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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #2, #24, #35, #47, #48


Learning Objectives

  • Recognize the scope, nature, and heterogeneity of community-based long-term services and support (CBLTSS) in the United States.

  • Describe the semantic challenges to evaluating CBLTSS due to heterogeneity of descriptive terms and delivery models.

  • Identify common models of CBLTSS delivery and reimbursement.

  • Recognize emerging trends in CBLTSS with the implementation of the Affordable Care Act of 2010.

Key Clinical Points

  1. The vast majority of care for older people at home is provided by friends and family as unpaid informal caregivers, at enormous indirect cost to society in the form of lost wages, lost productivity, and future social insurance costs.

  2. There is a substantial body of evidence suggesting that various models of CBLTSS are effective; cost-effectiveness and outcomes associated with these models depend substantially on targeting of services to appropriate populations.

  3. Innovative care delivery models funded by the Center for Medicare and Medicaid Innovation (CMMI) hold promise for improving health outcomes and controlling costs over the next several years.

In 2012, an estimated 11 million older Americans needed long-term care (LTC) due to functional impairment, usually as a result of chronic medical conditions and illnesses. Over half (57%) of these people are 65 years or older. Most choose to remain in the community, and require services to help them stay in their homes rather than enter an institution. These services constitute what is generally known as community-based long-term services and support (CBLTSS). As the population ages and the number of functionally impaired older adults increases, so will the need for CBLTSS. Unfortunately, no coherent national policy drives CBLTSS in the United States, which leaves a “system” that is inconsistent, decentralized, difficult to access, bewildering to navigate, and unable to fully meet the needs of many patients. Much of what is actually done to meet these needs is provided by unpaid family caregivers at great personal and economic cost. This chapter addresses CBLTSS for older adults in the United States. We outline the semantic challenges in understanding the scope and nature of CBLTSS and the heterogeneity of care models that comprise it; describe who receives, provides, and pays for it; and review the evidence for its effectiveness. We also discuss important public policy issues and identify emerging innovations and trends in CBLTSS delivery.


The term “community-based long-term services and support” overlaps with several other terms in the medical and social sciences literature, including home care, personal care services, home- and community-based services, home visits, house calls, and others. In general, these terms refer to nursing, personal care, or social services provided to older persons, with an explicit goal of filling unmet needs or maintaining them in the community. Most of this kind of care is provided by unpaid family members or ...

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