High-Performance Revisited: Examining Long-Term Services and Supports System Performance

Elderly woman sitting in a wheelchair facing the window in a bedroom
Published November 10, 2022

AARP Public Policy Institute (PPI) published the inaugural Long-Term Services and Supports (LTSS) State Scorecard (the Scorecard) in 2011. This first-of-its-kind project measured state LTSS system performance and ranked states in comparison to one another. Building on the work of previous scorecard projects focused on health care, PPI’s Scorecard sought to raise the profile of LTSS and drive action both federally and within states. Since that initial publication and through the release of three subsequent editions, the Scorecard has continually helped both effect and spotlight change in state LTSS systems as well as improve services and supports that older adults and people with physical disabilities receive. The Scorecard is a project from AARP Foundation and AARP, funded by The SCAN Foundation, The Commonwealth Fund, and The John A. Hartford Foundation.

Each edition of the Scorecard has measured state performance against an objective, data-driven set of metrics, or indicators, that collectively tell a story of how states were doing with their LTSS systems at a given time. This paper discusses our approach to the 2023 edition of the Scorecard, reflects on what has changed since the Scorecard was first published, and considers how future editions may best meet the needs of where we are today.

While the dictionary definition of LTSS has not changed significantly in recent years, it is clear based on all we know has occurred over the last decade that we must revisit how we define a high-performing LTSS system and how we measure success. As outlined in the list below, we intend to update the Scorecard framework to both retain many of the key characteristics from past editions but will also adapt to current times and make needed changes to reflect our current understanding of what drives a high-performing LTSS system.

In a high-performing LTSS system…

  1. Affordability and Access Consumers can easily find and afford services, with meaningfully available safety net for those who cannot afford services. Safety net LTSS does not create disparities by income, by race/ethnicity, or by geography.
  2. Choice of Setting and Provider A person- and family-centered approach allows for consumer choice and control of services (including self-directed models). A well-trained and adequately paid workforce is available to provide LTSS. Home and community-based services (HCBS) are widely available. Provider choice fosters equity, and consumers across communities have access to a range of culturally competent services and supports.
  3. Quality and Safety Consumers are treated with respect and preferences are honored when possible, with services maximizing positive outcomes- including during and after care transitions. Residential facilities and HCBS settings are adequately staffed and are prepared for emergencies. Policy-, system-, and practice-level efforts reduce and/or prevent disparities in quality and outcomes.
  4. Support for Family Caregivers Family caregivers’ needs are assessed and addressed, so they can receive the support they need to continue their essential roles. A robust LTSS workforce limits over-reliance on family caregivers. Family caregiver supports are culturally appropriate and accessible to all communities.
  5. Community and Integration Consumers have access to a range of services and supports that facilitate LTSS, including safe and affordable housing. Communities are age-friendly, supported by state master plans for aging. Policy and programming that facilitates livable communities also drive equitable communities.


High-Performance Revisited: Examining Long-Term Services and Supports System Performance

Download PDF

Suggested Citation

Flinn, Brendan. High-Performance Revisited: Examining Long-Term Services and Supports System Performance. Washington DC: AARP Public Policy Institute, November 10, 2022.


See what’s new in this edition…how did your state do?
Explore the LTSS State Scorecard

Stay up to date with LTSS. Receive News and Trends in your Inbox.