This paper examines the growing demand for home and community-based long-term care services (LTSS) in the United States, driven by an aging population and advances in medical technology. It reviews the current landscape of Medicaid and Medicare funding, the role of the Scorecard in assessing state performance, and the contributions of advanced practice registered nurses (APRNs) in home care settings. The paper also analyzes research on cost-effectiveness challenges, highlights wide funding disparities across states, and evaluates legislative frameworks such as the Affordable Care Act and the Deficit Reduction Act of 2005. It concludes with policy recommendations focused on interstate communication, stakeholder partnerships, consumer empowerment, and technology-enabled service delivery.
The paper demonstrates effective use of policy synthesis — drawing together legislative texts, government data, and academic proposals to evaluate a real-world public health challenge. Rather than simply summarizing each source, the author uses them comparatively to highlight interstate disparities and structural inefficiencies, a technique central to health policy writing.
The paper opens with a broad societal framing before narrowing to the mechanics of U.S. long-term care systems. A dedicated background section establishes the Scorecard framework and Medicaid ideals. Subsequent sections address the APRN workforce, cost-effectiveness research, financing reform proposals, and relevant legislation. The conclusion synthesizes findings into actionable recommendations, giving the paper a clear funnel structure from macro context to specific policy action.
Today, we face many challenges in society. Some of these relate to the costs of living, while others relate to political, social, educational, and a myriad of other issues. One major challenge facing society today — and for which we are somewhat ill-prepared — is the increasing number of years an average human being might expect to live. Medical technology and greater attention to longevity-increasing lifestyle habits have created a major demographic shift towards what is referred to as an "aging" society. This means that most people alive today face a situation in which they will probably reach extreme old age. In turn, many more people than in the past will be in need of long-term care, either at home or in an institutional setting. This challenge has created a great economic burden on states to fund such care for the citizens most in need.
Although all states have systems in place to deal with the care needs of their citizens, few of these are uniform. Some states, for example, emphasize institutional care in terms of their funding, while others have begun to place increasing emphasis on providing high-quality home and community-based long-term care for people who prefer it. In order to better address the needs of citizens in a truly person-driven way, states, professionals, and service users need to enter into partnerships to find solutions to funding challenges and to secure the highest quality of care resources for citizens across the country.
Today, the older, disabled, or otherwise care-dependent person has a choice of two basic options: receiving care in the home setting or receiving care in an institution. According to the AARP (2013), today's person in need of services has the option of long-term services and supports (LTSS). These include assistance with routine daily activities such as bathing, eating, and shopping. When a cognitive or chronic health condition affects daily life over the long term, this is the type of service that might interest a person. Long-term assistance might also include equipment such as wheelchairs or environmental modifications to the home.
The most widely used health care systems in the United States today are Medicaid and Medicare. These systems provide support for people in need of both short- and long-term care. Long-term services and supports listed under Medicaid fall under either institutional or home and community-based services, as noted above (Medicaid.gov, 2013). While both options have their benefits and drawbacks, most people today — especially when facing age-related challenges — prefer to remain at home for as long as possible before being institutionalized.
The ideal for home and community-based care is to provide the optimal quality of care a person might expect. According to Medicaid, this includes several guiding principles for long-term care in the home setting. At its foundation is the partnership paradigm, according to which service providers and institutions work in partnership with states, consumers, and advocates to promote an optimal level of care for individuals who need it.
The specific aims of this paradigm are to provide services that are person-driven. This means that people in need of long-term care should have choices regarding who is involved in their care, where care is provided, the level of participation in community life, and other decisions relating to their care. Another principle is inclusiveness: all users are supported and encouraged to live where they wish while having access to all the services and professionals they need. Effectiveness and accountability mean that a high quality of service is provided, while all partners ensure responsibility in terms of level of care and usage of funding, whether from private or public sources. The system should also be sustainable and efficient, balancing economy with coordinated care and payment. Finally, the system should be transparent, making effective use of tools such as information technology to provide consumers, providers, and taxpayers with fully disclosed information regarding the application of funding.
While these ideals look very good on paper, the reality is often that the system remains somewhat less than streamlined — especially regarding costs at the state level. This is not to say that services are not provided at the level promised. The simple reality, however, is that today's health care system in the United States tends to be overwhelmed by the increasing needs, especially among the aging population, for services that were unforeseen mere decades ago.
Today, an estimation device known as the "Scorecard" serves to stabilize the current divide among states regarding the quality, quantity, and costs of services provided. The current Scorecard focuses on state services provided for older people and adults with physical disabilities.
The main purpose of the Scorecard is to measure the ability of states to provide "high-performing" or "excellent" LTSS to individuals within that state. Several characteristics have been identified as markers of excellence for these services.
The first is affordability and access. Long-term care services provided at the state level must be both affordable and accessible to those who need them. It should be easy for consumers to find and afford these services.
The second is the choice of setting and provider. As noted, it is increasingly common for consumers to prefer long-term care services in their homes. This requirement therefore concerns the ability of states to offer a range of at-home and institutional settings for consumers to choose from. These services also need to take a person-centered approach regardless of setting, and must offer consumers a choice of caregivers.
A third requirement is quality of life and quality of care. Services are required not only to offer maximum positive outcomes, but also to include respect in the treatment of individuals. Whenever possible, personal preferences of care recipients should be honored.
In many cases, family members act as caregivers, especially in the care of older people. In such cases, the needs of non-professional caregivers should be taken into account by state services. Concerns include the risk of caregiver overburdening, particularly where issues such as employment and childcare are also involved.
According to the Scorecard, states are also required to offer effective transitions and organization of care. This means that long-term care services need to be coordinated and integrated with other health services and social supports. Where an older person already receives care from a social worker, for example, that professional needs to be involved when the individual's long-term care needs change.
The Scorecard provides a valuable tool for determining both the current level of services provided at the state level and the needs still unmet among clients. In addition, the organization, delivery, and financing of these services can be streamlined more effectively with the inclusion of the Scorecard or similar estimation tools. This remains a major challenge, however, since services currently offered by states and the policies supporting them are widely divergent.
One issue of great concern in the choice between home care and institutional care is the quality and type of care the individual is able to obtain. For this reason, advocates who promote increased home and community-based long-term care have also promoted the ability of individuals to enlist the services of professionals such as advanced practice registered nurses (APRNs) (Brassard, 2011, p. 4). According to Brassard (2011, p. 4), there are several benefits to allowing nursing practitioners to practice in the home setting. In addition to the professional service received at home, such an arrangement also allows the individual to receive institutional care once that becomes necessary.
Although a prolonged home setting for the long-term care of an aging, ill, or disabled person has become the increasing norm — and indeed the preferred choice within many families — it is also a fact that the home setting can become unviable when it can no longer meet the individual's needs. Involving a nursing practitioner has the advantage of helping patients and their family members make sound decisions regarding their health and the specific needs of continued care, whether at home or in an alternative care setting.
Proposed legislation to allow advanced practice registered nurses to certify home health services also has the advantage of relieving the burden on formal institutions by streamlining both the certification decision and the provision of home services to long-term care patients. Registered nurses are qualified, educated, and certified to provide a high quality of various care services in a home setting or elsewhere. Granting these practitioners the power to certify and provide home care is therefore a meaningful solution to an overwhelming problem that has plagued the health care environment in recent years.
Nursing practitioners, by the nature of their work, are closely connected to the needs of individual patients. This means they are often better positioned than many other health care providers to assess the needs of individuals, their households, and the level of care required. This places them in a strong position to accurately determine when long-term home care is appropriate and when it has become unviable. As such, registered nurses serving individuals in the home setting can maintain a clear estimate of their needs while also preserving the individual's dignity — especially in cases of terminal illness or extreme old age.
The ultimate result is that home-care delays and preventable hospitalization can be avoided, since nurses working directly with patients are generally more accessible than physicians, who are more often burdened with heavy workloads. Access to home care for the public will increase, while costs will be reduced, since nursing practitioners are more directly involved than external physicians in care certification decisions. Extra physician visits and possible ambulance services may thus be avoided.
In reviewing research on the cost-effectiveness of home care services, Doty (2000) found a somewhat different situation than the ideals suggested by Medicaid.gov. One finding, for example, suggests that the costs incurred by providing greater access to long-term care in a home and community environment often, at best, equal those of an institutional setting — or, at worst, create greater expenditures.
One significant reason for this is that the home-based care systems investigated often included formal home care for individuals who would not have been at high risk for institutionalization even without formal care at home — in other words, people who would have benefited from informal care provided by family or friends.
Doty (2000) therefore suggests that targeting individuals in actual need of formal care, combined with a higher availability of informal community supports to offset the costs of formal supports, could provide a higher likelihood of budget neutrality for home-based care systems. However, constrained budgets also mean a lower level of services available within communities, which in turn limits people's ability to make choices regarding their long-term care — an outcome that conflicts with the "person-driven" requirement outlined by Medicaid.
The result is a difficult trade-off between the services provided and the costs related to those services. A further challenge is that these costs are by no means consistent across the country. Some states focus their funding on encouraging individuals to use institutional care, while others invest in enhancing home-based and community services for their citizens. This creates wide disparities in the services and their quality across states. There is, however, an encouraging trend toward providing more home care services funded by entities such as Medicaid. The main challenge is to structure funding so that home and community-based services for those who prefer them are at least as cost-effective as institutional care settings.
While it is easy to make the case for home-based long-term care over institutionalized services, the challenges are significant. Financing is the primary concern. There is a wide discrepancy among states in the amount of expenditure related to long-term care services for individuals who need them.
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