Overview of Long-Term Services and Supports
Updated October 2, 2023
Overview of Long-Term Services and Supports
What Are Long-Term Services and
disabilities. LTSS also includes the use of supports such as
Supports?
special equipment, assistive devices, or technology.
Long-term services and supports (LTSS) refers to a broad
range of health and health-related services and supports
Who Needs Long-Term Services and
needed by individuals who lack the capacity for self-care
Supports?
due to a physical, cognitive, or mental disability or
The need for LTSS can affect persons of all ages—children
condition. Often an individual’s disability or condition
born with disabling conditions, such as intellectual or
results in the need for hands-on assistance or supervision
developmental disabilities; certain working-age adults with
over an extended period of time. An individual’s need for
inherited or acquired disabling conditions, such as serious
LTSS may change over time as his or her needs or
mental illness or traumatic brain injury; and older adults
conditions change.
with chronic conditions or diseases, such as severe
cardiovascular disease or Alzheimer’s disease and related
dementia. The need for LTSS is generally measured,
About 14 million adults in the United States are in
irrespective of age and diagnosis, by the presence of
need of LTSS, and over half (56%) are older adults
functional limitations in the ability to perform basic self-
aged 65 and over. Most are cared for in their own
care activities, known as activities of daily living (ADLs),
homes with the assistance of informal providers, such
or by the need for supervision or guidance with ADLs
as family members or friends.
because of a mental or cognitive impairment.
LTSS is different from acute care services or post-acute
ADLs refer to activities such as eating, bathing, using the
care services. In general, acute care services are health
toilet, dressing, walking across a small room, and
services provided for the prevention, diagnosis, or treatment
transferring (i.e., getting in or out of a bed or chair).
of a medical condition. Acute care services are often
Instrumental activities of daily living (IADLs) may also be
performed by licensed health care providers (e.g.,
used to measure a person’s need for LTSS. These activities
physicians) in a clinical setting, such as a doctor’s office or
are necessary for an individual’s ability to live
a hospital. In general, post-acute care services are health
independently in the community. IADLs include activities
services provided over a short term, typically after a
such as preparing meals, managing money, shopping,
hospitalization, to assist an individual with recovery from
performing housework, using a telephone, doing laundry,
injury or illness and return to as normal a condition as
getting around outside the home, and taking medications.
possible. While LTSS may be offered in combination with
acute care or post-acute care services, LTSS is not intended
While the need for, use of, and costs associated with LTSS
to treat or cure a medical condition. In contrast, LTSS
vary across individuals over their lifespan, the probability
provides assistance in maintaining or improving an optimal
of needing LTSS increases with age. It is estimated that
level of physical functioning and quality of life.
more than half (56%) of Americans who survive to age 65
will develop a disability at some point later in life that is
LTSS includes a variety of services and supports that can be
serious enough to need LTSS, 12% will need care for less
provided in either community-based or institutional
than a year, and 22% will need care for five or more years.
settings. Examples of community-based LTSS include a
As the population ages, the demand for LTSS is expected to
home health aide assisting a frail older adult with daily
increase. In addition, advances in medical care and
personal care activities such as bathing or dressing, a
supportive care are enabling younger persons with
contractor building a wheelchair ramp onto a home, or an
disabilities to live longer lives, requiring the delivery of
adult day program providing social and other related
services and supports for longer periods of time.
support services to a cognitively impaired individual. LTSS
can also be provided in a community-based residential care
Generally, public and private payers of LTSS determine
setting, such as a group home or assisted living facility
needs-based eligibility for LTSS. For example, publicly
(ALF) that provides housing and services such as meals,
financed programs that cover LTSS, such as Medicaid,
laundry and housework, and assistance with medication.
often use “functional” eligibility criteria (i.e., limitations in
ADLs and/or IADLs), as well as “clinical” criteria that
LTSS also includes more intensive nursing care, such as
include diagnosis of an illness, injury, disability or other
nursing care provided to a ventilator-dependent child in a
medical condition, treatment and medications, and
private home or institutional setting. Individuals who have
cognitive status, among other conditions (i.e., autism or
severe physical and/or cognitive impairments may need the
intellectual disability, serious mental illness, traumatic brain
24-hour supervision and convalescent care provided in an
injury).
institutional setting, such as a nursing home or institution
for individuals with intellectual and developmental
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link to page 2 Overview of Long-Term Services and Supports
Under a private long-term care insurance (LTCI) policy,
How Much Do Long-Term Services and
limitations in a specified number of ADLs are usually the
Supports Cost?
basis for triggering benefit eligibility. Specifically, federal
LTSS varies widely in terms of intensity and cost,
law provides federal tax benefits and minimum consumer
depending on individuals’ underlying conditions, the
protection standards for purchasers of “tax-qualified” LTCI
severity of their disabilities, the setting in which services
policies, as authorized by the Health Insurance Portability
are provided, and the caregiving arrangement (i.e., paid care
and Accountability Act of 1996 (HIPAA, P.L. 104-191; 26
versus uncompensated care). The cost of obtaining paid
U.S.C. §7702B). HIPAA tax-qualified LTCI products are
assistance for these services, especially over a long period
required to have defined benefit triggers for when the
of time, may far exceed many individuals’ financial
policy begins to pay long-term care benefits. In general,
resources. Moreover, public programs that finance this care,
these triggers require policyholders to be certified by a
such as Medicaid, may not cover all the services and
licensed health care practitioner as unable to perform at
supports an individual may need. Medicare does not cover
least two ADLs for a minimum of 90 days or require
most long-term care expenses. Large personal financial
substantial supervision due to severe cognitive impairment.
liabilities associated with paid LTSS can leave individuals
in need of LTSS and their families at financial risk.
Who Provides Paid Long-Term Services
and Supports?
For those receiving LTSS at home, the cost varies
The vast majority of LTSS is provided by caregivers, such
depending on the amount and duration of care provided (see
as family members, friends, and neighbors, who provide
Table 1). Assuming care is provided for 44 hours per week,
uncompensated LTSS. Some public programs may allow
per industry guidance, the median annual cost for
caregivers to be compensated to provide care and/or
homemaker services was about $59,500 in 2021, while the
provide resources to further assist caregivers. A national
median cost of home health aide services was over $61,800.
survey published in 2020 estimated that 53 million adults in
Adult day health centers have a median annual cost of
the United States served as family caregivers to an adult or
$20,300 per year in 2021. These estimates are national
a child with special needs in the past 12 months.
figures and can vary widely by geographic region. For
example, across the 50 states and the District of Columbia
Paid LTSS is provided by individuals employed by an
(DC), median daily rates for home health aide services
organization or agency, such as a nursing home or home
ranged from $122 to $227, and median daily rates for adult
health care agency, or by independent providers who are
day health centers ranged between $35 and $156.
hired by an individual or family member. The National
Center for Health Statistics estimated that about 69,000
Residential settings that provide housing and services as
paid, regulated LTSS and post-acute provider organizations
well as institutional settings tend to have higher annual
served over 9.5 million individuals in 2018. These
costs than home care services, on average. Assisted living
providers include an estimated 31,400 residential care
facilities had a median annual cost of $54,000, while the
communities, 15,600 nursing homes, 11,500 home health
median annual cost of nursing home care was about
agencies, 4,700 hospices, 4,200 adult day health centers,
$94,900 for a semi-private room and $108,400 for a private
1,200 inpatient rehabilitation facilities, and 400 long-term
room in 2021. As with estimated costs for home care
care hospitals.
services, these estimates are national figures and can vary
widely by geographic region. For example, across states
Licensed or skilled health care workers that provide LTSS
and DC, the median daily rate for a one-bedroom, single
include registered or licensed nurses, physical and
occupancy unit in an assisted living facility ranged from
occupational therapists, and social workers. However, most
$99 to $229; the median daily rate in a private nursing
LTSS is provided by nonlicensed providers who are
home room ranged from $195 to $1,036.
generally referred to as direct care workers and include
home health aides, personal care aides, and nursing
Table 1. Median Rates for LTSS Providers, 2021
assistants. PHI, a national policy and advocacy organization
on the direct care workforce, estimates about 4.8 million
Daily
Monthly
Annual
direct care workers in 2022. Among those, about 2.8
Rate
Rate
Rate
million worked in home care; 719,000 in residential care
Nursing Home (Private)
$297
$9,034
$108,405
homes; 448,000 in nursing homes; and 871,000 in other
industries. However, this likely underestimates the number
Home Health Aide
$169
$5,148
$61,766
of direct care workers, as it does not include those privately
employed by consumers, the so-called “grey market,”
Homemaker Services
$163
$4,957
$59,488
which is difficult to measure. Between 2022 and 2032, the
Assisted Living Facility
$148
$4,500
$54,000
Bureau of Labor Statistics estimates that home health aides
and personal care aides are projected to be among the top
Adult Day Health Care
$78
$1,690
$20,280
20 fastest growing occupations, both in terms of rate of
Source: Genworth Financial, Genworth 2021 Cost of Care Survey,
growth (a 22% increase) and numerical growth, with an
October, 2021.
increase of 805,000 new jobs. This is faster than the
average rate of growth for all occupations at 3%. Nursing
Kirsten J. Colello, Specialist in Health and Aging Policy
assistants are projected to grow by 4%, with a projected
increase of 58,000 new nursing assistants over the same
IF10427
time period.
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Overview of Long-Term Services and Supports
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