Improving Dementia Long-Term Care
by R. Shih, T. Concannon, J. Liu, E. Friedman;



In 2010, 15 percent of Americans much older than age 70 had dementia, and the number of new dementia cases among those 65 and older is predicted to double with the year 2050. As the baby boomer generation ages, many older adults will require dementia-related long-term services and supports (LTSS). This blueprint could be the only national document currently that engages local, state, and national stakeholders precisely to focus on policy options at the intersection of dementia and LTSS.

The authors undertook five major tasks that triggered a prioritized list of policy options and research directions to help you decisionmakers improve the dementia LTSS delivery system, workforce, and financing. These were to (1) identify weaknesses inside LTSS system which may be particularly severe for persons with dementia; (2) review national and state strategies addressing dementia or LTSS policy; (3) identify policy options in the perspective of the diverse group of stakeholders; (4) measure the policy options; and (5) prioritize policy options by impact and feasibility.

Stakeholders identified 38 policy options. RAND researchers independently evaluated these options against prespecified criteria, settling on 25 priority options. These policy options might be summarized into five objectives for that dementia LTSS system: (1) increase public awareness of dementia to cut back stigma and promote earlier detection; (2) improve usage of and using LTSS; (3) promote high-quality, person- and caregiver-centered care; (4) provide better support for family caregivers of folks with dementia; and (5) decrease the burden of dementia LTSS costs on individuals and families.

This policy blueprint gives a foundation on which to build consensus among a bigger set of stakeholders to put priorities and the sequencing of policy recommendations.

Key Findings

RAND identified 25 high-impact policy options covering five broad objectives to boost dementia long-term services and supports (LTSS) delivery system, workforce, and financing. Many options can not be pursued in isolation from others and must be bundled to optimize successful implementation and maximum influence on access, quality, and by using LTSS.

Objective 1: Increase public awareness of dementia to cut back stigma and promote earlier detection of signs or symptoms.

Create specialized and targeted outreach and education programs for the public, caregivers, professional services organizations, and persons with younger-onset dementia.

Encourage providers' using cognitive assessment tools for early dementia detection and recognition.

Objective 2: Improve usage of and usage of LTSS for persons with dementia.

Establish new and expand existing home- and community-based services (HCBS).

Integrate web- and also other technology-based services into dementia LTSS.

Create new and improve existing incentives for your direct care workforce.

Expand nurse delegation laws in all of the states.

Broaden Medicaid HCBS waiver programs, self-directed services, and states' infrastructures.

Include HCBS and managed care in state Medicaid plans.

Refine Medicare post-acute care and hospice benefits.

Objective 3: Promote high-quality, person- and family caregiver- centered care.

Establish Centers of Excellence models for dementia residential care through the end of life.

Minimize transitions and improve coordination of care across providers, settings, and stages of dementia.

Expand financial incentives for bundled home, community, and institutional services.

Establish cross-setting teams for persons with dementia, focused on returning the individual to the community.

Encourage the utilization of quality measurement to make sure consistent use of assessment tools for persons with dementia in addition to their family caregivers.

Identify persons with dementia jointly with their family caregivers during emergent, acute, and post-acute care.

Standardize complementary assessment tools for persons with dementia along with their family caregivers.

Create new and disseminate existing dementia recommendations and training programs for professional and paraprofessional care workers.

Provide specialized geriatric training to direct care professionals while in school.

Objective 4: Provide better support for family caregivers of individuals with dementia.

Provide dementia-specific training and information about resources to family caregivers and volunteer groups.

Offer business and individual tax incentives in promoting family caregiving.

Expand financial compensation programs to family caregivers.

Expand family-friendly workplace policies.

Objective 5: Reduce the burden of dementia LTSS costs on individuals and families.

Link private long-term care (LTC) insurance to medical insurance.

Create a national, voluntary opt-out LTC insurance program through a public-private partnership, or adopt a national single-payer LTC insurance system.


This policy blueprint offers a foundation upon which to engage a larger gang of stakeholders inside a robust debate and evaluation to create consensus on the set and sequencing of policy recommendations to pursue.

Future work will include convening stakeholders to assign low, moderate, or high strength-of-evidence metrics to each of the 14 impact, feasibility, and equity ratings and to construct consensus how best to group and execute priority policy options. This larger sample of stakeholders must look into whether policy options might have varied results depending on the types of dementia.

Future research also needs to undertake a stakeholder-engaged process to prioritize research needs, comparable to those conducted previously for long-term service and supports (LTSS) research. The qualitative rating approach employed in this blueprint must be supplemented by conducting systematic literature reviews of evidence-based programs, analyses of each policy option's cost-effectiveness, and analyses using existing administrative and clinical data. These kinds of studies would facilitate a greater understanding in the strength of evidence per rating and relative need for policies in terms of allocation of resources and urgency of implementation.

In the entire process of consensus-building, dementia LTSS stakeholders must also work together to develop metrics or key performance indicators of LTSS system performance for persons suffering from dementia in order to watch progressive improvements on each in the five overarching objectives.




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