Page images


[ocr errors]



a) Area Agencies on Aging should be given the option to provide

Recommendation 1 directly those services related to their statutory advocacy and administrative functions: information and referral, outreach, advocacy, program development, coordination, individual needs assessment, and case management. b) Area Agencies on Aging should be given the option to provide other services directly if, in the view of its State Unit on Aging, the AAA can provide the service substantially more effectively and efficiently than any other service provider. c) An Area Agency on Aging may plan, coordinate, and provide services funded through other sources if it continues to meet all its Area Agency responsibilities under the Older Americans Act.

In the early years of the Aging Network, issues regarding the respective authority and responsibilities of the State Unit and Area Agency on Aging were clarified in the regulations for the Older Americans Act. They provided the direction for the relationships that launched the OAA in its successful course. In the past decade the more recent generalized regulations have left in several instances insufficient direction and clarity relative to the authority of AAAs in the development of locally-based systems of services, despite the administration's assurance that precedent and practice had made these provisions in the regulations unnecessary.

Some progressive states had no difficulty recognizing that groups of services had differem characters and purposes, and that the direct provision of some kinds indeed enhanced the AAAs' capacity for advocacy and for the fulfillment of their mission; in other states, more rigid interpretations, ignoring the precedents in the early regulations and practices in other states, have caused hesitancy by states, frustration in AAAs, and occasional hostility between them.

Enacting the above recommendations would simply reaffirm what was once quite clear in the regulations.

Recommendation 2 - a) We recommend that the definition of in-home services in Title IIID and as a priority area in Title IIIB be expanded to include all services in the home directly relating to the support of a frail older person needing assistance, excepting structural repairs to the home. b) We further recommend that the Act give explicit authority to AAAS to use a portion of Title IIIB and Title IIID funds to purchase directly through case management on a client-by-client basis in-home and community services necessary to assist at-risk older persons to live in their own homes.

Currently, the restrictions on Title IIB priority and Title IIID services prohibit their use for critical needs. Often an older person needs not just a hands-on service but rather a minor home repair, or a home adaptation, such as grab rails or a ramp or tacked-down rugs; or an environmental aids, such as special eating utensils or a reach extender; or an electronic alert device - none of which satisfy priority requirements. The Medicaid agencyfunded pre-admission screening program we operate gives us wide flexibility, allowing us to purchase directly whatever it takes to support a frail, vulnerable person in the home. This flexibility has been extremely valuable, for we can respond directly to client need, instead of depending solely on the more cumbersome contracting system which leaves some critical gaps in services.

Recommendation 3 - We recommend that the staffing levels of the Administration on Aging be restored, the discretionary resources for the Commissioner's use in coordination among Federal agencies be made available, and the Commissioner's authority for interagency personnel placement by expanded.

Coordination activities, including those regarding housing, are mandated throughout the Older Americans Act The Administration on Aging, State Units on Aging, and Area

Agencies on Aging are directed to develop networks of comprehensive, coordinated systems of services. While long on the commitment to coordination, the Act is short on means to achieve that coordination.

The Administration on Aging, bike state and Area Agencies on Aging, is a change agent, and subject to all the slings and arrows attendant to effecting change. Absent the authority to deflect those slings and arrows or the resources to exercise that authority, AoA can have little hope of having a significant impact on agencies outside the formal Aging Network. And experience in some state systems suggest that the absence of power to effect horizontal change often results in stultifying vertical change, refining and re-refining procedures, standardizing service patterns, and generally imposing control and rigidity, which makes meaningful change even more difficult.

If the Aging Network is to have a national focus on this critical issue of Long Term Care, if we expect to have a significant impact on Medicaid and Medicare, on housing, on transit systems, etc., if we expect to have the enormous potential of the Aging Network recognized on the Federal scene as a key player in Long Term Care, then AoA must be revitalized.

The Commissioner has some stated authority: "... the Commissioner may utilize the services and facilities of any agency of the Federal government and of any other public or nonprofit agency or organization, in accordance with agreements between the Commissioner and the head thereof, and is authorized to pay therefore,..." But it may be more efficacious to give the Commissioner authority to place AoA staff in other Federal agencies to influence directly the development of policy, procedures, and programs, and to provide the resources to make it possible.

Recommendation 4- We recommend that the Older Americans Act be amended to include

major initiative on the planning of local comprehensive systems of senior housing, both

publicly and privately funded, developed by the AAAS and coordinated with the Aging Network's supportive services, and that the initiative be adequately funded.

The primary mission of the Older Americans Act centers on the home. Yet the Act makes only fleeting reference to housing, which is a major element in local systems of services to the aging. AAAs have become acutely aware of how the lack of affordable housing can frustrate the intent of the Act, for in-home services simply cannot meet a client's needs if the client's home itself is unmanageable or unlivable.

The current system for providing housing for seniors evades any kind of comprehensive planning, for the system is fundamentally reactive and market-driven, often leaving those elders most desperate without housing options.

Recommendation 5 - We recommend that the authorization levels for the very important Title IIID be doubled, and that Titles III B, C, and D of the Act be funded to authorized levels.

Although the increases in Titles B and C, and the enactment of Title D have relieved the long drought in funding increases, the levels have over the past decade remained static; yet the needs have grown exponentially. While many state and Area Agencies on Aging have developed the essential structures and systems to address the needs of older persons struggling to live independently, researchers and observers of the Aging Network, who often speak highly of the prescience and creativity of the Network, and who praise the goals of the Act, tend to treat lightly the key roles the Network can play in the emerging Long Term Care systems, primarily because of the woefully low OAA funding levels. At the same time, Medicare and Medicaid, whose funding dwarfs OAA funding, are locked into their respective medical and institutional roles.

If the local flexibility inherent in the Act were restored and if funding levels for Title III were increased with growing need, the state and Area Agencies on Aging could make a powerful and immediate impact on the emergence of community-based Long Term Care systems, the natural fulfillment of the Older Americans Act



January, 1985

The study of case management in the Region IV AAA conducted by Western Michigan
University demonstrates clearly that case management has a significant impact
on selected variables pertaining to (1) Health Care Utilization (2) Security
and Daily Care (3) Financial Concerns and (4) Basic Equipment Use. Statistically
significant beneficial differences for those high risk elderly receiving case
management, in comparison to those receiving services normally provided in the
community, are evident in seven of the twenty variables measured in this grouping.
(See attached graphs)

Of particular interest in the Health Utilization section is the finding that case management clients utilized all health services with less frequency during the project year than did the control group. For case management clients this meant approximately:

25% fewer in-patient hospital admissions

25% fewer out-patient doctor visits (for other than regular


13% fewer emergency room visits
12% fewer nursing home placements
6% fewer foster care placements
4% fewer medications used


All of these factors represent a'cost-savings for the group receiving case manag.
The two statistically signficant factors, reduced hospital and nursing home
admissions, indicate a 90% assurance that our findings can be generalized to the
target population. The remaining factors, while they are not generalizable to
the larger population at this time, might prove so with a larger sample. Five of
the fourteen remaining variables measured in this grouping were also statistically
significant. These are noted by the asterisk on the attached graph.

It is also important to note that the research design looked only at the nursing home admissions and not discharges. Sixty percent (60%) of nursing home residents receiving case management during the study year returned home with supportive services. This is certainly a positive outcome and a potential cost savings factor.

Researchers continue to locate and interview subjects from the treatment and control group in an attempt to increase the sample size and improve the data base. These responses will be included in the final research report along with analysis of responses from T-3 interviews which provide data at eighteen months after intake.


Finally, the proposed cost analysis could not be completed due to unavailability of health care cost data. The researchers are currently developing proxy measures to complete a cost analysis.

[ocr errors]
« PreviousContinue »