Challenges for Long-Term Care in the Future

The complex and diverse programs and services that make up long-term care have evolved greatly throughout the years, and will continue to evolve as the demographics of the U.S. population change. It is certain that this country will need to have more long-term care services in all settings available in the near future. The long-term care delivery system is currently facing five particular challenges:

1. The aging of the population. Concern about the aging of the population and the forecasted number of people likely requiring long-term care cannot be understated. According to the National Clearinghouse for Long-Term Care Information, approximately 70 percent of people over the age of sixty-five will require some type of long-term care in their lifetimes. For more than 40 percent of these people, that care will occur in a skilled care nursing home setting. It is clear that the combination of an aging population and longer life expectancies will increase the demand for all forms of long-term care services in the decades to come. Additional concerns are the trends showing smaller family sizes, higher rates of divorce, and higher costs for the provision of care to a family member. These are factors with the potential to reduce the amount of informal care available to the elderly from family and friends.

2. The staffing shortages in the health care workforce. The demand for long-term care is predicted to exceed the supply of trained professionals who are qualified to deliver the needed services, which will lead to severe workforce shortages of 30 percent or more. This shortage of health care professionals has already begun in some areas of the country, as there are not enough qualified applicants to fill open positions for direct caregivers to the elderly. Historically, long-term care workers have been paid less than workers in acute health care settings, and this is a factor in the shortage of workers in the long-term care system. The rapid employee turnover that is common in some long-term care settings also contributes to less than adequate staffing levels and compromises quality of care. Nurses and other long-term care professional staff members need a more competitive wage, opportunities for continuing education, and better working conditions than they have been receiving if the significant rate of turnover is to be reduced. Long-term care providers work in a difficult setting, as they must provide care for multiple clients with various medical conditions and disabilities to manage and also navigate the difficult family dynamics that often come with working in this setting. Low wages, stressful conditions due to inadequate staffing and frequent turnover, lack of benefits, lack of social support (child-care assistance, transportation), minimal job security, and high personal injury rates are the main problems that must be resolved to raise job satisfaction and increase employee retention (Sultz & Young, 2009). Additionally, long-term care facilities must begin acting now to attract additional health care personnel into their settings – possibly by offering a more competitive wage and attractive benefits, by partnering with educational institutions that train nurses and other needed professionals, or by assisting with educational scholarships and/or offering signing bonuses.

3. The overall quality of care. As long-term care settings have evolved, so has the need for quality care. Care for our most vulnerable population must be of the utmost quality, client-centered, responsive, efficient, accessible, and cost effective. The quality of care provided varies greatly from facility to facility at this time. Research to clearly define and update the overall outcomes that are necessary and desired in long-term care is needed. Additionally, studies should compare the quality of care and the outcomes of care across the various long-term care settings. Once clearly stated outcomes for this industry are developed, instruments to measure and benchmark the progress (or lack thereof) in long-term care can be created and put to good use. Only then can we begin to brainstorm the types of changes to the system that might lead to advances in rehabilitative care and also maintenance and custodial care. Best practices in each setting should be published and shared to promote the best types of care possible for Americans in their last phase of life. Finally, the gaps in the Medicaid long-term care safety net need to be addressed, as the quality of the safety net varies greatly from state to state. Eligibility for services and benefits is limited in many states, and not all will qualify for monetary waivers to assist with the cost of care. This, too, must be studied so that quality care is available to all, and the gaps in the safety net closed.

4. The integration of services. In the past few decades the longterm care delivery system has diversified its offerings and facilities have specialized in some areas of care. This kind of diversification and specialty care carries an inherent danger of fragmentation of care, duplication of services, and attempts to push clients into narrow categories of services (Sultz & Young, 2009). There is a great need to turn our attention to the coordination and better integration of services for those who receive services in one setting then move on to another setting over time. Payers and policy advocates must ensure that incentives, such as higher payments tied to faster discharges and the like, do not cause further splits in the optimal continuum of care. Pressure from competition between providers and facilities often prevents partnerships from forming that could greatly benefit the future of collaborative and seamlessly provided long-term care services. Care must be taken to create a smooth transition, in terms of both physical provisions and financial coverage, for people leaving one long-term care setting and entering another.

5. Financing the cost of care. It appears that state and federal governments (acting through Medicaid and, at a lesser level, Medicare programs) will continue to finance the majority of future long-term care services. In particular the burden on Medicaid will increase sharply in the next few decades, given rising health care costs, the aging of the population, and the growing demand for long-term care services. The net increase in pressure on Medicaid and other payers is going to be difficult to handle, and state budgets will carry a heavy burden of the long-term care spending that will be necessary to cover the needed services (Henry J. Kaiser Family Foundation, 2005). Public policy has a difficult question to face here: Should public funding to the states be increased to cover the services, or should more of the responsibility be transferred to private individuals, thereby lessening the burden on the government? This question is particularly concerning as a shift in the tax base is also forecast because the proportion of older individuals to working adults will change from one in five as of 2002, to one in three by the year 2025. The final part of addressing this challenge will be the consideration of policies and incentives to improve the market for purchasing private long-term care insurance and the affordability of that insurance. Incentives (such as tax credits) to purchase private long-term care insurance and/or to promote informal caregiving systems of family and friends who actively look after those close to them might alleviate some of the financial burden on the public sector as well.


Long-term care refers to a broad range of medical and social service options that are available to meet the needs and compensate for the functional disabilities of persons of any age, but this care most commonly serves the elderly who can no longer function independently. The evolution and specialization of residential, community-based, and home health care services will continue. The aging of the population, rising rates of chronic disease, longer life expectancies, and advances in public health and medical technology will result in unprecedented numbers of people requiring longterm care services in the near future – even as a shortage of health care personnel is occurring. The health care industry must begin to work now to reduce the fragmentation that exists both in the continuum of long-term care services and in the system of payment for those services. Health care managers must stay current on and attentive to data trends, be prepared to quickly expand current programs, and collaborate with other care providers within their communities, and thereby be ready to serve an even greater number of people by providing seamless care that is accessible, effective, efficient, and affordable.



assisted-living facilities

community-based residential care facilities

home and community-based services

institutional providers

Lifespan Respite Care Act

long-term care

respite care

Social Security Act of 1935

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