In the half century since enactment of the 1965 Great Society programs, accomplishments were gradually made to improve access to and quality of long-term services and supports (LTSS), including: mitigation of financial and care abuses in nursing facilities (NFs); substantial rebalancing of LTSS towards consumer-preferred home-and-community-based services (HCBS); increasing flexible consumer-centered HCBS including payment to family caregivers; and more assisted-living and housing options for seniors with heavy care needs. A unified planning and advocacy agenda across age and disability type and greater consumer transparency fueled progress. Nonetheless, LTSS is a broken system; persistent problems interfere with substantial and necessary change. These include; over-emphasis on safety for LTSS consumers; inattention to physical environments in all settings; regulatory and professional rigidity; and poor communication and information. Our recommendations are aimed at builders and designers, LTSS professionals, regulators, and educators/trainers; the last may be crucial in forging new consensus and over-coming entrenched beliefs. Policy recommendations include relatively narrow steps-for example, requiring single occupancy in all NFs and assisted living settings financed with public dollars-to broad reworking of the prerequisites for livable age-friendly (and dementia-friendly) communities and for a capable, flexible LTSS workforce.
Bibliographical noteFunding Information:
This article is built on insights gleaned from multiple research projects done by the authors over 25 years. We are grateful to our funders, including the Centers for Medicare & Medicaid Services (project officers Mary Pratt, Karen Schoeneman for Quality of Life studies, and Mary Beth Ribar, Dina Elani, and Kathryn King for Rebalancing Studies); the Retirement Research Foundation, which supported Small-House Nursing home studies (project officer Julie Kaufman) and Lois Cutler''s work on Design on a Dollar through a grant to the Pioneer Network; the Agency for Health Research and Quality (project officer William Spector); the Robert Wood Johnson Foundation; the Commonwealth Fund (project officer Mary Jane Koren); the Facility Guidelines Institute (especially Jane Rohde), the Maurice and Hulda Rothschild Foundation (Robert Mayer) and the University of Minnesota Center on Aging (Robert L. Kane). L. J. Cutler acknowledges the support and encouragement of Episcopal Church Homes in Minnesota, where she has long been a board member and/or consultant and project leader.
- Paid caregivers
- Physical environments
- Public policy
- White house conference on aging