Putting Data to Work for Older People

RESEARCH BRIEF NUMBER 1 • JULY 20 10

Aging in Place: Do Older Americans Act Title III Services 

Reach Those Most Likely to Enter Nursing Homes? 

by Norma Altshuler and Jody Schimmel, Mathematica Policy Research

Since the Older Americans Act (OAA) was passed in 1965, the Administration on Aging (AoA) has provided 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), and tribal partners, AoA works to 

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

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

assesses whether Title III services are reaching adults at higher risk of nursing home entry than the elderly population 

overall. The observed differences between Title III participants and other older adults point to the effective targeting of 

services by the Aging Services Network.

Background

Increasing emphasis is being placed on helping older 

individuals in declining health or with disabilities to 

maintain their independence and remain living in the 

community. Nonetheless, nursing home stays among the 

elderly are common. In 2008, 2.8 million adults over the 

age of 65, or 7.2 percent of the over-65 population, had 

at least one stay in a nursing home (Centers for Medicare & Medicaid Services 2009). 

AoA services help the elderly “age in place”—or 

remain in their homes and communities even as their 

health and functioning decline—by targeting the most 

vulnerable older adults. OAA Title III services such as 

case management, home-delivered meals, and homemaker services serve some of the frailest elderly, many 

of whom are homebound. The National Family Caregiver Support Program (NFCSP), also part of Title III, 

provides support including information and assistance 

and respite services to those who care for frail elderly.1

Title III also covers transportation, congregate meals, 

preventative health, and other community-based services, 

which provide important avenues for community and 

social involvement.

Nursing Home Predictors

Many studies have explored key determinants of nursing home entry. Drawing on two recent, comprehensive 

analyses of research on nursing home predictors (see 

Methods section), we identified the following factors 

as leading to increased risk of nursing home entry:

• Demographic characteristics: Older individuals and 

those who are non-Hispanic white 

• Socioeconomic status: Individuals with low incomes

• Health status and physical functioning: Those with 

certain health conditions (such as cognitive impairment, 

cancer, high blood pressure, diabetes, and a history 

of strokes and falls) and those who have difficulty 

performing activities of daily living 

1

Caregivers of adults age 60 and over are eligible for support under 

the NFCSP, even if they are under 60. Because of differences in the 

age profile of caregivers and other Title III participants, we focus on 

NFCSP care recipients.

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. 

What Is The Aging Services Network?
2

• Prior health care utilization: Individuals who have 

spent time in the hospital or in a nursing home

• Living arrangements and family structure: Those who 

live alone (including widowed and divorced individuals), do not own their home, and have fewer children 

than their peers not in nursing homes

• Availability of support: Individuals who lack 

caregiver support

Respondents to AoA’s Fifth National Survey of Program 

Participants, conducted in 2009, provided information 

about many, though not all, of these predictors. Using 

this information and nationally representative data about 

all older adults eligible to receive Title III services by 

virtue of age, we compared participants receiving Title 

III services to older Americans across the U.S. ages 60 

and older to assess relative risk of nursing home entry. 

Although we examine each characteristic in isolation, 

many characteristics of Title III participants are correlated. For example, the oldest are also usually the least 

healthy and most likely to be widowed or live alone. 

Are Title III Participants at Greater Risk? 

Title III participants share many of the characteristics 

that make older Americans more vulnerable to nursing 

home admissions (Table 1). Title III participants are 

older than their peers nationally. In each surveyed group, 

at least 5 out of 10 (and, in most cases, 7 out of 10) are 

age 75 or older, compared with only 35 percent of the 

national elderly population. Title III participants are also 

more likely to live in poverty and not be married. However, the racial and ethnic profile of Title III participants 

is similar to that of older adults nationally. 

People who live by themselves are at higher risk of 

nursing home entry because they may be isolated or lack 

supports to assist with activities of daily living (ADLs). 

In part because of this risk, AoA targets services to 

those who live alone, and participants in many Title III 

programs are more likely to live by themselves than 

older Americans nationally (Figure 1). Between 48 and 

69 percent of participants receiving case management; 

congregate or home-delivered meals; or homemaker 

Table 1: Demographic and Socioeconomic Characteristics, by Title III Program and Nationally 

(Percentages)

National 

population age 

60 and older

Case 

management 

Congregate 

meals

Home-delivered 

meals

Homemaker 

services

Transportation 

services

NFCSP care 

recipients

Age

60–64 29 8 10 9 2 10 3

65–74 38 29 33 22 24 28 17

75–84 24 40 39 40 37 36 39

85 or older 8 22 18 30 36 26 39

Race and 

ethnicity

Non-Hispanic 

white

79 74 80 76 78 77 N/A

Other 21 26 18 23 19 22 N/A

Marital status

Married 60 28 38 25 13 13 N/A

Not married 40 71 61 74 87 86 N/A

Income relative 

to poverty

Below 7 29 14 24 25 28 N/A

At or near 8 31 19 28 46 24 N/A

Above 85 26 51 35 21 35 N/A

Unknown N/A 13 16 13 8 13 N/A

Source: Fifth National Survey of OAA Program Participants (2009); Current Population Survey (2009). 

Notes: Data not available for care recipients because caregivers are the direct AoA participants. Caregivers have different age eligibility criteria than 

other participants and are therefore much younger and not directly comparable to other service categories. Not married includes those who have never 

been married, as well as those who are widowed, divorced, or separated. See Methods section for detail on construction of the poverty measure.
3

or transportation services live alone, compared with 

a national average of 27 percent of adults age 60 and 

older. Title III participants are also less likely to live 

with a spouse; between 13 and 38 percent of participants 

live with a spouse, compared with 60 percent of all 

Americans age 60 and older (not shown). Only 17 percent of Title III care recipients live alone, in part because 

about 7 in 10 live with the person who is caring for them 

and receiving NFCSP caregiver support services. 

Figure 1: Percentage Living Alone, Title III 

Participants and Those Age 60 and Older Nationally

Homemaker

services

Transportation

services

Home-delivered

meals

Case

management

Congregate

meals

NFCSP

care recipents

U.S. adults

age 60 and older

0 20 40 60 80 100

69

68

56

55

48

17

27

Source: Fifth National Survey of OAA Program Participants (2009); 

Current Population Survey (2009).

People who have difficulty performing three or more 

ADLs are at increased risk of nursing home placement, 

and Title III participants—especially those receiving 

home-delivered meals, case management, homemaker 

services, and NFCSP care recipients—are much worse 

off than the national population in this regard (Figure 

2). For example, compared with less than six percent of 

the national population age 60 and older with three or 

more ADLs, participants in these three services are six 

to eight times more likely to have this level of functional 

limitations. In general, Title III participants also have a 

higher average number of difficulties with ADLs, and 

more have been diagnosed with health conditions like 

stroke and diabetes, which also make nursing home 

entry more likely (not shown).

Title III participants share patterns of prior health care use

with other older adults that may put them at increased risk 

of a nursing home stay. Nationwide, 17 percent of adults 

over 60 spent at least one night in the hospital in the past 

year, compared to between 20 and 42 percent of Title 

III participants (not shown). In addition, many Title III 

participants had nursing home stays in the past year; ranging from 5 percent of congregate meals participants to 

16 percent of case management participants (not shown). 

Unfortunately, there is no directly comparable national 

statistic for the population over age 60. However, as mentioned previously, 7 percent of the over-65 population had 

at least one nursing home stay in 2008.

Do Services Support Aging in Place?

Title III participants report that AoA services are important in allowing them to remain in their homes (Figure 

3). More than 85 percent of those receiving homemaker 

services, case management, transportation, and homedelivered meals said this assistance helped them remain 

at home. Congregate meal participants were less likely 

to report this effect of services, though a majority still 

reported services helped them to remain in their homes. 

Figure 2: Percentage Reporting Difficulty with Three or 

More ADLs, Title III Participants and Those Age 60 and 

Older Nationally

Homemaker

services

Transportation

services

Home-delivered

meals

Case

management

Congregate

meals

NFCSP

care recipents

U.S. adults

age 60 and older

0 20 40 60 80 100

41

17

31

40

8

67

6

Source: Health and Retirement Study (2008); Fifth National Survey of 

OAA Program Participants (2009).

Note: Difficulty with three or more ADLs based on six ADLs contained in both data sources; eating, bathing, dressing, using the toilet, 

getting in and out of bed, and walking across a room.
4

The difference between congregate meals and other 

participants possibly exists because the former tend to 

be younger, in overall better health, and less reliant on 

this help to maintain independence. 

Caregiver support services also help care recipients 

avoid institutionalization. Most care recipients benefitting from the NFCSP live with a caregiver or their 

family, and 41 percent of caregivers said that without 

the NFCSP, the care recipient would not live in the same 

residence. Further, 32 percent said that the care recipient 

would be in a nursing home or assisted living facility 

without caregiver services (not shown). 

Figure 3: Percentage Reporting That Services Allow 

Them to Remain in Their Homes, Title III Participants 

Homemaker

services

Transportation

services

Home-delivered

meals

Case

management

Congregate

meals

0 20 40 60 80 100

99

86

91

87

59

Source: Fifth National Survey of OAA Program Participants (2009).

Conclusions and Implications 

Title III participants are at higher risk of nursing home 

placement than others in their age group nationally, based 

on common predictors of nursing home entry. Those 

who receive homemaker services, home-delivered meals, 

and case management appear especially vulnerable; this 

likely reflects AAAs’ targeting of services to those most in 

need. Even though they receive extensive supports from 

friends and family, care recipients are also vulnerable to 

future nursing home placement, although we do not have 

as much information about them on key predictors. The 

design of the National Survey of Program Participants 

does not allow us to conclude that Title III programs help 

keep participants out of nursing homes, but does show 

that most participants believe that the services help.

With the number of elderly individuals in the United 

States increasing, the number wanting to remain independent in their homes will continue to grow. Our analysis confirms that AoA is effectively reaching those most 

at risk of institutionalization, and that Title III services 

play an important role in helping elderly adults remain 

living independently in the community. 

Data Sources

The Fifth National Survey of OAA Program Participants 

was conducted in 2009 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 participants served in that particular program 

by the sampled AAA. All analyses use sample weights 

to account for this design. Additional data from and 

more detailed documentation are available on the AGing 

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

This brief looks at participation in six service types: 

NFCSP caregiver support (1,793 respondents), homedelivered meals (1,030 respondents), homemaker services 

(459 respondents), transportation services (824 respondents), congregate meals (903 respondents), and case 

management (486 respondents). Respondents 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. 

Demographic characteristics for the national population of older adults were drawn from the U.S. Census 

Bureau’s 2009 Annual Social and Economic Supplement 

to the Current Population Survey. Data and documentation for this survey are available at http://www.census.

gov/cps/. Health and physical functioning characteristics 

of the national population of older adults were drawn 

from the Health and Retirement Study (HRS), a nationally representative panel survey of the noninstitutionalized United States population over the age of 50, funded 

by the National Institute on Aging and the Social Security Administration. The HRS data used in this brief are 

based on respondents to the 2008 survey wave who were 

age 60 and older and 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. 
5

Methods 

We identified predictors of nursing home entry using 

two comprehensive analyses of predictors of nursing 

home entry (Gaugler et al. 2007; Miller and Weissert 

2000). Gaugler et al. used meta-analysis, a more rigorous methodology than Miller and Weissert’s synthesis 

of longitudinal data. Consequently, in the few instances 

in which these articles differed in identifying predictors 

of nursing home entry, we deferred to the Gaugler et al. 

study. We report on factors that the Gaugler et al. study 

found to be statistically important using the odds ratios 

reported in Table 2. Gaugler et al. also conducted a 

meta-analysis using the time to nursing home entry (hazard ratio); in general, these results confirmed the odds 

ratios results, except for health impairments such as 

cancer, stroke, high blood pressure, diabetes, and falls, 

which were only reported in the hazard ratio analysis.

Table 2: Odds Ratios on Selected Predictors 

of Nursing Home Entry

Predictor Odds Ratio (95% 

Confidence Interval)

Prior nursing home use 3.47 (1.88, 6.37)

Three or more ADLs 3.25 (2.59, 4.09)

Cognitive impairment 2.54 (1.43, 4.51)

Lives alone 1.90 (1.54, 2.35)

Non-Hispanic white 1.61 (1.22, 2.11)

Annual income < $5,000 

(vs. $5,000 - 10,000)

1.45 (1.15, 1.82)

Available informal caregiver 1.23 (1.04, 1.46)

Formal help 1.23 (0.93, 1.62)

Prior hospitalization 1.19 (1.07, 1.33)

Age 1.11 (1.08, 1.14)

ADLs 1.11 (1.07, 1.16)

Number of children 0.88 (0.80, 0.97)

Homeowner 0.82 (0.71, 0.95)

Married 0.63 (0.41, 0.95)

Source: Gaugler et al. (2008).

Note: Only significant predictors reported.

Gaugler et al. found that income below $5,000 in 1982 

dollars predicts nursing home entry. In today’s dollars, this amount is roughly equivalent to $10,830, the 

2009 U.S. Department of Health and Human Services 

(DHHS) poverty threshold for a one-person household in the mainland United States. Unfortunately, the 

article does not specify whether this threshold applies to 

individuals or to households. Because of this ambiguity, we used the federal poverty threshold to compare 

Title III participants to other Americans over 60. Using 

respondents’ reported income category, household size, 

and the 2009 DHHS poverty guidelines, respondents 

were classified as definitely in poverty (reported income 

category below 100 percent of the federal poverty level 

[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 2009 Current Population Survey respondents 

using reported income (adjusted for inflation between 

the survey years) and household size.

In some cases, data in the categories reported in this 

brief were not collected for AoA participants. For all of 

the variables reported, missing data comprised 5 percent 

or less of total responses. Percentages reported in this 

brief are based on the full sample of participants and use 

survey weights to construct population estimates. 

References

Centers for Medicare & Medicaid Services (CMS). 

“Nursing Home Data Compendium, 2009 Edition.” 

Baltimore, MD: CMS, 2009.

Gaugler, Joseph E., Sue Duval, Keith A. Anderson, and 

Robert L. Kane. “Predicting Nursing Home Admission 

in the U.S.: A Meta-Analysis.” BMC Geriatrics, vol. 7, 

no. 13, 2007.

Miller, Edward Alan, and William G. Weissert. “Predicting Elderly People’s Risk for Nursing Home Placement, 

Hospitalization, Functional Impairment, and Mortality: 

A Synthesis.” Medical Care Research and Review, vol. 

57, no. 3, 2000.

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