AARP, The Commonwealth Fund and The SCAN Foundation have released their second long term care scorecard, a state-by-state breakdown of performance of long-term services and supports that help older adults, adults with disabilities and their family caregivers. The rankings looked at 26 performance indicators within five dimensions of care for each of the 50 states, plus the District of Columbia and classifies them against each other.
Minnesota led the way among all states in all dimensions – affordability and access, choice of setting and provider, quality of life and quality of care, support for family caregivers, and effective transitions. It was the only state to rank in the top quartile for all five dimensions.
“The scorecard underscores value and importance and of state leadership and state policy,” said Melinda Abrams, vice president for health care delivery system reform, The Commonwealth Fund in a telephone press briefing. “Leading states have implemented laws and policies that build stronger Medicaid programs, and support the family caregiver.”
Policymaking at the state level sets the stage for a high performance system, she said. Indicators such as strong paid sick leave policies for caregivers and more funding of home- and community-based services help older adults age in place longer, or keep them out of nursing homes all together.
Other states in the top tier are Washington, Oregon, Colorado, Alaska, Hawaii, Vermont, Wisconsin, California and Maine. The lowest performing states were Indiana, Tennessee, Mississippi and Alabama; Kentucky ranked 51st.
This report is an important attempt to envision a multidimensional approach to what system performance looks like, said Susan Reinhard, AARP’s senior vice president for public policy. “We hope that states will look at it, that they will target areas for improvement, and engage both the public and private sectors.” It takes a combined public and private effort that can make all state long-term support systems better, she said.
Even the top-performing states have room to improve, Reinhard said, as they prepare for the first wave of baby boomers who turn 80 in just 12 years. This is a cohort in which many struggle with multiple chronic conditions, dementia, frailty and require help with basic activities of daily living.
The Scorecard shows that states that rely heavily on nursing homes for LTSS demonstrate less effective transitions across care settings. This leads to increased avoidable hospitalizations and higher costs, especially for people with complex care needs. They also receive less support when moving back into a community setting.
Another major finding was that adequate long-term care services continue to be out of reach for most middle-income families. On average, nursing home costs will consume 246 percent of the median annual household income of older adults. That means more people will quickly spend down their life savings and ultimately turn to Medicaid, the publicly financed safety net, according to the report.
State level data is available online, and that provides real insight in how to make improvements said Bruce Chernof, M.D., president and CEO of The SCAN Foundation. The database allows for comparisons among states and by individual indicators.
I asked whether CMS will use some of this data to enact more uniform national standards. Reinhard said that while CMS was “eager” to do more, it takes a long time to develop quality indicators. “The dearth of information on quality for home- and community-based services has been known for years, and there’s much activity in that area – so we have hope that we’ll be getting person- and family-centered care measured.”
A transitions improvement initiative may be easier to implement because claims data exists and “I know CMS is quite interested in this especially because of the penalties they have for hospital readmissions within 30 days,” she said.
Chernof, who was the chair of the Federal Commission on Long Term Care, said there is a role for federal policy to narrow the range of variability highlighted in the report, such as creating more level national standards around training home- and community-based workers. “In California, for example, you need more training to be a cosmetologist than you do to be a home care worker. As a physician, that for me, is a problem.”
Another area where federal policy might be helpful is in setting up uniform assessment. “We assess people once, we include the family in that assessment, and we share it with all the providers,” he said. “So the individual receiving care doesn’t spend most of their time repeating their name, their list of medications or trying to remember what was in some other provider’s file.
However, he said, these services are delivered state by state and community by community, so this in the end, this needs to be solved at the state level, through state leadership.
Where you live ultimately determines what LTSS you will receive, the report concluded. Tremendous variation between states – especially between high and low-performing states on some indicators – shows that there is still a long way to go to ensure adequate LTSS for everyone.
