Updated April 10, 2018
Overview of Long-Term Services and Supports
What Are Long-Term Services and
supervision or guidance with ADLs because of a mental or
Supports?
cognitive impairment.


Long-term services and supports (LTSS) refers to a broad
ADLs refer to activities such as eating, bathing, using the
range of health and health-related services and supports that
toilet, dressing, walking across a small room, and
are needed by individuals who lack the capacity for self-
transferring (i.e., getting in or out of a bed or chair).
care due to a physical, cognitive, or mental disability or
Instrumental activities of daily living (IADLs) are also used
condition. Often the individual’s disability or condition
to measure a person’s need for LTSS. These activities are
results in the need for hands-on assistance or supervision
necessary for an individual’s ability to live independently in
over an extended period of time (i.e., long-term). An
the community. IADLs include activities such as preparing
individual’s need for LTSS may change over time as his or
meals, managing money, shopping, performing housework,
her needs or conditions change.
using a telephone, doing laundry, getting around outside the

home, and taking medications.
LTSS is not medical or acute care services. In general,

acute care services are health services provided for the
In practice, defining the need for LTSS as the presence of
prevention, diagnosis, or treatment of a medical condition.
functional limitations measured by the number of
Acute care services are often performed by licensed health
limitations in specific ADLs or IADLs has important policy
care providers (e.g., physicians) in a clinical setting such as
implications. For example, publicly financed programs that
a doctor’s office or a hospital. While LTSS may be offered
cover LTSS, such as Medicaid, often use the number of
in combination with acute care services, LTSS is not
limitations in ADLs to determine LTSS program eligibility,
intended to treat or cure a medical condition. In contrast,
among other criteria. For those individuals who have a
LTSS provides assistance in maintaining or improving an
private long-term care insurance policy, the number of
optimal level of physical functioning and quality of life.
limitations in ADLs also forms the basis for triggering
benefit eligibility. Defining the need for LTSS through
Examples of LTSS include a home health aide assisting a
functional limitations and/or the need for supervision with
frail elderly person with daily personal care activities such
ADLs determines eligibility for public and private
as bathing or dressing, a contractor building a wheelchair
financing.
ramp onto a home, or a senior center providing
transportation to a cognitively impaired individual. LTSS
About 12 million Americans are in need of LTSS and about
includes the use of supports such as special equipment,
half are older adults aged 65 and over. Most individuals
assistive devices, or technology by a physically impaired
prefer to be cared for in their own homes with the
person. Services also include more intensive nursing care,
assistance of informal providers such as family members or
such as nursing care provided to a ventilator-dependent
friends, if available.
child. Residential LTSS settings such as group homes or
assisted living facilities (ALFs) may provide LTSS such as
While the need for, use of, and costs associated with LTSS
meals, laundry and housework, and assistance with
vary across individuals over their lifespan, the probability
medication. Individuals who have severe physical or
of needing LTSS increases with age. It is estimated that
cognitive impairments may need the 24-hour supervision
about half (52%) of individuals turning age 65 will develop
and nursing or convalescent care-related LTSS that are
a disability serious enough to need LTSS. Most will need
provided in a nursing facility.
care for two years, on average. However, one in seven is
expected to have care needs for five years or more. And, as
Who Needs Long-Term Services and
the population ages the demand for LTSS is expected to
Supports?
increase. In addition, advances in medical care and

supportive care are enabling younger persons with
The need for LTSS can affect persons of all ages—children
disabilities to live longer lives, and requiring the delivery of
born with disabling conditions, such as mental retardation,
services and supports for longer periods of time.
or cerebral palsy; certain working-age adults with inherited
or acquired disabling conditions, such as mental illness or
Who Provides Paid Long-Term Services
traumatic brain injury; and the elderly with chronic
and Supports?
conditions or diseases, such as severe cardiovascular

disease or Alzheimer’s disease and related dementia. The
LTSS can be provided in a private home or community-
need for LTSS is generally measured, irrespective of age
based setting such as an adult day health program. LTSS is
and diagnosis, by the presence of functional limitations in
also provided in a facility-based or institutional setting such
the ability to perform basic personal care activities, known
as a nursing home.
as activities of daily living (ADLs), or by the need for

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link to page 2 Overview of Long-Term Services and Supports
associated with paid LTSS can leave individuals in need of
The vast majority of LTSS is provided by caregivers,
LTSS and their families at financial risk.
such as family members, friends, and neighbors, who

provide unpaid LTSS. A 2014 national survey found
For those receiving LTSS at home, the cost varies
that 43.5 million individuals in the United States
depending on the amount and duration of care provided. In
served as an unpaid family caregiver to an adult or a
2017, the median daily cost of homemaker services (e.g.,
child in the past 12 months.

meal preparation, housework) is $131, whereas the median
cost of care provided by a home health aide (i.e., hands-on
Paid LTSS refers to services and supports provided by
assistance with personal care needs) is $135 (see Table 1).
individuals who are employed by an organization or
Assuming care is provided 44 hours per week, the median
agency, such as a nursing home or home health care
annual cost for homemaker services would be just over
agency, or by self-employed individuals. The National
$47,900 in 2017, while the median cost of home health aide
Center for Health Statistics estimated that about 63,000
services would be about $49,200. Adult day health centers
paid, regulated long-term care services providers served
that provide social and other related support services in a
over 7.4 million individuals in 2014. These providers
community-based setting for part of the day have a median
include an estimated 30,200 residential care communities,
daily cost of $70 per day, or $18,200 per year in 2016.
15,600 nursing homes, 12,400 home health agencies, and
These estimates are national figures and can vary widely by
4,800 adult day health centers. With the exception of adult
geographic region. For example, across the United States,
day health centers, the ownership status of most long-term
median daily rates for home health aide services range from
care providers was for-profit.
$96 to $175, and median daily rates for adult day health

centers range between $26 and $168.
Paid LTSS is provided by a range of health care workers
employed directly by a provider or hired by an individual or
Residential settings that provide housing and services as
family member. Licensed or skilled health care workers that
well as institutional settings that provide room and board
provide LTSS include registered or licensed nurses,
tend to have higher annual costs than home care services,
physical and occupational therapists, and social workers.
on average. Assisted living facilities that provide
However, most LTSS is provided by non-licensed providers
homemaker services (meals, laundry, or housework) and
such as certified nurse assistants (CNAs), home health
may provide personal care for those who need assistance
aides, and personal care aides. The Department of Labor
with ADLs (but do not yet require constant care provided in
(DOL), Bureau of Labor Statistics (BLS), estimated that
a nursing home) have a median cost of $45,000 annually in
there were just over 2.9 million home health aides and
2017. Nursing home care, on the other hand, generally costs
personal care aides in 2016 (the most recent year for which
more, because it provides assistance 24 hours a day and
data are available). This likely underestimates the number
includes the cost of room and board. In 2017, the median
of home care workers as it does not include self-employed
annual cost of nursing home care is $82,100 for a semi-
workers. BLS estimates another 1.6 million nursing
private room and about $97,500 for a private room. As with
assistants and orderlies in 2016, which is an overestimate of
estimated costs for home care services, these estimates are
the LTSS nursing assistant workforce as it includes
national figures and can vary widely by geographic region.
individuals who work in acute care hospitals as well as
For example, across the United States, the median daily rate
long-term care settings. Between 2016 and 2026 home
for a one-bedroom, single occupancy unit in an assisted
health aides are projected to be among the top 20 fastest
living facility ranges between $89 and $198, while the
growing occupations both in terms of rate of growth (a 47%
median daily rate in a private nursing home room ranges
increase) and numerical growth, with an increase of over
between $174 and $800.
431,000 new jobs. Personal care aides and nursing
assistants are projected to grow by 39% and 11%,
Table 1. Estimated Rates for Selected Long-Term
respectively, over the same period, which is faster than the
Services and Supports Providers, 2017
average rate of growth for all occupations at 7%. There are
also projected to be another 778,000 new personal care
Median
Median
Median
aides and 173,000 new nursing assistants over that time.
Daily
Monthly
Annual
How Much Do Long-Term Services and

Rate
Rate
Rate
Supports Cost?
Nursing Home (Private)
$267
$8,121
$97,455

Home Health Aide
$135
$3,994
$49,192
LTSS vary widely in their intensity and cost, depending on
an individual’s underlying conditions, the severity of his or
Homemaker Services
$131
$4,099
$47,934
her disabilities, the setting in which services are provided,
and the caregiving arrangement (i.e., paid care versus
Assisted Living Facility
$123
$3,750
$45,000
uncompensated care). The cost of obtaining paid assistance
Adult Day Health Care
$70
$1,517
$18,200
for these services, especially over a long period of time,
may far exceed many individuals’ financial resources.
Source: Genworth Financial, Genworth 2017 Cost of Care Survey,
April, 2017.
Moreover, public programs that finance this care, such as
Medicaid, may not cover all the services and supports an
individual may need. Medicare does not cover most long-
Kirsten J. Colello, Specialist in Health and Aging Policy
term care expenses. Large personal financial liabilities
IF10427
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Overview of Long-Term Services and Supports


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