Raising Expectations

The Scorecard is designed to help states improve the performance of their LTSS systems so that older people and adults with disabilities in all states can exercise choice and control over their lives, thereby maximizing their independence and well-being. Our intention is that this Scorecard will begin a dialogue among key stakeholders so that lagging states can learn from top performers and all states can target improvements where they are most needed. Furthermore, we hope that the Scorecard will underscore the need for states to develop better measures of performance over a much broader range of services and collect data in order to more comprehensively assess the adequacy of their LTSS systems.  

The Scorecard examines state performance across four key dimensions of LTSS system performance, developed in consultation with a team of expert advisors: (1) affordability and access; (2) choice of setting and provider; (3) quality of life and quality of care; and (4) support for family caregivers. Exhibit 1 illustrates each state's overall ranking as well as its quartile of performance in each of the four dimensions. These four dimensions align with the characteristics of a high-performing LTSS system as recently articulated by the authors in Health Affairs.¹ We identified a fifth dimension, coordination of LTSS with medical services, which is also critically important but were unable to create indicators to measure that dimension with currently available data. Indeed as we discuss below, one of the more noteworthy "findings" of our work on the Scorecard is how much we are not able to compare because information on quality, experiences, coordination, costs, or outcomes is simply not available. Information is critical to guide and inform improvement. We hope that this LTSS Scorecard will spark future federal and state action.   

Within the four dimensions, the Scorecard includes 25 indicators. Exhibit 2 lists the indicators that compose each dimension and shows the range of performance across the states for each indicator. While some of the indicators rely on data that have been reported elsewhere, many represent new measures. Several indicators are constructed from a range of data in a related area, facilitating the ability to rank states in areas of performance that are difficult to assess. As such, the findings differ from analyses that examine a single aspect of states' LTSS systems, such as the "balance" of public services provided in home- and community-based settings compared to nursing homes. This multidimensional analysis involves a richer exploration of data to assess performance, thereby capturing state performance across a complex range of system characteristics.