As the population of older adults in the United States grows with each passing day, policy makers and stakeholders are beginning in earnest to produce blueprints to tackle many of the challenges that will grow in intensity over the coming years. Here in California, Governor Gavin Newsom directed the state’s Department of Health and Human Services and Department of Aging to produce the recently released Master Plan for Aging.
A key domain in the report is California’s current Long-Term Services and Supports (LTSS) network. This expansive domain encompasses elements of care that older adults and persons with disabilities may require in managing tasks that impact their health, independence, and quality of life.
LTSS includes care and support services that occur in both institutional care settings such as assisted living, skilled nursing facilities, and nursing home environments, and within the homes of individuals who may otherwise face placement in formal care settings if not for community-based supports. Examples of support include help with personal care (e.g. bathing, dressing, toileting); complex care (e.g. medication management, wound care); home care (e.g. household tasks such as cooking, cleaning, shopping); and transportation.
In September 2020, a collaborative effort between AARP, The Commonwealth Fund and The Scan Foundation resulted in Advancing Action, Long-Term Services and Supports 2020 (The Scorecard). The comprehensive report is the fourth edition in a longitudinal effort to assess and rank the 50 states plus the District of Columbia in how well each jurisdiction is achieving gains in producing higher quality LTSS.
The Scorecard “offers policy ideas and best practices that can help states achieve high performance as they rebuild and reimagine their LTSS systems going forward.”
While work on the 2020 edition commenced prior to the COVID-19 pandemic and does not include recent data, it does state how the current public health crisis will impact future work in LTSS. The report emphasizes the importance of bringing a greater level of LTSS to consumers in their homes as opposed to far costlier institutional settings.
The report states:
“A fundamental shift to more consumer options for HCBS [home- and community-based services] will be both essential to keep consumers safe and a financial necessity for states struggling with post-COVID budget deficits. Once the public health emergency is over, states will likely face enormous budget shortfalls and an arduous economic recovery. This will put new pressure on policy makers to offer consumers choices that keep them safe at home and, from the budget-conscious policy-maker perspective, at a fraction of the cost of institutional care”.
The Scorecard creates a scoring hierarchy predicated on five dimensions of LTSS performance, constructed from 26 individual indicators.
Affordability and access
- Consumers are able to easily find, pay for, and receive the services they need in the setting they choose. Medicaid public safety nets are sufficient to provide peace of mind and security to those who cannot afford services.
Choice of setting and provider
- Consumers are at the center of care and have the choice of setting and control over their services and who provides them.
Quality of life and quality of care
- Consumers are treated with dignity and respect. Their personal preferences and aspirations are honored whenever possible. The services they receive are effective and quality is measured and compared both within and across states for continuous improvement.
Support for family caregivers
- Family caregivers are recognized as the backbone of the LTSS system. Caregivers’ own needs are identified and supported.
- Consumers experience seamless coordination across LTSS and health care systems with minimal disruption and unnecessary hospitalizations.
In comparison to other states, California is doing well in the construction of a more responsive and comprehensive LTSS environment. Across all dimensions, California ranks 9th out of the 51 jurisdictions (Minnesota is #1, Florida is #51). The state’s Individual category ranks are:
- Affordability: 7th
- Choice: 2nd
- Support for Family Caregivers: 8th
- Quality of Life: 24th
- Effective Transitions: 35th
The Scorecard data shows us why creating a high-performing LTSS system is critical now and into the future:
- Despite likelihood that more than half of Americans will need LTSS at some point in their lives, only 4% of California adults ages 40 and older purchase Long-Term Care Insurance (LTCI).
- The cost of nursing home care is unaffordable for middle-income Americans in every state. The average annual per-person cost of nursing home care is more than $100,000 a year in a private room, about 2.5 times the typical income for an older family.
- Home care services continue to be much more cost-effective than nursing home care for individuals and families. On average, the annual per-person cost of home care is roughly $35,000 a year (for 30 hours of weekly care at $23 per hour).
- Despite being relatively more affordable, home care still exceeds what many older households can afford to pay. Nationally, home care costs would consume more than three-quarters (80 percent) of the entire income of the typical, older middle-income family.
- Supporting family caregivers also has economic benefits. Most of the 41 million family caregivers in the United States have jobs outside the home. A strong LTSS system is critical to making sure those caregivers can continue to fully participate in the workforce and contribute to the economy.
California is well positioned to build on its relatively strong infrastructure of supports available in the state. But more resources and policy interventions will be needed. Efforts like The Scorecard and the California Master Plan for Aging exemplify the thought leadership needed to prepare for the unprecedented demographic shift ahead of us as our population rapidly ages.