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Long term care should also be disease-neutral, focusing on eligibility based on disability rather than the affliction which precipitated it. Physical, cognitive, and mental dysfunctions all can prevent adequate performance of activities of daily living, and although care plans may differ appreciably, eligibility for help should not. There should, of course, be clear standards for eligibility. An assessment should be made of on-going performance of the activities of daily living which can be seriously affected by memory loss and other symptoms of dementia. Being a safety hazard to oneself is surely a valid criterion for eligibility.
Long term care should also be income-neutral. Second only to the fear that disability means leaving home is the fear that disability means spending down to impoverishment. Long term care should be available to all regardless of income, and, while permitting affordable deductibles and cost-sharing, should require no one to become impoverished to become eligible and should not preclude reasonable opportunity for institutionalized persons to retura to
The Long Term Care System Should Link Wish Othe: Svstens
While the care interventions and reimbursement structures of the current Medicare program differ markedly from those in a comprehensive long term care system, they have in common concern for the vulnerable older person. The care coordinator must be alert to client acute care needs and be prepared to provide speedy access to the acute care system. Quick intervention when a disease is precipitating disability can go far in preventing the substantial loss of personal independence.
The care coordinator should also link up with the nursing home ombudsman, transportation systems, and legal services readily available through the contracted services of the Area Agency on Aging. The care coordinator should also be in continual contact with the planning operations of the Area Agency on Aging to be involved with developing appropriate services and settings. And the care coordinator should work closely with the network of the client's family and friends, not only apprising them of developments and options, but also supporting, encouraging, and even training them as caregivers. Families can not only save money by helping, but they also can give the afflicted family member love and moral support.
4. The Long Term Care System Should Have Clearly Delineated Lines of Responsibility For Insurers And Levels Of Government Administration
The most recent literature indicates that the private insurance industry `will not be able to market comprehensive long term care policies which will be affordable to more than a quarter of the nation's elders. Therefore, it is likely that public insurance will provide the broad base of support for the system. There is a danger in the rush of the private insurance industry to build a mechanism for a clientele parallel to the public one for the majority of functionally disabled. This could cause a two-tiered system or a constant restructuring of private policies. It may be more reasonable that the private insurers provide coverage of supplementals such as deductibles, co-pays, and extra amenities to avoid competition with the publicly-subsidized services. In this way, clients would utilize a single care coordinating system with a single system of eligibility, avoiding the inevitable bewildering fragmentation that comes with an array of eligibility requirements, with clients bouncing from system to system.
Client shifting also can result if the Federal and state roles are not clear. It is not in the scope of this paper to explore which level should carry the primary administrative role, but if the states have the lead, policy should eliminate those conflicting cost-sharing incentives which now encourage the states to "dump" clients into the federally subsidized Medicare acute care system or the Federal system to "dump" into the Medicaid nursing home system. Vulnerable clients ought zot to be pawns. Purther, there should be 20 differences in state cost-sharing by care setting. The at-risk person's care in the least restrictive setting should be the driving criterion.
In 1973, through the Older Americans act, Congress purposefully mandated Area Agencies on Aging to establish local long term care systems. It is time to integrate either Medicare or Medicaid with these Area Agency on Aging systems to realize a truly comprehensive, and coordinated long term care system. Medicare, Medicaid, and the Older Americans Act developed separately, but their functions are neither mutually exclusive nor incompatible. Through the Older Americans Act forward-looking policy-makers have already created the local foundations for a national comprehensive long term care program. Regardless of the vehicle used to reimburse - Medicare or Medicaid - fashioning a solid system is a matter of incorporating the reimbursement structure with the tested local systems and services operated by the Area Agencies on Aging.
AREA AGENCY ON AGING
SOUTHERN MISSISSIPPI PLANNING AND DEVELOPMENT DISTRICT
Mr. Chairman, distinguished members of the Subcommittee on Aging:
My name is Jane Kennedy and I am Director of the Area Agency on Aging of Southem Mississippi Planning and Development District. The Area Agency on Aging serves a population of some 87,000 alder individuals residing in the fifteen southernmost counties of the state. Initially established as one of the original nine Areawide Model Projects for Older Americans, and subsequently designated as an area agency on aging, we enjoy the unique position of having implemented the first Title VII nutrition project in the nation. I am privileged to have served as director of the model project and director of the area agency since its inception within the District some eighteen years ago.
Of the very greatest importance in considering long term care systems development are the opportunities of interaction and exchange with this subcommittee which constitutes a major link to the aging policy structure. With this in mind, I would commend the Committee for its significant and diligent efforts to consistently re-examine historical functions and practices of the aging network-to carefully assess where we are today even as we accept the formidable challenge of tomorrow-and to achieve our common goal of assuring independent and meaningful lives for all older Americans.
While it is readily apparent that no one element of the aging network is more inspired, more committed, or has greater vision, one above another, in addressing relevant issues associative with quality of life for older citizens, I am equally confident that the explicit mission of area agencies on aging to serve as catalysts in the development and promotion of home and community based long term care systems is both clearly reflected and responsibly demonstrated by area agencies across the narion; and that within the framework of the Older Americans Act despite its complexity and more so, because of its allowed flexibility, the aging network continues to advance efforts to support and sustain quality of life for millions of older persons. The elderly themselves serve as the driving force underlying our search for the appropriate and responsive care systems envisioned by the network; which are responsive to the diversity of need among older persons, which ensure service quality and equity in access, and which exhibit innovative and accountable vehicles for service delivery.
Issues in Long Term Care
Each of us present here today acknowledges the profound affect on every sector presented by the phenomenal growth in the numbers of older persons and the unprecedented growth of the very old. Heretofore, govemment has assumed primary responsibility for the level of public investment in service structures responsive to the pressing needs of these accelerating numbers - millions of whom may be at risk of loss of independency at any given time. At this point, budgetary constraints at all levels of government dictate a careful examination both within and beyond the aging network to characterize long term care systems and best determine the administrative systems capable of managing them in the most cost efficient and service effective marmer.
Area Agencies on Aging: Support for Long Term Care
For purposes of this discussion, I offer comments on the role of area agencies in our state as long term care systems developers within the central focus of our mission as advocates, coordinators, and quality monitors.
Recognizing, that, not unlike other states, wide variances exist between Mississippi's area agencies in the application of strategies intended to achieve our common goal of access to long term care, it
should be noted that Title III uniform service standards are in place statewide as is uz
v. standardized prescreening mechanism which provides for access based on management. While these procedures have aided in streamlining efforts to link client needs with service options and have virtually eliminated duplicative assessments for Older Americans Act services, with the exception of Medicaid Waivers, care management is confined in scope of authority to Title III programs.
Extension of care management linkages to other health and social systems is limited although area agencies are making inroads through service specific arrangements such as reimbursal of home health agencies for conducting joint client assessment. Direct involvement of the health care community with area agencies is most evident in the area of information exchange and referral which serves to enhance client care planning by drawing on the full array of identified community resources. We remain watchful, however, that information exchange does not serve as a replacement for more extensive coordination activities and the formalization of collaborative efforts to establish entry points that are strongly based in outreach and networking.
The dilemma of scarce resources in our rural state does not serve as reason for failure to be creative. Rural service agencies and organizations are usually small enough that they are not management layered and therefore are generally cooperative and experienced networkers. This very informality, however, may contribute to disregard for procedure. Program visions must be carefully communicated and anticipated results thoughtfully defined. Often simple solutions to client needs exist which can be facilitated by contact with church groups and neighbors. It is important to understand and appreciate this environment for few ancillary services are existent in rural Mississippi counties.
I would be remiss in not mentioning that Title III Part D funds, however limited, enabled the provision of respite care to care managed clients in service area where respite had been non-existent previously. We were amazed at the frugality of respite care demand and use on the part of these clients and their caregivers. This bolds true as well in the provision of respite care as one of the allowable services in the Medicaid Waiver for Home and Community Based Care. While utilization rates are generally low, clients and their caregivers contend that the availability of respite allays their fear of crisis situations which may otherwise be unmanageable.
Coordination activities on the part of area agencies under the guidance of the Mississippi Council on Aging have resulted in uniform standards of care, definitions of service, client satisfaction indicators, reporting procedures, requests for proposals, and service contracts; all are elements important to procedural quality assurances and most were developed through a long range planning coalition of state, area agency and provider representatives. In fact, coordination of funding sources and area agency experience in the management of limited resources are perceived as major strengths in bridging service voids in long term care - a role consistent with mandates of the Act
It is imperative that Medicaid Waivers for Home and Community Based Care continue and expand. The waivers are proven foundations; they are viable and logical approaches supporting the independence of vulnerable elderly at risk of institutionalization. Even as this statement is prepared, the Area Agency is responding to families who are desperate in their search for supportive series necessary t assist a parent, an aunt or a grandfather to remain in their homes. On this day, the calls are from Madiera, California, Chicago, Illinois and St. Louis, Missouri. Circumstances are varied as those families represented here today. The desire for independence, for security, dignity and comfort is the common thread that binds them.
I urge you direct attention to whatever barriers may be blocking needed expansion of the waiver programs. If the barrier is fear of the "flood gates opening", then examine historical utilization and results. While we wait, even now, vulnerable older persons and their families struggle as their independence erodes just beyond reach of suppon.
We rely heavily on Title V and other programs which support opportunities for older workers. Their community service is the life-blood of many helping programs filling voids resulting from level funding over the past decade. The values are three-fold, supplementing the limited income of participants, sustaining vital community services, and providing new job experience conducive to private sector placement.
The value of ACTION volunteers is beyond compare. Their contributions are tallied in hours, but their true worth is immeasurable, the human exchange beyond our scope. Sir Winston Churchill reminded us that "We make a living by what we get; a life by what we give". ACTION volunteers personify the philosophy of that great statesman. Fullest support for volunteer programs is recommended.
Trends in Mississippi
True, we are a poor state, but our older people exhibit strong self-reliance. A massive statewide needs assessment conducted just several years ago reflected high levels of life satisfaction among the hundreds of elderly interviewed. The thought, "a way-out, not a hand-out", pictures their wondrous spirit of survival. Overriding all others, the most prevalent desire voiced was to avoid being a burden to their family, their church, or their community.
Overall low levels of education and income among Mississippi's older population have contributed to high levels of poverty among them - estimated to be as high as forty-four percent. In the southern planning and service area, poverty levels in several counties range in fifty percentile, with one county considered the poorest in the state and one of the ten poorest counties in the nation. This small rural county contributes more in matching funds than the amount of their equitable share of Title III federal and state dollars. (The area agency allocates funds through a formula which considers both the sixtyplus population and poverty factors).
Because of current budget deficits, but also historically, Mississippi provides only the required matching funds to attract federal aging programs. The Mississippi Association of Ares Agencies an Aging recently convened forry individuals identified as community leaders across the state with the intent behalf of the developing long term care system. It is hoped that these newly enlightened advocates will continue to work shoulder to shoulder with the area agency on aging advisory councils.
It is of note also that Mississippi had the highest number of minority elected officials in attendance at the National Association of Minority Elected Officials/National Caucus and Center on Black Aged conference held in Prince George's county last year. We are grateful and justifiably proud that area agency advocacy efforts are reflective of this high degree of interest
While we do not profess to having developed a model approach to the issue of long term care, we are confident that Mississippi's aging network is well-positioned to respond to emerging issues and new commitments. You will find a not so surprising "can do" attitude present in area agencies across the board. Having served in the forefront of the shift from institutional bias to a national commitment to full participation of older persons in American society, we can look back to 1965 - to passage of the Act and the most remarkable progress already made. Reassured by this backward glance, we are future-oriented.
We rely on reauthorization of the Older Americans Act to guide us in the coming decade. We are committed to any provisions that assist us in targeting services to those elderly most vulnerable to loss of independence.
As to cost sharing, we have already put theory to practice by actively seeking sponsors of those elderly termed eligible, but necessarily placed on service waiting lists due to budget constraints. Sponsors are solicited from among family, churches and civic groups. This policy requires very careful management to avoid any connotation of inequity simply because a client came "last to the table", so to speak. An important consideration is that clients have appropriate service options at the time of need, ie, an older person recovering from surgical knee replacement may not need a home delivered meal when a meal becomes available six months later. This logic fosters consideration of voluntary cost sharing, but we caution against means testing.
We support any provisions of the Act that advance our concern for elder rights and reaffirms the strongest possible commitment to advocacy on their behalf.
Public/private partnerships should be supported. "Partnerships" denote mutual benefits are to be derived. Such partnerships can extend service availability. We need allowed flexibility as we explore this new marketplace.
We must not abandon those health promotion efforts directed to appropriate life styles and nutrition education for seniors. Preventive measures are basic to maintenance of independency.
However, we strongly support service standards and service eligibility for Older Americans Act programs which consider health care needs. We should continue to focus on care management as a core element of long term care systems.
Lastly, I would be remiss in not expressing support for elevation of the commissioner on aging position to that of assistant secretary. It is time to position the Administration on Aging to best coordinate federal planning on behalf of older persons. This is a basic charge to AOA, and is the area which may well serve as the measure of achievement for long term care far into the future.