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Individuals and Families

What is LTSS?

Also referred to as long-term care (LTC), long-term services and supports (LTSS) encompasses a broad range of services by paid or unpaid caregivers that assist people who have limitations in their ability to care for themselves due to a physical, cognitive, or chronic health condition that is expected to continue for at least 90 days.

A person who needs LTSS often requires assistance with one or more activities of daily living (ADLs) such as bathing, dressing, eating, transferring, and walking and/or instrumental activities of daily living (IADLs) including meal preparation, money management, house cleaning, medication management, and transportation. LTSS may include hands-on assistance, supervision, cueing or standby assistance as well as assistive technologies and devices.

Source: Long-Term Care Fundamentals No. 1: An Overview of Long-Term Care in California. The SCAN Foundation, November 2010.

Why is LTSS Important?

When it comes down to it, quality LTSS should make it easier for older adults and those with physical disabilities to live as independently as possible, and remain in their homes and communities where they prefer to be.

Family and other unpaid caregivers (e.g., friends, neighbors, etc.)  are the bedrock of any state LTSS system, providing nearly $470 billion in unpaid care. Any LTSS system should ensure that caregivers have access to the support they need. The Scorecard highlights the essential policies that can better support caregivers. 

How does the Scorecard work?

The Scorecard utilizes five categories, called dimensions, to measure state-level LTSS performance.

Affordability and access: consumers can easily find and afford the services they need, and there is a safety net for those who cannot afford services.

Choice of setting and provider: a person-centered approach to LTSS places high value on allowing consumers to exercise choice and control over where they receive services and who provides them.

Quality of life and quality of care: services maximize positive outcomes and consumers are treated with respect.

Support for family caregivers: the needs of family caregivers are assessed and addressed so that they can continue in their caregiving role without being overburdened.

Effective transitions: LTSS are arranged to integrate effectively with health care and social services, minimizing disruptions such as hospitalizations, institutionalizations, and transitions between settings.


Download the FAQs for Individuals and Families as a PDF.


Long-term services and supports (LTSS) may involve, but are distinct from, medical care for older people and adults with disabilities. Definitions of the term vary, but in this report we define LTSS as assistance with activities of daily living and instrumental activities of daily living provided to older people and other adults with disabilities who cannot perform these activities on their own due to a physical, cognitive, or chronic health condition that is expected to continue for an extended period of time, typically 90 days or more. LTSS include human assistance, supervision, cueing and standby assistance, assistive technologies and devices and environmental modifications, health maintenance tasks (e.g., medication management), information, and care and service coordination for people who live in their own home, a residential setting, or a nursing facility. LTSS also include supports provided to family members and other unpaid caregivers.Individuals with LTSS needs may also have chronic conditions that require health or medical services. In a high-performing system, LTSS are coordinated with housing, transportation, and health/medical services, especially during periods of transition among acute, post-acute, and other settings. For the purpose of this Scorecard, people whose need for LTSS arises from intellectual disabilities (ID) or chronic mental illness (CMI) are not included in our assessment of state performance. The LTSS needs for these populations are substantively different from the LTSS needs of older people and adults with physical disabilities. Including services specific to the ID and CMI populations would have required substantial additional data collection, which was beyond the scope of this project.

The Long-Term Services and Supports Scorecard (LTSS Scorecard) is a unique ranking and policy tool designed to inform people—ranging from policy makers and other stakeholders to members of the public—about the extent to which states have developed LTSS systems to meet the needs of older adults (ages 65 and above), adults with physical disabilities, and family caregivers. The Scorecard website includes performance rankings of the 50 states (and the District of Columbia)—both for overall performance and within five different categories, called dimensions: Affordability and Access, Choice of Setting and Provider, Quality of Life and Quality of Care, Support for Family Caregivers, and Effective Transitions. The rankings are derived from 25 indicators that measure state performance. You can interact with Scorecard data using the map and tools, which allow you to drill down into the indicator information for a single state or compare state performance on selected indicators. In addition to the state rankings, the Scorecard website includes a series of briefs on promising practices and emerging innovations. These briefs describe various strategies, practices, and tools states can use to improve the lives and well-being for older adults and people with physical disabilities, and their family caregivers. Additional case studies and reports are also available on the website. While the Scorecard is of great value to policy makers and other stakeholders, consumers can gain much from it as well, for they are the “customers” of any high-performing LTSS infrastructure. This is a particularly relevant issue as the population ages. Consumers can use the Scorecard to

  • understand the goals and benefits of a high-performing LTSS system,
  • learn the importance of such a system as well as the needs that arise as people age, and
  • help their communities and government representatives identify opportunities for improvement and establish priorities going forward as well as assess progress.

Policies at the state level play a huge role in shaping the LTSS system. States rely heavily on federal funding—including Medicaid and the Older Americans Act—to finance LTSS for their citizens, but these programs are administered at the state level and, consequently, vary widely. Nursing home care, for example, is a mandatory benefit under Medicaid and is provided by all states, but states have an array of options for providing home- and community-based alternatives to nursing home care. Other state choices and investments also affect the design and delivery of LTSS, from supplementing access to affordable services through state-funded homecare programs to providing consumer information, education, and outreach for aging services. States’ priorities and choices shape LTSS systems and how well they work for consumers and caregivers. For example, research consistently shows that people want to live in their communities as long as possible as they age, and so members of the public should be aware of various options that states have in this area so that they can help guide their state’s choices. The Scorecard ranks state performance to provide insight into what’s working and how states can do better.

To rank states, we developed five dimensions of LTSS system performance. Within each dimension, we selected indicators that would meaningfully represent state performance in each dimension. A National Advisory Panel helped ensure that the categories correspond to the issues that matter to consumers and families, and that categories are sensible and comprehensive. The five dimensions of LTSS system performance are (a) Affordability and Access, (b) Choice of Setting and Provider, (c) Quality of Life and Quality of Care, (d) Support for Family Caregivers, and (e) Effective Transitions. The expert panel provided input on the dimensions, the measures to be included in each category, and the data sources used. The rankings provide a meaningful comparison of state performance. However, information on some important aspects of LTSS is not available. Perhaps most important, we were unable to include measures of the quality of home- and community-based services (HCBS). Today, some states measure certain aspects of HCBS quality, but there are no standardized measures collected across all states. As a result, the quality category includes just two indicators that measure the quality of nursing home care—despite the fact most people who need and use LTSS are living at home or in another community setting. For more information, see the methodology section of the website. National efforts are underway to improve the collection and reporting of standardized HCBS quality measures. Ideally, states will adopt a core set of standardized measures that can be used to improve programs and outcomes—and that we can use to create a more robust quality category in the next version of the LTSS Scorecard.

The highest-performing states—that is, ranked in the top quartile overall—are those that perform relatively well across the five dimensions of LTSS system performance. A couple issues are of note: The first is how much better the states in the top quartile perform. The top-performing states tend to rank high across the board. Second, it’s important to be aware that the rankings don’t tell us whether the state systems at the top of the Scorecard rankings deliver the outcomes we want and expect for people who need LTSS and their families. In other words, in this still-advancing field of understanding LTSS quality and efficacy, there’s no absolute standard—for affordability or quality, for example—against which state performance is compared.

The lowest-performing states—that is, ranked in the bottom quartile overall—are those that perform relatively poorly across the five dimensions of LTSS system performance. Wide variation exists within all dimensions and on most indicators, with low-performing states being markedly different from those that score high.

It is tempting to compare the three Scorecards (2011, 2014, and 2017) to see whether a state has risen through the ranks (or perhaps fallen). Unfortunately, due to changes in data and methods, the Scorecard rankings cannot be compared in this way. The best way to tell if your state is improving or declining in performance is to assess change in the indicators that are measured consistently over time. For 23 of the 25 indicators in the current Scorecard, baseline data are available to measure change over time. See the list in Exhibit 1. Detailed performance data showing state-level change over time are available in the data tables in Measuring Change in Performance. One thing to note is that we report improvement or decline in an indicator only if a measure improved or declined by 10 percent or more. In some cases, another threshold was used. For more information about how the thresholds were calculated, see Measuring Change in Performance in the methodology section of the website. For those Scorecard readers who want to assess changes in rank, please note that ranks are not directly comparable between years. There were some changes in the indicators used (i.e., new indicators were added, some indicators were dropped, there were methodological changes in some indicators, and some indicators were moved to a different dimension, changing the computation of dimension and overall ranks).

Overall, there was more improvement than decline in LTSS system performance between the 2014 Scorecard and the current Scorecard: nearly all states (49) had more improved than declined indicators. Many indicators were unchanged. Most states had improved indicators in four of the five dimensions: Choice of Setting and Provider, Quality of Life and Quality of Care, Support for Family Caregivers, and Effective Transitions. States were less successful in achieving improvements in Affordability and Access. In only 17 states did the number of improved indicators exceed the number of declined indicators for Affordability and Access. Most states did not decline, but they didn’t improve, either—they mostly stayed the same. In contrast, states typically improved in the dimension of Support for Family Caregivers. Forty-nine states improved on at least one indicator, and 42 states had more improved than declined indicators in this category. In short, results from the Scorecard indicate that states can and should pick up the pace of improvement in order for America to meet its near- and longer-term LTSS needs.

All states have opportunities to improve LTSS system performance. Even the highest-ranked states can do better than they do today. States can use the Scorecard as a starting point for identifying opportunities for improvement and setting program and policy priorities. Since relatively few states improved in the Affordability and Access dimension, this may be an appropriate area of focus for many states. To increase the enrollment of poor and low-income people who need LTSS, state policy makers may want to consider reforms to Medicaid eligibility policies. One effective way for a state to improve on indicators in several areas is to expand outreach to populations that may be eligible for, but not enrolled in, Medicaid—including people who could benefit from community-based LTSS, for example. These eligibility expansion and outreach activities have the potential to improve state performance on several Scorecard indicators. As for the Affordability and Access indicators, many states could create better home- and community-based systems to reach people who may need only relatively modest home care to remain independent in the community may achieve higher rates of coverage in Medicaid. This approach, incidentally, also has been shown to be potentially more cost-effective than nursing home care. One goal of the Scorecard is to shed light on high-performing states so other states can learn from their strategies and successes. On the Scorecard website, states can find a variety of reports—case studies, promising practices, emerging innovations, and others—that describe the strategies used and outcomes achieved in several high-performing and fast-improving states.

We selected valid, objective, and reliable indicators to provide an overview of state performance in each dimension. Most of the indicators are derived from federal government administrative databases or surveys. These sources are considered among the most reliable because they are subject to some oversight by federal program administrators and social scientists who assess survey data for accuracy. The methods used to combine the data into composites and rankings are simple and transparent. We convened a National Advisory Panel of experts in LTSS to provide input on the indicators and the methods used.

For each indicator, the most recently available data as of January 2017 are used. The data-reporting years range from 2012 to 2016, with most indicators relying on 2015–16 data. See State LTSS Scorecard Ranking Methodology and Detailed Indicator Descriptions in the methodology section of the website.

The 2017 Scorecard relies mostly on the same indicators used in 2014. However, some indicators had to be dropped (because data were no longer available) and two new indicators were added. The major changes in the 2017 Scorecard affect three dimensions: Choice of Setting and Provider, Quality of Life and Quality of Care, and Support for Family Caregivers. For the implications of these changes, see How can I tell if my state is improving? For more information on changes to the data and definitions, see the methodology section on the LTSS Scorecard website.

The lack of affordable and accessible housing is a significant barrier to enabling people who use LTSS to live in their own communities. The 2017 Scorecard, therefore, includes a measure of subsidized housing opportunities. The indicator is an overall measure of the statewide availability of affordable housing; it is not limited to people who need LTSS. Since assisted living is often unaffordable to people with low or modest incomes, subsidized housing plays a large role for older adults and people with physical disabilities. More than half of all subsidized households are headed by a person age 62 or older or by a person with a disability. One indication of how closely related affordable housing and LTSS are is that states increasingly are providing housing-related services under Medicaid (such as tenancy services for community-based LTSS Medicaid beneficiaries) and Medicaid agencies are partnering with housing agencies to expand housing development opportunities for those who receive home- and community-based services. Without an adequate supply of subsidized housing units, states are likely to have difficulty finding housing for low-income older people and people with disabilities who do not own a home.

The LTSS Scorecard was released in 2011, and updated in 2014 and 2017. The goal is to update the Scorecard every two to three years.