US needs better long-term support for older adults, ACP says


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

The COVID-19 pandemic has presented an opportunity to revitalize the systems that provide long-term services and support (LTSS) to older adults in the United States, according to the American College of Physicians (ACP).

The organization released a new position paper with recommendations to improve quality, accessibility, equity and affordability in the face of growing older adult populations.

The paper, published in Annals of Internal Medicine, noted that many nursing homes were unprepared for COVID-19 due to shortages of qualified staff and personal protective equipment — issues that have garnered attention through national media reports. However, according to the position paper and released statement by ACP President Ryan D. Mire, MD, FACP, the COVID-19 pandemic is shedding new light on the challenges facing LTSS across sectors.

“We have seen the devastating impact the virus has had on nursing home residents, both because of their age and the higher risk associated with community housing situations,” Mire said in the statement. “We have also seen that the pandemic has greatly exacerbated staffing shortages in these facilities. We must ensure that the US has a highly functional LTSS system, ready to meet increased demand and handle potential future pandemics or other events that threaten the patients who depend on these services.

“The population over 65 is expected to increase by over 15 million between 2020 and 2030, and those individuals will need an LTSS system they can rely on,” Mire said. “We need to improve the system so that it can meet today’s challenges and provide older adults with the additional services and support they will need in the future.”

An overview

The current economy of LTTS “reflects the broader healthcare system: a patchwork of privately and publicly funded programs that exclude large segments of the population,” the paper says, and this fragmentation complicates coordination between the medical and LTSS sectors.

LTSS can be administered in nursing homes or other institutional settings, or to patients in their own homes. According to the ACP, the services include assistance with tasks such as bathing, eating, dressing and other activities of daily living so that the individual can maintain or improve his or her quality of life.

Medicaid is the primary sponsor of paid LTSS in the United States. Medicare covers little, but many people mistakenly believe it will cover LTSS and are therefore financially unwilling to pay for it.

Qualified veterans can obtain LTSS through the Veterans Health Administration. The newspaper noted that at least one report said the market for private long-term care insurance had “collapsed,” with a dwindling number of companies offering the policies.

“Care has major economic implications,” ACP said.

In home and community-based services (HCBS), most LTSS are provided by unpaid caregivers, often family members or friends of patients. A 2019 AARP report estimated that in 2017, 41 million caregivers provided 34 billion hours of care valued at US$470 billion, with many caregivers under financial pressure, the newspaper said.

Possible solutions

ACP has made five recommendations to improve LTSS:

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

“ACP envisions a three-legged stool for LTSS funding: a publicly funded, universal, catastrophic back-end coverage program; an affordable and accessible private LTCI market to meet front-end LTSS needs before 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 the LTSS labor shortage with comprehensive training, raises, benefits packages and opportunities for career advancement and growth. ACP also supports helping unpaid caregivers through respite care, training and reimbursement.

“Workforce challenges are an immense obstacle to meeting demand for HCBS and other LTSS,” with low wages, a lack of benefits and limited opportunities for direct caregivers, the newspaper said.

  • The LTSS sector needs evidence-based interventions to ensure and improve quality across all settings, including monitoring and enforcement, better care coordination, and federal minimum staffing levels for nursing home nurses.
  • Research on the impact of ownership on the LTSS sector using verified, publicly available data on quality of care, staff and patient safety, costs and staffing.
  • Funding, support and staff to develop and implement strong emergency plans for patients and staff, with staff training on emergency preparedness, evacuation and housing. The need extends beyond the response to COVID-19, as nursing homes must cope with natural disasters such as hurricanes, and on-site housing may be safer than evacuating patients “who are cognitively impaired, extremely frail, or bedridden.”


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