U.S. needs better long-term supports for older adults, ACP says

New position paper has five recommendations for financing, nursing homes, family caregivers.

The COVID-19 pandemic has provided the opportunity to reinvigorate the systems that provide long-term services and supports (LTSS) to older adults across the United States, according to the American College of Physicians (ACP).

The organization published a new position paper with recommendations to improve quality, accessibility, equity and affordability as the number of older adults grows.

The paper, published in the Annals of Internal Medicine, noted many nursing homes were unprepared for COVID-19 due to lack of qualified staff and personal protective equipment – problems that have received attention through national news media reports. But the COVID-19 pandemic shed new light on challenges to LTSS across all sectors, according to the position paper and the published statement from ACP President Ryan D. Mire, MD, FACP.

“We saw the devastating effect the virus had on residents in nursing homes, both because of their age and the higher risk associated with congregate living situations,” Mire said in the statement. ‘We also saw the pandemic greatly exacerbate staffing shortages in these facilities. We need to ensure that the U.S. has a high-functioning LTSS system that is ready to meet increased demand and deal with potential future pandemics or other events that threaten the patients who depend on these services.

“The population over age 65 is projected to increase by over 15 million between 2020 and 2030, and these individuals will need a system of LTSS they can rely on,” Mire said. “We need to make improvements to the system so that it is able to meet the challenges it faces today and provide older adults with the additional services and support that will be needed in the future."

An overview

The current economy of LTTS “reflects the broader health care system: a patchwork of private and public financed programs that exclude large segments of the population,” the paper said, and that fragmentation makes it difficult to coordinate between medical and LTSS sectors.

LTSS can be delivered in nursing homes or other institutional settings, or to patients in their own homes. The services include assistance with tasks like bathing, eating, dressing, and other activities of daily living so that the individual can maintain or improve their quality of life, according to ACP.

Medicaid is the primary funder of paid LTSS in the United States. Medicare covers little, but many people mistakenly believe it will cover LTSS, so they are financially unprepared to pay for it.

Qualified veterans may receive LTSS through the Veterans Health Administration. The paper noted at least one report said the market “has collapsed” for private long-term care insurance, with a dwindling number of companies offering those policies.

“Caregiving has major economic effects,” ACP said.

For home- and community-based services (HCBS), most LTSS provided by unpaid caregivers, often family members or friends of patients. A 2019 report from AARP estimated that in 2017, 41 million family caregivers provided 34 billion hours of care, with a monetary value of $470 billion, with many caregivers experiencing financial strain, the paper said.

Possible solutions

ACP proffered five recommendations to improve LTSS:

  • A multi-pronged public-private sector approach to reform financing.

“ACP envisions a three-legged stool for LTSS financing: a publicly finance, universal, catastrophic, back-end coverage program; an affordable and accessible private LTCI market to cover front-end LTSS needs before the catastrophic back-end coverage begins; and expanded HCBS benefits through Medicaid,” the paper said. “These components would complement each other and be implemented simultaneously.”

  • Policymakers and employers should address LTSS workforce shortages with comprehensive training, pay increases, benefit packages and opportunities for career advancement and growth. ACP also supports assistance to unpaid caregivers through respite care, training and reimbursement.

“Workforce challenges are an immense barrier to meeting demand for HCBS and other LTSS,” with low wages, lack of benefits and limited opportunities for direct care workers, the paper said.

  • The LTSS sector needs evidence-based interventions to assure and improve quality across settings, including monitoring and enforcement, better care coordination and federal minimum nurse staffing levels for nursing homes.
  • Research on the effect of ownership on the LTSS sector, with audited, publicly available data on quality of care, staff and patient safety, costs, and staffing ratios.
  • Funding, assistance and staff to develop and implement strong emergency preparedness plans for patients and staff, with staff training on emergency preparedness, evacuation and sheltering in place. The need goes beyond reaction to COVID-19 because nursing homes must deal with natural disasters such as hurricanes and sheltering in place may be safer than evacuating patients “who are cognitively impaired, extremely frail, or bed bound.”