Health care and long term care: two different worlds


alnorman_headshotBy Al Norman

State policymakers are once again trying to change the health care system to save money, produce better health outcomes, and increase the consumers’ satisfaction with their care. If the subject of long-term services and supports (LTSS) ever comes up, it is usually in the context of the larger health care system.

According to the Administration for Community Living, “the number of people 65 and older will exceed 70 million by 2030…doubling the total number of older Americans since 2000.” 21 million people will be living with multiple chronic conditions by 2040, many of whom will require LTSS. In 2013, annual costs for LTSS were $130 billion—with two-thirds of that coming from federal and state tax dollars.

LTSS is a collection of non-medical services like help with personal care activities (bathing, eating, dressing, toileting, walking) and with household activities (cooking, cleaning, shopping, laundry, etc.) These are supports that do not require a doctor—but they do require a care coordinator to help consumers understand what type of help they can receive.

But in addition to personal care supports, research has found that “social determinants” have a major impact on what determines health. Research says that 60 percent comes from social, environmental or behavioral factors, 20 percent comes from genetics, and 20 percent from health. A person’s well-being is affected by the quality of their health care—but it is also affected by income level, adequacy of housing, nutrition, access to transportation, etc. These factors are what one doctor called “the ambush of social circumstances,” which can marginalize the best intentions of health care providers. These studies suggest that non-medical factors play a substantially larger role than do medical factors in health.

According to a recent Blue Cross Blue Shield of Massachusetts Foundation study, “Health care and social services ultimately share a common goal: fostering a healthy and productive population. In order to achieve this common goal in the most cost-effective way, Massachusetts may wish to accelerate ongoing efforts to link health services and social services…There is strong evidence that increased investment in selected social services as well as various models of partnership between health care and social services can confer substantial health benefits and reduce health care costs for targeted populations. These programs may be deserving of immediate attention from Massachusetts policy makers.”

Despite the importance of these non-medical factors on health outcomes, when we hear policy makers talking about LTSS, it’s usually in the context of how it can be harnessed to improve health goals, like reducing Emergency Room or hospital re-admissions. One measure of how subjugated LTSS has become, is the fact that in the health care field, there are scores of quality outcome measures now in use that quantify the impact of medical procedures—but there are no quality measures commonly accepted for LTSS.

If we have no LTSS quality measures, then we have no way of evaluating how effective LTSS services really are. In a recent report by the National Quality Forum (NQF), a group which is working to develop home and community based performance measures, it was starkly admitted: “An array of home and community-based services now exist to maximize the ability of people to live independently in the community, but the quality of those services is not yet measured systematically.”

One of the debates now going on in Massachusetts is to what degree should LTSS be folded into medical care? The NQF report warns that integrating medical with LTSS care may be important, “but over-medicalizing home and community based services must be avoided….a greater emphasis within home and community based care on health services and health outcomes would eliminate opportunities for individuals to shape and direct their own services.”

Health care and LTSS come from two very different cultures. The Medical Model emphasizes the doctor as the center of decision-making; services based on what providers offer; and the need for patient safety. In the LTSS culture, the consumer is at the center; services are based on what the consumer wants; the acceptance of some risk is basic to autonomy; and independence and control are more important than safety.

The key to integrating care is for both worlds to accept the cultures of the other—and to stop insisting that the only goals for LTSS are health performance measures.

Al Norman is the Executive Director of Mass Home Care. He can be reached at: or at 978-502-3794. Archives of articles from previous issues can be read at