Evaluation of the Select Consumer, 

Program, and System 

Characteristics under the 

Supportive Service Program 

(Title III-B) of the Older Americans 

Act 

Interim Quantitative Report 

June 2006 

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. 

Galina Khatutsky, M.S. 

Joshua M. Wiener, Ph.D. 

Deborah S. Osber, M.P.H. 

David W. Brown, M.A. 

Beth Koetse, B.A. 

RTI International 

Health, Social, and Economics Research 

Research Triangle Park, NC 27709 
RTI Project Number 0208490.016 
 RTI Project Number 

 0208490.016 

Evaluation of the Select Consumer, 

Program, and System 

Characteristics under the 

Supportive Service Program (Title 

III-B) of the Older Americans Act 

Interim Quantitative Report

June 2006

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. 

Galina Khatutsky, M.S. 

Joshua M. Wiener, Ph.D. 

Deborah S. Osber, M.P.H. 

David W. Brown, M.A. 

Beth Koetse, B.A. 

RTI International* 

Health, Social, and Economics Research 

Research Triangle Park, NC 27709 

 

*RTI International is a trade name of Research Triangle Institute. 
iv 

CONTENTS 

Section Page

Executive Summary.............................................................................................................ES-1 

E.1 Introduction........................................................................................................ES-1 

E.2 Issue Areas and Relevant Data Sources.............................................................ES-3 

E.3 Conceptual Framework......................................................................................ES-5 

E.4 Quantitative Methods.........................................................................................ES-6 

E.5 Description of Quantitative Findings To Date...................................................ES-8 

E.5.1 Access ....................................................................................................ES-8 

E.5.2 Title III-B Services ..............................................................................ES-10 

E.5.3 Funding Sources...................................................................................ES-13 

E.6 Summary of Quantitative Findings To Date....................................................ES-14 

E.7 Next Steps/Areas Where Qualitative Data Are Needed ..................................ES-14 

1 Introduction................................................................................................................... 1-1 

1.1 Issue Areas and Relevant Data Sources............................................................... 1-3 

1.2 Conceptual Framework........................................................................................ 1-3 

1.3 Quantitative Methods........................................................................................... 1-7 

1.4 Presentation of Data in this Report ...................................................................... 1-9 

2 Role of Aging Network in Assessment and Care Planning and Importance of 

Assessment and Care Planning for Aging Network ..................................................... 2-1 

2.1 Characteristics of Network Participants............................................................... 2-1 

2.1.1 Information and Assistance Services....................................................... 2-1 

2.1.2 Case Management Services ..................................................................... 2-2 

2.2 Characteristics of Access Services....................................................................... 2-2 

2.2.1 Information and Assistance Services....................................................... 2-2 
v 

2.2.2 Case Management Services ..................................................................... 2-5 

2.3 Role/Importance of Access Services Delivered through Aging Network 

versus Elsewhere.................................................................................................. 2-5 

2.3.1 Information and Assistance Services....................................................... 2-5 

2.3.2 Case Management.................................................................................... 2-6 

3 Role of Aging Network in Managing Home Care and Transportation and 

Importance of Home Care and Transportation for Aging Network.............................. 3-1 

3.1 Characteristics of Network Participants............................................................... 3-1 

3.1.1 Home Care Services................................................................................. 3-2 

3.1.2 Transportation Services ........................................................................... 3-5 

3.2 Characteristics of Home Care and Transportation Services ................................ 3-7 

3.2.1 Home Care Services................................................................................. 3-7 

3.2.2 Transportation Services ........................................................................... 3-7 

3.3 Role/Importance of Home Care and Transportation Services Delivered 

through Aging Network versus Elsewhere .......................................................... 3-9 

3.3.1 Home Care Services................................................................................. 3-9 

3.3.2 Transportation Services ......................................................................... 3-11 

3.4 Satisfaction with Homemaker Services ............................................................. 3-12 

3.4.1 Results from Descriptive Analysis of Satisfaction with 

Homemaker Services ............................................................................. 3-12 

3.4.2 Approach to Multivariate Analysis of Homemaker Satisfaction........... 3-13 

3.4.3 Results from Multivariate Analysis of Homemaker Satisfaction .......... 3-15 

3.5 Satisfaction with Transportation Services ......................................................... 3-18 

4 Role of Aging Network in Financing Long-Term Care Services for Older 

Persons and Importance of Financing and Delivering Long-Term Care Services 

to the Aging Network.................................................................................................... 4-1 

4.1 Relative Scope/Importance of OAA Title III-B Services.................................... 4-1 

5 Summary of Interim Quantitative Findings and Next Steps......................................... 5-1 

5.1 Interim Findings To Date..................................................................................... 5-1 

5.2 Next steps/Where Qualitative Data Are Needed ................................................. 5-2 
vi 

References..............................................................................................................................R-1 

Appendices 

A NAPIS SPR 2001–2004 Tables Used in Construction of Charts ....................... A-1 

B Results from 2003 and 2004 National Surveys....................................................B-1 

C Topics to be Addressed by Qualitative Data Topics to be Addressed by 

Qualitative Data ...................................................................................................C-1 

D Potential Qualititative Discussion Topics from Technical Advisory Group ...... D-1 

E Technical Advisory Group Members who Participated in the April 27th, 

2006 Title III-B Meeting in Washington, DC......................................................E-1 
vii 

LIST OF FIGURES 

Number Page

E-1 Conceptual Framework for Evaluating Older Americans Act Title III-B Services....ES-5 

1-1 Conceptual Framework for Evaluating Older Americans Act Title III-B Services...... 1-6 

2-1 Percentage of Case Management Clients by Age Group.............................................. 2-3 

2-2 Percentage of Case Management Clients Needing Assistance with ADLs (Age 

60+)............................................................................................................................... 2-4 

2-3 Percentage of Case Management Clients Needing Assistance with IADLs (Age 

60+)............................................................................................................................... 2-4 

2-4 Title III-B Expenditures, Other Expenditures, and Total Expenditures for 

Information and Assistance Services............................................................................ 2-6 

2-5 Title III-B Expenditures, Other Expenditures, and Total Expenditures for Case 

Management Services ................................................................................................... 2-7 

3-1 Percentage of Home Care Clients by Age Group ......................................................... 3-2 

3-2 Percentage of Home Care Clients Needing Assistance with ADLs (Age 60+)............ 3-3 

3-3 Percentage of Home Care Clients Needing Assistance with IADLs (Age 60+)........... 3-4 

3-4 Percentage of Assisted Transportation Clients by Age Group ..................................... 3-6 

3-5 Title III-B Expenditures, Other Expenditures, and Total Expenditures for Home 

Care Services .............................................................................................................. 3-10

3-6 Title III-B Expenditures, Other Expenditures, and Total Expenditures for 

Transportation Services .............................................................................................. 3-11 

3-7 Rating of Homemaker Services in 2003 and 2004 ..................................................... 3-13 

4-1 Total Title III-B Expenditures by Service Type and Year............................................ 4-2 

4-2 Total Non-Title III-B Expenditures by Service Type and Year ................................... 4-3 

4-3 Total Expenditures (Title III-B and Non-Title III-B) by Service Type and Year ........ 4-4 
viii 

LIST OF TABLES 

Number Page

E-1 Key Study Questions, Issue Areas, and Data Sources................................................ES-3 

E-2 Key Study Questions, Issue Areas, and Qualitative Data Sources ...........................ES-15 

1-1 Key Study Questions, Issue Areas, and Data Sources.................................................. 1-4 

2-1 Living Alone Status and Gender of Case Management Clients ................................... 2-3 

2-2 Units of Case Management Service, Unduplicated Count of Persons, and Units 

of Service per Person .................................................................................................... 2-5 

3-1 Living Alone Status and Gender of Home Care Clients............................................... 3-3 

3-2 Living Alone Status and Gender of Assisted Transportation Clients........................... 3-6 

3-3 Units of Home Care Service, Unduplicated Count of Persons, and Units of 

Service per Person......................................................................................................... 3-8 

3-4 Units of Transportation and Assisted Transportation Service, Unduplicated 

Count of Persons, and Units of Service per Person ...................................................... 3-9 

3-5 Comparison of the “Least satisfied” Sample with the Overall Sample Receiving 

Homemaker Services .................................................................................................. 3-16 

4-1 Percentage of Total Expenditures from Title III by Service by Year........................... 4-5 

4-2 Comparison of Supportive Service Funding by Source................................................ 4-7 

5-1 Study Questions/Issues and Qualitative Data Source(s)............................................... 5-2 
ES-1 

EXECUTIVE SUMMARY 

E.1 Introduction 

The Older Americans Act (OAA) is an important federal program to support older 

Americans. The OAA was established in 1965 to help provide older Americans with the 

resources they need to remain independent and vital to communities across the nation. OAA 

provides funding to help older persons through the coordination and delivery of a wide 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, the programs sponsored by the OAA become increasingly critical. 

While Medicaid provides insurance coverage for long-term care services,1 it only covers those in 

the lowest income groups. Yet, many Americans are living longer today with more chronic 

impairments and with incomes above the level qualifying them for Medicaid. The OAA is the 

linchpin in the community, providing older Americans of all income levels with supportive 

services and coordinating and channeling additional services funded by other federal, state, and 

local sources. 

Title III-B is one of the largest components of the Older Americans Act. It directs state 

and area agencies to concentrate resources on fostering comprehensive and coordinated systems 

for providing supportive services and multipurpose senior centers. Title III-B funds, which 

helped to develop the infrastructure of State Units on Aging (SUA) and area agencies on aging 

(AAAs), collectively known as the “aging network,” have enabled Area Agencies on Aging 

(AAAs) to develop systems and programs to support local communities throughout the United 

States. In addition, Title III-B funds provide SUAs and AAAs with the flexibility needed to 

deliver a wide range of home and community-based services for individuals age 60 and over. 

This study focuses on SUA and AAA involvement with key services: case management, 

information and assistance, personal care, chore services, homemaker services, transportation, 

and assisted transportation services using a combination of quantitative and qualitative methods. 

The study addresses several policy issues related to Title III-B, and is designed to be of use to the 

Administration on Aging, the Aging Network, and the aging policy community at large. 

 

1

 Long-term care services provided by the Medicaid program for categorically eligible individuals include home 

health (including personal care) services, targeted case management, and other specific home and communitybased waivered services (which vary by state).
ES-2 

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 question is being 

addressed through three sub-questions: 

1. 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? 

2. 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? 

3. 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? 

This quantitative report summarizes the analyses conducted to date for the project. In 

addition to analyzing a number of quantitative data sets for AoA (most of which are reviewed 

here), Research Triangle Institute (RTI) also plans to collect and analyze qualitative data through 

a series of telephone-based interviews with national experts as well as a number of focus groups 

with AAA Directors, SUA directors, and Title III-B service providers. Administration on Aging 

(AoA) surveys have provided much of the data to address the study questions outlined above. 

The data sources used in this report include the 2003 National Survey of Older American Act 

participants (2003 national data), the 2004 National Survey of Older American Act Participants 

(2004 national data), and the 2001 through 2004 National Aging Program Information System 

State Program Performance Report (NAPIS SPR) data. RTI also relied on information from 

AARP and the Urban Institute to help determine the relative importance of OAA Title III 

services within the universe of home and community-based services.2

 In addition, AoA and RTI 

convened a Technical Advisory Group (TAG) meeting on April 27, 2006 in Washington, DC. 

This meeting, which was designed to allow TAG members to comment on, clarify, and interpret 

quantitative study findings, was instrumental in helping AoA and RTI to determine where 

additional qualitative research will be needed. Some of the findings/interpretations reported by 

TAG members during this meeting have been incorporated into this quantitative report. 

 

2

 RTI also plans to analyze the AAA Service Integration Survey, which is currently being fielded, at a later point in 

this project.
ES-3 

This report is an interim deliverable that was developed to help RTI and AoA to 

determine the nature and content of focus groups and expert interviews to be conducted in the 

summer/fall of 2006. A final set of quantitative data, including results from the AAA Service 

Integration Survey, will be forthcoming as part of RTI’s Final Report to the Administration on 

Aging in 2007.

E.2 Issue Areas and Relevant Data Sources 

A number of issue areas have been identified to address each research question. Table 

E-1 provides an overview of the key study questions and a summary of the types of data 

analyzed to address particular study issues. 

Table E-1. Key Study Questions, Issue Areas, and Data Sources 

Study Questions/Issues to Be Addressed with 

Quantitative Data Quantitative Data Sources 

Overarching Study Question: How, to what extent, and with 

what results has the aging network implemented Title III-B of 

the Older Americans Act? 

 2001–2004 NAPIS SPR data 

 AAA Service Integration Surveya

 2003 national data 

 2004 national data 

Sub-Question 1: 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? 

 2001–2004 NAPIS SPR data 

 AAA Service Integration Surveya

 2003 national data 

 2004 national data 

 Characteristics of network participants and access service 

activities (such as usage rates and client characteristics) 

 2001–2004 NAPIS SPR data 

 AAA Service Integration Surveya

(case management and I&A 

sections) 

 2003 national data (I&A) 

 2004 national data (I&A) 

 Role/importance of access service activities delivered 

through the aging network (I&A and case management) 

relative to access services activities delivered outside of 

the aging network (e.g., Medicaid or private pay) 

 2001–2004 NAPIS SPR (III 

expenditures versus total service 

expenditures) 

 AAA Service Integration Surveya

 

 Barriers to providing network access services  AAA Service Integration Surveya

 Ongoing project management activities (including strategic 

planning, outcome measurement, consumer assessment, 

and program monitoring) by AAAs and SUAs for access 

(I&A and case management) service activities 

 AAA Service Integration Surveya

(continued) 
ES-4 

Table E-1. Key Study Questions, Issue Areas, and Data Sources (continued) 

Study Questions/Issues to Be Addressed with 

Quantitative Data Quantitative Data Sources 

Sub-Question 2: 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? 

 2001–2004 NAPIS SPR data 

 AAA Service Integration Surveya

 2003 national data 

 2004 national data 

 Characteristics of network participants and home care and 

transportation services (such as usage rates and client 

demographic and functional status characteristics) 

 2001–2004 NAPIS SPR data 

 AAA Service Integration Surveya

2003 National Survey data (limited 

home care data, more extensive 

transportation data) 

 2004 national data (limited home 

care data, more extensive 

transportation data ) 

 Characteristics of providers of home care and 

transportation services 

 AAA Service Integration Survey* 

 Role/importance of home care and transportation service 

activities delivered through the aging network relative to 

home care and transportation services activities delivered 

outside of the aging network (e.g., Medicaid or private 

pay) 

 2001–2004 NAPIS SPR (III 

expenditures versus total service 

expenditures) 

 AAA Service Integration Surveya

 Barriers to providing network home care and 

transportation services 

 AAA Service Integration Surveya

(limited data) 

 Ongoing project management activities (including strategic 

planning, outcome measurement, consumer assessment, 

and program monitoring) by AAAs and SUAs for 

provision of home care and transportation services 

 AAA Service Integration Surveya

 Satisfaction with network home care and transportation 

services 

 2003 National Data (home care and 

transportation modules) 

 2004 National Data (home care and 

transportation modules) 

Sub-Question 3: 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? 

 2001–2004 NAPIS SPR data 

 AAA Service Integration Surveya

 2003 national data 

 2004 national data 

 Statistical tables from other 

national surveys 

 Relative scope/importance of OAA Title III-B services 

within the universe of long-term care and other 

community-based services within the universe of services 

 2001–2004 NAPIS SPR data 

 AAA Service Integration Surveya

 Statistical data provided from other 

national data sets 

(continued) 
ES-5 

Table E-1. Key Study Questions, Issue Areas, and Data Sources (continued) 

Study Questions/Issues to Be Addressed with 

Quantitative Data Quantitative Data Sources 

 Methods used by AAAs and SUAs to acquire, leverage, 

and manage multiple funding streams by the aging network 

 AAA Service Integration Surveya

 Barriers to the integration and management of multiple 

funding streams by the aging network 

 AAA Service Integration Surveya

(limited data) 

a

AAA Service Integration Survey data were still being collected at the time that this report was issued. 

E.3 Conceptual Framework3

The following conceptual framework was developed to guide this study and help the 

study team identify the independent and dependent variables to be used in the analysis of 

quantitative data. The overarching study question and three sub-questions directly relate to the 

conceptual model shown in Figure E-1.

Figure E-1. Conceptual Framework for Evaluating Older Americans Act Title III-B Services 

 

3

While we have attempted to link our key research questions to elements from the conceptual framework in this 

quantitative report, we plan to more fully explicate the components of the conceptual framework once we have 

(a) obtained and analyzed AAA Service Integration Survey data (still being fielded) and (b) completed the 

qualitative component to the study.
ES-6 

Consumer Needs. Consumers are the focus of AoA programs. The need for services 

among older people is a function of many factors, including health status, disability status, race 

and ethnicity, whether the consumer lives in a rural or urban area, their income and assets, and 

the availability of their informal support network. OAA places a strong emphasis on meeting the 

supportive service needs of minority groups and elders in rural areas. 

Access. One of the main functions of AAA is to provide a point of entry into the service 

system. It performs this function through information and assistance services, assessment, 

eligibility determination for publicly funded services, and care planning/case management. 

Increasingly, AAA are providing integrated access to a wide range of funding sources (including 

Medicaid, county levy funds, and other state programs) and are using integrated data systems to 

help manage clients, funding, and services. 

Funding Sources. The availability of financing is a major determinant of the use of 

services. AAA receive OAA Title III-B services funding, but many agencies also receive money 

from a broad range of other sources. These other sources include Medicaid, AoA/Centers for 

Medicare and Medicaid Services (CMS) for Aging and Disability Resource Centers (ADRCs) 

state taxes, county and local funds, and support from foundations. Increasingly, AAA are using 

OAA funds to leverage other funding sources. 

III-B Services. Title III-B of the OAA gives AAA broad flexibility in the provision of 

services. Among the services provided and reviewed in this evaluation are transportation, 

personal care, homemaker services, chore services, and assisted transportation. By providing this 

broad array of services, the AAA have the opportunity to tailor services to the needs of 

individuals and make them accessible. 

Consumer Outcomes. OAA services have a number of goals; the overriding one is to 

maintain the independence of older people in the community. Increasing satisfaction with 

services, reducing unmet needs, and increasing the efficient provision of services are other 

favorable outcomes considered in this evaluation. Increasingly, the AoA is measuring consumer 

outcomes in order to improve performance and to ensure that the goals of the Act are being met. 

Measuring these outcomes is a way of assessing “value for money” and providing feedback on 

program performance to both federal officials and state and local administrators. 

E.4 Quantitative Methods 

For this component of the overall study, RTI analyzed the data sets identified in Table 

E-1 to determine the characteristics of respondents and the various Title III-B services. In this 
ES-7 

report, we summarize NAPIS SPR data at the national level based on input provided from each 

state. We also summarize 2003 and 2004 national data based on input provided from randomly 

selected respondents using three Title III-B services: information and assistance, homemaker 

services, and transportation services. For the sake of brevity, we present most of the tabulated 

results in Appendices A and B. 

Analyses of 2003 and 2004 national data 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). However, no weights or survey design corrections were needed for 

analyses of NAPIS SPR since a census of all states/AAAs was taken. 

RTI also extended its analyses of the 2004 national data in order to more fully address 

elements of sub-study questions 1 and 2. For this one data source, we used multivariate modeling 

techniques to examine satisfaction with services, the likelihood of using Title III-B services, and 

key predictors of service use. We focused on the 2004 rather than 2003 national data because the 

2004 data were more complete, were of higher quality, and included a larger sample size. For 

this one year, we modeled satisfaction with and the likelihood of using three Title III-B 

services—information and assistance, homemaker services, and transportation—after taking into 

account key background characteristics of study respondents. These analyses were designed to 

provide AoA with additional insight into the types of individuals who appeared to be more or 

less likely to benefit from and be satisfied with different Title III-B services. 

Independent variables for all models included demographic characteristics such as age, 

gender, urban and rural residency, education, and minority status. Health and functional status 

variables included activities of daily living (ADL) and instrumental activities of daily living 

(IADL) impairment. In addition, we included indicator variables for living alone and being 

unmarried. Above all, we were interested in predictors that signaled vulnerability for older 

persons: being age 75 or older, being a minority, residing in a rural area, living alone, and having 

substantial ADL impairment. 

For each outcome variable, we estimated a full and a final model. To further identify 

predictors of satisfaction (or lack of satisfaction) with homemaker services, we examined 

differences in characteristics for the subset of homemaker survey respondents whose satisfaction 

was in the lowest quartile (bottom 25 percent) relative to the full sample responding to this 

particular survey module. By conducting this supplementary analysis, we were able to determine 

key characteristics of those least satisfied with homemaker services relative to the general 

population served. 
ES-8 

In order to fully address study sub-question 3, we supplemented our own analyses of 

AoA data by incorporating expenditure data to determine the relative role/contribution of Title 

III-B services in financing/providing long-term care services to older persons in the United 

States. To calculate the denominator for this analysis, we summed the following three types of 

supportive service expenditures: (a) total Title III-B funding (as reported through NAPIS SPR), 

(b) non-Medicaid state funding from AARP (Summer and Ihara, 2004), and (c) state Medicaid 

funding data that was analyzed and provided directly to RTI from the Urban Institute. The 

numerator for this analysis included NAPIS SPR-reported Title III-B funding only. The data 

needed to conduct this additional analysis was available for 2002 only. 

Since some study issues could not be fully addressed with the available quantitative data, 

in the final section of this report we delineate the types of questions that will need to be 

addressed using qualitative data sources, including expert interviews and focus groups with SUA 

and AAA directors. 

E.5 Description of Quantitative Findings To Date 

Based on RTI’s analysis of 2001–2004 NAPIS SPR data and 2003 and 2004 national 

data, it is clear that the Title III-B program serves as a critical resource to the states and their frail 

and older populations. In this section of our quantitative report, we summarize what we have 

learned to date from the quantitative data. We also have incorporated some 

insights/interpretation of study findings from TAG members into this revised document. More 

detailed information on each of these topics is shown in Appendices A and B.

4

 

E.5.1 Access 

Information and assistance and case management are the two Title III-B access services 

considered in this report. 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, to the extent possible, ensure that the 

individuals served receive needed services and are knowledgeable about the resources that are 

available to them in the community. Similarly, case management services provide access or care 

coordination in circumstances where the older persons and/or their caregivers are experiencing 

diminished functional capacities, personal conditions, or other characteristics that require the 

provision of services by formal service providers. These two access services help older adults 

 

4

 As noted previously, additional quantitative and qualitative data will be submitted as part of RTI’s Final Report at 

the end of the study once RTI has conducted focus groups/expert interviews and analyzed results from the AAA 

Service Integration Survey, which is currently still in the field.
ES-9 

and their families make contact with and navigate the aging network and the broader long-term 

care system (AoA Web site, accessed March 8, 2006). 

Title III-B is an important source of funding for the delivery of I&A services, supporting 

over 40 percent of all total expenditures reported through the NAPIS SPR system for this service. 

Stated differently, for every $2 provided by the Title III-B program to support I&A services, an 

additional $3 was leveraged from non-Title III-B funding sources. While contributing a smaller 

share, Title III-B is also an important source of funding to support the delivery of case 

management services, covering approximately 20 percent of total expenditures reported through 

NAPIS SPR to provide this service. In other words, for every $1 provided by Title III-B to 

support case management services, an additional $4 was leveraged from non-Title III-B sources. 

Highlights of RTI’s analysis of participant, program, and system characteristics of these two 

access services are provided below.

E.5.1.1 Information and Assistance 

Results from the analysis of 2001–2004 NAPIS SPR data and 2003 and 2004 national 

data on I&A services indicate that 

 I&A service supports both seniors and their caregivers: While the majority of 

persons receiving I&A services are over age 60, a considerable proportion (20 to 

30 percent) are under age 60. 

 Most individuals who use I&A service call for themselves and tend to be older, to 

be male, to live alone, and to have less formal education. Those contacting I&A 

for relatives tend to be younger, to be married, and to live with others. 

 Many are repeat users: A considerable proportion of users (about 25 percent) have 

used I&A service in the past. 

 As a service, I&A is somewhat less familiar to minorities: Based on analysis of 

NAPIS SPR national data, a smaller proportion of minority persons have used 

I&A services relative to other Title III-B services (including homemaker and 

transportation services). Qualitative data from interviews with national experts 

and focus groups with AAA directors will provide additional information to help 

AoA and RTI understand why this finding has occurred. 

 I&A service is efficient: Over 80 percent of calls are answered in fewer than five 

rings, the vast majority of I&A calls (80 percent) are answered directly by a 

person, and over 85 percent of callers receive information they were looking for. 

 I&A service is highly valued: Over 78 percent of respondents have rated the 

service as excellent or very good and over 93 percent would recommend the 

service to a friend. 
ES-10 

E.5.1.2 Case Management 

Results from the analysis of 2001–2004 NAPIS SPR data and 2003 and 2004 national 

data on case management indicate that 

 Title III-B case management serves the targeted population: the oldest old (those 

aged 75 and over), frail individuals, women, and those living alone. 

 Frailty of the population served increases 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 per person per year, 

consistent with Title III-B case management’s role as a brokerage service linking 

individuals to other supportive services rather than providing a direct service that 

is needed every week. 

E.5.2 Title III-B Services 

Home care and transportation services are two direct services that can make an important 

difference to the quality of life of frail and older persons living at home. Title III-B home care 

services—which for this study included personal care, chore, and homemaker services—provide 

in-home assistance to individuals with functional limitations to help them manage basic and 

instrumental activities of daily living. 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 (either assisted or 

unassisted), thereby helping them to remain active and independent in the community for as long 

as possible. 

From 2001 through 2004, the Title III-B program was a significant source of funds to 

states to support the delivery of home care services, covering approximately 12 to 17 percent of 

total expenditures reported through the NAPIS SPR system for personal care, approximately 22 

to 27 percent of total expenditures for homemaker services, and approximately 30 to 39 percent 

of total expenditures for chore services. In other words, every $1 provided by the Title III-B 

program for home care services generated an additional $2 to $6 of non-Title III-B funds 

(depending on the service) to support this service for older persons. This program has also 

provided substantial support to the states for the delivery of general and assisted transportation 

services, covering approximately 36 to 42 percent of total expenditures through the NAPIS SPR 

system for general transportation services and between 21 and 24 percent of total expenditures 

for assisted transportation services between 2001 and 2004. 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. 
ES-11 

E.5.2.1 Home Care 

Results from the analysis of 2001–2004 NAPIS SPR data and 2003 and 2004 national 

data indicate that 

 Home care serves the targeted population: the oldest old, frail individuals, 

women, and those who live alone. While most home care users have considerable 

functional limitations, impairment levels vary by type of home care service. 

 Frailty of the population served increases over time: The proportion of home care 

participants with three or more ADL limitations increased between 2001 and 

2004, as did the proportion living alone. 

 Home care services declined during the period 2001 to 2004: The total number of 

home care hours received declined slightly as did the total number of persons 

using home care. Information provided from qualitative interviews with national 

experts and focus groups with AAA directors, SUA directors, and providers 

should help us to determine why home care participation and utilization declined 

during this period. 

 Home care usage is low given the frailty of this population: Between 2001 and 

2003, approximately 1.3 hours of personal care and 1 hour of homemaker services 

were used per week, and about 1 hour of chore services are used every third week. 

In 2004, however, the average number of personal care hours per person per week 

increased to 1.5. TAG members felt that these relatively low home care utilization 

statistics were a reflection of the fact that the aging network typically referred 

older participants to other programs/providers of care (including state-provided 

home care, Medicaid home care services, etc) whenever possible (based on 

eligibility for such programs) to allow participants to obtain a fuller range of 

home care services elsewhere. 

 Title III-B provides a considerable source of funding for home care, although the 

relative contribution of Title III-B varies by type of home care: It supports a larger 

proportion of total expenditures for homemaker and chore services relative to 

personal care services. 

 Non-Title III-B expenditures for home care remained fairly stable between 2001 

and 2003, but declined considerably in 2004 (particularly for homemaker 

services). 

 Satisfaction with homemaker service is very high: Over 80 percent of survey 

respondents rated various aspects of homemaking service positively. 

 Some unmet need for home making is present: 36 to 39 percent of respondents 

want more hours of homemaker services and 44 percent wish that the homemaker 

could do more for them. 

 It would be worthwhile to devote additional attention to the needs of the most 

vulnerable service participants: Those who were least satisfied overall tend to be 

minority, to live in a rural/suburban area, and to report high ADL impairment. 

Having a combination of factors that increase personal vulnerability—such as 
ES-12 

both living in a rural area and having a high degree of ADL impairment (three or 

more ADLs), being a minority and having three or more ADLs, or being a 

minority and being of advanced age—further compound the likelihood of being 

less satisfied overall with homemaker services. 

E.5.2.2 Transportation 

Results from the analysis of 2001–2004 NAPIS SPR data and 2003 and 2004 national 

data indicate that 

 Title III-B assisted transportation serves the targeted population: the oldest old, 

women, and those living alone (no information was available on the health status 

of assisted transportation users from NAPIS SPR data). 

 National survey data indicate that over 75 percent of general transportation users 

have at least some ADL and IADL impairment. 

 The proportion of assisted transportation users living alone (many of whom may 

have relied exclusively on Title III-B transportation services) almost doubled 

between 2001 and 2004, increasing from 22.6 percent in 2001 to 42.9 percent in 

2004. 

 Total units of general and assisted transportation services declined slightly during 

the 4-year period, with the total number of persons being served declining 

considerably for assisted transportation. Information elicited by qualitative 

interviews with national experts and focus groups with AAA directors, SUA 

directors, and providers should help us to determine why use of assisted and 

general transportation services declined during this period. 

 Between 2001 and 2003, the average number of one-way assisted transportation 

trips remained fairly constant (about one trip every 11 days) but in 2004, the 

average number of assisted transportation trips increased slightly (to about one 

trip every 9 days). 

 Transportation service facilitates access to health care and social activities: 

Around 65 percent of respondents use it to get to their doctors and other health 

care providers and around 49 percent use it to get to senior centers. 

 Service users rely on transportation a great deal: The average number of general 

transportation trips ranges from 8 to 13 per month (or about one trip every 3 to 4 

days). Over 50 percent of general transportation users had used this Title III-B 

service less than 1 week prior to survey administration, and over 50 percent of all 

general transportation users relied on Title III-B transportation for at least threequarters of their trips. 

 While Title III-B transportation services are generally rated very highly by the 

majority of survey respondents, urban residents and highly impaired individuals 

are significantly more likely to rate this service positively. 

 Transportation services have been particularly helpful in increasing mobility for 

individuals with less formal education.
ES-13 

E.5.3 Funding Sources 

Each year, AoA spends approximately $300 million on supportive services for frail 

individuals and older persons. States provide an additional $750 million to $800 million annually 

to support these services using non-Title III-B dollars. In other words, for every $1 funded 

directly by the Title III-B program, more than $2 was generated by the aging network from other 

sources. During the period of RTI’s analysis, total expenditures (from both Title III-B and other 

sources reported through the NAPIS SPR system) to support Title III-B services exceeded $1 

billion annually (unadjusted for inflation). Results from the analysis of 2001–2004 NAPIS SPR 

data, plus a review of AARP and Urban Institute data on state supportive service expenditures 

for the year 2002, indicate that 

 The Title III-B program provides a significant proportion of total dollars spent on 

supportive services to frail individuals and older persons across the states. The 

proportion of funds provided to support Title III-B relative to non-Title III-B 

increased between 2001 and 2004 for most of the services; in particular, the 

relative contribution of Title III-B funds increased for chore services (from 32 

percent to 39 percent of total expenditures in 2004) and homemaker services 

(from 22 percent to over 27 percent of total expenditures). 

 Non-Title III-B funds are also considerable (especially for other supportive 

services,5

 general transportation, personal care, homemaker, and case 

management). These funds either remained stable during the period or declined 

slightly by 2004, with one notable exception: The relative contribution of nonTitle III-B funds increased for case management services between 2001 and 2004. 

 Total expenditures across all supportive services (unadjusted for inflation) 

remained stable between 2001 and 2004. 

 Between 2001 and 2004, the services using the largest proportion of total 

expenditures, as reported through NAPIS SPR system, included other supportive 

services (including respite, home repair/modification, screening/assessment and 

counseling), general transportation services, and case management services, with 

I&A and personal care services following closely behind. 

 For 2002, the one year for which expenditure data were available on other statefunded programs and Medicaid, Title III-B expenditures represented a 

approximately 4 percent of all funds spent on supportive services for individuals 

age 60 and above. Even so, TAG members reported that the aging network 

contributed substantially to the well-being of older persons in unmeasured ways 

by providing the leadership and infrastructure needed to help older persons to 

navigate the long-term care system and to serve as the entry and coordination 

point for older persons and their families.

 

5

 Other supportive services that use considerable Title III-B resources include respite, home repair/modification, 

screening and assessment, counseling services, home- and community-based services, and visiting/phone 

reassurance (results available upon request).
ES-14 

E.6 Summary of Quantitative Findings To Date 

It is clear from the quantitative data that Title III-B has been and remains an important 

source of supportive care service programming and funding to the states and to frail individuals 

and their families. Based on the limited quantitative data that we have received to date, if we 

were asked to answer the overarching study question, namely—How, to what extent, and with 

what results has the aging network implemented Title III-B of the Older Americans Act, we 

would report the following: 

 The aging network relies considerably on the Title III-B program to support and 

provide a large range of home- and community-based long-term care services to 

frail, older individuals and their families. 

 The aging network has been successful in obtaining non-Title III-B funding to 

support older persons across the states. 

 Generally, funding from the Title III-B program has remained stable or increased 

modestly across the years. 

 The number of people using Title III-B services has remained stable or decreased 

somewhat over time (particularly for home care and transportation services). 

 The frailty/vulnerability of the older population served by the Title III-B program 

has increased (particularly for case management, and home care services), as 

evidenced by increases in the proportion of older persons with 3 or more ADL 

limitations and/or living alone. 

• Older persons served appear to be extremely satisfied with Title III-B services, in 

some cases wanting to receive even more of them (particularly homemaker services). 

 Additional research from this study (including interviews with national experts 

and focus groups with AAA directors, SUA directors, and service providers) 

should help us better understand why general declines in Title III-B service usage 

have been accompanied by overall stability in Title III-B expenditures for most 

supportive services during this 4-year period. 

E.7 Next Steps/Areas Where Qualitative Data Are Needed 

As described above, results from the quantitative analyses provide insight into some of 

the issues of relevance to this study. However, a number of important issues cannot be addressed 

because these data do not include certain topics of relevance to the study and/or because 

additional information is needed to understand why certain quantitative findings have occurred. 

To address the need for more information, RTI will conduct a number of focus groups with AAA 

directors, SUA directors, and Title III-B service providers. We also plan to interview a number 

of experts in the field to obtain a national perspective on the Title III-B program. Based on 

information obtained (or not available) from our quantitative analyses, plus additional input from 
ES-15 

TAG members, we now plan to consider the following topics during expert interviews/focus 

group sessions: 

 the role/importance of Title III-B in providing the aging network with support for 

system and program development 

 how states and local governments decide to allocate/apportion Title III-B funds to 

support particular supportive services 

 perceived barriers to the use of Title III-B services 

 best practices in the use of Title III-B services 

 the role of volunteers in the delivery of Title III-B services 

 methods to acquire/leverage non-Title III-B resources 

 successful program management strategies 

 use of community assessments to determine the need for program services 

 variation in cost/pricing of Title III-B services inside versus outside the aging 

network 

Table E-2 summarizes the areas where qualitative data are needed to answer specific 

study questions/issue areas. An alternative grouping of these topics by key substantive area 

(Access Services, Title III-B Services, and Title III Expenditures) appears in Appendix C. 

Table E-2. Key Study Questions, Issue Areas, and Qualitative Data Sources 

Study Questions/Issues to Be 

Addressed with Qualitative Data Qualitative Data Sources 

Overarching Study Question: How, to what extent, and with what 

results has the aging network implemented Title III-B of the OAA? 

 In-depth interviews with experts 

 Focus groups 

Sub-Question 1: 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? 

 In-depth interviews with experts 

 Focus groups 

 Extent to which AAAs/SUAs conduct needs assessments to 

determine how AAA participants compare to the elderly population 

as a whole, what needs AAA participants have for assessment and 

care management services relative to the elderly population as a 

whole, best practices in the provision of access (I&A and case 

management) services to AAA participants, and extent to which 

results have been achieved 

 In-depth interviews with experts 

 Focus groups 

 Role/importance of access service activities delivered through the 

aging network (I&A and case management) relative to access 

services activities delivered outside of the aging network (e.g., 

Medicaid or private pay) 

 In-depth interviews with experts 

 Focus groups 

(continued) 
ES-16 

Table E-2. Key Study Questions, Issue Areas, and Qualitative Data Sources (continued) 

Study Questions/Issues to Be 

Addressed with Qualitative Data Qualitative Data Sources 

 Role of volunteers in providing I&A and case management 

services 

 In-depth interviews with experts 

 Focus groups 

 Barriers to providing network access services  In-depth interviews 

 Focus groups 

 Ongoing project management activities (including strategic 

planning, outcome measurement, consumer assessment and 

program monitoring) by AAAs and SUAs for access (I&A and 

case management) service activities 

 In-depth interviews 

 Focus groups 

 Satisfaction with network access services (I&A and case 

management) 

 In-depth interviews 

 Focus groups 

Sub-Question 2: 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? 

 In-depth interviews with experts 

 Focus groups 

 Extent to which AAAs/SUAs conduct needs assessments to 

determine what needs elderly participants have for home care and 

transportation services, best practices in the provision of home 

care and transportation services to AAA participants, and extent 

to which results have been achieved 

 In-depth interviews with experts 

 Focus groups 

 Characteristics of providers of home care and transportation 

services 

 In-depth interviews 

 Focus groups 

 Role/importance of home care and transportation service activities 

delivered through the aging network relative to home care and 

transportation services activities delivered outside of the aging 

network (e.g., Medicaid or private pay) 

 In-depth interviews with experts 

 Focus groups 

 Role of volunteers in providing home care and transportation 

services 

 In-depth interviews with experts 

 Focus groups 

 Barriers to providing network home care and transportation 

services 

 In-depth interviews 

 Focus groups 

 Ongoing project management activities (including strategic 

planning, outcome measurement, consumer assessment, and 

program monitoring) by AAAs and SUAs for provision of home 

care and transportation services 

 In-depth interviews 

 Focus groups 

Sub-Question 3: 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? 

 In-depth interviews with experts 

 Focus groups 

 Statistical tables from other national 

surveys 

 Prior AoA research (RTI studies) 

(continued) 
ES-17 

Table E-2. Key Study Questions, Issue Areas, and Qualitative Data Sources (continued) 

Study Questions/Issues to Be 

Addressed with Qualitative Data Qualitative Data Sources 

 Methods used by AAAs and SUAs to acquire, leverage, and 

manage multiple funding streams by the aging network 

 In-depth interviews 

 Focus groups 

 Barriers to the integration and management of multiple 

funding streams by the aging network 

 In-depth interviews 

 Focus groups 

 Financial management best practices and results  In-depth interviews 

 Focus groups 

 Variation in pricing/costs of OAA versus non-OAA home- and 

community-based long-term care services 

 In-depth interviews 

 Focus groups 

 The role/importance of Title III B in providing the aging 

network with support for system and program development 

 In-depth interviews 

 Focus groups 

 How states and local governments decide to 

allocate/apportion Title III-B funds to support particular 

supportive services 

 In-depth interviews 

 Focus groups 
1-1 

SECTION 1 

INTRODUCTION 

The Older Americans Act (OAA) is an important federal program to support older 

Americans. The OAA was established in 1965 to help provide older Americans with the 

resources they need to remain independent and vital to communities across the nation. OAA 

provides funding to help older persons through the coordination and delivery of a wide 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, the programs sponsored by the OAA become increasingly critical. 

While Medicaid provides insurance coverage for long-term care services,6 it only covers those in 

the lowest income groups. Yet, many Americans are living longer today with more chronic 

impairments and with incomes above the level qualifying them for Medicaid. The OAA is the 

linchpin in the community, providing older Americans of all income levels with supportive 

services and coordinating and channeling additional services funded by other federal, state, and 

local sources. 

Title III-B is one of the largest components of the Older Americans Act. It directs state 

and area agencies to concentrate resources on fostering comprehensive and coordinated systems 

for providing supportive services and multipurpose senior centers. Title III-B funds, which 

helped to develop the infrastructure of State Units on Aging (SUA) and area agencies on aging 

(AAAs), collectively known as the “aging network,” have enabled Area Agencies on Aging 

(AAAs) to develop systems and programs to support local communities throughout the United 

States. In addition, Title III-B funds provide SUAs and AAAs with the flexibility needed to 

deliver a wide range of home and community-based services for individuals age 60 and over. 

This study focuses on SUA and AAA involvement with key services: case management, 

information and assistance, personal care, chore services, homemaker services, transportation, 

and assisted transportation services using a combination of quantitative and qualitative methods. 

The study addresses several policy issues related to Title III-B, and is designed to be of use to the 

Administration on Aging, the Aging Network, and the aging policy community at large. 

 

6

 Long-term care services provided by the Medicaid program for categorically eligible individuals include home 

health (including personal care) services, targeted case management, and other specific home and communitybased waivered services (which vary by state).
1-2 

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 question is being 

addressed through three sub-questions: 

1. 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? 

2. 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? 

3. 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? 

This quantitative report summarizes the analyses conducted to date for the project. In 

addition to analyzing a number of quantitative data sets for AoA (most of which are reviewed 

here), Research Triangle Institute (RTI) also plans to collect and analyze qualitative data through 

a series of telephone-based interviews with national experts as well as a number of focus groups 

with AAA Directors, SUA directors, and Title III-B service providers. Administration on Aging 

(AoA) surveys have provided much of the data to address the study questions outlined above. 

The data sources used in this report include the 2003 National Survey of Older American Act 

participants (2003 national data), the 2004 National Survey of Older American Act Participants 

(2004 national data), and the 2001 through 2004 National Aging Program Information System 

State Program Performance Report (NAPIS SPR) data. RTI also relied on information from 

AARP and the Urban Institute to help determine the relative importance of OAA Title III 

services within the universe of home and community-based services.7

 AoA and RTI also 

convened a Technical Advisory Group (TAG) meeting on April 27, 2006 in Washington, DC. 

This meeting, which was designed to allow TAG members to comment on, clarify, and interpret 

quantitative study findings, was instrumental in helping AoA and RTI to determine where 

additional qualitative research will be needed.8

 

This report is an interim deliverable that was developed to help RTI and AoA to 

determine the nature and content of focus groups and expert interviews to be conducted in the 

 

7 RTI also plans to analyze the AAA Service Integration Survey, which is currently being fielded, at a later point in 

this project. 8 Some of the findings/interpretations reported by TAG members during meeting have been incorporated into 

revised version of the quantitative report.
1-3 

summer/fall of 2006. A final set of quantitative data, including results from the AAA Service 

Integration Survey, will be forthcoming as part of RTI’s Final Report to the Administration on 

Aging in 2007. 

The remainder of this chapter provides a summary of key sub-questions used to address 

the main research questions, and our research methods. Sections 2 through 4 provide a summary 

of results addressing the three key research questions. Section 5 summarizes interim quantitative 

findings to date. Finally, since some of the information needed to respond to the study questions 

cannot be addressed with quantitative data, Section 6 provides additional information on topics 

that we hope to address through the use of qualitative data. 

1.1 Issue Areas and Relevant Data Sources 

A number of issue areas have been identified to address each research question. 

Table 1-1 provides an overview of the key study questions and a summary of the types of data 

analyzed to address particular study issues. As noted previously, the main sources of AoA data 

used to address the research questions included the 2003 National Survey, 2004 National Survey, 

and the 2001–2004 NAPIS SPR data. We also relied on information from other sources, such as 

AARP and the Urban Institute, to help us determine the relative importance of OAA Title III 

services within the universe of home and community-based services (sub-question #3). We have 

noted in Table 1-1 those study questions that will best be addressed using the yet-to-be available 

AAA Service Integration Survey. 

1.2 Conceptual Framework9

The following conceptual framework has been developed to guide this study and help the 

study team identify the independent and dependent variables to be used in the analysis of 

quantitative data. The overarching study question and three sub-questions directly relate to the 

conceptual model shown in Figure 1-1. Specifically, sub-question 1 relates to characteristics and 

utilization of Title III-B access services as well as the consumer outcomes resulting from these 

services; sub-question 2 relates to characteristics and utilization of other Title III-B services 

(namely home care and transportation) and the consumer outcomes resulting from use of these 

services, and sub-question 3 relates to the funding of all Title III-B services. The main 

overarching study question to be addressed in this project will incorporate data from both 

 

9

 While we have attempted to link our key research questions to elements from the conceptual framework in this 

quantitative report, we plan to more fully explicate the components of the conceptual framework once we have 

(a) obtained and analyzed AAA Service Integration Survey data (still being fielded) and (b) completed the 

qualitative component to the study.
1-4 

Table 1-1. Key Study Questions, Issue Areas, and Data Sources 

Study Questions/Issues to Be Addressed with 

Quantitative Data Quantitative Data Sources 

Overarching Study Question: How, to what extent, and with what 

results has the aging network implemented Title III-B of the Older 

Americans Act? 

 2001–2004 NAPIS SPR data 

 AAA Service Integration Surveya

 2003 National Survey Data 

 2004 National Survey Data 

Sub-Question 1: 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? 

 2001–2004 NAPIS SPR data 

 AAA Service Integration Surveya

 2003 National Survey Data 

 2004 National Survey Data 

 Characteristics of network participants and access service 

activities (such as usage rates and client characteristics) 

 2001–2004 NAPIS SPR data 

 AAA Service Integration Surveya

(case management and I&A sections) 

 2003 National Survey Data (I&A) 

 2004 National Survey Data (I&A) 

 Role/importance of access service activities delivered through 

the aging network (I&A and case management) relative to access 

services activities delivered outside of the aging network (e.g., 

Medicaid or private pay) 

 2001–2004 NAPIS SPR (III 

expenditures versus total service 

expenditures) 

 AAA Service Integration Surveya

 Barriers to providing network access services  AAA Service Integration Surveya

 Ongoing project management activities (including strategic 

planning, outcome measurement, consumer assessment, and 

program monitoring) by AAAs and SUAs for access (I&A and 

case management) service activities 

 AAA Service Integration Surveya

Sub-Question 2: 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? 

 2001–2004 NAPIS SPR data 

 AAA Service Integration Surveya

 2003 National Survey Data 

 2004 National Survey Data 

 Characteristics of network participants and home care and 

transportation services (such as usage rates and client 

demographic and functional status characteristics) 

 2001–2004 NAPIS SPR data 

 AAA Service Integration Surveya

2003 National Survey Data (limited 

home care data, more extensive 

transportation data) 

 2004 National Survey Data (limited 

home care data, more extensive 

transportation data ) 

 Characteristics of providers of home care and transportation 

services 

 AAA Service Integration Survey* 

(continued) 
1-5 

Table 1-1. Key Study Questions, Issue Areas, and Data Sources (continued) 

Study Questions/Issues to Be Addressed with 

Quantitative Data Quantitative Data Sources 

 Role/importance of home care and transportation service 

activities delivered through the aging network relative to home 

care and transportation services activities delivered outside of 

the aging network (e.g., Medicaid or private pay) 

 2001–2004 NAPIS SPR (III 

expenditures versus total service 

expenditures) 

 AAA Service Integration Surveya

 Barriers to providing network home care and transportation 

services 

 AAA Service Integration Surveya

(limited data) 

 Ongoing project management activities (including strategic 

planning, outcome measurement, consumer assessment, and 

program monitoring) by AAAs and SUAs for provision of home 

care and transportation services 

 AAA Service Integration Surveya

 Satisfaction with network home care and transportation services  2003 National Survey Data (home 

care and transportation modules) 

 2004 National Survey Data (home 

care and transportation modules) 

Sub-Question 3: 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? 

 2001–2004 NAPIS SPR data 

 AAA Service Integration Surveya

 2003 National Survey Data 

 2004 National Survey Data 

 Statistical tables from other national 

surveys 

 Relative scope/importance of OAA Title III-B services within 

the universe of long-term care and other community-based 

services within the universe of services 

 2001–2004 NAPIS SPR data 

 AAA Service Integration Surveya

 Statistical data provided from other 

national data sets 

 Methods used by AAAs and SUAs to acquire, leverage, and 

manage multiple funding streams by the aging network 

 AAA Service Integration Surveya

 Barriers to the integration and management of multiple funding 

streams by the aging network 

 AAA Service Integration Surveya

(limited data) 

a

 AAA Service Integration Survey data were still being collected at the time that this report was issued. 

quantitative and qualitative data (yet to be collected and analyzed) to address the key 

components outlined in this conceptual framework. 

Consumer Needs. Consumers are the focus of AoA programs. The need for services 

among older people is a function of many factors, including health status, disability status, race 

and ethnicity, whether the consumer lives in a rural or urban area, their income and assets, and 

the availability of their informal support network. OAA places a strong emphasis on meeting the 

supportive service needs of minority groups and elders in rural areas. In this evaluation, we pay 

particular attention to consumer needs as a key determinant of subsequent consumer 

outputs/outcomes. 
1-6 

Figure 1-1. Conceptual Framework for Evaluating Older Americans Act Title III-B 

Services 

Access. One of the main functions of AAA is to provide a point of entry into the service 

system. It performs this function through information and assistance services, assessment, 

eligibility determination for publicly funded services, and care planning/case management. 

Increasingly, AAA are providing integrated access to a wide range of funding sources (including 

Medicaid, county levy funds, and other state programs) and are using integrated data systems to 

help manage clients, funding, and services. For this study, we focus on information and 

assistance and case management services. 

Funding Sources. The availability of financing is a major determinant of the use of 

services. AAA receive OAA Title III-B services funding, but many agencies also receive money 

from a broad range of other sources. These other sources include Medicaid, AoA/Centers for 

Medicare and Medicaid Services (CMS) for Aging and Disability Resource Centers (ADRCs) 

state taxes, county and local funds, and support from foundations. Increasingly, AAA are using 

OAA funds to leverage other funding sources. In this document, we include all Title III-B and 

non-Title III-B funding sources reported in the NAPIS SPR system. 

III-B Services. Title III-B of the OAA gives AAA broad flexibility in the provision of 

services. Among the services provided and reviewed in this evaluation are transportation, 
1-7 

personal care, homemaker services, chore services, and assisted transportation. By providing this 

broad array of services, the AAA have the opportunity to tailor services to the needs of 

individuals and make them accessible. 

Consumer Outcomes. OAA services have a number of goals; the overriding one is to 

maintain the independence of older people in the community. Increasing satisfaction with 

services, reducing unmet needs, and increasing the efficient provision of services, are other 

favorable outcomes considered in this evaluation. Increasingly, the AoA is measuring consumer 

outcomes in order to improve performance and to ensure that the goals of the Act are being met. 

Measuring these outcomes is a way of assessing “value for money” and providing feedback on 

program performance to both federal officials and state and local administrators. In this 

evaluation, we focus on patient satisfaction and other consumer-reported measures of program 

effectiveness. 

1.3 Quantitative Methods 

RTI analyzed each data set—NAPIS SPR and National Surveys—to determine the 

characteristics of both respondents and the various Title III-B Services. In this report, we 

summarize NAPIS SPR data at the national level based on input provided from each state. We 

also summarize 2003 and 2004 National Survey data based on input provided from randomly 

selected respondents using three Title III-B services: information and assistance, homemaker 

services, and transportation services. 

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). However, no weights or survey design corrections were needed for 

analyses of NAPIS SPR and since a census of all states/AAAs was taken for this data source. 

RTI also extended its analyses of the 2004 National Survey in order to more fully address 

elements of sub-study questions 1 and 2. For this one data source, we used multivariate modeling 

techniques to examine satisfaction with services, the likelihood of using Title III-B services, and 

key predictors of service use. We focused on the 2004 rather than 2003 national data since the 

2004 data were considered to be of higher quality and included a larger sample size. For this one 

year, we modeled satisfaction with and the likelihood of using three Title III-B services—

information and assistance, homemaker services, and transportation—after taking into account 

key background characteristics of study respondents. These analyses were designed to provide 

AoA with additional insight into the types of individuals who appeared to be more and/or less 

likely to benefit from and be satisfied with different Title III-B services. 
1-8 

Independent variables for all models included demographic characteristics such as age, 

gender, urban vs. rural residency, education, and minority status. Health and functional status 

variables included high ADL and IADL impairment (i.e., three or more ADLs or IADLs). In 

addition, we included indicator variables for living alone and for not being married. Above all, 

we were interested in predictors that signaled vulnerability for older persons: being aged 75 or 

older, being a minority, being from a rural area, living alone, and having substantial ADL 

impairment. 

For each outcome variable, we estimated a full and a final model. The full multivariate 

model consisted of the entire set of independent variables described above. For the final models, 

we tested the significance of each independent variable separately, and if the Wald test p-value 

was less than 0.1, we retained that variable in the final model; if the p-value was 0.1 or larger, 

the variable was excluded from the list of independent predictors. This approach allowed us both 

to improve the overall model fit and to eliminate multicollinearity problems inherent in the full 

model specifications. In describing the findings for the study in Section 3.4.3, we focus on the 

final models only, although we present both full and final models in the tables. 

To further identify predictors of satisfaction (or lack of satisfaction) with homemaker 

services, we examined differences in characteristics for the subset of homemaker survey 

respondents whose satisfaction was in the lowest quartile (bottom 25 percent) relative to the full 

sample responding to this particular survey module. By conducting this supplementary analysis, 

we were able to determine key characteristics of the least satisfied homemaker service sample 

relative to the general population served. We created 95 percent confidence intervals around the 

predicted scores (proportions) for each group to identify statistically significant differences in 

demographic characteristics for the full versus least satisfied sub-sample. Results from this 

analysis are shown in Section 3.4.3. 

In order to fully address study sub-question 3, we supplemented our own analyses of 

AoA data by incorporating expenditure data to determine the relative role/contribution of Title 

III-B services in financing/providing long-term care services to older persons in the United 

States. 

Since some study issues cannot be fully addressed with the available quantitative data, in 

Section 5 we delineate the types of questions that will need to be addressed using qualitative data 

sources, including expert interviews and focus groups with State Unit on Aging and AAA 

directors. 
1-9 

1.4 Presentation of Data in this Report 

In the sections that follow, we summarize large amounts of data from our two main 

secondary data sources. In many cases, the data within a given source have been reported over a 

number of years. Given the challenge of presenting findings from multiple sources over several 

years, we decided to limit the formal presentation of data in the text as follows. First, we focus 

predominantly on analyses of the 2001–2004 NAPIS SPR data in the body of the document 

since these data provide the most complete set of information available on all Title III-B services 

of interest to this study—namely, information and assistance, case management, home care 

services, and transportation services. Second, because we have only two data points for National 

Survey data—2003 and 2004—NAPIS SPR is the only data source that can be used to examine 

trends over time. Finally, the NAPIS SPR data have been collected by all states for almost 10 

years and are known to be of consistent and very high quality for the period under review. While 

the 2003 and 2004 National Survey data and AAA Service Integration Survey data are also 

considered to be of high quality, these surveys have not been fielded as often, and thus, have not 

been tested and evaluated to the same extent as have the NAPIS SPR surveys. While the sections 

that follow do include descriptions of results from the National Surveys when these data provide 

information otherwise unavailable from NAPIS SPR, for ease in readability and understanding of 

key findings the tabular presentation of results from these surveys is generally presented in the 

Appendices.10

 

10 We felt that the lack of consistency in reporting similar information across the various surveys would make 

comparisons across data sets difficult and complicate interpretation of study findings. Therefore, rather than 

place tabular data from different surveys side by side, using inconsistent reporting formats, we have chosen to 

select one main data set in the body of the report and include a limited amount of supporting material on 

alternative data sources—when available—in the body as well. We present alternative tabular data and more 

extensive findings from other surveys in the Appendices. 
2-1 

SECTION 2 

ROLE OF AGING NETWORK IN ASSESSMENT AND CARE PLANNING AND 

IMPORTANCE OF ASSESSMENT AND CARE PLANNING FOR AGING NETWORK 

In this section, we address the following study sub-question: 

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? 

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, to the extent possible, ensure 

that the individuals served receive needed services and are knowledgeable about the resources 

that are available to them in the community (AoA, 2006). Similarly, case management services 

provide access or care coordination in circumstances where the older person and/or his or her 

caregiver are experiencing diminished functional capacities, personal conditions, or other 

characteristics that require the provision of services 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 follow-up and 

reassessment (AoA, 2006). These services help older adults and their families make contact with 

and navigate the aging network and broader long-term care system. 

In this section, we highlight results from analyses of NAPIS SPR and 2003 and 2004 

National Survey data. As noted in the prior section, given space limitations, we present results 

from the 2001–2004 NAPIS SPR data for access services in the body of the text, and highlight 

only key findings from 2003 and 2004 National Survey in the document, reporting 

supplementary data and complete sets of tables in Appendices A and B. 

2.1 Characteristics of Network Participants 

This section reports on the characteristics of network participants using Title III-B I&A 

and case management services. Results are presented separately for each service type. 

2.1.1 Information and Assistance Services 

NAPIS SPR data do not contain information on the characteristics of I&A network 

participants. However, demographic data from the 2003 and 2004 National Surveys of I&A users 
2-2 

(shown in Table B-1 in Appendix B) indicate that, in contrast to participants for other Title III-B 

services (such as home care and transportation), over one-fifth of I&A participants are under age 

60, and a small proportion of I&A participants are of minority descent. The considerable 

proportion of those using I&A services who are under age 60 is likely due to the fact that I&A 

services are available both to older persons and to their family members/caregivers, while other 

OAA services are typically available only to those over the age of 60. Given that national data 

indicate that only 5 percent of the population receiving I&A services is of Hispanic descent, 

between 9 and 14 percent is of African American descent, and 1.5 to 6 percent is Asian/Pacific 

Islander/Native American in 2003 or 2004, RTI and AoA will further examine this issue using 

qualitative methods (i.e., through the collection and analysis of data from focus groups and 

expert interviews) to gain additional insight into access to I&A services for minority populations 

in the United States. 

2.1.2 Case Management Services 

Analyses of 2001–2004 NAPIS SPR data indicate that case management services are 

being targeted to the oldest old, those in frail health, those living alone, and women. Specifically, 

over 65 percent of all case management participants served by the Title III-B program are at least 

75 years of age (see Figure 2-1). Similarly, approximately 50 percent of those receiving Title 

III-B case management services live alone (see Table 2-1). Approximately 70 percent of case 

management participants are female. The proportion of case management participants with three 

or more activity of daily living (ADL) impairments is considerable, increasing from 40 percent in 

2001 to 46 percent in 2004 (see Figure 2-2). A relatively larger proportion of case management 

users needed help with IADL (versus ADL) activities during this period (see Figure 2-3). 

2.2 Characteristics of Access Services 

In this section, we provide information on characteristics of access services, including the 

overall numbers of people using I&A and case management services, and the average level of 

use per person served. Results are presented by service type. 

2.2.1 Information and Assistance Services 

No information is available on characteristics of I&A services from the NAPIS SPR data. 

However, results from 2003 and 2004 National Survey data (shown in Table B-2 in Appendix B) 

indicate that the majority of callers obtain help and/or services for themselves. An additional 40 

percent receive help for relatives/someone else, while roughly 6 to 10 percent call from another 

agency to obtain information on behalf of a participant. The majority of callers want to obtain 

information or services. Approximately one-quarter of all of callers have previously used I&A 
2-3 

Figure 2-1. Percentage of Case Management Clients by Age Group 

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

60–64 Years 65–74 Years 75–84 Years 85+ Years

Age

Percentage of Clients

2001 2002 2003 2004

Table 2-1. Living Alone Status and Gender of Case Management Clients 

2001 2002 2003 2004 

Number served 255,187 252,931 253,296 243,007 

Percentage living alone 47.3 48.6 48.8 50.3 

Percentage male 31.8 31.7 31.1 31.5 

Percentage female 68.2 68.3 68.9 68.5 

Source: RTI analysis of 2001–2004 NAPIS SPR data. Missing data excluded from calculations. 
2-4 

Figure 2-2. Percentage of Case Management Clients Needing Assistance with ADLs (Age 

60+) 

0%

10%

20%

30%

40%

50%

60%

70%

80%

2001 2002 2003 2004

Year

Percentage of Clients

1+ ADLs 2+ ADLs 3+ ADLs

Figure 2-3. Percentage of Case Management Clients Needing Assistance with IADLs (Age 

60+) 

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2001 2002 2003 2004

Year

Percentage of Clients

1+ IADLs 2+ IADLs 3+ IADLs

services. I&A services are reported to be efficient, with over 80 percent of calls being answered 

in fewer than five rings and about 80 percent of calls being answered by a person (rather than a 

message machine). 
2-5 

We also used 2004 National Survey data to determine which demographic and health 

status factors predicted whether participants had contacted I&A service providers for (a) 

themselves or (b) their relatives. Two logistic regression models were estimated. As shown in 

Table B-3 in Appendix B, several variables were significant predictors of the likelihood of 

calling the I&A service for him/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/her behalf. Conversely, those who were younger, were married, or lived with others (e.g., 

spouses or other family members) were more likely to contact I&A service providers for their 

relatives. 

2.2.2 Case Management Services 

The total hours of case management service provided during this period remained 

constant, while the number of persons using this service declined slightly (see Table 2-2). The 

average number of hours of case management services per person remained stable from 2001 to 

2004, ranging from 10 to 11 per person per year. The general volume of case management 

services received per person is in line with AoA expectations since case management services 

are designed primarily to help participants obtain other direct services from the aging network. 

Table 2-2. Units of Case Management Service, Unduplicated Count of Persons, and Units of 

Service per Person 

 2001 2002 2003 2004 

Units of service delivered (hours) 3,751,512 3,866,325 3,735,582 3,799,026 

Unduplicated count of persons 

using service 

433,546 412,099 412,564 402,254 

Units per person (outliers removed) 10 11 10 10 

Source: RTI analysis of the 2001–2004 NAPIS SPR data. 

2.3 Role/Importance of Access Services Delivered through Aging Network versus 

Elsewhere 

Information on Title III-B versus non-Title III-B access services was examined through 

the use of 2001–2004 NAPIS SPR expenditure data. Additional information on the relative 

importance of access services delivered through the aging network versus elsewhere was 

provided from the AAA Service Integration Survey. Results are provided by service type. 

2.3.1 Information and Assistance Services 

Based on NAPIS SPR expenditure data for 2001 to 2004 (as shown in Figure 2-4), it is 

clear that Title III-B represents an important and consistent funding source to support the 
2-6 

delivery of I&A services to older and disabled persons and their families. Specifically, over 40 

percent of the total I&A expenditures reported by the states have been funded by the Title III-B 

program. Stated differently, for every $2 provided by the Title III-B program to support I&A 

services, an additional $3 was leveraged from non-Title III-B funding sources. The proportion of 

funds provided through Title III-B increased slightly between 2001 and 2004. 

Figure 2-4. Title III-B Expenditures, Other Expenditures, and Total Expenditures for 

Information and Assistance Services 

$0

$20,000,000

$40,000,000

$60,000,000

$80,000,000

$100,000,000

$120,000,000

2001 2002 2003 2004

Year

Expenditures

 Title III-B Expenditures Non-Title III Expenditures Total Expenditures

During this same period, an additional $55 million to $60 million in non-Title III-B funds 

were used annually to support I&A services demonstrating states’ ability to leverage 

considerable resources to support the delivery of I&A services. A total of approximately $100 

million from all sources (unadjusted for inflation) was spent annually on I&A services. 

2.3.2 Case Management 

Analyses of the 2001–2004 NAPIS SPR data (shown in Figure 2-5) indicate that Title 

III-B represents an important but relatively modest source of funds to support the delivery of 

case management services. The actual proportion of case management services supported 

directly from Title III-B funds declined somewhat during this 4-year period. While 23.2 percent 

of all case management services provided by the states were funded by the Title III-B program in 

2001, by 2004, this percentage declined to 20.6 percent. Stated differently, for every $1 provided 

by Title III-B to support case management services during this period, another $4 was leveraged 

from non-Title III-B sources. An additional $66 million to $91 million was provided annually by 
2-7 

other sources to support these activities, with non-Title III-B funds to support case management 

increasing substantially during this 4-year period. Total funds used to support case management 

services increased considerably during this 4-year period, ranging from $85.5 million in 2001 to 

almost $114 million (unadjusted for inflation) in 2004. 

Figure 2-5. Title III-B Expenditures, Other Expenditures, and Total Expenditures for Case 

Management Services 

$0

$20,000,000

$40,000,000

$60,000,000

$80,000,000

$100,000,000

$120,000,000

2001 2002 2003 2004

Year

Expenditures

 Title III-B Expenditures Non-Title III-B Expenditures Total Expenditures
3-1 

SECTION 3 

ROLE OF AGING NETWORK IN MANAGING HOME CARE AND 

TRANSPORTATION AND IMPORTANCE OF HOME CARE AND 

TRANSPORTATION FOR AGING NETWORK 

In this section, we address the following study sub-question: 

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? 

For this study, Title III-B home care services include personal care, chore, and 

homemaker services. Home care and transportation services are two direct services that can 

make an important difference to the quality of life of frail and older persons living at home. Title 

III-B home care services—which for this study include personal care, chore, and homemaker 

services—provide in-home assistance to individuals with functional limitations to help them 

manage activities of daily living. Personal care provides in-home personal assistance, standby 

assistance, supervision, or cues for persons with the inability to perform with one or more of the 

following activities of daily living: eating, dressing, bathing, toileting, transferring in and out of 

bed/chair, and walking. Homemaker care provides assistance to persons unable to perform one or 

more of the following instrumental activities of daily living: preparing meals, shopping for 

personal items, managing money, using the telephone, and doing light housework. Chore 

services assist persons having difficulty with one or more of the following instrumental activities 

of daily living: heavy housework, yard work, or light housework (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 (either assisted or unassisted), thereby helping 

them to remain active and independent in the community for as long as possible. Similarly, our 

analysis of transportation services includes both general transportation and assisted 

transportation services (when available). 

In this section, we highlight results from analyses of NAPIS SPR and 2003 and 2004 

National Survey data. 

3.1 Characteristics of Network Participants 

This section reports on the characteristics of individuals using Title III-B home care and 

transportation services. Results are presented separately for each service type. 
3-2 

3.1.1 Home Care Services 

Analyses of 2001–2004 NAPIS SPR data indicate that home care services were targeted 

to the oldest old, those in frail health, those living alone, and women. Specifically, over 70 

percent of all home care participants served by the Title III-B program are at least 75 years of 

age (see Figure 3-1). Similarly, a large proportion of those receiving Title III-B home care 

services live alone, especially those needing homemaker services (over 60 percent) and chore 

services (over 50 percent in 2001 and over 60 percent in 2004) (see Table 3-1). A somewhat 

smaller proportion of personal care participants live alone (between 35 and 44 percent). This 

may be explained by the fact that Title III-B personal care users need more assistance with 

activities of daily living (see Figures 3-2 and 3-3), and thus, are less likely to be able to live 

alone. Approximately 75 percent of home care participants are female. 

Figure 3-1. Percentage of Home Care Clients by Age Group 

0%

10%

20%

30%

40%

50%

2001 2002 2003 2004 2001 2002 2003 2004 2001 2002 2003 2004

Personal Care Homemaker Chore

Type of Home Care by Year

Percentage of Clients

60–64 Years 65–74 Years 75–84 Years 85+ Years
3-3 

Table 3-1. Living Alone Status and Gender of Home Care Clients 

2001 2002 2003 2004 

Personal Care 

Number served 73,177 69,687 70,876 63,229 

Percentage living alone 37.4 40.2 39.9 44.2 

Percentage male 28.9 27.8 27.9 26.6 

Percentage female 71.1 72.2 72.1 73.4 

Homemaker 

Number served 119,553 118,575 114,240 107,897 

Percentage living alone 63.1 62.3 63.7 66.8 

Percentage male 22.5 22.3 22.5 21.8 

Percentage female 77.5 77.7 77.5 78.2 

Chore 

Number served 42,885 34,334 32,415 27,312 

Percentage living alone 53.4 58.5 63.9 63.1 

Percentage male 25.5 23.7 22.6 23.2 

Percentage female 74.5 76.3 77.4 76.8 

Source: RTI analysis of 2001–2004 NAPIS SPR data. Missing data excluded from calculations. 

Figure 3-2. Percentage of Home Care Clients Needing Assistance with ADLs (Age 60+) 

0

10

20

30

40

50

60

70

80

90

100

1+ 2+ 3+ 1+ 2+ 3+ 1+ 2+ 3+ 1+ 2+ 3+

2001 2002 2003 2004

Number of ADLs by Year

Percentage of Clients

Personal Care Homemaker Chore
3-4 

Figure 3-3. Percentage of Home Care Clients Needing Assistance with IADLs (Age 60+) 

0

10

20

30

40

50

60

70

80

90

100

1+ 2+ 3+ 1+ 2+ 3+ 1+ 2+ 3+ 1+ 2+ 3+

2001 2002 2003 2004

Number of IADLs by Year

Percentage of Clients

Personal Care Homemaker Chore

A significant proportion of home care participants need assistance with three or more 

activity of daily living (ADL) impairments, although the actual proportion requiring this level of 

assistance varies widely by home care service—ranging from a high of 60 percent for personal 

care services, to a low of 26 percent for chore services (see Figure 3-2).11 The proportion of 

home care participants with three or more ADL impairments increased between 2001 and 2004; 

this change was particularly large for chore services, where the proportion with three or more 

ADL impairments increased from 25.9 percent to 30.3 percent (a 15 percent increase) during the 

4-year period. 

Between 2001 and 2004, IADL (versus ADL) dependency remained stable by type of 

home care service (see Figure 3-3). Over 85 percent of those using personal care service needed 

help with three or more IADL activities, about 80 percent of those receiving homemaker services 

needed help with three or more IADLs, and approximately 55 percent of those receiving chore 

services needed help with three or more IADLs during this 4-year period. 

 

11 Some of the reported differences in prevalence of functional limitations by type of home care may be due to 

variation in AoA’s functional limitation definitions/requirements to obtain different Title III-B home care 

services.
3-5 

Comparable demographic and health status data on homemaker service users from the 

2003 and 2004 National Surveys may be found in Appendix B. Overall, demographic/functional 

status data from the National Survey samples are consistent with those found in the NAPIS SPR 

data, indicating that Title III-B homemaker service users typically are female, are of advanced 

age, are in frail health, and live alone. The few differences reported by data source include the 

fact that (1) a relatively larger proportion of National Survey homemaker participants live alone, 

and (2) a relatively smaller proportion of National Survey members have significant functional 

limitations. More specifically, during the same comparable period (2003 and 2004), a larger 

proportion of National Sample members reported having lower levels of ADL and IADL 

impairments and a smaller proportion of National Survey members report having higher levels of 

ADL and IADL impairments when compared to NAPIS SPR participants. These reported 

differences by data source may be due, in part, to the fact that NAPIS SPR data are reported by 

AAAs to the states, while National Survey data are self-reported by individual respondents. 

3.1.2 Transportation Services 

Analyses of the 2001–2004 NAPIS SPR data indicate that assisted transportation services 

are targeted to the oldest old, those living alone, and women. Specifically, about 60 percent all 

assisted transportation participants served by the Title III-B program are at least 75 years of age 

(see Figure 3-4). The proportion of assisted transportation service participants that lived alone 

increased substantially between 2001 and 2004. More specifically, 23 percent of those receiving 

Title III-B assisted transportation services lived alone in 2001 while 43 percent lived alone in 

2004 (see Table 3-2). Approximately 70 percent of assisted transportation participants are 

female. No information on the health status (ADL, IADL) of assisted transportation participants 

is available from the NAPIS SPR data. Similarly, no information on the demographic or health 

status of general transportation users is available from the NAPIS SPR data. 

Demographic and health status data of general (not assisted) transportation service users 

from the 2003 and 2004 National Surveys may be found in Table B-7 in Appendix B. The 

demographic data reported on assisted transportation users in NAPIS SPR varies slightly from 

that reported on general transportation users in the National Surveys, which is expected given 

that assisted transportation users are typically more impaired than the population using general 

transportation services. 
3-6 

Figure 3-4. Percentage of Assisted Transportation Clients by Age Group 

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

2001 2002 2003 2004

Age

Percentage of Clients

60–64 Years 65–74 Years 75–84 Years 85+

Table 3-2. Living Alone Status and Gender of Assisted Transportation Clients 

2001 2002 2003 2004 

Number served 60,667 42,057 47,329 33,438 

Percentage living 

alone 

22.6 35.3 40.9 42.9 

Percentage male 34.8 29.2 30.5 27.5 

Percentage female 65.2 70.8 69.5 72.5 

Source: RTI analysis of 2001–2004 NAPIS SPR data. Missing data excluded from calculations. 

When comparing results in Table 3-2 and Table B-7 in Appendix B, we found that both 

types of transportation users typically are older (75 years of age and over) and female, though a 

relatively larger proportion of males use assisted versus general transportation services. In 

contrast, a relatively smaller proportion of assisted versus general transportation users live alone, 

perhaps due to the fact that they are in poorer health. 

We were unable to compare functional status measures for both general and assisted 

transportation users across the two data sets since NAPIS SPR data did not provide information 

on the functional status of general or assisted transportation users. National Survey data, 

however (shown in Tables B-8 and B-9 in Appendix B) reveal that the majority of general 

transportation participants have one or two ADL and IADL impairments, documenting that these 
3-7 

individuals need at least some assistance with daily activities in order to remain independent in 

the community. 

3.2 Characteristics of Home Care and Transportation Services 

In this section, we provide information on characteristics of network services, including 

the overall numbers of people using home care and transportation services, and average use per 

person served. Results are presented by service type. 

3.2.1 Home Care Services 

The total number of hours of Title III-B home care services used by older and disabled persons 

declined somewhat over the 4-year period (see Table 3-3). The total (unduplicated) number of 

persons using home care services also declined during this period. Between 2001 and 2003, 

home care users typically received about 1.3 hours of personal care services per week (68 to 70 

hours over 52 weeks), just over 1 hour of homemaker services per week (roughly 56 hours over 

52 weeks), and about 1 hour of chore services every third week (18 to 20 hours over 52 weeks). 

However, in 2004, the average number of personal care hours increased from 68 to 77 hours per 

person per year, or approximately 1.5 services per person per week.12

No specific information on the characteristics of home care services is available from the 

National Survey data. 

3.2.2 Transportation Services 

The total units of general transportation and assisted transportation services declined 

during the 4-year period (see Table 3-4). The number of persons using assisted transportation 

services declined considerably between 2001 and 2004. However, the intensity of assisted 

transportation service use varied, 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). Although these data do not fully explain the overall decline in both assisted and general 

transportation usage during this 4-year period, AoA has speculated that the total use of 

transportation services declined as the proportion of Title III-B 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. It also is possible that the increased intensity 

 

12 TAG members felt that these relatively low home care utilization statistics reflected the fact that the aging 

network typically referred older participants to other programs/providers of care (including state-provided home 

care, Medicaid home care services, etc.) whenever possible, based on eligibility for such programs, to allow 

participants to obtain a fuller range of home care services elsewhere. 
3-8 

of service use per person served in 2004 was associated with at least some reduction in the total 

number of people having access to this service in 2004.13 

Table 3-3. Units of Home Care Service, Unduplicated Count of Persons, and Units of 

Service per Person 

 2001 2002 2003 2004 

Personal care 

Units of service delivered (hour) 9,775,736 9,011,187 9,062,786 9,200,518 

Unduplicated count of persons using 

service 

98,190 96,563 79,728 82,838 

Units per person (outliers removed) 70 71 68 77 

Homemaker 

Units of service delivered (hour) 11,664,344 9,743,962 9,328,207 10,365,330 

Unduplicated count of persons using 

service 

163,848 161,693 128,359 143,178 

Units per person (outliers removed) 63 56 55 63 

Chore 

Units of service delivered (hour) 1,265,559 1,270,075 1,169,965 1,160,334 

Unduplicated count of persons using 

service 

56,499 49,191 45,545 39,897 

Units per person (outliers removed) 18 20 21 21 

Source: RTI analysis of the 2001–2004 NAPIS SPR data. 

Additional data on characteristics of general (but not assisted) transportation services is 

provided from the 2003 and 2004 National Surveys. As shown in Table B-10 in Appendix B, 

over 50 percent of respondents had used transportation services less than 1 week earlier. 

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. 

 

13 Qualitative data from interviews with national experts and focus groups with AAA directors will provide 

additional information to help AoA and RTI understand why this finding has occurred.
3-9 

Table 3-4. Units of Transportation and Assisted Transportation Service, Unduplicated 

Count of Persons, and Units of Service per Person 

 2001 2002 2003 2004 

Transportation 

Units of service delivered (one-way 

trip) 

39,412,134 37,094,425 36,019,342 34,014,788 

Unduplicated count of persons using 

service 

N/A N/A N/A N/A 

Units per person (outliers removed) N/A N/A N/A N/A 

Assisted Transportation 

Units of service delivered (one-way 

trip) 

2,810,510 2,412,748 2,189,407 1,962,268 

Unduplicated count of persons using 

service 

86,640 60,862 62,274 46,740 

Units per person (outliers removed) 32 34 31 38 

Source: RTI analysis of the 2001–2004 NAPIS SPR data. 

NOTE: No information is available on persons served from NAPIS SPR data for general transportation services. 

The volume of activity for general transportation users as reported from the National 

Surveys is about three to five times that reported for assisted transportation users from NAPIS 

SPR, though this difference was to be expected because individuals needing assisted 

transportation use this service primarily for medical appointments while those using general 

transportation services rely on it for a variety of purposes ranging from attendance at senior 

centers, doctor’s appointments, lunch programs, shopping, social activities and recreation, and 

religious services (see Table B-10 in Appendix B for the types of locations visited by Title III-B 

transportation users). 

3.3 Role/Importance of Home Care and Transportation Services Delivered through 

Aging Network versus Elsewhere 

Information on Title III-B versus non-Title III-B home care and transportation service 

was examined through the use of 2001–2004 NAPIS SPR expenditure data. Results are provided 

by service type. 

3.3.1 Home Care Services 

NAPIS SPR expenditure data for 2001 to 2004 (as shown in Figure 3-5) indicate that the 

Title III-B program has represented a significant, albeit somewhat variable source of funding of 

home care services. 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 
3-10 

to support personal care activities in the states. Between 11 and 17 percent of funds to support 

personal care services were provided from Title III-B funds. In contrast, between 22 and 27 

percent of funds to support homemaker services and between 30 and 40 percent of funds to 

support chore services were from Title III-B. In other words, every $1 provided by the Title III-B 

program for home care services generated an additional $2 to $6 of non-Title III-B funds 

(depending on service) to support this service for older persons. Between 2001 and 2003, the 

total amount of both Title IIII 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 nonTitle III-B expenditures for home care generally declined. Similarly, between 2001 and 2003, 

total expenditures (Title III-B plus non-Title III-B) for home care services remained relatively 

constant, but in 2004, total expenditures for home care services declined considerably for all but 

personal care services. In particular, total expenditures for chore services declined by 23 percent 

and total expenditures for homemaker services declined by 13 percent in 2004. 

Figure 3-5. Title III-B Expenditures, Other Expenditures, and Total Expenditures for 

Home Care Services 

$0

$20,000,000

$40,000,000

$60,000,000

$80,000,000

$100,000,000

$120,000,000

Personal

Care

Homemaker 

Chore 

Personal

Care 

Homemaker 

Chore 

Personal

Care 

Homemaker 

Chore 

Personal

Care 

Homemaker 

Chore 

2001 2002 2003 2004

Type of Home Care by Year

Expenditures

 Title III-B Non-Title III-B Total
3-11 

3.3.2 Transportation Services 

Analyses of 2001–2004 NAPIS SPR expenditure (shown in Figure 3-6) indicate that 

Title III-B represents a substantial source of funds for the delivery of transportation services. 

Between 2001 and 2004, 36 to 42 percent of all general transportation services provided by the 

states were funded by the Title III-B program. Similarly, 22 to 24 percent of all assisted 

transportation services provided by the states 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 million to 

$120 million from non-Title III-B funds was used annually to support general transportation 

services, while approximately $11 million to $13 million (unadjusted for inflation) from 

Figure 3-6. Title III-B Expenditures, Other Expenditures, and Total Expenditures for 

Transportation Services 

$0

$50,000,000

$100,000,000

$150,000,000

$200,000,000

$250,000,000

Transportation

Assisted

TransportationTransportation

Assisted

TransportationTransportation

Assisted

TransportationTransportation

Assisted

Transportation

2001 2002 2003 2004

Type of Transportation by Year

Expenditures

 Title III-B Non-Title III-B Total

non-Title III-B funds annually supported assisted transportation services. Total expenditures for 

general transportation remained fairly constant, while total expenditures for assisted 

transportation services declined somewhat during this 4-year period. Overall, the total 
3-12 

expenditures for general transportation services exceeded that of assisted transportation services 

by a factor of 12 to 1. 

3.4 Satisfaction with Homemaker Services 

In order to assess correlates of satisfaction with Title III-B homemaker services, we 

analyzed the 2003 and 2004 National Survey satisfaction data. We also examined the literature 

on satisfaction with home care. Satisfaction relates to how beneficiaries experience the care 

received compared to their standards or expectations (Linder-Peltz, 1982). Satisfaction measures 

can provide important information about interpersonal aspects of care, such as interactions and 

communication between providers and clients; clients’ perceptions on how much providers 

respect, understand, and listen to them; and whether clients are treated with dignity (Aharony and 

Strasser, 1993; Keepnews, 2003). 

Although satisfaction with care received at home is now recognized as an important 

outcome (Geron et al., 2000), little is known about what factors affect satisfaction with home 

care services. People who use home care typically report high levels of satisfaction, but previous 

research found that the social desirability effect—the tendency of respondents to provide an 

answer they think interviewer wants to hear—leads to reporting of high levels of satisfaction 

(Geron et al., 2000). In studying correlates of satisfaction with health care, researchers usually 

examine demographic characteristics and health status. Earlier research points to a strong 

negative relationship between self-reported health and functional status and satisfaction with 

care, with poorer health and higher impairment levels resulting in less satisfaction, and to mixed 

findings on the effects of race, ethnicity, and age (Haviland, Morales, Reise, and Hays, 2003; 

Coughlin, Long, and Kendall, 2002; Pascoe and Attkisson, 1983). 

In the next section, we describe the methods we used and results of these analyses. 

3.4.1 Results from Descriptive Analysis of Satisfaction with Homemaker Services 

As shown in Figure 3-7, individuals responding to the 2003 and 2004 National Surveys 

were generally quite satisfied with homemaker services. Over 80 percent of those responding to 

most questions about homemaker thoroughness, comprehensiveness, willingness to do extra 

things, politeness, promptness, and competence responded “Yes, definitely/Yes, I think so” to 

the positively worded homemaker satisfaction items. In particular, over 90 percent of 

respondents said that the homemaker generally knows what to do, over 87 percent said that the 

homemaker is very thorough, and over 92 percent said that the homemaker takes an interest in 

the participant. Interestingly, 36 to 39 percent of respondents would have liked to receive more 

hours of homemaker services each week, and approximately 44 percent of respondents wished 
3-13 

that the homemaker could do more things for him/her. Satisfaction results were uniform across 

both years. 

3.4.2 Approach to Multivariate Analysis of Homemaker Satisfaction 

We relied on the 2004 National Survey data to estimate (a) a series of logistic regression 

models of satisfaction with specific components of homemaker care and (b) one ordinary least 

squares (OLS) model of overall satisfaction with homemaker services. Odds ratios and 

significance levels are presented for the logistic regression models (shown in Table B-13 in 

Figure 3-7. Rating of Homemaker Services in 2003 and 2004 

0

10

20

30

40

50

60

70

80

90

100

HM is thorough

HM does things the way participant wants

HM has become a friend

HM takes interest in participant

More hours of HM service needed

HM knows what to do

HM has enough time to do all jobs 

HM does extra things for participant

Participant wishes HM could do more

HM does not leave too early

HM is not rude

HM does not arrive late

HM does not ignore participant wishes

Homemaker Services

Percentage

2003 2004

Appendix B) and beta-coefficients and significance levels for the OLS model (shown in 

Table B-12 in Appendix B). 

For the logistic regression models, we examined satisfaction with the following specific 

aspects of homemaker care: 

 Participant needs more hours of homemaking each week (yes/no) 
3-14 

 Participant reports that homemaker is assigned enough time (yes/no) 

 Participant reports that homemaker arrives on time (yes/no) 

 Participant wishes homemaker would do more (yes/no) 

 Homemaking service increases social activities (yes/no) 

We also examined overall satisfaction with homemaking services using the wellestablished Home Care Satisfaction Measure (HCSM) scale developed by Geron and colleagues 

(Geron et al., 2000). The HCSM scale is a 13-item composite measure, ranging from 0 to 100, 

with higher values indicating greater satisfaction with home care. The scale consists of items that 

rate the quality and quantity of the homemaker’s work, as well as the relationship between the 

homemaker and client. The scale includes both positively worded and negatively worded items. 

Negatively worded items are scored in reverse order so that higher values on each item indicate 

greater satisfaction with care. 

The scale may be used as a national benchmark against which states, AAAs, and 

individual programs can compare themselves when they collect their own satisfaction data. 

Many local agencies have used the HCSM to assess client satisfaction, using national 

benchmarks as a basis of comparison. 

The 13 items comprising this scale are delineated below. 

Positively worded items: 

 Homemaker is very thorough. 

 Homemaker does things the way participant wants. 

 Homemaker has become a friend. 

 Homemaker takes interest in participant. 

 Homemaker generally knows what to do. 

 Homemaker is assigned enough time to do all the jobs for a participant. 

 Homemaker does extra things for participant. 

Negatively worded items: 

 Homemaker leaves too early. 

 Participant wishes homemaker would do more things. 

 Need more hours of homemaking service each week. 

 Homemaker is rude. 

 Homemaker arrives late. 
3-15 

 Homemaker ignores participant wishes. 

To further explore the relationship between satisfaction with homemaker services and 

characteristics of vulnerability (such as minority status, rural residency, and living alone), we 

compared the distribution of demographic characteristics for the sub-group of the homemaker 

sample having the lowest quartile of predicted HCSM scores (i.e., the group of survey 

participants who are least satisfied with the service) relative to the entire homemaker study 

sample. 

3.4.3 Results from Multivariate Analysis of Homemaker Satisfaction 

We used OLS modeling to identify factors associated with global satisfaction with 

homemaker services. Results are shown in Table B-12 in Appendix B. Overall, demographic 

characteristics were not strong predictors of satisfaction with this service. Urban residents were 

somewhat more satisfied with homemaker services, rating the service about 4 percentage points 

higher, on average, than those living in suburban or rural areas. 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. This finding is consistent with 

previous satisfaction studies (Haviland, Morales, Reise, and Hays, 2003; Coughlin, Long, and 

Kendall, 2002; Pascoe and Attkisson, 1983). 

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. Table 3-5 compares the demographic characteristics of the overall study 

sample to those with the lowest predicted ratings for the HCSM score. The proportions that are 

highlighted in Table 3-5 reflect statistically significant differences between the total sample and 

the lowest quartile (i.e., the sub-sample that is the least satisfied). Consistent with other findings, 

we found that those who were least satisfied with the homemaker service were more likely to 

live in a non-urban (i.e., suburban or rural) area, be non-white, and have a high level of 

functional impairment (three or more ADLs) relative to the overall homemaker sample. 

Furthermore, when examining interaction terms to incorporate the complex relationship among 

independent variables, we found that a larger proportion of rural residents with three or more 

ADLs, minorities with three or more ADLs, and older minority respondents were least satisfied 

with homemaking services relative to the total study sample. 
3-16 

Table 3-5. Comparison of the “Least satisfied” Sample with the Overall Sample Receiving 

Homemaker Services 

Total Sample 

(score range 70.1–85.1) 

Lowest quartile 

(score range 70.1–76.9) 

 n=968 n=177 

 Mean 95% LCI 95% UCI Mean 95% LCI 95% UCI 

Age 75 and over 71.6 64.8 78.4 67.6 57.9 77.2 

Male 19.1 14.7 23.5 18.7 9.2 28.2 

Urban resident 56.5 47.0 66.0 20.5 10.0 31.0 

Rural resident 20.2 14.6 25.8 37.8 25.2 50.3 

Education: High school or less 75.0 70.1 80.0 83.4 77.4 89.4 

Non-white race 21.3 13.6 28.9 51.6 34.9 68.3 

Not married 84.3 80.8 87.8 82.1 74.1 90.0 

Live alone 69.8 62.7 76.8 58.7 44.4 72.9 

Three or more ADLs 32.3 25.3 39.3 79.4 68.7 90.0 

Three or more IADLs 43.7 36.2 51.3 65.1 45.4 84.7 

Rural*Non-white 4.2 1.2 7.2 16.2 6.5 25.9 

Rural*3+ ADLs 7.2 3.6 10.7 28.2 16.0 40.5 

Non-white*3+ ADLs 7.9 3.6 12.1 30.9 18.6 43.2 

Non-white*age 75 and over 14.9 8.7 21.2 38.4 23.2 53.7 

Rural*Male 5.7 2.2 9.2 10.0 –0.2 20.2 

Three or more ADLs*Male 3.2 1.1 5.3 9.5 2.9 16.1 

Non-white*Male 5.3 1.4 9.1 14.8 5.1 24.6 

NOTES: 

“LCI” is the lower confidence interval; “UCI” is the upper confidence interval. 

“Least satisfied population” is defined as the population in the lowest quartile of the HCSM scale according to the 

prediction of the final model) 

Estimates adjusted for complex survey design 

Shaded results indicated statistically significant differences (p < .05) between the total sample and the least satisfied 

25 percent. 

Source: RTI analysis of the 2004 National Survey of OAA Programs. 

We also evaluated whether the receipt of homemaker services enhanced the likelihood of 

increasing social activities (see Table B-13 in Appendix B). Those aged 75 and over were 

substantially less likely to report increasing social activities relative to their younger 

counterparts, but males were twice as likely as females to report that having homemaker services 

helped them to increase social activities. 
3-17 

Finally, we decomposed the overall HCSM satisfaction scale (described above) to 

identify factors associated with satisfaction with particular components of the homemaker 

experience. Specifically, we estimated four logistic regression models for the following selfreported dependent variables: 

 Participants needs more hours of homemaker services each week (yes/no) 

 Participant wishes homemaker would do more (yes/no) 

 Homemaker assigned enough time (yes/no) 

 Homemaker does not arrive late (yes/no) 

Having substantial ADL impairment was the most important predictor of needing more 

hours of homemaker service each week. As shown in Table B-13 in Appendix B, program 

participants with three or more ADLs were 2.69 times more likely than those with less functional 

impairment to report needing more hours of homemaker services. Similarly, this same impaired 

group was twice as likely as its healthier counterparts to wish his/her homemaker would do 

more. In addition, those with three or more ADLs were 65 percent less likely to report that their 

homemaker was assigned enough time. 

Minority survey participants were more than twice as likely as white participants to wish 

their homemaker would do more. Similarly, while not statistically significant, minority survey 

respondents had an increased tendency to say that they needed more hours of homemaker 

services. 

While living alone has traditionally been associated with added vulnerability in old age, 

we found no evidence that it decreased satisfaction with various aspects of homemaking services. 

On the contrary, those living alone were about 50 percent less likely to report that they needed 

more hours of homemaker service each week and twice as likely as those living with others to 

report being assigned enough homemaker time. Perhaps this group of individuals was relatively 

independent by virtue of the fact that they could live alone, and thus, did not need additional 

assistance. 

A number of other demographic factors were associated with specific components of 

homemaker satisfaction, although the direction of the effect varied by demographic characteristic 

and satisfaction item. 

 Males were 83 percent less likely than females to report that their homemaker arrived 

on time (i.e., not late). 
3-18 

 Older respondents (aged 75 and over) and urban residents were about 50 percent 

less likely than younger-aged and suburban residents to wish their homemaker would 

do more. 

 Both older respondents (aged 75 and over) and those who were not married were 

significantly more likely than younger and married individuals to report that their 

homemaker arrived on time (i.e., not late). Specifically, those aged 75 and over were 

more than four times as likely as younger persons to report that their homemaker 

arrived on time, while unmarried individuals were about three times more likely than 

married persons to report that their homemaker arrived on time. 

In summary, we found a complex set of information from homemaker service users 

indicating that 

 Respondents with substantial ADL impairments reported needing more homemaker 

services and being less satisfied with homemaker services (overall). 

 Minority respondents were more likely to wish that their homemaker would do more. 

 Urban residents reported greater overall satisfaction with homemaker services relative 

to counterparts living in suburban or rural areas. 

 Males were twice as likely as females to report that having homemaker services 

increased their social activities but they were substantially less likely to report that 

their homemaker arrived on time. 

 Unmarried individuals were more likely to report that their homemaker arrived on 

time. 

 Those living alone were less likely to report that they needed more hours of 

homemaker services each week and more likely to report being assigned enough 

homemaker time. 

 Those with a combination of “vulnerability” factors, such as being rural and having 

substantial ADL impairment, or being non-white and having substantial ADL 

impairment, or being 75 and older and of minority descent, were less satisfied than 

sample counterparts without this combination of personal factors. 

We will more fully explore the relationship between these demographic/background factors 

and satisfaction with homemaker services through expert interviews and focus group sessions 

during the summer/fall of 2006. 

3.5 Satisfaction with Transportation Services 

We estimated two logistic regression models 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. As shown in 

Table B-14 in Appendix B, 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 
3-19 

to get around more than before due to Title III-B transportation services. However, for this one 

outcome, transportation service did not seem to be as helpful for people who lived alone: They 

were 50 percent less likely to report that transportation services helped them get around more 

than before. 

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 the 

transportation a good/very good/excellent rating; more specifically, urban residents were about 

five times more likely than those in suburban areas to rate transportation services positively. 

Similarly, respondents with three or more ADLs were over seven times more likely than their 

healthier counterparts to rate Title III-B transportation services as at least good. 

In summary, 

 While Title III-B transportation services generally were rated very highly by the 

majority of survey respondents, urban residents and highly impaired individuals were 

significantly more likely to rate this service positively. 

 In terms of getting around more, transportation services seemed to be particularly 

helpful to people with less formal education. 

 Individuals living alone were less likely to report that transportation service helped 

them to get around more than before, perhaps due to the fact that they already were 

independent and/or had previously established a suitable transportation system for 

themselves. 

We will continue to explore the relationship between these background factors and 

satisfaction with transportation services through expert interviews and focus group sessions 

during the summer and/or fall of 2006. 
4-1 

SECTION 4 

ROLE OF AGING NETWORK IN FINANCING LONG-TERM CARE SERVICES FOR 

OLDER PERSONS AND IMPORTANCE OF FINANCING AND DELIVERING LONGTERM CARE SERVICES TO THE AGING NETWORK 

In this section, we address the following study sub-question: 

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? 

For this one study question, we analyze all Title III-B services, including personal care, 

chore, homemaker, adult day care/health, case management, assisted transportation, 

transportation, legal assistance, information and assistance, and “other” Title III-B services. 

Although we focus primarily on analyses of the 2001–2004 NAPIS SPR data, for analyses of the 

relative scope/importance of Title III-B services, we also rely on AARP-reported state funded 

(non-Medicaid) supportive service expenditure data and Urban Institute-reported Medicaid 

service expenditure data. 

4.1 Relative Scope/Importance of OAA Title III-B Services 

This section includes a presentation of Title III-B expenditure data for all Title III-B 

services, non-Title III-B expenditures, and total expenditures (Title III-B plus non-Title III-B) 

data. In order to assess trends in service spending over time, we present this data in four tables by 

type of expenditure: Title III-B, non-Title III-B, total expenditures, and percentage of total 

expenditures from Title III-B. 

We also provide a summary table, compiled from other a number of data sources, that 

compares the relative contribution from Title III spending to other sources of funding. This table 

includes Title III and non-Title III expenditures (from NAPIS SPR), state funding (from AARP 

data), and Medicaid funding (from Urban Institute). Since there is not a complete set of data 

from all sources for each year, the table should not be used to provide a full accounting of funds 

provided by year by source. 

Figure 4-1 and the actual numerical data presented in Table A-12 in Appendix A provide 

a summary of Total Title III expenditures by type of service and year. The three services that 

expended the most Title III-B resources during this period were “Other Services,” transportation 

services, and I&A services. Most of Title III-B services shown in the chart in Figure 4-1 

increased modestly during this period; however, as noted previously, in 2004, Title III-B 
4-2 

Figure 4-1. Total Title III-B Expenditures by Service Type and Year 

0

20,000,000

40,000,000

60,000,000

80,000,000

100,000,000

120,000,000

Information

and

Assistance

Case

Management

Personal Care

Homemaker

Chore

Transportation

Assisted

Transportation

Adult Day

Care/Health

Legal

Assistance

Outreach

Other

Access Services Home Care Services Transportation

Services

Other Services

Type of Service

Expenditures

2001 2002 2003 2004

expenditures decreased across all services (with the exception of the “Other Services” category). 

The services benefiting the most (in absolute terms) from Title III-B sources included “Other 

services,” general transportation, I&A services, and homemaker services. 

Most of the other Title III-B services (adult day care, legal assistance, and outreach) grew 

modestly during this period; however, a category known as “Other Title III-B services” 

fluctuated—increasing significantly between 2001 and 2002 and then declining between 2002 

and 2003.14 RTI’s analysis of the “Other Title III-B service” category (from among the 18 to 20 

states that provided detailed information on the use of these funds) indicated that the primary 

“Other” services being provided included respite, home repair/modification, screening and 

assessment, counseling services, home and community-based services, and visiting/phone 

reassurance (results available upon request). 

 

14 Due to time and resource constraints, we did not analyze the “Other Title III-B expenditure” category for 2004. 

However, we did analyze “Other Title III-B expenditures for 1999 and 2000 (as well as 2001–2003) and 

commented on them in the text for additional points of reference.
4-3 

Figure 4-2 and the actual numerical data presented in Table A-13 in Appendix A indicate 

that non-Title III-B resources were considerable, doubling and sometimes tripling the amount of 

funding available to states depending on the year in question. In 2003, for example, non-Title IIIB funds more than tripled the amount of funding available to states, increasing total expenditures 

for supportive services from $344 million—the amount covered by Title III-B—to more than $1 

billion when both Title III-B and non-Title III-B expenditures were included (see Table A-14 in 

Appendix A for total expenditures spent on these supportive services). The services benefiting 

the most (in absolute terms) from non-Title III-B sources were “Other services,” transportation, 

case management, personal care, and homemaker services. 

Figure 4-2. Total Non-Title III-B Expenditures by Service Type and Year 

0

50,000,000

100,000,000

150,000,000

200,000,000

250,000,000

300,000,000

Information

and

Assistance

Case

Management

Personal Care

Homemaker

Chore

Transportation

Assisted

Transportation

Adult Day

Care/Health

Legal

Assistance

Outreach

Other

Access

Services

Home Care Services Transportation

Services

Other Services

Type of Service

Expenditures

2001 2002 2003 2004

While two non-Title III-B expenditures, I&A services and general transportation services, 

remained stable during this period, non-Title III-B expenditures for most supportive services 

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. Similarly, non-Title III-B expenditures for assisted transportation 

declined from almost $14 million in 2001 to $11 million in 2004. One important exception to 
4-4 

this general pattern, however, was for case management services; non-Title III-B expenditures 

for case management services increased dramatically from $65 million in 2001 to over $90 

million in 2004, potentially due, in part, to increases in Medicaid funding for case management 

during this period. Even so, total non-Title III-B expenditures decreased from over $782 million 

in 2001 to approximately $752 million in 2004. 

The total amount of resources (Title III-B and non-Title III-B) used to support all Title 

III-B services remained stable between 2001 and 2004, ranging from $1.08 billion in 2001 to 

$1.075 billion (unadjusted for inflation) in 2004. The Title III-B services using the largest 

(absolute) amount of total Title III resources during this period included “Other services,” 

general transportation services, and case management, with personal care services and I&A 

services following closely behind (see Figure 4-3). 

Figure 4-3. Total Expenditures (Title III-B and Non-Title III-B) by Service Type and Year 

0

50,000,000

100,000,000

150,000,000

200,000,000

250,000,000

300,000,000

350,000,000

400,000,000

Information

and

Assistance

Case

Management

Personal Care

Homemaker

Chore

Transportation

Assisted

Transportation

Adult Day

Care/Health

Legal

Assistance

Outreach

Other

Access

Services

Home Care Services Transportation

Services

Other Services

Type of Service

Expenditures

2001 2002 2003 2004
4-5 

Table 4-1 and the actual numerical data reported in Table A-14 in Appendix A highlight 

the percentage of total expenditures provided with Title III-B funds. The Title III-B services that 

relied most heavily on Title III-B funds included legal assistance, I&A services, and outreach. 

For each of these services, at least 40 percent of all expenditures came from Title III-B. In 

contrast, case management services were largely funded using 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) while 

homemaker and chore services relied somewhat more heavily on Title III-B funds. 

Table 4-1. Percentage of Total Expenditures from Title III by Service by Year 

 2001 2002 2003 2004 

Service

Title III as 

Percentage of 

Total 

Expenditures for 

Each Service 

Title III as 

Percentage of 

Total 

Expenditures for 

Each Service 

Title III as 

Percentage of 

Total 

Expenditures for 

Each Service 

Title III as 

Percentage of 

Total 

Expenditures for 

Each Service 

Title III-B Access Services 

Information and Assistance 41.2 44.4 44.1 43.0 

Case Management 23.2 21.6 19.9 20.6 

Title III-B Home Care 

Services 

 

Personal Care 12.5 11.5 16.6 14.6 

Homemaker 22.0 26.4 27.6 27.1 

Chore 32.1 29.9 39.3 39.1 

Title III-B Transportation 

Services 

 

Transportation 37.3 41.0 42.2 35.8 

Assisted Transportation 21.5 23.1 23.9 24.2 

Other Title III-B Services 

Adult Day Care/Health 12.7 15.7 14.6 15.9 

Legal Assistance 43.7 52.0 50.8 46.7 

Outreach 39.3 42.7 43.6 42.0 

Other 25.3 31.4 28.4 30.6 

Source: RTI analysis of the 2001–2004 NAPIS SPR data. 
4-6 

Due to the variability of non-Title III-B funding during this 4-year period, states appeared 

to increasingly rely on Title III-B funds to support the delivery of most supportive services by 

2004. For example, the relative proportion of total expenditures supported by Title III-B for 

chore services increased from 32 percent in 2001 to 39 percent in 2004. Similarly, the proportion 

of total expenditures supported by Title III-B for homemaker services increased from 22 percent 

in 2001 to 27 percent in 2004. As noted previously, the one exception to this general pattern was 

for case management services, which relied somewhat less on Title III-B expenditures in 2001 

than in 2004.15

Table 4-2, compiled from a number of data sources, compares the total amount of Title 

III spending to other sources of funding for similar supportive services. The information 

provided in this table came from NAPIS SPR data (for Title III and non-Title III expenditures), 

AARP (for state-funded services), and the Urban Institute (for Medicaid-covered services). 

Because we did not have access to complete information on all funding sources for each year, 

Table 4-2 is not meant to provide a full accounting of funds by year by source. Instead, it is 

meant to depict the total contribution from different funding sources to support community-based 

long-term care services. 

It is important to note that there may be substantial duplication in state-reported funding 

between NAPIS SPR and AARP dollars. More specifically, as shown below, it appears that 

approximately 54 percent of the state funding reported in the AARP study for 2002 was captured 

from the NAPIS SPR data.16 For this reason, it is not advisable to add funding across all 

categories to calculate the relative contribution of different sources for supportive services. 

As noted above, non-Title III-B expenditures also provided a critical source of funding to 

the states. According to the AARP report cited below, approximately half of state-funded 

supportive services in 2002 were reported by AAAs as non-Title III-B expenditures, while an 

additional 46 percent likely were distributed by the states through networks other than the AAAs 

(only $760,444,128 of the $1,411,949,161 spent on state-funded services according to AARP 

was reported through the NAPIS SPR system). 

 

15 As noted previously, additional data will be collected through qualitative methods to help us more fully 

understand why Title III-B funds were unstable during this period. 16 Stated differently, the non-Title III-B expenditure data from the NAPIS SPR system for 2002 indicate that 

$760,444,128 was provided by from non-AoA sources for supportive services. According to AARP, however, 

the states funded over $1.411 billion in supportive services in 2002. Given the discrepancy in reported state 

funds from NAPIS SPR versus AARP data, we have speculated that the revenue reported by NAPIS SPR 

(relative to AARP) included only those funds that went through the AAAs, while the additional 46 percent of 

state funds reported by AARP came directly from states (not through AAAs), and thus were neither known to nor 

reported by the AAAs. 
4-7 

Table 4-2. Comparison of Supportive Service Funding by Source 

Title III-B Supportive Servicesa

Title III-B 

Expendituresa

Non-Title III-B 

Expendituresa

State Funded, 

Non-MedicaidCovered Servicesb Medicaid Servicesc

2001 $297,409,975 $782,683,562 n/a $6,288,362,000 

2002 338,959,739 760,444,128 $1,411,948,161 6,993,949,000 

2003 344,375,815 775,343,107 n/a n/a 

2004 323,558,291 752,035,766 n/a n/a 

 (RTI analysis of the 

1999–2004 NAPIS SPR 

data) 

(RTI analysis of the 

1999–2004 NAPIS SPR 

data) 

(Summer and Ihara, 

2004) 

(Based on an analysis by the 

Urban Institute of statereported data for expenditures 

for service for elderly 

Medicaid beneficiaries) 

Services Covered: 

a

Personal Care, Homemaker, Chore, ADC/ADHC, Case Management, Assisted Transportation, Transportation, 

Legal Assistance, Information and Assistance, Outreach, Other. b

Personal Care, Homemaker, ADC, Case Management, Transportation, Assessment Services, Specialized Medical 

Equipment and Supplies, Emergency Response Systems, Habilitation, Home-Delivered Meals, Respite Care, 

Chore Services, Home Health Care, Home Health Aide, Skilled Nursing. 

c

Personal Care, Home Health, Targeted Care Management, and HCBS Waiver services 

NOTES: 

1. Medicaid expenditures are for direct service and do not include administrative overhead. 

2. The Medicaid expenditure data reported by Arizona, Hawaii, and Washington varies from that reported by other 

states in the following ways: Arizona does not report expenditures for the HCBS program variable; Hawaii does 

not report its data in a manner that allows it to be divided by age of beneficiary; and Washington does not report 

expenditure for the HCBS program variable, and its 2002 report for the other expenditure categories was not 

reported in a manner that allows it to be divided by age of beneficiary. Urban Institute has developed a protocol to 

compensate for these data irregularities. 

If we conservatively combine only NAPIS SPR-reported Title III-B expenditures, AARPreported state funded (non-Medicaid) supportive service expenditures and Urban Institutereported Medicaid service expenditures to assess the relative contribution of Title III-B in 

funding community-based long-term care services for older persons and disabled individuals, we 

find that Title III represented approximately 4 percent of total expenditures (i.e., $338.9 

million/$8.744 billion) spent on supportive services in 2002.17 Due to the lack of complete 

information across categories for other years, we are unable to make similar comparisons for 

2001, 2003, or 2004. 

 

17 Even so, TAG members reported that the aging network contributed substantially to the well-being of older 

persons in unmeasured ways by providing the leadership and infrastructure needed to help older persons to 

navigate the long-term care system and to serve as the entry and coordination point for older persons and their 

families 
5-1 

SECTION 5 

SUMMARY OF INTERIM QUANTITATIVE FINDINGS AND NEXT STEPS 

5.1 Interim Findings To Date

This evaluation of select consumer, program, and system characteristics under the 

Supportive Services Program (Title III-B) of the Older Americans Act was designed to answer 

the following overarching study question: 

How, to what extent, and with what results has the aging network implemented Title III-B of the 

Older Americans Act? 

It is clear from the available quantitative data that Title III-B has been and remains an 

important source of supportive care service programming and funding to the states and to frail 

individuals and their families. Based on the quantitative data that we have received to date, if we 

were asked to answer the overarching study question with the limited information available at 

this point in the evaluation, we would report the following: 

 The aging network relies considerably on the Title III-B program to support and 

provide a large range of home- and community-based long-term care services to 

frail, older individuals and their families. 

 The aging network has been successful in obtaining non-Title III-B funding to 

support older persons across the states. 

 Generally, funding from the Title III-B program has remained stable or increased 

modestly (unadjusted for inflation) across the years. 

 The number of people using Title III-B services has remained stable or decreased 

somewhat over time (particularly for home care and transportation services). 

 The frailty/vulnerability of the older population served by the Title III-B program 

has increased (particularly for case management, and home care services), as 

evidenced by increases in the proportion of older persons with 3 or more ADL 

limitations and/or living alone. 

 Older persons served appear to be extremely satisfied with Title III-B services, in 

some cases wanting to receive even more of them (particularly homemaker 

services). 

Additional research from this study, including interviews with national experts and focus 

groups with AAA directors, SUA directors, and service providers, should help us better 

understand why general declines in Title III-B service usage have been accompanied by overall 

stability in Title III-B expenditures for most supportive services during this 4-year period. 
5-2 

During the next phase of the study, we will analyze data from the AAA Service 

Integration Survey (still in the field at the time of this report), along with information provided 

from qualitative sources (described in the section below). These additional data sources will 

provide critical information to enable RTI and AoA to more fully address the overall study 

question posed above. 

5.2 Next Steps/Where Qualitative Data Are Needed 

Table 5-1 summarizes the areas where qualitative data are needed to answer particular 

study questions/issue areas. Rather than group each issue area separately for the three key 

substantive areas (access services, home/transportation services, and Title III service 

expenditures), we have grouped the areas by research question. An alternative grouping of these 

topics by topical area appears in Appendix C. 

Table 5-1. Study Questions/Issues and Qualitative Data Source(s) 

Study Questions/Issues to Be 

Addressed with Qualitative Data Qualitative Data Sources 

Overarching Study Question: How, to what extent, and 

with what results has the aging network implemented Title 

III-B of the Older Americans Act? 

 In-depth interviews with experts 

 Focus groups 

Sub-Question 1: 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 longterm care services to the aging network? 

 In-depth interviews with experts 

 Focus groups 

 Extent to which AAAs/SUAs conduct needs assessments 

to determine how AAA participants compare to the 

elderly population as a whole, what needs AAA 

participants have for assessment and care management 

services relative to the elderly population as a whole, 

best practices in the provision of access (I&A and case 

management) services to AAA participants, and extent to 

which results have been achieved 

 In-depth interviews with experts 

 Focus groups 

 Role/importance of access service activities delivered 

through the aging network (I&A and case management) 

relative to access services activities delivered outside of 

the aging network (e.g., Medicaid or private pay) 

 In-depth interviews with experts 

 Focus groups 

 Role of volunteers in providing I&A and case 

management services 

 In-depth interviews with experts 

 Focus groups 

(continued) 
5-3 

Table 5-1. Study Questions/Issues and Qualitative Data Source(s) (continued) 

Study Questions/Issues to Be 

Addressed with Qualitative Data Qualitative Data Sources 

 Barriers to providing network access services  In-depth interviews 

 Focus groups 

 Ongoing project management activities (including 

strategic planning, outcome measurement, consumer 

assessment and program monitoring) by AAAs and 

SUAs for access (I&A and case management) service 

activities 

 In-depth interviews 

 Focus groups 

 Satisfaction with network access services (I&A and case 

management) 

 In-depth interviews 

 Focus groups 

Sub-Question 2: 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? 

 In-depth interviews with experts 

 Focus groups 

 Extent to which AAAs/SUAs conduct needs assessments 

to determine what needs elderly participants have for 

home care and transportation services, best practices in 

the provision of home care and transportation services to 

AAA participants, and extent to which results have been 

achieved 

 In-depth interviews with experts 

 Focus groups 

 Characteristics of providers of home care and 

transportation services 

 In-depth interviews 

 Focus groups 

 Role/importance of home care and transportation service 

activities delivered through the aging network relative to 

home care and transportation services activities delivered 

outside of the aging network (e.g., Medicaid or private 

pay) 

 In-depth interviews with experts 

 Focus groups 

 Role of volunteers in providing home care and 

transportation services 

 In-depth interviews with experts 

 Focus groups 

 Barriers to providing network home care and 

transportation services 

 In-depth interviews 

 Focus groups 

 Ongoing project management activities (including 

strategic planning, outcome measurement, consumer 

assessment, and program monitoring) by AAAs and 

SUAs for provision of home care and transportation 

services 

 In-depth interviews 

 Focus groups 

(continued) 
5-4 

Table 5-1. Study Questions/Issues and Qualitative Data Source(s) (continued) 

Study Questions/Issues to Be 

Addressed with Qualitative Data Qualitative Data Sources 

Sub-Question 3: 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? 

 In-depth interviews with experts 

 Focus groups 

 Statistical tables from other national 

surveys 

 Prior AoA research (RTI studies) 

 Methods used by AAAs and SUAs to acquire, leverage, 

and manage multiple funding streams by the aging 

network 

 In-depth interviews 

 Focus groups 

 Barriers to the integration and management of multiple 

funding streams by the aging network 

 In-depth interviews 

 Focus groups 

 Financial management best practices and results  In-depth interviews 

 Focus groups 

 Variation in pricing/costs of OAA versus non-OAA 

home- and community-based long-term care services 

 In-depth interviews 

 Focus groups 

 The role/importance of Title III B in providing the aging 

network with support for system and program 

development 

 In-depth interviews 

 Focus groups 

 How states and local governments decide to 

allocate/apportion Title III-B funds to support particular 

supportive services 

 In-depth interviews 

 Focus groups 

We plan to conduct a total of six focus groups—four groups with AAA directors, one 

group with SUA directors, and one group with Title III-B service providers—to gain in-depth 

information to help us address the particular issue areas delineated above. We also plan to 

interview up to eight experts having a national perspective on issues related to access, financing, 

and delivery of Title III-B supportive services to supplement our understanding of the following 

topics and provide us with a national perspective: 

 the types of individuals to recruit for the four focus groups with AAA Directors

 the types of individuals to recruit for the one focus group with State Unit on 

Aging Directors

 the types of individuals to recruit for the one service focus group with Title III-B 

service providers;

 the types of national experts to interview, one-on-one, by telephone 
5-5 

 specific names of potential focus group members and expert interviewees 

 other topics to be included/considered in focus group/expert interview discussions 

A complete listing of items that the Technical Advisory Group (TAG) identified as 

potential discussion topics for qualitative focus group/expert interview discussions (many of 

which already have been identified in Table 5-1 above), is shown in Appendix D of this report.18

All TAG participants are identified in Appendix E. 

 

18 This listing of potential interview topics was developed during a brainstorming session held as part of the Title 

III-B TAG meeting in Washington, DC on April 27th
R-1 

REFERENCES 

Aharony, L., & Strasser, S. (1993). Patient satisfaction: What we know about and what we still 

need to explore. Medical Care Review, 50(1):49–79. 

Administration on Aging. (2006). The Aging Network: Title III and Title VII State Program 

Reports Definitions. Available from: http://www.aoa.gov/prof/agingnet/NAPIS SPR/ 

 SPR_guidance/definspr.asp. Accessed on March 8, 2006. 

Coughlin, T. A., Long, S. K., & Kendall, S. (2002). Health care access, use, and satisfaction 

among disabled Medicaid beneficiaries. Health Care Financing Review, 24(2):115–136. 

Geron, S. M., Smith, K., Tennstedt, S., Jette, A., Chassler, D., & Kasten, L. (2000). The Home 

Care Satisfaction Measure: A client-centered approach to assessing the satisfaction of 

frail older adults with home care services. Journal of Gerontology-Social Sciences, 

55B(5):S259–S270. 

Haviland, M. G., Morales, L. S., Reise, S. P., & Hays, R. D. (2003). Do health care ratings differ 

by race or ethnicity? Joint Commission Journal on Quality and Safety, 29(3):134–145. 

Keepnews, D., (2003). Using patient satisfaction data to improve home healthcare. Presented at 

the meeting “Charting the course for home health quality: Action steps for achieving 

sustainable improvement,” at Center for Home Care Policy and Research, New York. 

Linder-Pelz, S. (1982). Toward a theory of patient satisfaction. Social science & medicine, 

16:577–582. 

Pascoe, G. C., & Attkisson, C. C. (1983). The evaluation ranking scale: A new methodology for 

assessing satisfaction. Evaluation and Program Planning, 6:359–371. 

Summer, L., & Ihara, E. (2004). State Funded Home and Community Based Service Programs 

for Older People. AARP Public Policy Institute. 
APPENDIX A 

NAPIS SPR 2001–2004 TABLES USED IN CONSTRUCTION OF CHARTS 
A-1 

Table A-1. Number of Case Management Clients by Age Group 

Age Group 2001 2002 2003 2004 

60–64 years 30,268 26,083 26,335 25,520 

65–74 years 61,168 62,333 61,167 59,585 

75–84 years 106,996 111,292 106,518 101,291 

85+ years 74,652 79,558 77,316 74,133 

Total 273,084 279,266 271,336 260,529 

Source: RTI analysis of the 2001–2004 NAPIS SPR data. Missing data excluded from calculations. 

Table A-2. Percentage of Case Management Clients Needing Assistance with ADLs 

(Age 60 and over) 

2001 2002 2003 2004 

1+ADL 2+ADL 3+ADL 1+ADL 2+ADL 3+ADL 1+ADL 2+ADL 3+ADL 1+ADL 2+ADL 3+ADL

70.4 56.6 40.1 69.1 57.7 41.7 70.0 58.0 45.0 70.9 59.7 46.0 

Source: RTI analysis of 2001–2004 NAPIS SPR data. Missing data excluded from calculations. 

Table A-3. Percentage of Case Management Clients Needing Assistance with IADLs (Age 

60 and over) Group 

2001 2002 2003 2004 

1+ 

IADL 

2+ 

IADL 

3+ 

IADL 

1+ 

IADL 

2+ 

IADL 

3+ 

IADL 

1+ 

IADL 

2+ 

IADL 

3+ 

IADL 

1+ 

IADL 

2+ 

IADL 

3+ 

IADL 

89.9 85.5 73.9 87.1 82.7 71.2 87.2 81.9 71.7 87.5 82.5 72.4 

Source: RTI analysis of 2001–2004 NAPIS SPR data. Missing data excluded from calculations. 

Table A-4. Title III-B Expenditures, Other Expenditures, and Total Expenditures for 

Information and Assistance Services 

 2001 2002 2003 2004 

Title III-B expenditures $40,706,731 $44,110,708 $46,361,271 $44,389,169 

Non-Title III expenditures 58,170,428 55,222,458 58,692,364 58,902,881 

Total expenditures 98,877,159 99,333,166 105,053,635 103,292,050 

Percentage of total expenditures 

from Title III-B 

41.2 44.4 44.1 43.0 

Source: RTI analysis of 2001–2004 NAPIS SPR data. 
A-2 

Table A-5. Title III-B Expenditures, Other Expenditures, and Total Expenditures for 

Case Management Services 

 2001 2002 2003 2004 

Title III-B expenditures $19,816,453 $20,894,281 $22,698,541 $23,407,744 

Non-Title III-B expenditures 65,721,300 75,701,752 91,151,946 90,289,125 

Total expenditures 85,537,753 96,596,033 113,850,487 113,696,869 

Percentage of total expenditures 

from Title III-B 

23.2 21.6 19.9 20.6 

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

Table A-6. Number of Home Care Clients by Age Group 

Age Group 2001 2002 2003 2004 

Personal Care 

60–64 years 6,558 6,028 6,340 5,069 

65–74 years 15,395 14,124 14,123 12,276 

75–84 years 29,104 28,535 28,699 25,351 

85+ years 25,555 25,612 25,825 23,991 

Total 76,612 74,299 74,987 66,687 

Homemaker 

60–64 years 7,536 7,291 7,167 6,394 

65–74 years 26,850 26,495 25,282 23,574 

75–84 years 51,033 52,504 49,630 46,277 

85+ years 41,579 41,677 39,180 36,865 

Total 126,998 127,967 121,259 113,110 

Chore 

60–64 years 3,389 2,498 2,413 1,840 

65–74 years 10,938 9,374 8,476 7,192 

75–84 years 19,051 16,499 15,685 13,074 

85+ years 12,902 10,925 10,550 8,626 

Total 46,280 39,296 37,124 30,732 

Source: RTI analysis of the 2001–2004 NAPIS SPR data. Missing data excluded from calculations. 
A-3 

Table A-7. Percentage of Home Care Clients Needing Assistance with ADLs (Age 60 and over) 

 2001 2002 2003 

Service Type 1+ADL 2+ADL 3+ADL 1+ADL 2+ADL 3+ADL 1+ADL 2+ADL 3+ADL 1+AD

Personal care 87.9 75.0 57.4 85.6 74.3 59.0 85.8 75.0 60.9 86.5 Homemaker 65.9 51.6 39.4 65.2 52.0 40.5 67.3 54.7 44.0 65.6 Chore 50.4 34.4 25.9 50.9 37.6 27.6 53.6 41.5 32.4 52.8 

Source: RTI analysis of 2001–2004 NAPIS SPR data. Missing data excluded from calculations. Table A-8. Percentage of Home Care Clients Needing Assistance with IADLs (Age 60 and over) 

 2001 2002 2003 

Service Type 

1+ 

IADL 

2+ 

IADL 

3+ 

IADL 

1+ 

IADL 

2+ 

IADL 

3+ 

IADL 

1+ 

IADL 

2+ 

IADL 

3+ 

IADL 

1+ 

IADL 

Personal care 94.4 92.4 88.7 93.0 90.6 85.5 92.3 90.2 86.4 93.2 Homemaker 91.9 87.7 78.5 90.4 86.1 77.6 90.6 86.4 79.0 92.0 Chore 79.6 65.2 54.0 80.7 66.6 54.6 82.6 69.6 57.6 82.2 

Source: RTI analysis of 2001–2004 NAPIS SPR data. Missing data excluded from calculations. 
A-4 

Table A-9. Number of Assisted Transportation Clients by Age Group 

Age Group 2001 2002 2003 2004 

60–64 years 8,699 5,027 6,259 3,694 

65–74 years 16,787 10,482 12,368 7,970 

75–84 years 22,113 16,476 17,193 13,020 

85+ years 13,336 10,795 11,796 8,972 

Total 60,935 42,780 47,616 33,656 

Source: RTI analysis of the 2001–2004 NAPIS SPR data. Missing data excluded from calculations. 

Table A-10. Title III-B Expenditures, Other Expenditures, and Total Expenditures for 

Home Care Services 

 2001 2002 2003 2004 

Personal Care 

Title III-B expenditures $12,605,838 $12,644,067 $16,928,237 $14,681,278 

Non-Title III-B expenditures 88,143,747 97,584,277 84,878,391 85,832,168 

Total expenditures 100,749,585 110,228,344 101,806,628 100,513,446 

Percentage of total expenditures 

from Title III-B 

12.5 11.5 16.6 14.6 

Homemaker 

Title III-B expenditures 21,566,253 26,470,604 30,196,794 25,733,033 

Non-Title III-B expenditures 76,240,036 73,844,371 79,329,493 69,364,110 

Total expenditures 97,806,289 100,314,975 109,526,287 95,097,143 

Percentage of total expenditures 

from Title III-B 

22.0 26.4 27.6 27.1 

Chore 

Title III-B expenditures 5,870,893 5,844,989 8,257,617 6,351,626 

Non-Title III-B expenditures 12,409,792 13,720,865 12,778,912 9,889,821 

Total expenditures 18,280,685 19,565,854 21,036,529 16,241,447 

Percentage of total expenditures 

from Title III-B 

32.1 29.9 39.3 39.1 

Source: RTI analysis of 2001–2004 NAPIS SPR data. 
A-5 

Table A-11. Title III-B Expenditures, Other Expenditures, and Total Expenditures for 

Transportation Services 

 2001 2002 2003 2004 

Transportation 

Title III-B expenditures $68,770,128 $79,967,764 $78,437,319 $66,484,209 

Non-Title III-B expenditures 115,548,159 115,035,357 107,249,183 119,068,809 

Total expenditures 184,318,287 195,003,121 185,686,502 185,553,018 

Percentage of total expenditures 

from Title III-B 

37.3 41.0 42.2 35.8 

Assisted Transportation 

Title III-B expenditures $3,725,875 $3,664,807 $3,611,591 $3,574,395 

Non-Title III-B expenditures 13,607,866 12,166,307 11,513,291 11,192,621 

Total expenditures 17,333,741 15,831,114 15,124,882 14,767,016 

Percentage of total expenditures 

from Title III-B 

21.5 23.1 23.9 24.2

Source: RTI analysis of 2001–2004 NAPIS SPR data. 
A-6 

Table A-12. Total Title III-B expenditures by Service Type and Year 

Service 

2001 

Title III 

Expenditures 

2002 

Title III 

Expenditures 

2003 

Title III 

Expenditures 

2004 

Title III 

Expenditures 

Title III-B Access Services 

Information and assistance $40,706,731 $44,110,708 $46,361,271 $44,389,169 

Case management 19,816,453 20,894,281 22,698,541 23,407,744 

Title III-B Home Care 

Services 

 

Personal care 12,605,838 12,644,067 16,928,237 14,681,278 

Homemaker 21,566,253 26,470,604 30,196,794 25,733,033 

Chore 5,870,893 5,844,989 8,257,617 6,351,626 

Title III-B Transportation 

Services 

 

Transportation 68,770,128 79,967,764 78,437,319 66,484,209 

Assisted transportation 3,725,875 3,664,807 3,611,591 3,574,395 

Other Title III-B Services 

Adult day care/health 8,490,532 11,312,083 9,725,986 9,283,374 

Legal assistance 20,008,792 22,418,719 23,411,301 23,128,146 

Outreach 10,130,332 10,141,161 11,533,848 10,694,833 

Other 85,718,148 101,490,556 93,213,310 95,830,484 

Total III-B Services $297,409,975 $338,959,739 $344,375,815 $323,558,291 

Source: RTI analysis of the 2001–2004 NAPIS SPR data. 
A-7 

Table A-13. Total Non-Title III-B Expenditures by Service Type and Year 

Service 

2001 

Non-Title III 

Expenditures 

2002 

Non-Title III 

Expenditures 

2003 

Non-Title III 

Expenditures 

2004 

Non-Title III 

Expenditures 

Title III-B Access Services 

Information and assistance $58,170,428 $55,222,458 $58,692,364 $58,902,881 

Case management 65,721,300 75,701,752 91,151,946 90,289,125 

Title III-B Home Care 

Services 

 

Personal care 88,143,747 97,584,277 84,878,391 85,832,168 

Homemaker 76,240,036 73,844,371 79,329,493 69,364,110 

Chore 12,409,792 13,720,865 12,778,912 9,889,821 

Title III-B Transportation 

Services 

 

Transportation 115,548,159 115,035,357 107,249,183 119,068,809 

Assisted transportation 13,607,866 12,166,307 11,513,291 11,192,621 

Other Title III-B Services 

Adult day care/health 58,497,275 60,825,596 56,889,560 49,176,956 

Legal assistance 25,816,953 20,676,550 22,637,749 26,395,286 

Outreach 15,667,392 13,627,199 14,924,225 14,748,939 

Other 252,860,614 222,039,396 235,297,993 217,175,050 

Total III-B Services $782,683,562 $760,444,128 $775,343,107 $752,035,766 

Source: RTI analysis of the 2001–2004 NAPIS SPR data. 
A-8 

Table A-14. Total Expenditures (Title III and Non-Title III) by Service Type and Year 

Service 

2001 

Total 

Expenditures 

2002 

Total 

Expenditures 

2003 

Total 

Expenditures 

2004 

Total 

Expenditures 

Title III-B Access Services 

Information and assistance $98,877,159 $99,333,166 $105,053,635 $103,292,050 

Case management 85,537,753 96,596,033 113,850,487 113,696,869 

Title III-B Home Care 

Services 

 

Personal care 100,749,585 110,228,344 101,806,628 100,513,446 

Homemaker 97,806,289 100,314,975 109,526,287 95,097,143 

Chore 18,280,685 19,565,854 21,036,529 16,241,447 

Title III-B Transportation 

Services 

 

Transportation 184,318,287 195,003,121 185,686,502 185,553,018 

Assisted transportation 17,333,741 15,831,114 15,124,882 14,767,016 

Other Title III-B Services 

Adult day care/health 66,987,807 72,137,679 66,615,546 58,460,330 

Legal assistance 45,825,745 43,095,269 46,049,050 49,523,432 

Outreach 25,797,724 23,768,360 26,458,073 25,443,772 

Other 338,578,762 323,529,952 328,511,303 313,005,534 

Total III-B Services $1,080,093,537 $1,099,403,867 $1,119,718,922 $1,075,594,057 

Source: RTI analysis of the 2001–2004 NAPIS SPR data. 
APPENDIX B 

RESULTS FROM 2003 AND 2004 NATIONAL SURVEYS 
B-1 

Table B-1. Demographic Data on Information and Assistance Users 

Demographic Variable 

2003 National Survey Data

N=337 

Weighted N=12,102,005 

Percentage 

2004 National Survey Data

N=455 

Weighted N=12,255,160 

Percentage 

Age 

Under 60 20.8 29.2 

60–64 16.0 16.0 

65–74 34.2 20.9 

75–84 22.8 27.1 

85+ 6.3 6.8 

Gender 

Male 23.9 17.7 

Female 76.1 82.3 

Race/Ethnicity 

Hispanic origin 5.1 4.5 

White 86.1 83.4 

African American 9.1 13.5 

Asian/American Indian/Pacific 

Islander 

6.4 1.5 

Other 1.6 2.9 

Residence 

Urban 52.9 39.7 

Suburban 17.5 37.4 

Rural 29.6 22.9 

Education 

High school or less 53.5 36.0 

Some college or college degree 46.5 42.8 

Some post-graduate/advanced 

degree 

0.0 21.3 

Living Alone 42.2 42.9 

Married 38.9 45.4 

Source: RTI analysis of the 2003 and 2004 National Survey data. 
B-2 

Table B-2. Use of I&A Services: 2003 and 2004 National Survey Data 

Utilization Variable 

2003 National Survey Data

N=337 

Weighted N=12,102,005 

Percentage 

2004 National Survey Data

N= 445 

Weighted N=12.255,160 

Percentage 

Why I&A Call was Made 

Obtain help/services for self 58.1 57.2 

Get help for relative/someone else 41.5 37.6 

Calling from agency for participant 6.6 8.9 

Other 0.5 1.5 

Reason for Calla 

To obtain services 69.6 64.4 

To get information 44.4 89.1 

To express financial concerns 6.9 39.5 

To express health insurance 

concerns 

3.2 22.5 

To file a complaint 3.1 1.7 

To refer a participant for services 2.0 67.6 

To follow-up on a prior call 0.4 22.5 

If Ever Used Service Before 24.1 22.5 

Number Times Used Service in Past 

Year 

3.3 9.6 

How Quickly Call Answered 

Immediately, after 1 to 2 rings 41.6 39.5 

Quickly, fewer than 5 rings 53.3 50.8 

After a little while, 5 to 15 rings 2.7 7.5 

Had to wait a long time, more than 

15 rings 

2.5 2.3 

Who Answered Phone 

Voicemail 14.9 22.2 

Person 85.1 77.8 

a

 Survey respondents could provide more than one reason. 

Source: RTI analysis of 2003 and 2004 National Survey data. 
B-3 

Table B-3. Information and Assistance Service: Logistic Regressions Estimating Who 

People Call For 

Likelihood of Calling 

I&A for Self 

Likelihood of Calling 

I&A for Relative 

 Full Final Full Final 

Sample Size 349 349 352 352 

F-value 8.02 10.16 8.11 11.93 

Prob>F 0.000 0.000 0.000 0.000 

Variables 

Age 75 and over 3.59** 3.21* 0.34** 0.34** 

Male 6.12** 6.20** 0.33 

Urban resident 2.61* 0.97 

Rural resident 4.03** 0.44* 

High school or less 2.91** 3.23** 0.55 

Non-white race 1.84 2.11 0.88 

Not married 2.68 2.03 0.17** 0.26** 

Live alone 9.75*** 9.90*** 0.13*** 0.12*** 

Notes: * p < .10, ** p < .05, *** p < .01. 

Estimates adjusted for complex survey design 

Source: RTI analysis of the 2004 National Survey of OAA Programs. 
B-4 

Table B-4. Demographic Data on Homemaker Service Users 

Demographic Variable 

2003 National Survey Data

N=407 

Weighted N=163,463 

Percentage 

2004 National Survey Data

N=1,253 

Weighted N=161,693 

Percentage 

Age 

Under 60 0.1 0.5 

60–64 4.9 4.9 

65–74 22.7 25.1 

75–84 43.8 40.9 

85+ 28.6 28.5 

Gender 

Male 19.2 19.7 

Female 80.8 80.3 

Race/Ethnicity 

Hispanic origin 3.1 5.8 

White 79.1 81.3 

African American 17.3 15.6 

Asian/American Indian/Pacific 

Islander 

4.2 2.3 

Other 2.0 1.4 

Residence 

Urban 50.6 58.4 

Suburban 22.3 23.0 

Rural 27.2 18.6 

Education 

High school or less 73.9 73.7 

Some college or college degree 26.1 23.6 

Some post-graduate/advanced 

degree 

0.0 2.8 

Living Alone 69.5 72.5 

Married 16.8 14.5 

Source: RTI analysis of the 2003 and 2004 National Survey data. 
B-5 

Table B-5. Percentage of Homemaker Clients Needing Assistance with ADLs (Age 60 and 

over) 

 2003 National Survey 2004 National Survey 

Service Type 1+ADL 2+ADL 3+ADL 1+ADL 2+ADL 3+ADL 

Homemaker 85.4 64.4 44.6 77.3 54.4 31.9 

Source: 2003 and 2004 National Survey Data. 

Table B-6. Percentage of Homemaker Clients Needing Assistance with IADLs (Age 60 and 

over) 

 2003 National Survey 2004 National Survey 

Service Type 1+IADL 2+IADL 3+IADL 1+IADL 2+IADL 3+IADL 

Homemaker 91.3 71.2 36.6 92.4 68.4 44.1 

Source: RTI analysis of the 2003 and 2004 National Survey Data. 
B-6 

Table B-7. Demographic Data on Transportation Service Users 

Demographic Variable 

2003 National Survey Data

N=397 

Weighted N=430,310 

Percentage 

2004 National Survey Data

N=715 

Weighted N=359,145 

Percentage 

Age 

Under 60 3.8 0.0 

60–64 3.5 5.3 

65–74 26.5 21.1 

75–84 43.6 42.8 

85+ 22.6 30.8 

Gender 

Male 18.6 10.6 

Female 81.3 89.4 

Race/Ethnicity 

Hispanic origin 6.3 6.6 

White 76.4 69.9 

African American 19.0 25.0 

Asian/American Indian/Pacific 

Islander 

5.7 2.7 

Other 2.0 3.0 

Residence 

Urban 51.5 52.6 

Suburban 16.5 21.6 

Rural 32.0 25.8 

Education 

High school or less 77.7 75.0 

Some college or college degree 22.3 21.4 

Some post-graduate/advanced 

degree 

0.0 3.6 

Living Alone 60.9 65.1 

Married 21.9 15.1 

Source: RTI analysis of the 2003 and 2004 National Survey data. 
B-7 

Table B-8. Percentage of Transportation Clients Needing Assistance with ADLs (Age 60 

and over) 

 2003 National Survey 2004 National Survey 

Service Type 1+ADL 2+ADL 3+ADL 1+ADL 2+ADL 3+ADL 

Transportation 85.4 64.4 44.6 77.3 54.2 31.9 

Source: RTI analysis of the 2003 and 2004 National Survey Data. 

Table B-9. Percentage of Transportation Clients Needing Assistance with IADLs (Age 60 

and over) 

 2003 National Survey 2004 National Survey 

Service Type 1+IADL 2+IADL 3+IADL 1+IADL 2+IADL 3+IADL 

Transportation 91.3 71.2 36.6 92.4 68.4 31.9 

Source: RTI analysis of the 2003 and 2004 National Survey Data. 
B-8 

Table B-10. Use of Transportation Services: 2003 and 2004 National Survey Data 

Utilization Variable 

2003 National Survey 

Data 

N=397 

Weighted N=430,310 

2004 National Survey 

Data 

N=715 

Weighted N=359,145 

How many days ago used service last 

Mean number of days 16.9 days 20.2 days 

Less than 1 week ago (%) 55.0 54.8 

Between 1 and 2 weeks 10.2 13.6 

Between 3 and 4 weeks 11.4 6.5 

More than 4 weeks ago 23.4 25.2 

Average number of local trips/month 8.1 13.2 

How much rely on service in average month 

For just a few trips (%) 22.9 23.7 

One-quarter of all trips 13.5 11.4 

Half of all trips 16.5 11.5 

Three-quarters of all trips 8.9 9.5 

Nearly for all trips 38.3 43.9 

Where get on vehicle 

Door pick up (drive comes to door) (%) 50.2 48.4 

Door pick-up (driver does not come to door) 45.7 48.0 

Down the block 2.4 2.0 

Down several blocks 1.6 1.6 

Can get around more than before using 

service (%) 

74.5 65.0 

Improved access to activities due to 

transportation service usea

 

Physicians/other health providers (%) 70.4 64.2 

Senior center 47.8 49.3 

Shopping 43.2 38.6 

Lunch program 34.4 40.0 

Social events and recreation 31.5 28.8 

Volunteering 26.8 19.6 

Friends, neighbors, relatives 19.5 11.9 

Clubs/meetings 14.2 13.5 

Religious services 9.4 10.3 

Work 4.4 3.9 

Other 0.5 1.5 

a

 Respondents could provide more than one answer. 
B-9 

Table B-11. Satisfaction with Homemaker Services: 2003 and 2004a

Home Care Satisfaction Item 

2003 National Survey 

Unweighted N= 407 

Weighted N=163,463 

Percentage 

2004 National Survey 

Unweighted N=1,255 

Weighted N=161,693 

Percentage 

Homemaker is very thorough 87.2 87.5 

Homemaker does things the way participant 

wants 

88.3 90.4 

Homemaker has become a friend 82.1 83.9 

Homemaker takes interest in participant 92.1 92.0 

More hours of homemaker service needed 

each week 

39.3 36.0 

Homemaker knows what to do 94.2 95.7 

Homemaker has enough time to do all jobs 75.4 77.6 

Homemaker does extra things for participant 63.5 66.5 

Participant wishes that the homemaker could 

do more things 

44.7 44.7 

Homemaker does not leave too early 87.5 84.8 

Homemaker is not rude 97.9 98.0 

Homemaker does not arrive late 89.6 88.4 

Homemaker does not ignore participant wishes 91.8 91.2 

a

 These National Survey data were used in the construction of the Rating of Homemaker Services figure in Section 

3 of this report. 

Source: RTI analysis of 2003 and 2004 National Survey data. 
B-10 

Table B-12. Estimating Satisfaction with Homemaker Services Using the HCSM Scale 

(OLS Model) 

 Full Model Final Model 

N = 968 

F-value 1.34 4.42 

Prob>F 0.2391 0.0078 

R-square 0.0852 0.0665 

Variables 

Age 75 and over –0.17 

Male 1.80 

Urban resident 7.01** 4.51* 

Rural resident 5.15* 

High school or less –0.38 

Non-white race –5.19** –4.81* 

Not married 2.77 

Live alone –2.54 

Three or more ADLs –5.30* –4.97** 

Three or more IADLs 0.35 

Constant 77.68*** 80.60*** 

Notes: * p < .10, ** p < .05, *** p < .01. 

Estimates adjusted for complex survey design 

Source: RTI analysis of the 2004 National Survey of OAA Programs. 
B-11 

Table B-13. Estimating Logistic Regressions for Satisfaction with Homemaker Service Outcomes 

Increasing Social 

Activities Since 

Participating in 

HM 

Need More Hours 

of HM Each Week 

HM Assigned Enough Time 

Participant Wishes 

HM Would Do 

More 

Model Full Final Full Final Full Final Full Final 

N 944 956 947 947 F-value 1.59 4.86 2.84 5.48 2.25 5.54 3.5 3.79 Prob>F 0.141 0.012 0.008 0.001 0.032 0.001 0.002 0.009 Variables 

Age 75 and over 0.29*** 0.40** 1.28 1.40 0.53** 0.56** Male 1.83 2.14** 0.84 1.84 1.88 0.54* Urban resident 3.10** 0.87 0.97 0.48* 0.50* Rural resident 3.72*** 1.25 1.35 0.88 High school or less 0.83 0.89 1.40 0.81 Non-white race 1.00 1.69 1.61 1.28 2.51** 2.30* Not married 0.72 0.88 0.69 0.70 Live alone 0.96 0.48* 0.44** 2.68** 2.10*** 0.74 Three or more ADLs 0.67 2.75** 2.69** 0.35*** 0.35*** 1.86** 1.95*** Three or more IADLs 1.22 1.12 1.10 0.74 0.75 0.94 

Notes: * p < .10, ** p < .05, *** p < .01. 

Estimates adjusted for complex survey design 

Source: RTI analysis of the 2004 National Survey of OAA Programs. 
B-12 

Table B-14. Estimating Satisfaction with Transportation Service 

Likelihood of being able to get 

around more than before due to 

using transportation services 

Likelihood of rating 

transportation services as at least 

good 

 Full Final Full Final 

#Obs 550 550 574 574 

F-value 4.05 4.96 5.01 3.48 

Prob>F 0.0009 0.0114 0.0001 0.0395 

Variables 

Age 75 and over 0.70 0.68 

Male 0.90 1.47 

Urban resident 1.14 7.90** 4.90* 

Rural resident 0.91 1.02 

High school or less 2.59** 2.30** 1.60 

Non-white race 0.52 0.23** 

Not married 3.15* 10.73*** 

Live alone 0.24*** 0.48*** 0.19*** 

Three or more ADLs 1.78 14.58** 7.61* 

Three or more 

IADLs 

0.38** 0.19** 

Notes: * p < .10, ** p < .05, *** p < .01. 

Estimates adjusted for complex survey design 

Source: RTI analysis of the 2004 National Survey of OAA Programs. 
APPENDIX C 

TOPICS TO BE ADDRESSED BY QUALITATIVE DATA 
C-1 

TOPICS TO BE ADDRESSED BY QUALITATIVE DATA 

 Extent to which AAAs conduct needs assessments to determine what 

needs elderly participants have for Title III-B services: 

– to compare how AAA participants vary from elderly population as a 

whole 

– to determine need for access (I&A) and care management services 

– to determine need for home care (personal care, chore, homemaker) 

services 

– to determine need for transportation services 

 Best practices/results from 

– provision of access services 

– provision of home care services 

– provision of transportation services 

– financial management of Title III-B services 

 Role of the aging network relative to the non-aging network in 

– providing access/care management services 

– providing home care services 

– providing transportation services 

 Role of volunteers in 

– providing access/care management services 

– providing home care services 

– providing transportation services 

 Barriers to the 

– provision of access/care management services 

– provision of home care services 

– provision of transportation services 

– the integration and management of multiple streams by aging network 

 Ongoing program management (including strategic planning, outcome 

measurement, consumer assessments and program monitoring) of 

– access/management services 

– home care services 

– transportation services 
C-2 

 Characteristics of providers of 

– home care services 

– transportation services 

 Methods to acquire/leverage and manage multiple funding streams 

– All Title III-B services 

 Variation in pricing/costs of OAA versus non-OAA home- and 

community-based long-term care services 

– All Title III-B services 

 The role/importance of Title III B in providing the aging network with 

support for system and program development

 How states and local governments decide to allocate/apportion Title III-B 

funds to support particular supportive services
D-1 

APPENDIX D 

POTENTIAL QUALITITATIVE DISCUSSION TOPICS FROM 

TECHNICAL ADVISORY GROUP 

During the April 27th Title III-B TAG meeting, held in Washington, DC, TAG 

members were asked to suggest areas that potentially could be investigated through focus 

groups and expert interviews. A complete listing of TAG members who attended this 

meeting is shown in Appendix E. Suggestions made by TAG members (some of which 

already have been identified by AoA and RTI and included by research question in 

Section 5.2 of this report) include: 

• To investigate how the Title III B funding mechanism provides flexibility and is 

being used to support innovation and a wide variety of services in both rural and 

urban settings. 

• To investigate how the infrastructure created by Title III allows other programs to 

serve older people in a consistent manner with certain standards. 

• To investigate how Title III B funds are important to the states for their flexibility to 

support change through partnerships, and to fill gaps in needed services. 

• To examine how Title III B is helping communities adapt to the aging population by 

working with local government to enable older adults to age in place. 

• To investigate the outcomes made possible by the flexibility of Title III B in different 

states and identify best practice models for the states to consider. 

• To investigate the ability of Title III B to provide an incubator and launching point 

for systems change. 

• To investigate how Title III B can support a culture of innovation in the Aging 

Network through training to create the new skill sets needed to introduce systems 

change. 

• To investigate what changes are needed in Title III B to do a better job of serving the 

community. 

• To investigate what is happening in individual communities resulting in lower 

numbers of clients served. 

• To investigate the impact of Title III B on minority consumers. 

• To investigate how Title III B is working with the disabled community. 

• To investigate what AAAs would do with the Title III B funding if it came without 

restrictions. 

• To investigate the partnerships and coordination developed by Title III B funding that 

may not show up the AAA program budget because these services are not housed in 

AAAs or paid for by III B dollars. 

• To gain a better understanding of the barriers to service use. 

• To investigate what is being done to further develop and expand home and 

community based services for older persons and specifically what role is being played 

by the AAAs (e.g. leadership, technical assistance, coordination). 
D-2 

• To investigate how Title III B home care fits in the overall home and community 

based system, including who is served by Title III B and by state services, and what is 

each program able to do. 

• To investigate how the decision is made as to what programs are funded, and how 

that decision is influenced by how the state is structured and where the money comes 

from. 

• To examine to what degree decisions about the use of Title III B funds are driven 

from the bottom up and to what degree from the top down. 

• To investigate how AAAs are negotiating change in Title III B programming in the 

setting of an existing network of providers and infrastructure to which the 

organization is to some degree obligated. 

• To examine the degree to which State Units on Aging push AAAs to direct their Title 

III B efforts in a certain direction, and how much flexibility they are committed to 

granting AAAs. 

• To examine to what extent AAAs manage their Title III B funds separately and to 

what extent they manage these funds as part of integrated state long term care 

systems. 

• To investigate what policy changes are needed for AAAs to better provide and 

expand opportunities for older persons to improve their quality of care and quality of 

life, and to gain an in-depth understanding of the major problem barriers to that 

process. 
E-1 

APPENDIX E 

TECHNICAL ADVISORY GROUP MEMBERS WHO 

PARTICIPATED IN THE APRIL 27TH, 2006 

TITLE III-B MEETING IN WASHINGTON, DC 

1. Dan Berger 

US Department of Health and Human Services, 

Administration on Aging 

2. Virginia Dize 

Associate Director of Home and Community Based Services

National Association of State Units on Aging 

3. Pam Doty 

Senior Policy Analyst, US Department of Health and Human Services, 

Office of the Assistant Secretary for Planning and Evaluation 

4. Mary Lynn Kasunic 

President and CEO/Executive Director 

Area Agency on Aging, Region One, Arizona 

5. Jorge Lambrinos, PhD 

Executive Director, Roybal Institute for Applied Gerontology, 

University of Southern California 

6. Ms. Sandy Markwood 

Chief Executive Officer 

National Association of Area Agencies on Aging 

7. Cheryll Schramm 

Director 

Atlanta Regional Commission 

8. Jim Varpness 

Executive Director 

Minnesota Board on Aging