In conversations with people exploring senior living options, one common question I hear is which states offer the best long-term care. The Long-Term Services & Supports (LTSS) State Scorecard for 2020 provides data-driven insight into that question.
The scorecard, produced by the AARP Foundation, The Commonwealth Fund, and The SCAN Foundation, evaluates LTSS from the perspective of service users and their families. It compiles state-level data to reveal which states perform well and which have room for improvement when it comes to supporting people with long-term care needs.
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What are LTSS?
LTSS refers to the daily help needed by people with chronic health conditions, disabilities, or general frailty. This assistance can cover activities of daily living (ADLs) such as bathing, dressing, and toileting, as well as instrumental activities of daily living (IADLs) like housekeeping, medication management, transportation, paying bills, and meal preparation.
These supports can be delivered in a person’s private home, in assisted living communities, in skilled nursing facilities (nursing homes), or in continuing care retirement communities (CCRCs or life plan communities) that offer a continuum of care including independent living. LTSS also includes supports for family members and unpaid caregivers.
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Scorecard methodology and criteria
The 2020 LTSS Scorecard assessed 26 indicators across five dimensions to rank each state and Washington, D.C. The dimensions are:
- Affordability and access: Six indicators covering the cost of nursing homes and home care, the percentage of adults 40+ with long-term care insurance, Medicaid participation, and access to LTSS resources.
- Choice of setting and provider: Seven indicators measuring availability of home and community-based services, assisted living and residential care units, adult day services, subsidized housing, and home health and personal care aides for people with ADL needs.
- Quality of life and quality of care: Four indicators, including two key nursing home quality measures: the percentage of high-risk residents with pressure sores and the percentage of long-stay residents inappropriately receiving antipsychotic medication.
- Support for family caregivers: Twelve policy areas grouped into categories such as supports for working caregivers, assessment of caregiver needs, and the ability to delegate nursing tasks.
- Effective transitions: Five indicators focused on minimizing avoidable hospitalizations and institutional moves, especially near the end of life.
>> Learn more about each of the five dimensions used to rank states in the scorecard.
The researchers explain that indicators were chosen for clarity, importance, and state-level comparability. While no single measure captures LTSS system performance fully, the combined indicators give a useful picture of how states compare across important areas.
Top states for long-term care services
1. Minnesota
2. Washington
3. Wisconsin
4. Oregon
5. Vermont
6. Connecticut
7. Hawaii
8. Colorado
9. California
10. Massachusetts
Bottom states for long-term care services
40. Mississippi
41. Nevada
42. Louisiana
43. Tennessee
44. Indiana and Arkansas (tie)
46. Oklahoma
47. Kentucky
48. South Carolina
49. Alabama
50. West Virginia
51. Florida
>> View a map and listing of how states ranked on the LTSS State Scorecard.
Comparing the 2020 results to prior editions shows relative stability: several states consistently appear in the top 10 (Colorado, Hawaii, Minnesota, Oregon, Washington, and Wisconsin), while a group of states consistently ranks near the bottom (Alabama, Florida, Indiana, Kentucky, Oklahoma, Tennessee, and West Virginia).
>> Learn more about the specific indicators used to formulate the state rankings and the major findings.
>> Learn more about key findings by dimension.
What is happening with long-term care in Florida?
Florida stands out: it has the highest share of residents age 65 and older in the nation — about 21 percent of its population — yet it ranks last on the 2020 LTSS Scorecard. The report highlights several areas where Florida could improve:
- Affordability and access: Nursing home care is unaffordable for many middle-income families nationwide, but Florida ranks 39th for nursing home costs as a percentage of median household income for people 65 and older.
- Choice of setting and provider: Florida ranked 50th in this dimension, with low numbers of home health and personal care aides and limited subsidized housing for low-income residents who need care.
- Quality of life and quality of care: Florida has reduced inappropriate use of antipsychotic medications in nursing homes compared with earlier scorecards, but it still ranks 39th for pressure sores among high-risk residents.
- Support for family caregivers: Florida does not offer statewide protections or supports beyond the federal Family and Medical Leave Act minimums.
- Effective transitions: Florida ranks last for the percentage of nursing home residents who experienced one or more potentially difficult moves near the end of life.
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Seeing the larger picture
State rankings give a useful overview, but a lower-ranking state does not mean every provider there delivers poor care. Many committed providers in lower-ranked states offer high-quality services and compassionate care.
Florida, for example, has enacted changes that may improve access to LTSS. Recent legislation aims to reduce the number of low-income, disabled, and elderly residents waiting for placement in the state’s Medicaid-managed long-term care program.
In short: ranking toward the bottom of the LTSS Scorecard doesn’t mean you must abandon plans to retire in a particular state. It does mean you should research local providers, costs, and supports to ensure you can access the quality of long-term care you may need in the future.