LTSS Choices: From Ideation to Standard Practice: Scaling Innovation in Long-term Services and Supports

This article was originally posted on AARP. Read the full article here.

Most innovations take a long time to diffuse, or simply may fail to do so. For example, in health care, the average time it takes for an evidence-based practice to make its way into general practice is 17 years, and half of all new practices never become widespread. But five promising innovations that show positive outcomes in the long-term services and supports (LTSS) system are becoming more commonplace. This paper examines these innovative programs, and the diffusion of innovation, or scaling-up process, underlying them.

A widely accepted model for understanding the expansion or diffusion of an innovation was developed in the 1960s by sociologist E.M. Rogers, who coined the phrase “early adopter.” He theorized that innovations are most likely to be adopted if they have the following elements: greater relative advantage; more compatibility with innovators’ values; less complexity; more trialability or testing opportunities; and, greater renown or observability.

After reviewing the history of five promising and expanding innovations in LTSS systems through Rogers’s framework, this report finds that a combination of factors, predicted by the model, leads to their diffusion:

  • Innovators trying to solve problems with their state and local LTSS systems
  • Innovations that are compatible with the ethics and needs of the innovators
  • Local and state level experimentation that demonstrates the cost-effectiveness of the innovations
  • Foundations and government policy makers working together to test and refine the innovations and providing technical assistance to reduce complexity, costs, and risks for potential adopters
  • Successful innovations, in terms of diffusion, that have backers who disseminate information about them
  • Policy makers who alter policy, increase funding, and provide technical assistance to help states and localities expand the innovations
  • Relative advantage and compatibility appear to be the most influential factors affecting the speed at which innovations spread.

A note about scaling and LTSS equity: Research into new and existing models of LTSS should always include diverse populations and resulting publications should be specific about the populations included in a given study or intervention. This transparency is critical to understanding whether and to what extent the innovation is relevant across populations. At the same time, diverse communities should not be treated only as test populations. As innovations come to scale beyond the study phase, they should do so in ways that offer different types of communities access to the services and supports.

Five Promising LTSS Innovations

1) Program of All-Inclusive Care for the Elderly (PACE)

The genesis for PACE was called On Lok, and began in the early 1970s in the Chinatown district of San Francisco, helping older adults of Chinese, Filipino, and Italian heritage live at home while receiving LTSS. It began providing medical services, social rehabilitation, and daily care; over time, it added meals, transport, and at-home services and day-care centers. The heart of the PACE model is person-centered services led by an interdisciplinary team that includes primary care providers, social workers, dietitians, therapists, personal care attendants, and drivers. A combination of Medicare Parts A, B, and D and Medicaid cover the associated costs.

Although today more than 140 PACE sites exist, most are small; they serve, on average, about 470 people.

2) Green House® Nursing Homes

Bill Thomas, a medical director at a nursing home in rural New York State in the early 1990s, noticed that residents lived according to a fixed schedule, had little to do, were lonely, and had no control over their lives. Among the changes he implemented to remedy this were a focus on person-centered care and empowering staff to learn more about residents so they could better meet residents’ individual needs. He also created a more homelike environment by bringing animals into the building, giving residents more choices, and decreasing use of psychotropics. Thomas called his program the Eden Alternative, and hundreds of nursing homes adopted his principles, likely due to his active promotion through presentations and articles. Later, the Robert Wood Johnson Foundation (RWJF) provided a small grant, then a five-year, $10 million grant to fund the Green House Replication Initiative.

The first four Green House nursing homes were built in 2003; there are now 371 trademarked homes on about 70 campuses in 32 states. These homes serve about 3,200 people.

Read the LTSS Choices report on Green House homes for more information including a discussion of their unique staffing model.

3) Self-Directed Home and Community-Based Services (HCBS)

Self-directed HCBS (home and community-based care) programs typically give beneficiaries a monthly allowance they can use to hire their own workers, including family members, and, in many cases, to purchase care-related services and supplies. This type of program originated in the 1960s at the local and state levels and via a federal veterans home care allowance after World War II. One of the first major efforts was California’s independent living model, based on a program operated for college students with disabilities in Berkeley through the first Center for Independent Living. After successful testing of the “Cash and Counseling” program in the late 1990s and early 2000s, Medicaid, at the federal level, recognized two forms of self-direction: beneficiaries can employ workers directly, or they can manage a budget and purchase HCBS.

As of 2019, the National Inventory of Self-Directed Programs reported that self-direction models reached 1,234,214 participants through 267 separate programs, 71 of which were veteran directed. In fiscal year 2018, up to 4.8 million beneficiaries received Medicaid HCBS.

4) Supportive Services in Housing for Older Adults

Supportive services in housing programs for older adults are designed to connect residents with services that can help them remain at home. State and federal involvement began in the late 1980s; some funding from RWJF came in the late 1980s and early 1990s. In 1990, Congress permitted certain federally funded housing projects to hire service coordinators for elderly and disabled residents. In 2009, Cathedral Square, a Vermont nonprofit housing and services provider, piloted the SASH® (Support and Services at Home) model, which has led to important improvements in residents’ health. As a result, supported services in housing are poised for more replication, particularly if a related innovation, IWISH (Integrated Wellness in Supportive Housing) proves effective.

Read the LTSS Choices report on the SASH housing model, its multiple positive outcomes for residents and lower costs.


Two innovations, initiated by Johns Hopkins researchers, rely on occupational therapy, physical therapy, and home repair professionals to improve LTSS for older adults and help them remain at home.

The initial program, Advancing Better Living for Elders (ABLE), provided four visits and one telephone contact from an occupational therapist and one visit from a physical therapist during a six-month period. The occupational therapist worked with participants to identify problem areas and helped them to improve function through behavioral and environmental modifications. Physical therapists delivered strengthening and balance exercises to support improvement in targeted areas. In the second six-month period, occupational therapists had three telephone contacts with participants.

Community Aging in Place, Advancing Better Living for Elders (CAPABLE) built on the ABLE model by adding a registered nurse to address pain management, medications, depression, and a handyperson to perform home repairs and install assistive devices and modify the home. Participants work with an occupational therapist and a registered nurse to identify up to three achievable goals with each.

The CAPABLE innovation, when thoroughly implemented, is of real benefit to older adults in terms of function and quality of life as well as emotional well-being. It also shows sustained cost savings. It is poised to expand but needs more attention from the federal government and foundations

Recommendations for Choosing and Promoting LTSS Innovations

Based on this exploration of five promising innovations in various stages of diffusion or scaling up, the report offers five recommendations that tailor Rogers’s five elements to the project of selecting and promoting LTSS innovations. A second set of recommendations specify a role for a) policy makers, b) funders, c) researchers, d) innovators, and e) thought leaders in successfully scaling up LTSS innovations that benefit consumers and reduce costs.

Suggested Citation:
Reinhard, Susan, Jane Tilly, and Brendan Flinn. LTSS Choices: From Ideation to Standard Practice: Scaling Innovations in Long-Term Services and Supports. Washington, DC: AARP Public Policy Institute, November 2022.