Putting Data to Work for Older People

RESEARCH BRIEF NUMBER 4 • JULY 20 1 1

Multiple Chronic Conditions Among OAA Title III 

Program Participants

by Rebecca Kleinman and Leslie Foster, Mathematica Policy Research

Since passage of the Older Americans Act (OAA) in 1965, the Administration on Aging (AoA) has supported the delivery 

of services to elderly Americans, helping them maintain independence and remain in their own homes. Through its “Aging 

Services Network,” including State Units on Aging (SUAs), Area Agencies on Aging (AAAs), tribal partners, and service providers, 

AoA works to provide services designed to mitigate the effects of declining physical health and functioning experienced by frail 

older adults. This brief, the fourth in a series that presents findings from AoA’s National Survey of OAA Program Participants, 

explores the prevalence of and challenges associated with multiple chronic conditions among program participants.

The Aging Services Network provides a range of 

community-based services—home-delivered and 

congregate meals, case management, transportation, and homemaker and caregiver support. Such 

services enhance both the quality of life and social 

interaction, and reduce the effects of disability for 

homebound and more active seniors. Funded under 

Title III of the OAA, services are available to individuals age 60 and older, though delivery is targeted 

to the most vulnerable elderly. 

Background What Is The Aging Services Network?

A growing body of research points to the burden of 

chronic conditions and particularly of multiple chronic 

conditions (MCC) in the U.S. population (Vogeli et al. 

2007). Chronic conditions are illnesses or disabilities 

that persist for at least a year and require medical attention and/or self-care. In the United States, almost half of 

people in all age groups have at least one chronic condition; of these, almost half have two or more (Anderson 

2010). Likelihood of MCC increases with age. Thus, as 

the U.S. population ages the proportion of people living 

with MCC will grow.

The challenges posed by MCC are potentially great (Vogeli 

et al. 2007). Especially as the number of conditions mounts, 

people with MCC are more likely than others to have difficulty performing activities of daily living (ADLs), such 

as getting in or out of bed, eating, and using the toilet unassisted. They are at greater risk for complications of their 

conditions, adverse drug events, avoidable hospitalizations, 

and nursing home placement. People with MCC are more 

likely than others to be depressed. Their family members 

and friends face a more complicated caregiving role.

The U.S. Department of Health and Human Services 

is launching a coordinated public–private response to 

the growing challenge of chronic conditions and MCC 

(U.S. Department of Health and Human Services 2010). 

Because AoA’s partners in the Aging Services Network 

provide OAA Title III services to 10 million older, 

community-dwelling adults each year, the agency plays 

an important role in this response.

This brief describes MCC prevalence among Title III 

participants and examines its association with ADL limitations, hospital and nursing home stays, and well-being. 

Data are drawn from the Fifth National Survey of OAA 

Program Participants, which asks participants whether 

a doctor has ever told them they have any of 20 chronic 

conditions. Data are presented separately for participants 

in programs that provide congregate meals, transportation, 

home-delivered meals, homemaker services, case management, and caregiver support.1

 Because each program is 

designed to serve participants with certain types of needs 

and limitations, the prevalence of MCC among participants in each program might also be expected to differ.

1

 The National Family Caregiver Support Program (NFCSP), also part 

of Title III, provides respite, information, and other assistance to those 

who care for frail elderly relatives. The data in this brief describe the 

care recipients of participants in the NFCSP.
Nine of Ten Participants Have MCC

The prevalence of MCC among Title III participants is 

strikingly high. According to AoA’s Fifth National Survey 

of OAA Participants, at least 90 percent of participants in 

all programs have MCC (Figure 1). Another survey estimates that MCC prevalence among all adults 65 or older 

is 73 percent (Anderson 2010).2 Although some of the 

difference between the estimates could be methodological, previous briefs in this series have shown that Title III 

participants are less healthy than the national population 

of older adults (Barrett and Schimmel 2010).

Title III participants with MCC report a great number of 

chronic conditions. In four of six programs, more than 

one-third of participants report eight or more chronic 

conditions (Figure 1). In the congregate meals and transportation programs, 41 and 53 percent of participants, 

respectively, report six or more conditions.

In all six programs, high blood pressure, eye or vision 

conditions, and arthritis or rheumatism are the most common individual conditions reported by those with MCC 

(not shown). The prevalence of each ranges from 58 to 83 

percent. Among care recipients of participants in the caregiver support program, serious memory-related diseases—

such as Alzheimer’s or dementia (59 percent)—and heart 

conditions (50 percent) are also common. Persistent pain, 

aching, stiffness, or joint swelling (as distinct from arthritis 

or rheumatism) also are common among participants in all 

six programs (ranging from 41 to 69 percent).

2

 Anderson’s estimate is based on the 2006 Medical Expenditure Panel 

Survey (MEPS), which asks respondents to name all chronic conditions they experienced during a given period.

Figure 1: Number of Chronic Conditions Reported by Participants

8 or more

6 to 7

4 to 5

2 to 3

0 to 1

Home-delivered 

meals

Homemaker 

services

Transportation Case 

management

Congregate 

meals

Care 

recipients

Percentage of Participants

100

90

80

70

60

50

40

30

20

10

0

19

22

30

22

7

27

26

29

15

4

35

28

20

13

3

41

26

24

5 4

50

24

18

7 1

40

29

26

4 2

2

Source: Calculations based on the Fifth National Survey of OAA Program Participants, 2009.

Limitations in ADL Increase with MCC

In four of the six Title III programs, about one-third 

or more of participants with MCC have at least three 

ADL limitations (Figure 2). Such activity limitations 

can be a consequence of MCC. Whether MCC and ADL 

limitations coincide likely depends on the nature of the 

specific conditions (some, such as multiple sclerosis and 

Alzheimer’s, are inherently limiting as they progress), 

their severity and duration, and how well they are managed, among other factors. Although the Fifth National 

Survey of OAA Participants does not ask about the 

severity or duration of reported conditions, the survey 

data show that functional limitation becomes more likely 

as chronic conditions increase in number (Figure 3). 

In the homemaker services program, for example, 20 

percent of participants without MCC have limitations 

in at least three ADLs, compared with 36 percent of 

participants with four or five chronic conditions, 

and 54 percent of participants with eight or more 

chronic conditions.

Hospital and Nursing Home Stays 

Increase with MCC

AoA survey data demonstrate the relationship between 

MCC and greater use of intensive health services, such 

as overnight stays in hospitals and nursing homes. In the 

homemaker services program, for example, participants 

with more than seven conditions, the median number 

for participants in this program, were twice as likely as 

those with fewer conditions to have stayed overnight in 

a hospital and nursing home at least once in the past year 
3

(Figure 4). Although overnight stays are less common 

among participants in the congregate meals program, 

the association between hospital and nursing overnight 

stays and MCC is even starker. Twenty-eight percent of 

above-median participants stayed overnight in a hospital 

and 7 percent in a nursing home, compared with much 

smaller proportions of below-median participants (12 

percent and 1 percent, respectively).

Figure 2: Among Participants with MCC, Percentage 

Reporting Difficulty with at Least Three 

ADL Limitations

Home-delivered

meals

Homemaker

services

Transportation

Case

management

Congregate

meals

Care

recipients

31%

42%

18%

9%

68%

41%

0 20 40 60 80 100

Source: Calculations based on the Fifth National Survey of OAA 

Program Participants, 2009.

Figure 3: Relationship Between MCC and ADL Limitations

Home-delivered meals

Homemaker services

Transportation

Case management

Congregate meals

Care recipients

Number of Chronic Conditions

Limited in 3 or More ADLs (%)

100

90

80

70

60

50

40

30

20

10

0

0 to 1 4 to 5 8 or more

Source: Calculations based on the Fifth National Survey of OAA Program Participants, 2009.

Self-Reported Health and Well-Being 

Declines as MCC Increases

In each program, participants with an above-median 

number of chronic conditions were more likely than others to say their health was poor (not shown). Among participants in the transportation and home-delivered meals 

programs, for example, participants reporting abovemedian levels of MCC were three times as likely to 

rate their health as poor, compared with those reporting 

below-median MCC. For participants in the home-delivered meals program, 32 percent of the above-median 

group report having poor health—fully 23 percentage 

points higher than the below-median group.

Participants with an above-median number of chronic 

conditions were also more likely to say they felt downhearted or depressed (not shown). Fifteen percent of 

case management recipients with above-median MCC 
4

report feeling downhearted or depressed during all or 

most of the previous four weeks, compared with only 

5 percent of below-median participants. Conversely, a 

higher proportion of the below-median group said they 

were never depressed (24 percent), compared with the 

above-median group (18 percent).

Figure 4: Percentage Hospitalized or in Nursing Home Overnight in Past 12 Months

Home-delivered meals

(median = 6)

Homemaker services

(median = 7)

Transportation

(median = 6)

Case management

(median = 7)

Congregate meals 

(median = 5)

Hospitalized Overnight Nursing Home Overnight

0% 20% 40% 60% 0% 20% 40% 60%

Below median 

number of 

chronic conditions

Above median 

number of 

chronic conditions

12

28

21

36

30

44

24

48

46

51

1

7

5

10

9

14

10

20

13

19

Source: Calculations based on the Fifth National Survey of OAA Program Participants, 2009.

Conclusions and Implications

The older adults who receive Title III services report a 

high prevalence of MCC. The more chronic conditions 

OAA Title III participants have, the more likely they are 

to report ADL limitations, overnight stays in a hospital 

or nursing home, and poor health and well-being. With 

two-thirds of Medicare spending directed toward older 

and disabled adults who have five or more chronic 

conditions, and greater rates of inappropriate hospitalization among them, efforts to improve the health of 

older adults with MCC are critical to lowering spending 

(Anderson 2010).

AoA-funded service providers serve vulnerable populations that exhibit many and varied needs. These providers have great reach and direct, frequent contact with 10 

million Title III program participants. The aging services 

network is especially well placed to help achieve two 

goals established by U.S. Department of Health & 

Human Services Interagency Workgroup on Multiple 

Chronic Conditions:

1. To provide better tools and information to health 

care and social services workers who deliver care to 

individuals with MCC

2. To maximize the use of proven self-care management 

and other services by individuals with MCC (U.S. 

Department of Health and Human Services 2010)

In addition to helping participants manage particular 

chronic conditions—by serving meals that are appropriate for people on special diets, for example—AoAfunded service providers who have frequent contact with 

Title III participants can detect signs of worsening health 

status and refer at-risk participants to health professionals. AoA-funded service providers can also help achieve 

these national strategic goals by targeting evidencebased programs and strategies for MCC care management and self-care to Title III participants at greatest risk 

of declining health and functioning.

Data

Information on Title III participants was drawn from the 

Fifth National Survey of OAA Program Participants. 

Westat Inc. conducted the telephone survey in 2009, 

administering it to more than 5,000 people who reported 

receiving Title III services. The survey used a two-stage 

sample design, first selecting a sample of AAAs and 

then randomly sampling participants from each selected 
AAA by service type. The number of participants 

selected from each AAA was proportional to the number 

of participants served in that particular service by the 

sampled AAA. All analyses in this brief apply sample 

weights to account for this design. Additional data from 

and more detailed documentation for the Fifth National 

Survey and other AoA data sources are available on the 

new interactive AGing Integrated Database (AGID) at 

http://data.aoa.gov.

This brief includes data for participants in six of the 

service types included in the survey: home-delivered 

meals (1,030 respondents), homemaker services (459 

respondents), transportation services (824 respondents), 

congregate meals (903 respondents), case management 

(486 respondents), and caregivers (1,793 respondents). 

Individuals are categorized as program participants 

based on the program for which they were surveyed.

References

Anderson, Gerard. “Chronic Care: Making the Case for 

Ongoing Care.” Princeton, NJ: Robert Wood Johnson 

Foundation, 2010. Available at http://www.rwjf.

org/files/research/50968chronic.care.chartbook.pdf. 

Accessed on February, 23, 2011.

Barrett, Allison, and Jody Schimmel. “OAA Title III 

Services Target the Most Vulnerable Elderly in the 

United States.” Washington, DC: Mathematica Policy 

Research, August 2010.

U.S. Department of Health and Human Services. 

“Multiple Chronic Conditions—A Strategic 

Framework: Optimum Health and Quality of Life 

for Individuals with Multiple Chronic Conditions.” 

Washington, DC: DHHS, December 2010.

Vogeli, Christine, Alexandra Shields, Todd Lee, Teresa 

B. Gibson, William D. Marder, Kevin B. Weiss, and 

David Blumenthal. “Multiple Chronic Conditions: 

Prevalence, Health Consequences, and Implications 

for Quality, Care Management, and Costs.” Journal 

of General Internal Medicine, vol. 22, suppl. 3, 2007, 

pp. 391–395.

This series is funded by AoA, and presents analyses 

conducted by Mathematica Policy Research using 

data from AoA’s National Surveys of Program 

Participants. These surveys collect information 

from Title III participants about their demographics, 

socioeconomic status, health, and functioning, as 

well as their service use and client-reported service 

impact and quality. 

For more information about this study, please contact 

Leslie Foster, senior researcher at Mathematica, 

lfoster@mathematica-mpr.com.

About This Series

Visit our website at http://results.aoa.gov 5