At Home LTSS Services Emerging as a Powerful Data-driven Social Services Tool

With the recent rise of analytic data platforms, social services providers have found a viable path beyond the traditional avenue of eligibility and transactional help. According to a  Deloitte Insights report, the emerging goal is to advance past “a program-centric view” to “ultimate outcomes … programs are meant to produce.”

More and more, health and social services providers are seeking to achieve improved results by gathering and strategizing on the basis of social determinants of health (SDoH) information. The social determinants of health are all the social factors that can impact medical well-being, such as adequate housing and food, economic stability, access to transportation, and all else that contribute to an individual’s ability to live a healthy and autonomous life.

One of the emerging opportunities for SDoH data analytics is in the area of long-term services and supports (LTSS), especially for an aging baby boomer population that will number 61 million by 2030. This compares to 14 million people that the American Association of Retired Persons (AARP) estimated required LTSS services in 2018. Of this population, 56 percent were over the age of 65, and 44 percent were people aged 18 to 64 with disabilities.

The long-established solutions of assisted living and nursing homes are getting spread thin. Recent options, which are also available in many communities, include continuing care at home (CCaH), and a 2018 AARP survey found that 75% of adults aged 50+ prefer to age in place in their homes.

So why not transition to home-based LTSS services for more aging adults? According to a study released in 2019 by Johns Hopkins University, one-third of older adults have “substantial need” for assistance with daily activities like bathing, eating, getting dressed, using the toilet, transferring in and out bed, and moving around their homes. A 2017 Johns Hopkins study found that 42 percent of older adults with probable dementia or difficulty performing daily activities didn’t get assistance from family, friends, or paid caregivers. Of seniors with at least three chronic conditions and high needs, 21 percent lacked any assistance.

Improving a lot of adults aging in place at home relies more and more on Medicare and Medicaid. Indeed, in 2017, the largest payers in the $235 billion LTSS market were Medicaid and individuals paying out of pocket. Until recently, Medicare has not traditionally covered LTSS services. However, with the passage of the Bipartisan Budget Act in 2018, which included the provision of Medicare Advantage Plans, home-based LTSS services are becoming a more economically feasible option for seniors.

LTSS services achieve goals associated with successfully managing SDoH goals that impact overall whole-person care. But there are both pros and cons:


PROS: When a care provider needs to make medical decisions regarding a client, an organization needs a comprehensive health record that includes all relevant data provided by insurance carriers, doctors, therapists, community providers, and any other stakeholders. Prioritizing rapid and effective technological communication is the first step to population health management.

CONS: Older adults living at home may rely on remote monitoring and communications, which serve as the community’s eyes and ears for tracking members’ health and well-being. If those technologies are deployed, the operator must ensure that the data transmitted to and from a senior’s home are protected. Also, the technology needs to be compliant with HIPAA and data privacy laws.

Care Management:

PROS: Informed decisions should play an essential part in a client’s ongoing care. For example, readmission of congestive heart failure patients is common; Health Affairs reported proper management of clients using wireless scales and blood pressure monitors reduces readmission 90 days after initial treatment in 80 percent of cases. Prioritizing client needs prevents costly incidents and health concerns. Clients and their clinical caregivers need information when they leave a care center. Case management software should provide users with messages on when it’s time to reach out to a client or share breaking news with a population. Proper population health management requires solutions that provide immediate answers and facilitate future care activities.

CONS: Although technologies no doubt will enable remote oversight of seniors, arguably, no substitute exists for actually observing residents daily. Sponsors will have to consider how best to help prevent individuals from falling through the cracks.

As the senior population swells with the aging baby boomer generation, it is crucial to find ways to care for everyone with fewer resources to go around. While current LTSS solutions are imperfect, there is room to find ways to fill in the blanks and work out pain points before that time, and it will be worthwhile to keep abreast of developments in this area going forward.

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