security (1935)
      • SSDI/SSI (1956/1972)
    • Private:
      • Defined Benefit
      • 401K -- 403B
      • Private Disability Ins.
      • Earned Income
  • Health Security
    • Public:
      • ACA (2010)
      • Medicare/ Medicaid (1965)
      • VA (1930)
    • Private:
      • Medigap (1965)
      • Retiree Health Insurance
    • Pub/Priv:
      • Medicare Managed Care (1982; 1997; 2003)

2013 Commission on Long-Term Care

  • Commission's charge: To create a plan to...
    • Establish, implement, and finance a comprehensive, coordinated, and high-quality LTSS system
    • Ensure availability of LTSS to:
      • Older adults
      • People with substantial cognitive or functional limitations
      • Others needing ADL assistance
      • Those who plan for future needs
    • http://www.ltccommission.org/

Call to Action

  • 12+ million need LTSS
    • Diverse population: almost half under age 65
    • Most living in their homes and in the community
    • Most are assisted by family caregivers
    • Many get their needs met
  • Key problems more severe with population aging:
    • Paid LTSS is expensive & long periods can be catastrophic
    • Most retirees not adequately prepared for costs
    • Family caregivers provide most care
      • Financially and emotionally stressful
      • Availability will decline in the future
  • Direct care workforce capacity, quality, & training
  • Paid LTSS: highly fragmented & difficult to access
    • lack focus/coordination to get best outcomes
    • can be expensive and inefficient
  • Future growth in LTSS need with population aging
    • Major strain on federal/state budgets

Population Needing LTSS, by Age Group and Level of Need

Stacked Bar Chart: Children total 0.6; Working Age total 5.4; Elderly total 6.7.
SOURCE: S. Kaye, data from 2012 NHIS, 2010 Census, Nursing Home Data Compendium 2010.

The Number of Americans Needing Long-Term Care Will More than Double by 2050

Bar Chart: 2010 12 million; 2050 27 million.
SOURCE: S. Kaye, C. Harrington, and M. Laplante (2010), Analysis of 2005 SIPP, 2007 NHIS, 2007 ACS, 2004 NHHS, and the 2005-2006 Medical Expenditure Survey.

Call to Action

  • Projected increase in LTSS need will confront significant resource constraints due to current & projected fiscal challenges
    • New care integration, technology, & innovative workforce strategies needed to reduce costs & improve outcomes
    • Creative financing solutions needed to insure risk & encourage savings
    • More accessible & sustainable Medicaid safety net needed

Vision for Future LTSS System

  • Service Delivery
    • Person- & family-centered
    • Balance of options: HCBS/Institutional
    • Integrated medical & LTSS
    • Effective: outcomes focused
    • Efficient: financially sustainable
  • Financing
    • Full array of LTSS financing options
    • Balance of public/private financing
    • Protects against catastrophic costs
    • Enables individual preparation
    • Safety net for those in most need
  • Workforce
    • Attracts & retains trained workers
    • Adequately-sized
    • High quality, person-centered care across LTSS settings

Recommendations: Service Delivery

  • Rebalancing: incentivize states to balance HCBS & institutional care
  • Care Integration
    • Align incentives to integrate person-centered care
    • Establish a single point of contact for LTSS.
    • Use technology to mobilize and integrate resources
    • Create livable communities
  • Uniform Assessment: implement a standardized assessment tool to produce a single care plan

Recommendations: Service Delivery

  • Consumer Access: expand "No Wrong Door" to provide enhanced options counseling
  • Quality: accelerate development of LTSS quality measures for HCBS and make them available to consumers
  • Payment Reform: promote payment based on the service rather than the setting

Recommendations: Workforce

  • Family Caregiving
    • National strategy to maintain & strengthen family caregiving
    • Include family caregivers in needs assessment & care planning
    • Encourage expansion of caregiver interventions
  • Paid Workforce
    • Encourage revision of scope of practice to permit delegation with supervision to direct care workers
    • Enable criminal background checks for LTSS workforce
  • Direct Care Workforce
    • Create meaningful ladders & lattices for career advancement
    • Integrate direct workers in care teams
    • Collect detailed data on LTSS workforce
    • Encourage standards & certification for home care workers

Financing: Vision and Alternative Approaches

  • Common Vision: A balance of public and private financing to insure the most catastrophic expenses, encourage savings and insurance for more immediate LTSS costs, and provide a strong safety net for those without resources.
  • LTC Commission did not agree on a single approach, but offered two approaches that might achieve the common vision
    • Private options to strengthen financing
    • Social insurance

Recommendations: Financing

  • Medicaid Improvement
    • Demo to provide LTSS to those w/ disabilities to stay employed
    • Assist states to achieve greater uniformity in Medicaid buy-in programs
  • Medicare Improvement
    • Eliminate 3-day prior hospitalization requirement for skilled nursing facility stay
    • Reconsider "homebound" requirement for home health care
  • Savings
    • Allow individuals with disabilities & their families to set up section 529 savings funds

Long-Term Services & Supports State Scorecard, 2020 Edition

High-Performing LTSS System

  • Five dimensions of LTSS performance, constructed from 26 individual indicators.
    • Affordability and Access
      1. Nursing Home Cost
      2. Home Care Cost
      3. Long-Term Care Insurance
      4. Low-Income PWD with Medicaid
      5. PWD with Medicaid LTSS
      6. ADRC/NWD Functions
    • Choice of Setting and Provider
      1. Medicaid LTSS Balance: Spending
      2. Medicaid LTSS Balance: Users
      3. Self-Direction
      4. Home Health Aide Supply
      5. Assisted Living Supply
      6. Adult Day Services Supply
      7. Subsidized Housing Opportunities
    • Quality of Life and Quality of Care
      1. PWD Rate of Employment
      2. Nursing Home Residents with Pressure Sores
      3. Nursing Home Antipsychotic Use
      4. HCBS Quality Benchmarking
    • Support for Family Caregivers*
      1. Supporting Working Family Caregivers
      2. Person- and Family-Centered Care
      3. Nurse Delegation and Scope of Practice
      4. Transportation Policies
    • Effective Transitions
      1. Nursing Home Residents with Low Care Needs
      2. Home Health Hospital Admissions
      3. Nursing Home Hospital Admissions
      4. Burdensome Transitions
      5. Successful Discharge to Community

ADRC/NWD - Aging and Disability Resource Center/No Wrong Door
HCBS - Home- and Community-Based Services
LTSS - Long-Term Services and Supports
PWD - People with Disabilities
* Support for Family Caregivers Dimension evaluated across 12 individual policies, which are grouped into four broad categories.

SOURCE: Long-Term Services and Supports State Scorecard, 2020.

State Rankings Overall, 2020

State Map colored according to Top, Second, Third, or Bottom Quartile.

Key 2020 Scorecard Findings

  • States made progress since 2017, but status quo dominates
  • Even highest-performing states have room for improvement
  • Top- & bottom-ranked states have remained consistent
  • States showed significant decline in long-term care insurance policies
  • Affordable/accessible housing remain significant unmet need

The SCAN Foundation