A Tool for Catalyzing Progress in Long-Term Care

A Tool for Catalyzing Progress in Long-Term Care

Approximately 10,000 people in the United States turn 65 every day. Half of them will one day find themselves needing a high level of help with basic daily activities like walking, eating, getting out of bed in the morning, and bathing—assistance known as long-term services and supports (LTSS).

LTSS comes in different forms. It may be provided in the home, assisted living, nursing facilities, or integrated settings such as those that provide both health care and supportive services. LTSS also include supportive services provided to family members and other unpaid caregivers.

Anyone who has interacted with the “system” of long-term care, from older adults to people with disabilities and family caregivers, understands that it’s not really a system at all. It’s a patchwork of programs, policies, and funding streams largely built around federal and state decisions dating back nearly five decades.

Meanwhile, the number of aging Americans with significant health and personal needs is projected to grow from 6 million to almost 16 million in the next several decades. While each experience is unique, roughly three out of four older adults with this level of need live in their homes and communities. For those needing care, roughly 30 percent will need it for less than a year, but 25 percent will need it for five years or more.

Against this backdrop of an impending surge in demand for LTSS, decision makers in Washington, D.C., are debating a major overhaul of health care policy. The recent release of our Long-Term Services and Supports State Scorecard, therefore, could not have come at a more appropriate time.

Quadrupling the Rate of Change

Compiling state data and presenting it as usable and actionable material, the Scorecard comprises a multi-component report and interactive online tool. It provides state-level information on creating a high-performing system of care in order to drive progress toward improvement in services for older adults and people with physical disabilities, and their family caregivers. The focus is on the state level because our country does not have a single national system to address LTSS needs. The Scorecard examines 25 indicators across five LTSS categories—Affordability and Access, Choice of Setting and Provider, Quality of Life and Quality of Care, Support for Family Caregivers, and Effective Transitions.

Now in its third iteration, the Scorecard helps states understand their strengths – and there are many efforts to be proud of – as well as (perhaps more importantly) areas where they need to improve if they are going to meet the LTSS needs of their growing aging populations.

The Scorecard’s overarching message: much work remains—even for the top-performing states. That’s why we titled this edition Picking Up the Pace of Change. As we continue to edge toward 2026, the watershed year that boomers will first start to turn 80 and their LTSS needs will increase, few states have achieved meaningful change (generally defined as 10 percent or more over the past two to four years) on most of the measures that the Scorecard was able to track over time.

States, for example, have made steady but slow progress in increasing the proportion of Medicaid spending going toward home and community-based services – services the majority of people want – as opposed to nursing facilities, from 39 percent in 2011 to 41 percent in 2014 (the most current year of available data). At the current national rate of change, it would take 36 years for the average of the bottom five states in this category to reach the level of the median state today, and another 51 years for the median state to reach the level of the average of the top five states (64 percent).

We don’t have that much time. To reach these benchmarks by 2026, the rate of improvement must triple and in some cases quadruple. Meanwhile, as Congress debates health care reform, Medicaid funding levels allotted to states by the federal government hang in the balance. Significant portions of Medicaid dollars passed from the federal government to states play a key role in LTSS—and outcomes of the current health care debate could impact states’ ability to build on or even sustain their current residents’ needs.

The Right Information at the Right Time

During this critical time, both in terms of demographic trends and policymaking, the value of LTSS and urgency of taking action to strengthen it become all the more apparent. The Scorecard not only highlights the importance and urgency, it serves as a tool for states. It helps states identify where they need to focus their resources and efforts, while also enabling them to communicate with and learn from one another. (In fact, the Scorecard package includes such “promising practices” identified within specific states.)

Thus, we must ensure the Scorecard’s crucial information reaches decision makers – both state legislators and national policymakers – as the services and supports it evaluates are central to the well-being of older adults, people with disabilities, and family caregivers. Every stakeholder has a role to play in picking up the pace of change so we can all age with dignity, choice, and independence.

The Scorecard and related materials are available at

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Celebrate Our Interdependence

Celebrate Our Interdependence

Independence Day is coming. So is a significant change in our society.

As we celebrate our nation’s independence, we can also celebrate the vibrant interdependence of us all, across the age spectrum. Every day in this country, 10,000 people turn 65. With boomers beginning to turn 80 in 2026, we’re less than a decade away from this sizable generation’s increased need for long-term services and supports (LTSS). Has your state risen to the challenge of providing appropriate LTSS that will help enable you to live as you choose in your community as you age?

We examined such issues in the 2017 Long-Term Services & Supports State Scorecard, released June 14. The data-driven interactive tool and report found that while states have made incremental improvements since our last Scorecard was published in 2014, we need to triple or even quadruple the pace of change to accommodate the impending growth in the older segments of our population. (Thus, the report piece of the release is aptly titled “Picking Up the Pace of Change: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers.”)

In short, the Scorecard sounds the alarm. But its information on each state’s strengths and shortcomings also serves as a tool—for policymakers and stakeholders as well as concerned consumers dealing with the issue, either as caregivers or potential users of LTSS. The tool allows users to gauge what must be done to improve conditions in the years ahead.

Covering 25 indicators across five major dimensions, the Scorecard provides a comprehensive look at LTSS. Below are just a couple of highlights that provide examples of what the Scorecard examines.


The Need for Affordable, Accessible Housing

For the first time, the Scorecard includes housing and transportation measures, since the aging population, as well as those with physical disabilities, require more affordable and accessible housing and transportation to remain in their homes and communities.

What we found is that, since 2011, many states increased the percentage of housing units that can potentially be subsidized.  But there is much more to this story. While the total number of subsidized housing opportunities has risen since 2011, this is due in large part to the slow growth of the overall housing market. The increased use of vouchers, tax credits, and other financing mechanisms has also played a role, but they remain sparse and hard to come by in the housing market.  The end result is that the availability of affordable housing remains tremendously insufficient.

At a national level, there are still more than 18 million renters, and fewer than 8 million potentially subsidized units available. So, despite some improvement, it is clear that the current supply of affordable and accessible housing still falls far short of our current and future needs.

Moreover, simply having a relatively higher number of affordable units isn’t sufficient. Housing needs to be accessible to meet the needs of all as well.


The Truth about Transportation

We live in a car-oriented society, and when people stop driving, they may feel a loss of some freedom. Moreover, giving up driving puts a burden on family caregivers, who must transport individuals to appointments with health care professionals, friends’ homes, the local mall, or movie theater. Thus, this year’s Scorecard also looks at which states offer transportation options for those who don’t drive but still want to live in their current homes or communities.

Fortunately, several states have started providing volunteer driver programs as well as increasing community transportation for low-income Medicaid beneficiaries with disabilities and coordinating community transportation at all levels of government. The top-performing states in those areas this year were Colorado, South Carolina, California, Massachusetts, and Washington.

With resources getting tighter and the number of older Americans on the rise, the economic realities that states face are uncertain. Proposed health care legislation threatens key funding for LTSS, particularly home and community-based services. During this season of celebrating freedom, independence, and our vibrant interdependence, it’s time to think about the concrete consequences of such legislation. My colleagues and I have already written on this topic, and undoubtedly I’ll continue to do so in the near future.

We cannot afford to drop the ball on adequately building out our LTSS infrastructure. All states, from the top-performing ones on down in this year’s Scorecard, need to “pick up the pace” now to meet the needs of the aging population in the very near future.

Now it’s your turn to weigh in: How did your state rank on this year’s Scorecard, and what do you feel needs to be done to increase its standing by our next LTSS evaluation in 2020?

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