Long-term services and supports, usually shortened to LTSS, describe assistance that helps people live with ongoing functional and health-related needs. The term includes more than care delivered inside a nursing facility.
Medicaid's overview addresses children, adults and older people with disabilities or chronic conditions, and describes services across institutional and community settings. It emphasizes choice, control and coordination around the person's life.
For nursing practice, the starting point is understanding what the person needs help doing, what matters to them and which arrangements can realistically provide that support.
Describe the need before naming a setting
Replace vague phrases such as “needs placement” with a clear account of the concern. Describe the activities involved, the assistance currently available, the person's preferences and the questions still unresolved.
Distinguish an observed need from a proposed solution. A person's difficulty with one daily task does not, by itself, identify the right program, residence or funding source.
In a fictional example, a patient explains that the current arrangement works during the week but leaves a gap on weekends. The useful information is the specific uncovered need and when it occurs. Repeating “has family support” would conceal the gap.
Build a practical support map
List the people and services involved, with the person's permission and participation. Clarify which responsibilities each has actually accepted, how often help is available and who should be contacted when circumstances change.
Include unresolved items. A referral, application or authorization request should not be recorded as a service already in place. Check the start date and the plan for the interval before it begins.
Use accessible language and communication methods when discussing options. Invite the person to identify arrangements they would find unacceptable or difficult to sustain.
Connect with local navigation resources
ACL describes Aging and Disability Resource Centers as sources of information, counseling and assistance with public and private LTSS options. Their information services are intended for people at all income levels, and they are part of the No Wrong Door approach to access.
Use those resources to locate the appropriate local contact. Explain the purpose of the referral and ask how the person prefers to be contacted. A navigation service can help explore options; a referral to it is not an approval for a particular benefit.
Individual program eligibility, assessment and availability still need confirmation with the responsible organization.
Keep the plan current
When needs or available help change, bring the difference back to the care team and the person. Identify which existing services must be reassessed and who will follow through.
During a transition, communicate the support arrangements alongside the clinical information. Specify what is confirmed, what is pending and who owns the next action. This allows the receiving team to see the actual plan rather than a list of intended referrals.
For information about support at home, see assessing caregiver strain.
Related pages cover home and community-based services, caregiver readiness and care plans across organizations.
Sources
- Long Term Services & Supports (accessed 2026-09-17) — Medicaid.gov.
- Aging and Disability Resource Centers (accessed 2026-09-17) — ACL, updated March 18, 2026.