June 2007

Draft Final Report for the Evaluation of Select Consumer, Program, and
System Characteristics under the Supportive Services Program\
(Title III-B) of the Older Americans Act

Final Report

Prepared for

Mary A. Leary, M.A.S.

Administration on Aging

1 Massachusetts Avenue, NW

Washington, DC 20001

Prepared by

Donna J. Rabiner, Ph.D.

Joshua M. Wiener, Ph.D.

Galina Khatutsky, M.S.

David W. Brown, M.A.

Deborah S. Osber, M.P.H.

RTI International

3040 Cornwallis Road

Research Triangle Park, NC 27709

RTI Project Number 0208490.016.007

RTI Project Number

0208490.016.007

Draft Final Report for the Evaluation of Select Consumer, Program, and
System Characteristics under the Supportive Services Program\
(Title III-B) of the Older Americans Act

June 2007

Prepared for

Mary A. Leary, M.A.S.

Administration on Aging

1 Massachusetts Avenue, NW

Washington, DC 20001

Prepared by

Donna J. Rabiner, Ph.D.

Joshua M. Wiener, Ph.D.

Galina Khatutsky, M.S.

David W. Brown, M.A.

Deborah S. Osber, M.P.H.

RTI International

3040 Cornwallis Road

Research Triangle Park, NC 27709

# Acknowledgments {#acknowledgments .App-Heading-1}

The authors would like to thank Mary Leary, M.A.S., who served as our
lead project officer and colleague on this evaluation project. RTI also
expresses thanks to Kari Benson, Frank Burns, and Stephanie Whittier,
who served as interim project officers earlier in the project. RTI also
would like to acknowledge the many Administration on Aging (AoA) staff
who provided comments on earlier drafts and who provided technical
support during RTI's analysis of AoA's survey files. In addition, we
would like to thank members of our Technical Advisory Group, both for
their participation in the planning of this evaluation and their
expertise in guiding the interpretation of early quantitative survey
findings. Finally, we would like to thank the State Unit on Aging
directors, Area Agency on Aging directors, and private home health
providers who shared their experiences and perspectives on the Title
III-B program during focus group discussions.

Contents

Section Page

Executive Summary [vii](#executive-summary)

1 Background and Introduction
[1](#section-1-background-and-introduction)

1.1 Overview of the Study [1](#overview-of-the-study)

1.2 Conceptual Framework [2](#conceptual-framework)

2 Research Methods and Data Sources
[4](#section-2-research-methods-and-data-sources)

2.1 Quantitative Methods and Data Sources
[4](#quantitative-methods-and-data-sources)

2.2 Qualitative Methods and Data Sources
[5](#qualitative-methods-and-data-sources)

3 Access Services [7](#section-3-access-services)

3.1 Characteristics of Network Participants
[8](#characteristics-of-network-participants)

Information and Assistance Services
[8](#information-and-assistance-services)

Case Management Services [8](#case-management-services)

3.2 Characteristics of Access Services
[9](#characteristics-of-access-services)

Information and Assistance Services
[9](#information-and-assistance-services-1)

Case Management Services [11](#case-management-services-1)

3.3 Role of Access Services [12](#role-of-access-services)

3.4 Administration of Access Services
[13](#administration-of-access-services)

3.5 Access Services: Summary of Findings and Policy Implications
[14](#access-services-summary-of-findings-and-policy-implications)

4 Supportive Services [16](#section-4-supportive-services)

4.1 Characteristics of Network Participants
[16](#characteristics-of-network-participants-1)

Home Care Services [16](#home-care-services)

Transportation Services [18](#transportation-services)

4.2 Characteristics of Home Care and Transportation Services
[19](#characteristics-of-home-care-and-transportation-services)

Home Care Services [19](#home-care-services-1)

Transportation Services [23](#transportation-services-1)

4.3 Satisfaction with Supportive Services
[26](#satisfaction-with-supportive-services)

Home Care Services [26](#home-care-services-2)

Transportation Services [27](#transportation-services-2)

4.4 Administration of Supportive Services
[28](#administration-of-supportive-services)

4.5 Supportive Services: Summary of Findings and Policy Implications
[28](#supportive-services-summary-of-findings-and-policy-implications)

5 Financing and Management of Title III-B Services
[31](#section-5-financing-and-management-of-title-iii-b-services)

5.1 Title III-B Expenditures in the Long-Term Care System
[31](#title-iii-b-expenditures-in-the-long-term-care-system)

5.2 Issues Related to the Financing of Supportive Services
[35](#issues-related-to-the-financing-of-supportive-services)

Current Funding Challenges/Recommendations
[35](#current-funding-challengesrecommendations)

Support for Infrastructure Development
[36](#support-for-infrastructure-development)

Leveraging Multiple Sources of Funds
[37](#leveraging-multiple-sources-of-funds)

5.3 Issues Related to the Management/Delivery of Supportive Services
[37](#issues-related-to-the-managementdelivery-of-supportive-services)

Determination of Which Title III-B Services to Provide
[37](#determination-of-which-title-iii-b-services-to-provide)

The Role/Importance of State/Community Partnerships
[37](#the-roleimportance-of-statecommunity-partnerships)

The Availability/Use of Technology
[38](#the-availabilityuse-of-technology)

Performance Management Tools [38](#performance-management-tools)

5.4 Financing and Management of Supportive Services: Summary of Findings
and Policy Implications
[39](#financing-and-management-of-supportive-services-summary-of-findings-and-policy-implications)

6 Conclusions [42](#section-6-conclusions)

6.1 Access Services [43](#access-services)

6.2 Support Services [44](#support-services)

6.3 Financing and Management [45](#financing-and-management)

6.4 Looking Forward [45](#looking-forward)

References [47](#references)

List of Exhibits

Number Page

1-1 Title III-B Sub-Questions [2](#__RefHeading___Toc170629889)

1-2 Conceptual Framework for the Study of the Title III-B Program
[3](#__RefHeading___Toc170629890)

2-1 Topics Addressed by Type of Focus Group Session
[6](#__RefHeading___Toc170629891)

3-1 Percentage of Case Management Clients Needing Assistance with Three
or More ADLs [9](#__RefHeading___Toc170629892)

3-2 I&A Expenditures [11](#__RefHeading___Toc170629893)

3-3 Unduplicated Count of Case Management Participants
[12](#__RefHeading___Toc170629894)

3-4 Case Management Expenditures [12](#__RefHeading___Toc170629895)

3-5 I&A and Case Management: Key Findings
[15](#__RefHeading___Toc170629896)

4-1 Living Alone Status of Home Care Clients (percentage)
[17](#__RefHeading___Toc170629897)

4-2 Home Care Clients Needing Assistance with Three or More ADLs
(percentage) [17](#__RefHeading___Toc170629898)

4-3 Living Alone Status of Assisted Transportation Clients (percentage)
[19](#__RefHeading___Toc170629899)

4-4 Number of Hours of Home Care Services
[20](#__RefHeading___Toc170629900)

4-5 Unduplicated Count of Home Care Participants
[20](#__RefHeading___Toc170629901)

4-6 AAA Home Care Expenditures by Source of Funding, 2001--2004
[21](#__RefHeading___Toc170629902)

4-7 Title III-B Expenditures, Other Expenditures, and Total Expenditures
for Personal Care Services [22](#__RefHeading___Toc170629903)

4-8 Title III-B Expenditures, Other Expenditures, and Total Expenditures
for Homemaker Services [22](#__RefHeading___Toc170629904)

4-9 Title III-B Expenditures, Other Expenditures, and Total Expenditures
for Chore Services [23](#__RefHeading___Toc170629905)

4-10 Units of Transportation and Assisted Transportation Service
[24](#__RefHeading___Toc170629906)

4-11 Unduplicated Count of Assisted Transportation Participants
[24](#__RefHeading___Toc170629907)

4-12 Title III-B Expenditures, Other Expenditures, and Total
Expenditures for General Transportation Services
[25](#__RefHeading___Toc170629908)

4-13 Title III-B Expenditures, Other Expenditures, and Total
Expenditures for Assisted Transportation Services
[26](#__RefHeading___Toc170629909)

4-14 Home Care and Transportation: Key Findings
[29](#__RefHeading___Toc170629910)

5-1 Public Funding for Supportive Services, by Source, 2002
[32](#__RefHeading___Toc170629911)

5-2 Proportion of Total AAA Expenditures Supported by Title III-B, by
Service, 2004 [32](#__RefHeading___Toc170629912)

5-3 Title III-B Expenditures for Access and Care Services
[33](#__RefHeading___Toc170629913)

5-4 Non-Title III-B Expenditures for Access and Care Services
[34](#__RefHeading___Toc170629914)

5-5 Total Expenditures for Access and Care Services
[35](#__RefHeading___Toc170629915)

5-6 Financing and Management of Title III-B: Key Findings
[40](#__RefHeading___Toc170629916)

6-1 Highlights of the Analyses of Title III-B
[43](#__RefHeading___Toc170629917)

# 

# Executive Summary

The Older Americans Act (OAA) was established in 1965 to help provide
older Americans with the resources they need to maintain their health
and live independently in the community for as long as possible. The OAA
provides funding to help older persons through the planning,
coordination, and delivery of a range of home and community-based
services, including meals, home care, transportation services,
information and assistance, case management, senior centers, and respite
services. As the nation's population ages, these services will become
increasingly important in serving the needs of our citizens. Although
Medicaid provides coverage for long-term care services primarily for the
low-income population, many older Americans with chronic impairments
have financial resources above the eligibility level for Medicaid but
not high enough to pay out of pocket for services. While focusing on
underserved populations, the OAA addresses the needs of older Americans
of all income levels.

Title III-B is one of the largest components of the Older Americans Act.
Title III-B funds helped to develop the infrastructure of State Units on
Aging (SUAs), area agencies on aging (AAAs), and local community
providers, collectively known as the "aging network." The aging network
works in local communities to support older persons throughout the
United States. The Title III-B program helps the aging network to serve
as the entry point into the long-term care system, providing critical
information, case management services, and direct funding of long-term
care services for individuals who otherwise might go without needed
assistance. The Administration on Aging's (AoA's) current Choices for
Independence initiative, a demonstration project to promote home and
community-based long-term care options, builds directly on the mission
and success of the Title III-B program.

This study assesses Title III-B and its role in planning, coordinating,
and providing community services for older people. The overarching
research question is: *How, to what extent, and with what results has
the aging network implemented Title III-B of the Older Americans Act*?
This project focuses on the aging network's involvement with key
services supported by Title III-B: case management, information and
assistance, personal care, chore services, homemaker services,
transportation, and assisted transportation services using a combination
of quantitative and qualitative methods.

This report summarizes the main findings from this multicomponent
evaluation. In addition to analyzing several AoA quantitative data sets,
RTI International conducted six focus sessions with AAA directors, SUA
directors, and Title III-B service providers. RTI also convened a
Technical Advisory Group to provide additional input.

## E.1 How the Aging Network Has Implemented Title III-B {#e.1-how-the-aging-network-has-implemented-title-iii-b .App-Heading-2}

Since 1965, the aging network has relied on the Title III-B program to
provide a range of home and community-based long-term care services to
frail, older individuals and their families. Through this program, the
aging network provides older Americans of all income levels with
long-term care services and helps coordinate the delivery of services
funded by other federal, state, local, and private sources.

Title III-B finances a substantial proportion of spending by AAAs for
access services, which for this study include Information and Assistance
(I&A) and case management services. It is through these access services
that the AAAs act as navigators of the long-term care system, helping
people to get where they need to go and to do so efficiently. These
services serve a broad spectrum of seniors and their families. This
approach forms the foundation on which other AoA initiatives, such as
Aging Disability Resource Centers (ADRCs) and Choices for Independence,
can build.[^1]

Title III-B home care and transportation services, which for this study
include personal care, chore, and homemaker services, and both general
and assisted transportation, help seniors remain in the community for as
long as possible. The Title III-B program helps pay for the following:

-   Planning for a balanced long-term care system, which would provide a
    greater role for home and community-based services.

-   Services for individuals who do not qualify for Medicaid, either
    financially or functionally.

-   Services for individuals who live in states where the home and
    community-based waiver has waiting lists or where Medicaid coverage
    is limited (e.g., personal care is not a covered service).

-   Nonmedical services, such as homemaker services, that may not be
    covered by Medicaid or other programs.

-   Coverage for individuals who are waiting for their Medicaid or other
    applications to be processed or are waiting to transition to other
    settings.

The role of Title III-B varies by type of direct service. For example,
its role in the provision of chore and homemaker services is larger than
its role for personal care because there are more alternative funding
sources for personal care (largely Medicaid) than for homemaker
services. In deciding how to allocate Title III-B services, AAAs target
vulnerable populations, including the oldest of the old, people living
alone, and persons who are severely disabled.

The implementation of Title III-B varies by state. For example, some
states use Title\
III-B funding to support a large array of services, while others
concentrate their resources on a smaller number of services (e.g., I&A)
that are not likely to be covered by Medicaid or other state funding
sources.

Geography also affects the role and implementation of Title III-B
services. For example, the aging network reports that urban participants
typically have better access to Title III-B transportation services
relative to their more rural counterparts. Similarly, AAAs located in
metropolitan areas are more likely than their nonmetropolitan
counterparts to rely on performance measurement tools to monitor Title
III-B activity, and to provide toll-free lines so that I&A participants
can contact the AAA at no cost.

The aging network has successfully leveraged Title III-B funds to gain
additional financial support services for older persons. In particular,
the experience and expertise from the Title III-B program provides the
AAAs with the credibility to obtain additional state and Medicaid funds.
For example, for every dollar provided by Title III-B for case
management services, another \$4 was provided annually by other sources.
AAAs also have extended their influence and reach by partnering with
local, state, and other federal organizations to provide additional
resources.

As the demand for and use of technology has increased throughout the
aging network, AAA and SUA directors increasingly have relied on
computers and other automated services to help their participants
navigate the long-term care system and to obtain needed services in the
community. Some observers contend, however, that the reliance on online
systems exceeds the capacity of many older persons to use computers.
Finally, the aging network has become more adept at monitoring program
activity using a variety of tracking and performance management tools,
although many providers are still not capable of producing computerized
data on individuals.

## E.2 Extent to Which the Aging Network Has Implemented Title III-B {#e.2-extent-to-which-the-aging-network-has-implemented-title-iii-b .App-Heading-2}

For this study, we evaluated the extent of the aging network's
implementation of Title III-B by examining its "reach" (e.g.,
characteristics of the people served, the type of services provided to
help people stay in the community, and extent of involvement of
community partners). While the total number of people using Title III-B
services remained stable or decreased somewhat between 2001 and 2004,
the risk of institutionalization of the older population served has
increased, as evidenced by the fact that a larger proportion of AAA
participants were living alone and had three or more limitations with
activities of daily living.

Through its partnerships with state and local agencies, service
providers, businesses, academic institutions, civic organizations, and
volunteer associations, the aging network has successfully extended its
service net to a broader population.

## E.3 The Impact of the Aging Network's Implementation of Title III-B {#e.3-the-impact-of-the-aging-networks-implementation-of-title-iii-b .App-Heading-2}

In this study, we evaluated the impact of the aging network's
implementation of\
Title III-B by analyzing the following types of measures: volume of
service activity, participant satisfaction with program services, and
the perceived importance/value of the Title III-B program (as reported
by AAA directors, SUA directors, providers, and AAA participants).
Although Title III-B programs represent only a small proportion of total
expenditures for home and community-based care, SUA and AAA directors
report that the Title III-B program is important to communities across
the United States. Similarly, analyses of the 2003 and 2004 National
Surveys of OAA Program Participants demonstrate that older persons are
extremely satisfied with Title III-B services, in some cases requesting
even more of them.

The Title III-B program serves substantial numbers of older people.
Specifically, over 400,000 participants annually relied on Title III-B
case management services during the years 2001 to 2004. Similarly, over
9 million hours of Title III-B personal care services were delivered
annually, over 10 million hours of Title III-B homemaker services were
provided, and over 1 million hours of chore services were supplied to
older persons and their families during this 4-year period. In addition,
over 34 million one-way trips were provided to general transportation
users, and approximately 2 million assisted transportation trips were
supplied annually to individuals with physical or cognitive impairments
needing help to get to their appointments.

Title III-B transportation services facilitate access to health,
wellness, and social activities, which are key factors to living a
meaningful life in the community. Title III-B participants rely on these
transportation services a great deal. For example, over 50% of Title\
III-B general transportation users reported using this service within
the week prior to the survey, and over 50% of all general transportation
users relied on Title III-B transportation for at least three quarters
of their trips during the survey year.

Title III-B service participants value these services highly. Over 80%
of survey respondents rate aspects of homemaker service as good or
better, while the vast majority of respondents rate Title III-B
transportation services as good, very good, or excellent.

Given the modest amounts of Title III-B funding compared to Medicaid,
AoA, SUAs, and AAAs need to think strategically about how to spend
future resources. One option would be to focus on filling the direct
service gaps left by other funding programs. Another option would be to
concentrate on infrastructure development, with a focus on becoming the
single point of entry to the long-term care system.

# Section 1 Background and Introduction

Over the past century, advances in medical care and prevention have
increased life expectancy in the United States. They also have produced
a major shift in the leading causes of disease for all age groups. The
primary causes of death for all age groups, including older persons,
have changed from infectious disease and acute illnesses to chronic
disease and degenerative illnesses. Currently, about 80% of older
Americans live with at least one chronic condition (Centers for Disease
Control and Prevention & the Merck Company Foundation, 2007).
Accompanying these chronic diseases is an increase in the number of
people with disabilities and the need for long-term care services
(Kemper, Komisar, & Alecxih, 2005/6; Wiener, Illston, & Hanley, 1994).
Longer life spans and the aging of the Baby Boom generation will combine
to double the population of Americans aged 65 and over during the next
25 years.

The current population and projected growth in the number of older
people needing long-term care services is an increasing concern for
families and for federal and state governments. Challenges of the
current long-term care system include (Wiener et al., 2004):

-   a lack of awareness of available community-based health and social
    supports;

-   the fragmented financing and delivery system, making it difficult to
    navigate the long-term care system and coordinate the complex
    service needs of frail older people;

-   the institutional bias of the existing financing and delivery
    system; and

-   the high cost of long-term care, both to individuals and to federal
    and state governments.

Title III-B of the Older Americans Act (OAA) is a key federal response
to the problems of the current long-term care system. Title III-B funds
help to develop the infrastructure of State Units on Aging (SUAs), area
agencies on aging (AAAs), and local community providers, collectively
known as the "aging network." The aging network enables local
communities to support older persons throughout the United States. The
Title III-B program helps the aging network to serve as an entry point
into the long-term care system, providing critical information and case
management services in addition to direct funding of long-term care
services for individuals who otherwise might go without needed
assistance. In addition, Title III-B plays a crucial role as a catalyst
for overall long-term care reform and for planning for a more
comprehensive system. The overall purpose of the Title III-B program is
to help older persons and their family members maintain their health and
live independently in the community for as long as possible.

## 1.1 Overview of the Study

This study assesses Title III-B and its role in planning, coordinating,
and providing community services for older people. The overarching study
question is: *How, to what extent, and with what results has the aging
network implemented Title III-B of the Older Americans Act*? This study
question was addressed through the following three sub-questions (shown
in Exhibit 1-1):

[]{#__RefHeading___Toc170629889 .anchor}Exhibit 1-1\
Title III-B Sub-Questions

+-----------------------------------------------------------------------+
| -   What is the role/importance of providing information and          |
|     assistance (I&A) and care planning (case management) services for |
|     older persons through the aging network and what is the           |
|     role/importance of providing assessment and care planning for     |
|     community-based long-term care services to the aging network?     |
|                                                                       |
| -   What is the role/importance of providing transportation and home  |
|     care (personal care, chore, and homemaker) services for older     |
|     persons through the aging network and what is the role/importance |
|     of providing transportation and home care services to the aging   |
|     network?                                                          |
|                                                                       |
| -   What is the role/importance of financing long-term care services  |
|     for older persons (via home care, transportation, and other Title |
|     III-B in-home services) through the aging network and what is the |
|     role of financing and delivering long-term care services to the   |
|     aging network?                                                    |
+-----------------------------------------------------------------------+

Using a combination of quantitative and qualitative methods, this
project focuses on the aging network's involvement with key services
supported by Title III-B: case management, I&A, personal care, chore
services, homemaker services, transportation, and assisted
transportation services.

This report summarizes the main findings from this multicomponent
evaluation. In addition to analyzing several quantitative data sets, the
project conducted six focus groups with AAA directors, SUA directors,
and Title III-B service providers. The project also convened a Technical
Advisory Group meeting in Washington, DC, which provided additional
insight. For more detailed information on the quantitative study
findings, see the Interim Quantitative Report
(<http://www.aoa.gov/about/results/TitleIIIB_quantitative-report_6-1-06_psgFINAL.pdf>).

## 1.2 Conceptual Framework

A primary objective of OAA services is to maintain the independence of
older people residing in the community. As shown in the conceptual model
depicted in Exhibit 1-2, AoA accomplishes this objective by providing
OAA funding to SUAs, which in turn distribute it to the AAAs. As
depicted in Exhibit 1-2, AAAs partly depend on this support to address
the health and social services needs of AAA participants. AAAs provide
an entry point to the long-term care system for older persons and their
families, deliver a range of Title III-B services, leverage other
sources of funds to support additional services, and coordinate care
provided by other service providers. This conceptual framework guided
our analysis of the quantitative and qualitative data.

[]{#__RefHeading___Toc170629890 .anchor}Exhibit 1-2\
Conceptual Framework for the Study of the Title III-B Program[^2]

![](media/image1.wmf)

# Section 2 Research Methods and Data Sources

RTI used several data sources to examine the characteristics of
participants and Title\
III-B services and to evaluate the role/importance and administration of
Title III-B services for older persons and their families. RTI and the
Administration on Aging (AoA) relied on a multi-method design to
determine who received Title III-B services and in what amount (based on
quantitative data), and also explain why these findings occurred (based
on qualitative data). While the analysis of quantitative data enabled
RTI researchers to obtain estimates of the magnitude (and significance)
of particular effects (i.e., the "what" of a given question),
qualitative data were needed to help explain why (and how) certain
findings emerged. Qualitative data also provided detailed information on
topics that were not available/have not been addressed by the existing
quantitative data. By combining quantitative and qualitative methods,
RTI and AoA were able to mitigate some of the limitations of relying
solely on one particular research approach.

## 2.1 Quantitative Methods and Data Sources

The quantitative data sources used for this study included the 2003
National Survey of Older Americans Act (OAA) Program Participants (2003
National Survey), the 2004 National Survey of Older Americans Act
Program Participants (2004 National Survey), the 2001 through 2004
National Aging Program Information System State Program Performance
Report (NAPIS SPR) data, and the 2006 National Survey of Area Agencies
on Aging (AAA Survey). Information from AARP and the Urban Institute
also was used to help understand the financial role of Title III-B
services within the universe of home and community-based services. While
these data sources provided information that otherwise would not be
available given study resources, because they were not developed
specifically for this particular study they included only limited
information on some topics of interest to this study.

***NAPIS SPR.*** RTI analyzed the 2001--2004 NAPIS SPR data to examine
characteristics of Title III-B participants, characteristics of Title
III-B services, and Title III-B and non-Title III-B expenditures. In
this report, NAPIS SPR data were summarized at the national level based
on input provided from all AAAs in each state. Data were summarized
using descriptive statistics (totals, means, and frequencies) and
presented in graphical form.

***National Surveys*.** RTI analyzed the 2003 and 2004 National Survey
data provided by randomly selected respondents using three Title III-B
services: information and assistance, homemaker services, and
transportation services. Descriptive and multivariate (ordinary least
squares regression, logistic regression) analyses were conducted. All
analyses of 2003 and 2004 National Surveys were weighted and adjusted
for complex survey design effects resulting from the two-stage sampling
strategy (i.e., sampling first by AAA and second by respondent).

RTI also analyzed the 2004 National Survey to examine satisfaction with
services, the likelihood of using Title III-B services, and key
predictors of service use. In line with OAA priorities, we focused on
those predictors that signaled vulnerability for older persons: being
aged 75 or older, being a minority, living in a rural area, living
alone, and having substantial impairment in the activities of daily
living.

To further identify predictors of satisfaction (or lack of satisfaction)
with homemaker services, we examined differences in characteristics for
homemaker respondents whose satisfaction was in the lowest quartile
(bottom 25%) relative to the full sample. By conducting this
supplementary analysis of the 2004 National Survey, we determined key
characteristics of the least satisfied homemaker service sample relative
to the general population served.

***AAA Survey.*** Data from the following sections of the AAA survey
were analyzed: information and assistance, case management, providers,
and management information systems/ performance management activities.
Due to extensive missing data on a large number of questions, data were
imputed on a substantial number of responses.[^3] With the application
of these sampling weights, all survey data reported in the following
tables are representative of all AAAs in the United States. The data
were analyzed in total (nationally) using descriptive statistical
procedures (i.e., frequencies and means), and then by subgroup (i.e.,
metropolitan statistical area \[MSA\] versus non-MSA and by U.S. Census
region). We also tested for the statistical significance of differences
between subgroups.

***Supplementary Quantitative Data.*** RTI supplemented its analyses of
AoA data by incorporating Medicaid and state-only home care expenditure
data obtained from the Urban Institute and AARP, respectively, to assess
the financial role of Title III-B funding in the overall long-term care
system.

## 2.2 Qualitative Methods and Data Sources

RTI conducted six focus group sessions with AAA directors, State Unit on
Aging (SUA) directors, and community-based providers in order to more
fully examine the issues that could not be addressed by the quantitative
data. The issues shown in Exhibit 2-1 were discussed during four focus
group sessions with AAA directors and one focus group each with SUA
directors and home care providers.

Four of the six focus groups were conducted in person and two were
conducted by telephone in August and September 2006. Consistent with
standard practice, the focus group sessions

-   met for 1.5 hours,

-   included five and nine participants, and

-   addressed no more than three topics.

Focus group participants were selected using methods that varied by type
of respondent.

[]{#__RefHeading___Toc170629891 .anchor}Exhibit 2-1\
Topics Addressed by Type of Focus Group Session

  -------------------------------------- ---------- ---------- ----------
  **Topics Addressed**                   **SUA      **AAA      **Home
                                         Director   Director   Care
                                         Focus      Focus      Provider
                                         Group      Groups     Focus
                                         (n=1)**    (n=4)**    Group
                                                               (n=1)**

  Barriers to the provision of Title     X          X          X
  III-B services                                               

  The role/importance of Title III-B in  X                     
  the states' community-based long-term                        
  care system                                                  

  The extent to which AAAs and SUAs      X                     
  engage in program management                                 
  activities                                                   

  Changes needed to enable AAAs to do a             X          
  better job of serving their local                            
  communities                                                  

  Partnerships developed with external              X          
  providers to ensure that older persons                       
  get the services they need to stay in                        
  the community                                                

  How agency recruits/enrolls home care                        X
  participants                                                 

  Best practices in the provision of                           X
  home care services                                           
  -------------------------------------- ---------- ---------- ----------

***SUA Directors*.** The National Association of State Units on Aging
provided a listing of SUA directors who had extensive experience with
the Title III-B program. RTI and AoA selected a representative sample of
SUA participants from this list. Nine SUA directors participated in the
focus group discussion.

***AAA Directors*.** The National Association of AAA Directors (n4a)
provided a list of AAA directors. RTI and AoA asked n4a to provide two
lists of potential participants---those who were particularly innovative
in their use and delivery of Title III-B services and those experiencing
challenges in delivering Title III-B services. Although RTI conducted
two focus groups with each type of participant, findings did not differ
between types. As a result, the AAA focus group data were pooled across
all four groups and analyzed as a whole. Twenty-four AAA directors
participated in focus group discussions.

***Providers*.** This focus group included private home care providers
who served the AAA target population. In order to identify potential
providers, the AAA directors who participated in the focus group
sessions in Chicago were asked to nominate up to five private home care
providers knowledgeable of best practices in the delivery of home care
services. RTI stratified the list of potential providers by state and
urban/rural/suburban status and randomly selected 15 individuals to
contact. Nine of these individuals participated in the telephone-based
focus group session.

To encourage participants to speak candidly and fully disclose their
points of view, AoA staff did not attend focus group sessions. RTI staff
also assured focus group participants that they would not be identified
in any written report. RTI staff used digital audio recorders to record
all focus group sessions (for note-taking purposes only) and wrote
detailed notes following each session.

# Section 3 Access Services

The current long-term care financing and delivery system is fragmented,
making it difficult for older persons to find the services for which
they qualify and to develop a comprehensive set of services that can
maintain them in the community. Long-term care is funded by a mixture of
state, federal, and private funding sources, including Medicare,
Medicaid, the Older Americans Act (OAA), the Social Services Block
Grant, the Rehabilitation Act, and state and local general revenue
programs. Many of these programs have very different eligibility
requirements in terms of level and type of disability and financial
status and provide very different types of services (Wiener & Tilly,
2003).

State Units on Aging (SUAs) and area agencies on aging (AAAs) play a key
role in providing consumers with information and assistance as well as
case management to negotiate the long-term care system. In addition,
SUAs and AAAs help Medicaid and other state agencies plan a more
integrated and consumer-responsive long-term care system. Title III-B
finances a substantial proportion of spending for access services
provided by AAAs. AAAs act as navigators of the long-term care system,
helping older people and their families understand their options and
choose what is best for them. These services form the foundation on
which other Administration on Aging (AoA) initiatives such as Aging
Disability Resource Centers (ADRCs) and Choices can build.

This section addresses issues related to Title III-B access services,
including the characteristics of access service participants,
characteristics of access services, and the role/importance of Title
III-B access services. For this study, Title III-B access services
include information and assistance (I&A) and case management services.
I&A services:

-   provide individuals with current information on resources that are
    available in their communities,

-   assess the problems and capabilities of individuals,

-   link individuals to available community resources, and

-   help ensure that individuals receive needed services and are
    knowledgeable about the resources that are available to them in the
    community (AoA, 2006).

Similarly, case management coordinates and monitors care, where older
persons or their caregivers are experiencing diminished functional
capacities, health conditions, or other challenges that require
assistance by formal service providers. Case management activities may
include:

-   assessing needs,

-   developing care plans,

-   authorizing services,

-   arranging services,

-   coordinating the provision of services among providers, and

-   following up and reassessing needs (AoA, 2006).

## 3.1 Characteristics of Network Participants

### Information and Assistance Services

Demographic data from the 2003 and 2004 National Surveys of I&A users
indicate that between 21% and 29% of I&A participants were under age 60,
and less than 20% of I&A participants were of minority descent. The
considerable proportion of users under age 60 was likely due to the fact
that I&A services were available both to older persons and to their
family members/caregivers, while other OAA services were available only
to persons aged 60 and over. In addition, the 2003 and 2004 National
Survey data indicate that 5% of the population receiving I&A services
was of Hispanic descent, between 9% and 14% was of African American
descent, and between 1.5% and 6% was Asian/Pacific Islander/Native
American in 2003 or 2004.

### Case Management Services

Analyses of 2001--2004 National Aging Program Information System State
Program Performance Report (NAPIS SPR) data indicate that case
management services were used predominantly by older seniors, those in
frail health, those living alone, and women. Specifically, over 65% of
all case management participants served by the Title III-B program were
at least 75 years of age. About 50% of those receiving Title III‑B case
management services lived alone. Approximately 70% of case management
participants were female. The proportion of case management participants
with three or more activity of daily living (ADL) impairments, a
population at risk of institutionalization, increased from 40% in 2001
to 46% in 2004 (Exhibit\
3-1). A much larger proportion of case management users (at least 70%)
needed help with instrumental activities of daily living (IADLs)
relative to ADLs during this period.

[]{#__RefHeading___Toc170629892 .anchor}Exhibit 3-1\
Percentage of Case Management Clients Needing Assistance\
with Three or More ADLs

Note: The definition of ADL impairment used in the NAPIS SPR system is
the following: "the inability to perform one or more of the following
six activities of daily living without personal assistance, stand-by
assistance, supervision or cues: eating, dressing, bathing, toileting,
transferring in and out of bed/chair, and walking." See
<http://www.aoa.gov/prof/agingnet/NAPIS/SPR/SPR_guidance/definspr.asp>
for more information on the definition of ADLs used for the NAPIS SPR
data.

Source: RTI analysis of 2001--2004 NAPIS SPR case management data.

## 3.2 Characteristics of Access Services

### Information and Assistance Services

***Service Use***. Results from 2003 and 2004 National Survey data
indicate that approximately 58% of callers inquired about how to obtain
help for themselves. An additional 40% called for help for
relatives/someone else, while roughly 6% to 10% called from another
agency to obtain information on behalf of a client. Approximately one
quarter of all of callers previously had used I&A services, suggesting
that they had found the previous responses useful. I&A providers were
efficient in answering telephone calls, with over 80% of calls being
answered in fewer than five rings and about 80% of calls being answered
by a person (rather than an answering machine).

The 2004 National Survey data also were analyzed to determine which
demographic and health status factors predicted whether participants had
contacted I&A service providers for themselves or their relatives.
Results from logistic regression analyses indicated that the following
variables were significant predictors of the likelihood of a participant
calling the I&A service for him- or herself:

-   being aged 75 and over;

-   being male;

-   having less formal education; and

-   living alone, perhaps due to the fact that no one else was available
    to call on his or her behalf.

These results suggest that the I&A services provided the information to
a segment of the population that would have had particular difficulty
accessing services without help.

Conversely, those who were more likely to contact I&A service providers
for their relatives:

-   were younger,

-   were married, or

-   lived with others (e.g., spouses or other family members).

Because I&A services were available to family members and other
caregivers (in contrast to other Title III-B services, which primarily
benefit the older person), it was not surprising that a significant
proportion of I&A callers were under the age of 60 and living with
others.

***Expenditures**.* Title III-B represents an important funding source
to support the delivery of I&A services provided by AAAs. The NAPIS SPR
expenditure data for 2001 to 2004 show that over 40% of the total AAA
expenditures for I&A services was funded by the Title III-B program
(Exhibit 3-2). Importantly, AAAs did not rely solely on Title III-B
funding, but also used other sources. Every \$2 provided by the Title
III-B program to support I&A services leveraged an additional \$3 from
non-Title III-B funding sources.[^4] The AAAs spent a total of
approximately \$100 million annually (unadjusted for inflation) on I&A
services.

[]{#__RefHeading___Toc170629893 .anchor}Exhibit 3-2\
I&A Expenditures

![](media/image2.wmf){width="6.502777777777778in"
height="4.008333333333334in"}

Source: RTI analysis of 2001--2004 NAPIS SPR I&A expenditure data.

### Case Management Services

***Service Use**.* The total hours of case management service provided
per year between 2001 and 2004 remained constant, while the number of
persons using this service declined (falling from 433,546 in 2001 to
402,254 in 2004) (Exhibit 3-3). When outliers were removed, the average
number of hours of case management services per person remained stable
from 2001 to 2004, ranging from 10 to 11 hours per person per year. The
number of case management hours per person is consistent with the
hypothesis that case management services primarily help participants
obtain other services through other funding arrangements.

***Expenditures**.* Analyses of the 2001--2004 NAPIS SPR expenditure
data (shown in Exhibit 3-4) indicate that Title III-B represents an
important source of funds for case management services provided by AAAs.
However, most funding comes from other sources, which mostly likely
reflects the involvement of AAAs in Medicaid home and community-based
services waivers. For every \$1 provided by Title III-B to support case
management services during this period, another \$4 was obtained from
non-Title III-B sources. An additional \$66 million in 2001 to \$91
million in 2004 was provided annually by other sources to support these
activities, with non-Title III-B funds to support case management
increasing during this 4‑year period. The proportion of case management
services that were provided by AAAs and supported directly from Title
III-B funds declined slightly during this 4‑year period. Not adjusting
for inflation, total funds used by the AAAs to support case management
services increased during this 4‑year period from \$85.5 million in 2001
to almost \$114 million in 2004.

[]{#__RefHeading___Toc170629894 .anchor}Exhibit 3-3\
Unduplicated Count of Case Management Participants

![](media/image3.wmf){width="6.0125in" height="2.779166666666667in"}

Source: RTI analysis of 2001--2004 NAPIS SPR case management data.

[]{#__RefHeading___Toc170629895 .anchor}Exhibit 3-4\
Case Management Expenditures

![](media/image4.wmf){width="6.0125in" height="2.9402777777777778in"}

Source: RTI analysis of 2001--2004 NAPIS SPR case management expenditure
data.

## 3.3 Role of Access Services 

The aging network considers I&A services to be a key component of the
long-term care system. AoA classifies I&A as a core service provided by
the Older Americans Act. By design, I&A services help older persons and
their family members navigate the system, locate needed resources, plan
for the future, and identify providers to directly serve them.
Typically, I&A services are provided directly by AAAs. Similarly, focus
group discussions with SUA directors suggests that I&A services are
considered the single most important Title III-B service available to
the community at large. Focus group participants also reported that AAAs
are widely known as the place to go for this type of service. In their
view, I&A is the service initially needed by older persons and their
families to gain entry into the long-term care system.

While AAA directors stressed the importance of case management services
to the care and well-being of older individuals and their caregivers,
they acknowledged that some states have chosen other organizations to
provide most case management, especially to the Medicaid population
eligible for home and community-based services waivers. On the other
hand, in a number of states, such as Washington, case management for
home and community-based service waivers is provided by the AAAs
(<http://www.nasua.org/40YearsofLeadership.pdf>).

AAA directors felt that AAAs should have a central role in the care
management of their older participants. While some AAA directors wanted
all case management services provided by Medicaid waivers or through the
ADRCs to be performed by the AAAs, others simply wanted AAAs to have the
right of first refusal under a waiver for case management. The general
consensus among AAA directors was that since the aging network developed
a comprehensive infrastructure to help older persons and their families
navigate the long-term care system, the AAAs should have the opportunity
to coordinate service delivery for all community-dwelling older persons
(including those receiving services funded by Medicaid and other non-OAA
sources).

## 3.4 Administration of Access Services

Results of the AAA survey indicate that I&A and case management services
help ensure that older persons obtain a range of services needed to keep
them independent and engaged in their communities. While individuals in
urban and more rural areas generally have access to these I&A and case
management services, those living in urban areas appear to be
particularly likely to benefit. Highlights of AAA survey findings
follow:

-   Most AAAs provide I&A services directly rather than contracting them
    out. Over 70% of all AAAs provide I&A services themselves. Only 5%
    of AAAs provide I&A services through contracts with another agency.
    A significantly higher percentage of AAAs in nonmetropolitan versus
    metropolitan areas provide I&A services directly (over 78% versus
    63%).

-   Thousands of people are served by I&A programs annually. On average,
    over 13,000 I&A calls are handled annually by each AAA. AAAs located
    in metropolitan areas receive significantly more calls relative to
    nonmetropolitan areas (an average of almost 19,000 calls versus
    8,200 calls, respectively).

-   The vast majority of I&A providers screen participants for
    eligibility for home and community-based services programs.

-   More than half of the AAA I&A specialists screen callers to
    determine if case management services are needed.

-   Almost half of all AAAs (46.8%) provide a toll-free line so that I&A
    participants can contact the AAA at no cost. AAAs in metropolitan
    areas are significantly more likely to provide a toll-free phone
    number to I&A participants than AAAs in nonmetropolitan areas (53%
    versus 41%, respectively).

Results from the 2006 AAA Survey also indicate that slightly more than
half of AAAs provide or contract for case management services. AAAs
typically provide case management services for the population aged 60
and over. There is considerable regional variation in how these services
are delivered, with the Western region having the largest case loads and
the longest waiting lists relative to other U.S. census regions.
Specifically:

-   Of the AAAs that provide case management services, nearly three
    quarters provide this service only to participants aged 60 and over.
    A larger proportion of AAAs located in nonmetropolitan regions serve
    only people aged 60 and over relative to AAAs in metropolitan areas
    (80% and 65%, respectively). Regionally, AAAs in the Northeast and
    South are significantly more likely to provide case management
    services only to individuals aged 60 and over relative to other
    regions.

-   More than 61% of the AAA case managers have a case load of more than
    50 persons. On average, most AAA case managers work with 75 or more
    participants. AAAs in the West have the largest caseloads relative
    to AAAs in the other census regions.

-   Over a third of AAAs have waiting lists for case management
    services. AAAs located in metropolitan areas are more likely to have
    waiting lists than AAAs in nonmetropolitan areas. AAAs in the West
    have the longest waiting lists relative to AAAs in other census
    regions.

## Access Services: Summary of Findings and Policy Implications

I&A and case management help older persons and their families navigate
the long-term care system and identify needed resources in the
community. Highlights from RTI's analysis are summarized in Exhibit 3-5
below.

[]{#__RefHeading___Toc170629896 .anchor}Exhibit 3-5\
I&A and Case Management: Key Findings

+-----------------------------------------------------------------------+
| > ***Information and Assistance***                                    |
|                                                                       |
| -   Title III-B is an important source of funding for the delivery of |
|     I&A services by the AAAs, providing over 40% of total             |
|     expenditures for this service.                                    |
|                                                                       |
| -   The I&A service, in contrast to other Title III-B services        |
|     reviewed in this study, serves both older persons and their       |
|     family members.                                                   |
|                                                                       |
| -   Many callers are repeat users, suggesting that I&A services       |
|     satisfy the needs of callers to identify potential sources of     |
|     support and to navigate the long-term care system.                |
|                                                                       |
| -   The I&A service system is responsive to I&A callers, with the     |
|     vast majority of calls answered in fewer than five rings, and     |
|     directly by a person.                                             |
|                                                                       |
| > ***Case* *Management***                                             |
|                                                                       |
| -   While contributing a smaller share of revenue than for I&A        |
|     services, Title III-B is also an important source of funding to   |
|     support the delivery of case management services, accounting for  |
|     approximately 20% of total expenditures for this service by AAAs. |
|                                                                       |
| -   Title III-B case management serves a population that is at risk   |
|     of institutionalization---those aged 75 and over, people with     |
|     substantial disabilities, and those living alone.                 |
|                                                                       |
| -   The frailty of the population served increased over time: The     |
|     proportion of case management participants with three or more ADL |
|     limitations increased between 2001 and 2004, as did the           |
|     proportion living alone.                                          |
|                                                                       |
| -   Seniors receive about 10 hours of case management services per    |
|     person per year, consistent with Title III-B case management's    |
|     role as a temporary brokerage service linking individuals to      |
|     other supportive services rather than providing an ongoing        |
|     service.                                                          |
+-----------------------------------------------------------------------+

I&A services help family caregivers and vulnerable individuals---people
living alone, the oldest of the old, and persons with significant
functional limitations---to navigate the long-term care system and
identify needed resources in their communities. Similarly, case
management services enable at-risk individuals to obtain needed home and
community-based services. In cases where older individuals are eligible
to receive other long-term care services (such as Medicaid or other
state-provided service benefits), the aging network locates and
coordinates benefits for older persons and their family members. The
Aging and Disability Resource Center Program, part of the AoA's Choices
for Independence Initiative, builds on the Title III-B I&A and case
management roles that were firmly established by the aging network.

# Section 4 Supportive Services

Creation of a more balanced long-term care financing and delivery system
by expanding home and community-based services is a major goal of the
federal government and the states. Older people want to stay in the
community if at all possible. In one study, 30% of older people
indicated that they would rather die than move to an institutional
setting (Mattimore et al., 1997). However, in order to stay in the
community, older persons need appropriate supports, including assistance
with personal care, help with domestic chores, and transportation. Prior
research has indicated that older people in the community often have
unmet needs for personal care and other home and community-based
services. This may lead to higher rates of adverse events, including
weight loss, dehydration, falls, burns, skin problems, missed meals,
inability to follow special diets, missed doctor visits, and wearing
dirty clothes (LaPlante et al., 2004).

For this study, RTI analyzed a subset of Title III-B home care services
for which data were available---personal care, chore, and homemaker
services; transportation services; and assisted transportation services.
Personal care consists of in-home personal assistance for persons with
the inability to perform activities of daily living (ADLs), such as
eating, dressing, bathing, toileting, transferring in and out of
bed/chair, and walking. Homemaker services provide assistance to persons
unable to perform instrumental activities of daily living (IADLs), such
as preparing meals, shopping for personal items, managing money, using
the telephone, and doing light housework. Chore services assist persons
having difficulty with heavy housework, yard work, or light housework
(Administration on Aging \[AoA\], 2006). Similarly, transportation
services---which for this study include both general transportation and
assisted transportation services---provide frail individuals and older
persons with the means to get from one location to another. While
general transportation services provide a means of going from one
location to another (with no other service provided), assisted
transportation services provide assistance, including escort, to a
person who has difficulties (physical or cognitive) using regular
vehicular transportation. For more information on transportation service
definitions using in the NAPIS SPR data, see
<http://www.aoa.gov/prof/agingnet/NAPIS/SPR/SPR_guidance/definspr.asp>.

## 4.1 Characteristics of Network Participants

Vulnerable individuals---those who are older, living alone, and persons
with three or more functional limitations (ADLs and IADLs)---are
particularly likely to use Title III-B direct care services. However,
Title III-B direct care services also serve others who may not qualify
for services through other programs.

### Home Care Services

Title III-B home care services serve a frail population. Analyses of
2001--2004 National Aging Program Information System State Program
Performance Report (NAPIS SPR) data indicate that Title III-B
participants were the oldest of the old, those in poor health, and those
living alone. Specifically, over 70% of all Title III-B home care
participants were at least 75 years of age. As shown in Exhibit 4-1, an
increasingly large proportion of persons receiving Title III-B home care
services lived alone, especially those receiving homemaker services
(over 60%) and chore services (over 50% in 2001 and over 60% in 2004). A
somewhat smaller proportion of personal care participants lived alone
(between 35% and 44%). This may be explained by the fact that Title
III-B personal care users have greater assistance needs, which make
living alone more difficult (Exhibit 4-2). Approximately 75% of home
care participants were female.

[]{#__RefHeading___Toc170629897 .anchor}Exhibit 4-1\
Living Alone Status of Home Care Clients (percentage)

![](media/image5.wmf){width="5.705555555555556in"
height="2.7708333333333335in"}

Source: RTI analysis of 2001--2004 NAPIS SPR home care data.

[]{#__RefHeading___Toc170629898 .anchor}Exhibit 4-2\
Home Care Clients Needing Assistance with Three or More ADLs
(percentage)

![](media/image6.wmf){width="5.705555555555556in" height="2.78125in"}

Note: The definition of ADL impairment used in the NAPIS SPR system is
the following: "the inability to perform one or more of the following
six activities of daily living without personal assistance, stand-by
assistance, supervision or cues: eating, dressing, bathing, toileting,
transferring in and out of bed/chair, and walking." See
<http://www.aoa.gov/prof/agingnet/NAPIS/SPR/SPR_guidance/definspr.asp>
for more information on the definition of ADLs used for the NAPIS SPR
data.

Source: RTI analysis of 2001--2004 NAPIS SPR home care data.

A significant proportion of home care participants needed assistance
with three or more ADL limitations, although the actual proportion
requiring this level of assistance varied widely by the type of home
care service---ranging from a high of 60% for personal care services to
a low of 30% for those receiving chore services in 2004 (see Exhibit
4-2). Some of the reported differences in prevalence of functional
limitations by type of home care may reflect variation in AoA's
functional limitation requirements to obtain different Title III-B home
care services. More specifically, those individuals who were eligible
for personal care assistance must need help with one or more of the
following ADLs: eating, bathing, dressing, toileting, transferring
in/out of bed, or walking. Alternatively, those eligible for homemaker
services must need help with one or more of the following IADLs:
preparing meals, shopping for personal items, managing money, using the
telephone, or doing light housework. Finally, those eligible for chore
services must need help with one of the following IADLs: heavy
housework, yard work, or sidewalk maintenance. (See
<http://www.aoa.gov/prof/agingnet/NAPIS/SPR/SPR_guidance/definspr.asp>
for more information on the various home care entry criteria.) The
proportion of home care participants with three or more ADL limitations
increased between 2001 and 2004, suggesting increased targeting on the
frailest population by the area agencies on aging (AAAs).

While the percentage of home care users who had high ADL needs increased
between 2001 and 2004, IADL dependency remained stable by type of home
care service. Over 85% of seniors using personal care service needed
help with three or more IADL activities, about 80% of those receiving
homemaker services needed help with three or more IADLs, and
approximately 55% of those receiving chore services needed help with
three or more IADLs during this 4‑year period.

### Transportation Services

No information on the demographic characteristics or functional status
of general transportation users is available from the NAPIS SPR data.
However, analyses of the 2001--2004 NAPIS SPR data indicate that
assisted transportation services were targeted to older seniors and
those living alone. About 60% of all assisted transportation
participants served by the Title III-B program were at least 75 years of
age. The proportion of assisted transportation service participants who
lived alone increased substantially between 2001 and 2004. As shown in
Exhibit 4-3, 23% of those receiving Title III-B assisted transportation
services lived alone in 2001, while 43% lived alone in 2004.
Approximately 70% of assisted transportation participants were female.

[]{#__RefHeading___Toc170629899 .anchor}Exhibit 4-3\
Living Alone Status of Assisted Transportation Clients (percentage)

![](media/image7.wmf){width="5.695138888888889in"
height="2.685416666666667in"}

Source: RTI analysis of 2001--2004 NAPIS SPR assisted transportation
data.

## 4.2 Characteristics of Home Care and Transportation Services

RTI's quantitative analysis identified several trends in home care and
transportation services use during the 4-year period. In general, Title
III-B home care use declined somewhat between 2001 and 2004. The number
of persons using assisted transportation services declined markedly.
However, the decline in the number of persons using assisted
transportation was offset somewhat by a rise in the intensity of those
services. Home care expenditures varied widely by type of service. This
could be explained, in part, by the availability of other funding
sources for personal care services.

### Home Care Services

***Service Use.*** The total number of hours of Title III-B home care
services used by older disabled persons declined somewhat over the
2001--2004 period (Exhibit 4-4). The total (unduplicated) number of
persons using home care services also declined during this period
(Exhibit 4-5).

[]{#__RefHeading___Toc170629900 .anchor}Exhibit 4-4\
Number of Hours of Home Care Services

![](media/image8.wmf){width="6.0125in" height="2.911111111111111in"}

Source: RTI analysis of 2001--2004 NAPIS SPR home care data.

[]{#__RefHeading___Toc170629901 .anchor}Exhibit 4-5\
Unduplicated Count of Home Care Participants

![](media/image9.wmf){width="6.022916666666666in"
height="2.9159722222222224in"}

Source: RTI analysis of 2001--2004 NAPIS SPR home care data.

***Expenditures**.* NAPIS SPR expenditure data for 2001 to 2004 indicate
that the Title III-B program has represented a stable source of funding
of home care services for AAAs (see Exhibit 4-6).

[]{#__RefHeading___Toc170629902 .anchor}Exhibit 4-6\
AAA Home Care Expenditures by Source of Funding, 2001--2004

+-------------------------+----------+----------+----------+----------+
|                         | **2001** | **2002** | **2003** | **2004** |
+-------------------------+----------+----------+----------+----------+
| **Personal Care**       |          |          |          |          |
+-------------------------+----------+----------+----------+----------+
| > Title III-B           | \$12     | \$12     | \$16     | \$14     |
| > expenditures          | ,605,838 | ,644,067 | ,928,237 | ,681,278 |
+-------------------------+----------+----------+----------+----------+
| > Non-Title III-B       | 88       | 97       | 84       | 85       |
| > expenditures          | ,143,747 | ,584,277 | ,878,391 | ,832,168 |
+-------------------------+----------+----------+----------+----------+
| > Total expenditures    | 100      | 110      | 101      | 100      |
|                         | ,749,585 | ,228,344 | ,806,628 | ,513,446 |
+-------------------------+----------+----------+----------+----------+
| > Percentage of total   | 12.5     | 11.5     | 16.6     | 14.6     |
| > expenditures from     |          |          |          |          |
| > Title III-B           |          |          |          |          |
+-------------------------+----------+----------+----------+----------+
| **Homemaker**           |          |          |          |          |
+-------------------------+----------+----------+----------+----------+
| > Title III-B           | 21       | 26       | 30       | 25       |
| > expenditures          | ,566,253 | ,470,604 | ,196,794 | ,733,033 |
+-------------------------+----------+----------+----------+----------+
| > Non-Title III-B       | 76       | 73       | 79       | 69       |
| > expenditures          | ,240,036 | ,844,371 | ,329,493 | ,364,110 |
+-------------------------+----------+----------+----------+----------+
| > Total expenditures    | 97       | 100      | 109      | 95       |
|                         | ,806,289 | ,314,975 | ,526,287 | ,097,143 |
+-------------------------+----------+----------+----------+----------+
| > Percentage of total   | 22.0     | 26.4     | 27.6     | 27.1     |
| > expenditures from     |          |          |          |          |
| > Title III-B           |          |          |          |          |
+-------------------------+----------+----------+----------+----------+
| **Chore**               |          |          |          |          |
+-------------------------+----------+----------+----------+----------+
| > Title III-B           | 5        | 5        | 8        | 6        |
| > expenditures          | ,870,893 | ,844,989 | ,257,617 | ,351,626 |
+-------------------------+----------+----------+----------+----------+
| > Non-Title III-B       | 12       | 13       | 12       | 9        |
| > expenditures          | ,409,792 | ,720,865 | ,778,912 | ,889,821 |
+-------------------------+----------+----------+----------+----------+
| > Total expenditures    | 18       | 19       | 21       | 16       |
|                         | ,280,685 | ,565,854 | ,036,529 | ,241,447 |
+-------------------------+----------+----------+----------+----------+
| > Percentage of total   | 32.1     | 29.9     | 39.3     | 39.1     |
| > expenditures from     |          |          |          |          |
| > Title III-B           |          |          |          |          |
+-------------------------+----------+----------+----------+----------+

Source: RTI analysis of 2001--2004 NAPIS SPR data.

Title III-B funds supported a larger proportion of homemaker and chore
services relative to personal care services, most likely due to the
availability of Medicaid dollars to support personal care activities in
the states (Exhibit 4-6). Over the period from 2001 to 2004, Title III-B
provided between 12% and 17% of funds to support personal care services.
In contrast, Title III-B provided between 22% and 28% of expenditures to
support homemaker services and between 30% and 39% of expenditures to
support chore services. Stated differently, every \$1 provided by the
Title III-B program for home care services leveraged an additional \$2
to \$6 of non-Title III-B funds (depending on service). Between 2001 and
2003, the total amount of Title III-B and non-Title III-B funds used to
support home care services remained fairly stable across home care
services; however, in 2004, both Title III-B and non-Title III-B
expenditures for home care generally declined (see Exhibits 4-7 through
4-9). Similarly, between 2001 and 2003, total expenditures for home care
services remained relatively constant, but in 2004, total expenditures
for home care services declined for all but personal care services.

According to home care providers participating in the focus groups, the
recent decline in Title III-B expenditures for home care may be
attributable to the AAA negotiated reimbursement rates, which are lower
than those paid by Medicaid for the same type of care. While home care
providers participating in focus groups claimed that they did not
discriminate among clients based on payment or reimbursement rates, they
reported that their ability to provide services was compromised when a
funding agency would not pay enough for services. The home care
providers suggested that while home care providers tried to include
Title III-B participants in their mix of home care clients, ultimately
only a limited number of such participants could be served, signaling
potential access problems for AAA participants.

[]{#__RefHeading___Toc170629903 .anchor}Exhibit 4-7\
Title III-B Expenditures, Other Expenditures,\
and Total Expenditures for Personal Care Services

![](media/image10.wmf){width="6.0125in" height="2.9194444444444443in"}

Source: RTI analysis of 2001--2004 NAPIS SPR home care expenditure data.

[]{#__RefHeading___Toc170629904 .anchor}Exhibit 4-8\
Title III-B Expenditures, Other Expenditures,\
and Total Expenditures for Homemaker Services

![](media/image11.wmf){width="6.0125in" height="2.834722222222222in"}

Source: RTI analysis of 2001--2004 NAPIS SPR home care expenditure data.

[]{#__RefHeading___Toc170629905 .anchor}Exhibit 4-9\
Title III-B Expenditures, Other Expenditures,\
and Total Expenditures for Chore Services

![](media/image12.wmf){width="6.0125in" height="2.9402777777777778in"}

Source: RTI analysis of 2001--2004 NAPIS SPR home care expenditure data.

Technical Advisory Group (TAG) members and AAA directors offered another
potential reason for the recent decline in home care use. Based on their
collective experience, AAAs increasingly have targeted home care
services, referring older persons to other state and local home care
programs (such as Medicaid and state-funded home care services) whenever
they were eligible to receive them. These alternative programs sometimes
provide a larger array and higher intensity of home care services than
Title III-B programs. Thus, AAAs may be shifting their focus away from
the direct funding of services and concentrating on becoming navigators
of the long-term care system for older adults.

### Transportation Services

***Service Use.*** The total units of general transportation and
assisted transportation services declined during the 4‑year period
(Exhibit 4-10). In particular, the number of persons using assisted
transportation services declined markedly between 2001 and 2004 (Exhibit
4-11). However, the decline in the number of persons served by assisted
transportation was offset somewhat by a rise in the intensity of
services, increasing from 32 one-way trips per person per year in 2001
(or roughly one trip every 11 days) to 38 one-way trips in 2004 (or
roughly one trip every 9 days). AoA staff speculate that the total use
of transportation services declined as the proportion of nutrition
service participants obtaining their meals at home (rather than at
congregate meal sites) increased, reducing the need for at least some
Title III-B transportation services.

[]{#__RefHeading___Toc170629906 .anchor}Exhibit 4-10\
Units of Transportation and Assisted Transportation Service

![](media/image13.wmf){width="6.0125in" height="2.9159722222222224in"}

Source: RTI analysis of 2001--2004 NAPIS SPR transportation data.

[]{#__RefHeading___Toc170629907 .anchor}Exhibit 4-11\
Unduplicated Count of Assisted Transportation Participants

![](media/image14.wmf){width="6.001388888888889in"
height="2.890277777777778in"}

Source: RTI analysis of 2001--2004 NAPIS SPR assisted transportation
data.

AAA directors provided several alternative explanations for this decline
in transportation services. First, AAA directors reported that increases
in the price of gasoline limited their ability to provide transportation
services to seniors. Second, the limited number of transportation
providers available was considered a major barrier to the provision of
services. Third, volunteers, who until recently provided a large
proportion of the transportation services to frail older persons living
in rural areas, have become less willing to offer these services to AAA
participants as the cost of fuel has increased.

Additional data on characteristics of general (but not assisted)
transportation services are available from the 2003 and 2004 National
Surveys. General transportation services were extremely important to
individuals who relied on them to participate in the community. For
example, over 50% of respondents used transportation services within the
week prior to the survey. Similarly, approximately half of all
respondents used Title III-B transportation services for at least three
quarters of all trips. The average number of general transportation
trips used varied by year, ranging from 8 to 13 per month, reflecting
the fact that individuals used Title\
III-B transportation services about every 3 to 4 days. Survey
respondents reported that transportation services helped them to get to
medical appointments and senior centers.

***Expenditures.*** Analyses of 2001--2004 NAPIS SPR expenditure data
(shown in Exhibits 4-12 and 4-13) indicate that Title III-B represents a
substantial source of funds for transportation services funded by AAAs.
Between 2001 and 2004, 36% to 42% of all general transportation services
provided by the AAAs were funded by the Title III-B program. Similarly,
22% to 24% of all assisted transportation services provided by the aging
network were funded by the Title\
III-B program. This means that for every \$1 of Title III-B funds
provided, an additional \$2 or \$3 came from other sources for general
and assisted transportation services, respectively. Roughly \$110 to
\$120 million from non-Title III-B funds was used annually to support
general transportation services, while approximately \$11 to \$13
million from non-Title III-B funds annually supported assisted
transportation services. Total expenditures for general transportation
remained fairly constant over time, while total expenditures for
assisted transportation services declined somewhat during this 4‑year
period. Overall, the total expenditures for general transportation
services exceeded those for assisted transportation services by a factor
of 12 to 1.

[]{#__RefHeading___Toc170629908 .anchor}Exhibit 4-12\
Title III-B Expenditures, Other Expenditures, and Total Expenditures\
for General Transportation Services

![](media/image15.wmf){width="6.0125in" height="2.9006944444444445in"}

Source: RTI analysis of 2001--2004 NAPIS SPR general transportation
expenditure data.

[]{#__RefHeading___Toc170629909 .anchor}Exhibit 4-13\
Title III-B Expenditures, Other Expenditures, and Total Expenditures for
Assisted Transportation Services

![](media/image16.wmf){width="6.0125in" height="2.8402777777777777in"}

Source: RTI analysis of 2001--2004 NAPIS SPR assisted transportation
expenditure data.

## 4.3 Satisfaction with Supportive Services

Satisfaction with care is the main client outcome available from AoA
data sources. Satisfaction relates to how older persons experience the
care/services received compared to their standards or expectations
(Coughlin, Long, & Kendall, 2002; Haviland et al., 2003; Linder-Peltz,
1982; Pascoe & Attkisson, 1983). Satisfaction measures provide important
information on interpersonal aspects of care, such as communication
between providers and participants; participants' perceptions of how
much providers respect, understand, and listen to them; and whether
participants are treated with dignity (Khatutsky, Anderson, & Wiener,
2006). The 2003--2004 National Surveys were used to examine participant
satisfaction with homemaker and transportation services. Findings
indicate that Title III-B users were very satisfied with these services.

### Home Care Services

Consistent with other reports of home care satisfaction (Doty, Kasper, &
Litvak, 1996; Geron et al., 2000; Khatutsky, Anderson & Wiener, 2006;
Office of the Inspector General, 1995), participants responding to the
2003 and 2004 National Surveys generally were quite satisfied with
homemaker services. However, RTI's research indicates that survey
respondents responded with more satisfaction with the quality than with
the quantity of services: over 80% of those responding to most questions
about homemaker thoroughness, comprehensiveness, willingness to do extra
things, politeness, promptness, and competence responded "Yes,
definitely" or "Yes, I think so" to the positively worded homemaker
satisfaction items. However, 36% to 39% of respondents wanted more hours
of homemaker services each week, and approximately 44% of respondents
wished that the homemaker could do more things for them. Satisfaction
results were consistent for both years.

We used multivariate OLS modeling to identify factors associated with
general satisfaction with homemaker services. Overall, demographic
characteristics were not strong predictors of satisfaction with this
service. Urban residents were somewhat more satisfied with homemaker
services than those living in suburban or rural areas, rating the
service about 4 percentage points higher, on average. This may reflect
the greater access to services that persons in urban areas have. Having
substantial functional impairment (three or more ADL limitations) was a
negative predictor of satisfaction, reducing the overall satisfaction
score by about 5 percentage points. On the other hand, having
significant IADL impairment did not significantly affect satisfaction
with care. The finding on ADLs may reflect the desire on the part of
participants for homemakers to perform a wider range of tasks than they
are allowed and a desire for more hours of service.

We performed a supplementary analysis of the 2004 homemaker satisfaction
sample to compare the characteristics of those least satisfied with
homemaker services versus the overall homemaker sample. Consistent with
other studies reporting that vulnerability groups generally experience
low satisfaction with services, we found that those with a combination
of "vulnerability" factors, such as living in a rural area and having
substantial ADL impairment, or being nonwhite and having substantial ADL
impairment, or being 75 and older and of minority descent decreased
satisfaction with homemaker services.

In summary, we found that AAA participants with more physical
limitations, of minority descent, living in a suburban or rural area,
and with a combination of vulnerability factors were less satisfied with
homemaker services relative to their counterparts.

### Transportation Services

RTI analyzed predictors of use and satisfaction with Title III-B
transportation services. Two logistic regression models were estimated
to determine factors that affected the likelihood of (1) being able to
get around more than before because of Title III-B transportation
services; and (2) rating the transportation service as good, very good,
or excellent. We found that respondents with the least amount of formal
education were twice as likely as those with a college degree or more to
say that they were able to get around more than before due to Title\
III-B transportation services. Functional status was not a significant
predictor of the likelihood of being able to get around more than before
because of Title III-B transportation services. In summary, use of
transportation services was significantly higher for AAA participants
with less education.

Urban/rural status and levels of functional impairment were significant
predictors of satisfaction with transportation services: when all other
factors in our models were held constant, we found that urban residents
and those with a high level of functional impairment were significantly
more likely to give transportation a rating of at least good. Urban
residents were about five times more likely than those in suburban areas
to rate transportation services positively. This finding may reflect the
fact that it is difficult to run transportation services across large
suburban areas. Similarly, respondents with three or more ADLs were over
seven times as likely as their healthier counterparts to rate Title
III-B transportation services as at least good, indicating the
transportation service's value to older persons with high levels of
frailty.

## 4.4 Administration of Supportive Services

Home care services typically initiate services after receiving a
referral from other service providers. According to home care focus
group participants, a wide range of referral sources are used, ranging
from AAAs and other public agencies to health care organizations, other
community-based organizations, direct marketing campaigns, and personal
contacts. Home care providers consider AAAs to be an important but not
primary source of client referrals to home care. Among the more novel
sources of referrals to home care agencies are insurance companies
selling long-term care policies and utility companies.

Home care providers reported that a number of administrative problems
hampered their ability to work with the AAAs. Most participating
providers came from states where each AAA was allowed to determine its
own reimbursement rates. As a result, home care agencies contended with
numerous reimbursement rates and extensive paperwork to obtain contracts
with each AAA in their service area. Overall, home care providers wanted
more consistency in reporting and contractual requirements across AAAs
to simplify their administrative work load and to reduce barriers to
providing home care service for Title III-B participants.

While focus group protocols did not contain specific questions on the
administration of transportation services, it was clear from
conversations with AAA directors that transportation services, like
other direct services, were in short supply in many community settings
(particularly in inner cities and rural areas) and that volunteers and
waiting lists were being used to address the imbalance between the
demand for and supply of direct care services.

Given the limited number of providers in some service areas, direct
services were administered on an as-needed basis. Typically, AAA
participants were referred to other service providers whenever more
comprehensive benefits were available elsewhere. This strategy has
enabled AAA directors to retain their limited direct service dollars for
those individuals who either had incomes too large to qualify for
Medicaid or other state-provided benefits or who did not meet the
functional limitation requirements to be eligible for alternative
service programs.

## 4.5 Supportive Services: Summary of Findings and Policy Implications 

Home care and transportation services are two direct services that make
an important difference to the quality of life of frail and older
persons living at home. Highlights from RTI's analysis of qualitative
and quantitative data are summarized in Exhibit 4-14 below.

[]{#__RefHeading___Toc170629910 .anchor}Exhibit 4-14\
Home Care and Transportation: Key Findings

+-----------------------------------------------------------------------+
| ***Home Care***                                                       |
|                                                                       |
| -   The Title III-B program is a significant, but not primary, source |
|     of AAA funds for home care services, covering approximately 15%   |
|     of total expenditures for personal care, 25% of total             |
|     expenditures for homemaker services, and 35% of total             |
|     expenditures for chore services from 2001 to 2004.                |
|                                                                       |
| -   Home care serves a population at risk of institutionalization:    |
|     the oldest of the old, frail individuals, and those who live      |
|     alone.                                                            |
|                                                                       |
| -   Home care services utilization declined during the period 2001 to |
|     2004: Information provided from AAA directors and TAG members     |
|     suggests that the aging network referred people to other service  |
|     programs/providers whenever possible to allow these individuals   |
|     to obtain a broader range of home care services elsewhere.        |
|                                                                       |
| -   Satisfaction with homemaker service is very high: Over 80% of     |
|     survey respondents rated various aspects of homemaking service    |
|     positively. Those who were least satisfied tended to be minority, |
|     live in a rural/suburban area, and report high ADL impairment.    |
|     Having a combination of vulnerability factors compounded the      |
|     likelihood of being less satisfied with homemaker services.       |
|                                                                       |
|     ***Transportation***                                              |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   The Title III-B program provides substantial support for the      |
|     delivery of general and assisted transportation services,         |
|     covering approximately 40% of total AAA expenditures for general  |
|     transportation services and 23% of total AAA expenditures for     |
|     assisted transportation services from 2001 and 2004.              |
|                                                                       |
| -   Title III-B assisted transportation serves a population needing   |
|     transportation services: the oldest of the old and people living  |
|     alone.                                                            |
|                                                                       |
| -   Seniors using transportation rely heavily on this service: Over   |
|     50% of general transportation users had used this Title III-B     |
|     service in the week prior to the survey, and over 50% of all      |
|     general transportation users relied on Title III-B transportation |
|     for at least three quarters of their trips.                       |
|                                                                       |
| -   While Title III-B transportation services are generally rated     |
|     very highly by most survey respondents, urban residents and       |
|     highly impaired individuals are significantly more likely to rate |
|     this service positively.                                          |
+-----------------------------------------------------------------------+

Despite the presence of a number of a number of home and community-based
initiatives such as the Real Change System Change Grants to States
Program that have sought to rebalance the long-term care system, the
delivery of long-term care services in the United States remains biased
toward institutional care. While the Medicaid program provides services
to low-income and categorically needy individuals, benefits vary widely
by state. Medicare covers a finite set of long-term care services, but
many older persons need additional supports in order to remain living in
the community. Only a small proportion of the older population has
private long-term care insurance. To help fill this gap, Title III-B
funds additional long-term care services and infrastructure development
to help older people remain in the community. Title III-B helps pay for
the following:

-   Planning and infrastructure development for a more balanced
    long-term care system, which would provide a greater role for home
    and community-based services.

-   Services for individuals who do not qualify for Medicaid, either
    financially or functionally (e.g., they do not qualify for Medicaid
    home and community-based services waivers because they do not need
    an institutional level of care).

-   Services for individuals who live in states where the home and
    community-based waiver has waiting lists or where Medicaid coverage
    is limited (e.g., there is no personal care benefit).

-   Nonmedical services, such as homemaker services, that may not be
    covered by Medicaid or other programs.

-   Coverage to individuals who are waiting for their Medicaid or other
    applications to be processed or are waiting to transition to other
    settings.

By gaining experience through the design and contracting of services,
AAAs and State Units on Aging have acquired the credibility and
expertise to obtain additional state and Medicaid funds for home and
community-based services that leverage Title III-B resources.

General transportation and assisted transportation services are a
critical component of the home and community-based services system.
Transportation services ensure that older frail people living at home
are able to participate in the community---by providing rides to medical
providers, to social events, and to visit family members. Without these
services, many older people with disabilities would be unable to
participate in the many positive aspects of community living. The data
demonstrate that people who use these services rely heavily on them.

The implementation of Title III-B direct services varies by state. For
example, some states use Title III-B funding to support a large array of
services, while others concentrate their resources on a smaller number
of services that are less likely to be covered by Medicaid and other
state funding sources.

Geography also affects the role and implementation of Title III-B
services. For example, the aging network reports that urban participants
typically have better access to Title III-B transportation services
relative to their more rural counterparts.

The role of Title III-B financing varies by service type. For example,
its role in providing personal care services is smaller than its role in
the financing of chore services because there are alternative funding
sources available for personal care (such as Medicaid) but not as many
alternative funding sources for chore and homemaker services. In
allocating resources for direct care services, AAAs target vulnerable
populations, particularly the oldest of the old, persons with functional
disabilities, and those living alone.

# Section 5 Financing and Management of Title III-B Services

The aging network has used Title III-B funds to guide older people and
their families through the complex home and community-based service
system, and as a base onto which they have built a broader system of
long-term care services. However, since Title III-B funding is not
unlimited, questions of allocation and management of resources are
crucial to the success of the program and to the broader question of how
the program fits into the larger long-term care system. This section
addresses the following questions:

-   How does funding for Title III-B fit into the larger financing of
    long-term care?

-   How should Title III-B funds be allocated and integrated with other
    long-term care funding streams?

-   How should Title III-B and, by implication, other Older Americans
    Act (OAA) programs be managed?

## 5.1 Title III-B Expenditures in the Long-Term Care System

Exhibit 5-1 provides a graphical portrayal of estimated total federal
and state spending for home and community-based services by source of
funding. This graph includes all Title III-B services, including those
beyond the access and supportive services highlighted in this report.
Title III-B expenditures were compiled from National Aging Program
Information System State Program Performance Report (NAPIS SPR) data,
state-funded service expenditures were reported by AARP (Summer & Ihara,
2004), and Medicaid home and community-based service expenditures for
older people were provided by the Urban Institute.[^5]

[]{#__RefHeading___Toc170629911 .anchor}Exhibit 5-1\
Public Funding for Supportive Services, by Source, 2002

![](media/image17.wmf){width="4.118055555555555in"
height="3.0027777777777778in"}

Source: RTI analysis of NAPIS SPR, AARP, and Urban Institute data.

RTI combined data from the three expenditure sources to determine that
Title III-B represented approximately 4% of estimated total government
expenditures on home and community-based services in 2002. Similar
information was not available for other years.

Exhibit 5-2 depicts the proportion of service expenditures by area
agencies on aging (AAAs) directly supported by Title III-B by type of
service. This chart includes all Title III-B services, including
services not highlighted in this report. Since the relative contribution
of Title III-B funds does not vary much from 2001 to 2004, we highlight
the proportion of Title III-B funding only in 2004.

[]{#__RefHeading___Toc170629912 .anchor}Exhibit 5-2\
Proportion of Total AAA Expenditures Supported by Title III-B, by
Service, 2004

![](media/image18.wmf){width="5.344444444444444in"
height="2.823611111111111in"}

Source: RTI analysis of 2004 NAPIS SPR expenditure data.

The Title III-B services that relied most heavily on Title III-B funds
included legal assistance, information and assistance (I&A), and
outreach. For each of these services, at least 40% of all AAA
expenditures came from Title III-B. In contrast, case management
services were largely funded by non-Title III-B resources. Home care
services were funded by a combination of Title III-B and non-Title III-B
funds, with the proportion paid for by Title III-B varying by type of
service. Personal care services relied less heavily on Title III-B
sources (due, most likely, to the availability of Medicaid funds) than
did homemaker and chore services.

Exhibit 5-3 depicts Title III-B access and care expenditures for the
years 2001 and 2004. Title III-B expenditures are typically under the
control of AAAs. The Title III-B access and direct services that
expended the most absolute dollars from 2001 through 2004 were general
transportation services, I&A services, and homemaker services, with each
service expending more than \$25 million by 2004. Most Title III-B
services increased slightly during this period.

[]{#__RefHeading___Toc170629913 .anchor}Exhibit 5-3\
Title III-B Expenditures for Access and Care Services

![](media/image19.wmf){width="5.845138888888889in"
height="3.486111111111111in"}

Source: RTI analysis of 2001 and 2004 NAPIS SPR data.

As shown in Exhibit 5-4, non-Title III-B expenditures for access and
care services were two to three times the amount of funding provided by
Title III-B.[^6] The services covered in this study that benefited the
most (in absolute terms) from non-Title III-B sources were
transportation, case management, and personal care services (with each
service expending more than \$85 million by 2004). Medicaid home and
community-based services waiver programs are often the largest payer.
For example, a National Association of State Units on Aging (NASUA,
2004) study indicates that over 33 of the 50 SUAs (approximately two
thirds) also serve as the designated operating agency for one or more
Medicaid home and community-based services waiver programs.

[]{#__RefHeading___Toc170629914 .anchor}Exhibit 5-4\
Non-Title III-B Expenditures for Access and Care Services

![](media/image20.wmf){width="5.788194444444445in"
height="3.522222222222222in"}

Source: RTI analysis of 2001 and 2004 NAPIS SPR data.

Non-Title III-B expenditures for most supportive services administered
by the AAAs either remained stable or declined somewhat by the end of
the 4‑year period (2001 to 2004). For example, non-Title III-B
expenditures for homemaker services declined from over \$76 million in
2001 to \$69 million in 2004. One notable exception to this general
pattern, however, was case management services. Non-Title III-B
expenditures for case management services increased from \$65 million in
2001 to over \$90 million in 2004, potentially due to increases in
Medicaid funding for case management.

As shown in Exhibit 5-5, the total amount of resources (Title III-B and
non-Title III-B) available to AAAs to support Title III-B programming
remained stable between 2001 and 2004, at about \$1.1 billion. Of the
Title III-B services studied in this report, those that used the largest
amount of total Title III resources during the period were general
transportation services and case management, with personal care,
information and assistance (I&A), and homemaker services following
closely behind.

[]{#__RefHeading___Toc170629915 .anchor}Exhibit 5-5\
Total Expenditures for Access and Care Services

![](media/image21.wmf){width="5.706944444444445in"
height="3.560416666666667in"}

Source: RTI analysis of 2001 and 2004 NAPIS SPR data.

## 5.2 Issues Related to the Financing of Supportive Services

The focus group participants raised several issues related to the
financing of supportive services for older persons. These topics relate
to:

-   current funding challenges/recommendations,

-   support for infrastructure development, and

-   the leveraging of multiple sources of funds.

### Current Funding Challenges/Recommendations

During the four focus group sessions, AAA directors raised several
issues related to the OAA funding formula. While AAA directors knew that
OAA allocation formulas were set at the state level, they were not fully
familiar with how the formula has been implemented at the state level.
AAA directors asked that the federal guidelines be changed to give
greater weight to the growing number of older persons, the needs of
seniors in poverty and persons aged 75 and older, and the special needs
of those living in rural areas. AAA directors also wanted Congress to
reconsider age 60 as the main eligibility criterion for OAA-funded
services. In particular, AAA directors wanted the allocation formula to
do the following:

-   *Reflect the growing number of people over age 60 between U.S.
    Census measurements.* AAA directors in one group wanted to update
    AAA funding allocations to reflect the changing demographics of the
    population between decennial censuses.[^7]

-   *Support seniors in poverty and the oldest of the old.* AAA
    directors in one focus group asked that the formula for determining
    AAA allocations be changed to provide extra support for AAAs that
    serve a population with a disproportionate number of participants in
    poverty or the population aged 75 and older.

-   *Address special needs of rural and minority populations.* In one
    group, AAA directors asked for more support for services to rural
    clients and minority groups. AAA directors in another group
    requested that the number of square miles in an AAA service area be
    considered as a factor in allocating funding to better reflect the
    special needs of rural areas.

-   *Alter the role of age in service eligibility.* AAA directors in
    another group asked for flexibility in the age criteria used to
    establish eligibility for OAA-funded services. A number of AAA
    directors wanted to be able to provide preventive services to
    persons under age 60 rather than having to wait until they are older
    and "in serious trouble."

### Support for Infrastructure Development

AAA directors report that the infrastructure supporting the aging
network needs to be updated. They were interested in further developing
capacities for long-range planning, grant writing, research and
development, data management/information systems, and management
training on established business practices. AAA directors stressed the
need to plan for the Baby Boomer generation, reported having
insufficient capacity to write grant applications to obtain additional
funding, and wanted to learn about potential funding to support staff
training and to conduct research.

Both State Unit on Aging (SUA) directors and AAA directors hoped that
the aging network's data management systems would provide more extensive
information on Title III-B program performance over time. In addition,
AAA directors were eager to find ways to share resources, including
information on computer technologies, best practices, and other
management tools, but felt that dissemination might be more effectively
handled at the national level, with technical assistance provided to the
AAAs. Support for the initial and ongoing training of AAA and SUA
directors was recommended to provide the critical skills needed to
effectively manage the increasingly complex home and community-based
services programs.

Home care providers also asked for support to help the aging network
develop more uniform systems/procedures to enhance program operations
and to make it more appealing for providers to work with AAAs. Most of
the participating providers came from states where each AAA determined
its own reimbursement rates, reporting requirements, and standard
operating procedures. As a result, participating providers were required
to contend with multiple reimbursement rates and extensive paperwork to
manage contracts with each AAA in a region.

### Leveraging Multiple Sources of Funds

Both SUA and AAA directors reported difficulty integrating multiple
sources of funds to support the delivery of Title III-B services to
their AAA participants. However, neither group of participants was able
to identify specific regulations/rules that prevented them from doing
so. AAA directors generally felt that state interpretations of federal
regulations precluded them from relying on both Medicaid and Title III-B
funds to support a given AAA participant.

According to AoA staff, federal regulations do not preclude the use of
other sources of funding to support Title III-B participants. Not only
can states move funds between titles of the OAA (if state policies allow
for the transfer of such funds), they also can tap into multiple funding
streams (e.g., other state-supported programs) when serving a given AAA
participant.[^8]

## 5.3 Issues Related to the Management/Delivery of Supportive Services

Key findings from focus group discussions and the analysis of AAA survey
data on the management/delivery of supported services related to four
issues:

-   determination of which Title III-B services to provide,

-   role/importance of state/community partnerships,

-   availability/use of technology, and

-   use of performance measurement to enhance program operations.

### Determination of Which Title III-B Services to Provide

AAA directors in all the focus groups wanted more local authority to
distribute Title III funding among Title III-B and other Title III
programs. In particular, they wanted increased flexibility at the AAA
level to more effectively support their most frail AAA participants. AAA
directors also wanted to be empowered to make decisions locally and to
manage their own Title\
III-B budgets.

### The Role/Importance of State/Community Partnerships

AAA directors identified a large group of partnerships with external
providers and other organizations. Established relationships included
federal, state, and local government agencies and programs; research and
academic institutions; healthcare providers; advocacy groups; and
volunteer, not-for-profit groups. These partners helped the AAAs to
serve additional participants, refer existing participants to other
needed services, obtain information on new developments/best practices
in the field, and share program resources.

Of note were some more recent or emerging partnerships formed with
emergency and disaster response officials at the federal, state, and
local levels, and private businesses. Partnerships to meet the emergency
needs of older persons developed around issues such as disaster planning
with the Federal Emergency Management Agency, emergency preparedness
agencies at the local level, and development of communication networks
with emergency medical technicians, law enforcement officials, and fire
departments.

Similarly, several AAAs said that they were forging partnerships with
private corporations and employer groups to obtain highly skilled
volunteers and in-kind services for their AAA participants. Important
new partners included the utility companies (which provided
weatherization or heat for individuals in poverty), financial
institutions (which provided financial management advice), and media
companies (which provided public service announcements, as well as
stories in newspapers and on the evening news).

### The Availability/Use of Technology

The use of computers to inform the public and to support AAA operations
has increased in recent years. In particular, some AAAs expressed
concern over the lack of a formal computer strategy within the aging
network and the limited comfort with computers among participants and
providers.

***Lack of Strategy/Sophistication with Computer Technology**.* AAA
directors reported that the aging network lacked a standard approach to
the use of technology to ensure that scarce resources were being used
effectively. In particular, AAA directors said that the aging network
had developed a "plethora of solutions" to address a common set of
problems. While a one-size-fits-all approach was not necessarily being
recommended, AAA directors saw value in having the computer systems be
sufficiently compatible to enable AAAs to communicate with each other
and to share resources across the network. A related issue raised by the
AAA directors was the cost of updating Internet-based applications to
remain current with software upgrades and licenses.

***Limited Access to and Participant Comfort with Computers**.* AAA
directors observed that AoA, the aging network, and other federal
agencies increasingly were encouraging the use of online resources.
However, AAA directors felt that many older persons could not take
advantage of these tools since they often were not computer literate and
would not feel comfortable using these online resources for some time to
come. Another barrier cited by AAA directors was that computers were
intimidating to some of the smaller "mom and pop" service providers.
Finally, some AAA directors were concerned about the uneven distribution
of technology across AAAs.

### Performance Management Tools

Based on information provided from focus groups and AAA survey data, the
aging network depended on a variety of performance management tools to
oversee Title III-B operations. Despite the fact that AAA directors
reported facing a number of challenges in accessing and using computers,
AAA survey results indicate that the majority of AAA directors do take
advantage of computer support tools at their agencies. For example, over
65% of AAAs have computerized client tracking systems to collect
individual-level data. Similarly, the vast majority have the following
computerized management information systems: intake/registration,
assessment, referral, case management, use of services, and provider
billing, although almost three quarters of these AAAs reported using
commercial vendors/software packages (rather than in-house resources) to
provide these services for them.

SUA directors, in particular, reported that their states regularly
engaged in a variety of management practices to monitor Title III-B
activity. The strategies they employed to track program performance
included the following:

-   *Conducting needs assessments*. These assessments educate the
    public, help AAAs determine where to target local activities, and
    empower local communities with necessary information to advocate for
    the needs of their older populations.

-   *Monitoring data from local service providers.* While SUA directors
    were eager to analyze utilization data from local service providers,
    they reported that many community-based agencies did not have the
    resources to enter individual-level data. As a result, the
    monitoring of local service providers continued to be a work in
    progress, with a few states being able to obtain point-of-service
    data from providers, while others were only able to analyze
    aggregated data on overall service activity.

-   *Using performance outcome data.* Almost 80% of all AAAs rely on
    performance data to better manage their programs and over 90%
    conduct consumer assessments to ensure continuous quality
    improvement.While these activities are somewhat more likely to occur
    in metropolitan areas than nonmetropolitan areas, the vast majority
    of AAAs from both types of settings make use of these performance
    measurement tools (ranging from 84% to 74% for performance outcomes
    in metropolitan versus nonmetroplitan areas, respectively, and from
    94% to 88% for consumer assessments).

## 5.4 Financing and Management of Supportive Services: Summary of Findings and Policy Implications

Each year, AoA provides approximately \$300 million in Title III-B funds
for home and community-based services and other social supports to frail
and older individuals. States provide an additional \$750 to \$800
million annually to support these services in AAAs using non-Title III-B
dollars. During 2001--2004, total expenditures through the AAAs to
support Title III-B services and to provide other essential care
coordination and planning activities exceeded\
\$1 billion annually (unadjusted for inflation) and have remained
relatively constant. Highlights of the analysis of qualitative and
quantitative data on the financing and management of Title\
III-B services are summarized in Exhibit 5-6.

[]{#__RefHeading___Toc170629916 .anchor}Exhibit 5-6\
Financing and Management of Title III-B: Key Findings

+-----------------------------------------------------------------------+
| ***Title III-B Expenditures in the Long-Term Care System***           |
|                                                                       |
| -   The Title III-B program funded approximately 4% of total          |
|     government funding for home and community-based services in 2002. |
|                                                                       |
| -   Although the proportion of long-term care expenditures directly   |
|     funded by the Title III-B program is small, Title III-B funds     |
|     have enabled AAAs to develop long-term care service delivery      |
|     systems and programs to support local communities throughout the  |
|     United States.                                                    |
|                                                                       |
| -   Technical Advisory Group members reported that the aging network  |
|     contributed to the well-being of older persons by providing the   |
|     leadership and infrastructure needed to help older persons        |
|     navigate the long-term care system and to serve as the entry and  |
|     coordination point for older persons and their families.          |
|                                                                       |
| ***Policy Issues Related to the Financing of Long-Term Care           |
| Supportive Services***                                                |
|                                                                       |
| -   Some AAA directors would like to reexamine the criteria for       |
|     allocating OAA resources to and within states to reflect the      |
|     growing numbers of people over age 60, seniors in poverty, the 75 |
|     and older population, rural location, and minority populations.   |
|     Directors would also like more flexibility to provide services to |
|     persons under age 60.                                             |
|                                                                       |
| -   Although the Older Americans Act does not preclude states or      |
|     local governments from integrating multiple sources of funds, SUA |
|     and AAA directors report being hampered in their efforts to do    |
|     so.                                                               |
|                                                                       |
| -   AAA directors would like the aging network's infrastructure to be |
|     updated. Among the areas cited for future development are         |
|     long-range planning, grant writing, research and development,     |
|     data management/information systems, and management skills.       |
|                                                                       |
| ***Policy Issues Related to the Management/Delivery of Long-Term Care |
| Supportive Services***                                                |
|                                                                       |
| -   Partnerships, including newer collaborations with emergency and   |
|     disaster response officials and private businesses, are critical  |
|     to the aging network's ability to serve their older participants  |
|     and manage program resources.                                     |
|                                                                       |
| -   While AAA directors are eager to find ways to share resources,    |
|     information on computer technologies, best practices, and other   |
|     management tools, they believe that this type of information      |
|     dissemination should be supported at the national level, with     |
|     technical assistance provided to AAAs.                            |
|                                                                       |
| -   Although the use of technology is fairly widespread among the     |
|     aging network, SUA and AAA directors would like the aging         |
|     network's data management systems to provide more extensive       |
|     information on Title III-B performance.                           |
+-----------------------------------------------------------------------+

Title III-B funds have enabled AAAs to work toward comprehensive
long-term care service delivery systems, but the total level of funding
is limited as a proportion of total government funding for home and
community-based services, especially compared to Medicaid. As a result,
the aging network needs to think strategically about how to use these
critical resources---especially the balance between direct provision of
services and infrastructure development.

The main argument in favor of the provision of these supportive services
is that Title\
III-B fills some clear gaps in the financing system, providing services
to severely disabled older people who cannot otherwise afford them and
where there are limited other sources of financing. In addition, by
directly providing these services to older individuals in communities
across America, AAAs have the expertise and experience to leverage other
funds for home and community-based services. Within the aging network,
there are voices for a different allocation of existing resources that
would target funding to populations likely to be in greater need---areas
with rapidly growing older populations, with high concentrations of
low-income persons and the oldest of the old, and with rural and central
city locations. At current funding levels for Title\
III-B, this implies a zero sum game---some AAAs would receive more money
and others would receive less, always a difficult dynamic.

The main argument in favor of focusing on I&A, case management, and
infrastructure development is that funding for Title III-B is likely to
remain modest compared to the dominance of Medicaid. As a result, the
aging network could be more influential in shaping the overall system if
it was involved in planning the system, providing information, and
acting as the main point of access for the overall long-term care
system.

In addition, while there is always a fine line between local control and
central direction, the focus groups also suggested that AAAs would
welcome more help from AoA regarding matters of computer technologies,
best practices, and other management tools that would allow them to make
better use of the funds they receive. They also would appreciate
learning strategies to integrate funding streams and to leverage other
funds.

# Section 6 Conclusions

America is aging, and with it the number of people with disabilities is
increasing. With the aging of the "baby boom" generation, the number of
older persons in the United States is projected to increase from 35
million persons to 80 million persons between 2000 and 2040 (U.S. Census
Bureau, 2004). The 85-and-over population, which has the highest
disability rate of any age group, is expected to grow even faster, from
4 million persons in 2000 to 15 million persons by 2040. Since
disability rates are strongly correlated with age, this growing number
of older people has profound implications for the number of people with
disabilities. Although estimates vary, one recent projection suggested
that the number of older adults with disabilities will more than double
from 2000 to 2040, increasing from about 10 million persons to about 21
million persons (Johnson, Toohey, and Wiener, 2007). Similarly, the
demand for informal care, paid home care, and nursing home care is
likely to more than double as well.

The Older Americans Act (OAA) was established in 1965 to help provide
older Americans with the resources they need to maintain their health
and live independently in the community for as long as possible. The OAA
provides funding to help older persons through the planning,
coordination, and delivery of a range of home and community-based
services, including meals, home care, transportation services,
information and assistance, case management, senior centers, and respite
services. As the nation's population ages, these services will become
increasingly important in serving the needs of our citizens. Although
Medicaid provides coverage for long-term care services primarily for the
low-income population, many older Americans with chronic impairments
have financial resources above the eligibility level for Medicaid but
not high enough to pay out of pocket for services. While focusing on
underserved populations, the OAA addresses the needs of older Americans
of all income levels.

Title III-B is a key component of the OAA. Title III-B funds helped to
develop the infrastructure of State Units on Aging (SUAs), area agencies
on aging (AAAs), and local community providers, collectively known as
the "aging network." The aging network works in local communities to
support older persons throughout the United States. The Title III-B
program helps the aging network to serve as the entry point into the
long-term care system, providing critical information, case management
services, and direct funding of long-term care services for individuals
who otherwise might go without needed assistance. The Administration on
Aging's (AoA's) current *Choices for Independence* initiative, a
demonstration project to promote home and community-based long-term care
options, builds directly on the mission and success of the Title III-B
program.

This study assesses Title III-B and its role in planning, coordinating,
and providing community services for older people. **Exhibit 6-1**
briefly summarizes the broad highlights of the analyses.

[]{#__RefHeading___Toc170629917 .anchor}Exhibit 6-1\
Highlights of the Analyses of Title III-B

+-----------------------------------------------------------------------+
| -   In contrast with other Older Americans Act services, information  |
|     and assistance serve both older persons and their family members. |
|                                                                       |
| -   Case management and supportive services, including home care and  |
|     transportation services, are targeted to people at risk of        |
|     institutionalization---persons aged 75 and older, people with     |
|     substantial disabilities, and those living alone.                 |
|                                                                       |
| -   For virtually all services, Title III-B provides a minority of    |
|     funding to AAAs, who successfully obtain funds from other         |
|     sources. For example, Title III-B funds about 15% of AAA spending |
|     for personal care, 25% of their spending for homemaker services,  |
|     and 23% of AAA expenditures for assisted transportation services. |
|                                                                       |
| -   For homemaker and transportation services, the two Title III-B    |
|     services for which measures are available, satisfaction among     |
|     participants is quite high. For example, over 80% of survey       |
|     respondents rated various aspects of homemaker services           |
|     positively.                                                       |
|                                                                       |
| -   The Title III-B program funded approximately 4% of total          |
|     non-Medicare government expenditures for home and community-based |
|     services in 2002.                                                 |
|                                                                       |
| -   While there have been some changes over time in the allocation of |
|     resources, funding of Title III-B services were stable between    |
|     2001 and 2004, while the number of persons served and the number  |
|     of hours of service declined slightly over time.                  |
+-----------------------------------------------------------------------+

## 6.1 Access Services

The financing and organization of long-term care is fragmented, with
funding coming from Medicare, Medicaid, the Older Americans Act, Title
XX of the Social Security Act, the Department of Veterans Affairs,
various state programs, private long-term care insurance, and out of
pocket (Wiener & Tilly, 2003). Because of this complexity, many seniors
do not know what community-based long-term care services are available
and what the eligibility requirements are for services for which they
might be eligible. As a result, it is difficult for older people and
their families to navigate the system and to put together a
comprehensive set of services that will allow them to remain in the
community. Title III-B access services provide a central community
location where older persons and their family members can obtain help
identifying community resources and coordinating necessary supportive
services.

The grants by the AoA and the Centers for Medicare & Medicaid Services
(CMS) for Aging and Disability Resource Centers (ADRC) consciously build
on the expertise and infrastructure developed by Title III-B on
information and assistance and case management. The ADRC initiative
supports state efforts to develop "one-stop shop" programs at the
community level that will help people make informed decisions about
their service use and support options and serve as the entry point to
the long-term care system (U.S. Administration on Aging, 2005). In
addition to providing information and assistance, ADRCs serve as the
entry point to publicly administered long-term care, including those
funded by Medicaid, the Older Americans Act, and state revenue programs.
The premise of the ADRC is that empowering individuals to make informed
choices and to streamline access to comprehensive home and
community-based services will enable people with disabilities to put to
access the services that will enable them to stay in the community.

## 6.2 Support Services

A broad consensus exists across the federal and state governments that
the current long-term care system is institutionally biased. The U.S.
Congressional Budget Office (2004) estimated that 32% of total (public
and private) long-term care spending for older people was for home and
community-based services in 2004. Within Medicaid, home and
community-based services accounted for 27% of long-term care
expenditures for older people in 2002, much less than for people with
developmental disabilities (Urban Institute, unpublished data, 2006).

The Title III-B program is a source of funding for home and
community-based services. For home care and transportation services,
Title III-B directly funds services that help seniors to remain in the
community for as long as possible. The flexibility of Title III-B allows
the AAAs to adapt to the local situation and needs. The Title III-B
program pays for:

-   Planning for a balanced long-term care system, which would provide a
    greater role for home and community-based services.

-   Services for individuals who do not qualify for Medicaid, either
    financially or functionally (e.g., they do not qualify for Medicaid
    home and community-based services waivers because they do not need
    an institutional level of care).

-   Services for individuals who live in states where the home and
    community-based waiver has waiting lists or where Medicaid coverage
    is limited (e.g., there is no personal care benefit).

-   Nonmedical services, such as homemaker and transportation services,
    that may not be covered by Medicaid or other programs.

-   Coverage for individuals who are waiting for their Medicaid or other
    applications to be processed or waiting to transition to other
    settings.

A challenge for the AAAs will be how to incorporate consumer-directed
care into their home care services. A growing number of American states,
including California, Michigan, Oregon, Washington, and Wisconsin, are
integrating consumer direction into their home care programs (Tilly and
Wiener, 2001; Wiener, Tilly, and Alecxih, 2002). The National
Association of State Units on Aging reported that 40 states and
territories operated a total of 62 consumer-directed programs that
served older people in 2004 (Infield, 2005). Consumer-directed care is
also a key component of the Administration on Aging's *Choice's for
Independence* strategy (Administration on Aging, 2007). CMS is promoting
consumer-directed services through the Real Choice Systems Change Grants
and the Independence Plus Initiative (O'Keeffe, Wiener, and Greene,
2005). In addition, the Office of the Assistant Secretary for Planning
and Evaluation, CMS, and The Robert Wood Johnson Foundation are
sponsoring "cash and counseling" demonstrations in Arkansas, Florida,
New Jersey, and other states (Dale et al., 2003).

## 6.3 Financing and Management

The Older Americans Act provides Title III-B funds to the states and
AAAs, which are supplemented at the AAA level by money from state
programs, Medicaid, and the private sector. States and AAAs have
substantial flexibility in how they spend and manage their Title III-B
dollars.

This arrangement has both strengths and challenges for financing and
management. On the one hand, Title III-B forms a consistent and stable
base of funding for AAAs and the long-term care system. Over the period
for this study, 2001--2004, funding for Title III-B services was level,
unadjusted for inflation. AAAs have used Title III-B as a platform,
using the expertise and experience they have with Title III-B services
to obtain additional funding, which accounts for most of their funding.
The flexibility in management allows the AAAs to tailor their resource
allocation and management choices to the local situation, preferences,
and values rather than requiring a "one size fits all," uniform national
approach.

On the other hand, Title III-B accounted for approximately 4% of
government spending for home and community-based services in 2002; if
Medicare were included, the percentage would be lower. Non-Title III-B
funding for AAA services was also level during 2001 to 2004, with the
exception of funds for case management which increased substantially in
percentage terms. In contrast, Medicaid spending for home and
community-based services for persons of all ages increased by 37%
between 2001 and 2004, further increasing its dominance of long-term
care funding (Burwell, Eiken, and Sredl, 2006). From the management
perspective, the lack of national guidance and administrative tools may
leave individual AAAs "reinventing the wheel" in some instances.

## 6.4 Looking Forward

Title III-B provides older Americans with a range of needed services and
helps them navigate a complex and confusing long-term care system.
Looking forward, the Administration on Aging, the State Units on Aging,
and the AAAs face two broad challenges. The first challenge is how to
reinvent the long-term care system so that it is more consumer directed.
The key issue is how to empower people with disabilities and their
families. The second challenge is how to make the most strategic use of
Title III-B funding so that it will have the largest impact. One option
would be to continue to focus on filling the direct service gaps left by
other service programs. Another option would be to concentrate on
infrastructure development, with a focus on becoming the single point of
entry to the long-term care system.

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[^1]: Choices for Independence aims to strengthen the nation's capacity
    to promote the dignity and independence of older people and meet the
    challenges associated with the aging of the baby boom generation.
    Choices integrates best practices from recent Department of Health
    and Human Service initiatives, including the ADRC initiative, the
    Cash & Counseling Demonstration, Evidence-Based Disease Prevention
    for the Elderly Program, etc., into a three-pronged strategy to: (1)
    empower individuals to make informed decisions about their long-term
    support options, (2) provide more choices for individuals at high
    risk of nursing home placement; and (3) enable older people to make
    behavioral changes that will reduce their risk of disease,
    disability, and injury. For more information on the Choices
    initiative, see
    <http://www.aoa.gov/about/legbudg/oaa/Choices_for_Independence_White_Paper_3_9_2006.doc>.

[^2]: We recognize that in a few states, there is only one Planning and
    Service Area obtaining OAA funds to support older adults in the
    community. In these cases, the conceptual model would be adjusted to
    reflect the fact that the SUAs do not distribute funds to a series
    of AAAs.

[^3]: AAA survey data were imputed when the rate of missing data was
    less than 54%. Depending on the item to be imputed, we used one of
    the following methods: cold-deck imputation, hot-deck imputation, or
    regression imputation. While imputation accounted for item-level
    nonresponse, sampling weights were constructed and used in all
    analyses to compensate for unit-level nonresponse.

[^4]: Non-Title III-B expenditures included all funds that flowed
    through the AAAs from sources other than Title III.

[^5]: The Medicaid data came from Urban Institute's analysis of
    state-reported service expenditures for elderly Medicaid
    beneficiaries. For more information on this analysis, see RTI's
    Interim Quantitative Report
    (<http://www.aoa.gov/about/results/TitleIIIB_quantitative-report_6-1-06_psgFINAL.pdf>).

[^6]: As noted previously, non-Title III-B expenditures were defined by
    the AAAs and entered into the NAPIS SPR system. These funds included
    any dollars that passed through the AAA and were not associated with
    Title III-B.

[^7]: Although the proportion of the population over age 60 is taken
    into account in the intrastate funding formula, the age distribution
    often used is based on the last published decennial census. Because
    of the time lag in reporting and accounting for changes in
    population growth occurring between census measurement points, some
    states with substantial increases in their older population between
    U.S. censuses do not "get credit" for this growth until the next
    census. AoA staff noted that states that serve populations living in
    areas that do not coincide with the geographic units for which
    annual census estimates are issued are particularly likely to use
    outdated census data since these states are unable to benefit from
    the annual updates provided by the Census.

[^8]: AoA clarified that Medicaid rules strictly prohibit Medicaid
    providers from billing any other party for services reimbursed by
    Medicaid, thereby precluding the use of Title III-B funding to
    supplement Medicaid reimbursement for particular services.