In my conversations with people who are exploring their senior living options, I’ve had many people ask about which states have the best long-term care. The Long-Term Services & Supports State Scorecard for 2020 puts some objective numbers to this common query.
The scorecard was produced by the AARP Foundation, The Commonwealth Fund, and The SCAN Foundation to look at long-term services and supports (LTSS) by state, from the vantagepoint of users of these services and their families. Created using a compilation of state data and analysis, the scorecard presents some rather stark finds about which states rank highest — and lowest — in terms of LTSS available to their residents.
What are LTSS?
As the report notes, the term LTSS is defined as the day-to-day assistance needed by people with long-term health conditions, disabilities, or general frailty. Help may be required for activates of daily living (ADLs) like bathing, dressing, or using the toilet. LTSS could also be applied to the assistance needed with instrumental activities of daily living (IADLs) such as housekeeping, medication management, transportation, paying bills, and meal preparation.
These support services may be provided in the person’s private home, in an assisted living community, or in a skilled nursing facility (aka, a nursing home), or in a continuing care retirement community (CCRC, or life plan community), which offers a continuum of care services, as well as independent living. LTSS also encompass the support services provided to family members and other unpaid caregivers.
Scorecard methodology and criteria
The LTSS Scorecard for 2020 looked at a wide array of criteria in order to come up with a ranking for each state as well as Washington, D.C. The report measured 26 indicators (or policy categories) across these five dimensions:
- Affordability and access: Six indicators including cost of nursing homes and home care; percentage of adults 40+ with long-term care insurance; percentage of people on Medicaid; and access to long-term care resources
- Choice of setting and provider: Seven indicators including home and community-based service services; assisted living and residential care units; adult day services; subsidized housing; and home health and personal care aides for people with ADL disabilities
- Quality of life and quality of care: Four indicators including two key measures of nursing home quality: the percentage of high-risk nursing home residents with pressure sores and the percentage of long-stay nursing home residents who inappropriately receive antipsychotic medication
- Support for family caregivers: Twelve policy areas, grouped into four broad categories including things like state supports for working caregivers; assessing family caregiver needs; and the ability to delegate nursing tasks
- Effective transitions: Five indicators that include measures of hospitalization and institutionalization that should be minimized in a high-performing LTSS system
The scorecard researchers note that, “Indicators had to be clear, important, and meaningful, and have comparable data available at the state level. These 26 indicators were selected because they represent the best available measures at the state level. While no single indicator can fully capture LTSS system performance, taken together they provide a useful measure of how state LTSS systems compare across a range of important dimensions.”
Top states for long-term care services
Bottom states for long-term care services
44. Indiana and Arkansas (tie)
48. South Carolina
50. West Virginia
Interestingly, when comparing the 2020 scorecard data to previous years, state performance remained fairly flat across most indicators. For example, six states have consistently ranked in the top 10 (Colorado, Hawaii, Minnesota, Oregon, Washington, and Wisconsin), and seven states have consistently ranked in the bottom 10 (Alabama, Florida, Indiana, Kentucky, Oklahoma, Tennessee, and West Virginia) across all four editions of the scorecard.
What is happening with long-term care in Florida?
There may be one state’s ranking that jumps out at many of you, like it did for me: Florida. The Sunshine State has the highest percentage of residents age 65 and older in the nation — about 21 percent of its population — yet they rank last on this 2020 LTSS Scorecard.
The report revealed a number of opportunities for improvement in Florida.
- Affordability and access: While the cost of nursing home care is unaffordable for middle-income Americans in every state (upwards of $100,000 per year for a private room), Florida nursing homes ranked 39 out of 51 for cost as a percentage of median household income for people age 65 and older.
- Choice of setting and provider: Ranking 50 out of 51 for this category, Florida scored particularly low for its number of home health and personal care aides, as well as for availably of subsidized housing for low-income residents who need care.
- Quality of life and quality of care: Florida improved here versus previous years’ scorecards by reducing the number of nursing home residents being given antipsychotics drugs, but they still ranked just 39th for pressure sores among nursing home residents.
- Support for family caregivers: Florida is not among the states offering residents more than the federal minimum Family and Medical Leave Act (FMLA) requirements.
- Effective transitions: Florida ranked last for the percentage of nursing home residents who experienced one or more potentially difficult moves at the end of their life.
Seeing the larger picture
Looking at these state rankings, it is important to reiterate that just because a state doesn’t rate well overall doesn’t mean that every single provider in the state is doing a poor job. On the contrary, there are thousands of seniors in even the lowest-ranked states who are receiving high-quality long-term care services thanks to the hard work of dedicated care providers.
And as for Florida, there are promising changes being made that will hopefully impact their future long-term care scorecard rankings for the better. For example, the Florida legislature recently passed a law aimed at reducing the number of poor, disabled, and elderly residents who are on the wait list for placement in the state’s Medicaid-managed long-term care program.
To sum up: If you have always imagined you’d retire to one of the states that is ranked toward the bottom of the LTSS Scorecard, you don’t necessarily need to quash your dream. It may be wise, however, to do a bit more research to determine if you will be able to afford and access the quality of long-term care you may potentially need one day.