Published on: Apr 10, 2025
A recent study led by Katherine E.M. Miller, Chase Mulholland Green, Abigail Fassinger, and Jennifer L. Wolff of the Johns Hopkins Bloomberg School of Public Health highlights the urgent need for an expanded infrastructure to support long-term care services (LTSS) and enable successful aging-in-place. The study, Long-Term Care Services and Supports Needed for Successful Aging-in-Place: A Critical Review, published April 8 in the Annual Review of Public Health, points to critical gaps in care and services that must be addressed to meet the growing demands of the aging population in the U.S.
Aging Population and Increasing Demand for Long-Term Services
According to the study, by 2034, the number of U.S. adults aged 65 and older will, for the first time in history, exceed the of children under age 18, leading to an unprecedented demand for LTSS. LTSS refers to the range of paid and unpaid services that help people with physical or cognitive impairments live independently at home. The study stresses that without significant improvements in the LTSS infrastructure, many older adults may struggle to remain independent as they age.
Aging in place is a primary goal for most aging adults, however, without a national long-term care insurance system in the U.S., most services, which are often expensive, must either be paid out of pocket or be provided by unpaid family members. Additionally, the study emphasizes that current LTSS offerings are often woefully inadequate to meet the needs of aging populations, with pronounced inequities in access to these services based on financial resources, geography, and family structure.
A literature review identified two significant barriers to aging-in-place: inadequate availability of affordable services and insufficient numbers of trained and qualified health personnel to meet emerging needs. The review concluded that although there has been a shift from institutional care such as nursing homes to home-based care, the infrastructure to support aging-in-place remains fragmented and underfunded.
According to the study, the health workforce faces an acute recruitment and retention challenges and specialists involved in geriatrics the geriatricians, nurses, and home health aides face considerable excess demand relative to supply. The reasons for this include factors such as inadequate pay levels, difficult work environments, and scarce training opportunities, which can contribute to the high turnover rates and poor retention of qualified staff.
Technology plays an increasingly important role in enabling aging-in-place with innovations like telemedicine, remote patient monitoring, and home-based care frameworks, such as those under hospital-at-home initiatives, promising to improve communication among patients, caregivers, and healthcare professionals. However, availability of such technological advances is unbalanced especially in rural areas, and privacy concerns exist. This study calls for further research on scalable and affordable technological solutions that can be implemented equitably among diverse populations.
Family caregivers provide most LTSS, with three-quarters of the US’s older adults with functional or cognitive impairments relying on unpaid family members for support. Caregivers make substantial financial, emotional, and physical sacrifices with little training or backing from support systems. Although over 40 states have implemented programs like paid family leave and the Caregiver Advise, Record, Enable (CARE) Act to improve communication between healthcare providers and caregivers, these policies are not yet widespread or adequately funded. The study highlights the need for policies to support caregivers and the potential benefits of integrating caregivers more fully into care teams.
Financing Long-Term Care: A Fragmented System
Medicare serves most adults over age 65 but covers only post-acute care because currently, coverage does not extend to long-term maintenance services. As a result, many families must bear the expenses of long-term care services themselves, causing considerable financial strain. Without reform to make LTSS more affordable, middle-income families who do not qualify for Medicaid but cannot afford private long-term care insurance are at particular risk of facing financial hardship as they care for aging family members.
“An integrated public health delivery system with full support for aging in place, such as increasing opportunities for home-based care, improving access to affordable housing, and providing solutions to satisfy older adults’ transportation and social participation needs will be critical to meet care needs of the aging population,” said Miller.
The researchers stress the importance of further research into innovative care models that can be scaled to meet growing demand. Programs like the Program of All-Inclusive Care for the Elderly (PACE) and hospital-at-home initiatives are promising but will require policy change and funding support to reach more people.
As the U.S. population ages, the need for a comprehensive and adequately financed structure to support aging-in-place becomes increasingly urgent. The study’s findings emphasize several challenges older adults and their caregivers face and encourage stakeholder collaboration from multiple sectors to achieve a sound financial future for multi-faceted long-term care services. Without significant changes, the current LTSS infrastructure will continue to be overburdened, and workforce shortages will persist, resulting in many older adults not receiving the support they need to enable them to continue to live in their homes. Addressing these challenges is essential for policymakers, healthcare providers, and communities that desire to ensure that older Americans can age with dignity, independence, and a high quality of life.
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