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munity-based in-home services which literally makes the difference for the elderly of living out their lives in loneliness and despair or of being able to enjoy a basic quality of life in their own community with dignity and self-respect.

The Older Americans Act has recognized the pride and independence which is such an integral part of Americans and especially of the elderly. It does not force them to demean themselves and try and demonstrate their poverty and their need for aid.

I am on the board of a homemaker health agency here in DC, and we know from our own experiences that people simply would not seek our help if they had to declare their poverty and prove their eligibility. We know in some of the senior centers that I work at, in the lunch program that we give, which people do contribute to, that if they were asked to demonstrate they could not afford to eat, they would rather not eat. The system of asking for voluntary contributions on a sliding scale works very well. We collect about 80 percent of the contributions that we ask our clients to provide to us. It works well. It is a good system. I hope that we will not move it into the demeaning means testing system.

The only other thing I would like to say is there has been some suggestion in terms of providing more Federal direction to how the money should be spent and what groups should be served. I think the great beauty of the Older Americans Act is the flexibility that it gives to States. I am an ex-Federal regulator. I like Federal regulations, but I think in this area, I do not think Washington can tell Washington, DC or any other city what groups have the greatest need in their community and what are the needs for services. In rural areas, the needs for transportation will be given enormous priority. In local DC, other kinds of needs will be given priority, and only the local areas can really know this.

So, I hope we will maintain the two magnificent features of the Older Americans Act: the fact that it does not require means testing, and the fact that it provides flexibility to the States to allocate the moneys as they see the needs.

Thank you, Mr. Chairman.

[The prepared statement of Ms. Jones appears in the appendix.] Senator ADAMS. Thank you for a very eloquent statement, Ms. Gardiner Jones, very eloquent.

Dr. Redford.

Dr. REDFORD. Thank you, Mr. Chairman. I am also going to diverge somewhat from my written testimony.

Senator ADAMS. Without objection, your full testimony will appear in the record as though given, and you may extemporize as you wish.

Dr. REDFORD. Thank you.

NCOA is pleased to join you here today in considering changes in the Older Americans Act. We are going to take a little different stand than what you have heard here so far today.

We understand that the Older Americans Act for the last two decades has provided an array of advocacy, nutrition, and social services. Those services regrettably have been underfunded generally. The addition of long-term care services, which are also highly inadequately funded, as we have talked here today, are adding a further burden to Older Americans Act programs in terms of

meeting some of those basic focuses that they originally had. They have become very over-programmed and very underfunded in what they are doing. We have seen consistently over the last few years more and more activities of the Older Americans Act programs diverted toward long-term care, toward those individuals who have chronic illnesses and disabilities.

It is very understandable why this has happened. When you are dealing with long-term care needs of our older population, they are very immediate and they are very, very compelling. And we feel that it is admirable that there has been attempt to address this through the Older Americans Act, but we feel that this solution is inadequate and inappropriate.

NCOA supports continuation of the long-term care services that are currently being provided under the act. We should not pull those out. But we do not advocate a significant expansion of these services, nor do we support the inclusion of additional in-home services under this act. NCOA has long supported the Older Americans Act, and we have been a vocal advocate for the expansion of resources under this act. So, this stand may be a little surprising to members of this committee and others in the room. However, we feel that it is time to stop fractionalizing and fragmenting longterm care in this country.

Mr. Chairman, it is time, that this country develop a long-term care policy and implement a system of care which serves all Americans regardless of age and regardless of type of disability. Such a system must be adequately funded and operate under national standards to ensure that the needs of people can be met at the most effective and efficient level possible and by adequately trained personnel. This system and the programs within it must be designed to integrate and have the capability to address both the social and health needs of the frail and disabled or physically challenged in our population.

Much has already been said about case management, and I think anything I would say would reiterate the importance of care management. I do not think there is any way that we can have a system of long-term care that is equitable, that is high quality in this country, without having care management. But I would like to say a few things about it.

First of all, not all people need care management. Care management is for those people who really cannot or whose family members cannot adequately identify their needs and access the resources to meet those needs; those persons who really do need advocacy.

It is also a cost containment mechanism. It is a gatekeeping mechanism, and it is going to be in the future.

But it should be remembered that those persons who need longterm care and case management, who need the very complex kinds of long-term care, also face very complex and very intermeshed social, health, and environmental challenges. And they deserve to have available to them and their families highly educated and experienced professionals who can assist them in clearly delineating and addressing their health, social, financial, and informational, and all other needs that are going to help them maintain their optimal well-being.

Case management should not, therefore, be delegated to agencies or organizations based on a funding source. We know that there is great variability within our States and between our States in regard to the level of services provided, the competency of various organizations and agencies to provide those services. The selection of individuals and organizations to provide care management should be based on very specific and stringent standards.

NCOA strongly advocates the development of national standards for both the managers and providers of long-term care. Based on these standards, States should have the option of selecting or developing the organizational entities most appropriate for carrying out these functions. Examples of some of the minimum standards that NCOA would recommend can be found in my written testi


I think we have heard today about the really premier Older Americans Act programs in our country, and in many cases I think States quite possibly will select Older Americans Act programs to be the care managers. However, we feel if they are selected for this, that their role in long-term care should not be at the sacrifice of health promotion and wellness activities, nor through a reduction in educational and advocacy activities which protect the rights and promote the well-being of all segments of older Americans. There are in most States other organizational structures which have vast experience in long-term care. In contrast, Older Americans Act programs are usually the only programs in States which focus primarily on health promotion and health maintenance, education and advocacy related to all older Americans.

You would be interested to know that a recent study by NCOA found that senior centers have a very, very strong focus on health promotion, and recently one of the senior centers that is part of the NCOA network did mammography screening. And you would be interested to know that 3 of the first 11 women screened were found to have breast cancer and had the option for early treatment of breast cancer which saved their lives. Since that time, one in nine women in subsequent screenings have been found to have breast cancer, and this is approximately the national average.

So, the health promotion and advocacy programs, the early detection programs that are being offered now within the Older Americans Act in senior center programs, are vital and we cannot let this focus change. These mean the difference between life and death for many people. Senior centers serve as a natural focal point for a lot of services health promotion, supportive services, and educational activities.

There are also a number of other areas in which the Older Americans Act can really play a very critical and pivotal role in longterm care. They have played a substantive role in advocating for the rights of older persons in ombudsman programs, legal rights programs, and so forth. And at a time when we have increasing numbers of cognitively and physically impaired older persons who cannot speak for themselves, it is vital that we keep this advocacy role going.

Educational programs for the elderly are vital. Information empowers people to be able to better identify their own needs and to

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be able to better tap their own resources and those of their formal and informal caregiver network in meeting those needs.

They also need considerable education. Caregivers, formal and informal caregivers, need much more education in relation to the most appropriate caregiving approaches, and caregiving techniques. They need to be able to recognize when they need assistance and how to get that assistance and what assistance they should be able to expect. And many people probably would not need case management today if they had better informational and educational programs provided.

The same thing applies with the formal provider system. Burnout, inadequate and inappropriate care are not the province of any one caregiving group. It can occur with informal and formal caregivers alike, and many times it is because of inadequate information and inadequate support and resources. I think the Older Americans Act programs can certainly provide these things or facilitate the development and provision of these kinds of services.

There are two other areas that I would like to mention that I think have traditionally been under the purview of Older Americans Act programs. One is in developing data systems to let us know what the real needs are of our older population. We have for a long time had need assessments in our older Americans programs. The problem is these have not been particularly scientific nor done in the most useful manner. We need systematic, longitudinal data and information at our local and State levels to adequately plan for services in the future. We constantly hear about services that are started that fail because people do not use them. We cannot afford to continue this. There are too many services that are needed out there.

We need this information in order to better coordinate. We need it at the national level. We need it at the State level and at the local level. And I think it would be quite appropriate to provide and to revitalize and restructure the data collection system of the Administration on Aging so that we could have better data available, better data collection processes, retrieval, and analyses of that data.

The other area is in information and referral. A lot of case manager's time and a lot of family members' time and providers' time is spent trying to find a service in a community, find who has that service available, who does not have a waiting list for that service. What we really need to have available are information and referral systems within our communities that help us to identify the local providers of services, all sorts of providers, whether it is a church or a federally funded or a State funded program or whatever, people need to know who is providing a service and who has a specific service that might be needed available when people need that service.

I think the information and referral services that have traditionally been within area agencies on aging and Older Americans Act programs can certainly be upgraded. They can certainly be continually updated so that this information is available. And it will certainly in the long run save very high costs of searching for services and everyone having do the search over again because there is not one place that we can identify that is available in the community.

Mr. Chairman, NCOA does not feel the Older Americans Act is the appropriate mechanism for long-term care coordination and service provision, at least for moneys to go directly into that act. That does not mean that Older Americans Act programs might no play a very important role in this.

We feel that Older Americans Act programs can and must play a significant role in preventing or delaying the need for long-term care, in protecting the rights of older persons in the long-term care system, and in advocating for and supporting a long-term care system which acceptably, effectively and efficiently meets the needs of our older population.

I would like to conclude, Mr. Chairman and members of the committee, with the plea that you give serious consideration to the proper placement of long-term care services during your deliberations. Thank you.

[The prepared statement of Dr. Redford appears in the appendix.]

Senator ADAMS. My first question to you, Dr. Redford, is if OAA is not an appropriate place for financing of long-term care, who should the OAA programs work with to advocate for and facilitate the development of such a long-term care system? Because what we have now is Medicaid, and that is what we are likely going to continue with. And if we do not take a step here, I think that is what you are going to end up with.

Dr. REDFORD. I expected to be asked that question, and in searching for what else is out there, I feel a lot has fallen into the Older Americans Act because there is not much else out there right now. There is not another good mechanism for putting services into and putting moneys into. But I think we need to look, as we develop long-term care systems around the country, at Federal funding of a long-term care system, at what would be an appropriate mechanism that would really meet the needs of all people regardless of age.

Certainly I agree with Dr. Capitman in what he said and what Dr. Kane said today in the fact that we have to have these programs working very closely with Medicaid programs. Certainly that is not a place that we want to see all of our funds go because of the means testing of those programs.

We have social services block grant programs which provide some moneys. There are certainly tremendous inadequacies in those, and usually those are also to some degree means tested in our States.

I think what I am saying is we have to find another approach. We have to find way to integrate our funding systems better. We have to find a way to improve communication among those providers and the people out there who are coordinating for all people needing long-term care.

There is a tremendous amount of information that we do not know about or that we do not often hear about that comes from other people who have been out there providing long-term care to other populations or segments of population. I think we can learn a lot from independent living movements of the younger disabled. We can learn a lot from the mental retardation, developmentally disabled programs. They have been out there a long time providing

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