Putting Data to Work for Older People

RESEARCH BRIEF NUMBER 2 • AUGUST 2010

OAA Title III Services Target the 

Most Vulnerable Elderly in the United States

by Allison Barrett and Jody Schimmel, Mathematica Policy Research

Since the Older Americans Act (OAA) was passed in 1965, the Administration on Aging (AoA) has provided elderly 

Americans with home and community-based services to help them maintain their independence and remain in their 

own homes for as long as possible. Through its “Aging Services Network” including State Units on Aging (SUAs), Area 

Agencies on Aging (AAAs), and tribal partners, AoA works to provide an array of services designed to alleviate the 

difficulties in performing daily activities that frail, ill elders experience. This brief, the second in a series that presents 

findings from AoA’s National Survey of OAA Program Participants, compares the health and physical functioning of 

elderly adults who receive Title III services (“Title III participants”) to that of older adults across the United States who 

meet the age criteria for Title III services. Our analysis takes into account differences in the demographic profile and 

socioeconomic status of Title III participants relative to older adults nationwide.

Background

In passing the OAA, Congress sought to ensure that the 

nation’s most vulnerable elderly adults would have the 

services they need to remain independent in their communities. Title III participants are known to be among 

the “oldest-old” compared to others in the national 

population who are also age 60 and older (Altshuler 

and Schimmel 2010). They are also more likely than 

older adults nationwide to be female, non-white, to 

have less than a high school education, and to live in 

poverty. These characteristics are often associated with 

worse health and diminished physical functioning, so 

it is difficult to know whether the differences in health 

and functioning that have been observed between 

Title III participants and other older adults arise solely 

because participants are concentrated within certain 

demographic and socioeconomic groups, or because 

their health is poor even in comparison with other older 

adults who are similar to them.

To help AoA understand how well-targeted OAA’s Title 

III services are, we used data from the Fourth National 

Survey of OAA Program Participants and from the 

Health and Retirement Study (HRS) to compare the 

health and physical functioning of Title III participants 

to that which would be expected if the health and physical functioning of Title III participants matched older 

adults with similar demographic and socioeconomic 

characteristics nationwide (see Methods section).

What Is The Aging Services Network?

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. 

Physical Health of Title III Participants

Older adults who receive Title III services generally rate 

themselves to be in poorer health than do older adults 

across the country. For instance, on a 5-point scale in 

which 1 indicates poor health and 5 indicates excellent 

health, Title III participants rate their health from 2.2 to 

3.2, compared with an average of 3.1 among all older 

adults (Figure 1). 

When accounting for the demographic and socioeconomic differences between Title III participants and 

older adults nationally, we find that some groups of 

Title III participants are in worse health than their age, 

gender, race, education level, and poverty status would 

predict (Figure 1). For example, participants who 

receive in-home services—including home-delivered 
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Figure 1: Reported and Expected Self-Rated Health 

Status of Title III Participants

Homemaker

services

Transportation

services

Home-delivered

meals

U.S. adults 

age 60 and older

Congregate

meals

Case 

management

Good

(3)

Fair

(2)

Very

Good

(4)

Excellent

(5)

Poor

(1)

2.9

2.5

2.8

3.2

2.3

2.7

2.8

2.8

2.8

2.2

3.1

 Reported  Expected

Source: Fourth National Survey of OAA Program Participants (2008) 

and 2008 HRS.

Note: Health is rated on a scale in which 1 is poor and 5 is excellent. 

meals, case management, and homemaker services—rate 

their health 10 to 20 percent lower than what would be 

expected given their demographic and socioeconomic 

characteristics. On the other hand, participants who 

receive congregate meals say that they are in better 

health than their demographics and socioeconomic 

status would predict, while those who receive transportation services rate their health at about what would be 

expected, given their individual characteristics.

The difference between reported and expected self-rated 

health is confirmed by more objective measures of health 

status, such as receiving a doctor’s diagnosis of certain 

health conditions (Table 1). Compared to all elderly adults 

in the United States, a larger share of Title III participants report that a doctor ever told them that they had 

a heart condition; breathing or lung condition; diabetes 

or high blood sugar; stroke; or memory-related disease. 

After accounting for Title III participant characteristics, 

participants in most programs are still more likely to have 

diagnosed health conditions than their characteristics 

would predict. If we look at diabetes, for example, based 

on the demographics and socioeconomic status of Title III 

participants, we would expect the proportion of participants ever diagnosed with diabetes to range from 23 to 25

percent. In actuality though, 26 to 35 percent of participants reported having been diagnosed with this condition. 

Expected levels of heart conditions, breathing or lung 

conditions, and diabetes fall below reported levels across 

all participant groups. Participants receiving in-home services also reported higher-than-expected levels of stroke 

and memory-related disease, while participants in the 

transportation services and congregate meals programs 

reported lower-than-expected levels of these conditions, 

given their characteristics. 

Functional Status of Title III Participants 

A person’s ability to continue to live in his or her own 

home depends in part on how much difficulty they have 

performing activities of daily living (ADLs), such as 

bathing or using the toilet, as well as any difficulty they 

have completing instrumental activities of daily living 

(IADLs), such as preparing meals or taking medications. 

The average number of ADL difficulties reported by Title 

III participants is much higher than the number reported 

by the national population of older adults (Figure 2). 

For example, Title III participants who receive in-home 

services report difficulty with an average of two of six 

ADLs—five times as many as the average among older 

adults nationally (0.4 of six ADLs). 

The difference in demographic and socioeconomic 

characteristics among Title III participants compared 

with other older adults only partially explains the higher 

number of reported ADL difficulties among participants. 

For instance, given their age, gender, race, education, and 

poverty level, the participants who receive home-delivered meals have difficulty with almost triple the number 

of ADLs than what would be expected. This level of difficulty is similar to the expected level among case management and homemaker services participants. On the other 

hand, the average number of ADL difficulties among 

participants who receive congregate meals and transportation services is about what we would expect to see, given 

their demographic and socioeconomic characteristics.

IADL difficulties are also reported more often by Title III 

participants than would be expected given their individual 

characteristics (not shown). When considering difficulty 

with preparing meals, taking medications, shopping, using 

the telephone, and managing money, Title III participants 

report difficulty with anywhere from 0.5 IADLs (those 

who received congregate meals) to 1.5 IADLs (those who 
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receive homemaker services or home-delivered meals). 

Accounting for the demographics and socioeconomic 

status of Title III participants yields an expected number 

of IADL difficulties ranging from 0.4 to 0.7, indicating 

that participants have more IADL limitations than their 

characteristics predict. 

Conclusions and Implications

Title III participants are not as healthy as older adults 

nationally, nor do they function as well physically. 

Some of the observed differences in health and physical functioning are explained by the demographic and 

socioeconomic profile of Title III participants compared 

with all older adults. However, even after demographic 

and socioeconomic differences are accounted for, we 

still find that Title III participants who receive in-home 

services—those in the home-delivered meals, case management, and homemaker services programs—tend to be 

less healthy and more limited than other older adults. 

Much of the difference in health and functional status 

across Title III programs can likely be explained by the 

services offered by each program attracting a different 

pool of participants. For example, because home-delivered meals and homemaker services target the homebound, clients receiving these services are more likely 

to have multiple functional limitations and lower overall 

health status. Despite the differences between participants in each program, it is clear from our findings that 

Title III services are indeed reaching the most vulnerable elderly people in the nation—those most in need of 

services to remain independent.

Data Sources

Information on Title III participants was drawn from the 

Fourth National Survey of OAA Program Participants. 

This survey was conducted in 2008 by Westat Inc., via 

telephone, and administered to more than 5,000 individuals 

who reported receiving Title III services. The survey used a 

two-stage sample design, first selecting a sample of AAAs, 

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 particiTable 1: Reported Versus Expected Percentages of Title III Participants with a Doctor’s Diagnosis 

of Various Conditions, by Program

U.S. adults age 

60 and older

Case 

management

Congregate 

meals

Home-delivered 

meals

Homemaker 

services

Transportation 

services

Arthritis or rheumatism

Reported 66.9 75.3 56.7 64.6 78.1 69.6

Expected N/A 76.6 74.5 76.2 78.4 77.5

Heart condition

Reported 28.6 44.8 33.9 43.1 52.8 39.4

Expected N/A 37.3 34.4 38.1 37.0 35.1

Breathing or lung condition

Reported 11.9 49.3 32.1 41.7 42.2 42.2

Expected N/A 17.0 14.8 14.6 15.4 15.5

Diabetes or high blood sugar

Reported 22.2 25.6 26.8 35.0 32.8 32.4

Expected N/A 24.3 22.7 23.7 24.8 23.8

Stroke

Reported 9.7 23.1 10.9 23.2 23.9 13.1

Expected N/A 15.8 13.8 16.6 16.8 14.4

Memory-related disease

Reported 4.8 12.2 5.7 12.2 16.9 5.7

Expected N/A 8.1 6.1 8.1 8.9 7.4

Source: Fourth National Survey of OAA Program Participants (2008) and 2008 HRS.

Note: The Fourth National Survey and the HRS both ask respondents if a doctor has ever diagnosed them with each of the conditions reported above. 

With the exception of a lung condition, the question wording in both surveys is comparable, so that difference in the proportion with a diagnosis 

between the surveys is likely not due to survey design. However, the HRS explicitly includes asthma as a lung condition, while the Fourth National 

Survey does not. Despite this difference, the actual rates reported in the surveys are still higher among Title III participants, but the expected rates for 

a lung condition for participants in each Title III service are higher than they would be if the Fourth National Survey data excluded asthma.
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pants served in that particular service by the sampled AAA.

All analyses in this brief apply sample weights to account 

for this design. Additional data and more detailed documentation for the Fourth National Survey and other AoA 

data sources are available on the new interactive AGing 

Integrated Database (AGID) at http://data.aoa.gov. 

Participants in five of the service types included in the 

survey are reported in this brief: home-delivered meals 

(916 respondents), homemaker services (407 respondents), transportation services (817 respondents), congregate meals (861 respondents), and case management 

(455 respondents). Participants in this brief are categorized as program participants based on the program for 

which they were surveyed, but in many cases, individuals receive services from multiple OAA programs. 

Health and physical functioning characteristics of the 

national population of older adults, used to calculate the 

expected health measures of Title III participants, were 

drawn from the HRS, a nationally representative panel 

survey of the non-institutionalized United States population over the age of 50 funded by the National Institute 

on Aging (NIA) and the Social Security Administration 

(SSA). The HRS data used in this brief are based on 

respondents to the 2008 survey wave who were age 60 

and older and were residing in the community at the 

time of the interview. These data were extracted from 

RAND’s analytic file from the HRS, available at http://

hrsonline.isr.umich.edu. 

Figure 2: Reported and Expected Number of ADL 

Difficulties Among Title III Participants

Homemaker

services

Transportation

services

Home-delivered

meals

U.S. adults 

age 60 and older

Congregate

meals

Case 

management

0 21 3 4

0.6

1.9

0.7

0.6

2.0

0.7

0.8

1.0

0.7

2.0

0.4

 Reported  Expected

5 6

Average Number of ADL Difficulties

Source: Fourth National Survey of OAA Program Participants (2008) 

and 2008 HRS.

Note: Average calculated based on reported difficulties with six ADLs: 

eating, dressing, bathing, toileting, walking short distances, and getting into and out of bed.

Methods 

To derive the expected values of health and functioning 

reported in the brief, we used indirect standardization. 

To do this, we calculated health and functional status 

values using the HRS for each combination of age, gender, race, educational attainment, and poverty category. 

The resulting cell means were then assigned to Title 

III participants in the same demographic and socioeconomic categories. The value obtained after indirect 

standardization indicates what would be expected if Title 

III participants had the same health and functional status 

as those in the national population who share the same 

age, gender, race, educational attainment, and poverty 

status. Overall averages were obtained by aggregating 

across the constructed cells in proportion to each cell’s 

weight in the overall Title III service group.

The categories used to construct the cells for indirect 

standardization were (1) age, using five-year intervals 

between 60 and 85, with a separate category for everyone 

85 years or older; (2) gender; (3) race, with a category for 

non-Hispanic white and one for Hispanic and/or nonwhite; (4) education, measured as more or less than a high 

school diploma; and (5) income relative to the federal 

poverty level (FPL). Because income was collected categorically in the Fourth National Survey, it was impossible to precisely determine poverty status in some cases. 

Using respondents’ reported income category, household 

size, and the 2008 DHHS poverty guidelines, respondents 

were classified as definitely in poverty (reported income 

category below 100 percent of the FPL), definitely not 

in poverty (reported income category above 100 percent 

of the FPL), or possibly in poverty (reported income category included values below and above the FPL). A comparable value was created for HRS survey respondents 

using reported income (adjusted for inflation between 

the survey years) and household size. In the minority of 

cases in which income or household size was not available for the construction of poverty, standardization was 

performed using the remaining available measures. 
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Reference

Altshuler, N., and J. Schimmel. “Aging in Place: Do 

Older Americans Act Title III Services Reach Those 

Most Likely to Enter Nursing Homes?” Washington, 

DC: Mathematica Policy Research, July 2010. 

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 

Jody Schimmel, senior researcher at Mathematica, 

jschimmel@mathematica-mpr.com.

About This Series

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