LTSS Choices: Home and Community-Based Services for Older Adults – AARP

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LTSS Choices: Home and Community-Based Services for Older Adults (PDF)
Demand for home and community-based services (HCBS) is expected to continue to increase over time as the 65+ population grows larger and older and has a greater need for long-term services and supports. More than 80 percent of adults have expressed a desire to remain in their homes and communities as they age and prefer a home setting over a nursing home or other institutional setting.  
HCBS includes a wide range of services and supports provided at home (e.g. personal/home care, home health services, home modifications) and in the community (e.g. transportation, meal services, and adult day services).
The $12.7 billion investment in state Medicaid HCBS programs from the American Rescue Plan Act has the capacity to transform state HCBS systems in the coming years. This fact sheet serves as a primer on the current state of home and community-based long-term services and supports for older adults and highlights successful models for expanding these services.
HCBS Recipients and Providers
Most people who receive HCBS are older adults and people of all ages with disabilities. In 2018, for example, about 12.6 million American adults living in the community needed LTSS, and more than half (6.7 million) were over age 65. 
Much of the work of HCBS is performed by more than one million direct care workers, including personal care aides and home health aides, more than half of whom are Black or Hispanic/Latino and 87 percent of whom are women. HCBS settings also serve more diverse populations than nursing homes and other institutional settings.
Family support underpins the entire LTSS system, and unpaid family caregivers furnish the majority of activities of daily living (ADL) supports to older adults and people with disabilities. As of 2020, more than 40 million adults served as family caregivers (which includes friends and neighbors) and many incur out-of-pocket costs.
HCBS Financing
People receive HCBS by paying for services and supports a) privately, b) through enrollment in public coverage, or c) through private long-term care insurance. And despite the common misperception, Medicare does not cover most LTSS costs, with only a subset of HCBS services (e.g., home health services) covered for a limited duration of time.
Medicaid is the primary source of public HCBS funding, with more than $50 billion going to HCBS for older adults and people with physical disabilities in recent years. Under federal Medicaid law, most HCBS are included as an optional benefit, while nursing home services are categorized as mandatory. The optional nature of these services gives states discretion and results in significant variation across states, as reviewed in detail in the fact sheet.
Other sources of HCBS funding are:
Expanding HCBS
Some of the service delivery models and policy solutions that have helped expand HCBS access and improve services in recent years could be further expanded to accommodate older adults’ and people with disabilities’ overwhelming preference to age in their own homes and communities.
 
Suggested citation:
Hado, Edem, and Brendan Flinn. LTSS Choices: Home and Community-Based Services for Older Adults. Washington, DC: AARP Public Policy Institute, November 2021. https://doi.org/10.26419/ppi.00153.001
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A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers
 
Aging Demographics

By 2030, one out of every five people in the United State will be 65-plus. Will your community be ready?
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