Methodology

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Dimensions and Indicators: The Scorecard measures LTSS system performance using 26 indicators, grouped into five dimensions:

Affordability and Access includes the relative affordability of private pay LTSS, the proportion of individuals with private long-term care insurance, the reach of the Medicaid safety net and the Medicaid LTSS safety net to people with disabilities who have modest incomes, and the ease of navigating the LTSS system.

Choice of Setting and Provider includes the balance between institutional services and HCBS, the extent of participant direction, and the supply and availability of alternatives to nursing homes.

Quality of Life and Quality of Care includes level of support, life satisfaction, and employment of people with disabilities living in the community, and indicators of quality in nursing homes.

Support for Family Caregivers includes legal and system supports available in states and localities, the extent to which registered nurses are able to delegate health maintenance tasks to non–family members, and aspects of caregiver well-being.

Effective Transitions includes measures of hospitalization and institutionalization that should be minimized in a high-performing LTSS system.

For each of the five dimensions, the Scorecard uses specific indicators that are important, meaningful, conceptually valid, and unambiguous in regard to directionality; these are combined to obtain state rankings at the dimension level. In some cases, composite indicators have been formed from thematically related program and policy data. Indicators are based on data that are expected to be updated regularly so that change can be observed over time. (See Exhibit 2 in the Executive Summary for a complete list of the indicators.) Appendix B2 describes the methodology for the development of each composite indicator. 

The five measured dimensions of system performance approximately correspond to the five key characteristics of a high-performing LTSS system (see Exhibit 5). However, the correspondence is not complete, as data are not currently available to measure important aspects of some of the characteristics. Notable data gaps include coordination of LTSS with other services (medical, housing, transportation, and more), consumer reports of quality of HCBS, and consistent definition and measurement of respite for family caregivers. All indicators are subject to definitional and measurement issues; these 26 were selected because they represented the best available measures at the state level. While no single indicator may fully capture state performance, taken together they provide a useful measure of how state LTSS systems compare across a range of important dimensions. 

Ranking Methodology: The Scorecard ranks the states from highest to lowest performance on each indicator. We averaged rankings across all indicators within each of the five dimensions to determine each state’s dimension ranks, and then averaged the dimension ranks to arrive at an overall ranking. This approach gives each dimension equal weight in the overall rankings, and within dimensions gives equal weight to each indicator. In the case of missing data or ties in rank for an indicator, minor adjustments were made to values used in the average so that all indicators were given equal weight.

  • For ties: the average rank is given for the computation of the dimension or overall average (e.g., two states tied at third; both get a score of 3.5 for the calculation of the dimension average).

  • Missing data: a constant value is added to all ranks so that the average rank for the indicator is 26 (e.g., if there were 4 missing values, the scores would run from 3 to 49 instead of 1 to 47 for the calculation of the dimension average). This approach was chosen for ease of understanding and interpreting the results, and for consistency with the 2011 State LTSS Scorecard. The methodology was based on the approach used by The Commonwealth Fund’s 2007, 2009, and 2014 State Scorecards on Health System Performance.