Long-term care (LTC) refers to a broad range of services designed to provide assistance over prolonged periods to compensate for loss of function due to chronic illness or physical or mental disability. LTC includes hands-on, direct care as well as general supervisory assistance. The type, frequency, and intensity of services vary; some people need assistance for a few hours each week, whereas others need full-time support. LTC differs from acute or episodic medical interventions because it is integrated into an individual's daily life over an extended time. LTC spans three realms: (1) assistance with essential, routine activities such as eating, bathing, dressing, and tasks required to maintain independence, such as preparing meals, managing medications, shopping for groceries, and using transportation; (2) housing; and (3) medical care. Often, LTC is associated with institutional settings such as nursing homes (NHs). However, LTC is also provided in a variety of noninstitutional settings collectively referred to as Home and Community-Based Services (HCBS). For this report, we compared LTC for older adults delivered through HCBS with care delivered in NHs. This comparative effectiveness review targets direct comparisons of LTC provided through HCBS and in NHs. Substantial differences in case mixes between older adults served through HCBS and in NHs made indirect comparisons impossible. That is, heterogeneity in case mix precluded our ability to compare the findings of the two bodies of literature that focused either on older adults served by HCBS or on adults in NHs. We examined studies with both crosssectional and longitudinal designs. Cross-sectional studies compared outcomes across settings at a specific time. Longitudinal studies compared change in outcomes over a defined time period ranging from 6 months to 5 years. We examined published and grey literature from the United States and published literature from economically developed countries with well-established health and LTC systems. Key Questions include: KQ 1. What are the benefits and harms of long-term care (LTC) provided through home and community-based services (HCBS) compared with institutions such as nursing homes (NHs) for adults age 60 and older who need LTC? a. To what extent do HCBS and NHs serve similar populations? b. How do the outcomes of the services differ when tested on similar populations? c. What are the harms to older adults as a result of care at HCBS and NHs? KQ 2. What are the costs (at the societal and personal levels) of HCBS and NHs (per recipient and in the aggregate) for adults age 60 and older? Costs may include direct costs of care as well as resource use and family burden. Direct costs of care refer to program and individual spending on LTC services for HCBS recipients and NH residents. Resource use includes program and individual spending on acute care services such as physician and hospital care as well as spending by other subsidy or transfer programs. Family burden includes the opportunity costs of care.