THE VBP Blog
Addressing Challenges in MLTSS Implementation: What’s Needed for Success
Ensuring Home-Based Care Through Strong Workforce, Better Assessments, and Effective Care Coordination
March 14, 2025 – Managed Long-Term Services and Supports (MLTSS) programs are transforming Medicaid-funded long-term care by expanding access to home-based alternatives instead of institutional care. While these programs prioritize independence and care coordination, their success depends on addressing persistent challenges that impact consumers, caregivers, and providers.
However, despite the growth of MLTSS, many states face workforce shortages, inconsistencies in assessment processes, care coordination gaps, and barriers to transitioning individuals from institutional settings to home-based care. In this blog, we explore these concerns in MLTSS implementation and what needs to be done to ensure these programs fulfill their promise of keeping individuals in their homes and communities.
Expanding the Home Care Workforce to Address the Workforce Shortages
One of the most pressing challenges in MLTSS is the shortage of direct care workers, including home health aides and personal care assistants. Between 2000 and 2022, the number of direct care workers more than doubled from 2.2 million to 5.1 million. However, projections indicate a shortfall to meet the 8.9 million job openings expected between 2022 and 2032. With demand for these workers continuing to grow as states shift toward home-based care, low wages, high turnover rates, and limited career advancement opportunities make recruitment and retention difficult. When there aren’t enough caregivers, consumers experience service delays or lack access to the care they need.
To combat this, states must invest in the home care workforce. Increasing wages, offering better benefits, and providing comprehensive training programs can help recruit and retain qualified workers. Some states like Colorado and Indiana are using Medicaid rate adjustments to ensure that home care providers receive fair compensation. 14 were also selected to participate in the Direct Care Workforce Strategies Center’s new State Peer-Learning Collaboratives, which meet monthly to share resources and innovative strategies for expanding and retaining their direct care workforces. Expanding opportunities for career advancement—such as specialized training for home health aides—can also improve job satisfaction and retention. Additionally, states can strengthen workforce pipelines by creating partnerships with community colleges and vocational programs to train new caregivers.
Assessment and Eligibility Issues: Standardizing and Improving Processes
Another challenge in MLTSS is how individuals are assessed for eligibility and the level of care they receive. There is a large variability in assessment tools across states, which can result in inconsistencies in determining eligibility and service levels for LTSS beneficiaries.
Inconsistent or overly complex assessment tools can result in inaccurate determinations, delays in care, and consumers being denied necessary services. When assessments fail to reflect a person’s full needs, individuals may not receive enough support to safely remain in their homes.
To improve MLTSS, states need standardized, person-centered assessment tools that accurately reflect the individual’s medical, behavioral, and social needs. Colorado’s new Person-Centered Support Plan (PCSP) is one example of how states are refining assessments to prioritize consumer input and improve care planning. Additionally, ensuring that assessors are well-trained and that decisions are transparent and appealable will prevent consumers from falling through the cracks. By making eligibility assessments more consistent, fair, and reflective of real-world needs, MLTSS can better serve those who rely on these programs.
Streamlining the Process of Transitioning from Institutional to Home-Based Care
Many individuals want to transition out of nursing homes and back into community settings, but barriers in the transition process can make it difficult. Delays in securing housing, in-home care services, and assistive technology often keep people in institutional settings longer than necessary. Without strong transition programs, individuals who could live safely at home are often forced to remain in costly nursing facilities.
To make MLTSS more successful, states need robust transition programs that provide financial and logistical support for individuals moving from nursing homes to home-based care. Programs like Money Follows the Person (MFP) help consumers transition by covering the costs of home modifications, personal care, and transportation.
Another way to streamline the process is by incentivizing MCOs to act. Many states are structuring MLTSS payment rates to encourage MCOs to use HCBS instead of nursing facility services. For example, Florida developed a method to adjust health plan payments annually to provide incentives for MCOs to meet rebalancing targets. The state pays a blended rate, assuming a specific mix of consumers in nursing facilities and in the community, as well as a ‘transition’ target. If the MCOs meet or exceed those targets, they benefit financially; if they don’t, they lose money.
Advocate’s Perspective
While MLTSS has made progress in shifting long-term care toward home and community-based settings, its success depends on addressing workforce shortages, improving assessment processes, and streamlining/incentivizing transitions from institutional care. These issues can undermine access to quality home-based services if not properly addressed. As advocates, we support expanding MLTSS, but we urge states to prioritize workforce development, ensure fair and transparent assessments, strengthen care coordination, and remove unnecessary barriers to home-based care. As advocates, we support expanding MLTSS, but urge states to prioritize workforce development, ensure fair and transparent assessments, and remove unnecessary barriers to home-based care. If these challenges are tackled effectively, MLTSS can continue to transform long-term care by allowing more individuals to remain in their homes, maintain independence, and receive high-quality, person-centered services.
Onward!
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About the Author
Fady Sahhar brings over 30 years of senior management experience working with major multinational companies including Sara Lee, Mobil Oil, Tenneco Packaging, Pactiv, Progressive Insurance, Transitions Optical, PPG Industries and Essilor (France).
His corporate responsibilities included new product development, strategic planning, marketing management, and global sales. He has developed a number of global communications networks, launched products in over 45 countries, and managed a number of branded patented products.
About the Co-Author
Mandy Sahhar provides experience in digital marketing, event management, and business development. Her background has allowed her to get in on the ground floor of marketing efforts including website design, content marketing, and trade show planning. Through her modern approach, she focuses on bringing businesses into the new digital age of marketing through unique approaches and focused content creation. With a passion for communications, she can bring a fresh perspective to an ever-changing industry. Mandy has an MBA with a marketing concentration from Canisius College.