Re-imagining Long-Term Care

Robert Kane from the University of Minnesota’s Division of Health Management and Policy recently published “A New Long-Term Care Manifesto,” in which he argues for a fresh look at how long-term care (LTC) is provided to older adults. He proposes providing a more proactive approach to care, one that encourages innovation and rewards both quality of care and quality of life. However, to accomplish this and to provide the best possible care to all LTC recipients, he advocates significant changes to the system in which long-term care is provided and paid for in the United States. Moreover, he suggests reinventing and rebranding LTC in order to build greater societal support.

Kane begins by noting that the current LTC system is one that has grown in fits and starts, and suggesting that this system is “not one that anyone would have designed.” The current system has been formed with “one eye on efforts toward improving clients’ function and the other on market opportunities,” and as a result has been shaped predominantly by payment policies and regulation, which results on an emphasis on technical care and concerns about safety. Instead of this being the focus of LTC, he suggests that instead the focus and subsequent incentives in LTC be on outcomes related to goals centering on the dignity, compassion, and autonomy of care recipients. In his vision, “The goal for LTC is to create an affordable system of care and support that allows people to get the help they need in a way that maximizes their autonomy and fits with their lifestyle.” This would involve creating a system that supports innovation and gives frail elderly the right to take informed risks. This is not to say that an LTC solution should lack protection of frail older adults; the point is that an overemphasis on such protection has led to a system that discourages innovation and provides an overly limited range of options for older adults.

One of the major changes proposed is a focus on payment for services, regardless of the context in which these services are provided. In line with this, Kane proposes that Medicaid only pay for services and not housing, in order to “automatically level the playing field between nursing homes and community-based services.” Any housing needs could then be addressed through a separate system based on social security and supplemental income sources. Care recipients would still be entitled to care that meets their needs, but this care could be provided in a variety of settings that would better align with the recipient’s preferences.

This focus on services should also be geared toward proactive care and incentivizing outcomes of care more directly related to the long-term goals of LTC. Here, instead of a fee-for-service arrangement, reduced use of hospitals and the stabilization of clinical trajectories would be rewarded.

In addition to the focus on services, another major component of the change proposed here is separating the provision and payment of LTC from post-acute care. Instead, subacute care should be viewed as a continuation of hospital care, and be reimbursed under a bundled payment system. A related suggestion is that older adults should not be admitted to long-term care directly from a hospital. Instead, an interim setting or other alternatives could provide a “cooling-off period” which places less time pressure on care recipients and will allow them to make more thoughtful and well-informed decisions about which LTC solution works best for them.

Kane also suggests that advances in health-monitoring technology could permit a larger caregiving workforce that would require less technical training. By implementing technology that monitors care recipients’ health status, wasteful scheduled appointments can be replaced by more proactive primary care that occurs in response to a changes in measured conditions that suggest deterioration. Prior to this point, interactions with highly trained health professionals would be replaced by aide-level workers who could be supervised through the use of information technology, resulting in considerable cost savings.

Kane also notes the crucial contributions of informal caregivers in providing long-term care. He describes these caregivers as “the unsung heroes of LTC” and notes that in light of the cost burden and sacrifices that these caregivers make in order to provide care, they need to receive greater support and acknowledgement for the crucial work that they perform. He suggests that family members should be eligible for both financial and supportive assistance for their caregiving work. He also notes that informal caregivers should receive better tools and training.

This manifesto also notes that both paid and unpaid caregiving needs to be made more attractive. In addition to raising wages for paid caregivers, this paper suggests that caregivers need to be made more aware of the benefit their services provide. At present, the most visible outcome for those providing LTC is the decline of the care recipient. Less evident to caregivers is what the course of the care recipient would look like in the absence of their care. This paper suggests that as an incentive for providing good care, caregivers should be made more aware of how their care is positively affecting the trajectories of the individuals that they are serving.

The final portion of this vision is creating a situation in which there is a greater appetite for change to the LTC system, and greater overall public support for LTC initiatives. To accomplish this, public discourse surrounding LTC needs to revolve less around costs and focus more on what the people report wanting from such care: choice, dignity, respect, and control. To accomplish these desired outcomes, an LTC system needs to allow for informed risks to be taken.

The above suggestions would require substantial changes to the current system in which LTC is provided, but they are born from an effort to get back to the basics and asking what the primary goals of LTC should be. For Kane, the core goals of long -term care revolve around allowing people to age with dignity and choice. His proposals are born from that commitment, along with the aim of addressing the substantial personal and financial costs imposed by long-term care.


Kane RL. A new long-term care manifesto. The Gerontologist (2015); 55(2): 296–301.


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