Re-imagining long-term services and supports: towards livable environments, service capacity, and enhanced community integration, choice, and quality of life for seniors.

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In the half century since enactment of the 1965 Great Society programs, accomplishments were gradually made to improve access to and quality of long-term services and supports (LTSS), including: mitigation of financial and care abuses in nursing facilities (NFs); substantial rebalancing of LTSS towards consumer-preferred home-and-community-based services (HCBS); increasing flexible consumer-centered HCBS including payment to family caregivers; and more assisted-living and housing options for seniors with heavy care needs. A unified planning and advocacy agenda across age and disability type and greater consumer transparency fueled progress. Nonetheless, LTSS is a broken system; persistent problems interfere with substantial and necessary change. These include; over-emphasis on safety for LTSS consumers; inattention to physical environments in all settings; regulatory and professional rigidity; and poor communication and information. Our recommendations are aimed at builders and designers, LTSS professionals, regulators, and educators/trainers; the last may be crucial in forging new consensus and over-coming entrenched beliefs. Policy recommendations include relatively narrow steps-for example, requiring single occupancy in all NFs and assisted living settings financed with public dollars-to broad reworking of the prerequisites for livable age-friendly (and dementia-friendly) communities and for a capable, flexible LTSS workforce.