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The 4 Steps of Long Term Care Planning Book (2014): How to Deal with 21 Critical Issues Facing Aging Seniors

Aging seniors and their families are often confounded by the complexity of issues facing the elderly (including declining income, increased debt, poor investment returns, declining health, medical crises, complex insurance programs, long term care challenges, etc...). This book (published in 2014) takes a comprehensive approach to address these challenges and provide solutions.

$44.00 | 310 pages | More about the Book

Book:

by Thomas Day

Community Aging Services and Long Term Care
Why Is the Older Americans Act Important?
The National Aging Network
The Benefits Dilemma
"An Ounce of Prevention Is Worth a Pound of Cure"
Administration on Aging
State Units on Aging
List of State Aging Units (All programs can be reached from this list)
Managing Elder Rights Programs
Area Agencies on Aging
How Services Are Provided
Senior Citizen Centers
Meal Programs
Targeting and Outreach Programs
Services Available
Broward County Area Agency on Aging Example
The Impact of Olmsted
The National ADRC Initiative
Oregon's Community-Based Care (Example of Where Aging Services Are Headed)
New York State Single Point Resource (Example of All Aging Services)

Community Aging Services and Long Term Care

There are many private, religious and government organizations across the country that provide supportive services for older people. Many of these services center around helping people stay in their homes and avoid having to go to live in an institution or perhaps move in with family. Because of the emphasis on helping people remain independent, many community aging programs could be viewed as long-term care programs. In fact it's probably just a matter of semantics; long-term care and community aging services are just two sides of the same coin. Other communityservices may provide socialization or training opportunities. Community aging programs might include:

  • Meals served in community centers or delivered to the home
  • Community Senior Center activities and training
  • Transportation and shopping services for people who can't drive or leave their homes
  • Home repairs, snow shoveling, telephone support, caregiver support, care management, legal services, energy and weatherization services, housing subsidies, home health care, counseling and much more
  • Adult day care
  • Protection from abuse
  • Help with health insurance and government entitlement programs

Private support groups might be the Red Cross, women's auxiliaries or foundations. Many religious communities support activities for their elderly members as well as nonmembers. Both private and religious groups often provide services for free to people with little income and few assets. They may, however, charge people for services who have adequate income or assets. Many of these groups may also operate nursing homes and assisted-living facilities.

Senior centers are often the focal point for all aging services in a community. Experts or contact people are housed in senior centers and can provide many services in the center itself or refer out to other organizations that can help. The community served meals or congregate meals in senior centers are a means for attracting older people into the centers. Seniors can then be exposed to the many services that are available.

Government support for aging services comes from the Older Americans Act, passed in 1965. This act, over the years, has produced a large network of care providers and local government managers called Area Agencies on Aging. This network also includes federal agencies, state agencies as well as local area agencies and is called the "national aging network". Although currently area agencies on aging do not usually track and direct people to non-government services, in the future, the Government intends on being the single source coordinator of all aging services in the community. Therefore, if you're looking for any services in the community, public or private, you should contact your area agency on aging first. We have provided a list of all 655 area agencies on aging in the United States . Click on the appropriate link above.

Why Is the Older Americans Act Important?

The decade from 1960 to 1970 was a period of social unrest and change. We lived through an unpopular war which resulted in student protests and mass demonstrations. Hippies, it seems, were everywhere and we were experiencing the so-called sexual revolution. It was a exciting time when civil rights were being extended to all Americans.

During this same period a number of organizations were lobbying Congress for the rights of older Americans. An outcome of this effort was not only the 1965 creation of Medicare and Medicaid but also the passage of the Older Americans Act. The act was designed to protect elderly Americans, including Indians, from unfair discrimination in the workforce as well as providing protection and services to help older people stay independent and remain in their homes.

Although the initial emphasis was directed more towards civil rights and recognition of the dignity of the elderly, over the years, new provisions of the Older Americans Act have become more focused on providing long-term care services for older Americans. These benefits are designed to help frail, memory-impaired, disabled, poor and socially needy elderly remain in their homes and avoid the cost of elder care institutions. And more recently, funds were provided under the act to support caregivers of the elderly and elderly grandparents babysitting or raising minor children at home.

The OAA provides benefits to all Americans over the age of 60. And employment benefits are available for all Americans over the age of 55. The act itself stipulates reauthorization or amendment on an ongoing basis and since 1965 the OAA has been changed and updated 14 times. The year 2005 is designated as a reauthorization year and Congress is busily working on additions to the act. Because of the constant additions, the Older Americans Act has become a giant mishmash of thousands of words, redundant sentences and hundreds of rules and procedures. It's our guess that the complexity of the act probably requires states to hire attorneys to run their aging departments. Notwithstanding, members of the care community who provide administration and services with the Older Americans Act work around the complexity of its rules in serving the aging community.

Funding for the services required under the OAA is provided by Congress yearly. These funds are then distributed to states, territories, the District of Columbia , Indian tribes and native Hawaiians on a formula basis which provides minimum funding levels to small population groups and sparsely populated states and proportional funding levels based on state elderly populations of the majority of the other states. Because of its large elderly population, as an example, California receives almost 10% of the money. And because of its high proportion of older people, Florida is next. Ten states receive 52% of the money.

Funds are provided in the form of grants for various programs authorized under the act and states have some limited latitude in administering these monies in local areas. Certain of the mandated programs require matching funds from state and local governments. Other program funds do not require matching dollars. Many states chip in additional funds to maintain their programs and these funds often exceed matching requirements. States, counties and cities recognize the value of these services and are often generous in providing additional funds, buildings, office space and other in-kind economic benefits. For every dollar provided by Congress local governments provide about two dollars in direct money, in-kind services from volunteers, community voluntary contributions and cost sharing funds.

The federal appropriation for 2005 is $1,369,028,000 and the breakdown for specific spending categories is listed below. Notice that over half of the dollars goes towards nutrition services which are typically weekday meals provided in community settings or delivered at home as well as incentive programs to help the elderly maintain proper nutrition.

  • Congregate Nutrition Services, Home-Delivered Nutrition Services, and Nutrition Services Incentive Program (money from the Department of Agriculture), 52.1%
  • Home & Community-Based Services, 25.9%
  • National Family Caregiver Support Program, 11.7%
  • Grants for Native Americans, 1.9%
  • Program Innovations Grants, 1.7%
  • Preventive Health Services, 1.6%
  • Protection of Vulnerable Older Americans, 1.3%
  • Program Administration, 1.3%
  • Aging Network Support Activities Grants, 1%
  • Alzheimer's Disease Demonstration Grants, 0.8%
  • White House Conference on Aging, 0.3%
  • Senior Medicare Patrols (HCFAC), 0.2%

The National Aging Network

The Older Americans Act establishes an effective interrelationship between the federal government, State aging units and local service coordinators called Area Agencies on Aging. All three centers of service, the Federal, the state and the local engage in detailed future planning in order to accomplish their jobs. Input at the local level is received from diversified advisory boards representing stakeholders in the elder community. Community meetings and feedback from patrons of senior centers are also used in the planning process. Over the past 40 years, a great deal of thought and energy and research has gone into devising a delivery system that is both efficient and cost effective. In fact, the 29,000 service providers nationwide providing care under the act are the largest single network of long-term care providers in the country.

Local agencies on aging represent geographic areas in a state that can be serviced effectively by that local unit. Area agencies on aging normally contract with local for profit or nonprofit or public providers to deliver benefits. An agency may be allowed to provide directly, supportive services, nutrition services, or in-home services if it can prove a case for providing these services more effectively. An agency may also provide directly, case management services and information and assistance services depending on the methods used for such services in that state. Agencies may also use employees from cooperating or sponsoring counties or cities to staff and administer programs such as senior centers. Much of the work performed comes from dedicated volunteers who are both individuals and employer sponsored teams. This entire aging network system seems to work very well in accomplishing the goals of the Older Americans Act.

The Benefits Dilemma

The Older Americans Act was designed to provide benefits to all Americans over the age of 60. In the year 2003, there were approximately 50 million Americans over the age of 60. Based on an estimated $3,660,000,000 from federal appropriations and state and local matching, this means there was only about $74 available for each older American in that year. This could have bought a couple of hours of care services for each person that year or maybe paid for 10 meals for each person, but that's not very much. The fact is there is not enough money to provide adequate services for all older Americans. To adequately serve the needs of an individual under the act would probably require 20 or 30 times a paltry $74 each year.

Because of an extreme lack of funding, services for older Americans have to be rationed. Recognizing this dilemma, Congress has made provision in the act to target certain needy individuals. These individuals are defined as people having the greatest economic need and or social need. Economic need means inadequate income. Social need can include people who are frail and homebound, have severe disabilities, are institutionalized, live in disadvantaged areas, suffer from cognitive impairment, have language barriers, are members of a minority group or live in rural and underserved areas. The dilemma posed to providers of local services is the act prohibits using means testing -- asking questions about income and assets -- as a basis for providing services. So how do you discriminate without actually discriminating?

Local service providers have become adept in the technique of "targeting". There is no mass media advertising for Older American Act services. As a result, much of the general public is unaware of the availability of these services. Requests for benefits usually come from referrals from state social service units, elder care service groups, doctors offices, religious groups, contacts at elder fairs, lectures, encounter groups or providers of services under the act. Everyone involved in this referral network is well aware of the restrictions of funding and it is unlikely anyone with sufficient assets or income would be referred. In the event that someone with means calls and asks for services, local providers are skilled in recommending and directing those people to other programs not funded under the act.

A result of this selective targeting essentially makes the services of the older Americans act a program for disadvantaged and poor Americans. In essence the program has become a welfare service although it is intended not to be and should be available to everyone. In theory anyone requesting services under the older Americans act is entitled to receive them regardless of income or assets. In practice, wealthy people may be told that funds are lacking to help them or they may be told they will have to go on a waiting list until targeted individuals are covered.

Certain programs are not targeted . Even though many people with means may not receive benefits under the act, the following services are available to anyone on a first-come basis:

  • Use of senior centers
  • Legal services
  • Ombudsman
  • Elder abuse services
  • Other consumer protection services
  • Information and assistance, outreach, benefits counseling, or case management services.
  • Community served meals (Recipients may be encouraged to provide voluntary donations.)
  • Home delivered meals (Recipients may be encouraged to provide voluntary donations.)
  • Selected caregiver support services as designated by the state
  • Services provided through tribal units

Unfortunately, because of chronic under-funding some of the services above are inadequate or even lacking or in many cases there may be waiting lists. Community served meals, however, are typically available for all who want them. Home delivered meals often have waiting lists for recipients.

Many state providers allow for "cost sharing" on certain other services such as supportive programs in the home, thus making these services available to anyone as well. In this case a person's income can be asked for and services can be provided on a sliding scale, cost-sharing basis tied to income. Anyone below the poverty level must receive these services for free.

"An Ounce of Prevention Is Worth a Pound of Cure"

In 2003 Medicaid paid about $42,045,000,000 for an estimated 1,780,000 elderly nursing home residents who were unable to pay all or part of their nursing home bill. In the same year about 8,200,000 older Americans were served by Older Americans Act providers. The cost of providing these services is estimated to be $3,660,000,000. The chart below summarizes these numbers and also includes the per capita amount that would have been available for all older Americans with available funding from the act.

Older Americans Recipients vs. Medicaid Nursing Home Recipients

What is important to note is that the cost for maintaining one elderly person in a nursing home under Medicaid is about 50 times the cost of providing services to help an older American remain in the community. There is no question that directing government money to prevent people from having to go to a nursing home is much more cost effective than actually paying for nursing home care. One wise observer put it this way...

"Spending money to build a fence at the top of a cliff is much better than spending money on medical treatment and ambulance service to pick people up at the bottom of the cliff."

Or as Benjamin Franklin once wrote, "An ounce of prevention is worth a pound of cure".

It's an age old problem and occurs in many forms in the community. For instance, spending money on drug prevention programs is usually more cost effective than treating or incarcerating drug users. Programs to keep people healthy are much cheaper than paying for expensive medical treatments. Educating our youth and equipping them to be productive, taxpaying citizens is much less costly than providing welfare support.

If Congress were to appropriate just another $446 for someone to receive services under the Older Americans Act, the government might be able to delay spending $23,515 on supporting that person in a nursing home. Multiply this by thousands of people and we could save billions of dollars directing the money where it would do the most good by helping people to remain in their homes in the community and delay their need for expensive nursing home care. Or looking at it differently, if Congress were to appropriate an additional $23,515 towards Older Americans Act services, instead of serving just one individual under Medicaid, about 50 people could be helped with the same money under OAA.

Administration on Aging

The Administration on Aging is established by the Older Americans Act as a separate agency under the Department of Health and Human Services. HHS has the largest single budget in the executive branch and includes the centers for Medicare and Medicaid services (CMS) , the FDA, Centers for Disease Control (CDC), the National Institutes of Health (NIH) and a number of other smaller agencies. The AoA is a small agency with only about 130 employees and compared to its huge sister agency, the CMS, its budget is very tiny. The work of the agency is carried out by a staff in Washington , DC and through 10 regional offices that serve the states, territories, the district of Columbia and about 250 tribal organizations throughout the country. The president appoints an Assistant Secretary of the Administration on Aging to manage its affairs.

The Administration on Aging has guided the development of the national aging services network that today consists of 56 State units on aging, 655 area agencies on aging, almost 250 Tribal organizations, 29,000 community-based provider organizations, over 500,000 volunteers, and a wide variety of national non-profit organizations. This nationwide infrastructure currently provides a wide array of home and community-based services to over 8 million elderly individuals each year, which is 17 percent of all people aged 60 and older, including 3 million individuals who require intensive services and meet the functional requirements for nursing home care. It also provides direct services to over 600,000 informal caregivers each year, who are struggling to keep their loved ones at home. The national aging network is the largest long-term care provider network in the country.

The AOA works closely with other agencies in the Department of Health and Human Services to help formulate and administer programs for the elderly. In fact over two thirds of state Medicaid programs for home care (home and community-based waivers) are administered by area agencies on aging. Investigative and demonstration grants and surveys are often jointly pursued by a number of agencies in the department.

State Units on Aging

State Units on Aging (SUAs) are agencies of state and territorial governments designated by governors and state legislatures to administer the Older Americans Act in their area. No state uses the term "State Unit on Aging" and each state has devised its own title for its agency. Also each state has chosen to organize its aging department differently. In some states, services are spread across several departments and in other states they are integrated together. Alaska , The District Of Columbia, Delaware , New Hampshire , North Dakota , Rhode Island and South Dakota do not have Area Agencies on Aging and services are provided directly by the state. Nevada and Wyoming have a hybrid system where most services are provided by the state. A few states have chosen to assign the responsibility to an elected official. We have included a list of all 50 states and the District of Columbia with their respective titles. We also include a link for contacting the area agencies on aging in each state.

List of State Aging Units

State Aging Units and Area Agencies on Aging

Dispersing Funds
States receive federal grants based on the number of residents over the age of 60. The federal money is divided up proportionately among states and territories. Small population states and US territories under this formula might not get enough money to operate their programs, so the Administration on Aging provides a minimum funding floor for these aging units. Federal grants provide specific amounts of funding to the states for each of the seven service categories listed below.

  1. Supportive Services
  2. Congregate (community served) Meals
  3. Home Delivered Meals
  4. Preventive Health
  5. National Family Caregiver's Support Program
  6. Elder Abuse Prevention
  7. Ombudsman

State units have the responsibility of dividing up the federal money among service and planning areas. Money is usually divided proportionately among service areas by population of older Americans but the state has discretion to put money where it will target people in most need. There is also a responsibility to make sure that local area agencies are securing the federal matching requirements under the Older Americans Act. Supportive services require a 15% match in money or in-kind services or assets. The national family caregivers support program requires a 25% matching requirement. There are numerous and complicated rules for moving money around between categories, for administrative costs and in meeting matching requirements. Here are a few of these. The state must use at least $150,000 but not more than 4% of supportive services money for outreach programs. Not more than 85% of supportive services money can be used for a combination of supportive services, senior centers and nutrition programs. State may transfer up to 40% of funds in the two meal programs between congregate meals and home delivered meals as it sees fit.

The federal grants to states and their amounts for 2005 are listed below.

State Administration on Aging Grants

The Administration On Aging also provides the states with about $149 million under the nutrition services incentive program for meal programs from the Department Of Agriculture, which is not included above.

Cost Sharing and Voluntary Contributions

Recipients of services provided through state agencies or area agencies on aging can be asked to share in the cost of those services if the state implements a policy to do so. Cost sharing is based strictly on income and a sliding scale based on income is charged. Recipients below the poverty level do not participate in cost sharing. Cost sharing is not allowed for the following programs.

  • Information and assistance, outreach, benefits counseling, or case management services.
  • Ombudsman, elder abuse prevention, legal assistance, or other consumer protection services.
  • Congregate and home delivered meals.
  • Any services delivered through tribal organizations.

Voluntary contributions can be solicited for all services offered in the state as long as the method of solicitation is non-coercive. Recipients are to understand that contributions are not an obligation and that income is not a test for those contributions. Some area agencies have become quite adept at innovative ways to get people to contribute to community served meals. Such things as reservations or meal tickets that remind people they can contribute work quite well.

Matching funds
It has already been noted that certain service categories require matching funds from states or area agencies on aging. But many state and local government and private organizations typically provide money for other programs not requiring matching. This may be in the form of dollars from other federal programs, state legislatures, counties and cities or it may be in the form of equivalent assets or services. For instance a county acting as an area agency on aging may use its own employees for the agency. Or offices and buildings as well may be provided. The value of these in-kind services and assets is counted towards matching.

AoA Funds Versus Local Matching Funds

A large contributor of matching funding to help with the aging program are title XX block grants from the Social Security Administration. Federal grants to states and territories from these funds amount to $1,700,000,000 a year. Some of this money is used by states and applied to its aging programs including area agencies. These funds are earmarked for such things as adult protective services, home-delivered meals, transportation, in-home services and community mental health. One of the biggest contributors to matching are the 500,000 nationwide volunteers whose services are also counted as in-kind matching.

Managing Elder Rights Programs

In Title VII of the Older Americans Act Congress established a vision and unique mission for state aging networks. The Act requires State Units on Aging to assure that older individuals have access to and assistance in securing and maintaining benefits, rights, opportunities and protections promised to them through public programs. These programs include the ombudsman program, elder abuse services, legal assistance and health insurance counseling.

The long-term care ombudsman program is required to be coordinated at a state level and a state long-term care ombudsman is to be appointed to manage other ombudsman and volunteer ombudsman throughout the state. Most states have elder abuse laws and management of elder abuse is often combined with state aging units. States are also required to have a legal assistance development person at the state level who coordinates the services with local agencies. Finally many states provide health insurance counseling at the state level.

Elder Abuse Services
All states have laws regarding the physical and sexual abuse of minors. Most states feel it is important to protect vulnerable adults from abuse as well. As a result most states have passed legislation to protect older individuals, mentally incompetent adults and severely disabled adults from abuse. The definition of abuse for adults is typically a little more broad than the definition for minor abuse and might include misconduct such as sexual abuse, emotional abuse, financial exploitation, active and passive neglect by caregivers and self-neglect which means an individual is failing to care for his or her own self needs. Most of these abuse descriptions are self explanatory; however for those who question it, here is an explanation of what active and passive neglect means:

"Active neglect is the willful failure by a caregiver to fulfill care-taking functions and responsibilities. This includes, but is not limited to, abandonment, deprivation of food, water, heat, cleanliness, eyeglasses, dentures, or health-related services. Passive neglect is the non-willful failure to fulfill care-taking responsibilities because of inadequate caregiver knowledge, infirmity, or disputing the value of prescribed services."

Vulnerable adult and elder abuse can occur in any setting and in recent years there has been much concern about the treatment of residents in nursing homes. But most abuse occurs in the home and is most generally perpetrated by family members. Estimates are that 5% to 10% of the elderly and vulnerable adults in America are suffering abuse. The public knows little about elder abuse at home because this kind of treatment goes mostly unreported. It is the so-called "dirty little secret" of caregiving. Workers in this field often refer to elder abuse as being like an iceberg; we are only seeing the tip of it and 90% of it is hidden from our view.

The term commonly used by most states to describe the department responsible for adult abuse is "adult protective services". But not all states use this term. A few states have put adult protective services under their social service, health or human service or children and family services departments. But most states have put protective services under the state aging units described above. This is because the Older Americans Act already requires services for elder abuse and also some funding. In addition, local area agencies on aging are in a good position to report abuse and help with abuse problems. Many states that have elder abuse laws combine legislative funding and other federal funding with OAA funding and give the responsibility for elder and vulnerable adult abuse to the state unit on aging.

State laws require that reports of abuse must be investigated. A few states require anyone aware of elder or vulnerable adult abuse must report it to authorities. Failure to do so can be a criminal offense. But most states only require mandatory reporting from people or professionals who deal with a vulnerable adult population. Here is an example of one state's list of mandatory reporters.

  • Medical professionals
  • Employees of hospitals and home health agencies
  • Social workers
  • Coroners
  • Law enforcement employees
  • Adult or juvenile probation officers
  • Department of Human Resources' employees
  • Clergy
  • Attorneys
  • Mortuary or funeral home employees
  • Employees of the facilities providing care for older persons

We have provided a list of all states' online adult protective services sites at www.longtermcarelink.net/eldercare/ref_adult_protective_services_elder_abuse.htm

Legal Services
The Older Americans Act requires state aging units and area agencies on aging to provide legal services for older Americans. There is also a requirement for the state to appoint a person known as a "legal assistance developer" to coordinate legal services in the state. The administration on aging has also formed coalitions with various national groups to help states and local agencies implement legal services. Not only is there concern for the elderly about dealing with issues relating to estate planning, income and long-term care planning but there is a great deal of concern that the elderly may be vulnerable to exploitation by con artists and unscrupulous businesses. The OAA specifically directs legal services for the following issues: income, health care, long-term care, nutrition, housing, utilities, protective services, defense of guardianship, abuse, neglect, and age discrimination.

There may only be enough money for most states to hire a legal assistance developer and other staff attorneys may only be possible for larger states. States and local area agencies on aging must rely on the volunteer services of the legal community. Some states and federal government agencies may also provide money for this program. Licensed attorneys may donate some of their time for assessments and law students may be used to help identify problems and offer solutions. Extensive legal help is only available without recipient out-of-pocket cost in a few cases.

Long-Term Care Ombudsman
A long-term care ombudsman is a sounding board for residents of long-term care facilities such as nursing homes, assisted living or board and care facilities. Residents or families of residents can contact an ombudsman if there is concern about services or treatment from staff in a facility. The ombudsman investigates and if necessary resolves the problems.

Each state, under the older Americans act, is required to have a state long-term care ombudsman program that is managed at the state level. About 38 states include the office of ombudsman under the state aging unit and 15 other states or territories manage the office under a different state agency or use a private contractor. The state office manages a corps of local volunteers who respond to complaints or, time allowing, visit with residents of long-term care facilities to gain feedback. In 2002 more than 261,000 complaints were handled by about 8,000 volunteer ombudsmen nationwide.

We have provided a list of all states' online ombudsman services sites at http://www.longtermcarelink.net/eldercare/ref_ombudsman.htm

Health Insurance Counseling.
Many elderly have difficulty understanding their Medicare coverage and many unscrupulous health care providers may be preying on the system by charging for services not actually provided. The elderly may also have questions about whether to buy Medicare supplement policies or buy into Medicare advantage plans. In the fall of 2005 Medicare is introducing part D, the new drug prescription program. The aging network has been given responsibility by the Centers for Medicare and Medicaid services to counsel the elderly about this program. The health insurance counseling services, typically coordinated at the state level, are designed to deal with these issues.

Senior Medicare Patrols-- administration on aging grants to 47 states have provided seed money for volunteer programs to prevent Medicare fraud. The AoA maintains a web site to support this activity at http://www.aoa.gov/smp/grantee/grantee_state.asp

Here is a statement from the site detailing the purpose for the program.

"The U.S. General Accounting Office (GAO) estimates that billions of dollars are lost annually from the Medicare and Medicaid programs due to improper payments through error, fraud, or abuse. While the vast majority of health care providers are honest, the efforts of a small number of unscrupulous individuals are causing our health care programs to lose hundreds of millions of dollars per year and reducing the quality of care provided to many older and disabled Americans.

Since 1997, the U.S. Administration on Aging (AoA) has worked in partnership with the Department of Health and Human Services' Office of Inspector General, the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration), the Department of Justice, community-based grantees, retired professionals, service and health care providers, AARP, and other interested individuals and organizations to address this serious national problem.

In the initial phase of this initiative, known as ORT, $23 was returned in improper payments, fines and settlements for every dollar spent on the effort. Today, AoA provides grants to community-based agencies in nearly every state to train volunteers how to educate Medicare and Medicaid beneficiaries and their families how to protect their Medicare number as they would their credit card, how to take a more active role in protecting their health care programs, and how to detect and report potential instances of error, fraud, and abuse.

You may also interact with AoA by sending comments and suggestions to Barbara.Lewis@aoa.gov."

Area Agencies on Aging -- Purpose and Description

Area agencies on aging are the designated managers for state service and planning areas. A service and planning area is a geographic area of the state with more than 100,000 people and containing a significant number of elderly over the age of 60 that can be effectively served by the area agency under the Older Americans Act. The following can be designated as an area agency on aging to manage a service and planning area:

  • An already established entity that is meeting the requirements of the state.
  • A city, a county, a council of government or a regional planning commission in the service and planning area where the elected official in charge has designated an agency or office in its government organization to act as an area agency on aging.
  • A public or nonprofit private agency in a planning and service area which can meet the requirements from the state as an area agency on aging.

Any of these organizations must be able to meet the statutory requirements and state requirements and operate as an area agency on aging.

In many states, area agencies on aging operate as an office of a county and county employees are used to run the organization. In large urban areas cities may manage an area. In areas that are sparsely populated, area agencies may operate under a regional planning commission or a council of government with multi-county employees or with a nonprofit company providing the management.

A number of states have chosen to divide their states into multi-county regions or service areas. Where none of these natural subdivisions fit, a large rural area may be defined as a service and planning area and receive a suitable name to identify it. Where county or city governments are unwilling or unable to provide management, a number of states have chosen to contract with nonprofit organizations to run those particular area agencies in their states. Of the 655 AAAs across the country, approximately 67 percent are public agencies such as cities, counties, councils of government or regional planning commissions and 33 percent are private, non-profit organizations.

Area agencies do not always call themselves an "area agency on aging" and may use other names to identify themselves. Many nonprofits that receive their operating funds from state aging units typically use their nonprofit name instead of identifying themselves as an area agency on aging. Large county and large city AAA's often disguise themselves under government designated aging departments. States divided into multi-county regions may identify themselves as region one or planning area 2 and so forth. These many name conventions can be confusing to the public since using another name may not alert seniors or their families to the services they would expect under the Older Americans Act, national aging network. On the other hand, many nonprofit agencies that except money under the older Americans act and operate service areas are required to offer the same services as government-sponsored agencies. Here are some examples of some of the names.

  • Northwest Alabama Council of Local Governments
  • Southern Alabama Regional Council on Aging
  • South Alabama Regional Planning Commission
  • Middle Alabama Area Agency on Aging Central
  • Alabama Aging Consortium
  • Division of Aging and Community Services/Aging and Adult Administration - Regions 1 to 8
  • IMAAA/IMSP
  • Central Coast Commission for Senior Citizens
  • San Francisco Department of Aging and Adult Services
  • Los Angeles City Department of Aging
  • Los Angeles County Aging and Adult Services
  • Denver Regional Council of Governments Aging Services Division
  • South-Central Colorado Seniors, Inc.
  • Senior Resources
  • Senior Resource Alliance
  • Alliance for Aging
  • Southern Crescent Region
  • Metro Atlanta Region Commission
  • Heart of Georgia Region
  • Chicago Department on Aging
  • Northwest Indiana Community
  • Action Corp.
  • REAL Services, Inc.
  • Aging and In-Home Services of Northeast Indiana, Inc.
  • Senior Spectrum
  • (and the list goes on and on)

The older Americans act funding is not the only source of money for area agencies on aging. Agencies may also manage other government programs such as Medicaid waivers for home care, social service block grants, transportation programs and other state home care service programs. Currently about two thirds of all Medicaid home and community waivers are managed by area agencies on aging. Many agencies may have 10 or more different government funding sources for programs under their management. Nonprofit organizations acting as area agencies on aging may also be receiving community donations as well. And on the other hand many nonprofits who are not area agencies may be accepting funding under the older Americans act to furnish programs such as community meals or homes served meals.

For a complete list of state units on aging and area agencies on aging across the country go to http://www.longtermcarelink.net/eldercare/ref_state_aging_services.htm

How Services Are Provided

Area agencies normally contract with local for profit or nonprofit or public providers to deliver benefits. The 29,000 contract service providers nationwide, providing care under the act, are the largest single network of long-term care providers in the country. An agency may be allowed to provide directly, supportive services, nutrition services, or in-home services if it can prove a case for providing these services more effectively. An agency may also provide directly, case management services and information and assistance services depending on the methods used for such services in that state. Much of the work performed for area agencies on aging comes from 500,000 dedicated volunteers nationwide who are both individuals and employer sponsored teams.

The typical beneficiary served by an Area Agency on Aging is a woman over age 75, with limitations in activities of daily living, such as bathing, eating and dressing. AAAs throughout the country find that they are working more and more with vulnerable and "hard-to-reach" populations, as well as persons with chronic disabilities of all ages.

Senior Citizen Centers

The first Senior Center in the country opened in 1943 in the Bronx, New York and was called the William Hodson Community Center . By 1961 about 218 senior centers had opened all across the country. The first Senior centers were operated by cities or nonprofit or religious organizations. Funding came from government, community donations and fees from people using the facilities. In the early days some federal funding came from Title XX of the Social Security act but funding for Title XX has been decreasing and much of that money today is being used for other programs. In 1972, the Older Americans Act was amended to provide funding for senior centers as this was considered to be an important piece of the aging network. Today, there are estimated to be about 15,000 senior centers across the country serving about 10 million older Americans annually. About 6,000 of these centers receive part or all of their funding through the Older Americans Act.

Senior centers act as a focal point for older Americans to receive many aging services. They are a vital part of the aging network. For Area Agencies on Aging, the senior center has become a place where many AAA services can be provided, where outreach and targeting can occur and where feedback can be received from the elderly. The most common services offered at a senior center are:

  • Health and wellness programs
  • Arts and humanities activities
  • Intergenerational programs
  • Employment assistance
  • Community action opportunities and social networking opportunities
  • Transportation services
  • Volunteer opportunities
  • Educational opportunities Information and referral
  • Financial assistance
  • Senior rights counseling and legal services
  • Meal and nutrition programs
  • Leisure travel programs

Larger senior centers in major cities may offer additional specific services because they serve a large and diverse group of patrons. Here are some examples:

  • Education classes, perhaps through a local college
  • Foot care
  • Health clinics
  • Haircuts
  • Daily exercise
  • Telephone friends
  • Support groups for Alzheimer's caregivers
  • Support for Parkinson's disease
  • Low vision and diabetes services
  • Weekly health speakers
  • Grocery shopping
  • Many and varied classes for personal growth and learning
  • Special events and fundraisers such as auctions, raffles, sales, bazaars, rummage sales, bingo, special meals and parties, fashion shows and facility rentals

Most elderly people are aware of senior centers in their neighborhoods but for those who are not familiar with the program, senior centers are listed under that title in the Yellow Pages.

Meal Programs

The Administration On Aging provided state agencies with about $719 million in 2005 for nutrition programs.(Meal programs) A certain percentage of $569 million of that money can be transferred to other programs by state and local agencies. (The balance is money or commodities from the agricultural Department that must be used for nutrition.) But assuming states don't do a lot of transferring, at least 50% or more of federal grants to states is earmarked for meals. And a great number of volunteers who help area agencies on aging are also involved in the meal program. In addition, state and local governments, direct public contributions and the United Way may provide additional money to run nutritional programs. It is obvious that the meal program is one of the most important and largest components of the aging network.

It is felt by all who serve elderly Americans that providing at least one meal a day, which is equivalent to at least a third of the daily recommended caloric intake and nutritional needs, is important in helping the elderly remain independent in the community. Just making sure that older Americans receive proper nutrition and nutrition counseling has probably kept a large number of people out of long-term care institutions. Also the congregate or community served meal program, which is designed for people who are not homebound, is an incentive for the elderly to get together in groups for not only a daily meal but also for social stimulation, awareness of the other aging programs, caregiver training and input from other supportive programs. Some programs can afford to offer more than one meal a day and also offer meals on weekends as well.

But area agencies on aging aren't the only programs providing nutritional service to elderly Americans. A diverse number of organizations from local government, church groups or nonprofit groups serve meals everyday to a large number of elderly Americans, all over this country. Some of these groups may accept money from area agencies but many do not. Although the number of meals served by other groups may exceed that provided directly through area agencies, Older Americans Act meal services are by far the largest single program in the United States . Since the meal program's authorization in the Older Americans Act in 1972, approximately 7 billion meals have been served. Here are some numbers for older Americans act nutrition programs.

During 2001, 112,000,000 congregate meals were served to 1,750,000 older adults. Services provided in addition to meals:

  • Nutrition assessment
  • Nutrition education and counseling when appropriate
  • Social activities

Profile of a Congregate Participant:

  • 80% are at 200% of poverty
  • 60% live alone
  • 70% women
  • 28% rural
  • 25 % minority
  • Average age 76 years

During 2001, 143,000,000 home-delivered meals were served to 927,000 older Americans. These were mostly homebound people who greatly appreciated the services.

Here's a list of some of the organizations directly involved in meal programs throughout the United States.

Congregate (Community) Meals
This meal program is usually offered in senior centers which may be sponsored by area agencies on aging or sponsored by other community organizations or churches. Area agencies may also make arrangements with religious groups or other providers of gathering places for the elderly to serve these meals in places other than senior centers. Organizations not receiving funds from area agencies might be offering meals in churches, non-OAA senior centers, local government and community gathering places and so forth.

The older Americans act does not allow providers receiving its funds to charge for these meals, although voluntary donations are encouraged and often received. This creates a dilemma for organizations that may want to use these funds but typically charge for meals on a sliding scale fee, based on income. Even by charging, most of these organizations only receive about a third of the cost of the meal from cost sharing. Some of the organizations providing meals will accept money from area agencies but have to segregate their programs into voluntary contribution meals and cost sharing meals. In order for area agencies to have a greater impact on the congregate meal programs in the United States , the rules must change to allow for cost sharing.

Home Delivered Meals
Home delivered meals are commonly known under the name , "meals on wheels". The first American home-delivered meal program in the United States began in Philadelphia , Pennsylvania , in January of 1954. With help from a local grant, Margaret Toy, a social worker, started providing meals for homebound elderly people and other "shut-ins" who were in dire need of nutritional support. She solicited local high school students to volunteer to prepare and deliver meals to the needy homebound people. These young volunteers were called "Platter Angels." Platter angels were so reliable in their duties that the people receiving meals often jokingly chided them if they were but a few minutes late.

There is great demand for home delivered meals and in some cases people are put on waiting lists for months before they can receive the services. There is typically not enough money and not enough volunteers to go around. And with chronic budget shortages, increased insurance premiums and higher fuel costs it is becoming more and more difficult to provide meals to those who want them. As with community served meals, home served meals through area agencies on aging cannot require cost sharing. And this creates a dilemma for organizations wanting to receive money through the older Americans act. And as with community served meals many of the organizations providing home-based nutritional services are not associated with area agencies on aging.

Meals are typically delivered between 11 a.m. and noon, five days a week. They are typically prepared in community kitchens or by catering companies. They are likely to be designed by nutritionists to offer at least one third of the daily recommended nutritional intake. If a recipient is not at home the meal is returned to the kitchen. Many providers are now delivering frozen meals as well and these can be used on weekends or at other times of the day.

Meals on Wheels
The "Meals on Wheels" name is well recognized across the nation as a provider of home delivered meals for the elderly. The name does not represent a specific organization or a business but is simply a way of identifying meal services. "Meals On Wheels" derived its name during World War II in England . A woman's volunteer organization would deliver snacks and other treats to servicemen on duty and this service became affectionately dubbed by the soldiers as "Meals on Wheels".

Many cities, area agencies on aging, church groups and nonprofit organizations that provide nutritional services have adopted the name, "Meals on Wheels", to afford the public a recognition of trusted services provided by volunteers and community donations. People dealing with Meals on Wheels programs have the assurance of knowing from the name what is provided and how it is going to be administered. There is also a national association called the Meals on Wheels Association of America that coordinates efforts and provides training for over 900 meal programs across the country. Any entity can use the name and does not have to be a member of the Association and some members of the Association do not even use the name "Meals on Wheels". And of course not all organizations providing meals are members of the national Association. It should also be noted that many local nutritional services may use another name and not the Meals on Wheels moniker.

Home delivered meals have their origin in hundreds of difference scenarios across the country. Over the past 50 years government organizations as well as religious communities and private nonprofit groups have all recognized the need for providing meals for homebound elderly people or younger people who are able to take care of themselves at home but are disabled and unable to get out. Incorporation of meal services into the older Americans act in 1972 has given some administrative and national organization to meal programs. And many of these programs, as a result, receive a portion of their funding through the older Americans act.

Older people living by themselves at home often have a tendency to deprive themselves of proper nutrition. Perhaps because of depression, loneliness or a medical condition, many older people lose their appetites and do not eat properly. In addition a large number of older people are living in poverty and cannot afford to buy nutritious food. They may also not have transportation to get out and go shopping or they may not have the desire to prepare meals for themselves. Additionally, many older people, because of frailty or because of fear, cannot leave their homes and are often trapped at home for days or weeks at a time without ever seeing anyone else. All of these problems can lead to a situation where because of improper nutrition, older people will decline in health and mobility. Proper nutrition is essential in helping people remain independent in the community.

The majority of individuals receiving home delivered meals are elderly, single women with chronic health conditions. These women are often confined to their homes because of lack of transportation or their own inability to walk very far. A noon meal delivered by a volunteer, five days a week not only provides these shut-ins a nutritious meal , but also provides them contact with another person. And many of these people cherish the attention from the volunteer much more than the availability of a hot meal.

Meals are typically delivered between 11 a.m. and noon, five days a week. They are typically prepared in community kitchens or by catering companies. They are likely to be designed by nutritionists to offer at least one third of the daily recommended nutritional intake. If a recipient is not at home the meal is returned to the kitchen. Some organizations will allow seniors to order extra meals for the weekend when that service is not provided. Many providers are now delivering frozen meals as well and these can be used on weekends or at other times of the day.

Volunteerism and public contributions are an essential cornerstone of Meals on Wheels programs. With the exception of the cost of food, transportation, key kitchen workers preparing the meals and administrators, all other services are provided by volunteers. These can be older individuals themselves who have a desire to serve in the community or oftentimes teenagers especially enjoy serving the elderly or in many cases volunteers come from employer-sponsored volunteer programs. Perhaps more than any other form of volunteering, hand delivering meals to a needy person at home can be the most satisfying public service a healthy person can perform. Many companies recognize the power and compassion of this form of service and they readily embrace programs for their employees to provide volunteer hours. Many other organizations seeking employer supported volunteers may have a more difficult time receiving the attention of corporate decision-makers because their services are not as profound as home delivered meals to the elderly. Companies are also often generous in providing funds for the cost of administration, transportation and meal preparation.

Funding for Meals on Wheels programs typically comes from a variety of different sources. Cities and local governments may provide funds and as has been mentioned before, money can also be provided under the older Americans act. In fact, some area agencies on aging support home delivered meals entirely under their agency administration. In some cases home delivered meals may not have any connection with government programs. Many funds come from community donations either directly or through programs such as United Way or Red Cross. Fundraisers are also a large part of some programs. With the exception of programs provided with older Americans act funds, most Meals on Wheels organizations charge the recipients for their meals. The cost is based on income. If a person receiving a meal is impoverished, generally no money is charged. Otherwise, costs are almost always based on a sliding scale based on a person's income. Depending on a person's income, the cost of a meal could vary from $.80 to $4.00. Due to a chronic lack of funding, over 40% of all home delivered meal programs have waiting lists. Much more government and community support is required to reach those in need.

In recent years many Meals on Wheels organizations have been providing other services to the elderly at home. This is because many homebound older people have needs in addition to proper nutrition and because of contact through the nutrition service, the Meals on Wheels program has been able to identify those people in greatest need. Case managers may come into the home and make an assessment of the needs and coordinate in-home services from other community programs. Visiting nurses and home health aides may be provided to help with medical problems or with activities of daily living. Arrangements for the installation of emergency response systems or GPS location bracelets for those who might wander can also be made.

Targeting and Outreach Programs

Area agencies on aging are required to design programs to identify and service those older Americans in the community most in need. Programs are designed to "reach out" and identify those people who are in need. As a general rule area agencies do not advertise or use mass media to locate people needing their services. This may be due to the fact that advertising would be very costly and it may also have the inadvertent effect of bringing in people who are not considered needy. The fact remains that many needy older Americans, those who have low income or are disadvantaged, simply do not know about the services of area agencies on aging. This presents a constant and ongoing dilemma for area agencies because many people in need may be falling through the cracks.

Most people are attracted to aging services by referral. These referrals may come from doctor's offices, senior centers, government agencies who service the elderly, home health agencies, home delivered meals programs, senior fairs, seminars and from a host of other providers who rub shoulders with elderly Americans. It is a constant challenge for agencies to develop adequate outreach programs and there is constant pressure from state and federal administrators to not leave anyone behind.

Another challenge posed for area agencies on aging is being able to bring to bear all the services necessary to help older Americans in need. Some programs such as protective services, community meal programs and legal help must be provided to all Americans over the age of 60 on a first-come, first-serve basis. On the other hand, there is never enough funding to provide help for all Americans in the area of supportive services and caregiver support. Targeting scarce funds to those most in need is a particular challenge for many area agencies on aging. This often means that some people requesting services may not be able to receive those services because they have too much income or they are not identified as someone having a pressing social need.

Services Available

Supportive Services and Senior Centers (Title III, Part B) -- 27.9% of total grants
States and local agencies provide a large number of supportive services based on need and available funding. States are also required to provide an additional 15% in matching funds for this section of the act. Most of these services fall under three broad categories and include a great many of the 23 authorized services under the older Americans act:

Access Services , such as transportation, outreach, information and assistance, case management and so on

In-Home Services , including homemaker and home health aides, chore and maintenance, supportive services for families of older individuals who have Alzheimer's disease and so on

Community Services such as adult day care, senior centers, legal assistance, recreation and so on

As an example, supportive services funding allows a community to provide rides to medical appointments, grocery stores and drug stores. It provides handyman and chore services so that older persons can stay in their homes. It also is used for community services such as adult day care, health education activities and information and assistance.

Senior centers may be sponsored under the older Americans act but funds for construction and administration may come from a large variety of sources in addition to agency funds. Also many existing senior centers that were not built under the Older Americans Act may receive support and partial funding through the act. The purpose and scope of senior centers have been outlined in a section above.

Nutrition Service, Subpart 1-Congregate Nutrition Services, Subpart 2-Home Delivered Nutrition Services (Title III, Part C) -- 56.7% of total grants (includes USDA funds)
Federal funding for these services represents 52% of the total federal budget and represents 56.7% of state direct title grants. This also includes some money for nutrition counseling and other nutrition service programs. Also a large block of this money comes from the Department of Agriculture in the form of cash or commodities. At the state and local level these programs also represent the greatest part of matching funds and the largest share of volunteer hours. Nutritional services have been thoroughly discussed in sections above.

Disease Prevention and Health Promotion Services (Title III, Part D) -- 1.7% of total grants
Preventive Health Services programs provide health screenings and risk assessments for a range of preventable illnesses and chronic diseases. Programs are designed to prevent some of the key health issues affecting older individuals. Funding for 2005 for the entire country is about $22 million. These programs include efforts to:

  • Prevent and reduce alcohol and substance abuse
  • Smoking cessation
  • Manage the many medications seniors often take
  • Guard against dangerous drug interactions and
  • Highlight the importance of remaining physically fit as a means of preventing the onset of chronic disease and maintaining good health.

National Family Caregiver Support Program (Title III, Part E) -- 12.2% of total grants
This program was added to the Older Americans Act in the revision of 2000. These services have experienced the largest year-to-year increase of any services under this act and are currently at about $162 million. Proposals for the year 2006 are for $250 million of funding. States are required to chip in an additional 25% in matching funds. It is apparent the aging network has put a huge priority on supporting family caregivers.

About 10% of the funds are earmarked to support a grandparent or older individual, 60 years of age or older, who is the primary caregiver of a grandchild or a child directly related by blood or marriage. Many older people are caring for their grandchildren or other children in the family because the parents are either unwilling or unable to do so. There is a proposal in the upcoming revision of the act to also support older adult caregivers for anyone related by blood or marriage not just for minors. Many parents are still caring for their grown developmentally disabled or mentally retarded children. They need support as well.

The term ''family caregiver'' means an adult family member, or another individual, who provides informal care in the home or in the community for an older individual. The act defines the following services for family caregivers to be provided by a state program, a local area agency on aging or by a contract service provider.

  1. Information to caregivers about available services;
  2. Assistance to caregivers in gaining access to the services;
  3. Individual counseling, organization of support groups, and caregiver training to caregivers to assist the caregivers in making decisions and solving problems relating to their caregiving roles;
  4. Respite care to enable caregivers to be temporarily relieved from their caregiving responsibilities; (Some states are providing a certain number of hours of respite care per year for all caregivers on a first-come first-served basis.)
  5. Supplemental services, on a limited basis, to complement the care provided by caregivers. (Operating practices are to use about 20% of available funds for these services)

Allotments for Vulnerable Elder Rights Protection Activities ( Title VII ) 1.5% of total grants
As has been outlined above these are programs that are administered typically at the state level or are required to be administered at the state level. But all of these programs require volunteers or contract service providers at the local level to carry them out. They include the following:

1. The long-term care ombudsman program,

2. Programs for the prevention of abuse, neglect and exploitation, (may be part of adult protective services)

3. State elder rights and legal assistance development programs, and

4. Insurance and benefits outreach, counseling and assistance programs

Other Important Titles under the Act

Grants to Native Americans (Title VI) -- $26,610,000, 1.9% of federal budget
This money is provided to over 240 tribal units and native Hawaiians to administer the 23 authorized service programs under the older Americans act.

Community Service Employment for Older Americans (Title V) no direct grant money
This section is one of the largest and most complicated titles in the act. Most of the verbiage is directed to specific procedures and cooperation with other government agencies. If we were to distill the essence of this title here is our offering.

This title covers a part-time job employment program for low-income persons age 55 or over who are unemployed or whose prospects for employment are limited. Program participants work at community and government agencies and are paid the federal or state minimum wage whichever is higher. They may also receive training and can use their participation as a bridge to other employment positions that are not supported with Federal funds.

The title also provides incentives for job fairs and other initiatives to help people over age 55 find employment.

Broward County Area Agency on Aging Example

The Broward County area agency on aging has one of the largest elderly populations of any AAA in the country. The agency is also one of the most completely organized of any of the 655 AAA's nationwide. Broward County has adopted a single source service initiative as outlined below and has become an Aging and Disability Resource Center (ADRC) for all residents of Broward County , Florida . All aging and disability services in the county are tied together through this one government agency. We urge you to go to the web site at http://www.adrcbroward.org/ and see an example of the future goal for aging services nationwide.

The Impact of Olmsted

The 1999 Supreme Court Olmstead decision in the case of Olmstead v. L.C. and E.W. has had a major impact on the delivery of government-sponsored long-term care services. Two women with mental disabilities, Lois Curtis, 31, and Elaine Wilson, 47, were, against recommendation by state mental health employees, shuttled by the state of Georgia , over a period of 20 years, between hospitals, mental institutions and other settings that were in many cases determined, not appropriate for their treatment. A lawsuit brought by an Atlanta Legal Aid attorney, Susan Jamieson, in 1995, eventually lead to a Supreme Court ruling in favor of the rights of the two women and against the Georgia Department of Human Resources. According to the Center for an Accessible Society:

"Under Title II of the federal Americans with Disabilities Act, said Justice Ruth Bader Ginsburg, delivering the opinion of the court, "states are required to place persons with mental disabilities in community settings rather than in institutions when the State¹s treatment professionals have determined that community placement is appropriate, the transfer from institutional care to a less restrictive setting is not opposed by the affected individual, and the placement can be reasonably accommodated, taking into account the resources available to the State and the needs of others with mental disabilities.

"The 'integration mandate' of the Americans with Disabilities Act requires public agencies to provide services "in the most integrated setting appropriate to the needs of qualified individuals with disabilities." The high court upheld that mandate , ruling that Georgia's department of human resources could not segregate two women with mental disabilities in a state psychiatric hospital long after the agency's own treatment professionals had recommended their transfer to community care."

Since 1999, all states, in order to avoid future lawsuits, have been struggling with providing appropriate settings for disabled adults under their care. Although the emphasis has been on integrating state services in order to offer appropriate care settings for non-aged adults who are mentally retarded or developmentally disabled, many older Americans also have varying degrees of disabilities and must be considered under the Olmstead ruling as well.

As a general rule, states have done little in a practical way to solve the problem of identifying appropriate settings and providing appropriate care for disabled Americans. Much time has gone into commissions, grants and government appointed community action groups to study the problem and provide recommendations but only recently have a few states organized their care systems around compliance with the Olmstead decision. The major problem is a lack of funding at the state level to provide integration of services necessary to provide appropriate community settings for disabled people.

The biggest problem with implementing Olmstead seems to be that the responsibility for state care delivery services is spread out among many departments and is funded from a variety of federal, state and local funding sources, each with their own complicated rules and restrictions. In addition many nonprofit community organizations offer services that could be integrated into a state's care delivery system but, at present, may not be. The challenge is to find a way to structure all care delivery systems so that care decisions and services are coordinated by one central, point of entry for people needing these services. By providing such a one-stop-shopping concept, care can be delivered more efficiently, effectively and in the proper setting. Because of its low cost and growing use by the public, the Internet is being used by many state programs who are providing web sites loaded with single source resources. But this does not solve the organizational and administrative problem of a disparate number of agencies spread through a number of departments who are not communicating with each other or who have their own set of rules.

In 2001, President George W. Bush issued an executive order called the New Freedom Initiative. Although the emphasis was on providing access, transportation, education, homeownership, employment and voting accessibility mostly for disabled non-aged Americans, the president also reiterated his commitment to implementing the Olmstead decision for the disabled and the providing of long-term care in suitable community settings, primarily by moving people out of institutions and into community care settings. As part of his initiative President Bush signed an order directing the Department of Health and Human Services and its agencies, the Centers for Medicare and Medicaid Services and the Administration on Aging to begin providing funds to help states provide more community-based care settings for older Americans.

A great deal of this national effort is in integrating Medicare and Medicaid services with services of state aging units and area agencies on aging. The primary long-term care provider for mentally retarded and developmentally disabled and older Americans over age 65 is Medicaid. Federal Medicaid rules require the use of nursing home care for these eligible groups and home and community-based care can only be offered through federally granted waivers to a state's Medicaid program -- a cumbersome and inefficient system. Medicaid is outdated and inappropriate for implementing Olmstead and should be revised. In lieu of a revision of Medicaid, numerous demonstration grants and study grants have been awarded by the Department to investigate and implement the best ways to integrate services. HHS has adopted the following four goals to implement its new policy of increasing the use of home and community-based services.

  1. Providing comprehensive information about available services, designing simplified eligibility requirements, and implementing single access points of service.
  2. Giving consumers more choice in the types of settings and providers they can receive.
  3. Coordinating various funding sources and providing single-pool funding for consumers to choose among a variety of home and community services.
  4. Establishing procedures to ensure quality control of services across various care settings.

Some of the more significant federal programs to achieve these goals include

  • The program, "Money Follows the Person"; providing monies for this program to fully fund one year of the cost of helping Medicaid nursing home residents return to the community;
  • Continued implementation of the National Family Caregiver Support Program (Already covered in sections above);
  • Replication in other states of the successful "Cash and Counseling" model (An experiment in some states where Medicaid recipients receive cash payments and make decisions for and pay for their own Medicaid authorized services.);
  • The Aging and Disability Resource Center Initiative (Explained in more detail below);
  • The "Own Your Future Campaign" (An initiative to be funded for all states by 2006 to make the public aware of the need for long-term care planning).

Because of the national emphasis on coordinating care programs and providing a single source point of service, the national aging network now administers and manages almost two-thirds of this nation's Medicaid waiver programs. Also all State units on aging have been given responsibility to administer State revenue programs; over 30 State units administer Medicaid Waiver Programs and State Health Insurance Counseling Programs; over 25 States have expanded the authority of the State aging units to serve younger populations with disabilities; and 24 States have authorized their State units to administer the Aging and Disability Resource Center program.

The ADRC Initiative

A major focus of the federal initiative programs is the goal of establishing "Aging and Disability Resource Centers " (ADRC's) at state and local levels all over the country. Federal grants from the Administration on Aging and the Centers for Medicare and Medicaid Services have provided, to date, demonstration grants to 24 states for resource centers. These states are using the money to demonstrate the concept in a small number of in-state designated service areas. Florida has been more enthusiastic. The Florida legislature expanded its program in 2004 and appropriated money for statewide centers for all older Florida residents. Starting dates for demonstration grants have been staggered over the years. Regardless of when the grant starts, the state will receive ongoing funding for a three-year period at which time the state is expected to have a fully mature test program. States participating in the project are

  • Alaska
  • Arkansas
  • California
  • Florida
  • Georgia
  • Illinois
  • Indiana
  • Iowa
  • Louisiana
  • Maine
  • Maryland
  • Massachusetts
  • Minnesota
  • Montana
  • New Hampshire
  • New Jersey
  • New Mexico
  • North Carolina
  • North Marianna Islands
  • Pennsylvania
  • Rhode Island
  • South Carolina
  • West Virginia
  • Wisconsin

A web site on how these states are progressing with their programs can be found at http://www.adrc-tae.org/

The goal is to create a local community, single entry point for

  • information,
  • counseling,
  • qualification and
  • services

for all aging, disability and long-term care programs in the state, both public and private.

Services are to be integrated not only for the elderly but for all physically and mentally disabled adults in the state as well as their caregivers. Long-term care planning services for healthy people will also be offered. The intent is to provide a comprehensive service source with input from all interested public, private and faith-based groups in the state. This list of input providers might include the following:

  • State Medicaid uptake, qualification and services agencies
  • Aging and disability associations and nonprofit organizations
  • Public and private providers such as nursing homes, assisted living, independent living, adult day care, medical equipment suppliers, assistive technology suppliers and home health agencies
  • State and private mental health organizations
  • State adult protective services organizations
  • State assistive technology organizations
  • Public and private housing agencies
  • Public and private transportation services
  • Hospitals and hospice services
  • Legal services
  • And the list could go on and on

Here is a list of the services a resource center is expected to provide.

  • Actively promote public awareness of both public and private long-term support options, as well as awareness of the Resource Center , especially among underserved and hard-to-reach populations.
  • Provide information, and counseling as needed, on all available long-term support options.
  • Help people assess their potential eligibility for public long-term support programs and benefits.
  • Determine eligibility for public long-term support programs and benefits, including level of care determinations for Medicaid nursing home and Medicaid home and community-based services, waiver programs.
  • Assist people with the Medicaid eligibility determination process (in collaboration or coordination with Medicaid eligibility determination staff).
  • Provide short-term assistance or case management to stabilize long-term support individuals and their families in times of immediate need and before they have been connected to ongoing support (e.g., enrolled in a home or community-based waiver). Resource Centers may also provide on-going case management to public- and/or private-pay individuals.
  • Provide information and referral to other programs and benefits that can help people remain in the community, such as disease prevention and health promotion programs, transportation services, and income support programs.
  • Help people plan for their future long-term support needs.
  • Organize, simplify, and ensure “one-stop shopping” for access to all public long-term support programs.

One of the biggest challenges of this program is going to be making the public aware that the program exists. A general lack of funds will simply not allow for very much if any television, radio, magazine or newspaper advertising or for direct mail campaigns. Besides, such campaigns could bring in droves of people who would overload the system and who might not qualify as a targeted group and money would be lacking to help them. As with aging programs, this program, as well, will have to reach out and identify low income and socially needy individuals.

Based on a description of outreach efforts in a previous section, recipients would probably come through a referral process from organizations serving the elderly and disabled. All of the 24 test programs are using web sites that list services and contact information. This is obviously the cheapest, easiest to implement and most direct method of promotion. But many of the needy or their families may not even have computers or if they do, they may not be using Internet services. It also takes a lot of time and effort to get a web site linked to other pertinent sites and to achieve a high profile on search engines. The Internet can only be a source that other marketing methods will direct people to. This means that without other forms of promotion to provide outreach, the Internet approach by itself, will miss a large number of potential recipients.

Example of Oregon's Community-Based Care Initiative

A number of states have seen the need to give their citizens more choice with long-term care settings without the prodding of the federal government or without the Olmstead decision hanging over their heads. These states recognized well before Olmstead, that the undue emphasis on providing care in nursing homes is neither cost effective nor fair to care recipients and their families.

Of all states attempting to change the system, Oregon has been the most effective in keeping developmentally disabled and mentally retarded and elderly long-term care recipients out of nursing homes. Oregon's program started in the late 1970s as a result of concern over escalating costs for long-term care Medicaid recipients. Unlike most states where more than 70% or 80% of Medicaid long-term care recipients are in nursing homes or intermediate care facilities, Oregon has more than 80% of its recipients in community care homes or receiving home-based care. In addition Oregon has been successful in allowing people receiving care to make their own choices through a consumer directed payment program where these people receive monthly allowances and purchase their own care. Many states are participating in this concept of giving money to eligible participants and allowing them to use the money as they see fit for their care, but these programs may be giving only small monthly allowances of $200-$400 a month. In Oregon, many recipients are given discretion to spend well over $2,000 a month for their care.

This quote is taken from the national conference of State legislatures, 2000:

"This year, for the first time ever, a state will spend more on home and community-based services than on nursing home care. In Oregon, nearly 80 percent of Medicaid patients needing long-term care are getting help in their homes or in the community, while only 20 percent are in nursing homes.

The key to Oregon's success, according to Roger Auerbach of the Oregon Senior and Disabled Services Division, is legislative policy that directed agencies to serve seniors in their homes and in the community and keep them out of nursing homes. Nursing home care per patient costs the state roughly $2,800 a month. Home and community-based care runs around $1,200. With the savings reinvested in services that keep seniors in their homes, Oregon "can serve thousands more," Auerbach says.

Also important to the state's success is the legislature's move to consolidate services into one department-the Senior and Disabled Services Division-which licenses caregivers and nursing homes, monitors quality of care and determines eligibility for people with disabilities and seniors. Another key, according to Auerbach, is that the state now allows in-home caregivers who receive training to do certain tasks without a home health nurse.

Oregon will continue to develop ways to encourage informal caregiving, Auerbach says. To help citizens caring for their relatives as well as paid caregivers, the state is developing an educational television special, planning for an 800 phone number, establishing registries for trained respite caregivers and piloting a closed-circuit broadcast to educate people who run adult foster homes."

The state has demonstrated what others in the country have been saying all along, that it is less expensive to maintain care recipients in the community or at home than paying for nursing home care. The state has been able to serve an increasing number of younger disabled and elderly people than it could have only by utilizing nursing home care. Options available to recipients under comprehensive Medicaid waivers in the state include: respite care, adult day services, adult foster care, assisted living facility care, residential care, and in-home care. Oregon also offers services in a range of settings to people who need assistance with activities of daily living. In addition, case management staff helps clients select the option that is right for them. One negative note, however, is the state has not effectively integrated mentally ill people into this system and that program has not been as successful in providing community-based care.

In the late 1970s and early 1980s, the state adopted a policy of combining budgets for Medicaid and aging services together under one roof. Area agencies on aging were given responsibility to act as single entry points for all long-term care elderly services. During the 1990s, the state discontinued using institutions for mentally retarded and developmentally disabled persons and went to a community care and home-based care system. Responsibility for these people was also given to the county, single source entry systems. In 2001 the state reorganized its health Department and included services for younger disabled people, mental health, aging services and vocational rehabilitation under one department called the Seniors and People with Disabilities Office. All moneys for these services are under one budget. Another important innovation was the recognition that disability and aging services should be managed and budgeted at the local level and not at the state level. Local area agencies on aging manage their own programs for Medicaid, disabled adults and aging services including applying for and receiving Medicaid waivers.

Early in its program the state experienced considerable opposition from nursing homes who were unwilling to give up patients. One of the solutions to this problem was that nursing homes were encouraged to purchase or add assisted-living and home health services to their programs. This helped considerably since nursing homes could now participate in the transition to community-based care. Another effort that helped direct people to home and community care was educating doctors on the benefits of not sending people directly to nursing homes unless it was absolutely necessary.

One drawback in Oregon is that even though services for younger disabled, the elderly and mentally ill are all housed within the same department and they share the same budget, they are still in separate offices and communication and cooperation is still lacking. Mental health particularly has not been integrated effectively into the system. Another drawback is that so much emphasis has been put on moving people into the community that feedback and control procedures in monitoring community care have been late in coming. For community care, the state uses assisted-living facilities with six or more residents and over 2,000 foster homes with five or fewer residents. Oversight for foster homes is on a county level and the handling of inspections and complaints is not as thorough as it should be.

New York State Single Point Resource Example

New York offers an Internet site and a published book called the "New York State Senior Citizen Resource Guide". These booklets are made available throughout the state and New York also has a television station devoted to promoting the services of the State Office of Aging.

New York's list of aging services is very large and extensive and your state may not offer as many services, but it will give you a good idea of the types of services available when you contact your local area agency on aging.

The following was taken from the following URL http://aging.state.ny.us/findhelp/guide/index .htm

"INTRODUCTION
The New York State Office for the Aging was created by Executive Order of the Governor in 1961 and was one of the first State Units on Aging in the nation. In 1965 the office was made an independent agency in the Executive Department and became the central state agency to plan and coordinate programs and services for the aging at all levels in both the public and private sectors. Since its beginning, the Office for the Aging has been in the forefront of special initiatives for older people, and many of the concepts and programs which began in New York have been adopted nationally.

MISSION
It is the mission of the New York State Office for the Aging to help older New Yorkers to be as independent as possible for as long as possible through advocacy, development and delivery of cost-effective policies, programs and services which support and empower the elderly and their families, in partnership with the network of public and private organizations which serve them.

The New York State Office for the Aging serves as an advocate for over 3.2 million New Yorkers age 60 and older. The office advocates for older people at all levels of government and the private sector with the cooperation of concerned organizations and older New Yorkers.

Under Executive Order No. 12, Governor Pataki has empowered the office to review and comment on all state agencies' programs, policies and legislative proposals which would affect aging people.

In addition, the office:

  • advises and assists the Governor in developing policies to help meet the needs of older New Yorkers and to encourage their full participation in the community;
  • coordinates state programs and services for our older residents;
  • stimulates community interest in problems of the aging;
  • promotes public awareness of resources available for aging persons;
  • ensures the development of local programs; and,
  • fosters and supports studies, research and education on issues and concerns of older New Yorkers.

The New York State Office for the Aging administers various titles under the federal Older Americans Act of 1965, as amended, and a variety of state-funded programs which serve mature citizens. In these programs preference is given to older persons who have been historically underserved, including those with the greatest economic or social need, with special emphasis on the needs of low income minority seniors.

The majority of programs are administered through local offices for the aging. There are 59 local offices which serve each county, the City of New York, the St. Regis Mohawk Indian Reservation and the Seneca Nation of Indians which includes the Cattaraugus and Allegany Reservations. These are the only Indian Reservations with offices for the aging east of the Mississippi River.

As people age, legal issues arise that need their attention. Some face age discrimination in the workplace; others become victims of fraud. The following examples are provided to assist seniors in determining where to turn for help."

(The state and local agencies coordinate all of the services below through one central clearinghouse or through referral to local agencies on aging)

BALANCE BILLING
DISEASE PREVENTION AND HEALTH PROMOTION SERVICES
ELDERLY PHARMACEUTICAL INSURANCE COVERAGE (EPIC)
HEALTH CARE PROXY
HEALTH INSURANCE INFORMATION, COUNSELING AND ASSISTANCE PROGRAM (HIICAP)
HOSPITAL PATIENT'S RIGHTS ISLAND PEER REVIEW ORGANIZATION (IPRO)
LONG TERM CARE OMBUDSMAN PROGRAM
MEDICAID
MEDICARE
NEW YORK STATE PARTNERSHIP FOR LONG TERM CARE INSURANCE
MEDICARE SAVINGS PROGRAM
ONLINE RESOURCES
AGE DISCRIMINATION
MEDICAID ELIGIBILITY PLANNING
CONSUMER ISSUES
POWERS OF ATTORNEY
ESTATE PLANNING
GUARDIANSHIP
EMERGENCY ASSISTANCE FOR ADULTS (EAA)
SENIOR CITIZEN PROPERTY TAX EXEMPTION
REAL PROPERTY TAX CREDIT
SOCIAL ADULT DAY SERVICES
ELDERCARE LOCATOR
EXPANDED IN-HOME SERVICES FOR THE ELDERLY PROGRAM (EISEP)
HOME CARE SERVICES
HOSPICE SERVICES
NATIONAL FAMILY CAREGIVER SUPPORT PROGRAM
TARGETED CAREGIVERS INITIATIVE (TCI)
GRANDPARENTS RAISING GRANDCHILDREN WITH DEVELOPMENTAL DISABILITIES
FOSTER GRANDPARENT PROGRAM
RESPITE SERVICES
SENIOR CENTERS
SUPPORTIVE SERVICES
TELEPHONE REASSURANCE AND FRIENDLY VISITING
ACCESSORY APARTMENTS
ADULT HOME
ELDER COTTAGES
ASSISTED LIVING
CONGREGATE HOUSING
SUPPORTIVE HOUSING
ENRICHED HOUSING PROGRAM
NATURALLY OCCURRING RETIREMENT COMMUNITY SUPPORT SERVICE PROGRAM (NORC-SSP)
RENTAL ASSISTANCE
RESIDENT ADVISOR PROGRAM (RAP)
REVERSE MORTGAGE LOANS FOR SENIOR CITIZENS
NURSING HOMES
SENIOR CITIZEN RENT INCREASE EXEMPTION (SCRIE)
SENIOR HOUSING DEVELOPMENTS
SHARED LIVING RESIDENCE
SENIOR COMMUNITY SERVICE EMPLOYMENT PROGRAM (SCSEP or Title V)
WORKFORCE INVESTMENT ACT (WIA)
TRANSPORTATION TO APPOINTMENTS
TRANSPORTATION DISCOUNTS
CONGREGATE MEALS
FOOD STAMPS
HOME DELIVERED MEALS
FEDERAL GOLDEN AGE PASSPORT
FEDERAL GOLDEN ACCESS PASSPORT
NEW YORK STATE PARKS (GOLDEN PARK PROGRAM)
EMPIRE STATE SENIOR GAMES
NEW YORK SPORTING LICENSE
EXERCISE CLUBS
STATE TOURISM OFFICES
TRAVEL & TOURISM OFFICES:
HOME ENERGY ASSISTANCE PROGRAM (HEAP)
UTILITY RIGHTS
WEATHERIZATION REFERRAL AND PACKAGING PROGRAM (WRAP)
OTHER ASSISTANCE WITH UTILITY EMERGENCIES
REAL PROPERTY TAX CREDIT
LOCAL REAL PROPERTY TAX EXEMPTION
VETERAN'S EXEMPTION
SCHOOL TAX RELIEF (STAR)
ONLINE RESOURCES
LONG TERM CARE OMBUDSMAN PROGRAM
RETIRED SENIOR VOLUNTEER PROGRAM (RSVP)
SENIOR COMPANION PROGRAM
DISABILITY COMPENSATION AND PENSION
VETERAN'S HEALTH CARE
BLIND ANNUITY
BURIAL
CITIZEN PARTICIPATION
CRIME PREVENTION
CRIME VICTIMS PROTECTION
ELDER ABUSE PREVENTION
LEGAL ASSISTANCE
PERSONAL NON-DRIVER IDENTIFICATION
OLDER DRIVER FAMILY ASSISTANCE PROJECT
PUBLICATIONS
"AGING & YOU"
The New York State Office for the Aging's award-winning cable TV program