Evaluating delivery of long-term services and supports (LTSS) to older adults and people with disabilities

A new report released jointly today by AARP's Public Policy Institute, The Commonwealth Fund and The SCAN Foundation shows some states significantly out-perform others in the delivery of long-term services and supports (LTSS) to older adults and people with disabilities.

The study finds, however, that even the top three states—Minnesota, Washington and Oregon—have a long way to go to create a high-performing system of long-term services and supports. It shows that all states need to vastly improve in areas including home care, assisted living, nursing home care, and supports for family caregivers, and more efficiently spend the substantial funds they currently allocate to LTSS.

Connecticut Ranks 11th overall.

The report, Raising Expectations: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers, examines four key dimensions of state LTSS system performance: affordability and access; choice of setting and provider; quality of life and quality of care; and support for family caregivers. It assesses each state's performance as a whole and on 25 individual indicators, some of which were measured for the first time.

"This report will help states make and sustain targeted improvements so that people can live and age with dignity in their own homes and communities," said Susan Reinhard, Senior Vice President for Public Policy at AARP. "Achieving a high-performing long-term supports and services system will require a concerted effort from both the public and private sectors."

How State Policies Impact Care and Costs

This Scorecard finds that generally states with the highest level of performance have enacted public policies designed to:

• Improve access to services and choices in their delivery by directing state Medicaid programs to serve more people in need and offer alternatives to nursing homes that most consumers prefer.
• Establish a single point of system entry to help people find needed information and more easily access services.
• Improve support for family caregivers by offering legal protections as well as other services to address caregiver needs.

The study shows that states with the lowest overall performance—such as Mississippi, Alabama, and West Virginia—have some of the lowest median incomes and highest rates of both poverty and disability in the nation. Despite these challenges, each of these states scores in the top quartile for at least one of the 25 indicators. The Scorecard points out that lower performing states can improve their overall ranking by adopting policies and procedures shown to provide better outcomes.

"This Scorecard is a critical first step toward creating a much more person- and family-centered system of care that delivers services honoring each individual's dignity and choices," said Bruce Chernof, president and CEO of The SCAN Foundation. "To fully realize the vision of a high-performing long-term services and supports system, we must measure performance, track improvements and create opportunities for states to learn from each other."

Room to Improve Across All Dimensions of Care

The report shows all states can do better in areas where performance lags. Wide variation in performance in specific dimensions makes this clear:

• Percent of LTSS spending going for home- and community-based services—60 percent in the top five states, 13 percent in the bottom five, the average is 37 percent.
• Percentage of Medicaid LTSS coverage of low- and moderate-income people with disabilities—the top five states cover 63 percent, the bottom five cover 20 percent, the national average is 36 percent.
• Percent of Medicaid LTSS recipients receiving home- and community-based services before nursing home placement— 77 percent in top five states, 26 percent in bottom five states, average is 57 percent.
• Rate of Medicaid LTSS recipients receiving self-directed services—143 per 1,000 in the top performing state, fewer than 1 per 1,000 in the bottom 6 states, 22 per 1,000 people national average.
• Hospitalization rates of nursing home residents—10 percent in top five states, 29 percent in bottom five states, median of 19 percent.

The authors say that gaps in available data made it difficult to measure important characteristics of a high-performing LTSS system, such as how well states ensure effective transitions between hospitals, nursing homes and home care. They note that improving consistent, state-level data collection is essential to evaluating state LTSS system performance more comprehensively.

"Millions of older adults and those with disabilities need access to high quality services and there isn't enough information out there to allow consumers and policymakers to make sound choices," said Mary Jane Koren, M.D., Vice President for Long-Term Care Quality Improvement at The Commonwealth Fund. "It is essential that care providers publish data about their services and outcomes so states can address the growing need for these services."

If all states reached levels currently achieved by leading states, the study finds, the U.S. could realize significant gains in health, better care experiences and potentially lower costs:

• 667,171 more individuals with disabilities would be covered by Medicaid if all states could achieve the rate of the top-performing state on this indicator;
• There would be 201,531 fewer costly and unnecessary nursing home admissions if all states could do as well as the state with the lowest rate of unnecessary nursing home admissions; and,
• There would be 120,602 fewer avoidable hospitalizations—at a savings of $1.3 billion nationally—if all states could achieve the rate of avoidable hospitalizations of the state that performs best on this indicator.