The County Role in Long-Term Care 1
2 The County Role in Long-Term Care
County governments play an essential role in ensuring the health and safety of
older Americans and individuals with disabilities as key administrators of safety
net programs and services. Through 758 county-owned or operated long-term care
facilities and community-based services, counties ensure that the more than 27
percent of adults age 65 and older, and the 61 million individuals with disabilities in
the U.S. who require assistance to perform everyday activities, have the resources
needed to live a long, healthy and independent life.
This brief provides an overview of the critical role counties play in providing
services for aging Americans and individuals with disabilities through long-term
care and supportive services, and offers policy recommendations for our federal
partners on ways to strengthen county long-term care infrastructure.
The County Role in Long-Term Care 3
COUNTY LONG-TERM CARE
INFRASTRUCTURE
Counties deliver long-term care (LTC) services and support to aging adults and individuals at home, in the
community and through 758 county-owned and operated facilities. These services include adult day care,
transportation, respite care, housing alternatives, caregiver training, support groups, in-home support services,
family counseling, daily money management, public conservatorship and guardianship services, as well as
chore services and personal care.
0 1 2 3 4 13
2749 283 24 8 5
NURSING HOMES - 2022 COUNTY FACILITIES
Explorer.NACo.org
4 The County Role in Long-Term Care
Below is a list of facilities that are owned or operated by counties, and the services we provide, to older adults
and individuals with disabilities.
County-Owned and Operated Facilities to Support Long-Term Care
NURSING HOME
A nursing home is a long-term care facility that
provides residential healthcare and custodial care
to older adults and individuals with disabilities.
Licensed practical nurses and nurse aides – under the
supervision of a registered nurse - monitor the health
of residents, assist with administering medications,
manage chronic conditions, and help with daily
activities such as dressing, bathing and eating.
SKILLED NURSING FACILITY
Skilled nursing facilities (SNF) provide post-acute
transitional care with the goal of returning patients
to their homes. SNFs oer rehabilitative services
through trained registered nurses that help patients
recovering from illness, injury or surgery and
specialized sta such as physical, occupational or
speech therapists. In some counties, care facilities
can operate as both a nursing home and SNF with
separate floors dedicated to each.
ASSISTED LIVING RESIDENCE/FACILITY
An assisted living facility is a residential facility
for people with disabilities or for adults who
need assistance with daily life and routine self-
maintenance. These facilities provide limited
healthcare support but do not provide extensive
medical care like a nursing home or skilled nursing
facility.
County-owned nursing or assisted living facilities
represent 75 percent of all publicly owned
nursing homes in the U.S.
There are currently 32 states with county-owned
nursing homes and 40 states with county-
supported nursing homes, with Indiana
and Texas each maintaining
over 100 county-owned or
supported nursing homes.
As of 2019, there are 14,871 nursing
homes located in counties across the
U.S. with 1.26 million residents.
The County Role in Long-Term Care 5
6 The County Role in Long-Term Care
COUNTY AGENCIES
County-run agencies and services also play a key role in ensuring access to community-based long-term care
and supports for aging and disabled Americans.
The Montgomery County, Md. Aging and
Disability resource unit is housed in the
county’s health department and provides
personalized hands-on assistance,
service referrals and information to
seniors, people with disabilities and
caregivers by phone and in person. This
program serves as the primary point
of entry for most services within the
county’s aging and disability services.
MONTGOMERY COUNTY, MD.
AGING AND DISABILITY
RESOURCE UNIT
County Health Departments
Counties support 70 percent of America’s
approximately 2,800 local health departments
(LHDs). Many have a Division on Aging that
provides programming and supports for addressing
the needs of older adults.
Broadly, all county health departments coordinate
services for older adults, adults with disabilities and
their families and often fill gaps in health care and other
social service needs. These services may include:
• Evaluation Services
• Senior Care
• Home and Community-Based Care
• Nurse Monitoring Services
• Caregiver Support
• Companion Programs
• Delivered Meals
• Transitional Services
Area Agencies on Aging
Area Agencies on Aging (AAA) provide a range of vital
services that address the local needs of the growing
older adult population in communities across the
country. AAAs help older adults age successfully at
home and in their communities through the provision
of services such as meals, transportation, personal
care and caregiver assistance. During the COVID-19
pandemic, 69 percent of AAAs saw an increased
demand for services such as meal delivery services
and telephonic wellness checks.
The County Role in Long-Term Care 7
County Long-Term Care Services and Support
HOME AND COMMUNITY-BASED CARE
Home and community-based services (HCBS)
allow people with significant physical and cognitive
limitations to live and receive person-centered
care in their homes and community rather than
institutions or other isolated settings. A variety of
health and human services can be provided through
HCBS programs that address the scope of medical
needs of people with functional limitations who need
assistance with activities of daily living, like getting
dressed or bathing.
ADULT PROTECTIVE SERVICES
In 14 states, counties are responsible for administering
Adult Protective Services (APS), which are programs
that prevent neglect, self-neglect, and fiduciary and
physical abuse of older and disabled adults. While
services can vary from state to state and county to
county, most states provide APS for adults 18 and older
with a significant physical and/or mental impairment.
In some states, APS serves older individuals without
disabilities, and about half of all states allow APS
reporting of vulnerable older adult abuse in nursing
homes and other long-term care facilities.
Currently, there is no direct federal funding allocated
towards APS, and programs are primarily funded at
the state or county level.
Rural counties are particularly
reliant on AAAs, as they account
for 85 percent of counties with
populations of individuals 65 and
older that make up 20 percent or
more of their total population.
Counties operate and fund
25 percent of the 625 Area
Agencies on Aging (AAA)
across the nation and another
28 percent operate within
regional planning councils or
councils of governments that
often include counties.
56 percent of AAAs rely
on local funding streams
through counties or
other local governments
to provide additional
programs and services.
85% 56%
25%
28%
8 The County Role in Long-Term Care
KEY FEDERAL PROGRAMS AND
POLICIES FOR SUPPORTING COUNTY-
BASED LONG-TERM CARE SERVICES
MEDICAID
Medicaid is the primary financer for long-term care
services and facilities throughout the U.S., with over
60 percent of all individuals residing in long-term
care facilities relying on Medicaid as the primary
payer for their long-term care services provided in
county-owned and operated facilities.
OLDER AMERICANS ACT
Approximately ten million older Americans are
beneficiaries of programs under the Older Americans
Act (OAA), which was passed in 1965 to establish
grants for community planning and social services,
research and development projects and personnel
training in the field of aging.
The majority of OAA programs are “core services”
authorized by Title III of the legislation. These
core services vary depending on local needs but
often include transportation, nutrition, support for
caregivers, recreation, in-home assistance, disease
prevention and more. In addition to the core
services, the OAA provides community service and
employment opportunities for low-income older
Americans and authorizes elder rights protection
activities.
States receive Title III Grants according to a formula
based on their share of the nation’s population of
individuals 60 and older. States then pass these funds
to Area Agencies on Aging (AAAs), which coordinate
programs and services for older adults at the local
level. Counties are direct recipients of Title III grant
funding and key administrators of OAA programs.
THE ELDER JUSTICE ACT
The Elder Justice Act (EJA) was enacted in 2010 and
operates under the U.S. Department of Health and
Human Services, Administration for Community
Living. EJA is the first federal program designed to
combat the abuse, neglect and exploitation of older
adults. The law authorized a variety of programs and
initiatives to better coordinate federal responses
to elder abuse, promote elder justice research
and innovation, support APS systems and provide
additional protections for residents of long-term care
facilities.
SOCIAL SERVICES BLOCK GRANT
Due to a lack of dedicated and direct federal funding,
APS programs are funded in a variety of ways, mainly
through the state’s general revenue or through
federal funds available to states for social services
through the Social Services Block Grant (SSBG).
SSBG provides states a list of options of 29 services
that they can opt to fund from their SSBG allocation
including services for persons with disabilities and
protective services for adults. Approximately 37 states
choose to use SSBG to fund some portion of their
APS program. Several states completely or almost
entirely fund their APS program with SSBG funding,
such as South Carolina, Oklahoma, Tennessee and
Alabama.
The County Role in Long-Term Care 9
10 The County Role in Long-Term Care
FEDERAL POLICY
RECOMMENDATIONS
County governments have a long, established role as providers, purchasers and administrators of long-term
health care and supportive services for older Americans and individuals with disabilities. Federal policies and
funding should acknowledge this vital role and help ensure that counties have the resources and flexibility to
continue to provide these critical services to some of our most vulnerable populations. Specifically, counties
urge Congress to:
• Expand mandatory HCBS state plan benefits
and provide sustained funding incentives
for HCBS service expansion options. Under
federal Medicaid law, all states must provide a
minimum set of “home health” benefits under
their state plan, however, the full range of HCBS
under Medicaid is optional, and states vary
considerably in how they organize their HCBS
programs. Counties urge Congress to expand
the mandatory HCBS state plan benefits to
ensure equitable access to community-based
services for all residents. Additionally, we urge
our federal partners to maintain the Federal
Medical Assistance Percentage (FMAP)
increase provided in the American Rescue
Plan Act for HCBS for states that implement
improvement plans to continue eorts toward
a broadly accessible, high-quality system of
HCBS care for those who need it.
• Provide funding and incentives towards
long-term care workforce recruitment,
development, training and retention as well
as informal caregiver support. Workforce
recruitment and retention have been a persistent
challenge for long-term care providers due to
the ongoing shortage of trained caregivers for
critical roles, an issue that was exacerbated
by the COVID-19 pandemic. Counties depend
on partnerships at the federal level that will
establish a strong healthcare workforce in long-
term care and nursing environments to provide
the highest level of care to our most vulnerable
residents. Counties support federal policies
that enhance the long-term care workforce
including the recruitment, training, licensure and
retainment of providers such as nurses, formal
and informal caregivers and direct support
professionals. Furthermore, federal policies
should support targeted incentives including
scholarships, loan forgiveness and low-interest
loan repayment programs to encourage more
providers to enter and remain in long-term care
careers.
• Full funding of the Older Americans Act in all
future appropriations. The Supporting Older
Americans Act (P.L. 116-131) reauthorized the
Older Americans Act (OAA) for five years and
provided a critical increase in the authorized
funding level for core services. However,
programs under OAA are discretionary and
subject to the annual appropriations process.
As the nation’s population rapidly ages, counties
face increasing demands and challenges in
providing comprehensive systems of care to our
older residents. Without reliable OAA resources
that keep pace with the demand for services,
counties will face new and more extensive
challenges in our eort to provide access to
critical services to our rapidly aging population.
The County Role in Long-Term Care 11
local APS programs was authorized initially at
$100 million annually but was first funded in
2020 with an appropriation of nearly $94 million
as part of the Coronavirus Response & Relief
Supplemental Appropriations Act (CRRSAA).
Given its authorization levels, the EJA has great
potential to provide support for local programs
that target elder abuse, but until appropriators
begin to fund the programs established by the
legislation, that potential will far outweigh the
act’s impact.
Government Aairs Sta Contacts
Mark Ritacco
Chief Government Aairs Oicer
202.942.4272
Eryn Hurley
Director of Government Aairs & Federal Fellowship Initiative
202.942.4204
Blaire Bryant
Legislative Director | Health • Large Urban County Caucus
202.942.4246
bbryant@naco.org
Rachel Mackey
Legislative Director | Human Services & Education • Veterans & Military Services
202.661.8843
rmacke[email protected]g
Brayden Cohen
Legislative Assistant
202.942.4259
• Full funding for the Elder Justice Act. The
Elder Justice Act (EJA), enacted in 2010 as
part of the Aordable Care Act, represents an
eort by Congress to provide a funding stream
specifically to address elder abuse and support
adult protective services (APS) programs,
including those operated by counties. However,
the level of funding the legislation has received
since it was enacted has not kept up with
inflation or need. Federal funding for state and
12 The County Role in Long-Term Care
660 North Capitol Street, N.W.
Suite 400 • Washington, D.C. 20001
202.393.6226 • www.NACo.org
FB.COM/NACoDC
TWITTER.COM/NACoTWEETS
YOUTUBE.COM/NACoVIDEO
WWW.NACo.ORG/LINKEDIN
