The National Aging Network Survey: 2010 Results Suzanne R. Kunkel and Elizabeth Carpio June 2011
Background With a grant from the Administration on Aging (AoA), the National Association of Area Agencies on Aging (n4a) partnered with the Scripps Gerontology Center of Excellence to conduct the 2010 National Aging Network Survey of Area Agencies on Aging. The survey was designed to assess the evolving role of the aging network in a balanced long-term care system. This strategy includes an expansion of the aging network’s activities in three major programmatic areas: person-centered access to information; evidence-based disease prevention and health promotion, and livable communities and enhanced community living options. The survey was launched in September 2010 to all AAAs. Data collection concluded in February of 2011 with over 71% of AAAs responding. This brief report provides key findings from the survey as they relate to the following topics: • Organizational Infrastructure • Key Features and Services • Opportunities and Challenges In addition, the report provides comparison data from the 2007 and 2008 survey, where appropriate, to track changes in the aging network over time. Organizational Infrastructure
Budget (in millions) Proportion of budget from OAA Proportion of budget from Medicaid* Proportion of budget for Contracted Services Clients served Full-time Staff Part-time Staff Volunteers
Average (mean) 2008 2010 $9.1 $8.9
50th Percent (median) 2008 2010 $4.0 $4.0
40.2 21.2
40.7 24.5 50.4
35.0 12.0
35.0 17.0 50.0
12,512 41 23 187
9,206 38 20 158
5,248 22 6 60
3,900 20 6 54
*These numbers reflect only those agencies which get at least some proportion of their budget from Medicaid.
Range 2008 2010 <$141,000 <$150,000 >$190 million >$167 million 1 -100 1 - 100 1 - 95 1 - 95 1 - 100 45 - 263,509 0 - 579 0 - 598 0 - 345
22 - 242,700 1 - 638 0 - 530 0 - 1,850
Area served – proportion of AAAs that serve the following areas:
Structure – proportion of AAAs that identify their structure as the following:
Urban - 5.9% Suburban - 3.9% Rural - 42.2% Remote or Frontier - 4.1% A mix of urban and suburban - 10.4% Mix of suburban and rural - 8.5% Mix of urban, suburban and rural - 25.2%
Independent, non-profit - 42.0% Part of city government - 2.0% Part of county government - 28.4% Part of COG or RPDA - 23.4 % Other - 4.1%
Population served - While all AAAs serve older people, many of these agencies also serve other target populations. As Figure 1 shows, nearly 60% provide support to younger consumers with a disability, and more than one-quarter serve veterans of all ages. Figure 1. Population served by AAAs in addition to older adults 60+ in at least one service
Services provided - AAAs provide a range of services in addition to those specified in the Older Americans Act. Over 80% of AAAs provide the following services in addition to OAA services: • • • • • • • •
2
June 2011
Respite Care Benefits/Health insurance counseling Case Management Homemaker Personal assistance/Personal care Assessment for care planning Emergency response system Senior Center
93.7% 93.4% 91.6% 88.5% 84.2% 82.0% 81.1% 80.2%
Scripps Gerontology Center
Key Features and Services of the Aging Network In order to get a clearer picture of the different ways in which AAAs provide the core services and supports, the 2010 survey asked AAAs to check all of the arrangements that describe their service provision model. These results are shown in Table 1. The core OAA services most likely to be provided directly by AAAs are information and referral, outreach, and family caregiver support. Meals, transportation, and legal assistance were the services most likely to be delivered by a contracted provider. Table 1. 2010 Older American’s Act (OAA) service provision structure Services Information and referral Outreach Family Caregiver Support Program Ombudsman Congregate meals Home-delivered meals Transportation (medical) Transportation (non-medical) Legal assistance
Provided directly by AAA 90.4% 81.5% 66.9% 58.7% 35.5% 34.9% 19.4% 18.8% 11.6%
AAA contracts with providers 28.5% 37.6% 59.1% 27.3% 74.9% 76.9% 67.5% 77.8% 87.7%
Provided with funding in addition to OAA funds 44.1% 32.0% 36.8% 37.7% 50.3% 55.6% 44.2% 44.1% 25.5%
These same arrangements are used to deliver the additional services AAAs provide. The information below shows the additional services that are most likely to be provided utilizing various service delivery modes: provided directly, through contracts with providers, or by referring individuals to providers that are not under contract. Additional service provided directly by AAAs Benefits/Health insurance counseling Case Management Assessment for care planning Senior Medicare Patrol Assessment for long-term care service eligibility Additional services provided through AAA contracts with providers Homemaker Respite care Personal assistance/ Personal care Chore Adult day services Additional services provided by AAA referral to providers not under contract Food pantry Adult Protective Services Assistive technologies
Scripps Gerontology Center
79.1% 78.7% 77.3% 69.1% 67% 77.7% 76.3% 74.9% 71.3% 67.1%
83.3% 62.0% 60.9%
June 2011
3
Leveraging Multiple Funding Sources The network successfully leverages multiple funding sources to meet the long-term care needs of the elders in their communities. Virtually every area agency on aging receives funds from sources in addition to the Older Americans Act.
Figure 2. Proportion of agencies receiving funds from various sources (in addition to OAA funding)
• The most common sources of funding
come from participant donations, local (county and city) and state funding, as shown in Figure 2. Slightly over half are involved in Medicaid waiver funding.
• The average AAA receives funding from
seven sources in addition to OAA.
Figure 3. Fund allocation model for home and community-based provider agencies
• The most common fund allocation model
is the fee-for-service (cost reimbursement) model (see Figure 3).
Connected to the Community The landscape of health and long-term care systems is shifting in response to federal initiatives that emphasize access, integration and options. Because of their positions in their communities, AAAs are key partners in collaborations that strengthen services for older adults and other groups with long-term care needs. • On average, AAAs have 11 informal partnerships and five formal partnerships with other agencies or organizations that serve the older population. 4 June 2011
Scripps Gerontology Center
Figure 4. Most common AAA partnerships • Some of the most common partnerships are with transportation agencies, state health insurance assistance programs (SHIP), advocacy organizations, adult protective services, and Medicaid and federal programs (i.e. Social Security, Medicare, Department of Veterans Affairs, Bureau of Indian Affairs), as shown in Figure 4. • Over 70% of AAAs have partnerships with hospitals, disability service organizations, and housing programs in their communities.
Enhanced Community Living Options AAAs provide a number of services that help individuals at risk of institutional care to remain in the community and to transition back to the community when long-term care facility placement is no longer necessary or desirable.
• Over 43% of AAAs assess consumers risk for Medicaid spend down and take a number of actions when an individual is at risk for Medicaid spend down. The most common actions taken are: providing options counseling, referring clients to other publicly funded services, provided supportive decision making, and referring to other agencies/organizations for services, as shown in Figure 5.
Figure 5. Action taken by AAAs when an individual is at risk of spending down to Medicaid Provide options counseling
74.3%
Refer to other publicly funded services
65.4%
Provide supportive decision making
62.8%
Refer to other agencies/organizations for services
62.8%
Provide intensive case management
26.2%
Give the individual priority over those facing less risk
22.0%
0%
Scripps Gerontology Center
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
June 2011
5
Figure 6. Proportion of AAAs that have diversion or transition programs •
Nearly 60% of AAAs indicated they have a program to divert consumers from institutional care. This is a significant increase over 2008, when 27% of AAAs reported having a diversion program. (See Figure 6).
• Nearly 55% indicated they facilitate
Figure 7. Strategies used to assist individuals to remain in the community - 2010
the transition of consumers from institutional placements into the community. It is common for a AAA to have both transition and diversion programs: over 70% of agencies that had a program to divert consumers from institutional care also facilitated the transition of consumers from institutional placement back into the community.
• The common strategies used to main-
tain or transition individuals back to a community setting are: working with the care recipient’s family and social supports, options counseling, and developing partnerships with hospitals, rehabilitation and nursing facilities, as shown in Figures 7 and 8.
Figure 8. Strategies used to facilitate transition from institutional placement into the community - 2010
6 June 2011
Scripps Gerontology Center
Table 2. AAAs involvement in livable communities (proportion of AAAs that have made progress or have these items in place)
Meeting with public entities to address housing or transportation needs Establish coalitions with other entities to promote coordination across service sectors and planning department Meeting with other private entities to address housing or transportation needs Developing projects to promote aging in place
Have made progress or have in place 78% 66.1%
63.9% 56.1%
• AAAs have taken steps to develop livable communities for all ages. This complex concept requires extensive collaboration across community organizations, and calls for the provision of affordable housing, accesible services, and transportation. The most common steps taken by AAAs towards livable communitities are shown in Table 2. • Figure 9 shows there is room for growth in AAAs involvement in developing initiatives to plan for livable communities, designating staff within the organization to develop/work on livable community projects, obtaining funding from other sources for livable community planning/work, and obtaining OAA funding for livable communities planning/work. Figure 9. AAAs involvement in livable communities
Scripps Gerontology Center
June 2011
7
Self-Directed Services Over half (51%) of AAAs provide self-directed services (compared to 48.4% in 2008) whereby individuals have choice and control over their services and supports, including the ability to hire, manage and dismiss their workers and the opportunity to plan and budget for services.
• The most common self-directed services are Family Caregiver Support Program (FCSP), personal care/assistance, respite, homemaker and fiscal intermediary services. The proportion of AAAs offering FCSP service with self-directed option increased significantly from 2008 to 2010, as seen in Figure 10. The decline in respite from 2008 to 2010 may reflect that respondents consider this service a part of FCSP.
• Figure 11 shows that most participant-directed programs allow consumers to hire workers, including relatives. Fewer self-directed programs allow the participants to manage their own budgets; however, the proportion of AAAs including this component in their consumer-directed option has increased since 2008, as did case manager utilization for service planning, use of a representative to help manage responsibilities, ability to purchase goods and/or services, and fiscal intermediary services.
Figure 10. Services most likely to be offered with self-directed option
Figure 11. Self-directed program components provided by AAAs
• Most (53.8%) consumer-directed programs are small (between 1-50 people enrolled in the program); another 28% have between 51 and 250 participants enrolled.
8 June 2011
Scripps Gerontology Center
• Over 45% of agencies expect to increase both the number of services offered and number of people served in consumer-directed programs over the next year.
Figure 12. Involvement in self-direction (proportion of AAAs that have made progress or have these items in place)
• Even if they do not provide a consumer-directed option, AAAs continue to be highly involved in a number of activities related to participant-directed activities which give consumers voice, choice and control over the services they receive. These findings are shown in Figure 12. There have been gains in nearly every area of involvement since 2008. There is still room for growth in AAA involvement in determining the ability of consumers to manage their own services, and in assisting consumers in managing their own services. Private Pay Building systems for private pay continues to be an area of potential growth in business planning and outreach for the network. However, it appears the network is in a period of transition regarding this potential area of development. About one fourth of AAAs say they have made progress or have in place some services for private pay clients. This is a slight decline from 2008. In response to a question asking participants to explain the reasons why their organization is not involved with the private pay population, AAA directors cited the following most frequently: inadequate resources (staff, database, or billing system) to work with private pay consumers; providing services to private pay consumers is not in line with our organization’s mission, vision and philosophy; and lack of knowledge regarding a private pay system. Figure 13. AAAs involvement in providing services to private pay consumers
• The proportion of AAAs that have made progress or currently provide services to private pay clients has declined from 2008 to 2010, as shown in Figure 13.
Scripps Gerontology Center
June 2011
9
Figure 14. AAAs involvement in building a system for private pay consumers • AAAs were also asked about their plans to build a system to serve private pay clients. Those results are shown in Figure 14. The proportion who are currently involved in system building has remained constant since 2008, and the proportion who plan to build a private pay system has increased.
Single Point of Entry/ADRC AAAs have developed streamlined systems that support consumer-centered access to information and long-term care services. Since 2008, AAAs have increased their involvement in serving as the single point of entry for various target populations, including all age groups, and children 0-17, as shown in Figure 15. However, AAA involvement in serving as the single point of entry for private pay consumers has noticably decreased since 2008. As discussed on page 9, the decline in private pay initiatives is likely related to constraints on the resources necessary to develop such a system.
Figure 15. Proportion of AAAs who are the single point of entry for at least some services, by target population
10 June 2011
Scripps Gerontology Center
• A variety of models allow consumers streamlined access, as shown in Figure 16. Since 2008, AAA use of an ADRC single point of entry model has significantly increased. An increasing proportion of AAAs have in place or are actively working on seamless intake, assessment, and eligibility processes, as shown in Figure 17. However, there has been a significant decrease in the proportion actively involved in some specific streamlined access activities since 2008. For example, the proportions involved in developing and maintaining electronic consumer, provider, and service records has declined significantly in the past two years (see Figure 17). Again, resource constraints are the likely explanation for this decline; Table 3 supports this explanation, showing a marked increase in the proportions who would like to but cannot or do not plan to work on these resource-intensive activities.
Figure 16. Single point of entry models
Figure 17. Person-centered access to information (proportion of AAAs that have made progress or have these items in place)
Scripps Gerontology Center
June 2011
11
Table 3. Proportion of AAAs that would like to but cannot or do not plan to have person-centered access activities in place Maintaining an electronic billing system Maintaining an electronic consumer services information system Maintaining an electronic consumer functional information system (ADLs, IADLs) Maintaining an electronic provider information system Developing a cross-agency data system to share provider information Developing a cross-agency data system to share consumer information Developing innovative technology to improve consumer access
2008
2010
26.8% 3.2%
40% 15%
5.6%
21.3%
4%
21.3%
22.4%
31.8%
26.1%
37.3%
22.9%
33.1%
Evidence-Based Disease Prevention and Health Promotion AAAs provide services that allow older adults and their caregivers to stay active and healthy. The implementation of evidencebased health and wellness programs has increased significantly since 2007, as shown in Figure 18. AAAs use OAA funds to provide these services, but also have funding from state general revenue, local sources, other state funding, charitable donations and other grant funding including foundation grants and other federal programs. Figure 19 shows that since 2008, the proportion of AAAs receiving funding from AoA evidence-based diseased prevention grants significantly increased.
• The most common, formally recognized evidence-based health promotion programs used by AAAs since 2008 are the Chronic Disease Self-Management Program, A Matter of Balance, and Enhanced Fitness. Healthy Eating for Successful Living (nutrition) was not included in the 2008 survey, but ranked in the top five most common programs implemented by AAAs in 2010.
12 June 2011
Figure 18. Proportion of AAAs involved in evidence-based programs
Scripps Gerontology Center
Figure 19. Evidence-based disease prevention and health promotion funding sources (other than OAA)
• Over 40% of AAAs partner with other organizations to expand and evaluate their evidence-based health and wellness programs. Figure 20 also shows several opportunities for growth - those activites for which the largest proportion of AAAs report no current involvement. These include playing a role in Patient Centered Medical Homes, seeking external funds to support evidence-based health and wellness programs, partnering with research organizations to evaluate health programs, and purchasing a standard evidence-based wellness package.
Figure 20. Involvement in evidence-based programming - 2010
Playing a role in a Patient Centered Medical Home
9.8
Purchasing a standard evidence-based wellness program package
15.1 17.1 10.8
Partnering with research organizations to evaluate our evidence-based health and wellness programs
16.5 16.2 6.2 7.4
Partnering with organizations to expand our evidencebased health and wellness programs Evaluating our evidence based health and wellness programs
8.2
0%
Scripps Gerontology Center
10%
35.3
29.9 26.4 Do not plan to work on this
17.1
43.5
Would like to but cannot
12.8 28.3 13.9 14.4
Seek external funds to support evidence-based health and wellness programming
50.9
17.8 20.2
20%
Plan to but have not begun
33.4
Have made progress or have in place
31.0 28.1 30%
40%
50%
60%
June 2011
13
Opportunities and Challenges The aging network is expanding its role in the long-term care and health care systems in challenging economic times and under a unique set of demographic circumstances, with the first wave of Baby Boomers turning 65 in 2011. AAAs are in a precarious situation in which budget cuts due to state budget crises are coupled with unprecidented demands for services. For example, only 41% of AAAs said that they have made progress on, or have completed, efforts to have enough staff to move forward with new initiatives; this proportion is a significant decline from 2007 and 2008, in which 63% and 56%, respectively, had these strategies in place or in progress. To further illustrate the dramatic recent shifts in the landscape of aging services, Figure 21 shows the changes over time in the proportions of AAAs who have made progress on, or have in place, several operational, business, planning and development initiatives. Figure 21. Proportion of AAAs who have made progress on, or have in place, specific business strategies: 2007, 2008, 2010
14 June 2011
Scripps Gerontology Center
Over a quarter of survey participants responded to an open-ended question regarding the issues facing their organization or the Aging Network in general. AAA directors offered numerous comments on the current economic challenge. The following comments illustrate the overall concerns, and mirror the patterns noted above in the quantitative data. • • • • •
“Growing senior population/demand with stagnant or decreased funding putting services/consumers in jeopardy.” “Unable to grow due to a lack of staff.” “Need to redesign services/service delivery approaches for the next generation of seniors (i.e. Baby Boomers).” “We are in a slow bleed phase- must cut services due to decreased funding.” “Not enough staff to meet current need/demand.”
Because the economic downturn was underway when the 2010 AAA National Survey was fielded, respondents were asked about different measures they might have taken in response to the fiscal situation. Table 4 shows their responses. The action steps have been categorized into those affecting operations, those affecting clients and staff, and those that are proactive steps to seek new opportunities. The latter category is a crucial part of the story: AAAs continue to seek opportunities and to take strategic steps to reorganize for a brighter future, even as they are dealing with the dual challenge of increasing demands for service and decreasing resources. Table 4. Proportion of AAAs who have made specific changes in response to the economic downturn Changes made Proportion of AAAs Proactive and strategic reorganization measures Explored new funding opportunities 61.4% Explored new partnerships 50.5% Reorganized the agency 39.0% Increased program evaluations to determine where 25.3% resources can best be allocated Renegotiated contracts with providers 26.7% Changes to operations Increased caseloads Reduced staff by not replacing those who leave Cut budgets of at least some departments Cut or eliminated business travel Cut or eliminated staff training Eliminated programs (temporarily or permanently) Expanded consumer-directed options Cut budgets of all departments Changes directly affecting staff and clients Instituted waiting lists for at least some services Eliminated or reduced salary increases Reduced total staff hours by converting some positions from full-time to part-time Reduced total number of staff through layoffs Reduced staff benefits
Scripps Gerontology Center
52.7% 49.3% 47.7% 44.1% 39.3% 18.7% 12.6% 12.8% 58.7% 50.2% 24.2% 23.3% 22.8%
June 2011
15
For More Information Visit Scripps at www.scrippsaging.org 396 Upham Hall . Miami University . Oxford, Ohio 45056 . 513.529.2914 To print/download this report go to:
http://www.scripps.muohio.edu/content/AAA-2010-researchrecord
Funding for this document was made possible (in part) by grant 90PG0003 from the Administration on Aging. The views expressed in these materials do not necessarily reflect the official policies of the Department of Health and Human Services, or represent official Administration on Aging policy. The project team would like to acknowledge Jane Straker and Abbe Lackmeyer, Scripps Gerontology Center, and Abigail Morgan, n4a, for their central role in the development and refinement of the 2010 AAA survey; Kimberly Linde and Emily Robbins at Miami University and Scripps Gerontology Center for assistance with report development; Sandy Markwood, Jo Reed, Theresa Lambert and Helen Eltzeroth with the National Association of Area Agencies on Aging, Greg Case with the U.S. Administration on Aging, and the n4a Advisory Committee for their valuable input and assistance in the development of the National Aging Network Survey and research record.
16 June 2011
Copyright © Scripps Gerontology Center
