```
Long-Term Care: Support For Elder Care Could Benefit the Government
Workplace and the Elderly (Letter Report, 03/04/94, GAO/HEHS-94-64).

Today, about six million older Americans living at home need help with
day-to-day activities, such as eating, bathing, shopping, and house
cleaning. Most disabled elderly get all their care informally, from
family members and friends, mainly women. Greater geographic dispersion
of families, small families, and more women working outside the home are
straining the ability of informal caregiving. Some private and
public-sector employers are now providing assistance known as "elder
care" to alleviate work and caregiving conflicts. This assistance may
include leave policies, alternative work schedules, and referral
services to help employees care for their elderly relatives. Little is
known nationwide about the extent and content of elder care
generally--and even less is known about elder care in government, which
employs 18 million people or 15 percent of the workforce. This report
evaluates (1) the extent and nature of government practices facilitating
elder care; (2) planned changes in these practices; and (3) their
potential to further support informal caregivers.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-94-64
     TITLE:  Long-Term Care: Support For Elder Care Could Benefit the 
             Government Workplace and the Elderly
      DATE:  03/04/94
   SUBJECT:  Long-term care
             Elderly persons
             Aid for the elderly
             Flexible work schedules
             Personnel management
             Federal employees
             Working conditions
             Fringe benefits
             Labor-management relations
IDENTIFIER:  Medicaid Program
             Medicare Program
             Social Services Block Grant
             Supplemental Security Income Program
             OPM Work and Family Program Center
             
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Cover
================================================================ COVER

Report to the Chairman, Subcommittee on Employment, Housing and
Aviation
Committee on Government Operations
House of Representatives

March 1994

LONG-TERM CARE - SUPPORT FOR ELDER
CARE COULD BENEFIT THE GOVERNMENT
WORKPLACE AND THE ELDERLY

GAO/HEHS-94-64

Public-Sector Elder Care

Abbreviations
=============================================================== ABBREV

  AOA - Administration on Aging
  APHIS - Animal and Plant Health Inspection Service
  DCAP - Dependent Care Assistance Plan
  DOD - Department of Defense
  IRS - Internal Revenue Service
  OPM - Office of Personnel Management
  SSA - Social Security Administration
  USDA - U.S.  Department of Agriculture

Letter
=============================================================== LETTER

B-251010

March 4, 1994

The Honorable Collin C.  Peterson
Chairman, Subcommittee on Employment,
 Housing, and Aviation
Committee on Government Operations
House of Representatives

Dear Mr.  Chairman: 

Today, about 6 million older Americans living at home need assistance
in everyday activities because of their disabilities.  These elderly
people need assistance with activities such as eating, toileting,
bathing, house cleaning, moving about the house, shopping, managing
money, and other activities most Americans take for granted. 
Population aging will significantly increase demand for this type of
assistance, as the number of elderly needing long-term care reaches
an expected 10 million or more by 2020. 

Most disabled elderly people get all their care informally from
family members and friends, primarily women.  However, greater
geographic dispersion of families, smaller families, and the large
percentage of women working outside the home are straining the
capacity of informal caregiving.  Employed caregivers often face
challenges in balancing their work and caregiving responsibilities
that can adversely affect both roles. 

Some private- and public-sector employers are responding to the needs
of their employees with assistance known as "elder care" to alleviate
work and caregiving conflicts.  In this report, we define elder care
as any employer-sponsored practice, policy, or program offered by
federal, state, or local governments that directly or indirectly
helps their employees or retirees care for elderly relatives and
friends.  Employer-sponsored elder care assistance may include leave
policies, alternate work schedules, educational materials and
seminars, information and referral services, financial arrangements,
and other options to help employees care for their elderly relatives. 

Little is known nationwide about the extent and content of elder care
generally--and even less is known about elder care in government,
which employs 18 million people or 15 percent of the work force. 
Therefore, your subcommittee requested that we evaluate (1) the
extent and nature of government practices facilitating elder care,
(2) planned changes in these practices, and (3) their potential to
further support informal caregivers.\1

--------------------
\1 We issued a separate report on the availability of elder care
assistance to employees in the private sector, Long-Term Care: 
Private Sector Elder Care Could Yield Multiple Benefits
(GAO/HEHS-94-60, Jan.  31, 1994). 

   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

Currently, about two million working Americans, including government
employees, are providing significant unpaid care to their elderly
relatives in the community who need help with everyday activities. 
Surveys indicate that 3 to 5 percent of the federal work force have
significant elder care responsibilities and that as many as 12
percent have some elder care responsibilities.  According to the
Office of Personnel Management (OPM), up to an additional 13 percent
of federal employees without elder care responsibilities now expect
to have such responsibilities within the next 5 years. 

Work and family responsibilities often conflict for caregivers living
near their disabled elderly relatives and for the many caregivers who
provide assistance long distance.  To maintain both work and
caregiving roles, caregivers identify both work schedule flexibility
and information about community services for the elderly as the most
useful options employers could offer. 

The federal government, state governments, and city governments with
the largest work forces that we studied offer flexible schedule
options and elder care information.  OPM reports that federal
employees can use 7 of 10 schedule flexibility options that we
examined for elder care assistance purposes.  These include leave
without pay, flex-time, compressed work schedules, job sharing,
flexplace, allowing temporary reductions in work hours, and part-time
employment with benefits.  We surveyed the states and 100 cities, and
all 47 states that responded have at least two of these options and
most had six or more.  Seventy-three out of 80 large cities
responding to our survey reported having two or more of these
options, and 35 had at least six.  However, managerial discretion may
restrict actual schedule flexibility to employees at all levels of
government in different agencies and in units of the same agency. 

Providing elder care information in the workplace is less common
because elder care has only recently become recognized as a workplace
issue.  Nonetheless, information resources are developing.  OPM, in
collaboration with the Administration on Aging (AOA), is promoting
awareness of a publicly available toll-free Eldercare Locator Number
to federal employees to assist them in locating home and
community-based services for the elderly wherever they live.  In
addition, OPM is sponsoring several other activities to encourage
broader availability of elder care information resources in the
federal government.  Fifteen state governments and 24 big-city
governments also reported having at least two of the elder care
information options that we examined.  These options include seminars
on aging, information on services, and elder care reference
materials. 

The federal government, as well as some state and big-city
governments, plan to make additional support available or to expand
availability of existing elder care programs, but many of these
governments are uncertain of their future plans.  This is partly
because agency officials are often unsure of the extent of elder care
needs or how they can be met inexpensively.  Planned expansions
include greater promotion of flexible schedule options for elder care
and the provision of information on community services for the
elderly.  Government's greater recognition and promotion of existing
schedule flexibility options for elder care purposes is an effective
way to address these issues.  Such promotion, coupled with
information resources, can help caregivers balance their work and
family responsibilities, help the elderly to live independently in
their homes, and strengthen government's efforts to improve employee
retention and productivity. 

OPM's efforts are a good start to promote elder care at the federal
level.  It is too early, however, to evaluate the effectiveness of
these efforts in creating changes at other federal agencies.  If
agencies change policies, programs, and practices to promote elder
care, determining their effectiveness will depend on how well the
initiatives are implemented and the extent to which employees use
them. 

   BACKGROUND
------------------------------------------------------------ Letter :2

More and more Americans are facing the need for long-term care in
their families.  Among people 45 years of age or older, approximately
two in five report some experience with long-term care in their
families.\2 Approximately 13.3 million people have a disabled parent
or spouse who may require long-term care services.\3 In most cases,
these needs are primarily for nonmedical care provided outside of
nursing homes and are met by using unpaid, informal assistance from
family and friends.  This assistance is instrumental in helping
elderly disabled people with basic tasks of everyday living so that
they can remain in their homes and communities.  In addition, about 2
million elderly people receive formal, paid home and community-based
long-term care services such as home health care, meals, and
transportation.\4 These services are either purchased by the elderly
and their families or paid for with public funds, primarily by
Medicaid and Medicare. 

When families can no longer provide sufficient care alone or in
combination with paid home and community-based services, elderly
persons may be placed in nursing homes, the average annual cost of
which was $34,000 in 1991.  About half of these costs is paid for by
the elderly and their families, and the other half is paid by federal
and state governments.  About 1.5 million older Americans, usually
those with severe disabilities, live in nursing homes. 

While most care to the elderly is provided by unpaid family and
friends, federal spending for long-term care to the elderly is
substantial.  In 1991, state and federal long-term care spending
totaled more than $38 billion through the Medicare and Medicaid
programs, primarily for institutional care.  Other federal long-term
care funds are provided through the Older Americans Act, the Social
Services Block Grant, the Supplemental Security Income program, and
several Department of Veterans Affairs programs.  In addition, some
proposals for health care reform, including the Administration's,
include federal payment for additional long-term care services. 

--------------------
\2 Margaret K.  Straw, Home Care:  Attitudes and Knowledge of
Middle-Aged and Older Americans.  American Association of Retired
Persons, (Washington, D.C.:  1991) , p.  2. 

\3 Robyn Stone and Peter Kemper, "Spouses and Children of Disabled
Elders:  How Large a Constituency for Long-Term Care Reform?" The
Milbank Quarterly, Vol.  67, Nos.  3-4 (1989) pp.  485-505. 

\4 National Medical Expenditure Survey:  Use of Home and Community
Services by Persons Ages 65 and Older with Functional Difficulties,
Research Findings 5; Agency for Health Care Policy and Research,
Public Health Service, Department of Health and Human Services,
(Washington, D.C.:  1990), p.  6. 

   SCOPE AND METHODOLOGY
------------------------------------------------------------ Letter :3

To respond to the Subcommittee's request, we (1) reviewed the
literature on elder care and government agencies' development of
elder care assistance; (2) interviewed federal, state, and local
officials and elder care experts; (3) reviewed documents concerning
elder care practices from personnel, benefits, work/family, and line
divisions of government agencies; (4) surveyed the 50 states, and the
100 city governments with the largest work forces; and (5) attended
the federal Interagency Adult Dependent Care Working Group meetings
sponsored by OPM in the past year.  (See app.  I for a full
description of our methodology.)

Our study is the first nationwide examination of elder care practices
focusing on all levels of government.  Although we did not survey all
federal agencies, we collected extensive information from OPM's Work
and Family Program Center, which has responsibility for promoting
elder care in all federal agencies and from a variety of other
federal sources.  We also received survey responses from 47 of the 50
states and 80 of the 100 cities with the largest work forces (see
app.  II for the survey instruments used and data reported).  The
survey data do not include all state and big-city employees, however,
because the principal reporting authority could not always respond
for employees under other personnel systems. 

Our data on local governments generally are limited because they do
not include comprehensive information on county governments, school
districts, special districts, smaller municipalities, and townships,
which employed about 8.7 million employees in 1987.  Based on other
information that we collected on these governments, however, we have
no reason to believe that they have more comprehensive elder care
coverage than other governments. 

   INFORMAL CAREGIVING GROWING;
   CAN CONFLICT WITH WORK
------------------------------------------------------------ Letter :4

Because women's participation in the work force and the number of
disabled elderly have grown, more employees are caring informally for
older Americans in their homes and communities.  Approximately two
million working Americans provide informal caregiving assistance to
their disabled elderly relatives, including help with eating,
bathing, moving around the home, housework, and financial management. 
Nearly three-quarters of all caregivers are women, many of whom are
employed outside the home.  An additional six million employees have
a disabled spouse or parent who may also require help with these or
other activities.  As the population ages, the number of employed
caregivers is expected to grow.  Potential caregivers, spouses and
children of disabled elders, currently account for about 9 percent of
the work force of full-time employees.\5

Employees' caregiving demands can adversely affect their work
performance.  Caregiving problems may lead to increased absenteeism,
tardiness, work disruptions, turnover, and stress, with damaging
effects on employee productivity and morale.  Employed caregivers
report making adjustments in both caregiving and at work to
accommodate their dual roles.  At work, many caregivers rearrange
their schedules, reduce their overall hours, take leave without pay,
and even forgo career opportunities or quit their jobs to fulfill
elder care responsibilities. 

--------------------
\5 Stone and Kemper, p.  497. 

   GOVERNMENT HAS INTEREST IN
   ENCOURAGING ELDER CARE
------------------------------------------------------------ Letter :5

Government has the same stake as private industry in recruiting and
retaining productive employees.  A GAO study that compared federal
and nonfederal work/family programs and approaches concluded that the
federal government's work/family efforts, including elder care,
should be improved to respond to changes in the work force and to
compete for high-quality employees.\6 State and local governments
face similar pressures in recruiting and retaining high-quality
employees. 

A GAO survey revealed that 65,000 employees, or 5 percent of the
federal executive branch, excluding postal employees, have
responsibilities for an adult dependent 65 years of age or older
during the workday.\7 About 3 percent of federal employees responding
to an OPM survey said that they spend 10 or more hours a week caring
for an elderly person.  Altogether, 12 percent of those responding to
OPM's survey reported that they have some responsibility for an
elderly dependent and that 13 percent without those responsibilities
now expected to have such responsibilities within 5 years.\8 We did
not find comparable information on state and local government
employees. 

--------------------
\6 The Changing Workforce:  Comparison of Federal and Nonfederal
Work/Family Programs and Approaches (GAO/GGD-92-84, Apr.  23, 1992). 

\7 Information derived from survey data reported in Federal
Employment:  How Federal Employees View the Government as a Place to
Work (GAO/GGD-92-91, June 1992) pp.  28-29. 

\8 A Study of the Work and Family Needs of the Federal Workforce:  A
Report to Congress by the Office of Personnel Management, Office of
Personnel Management, (Washington, D.C.:  1992), pp.  15-18 (and more
detailed information supplied by OPM on survey results). 

   GOVERNMENT OFFERS MOST USEFUL
   OPTIONS BUT OFTEN DOES NOT
   ENCOURAGE THEIR USE FOR
   CAREGIVER ASSISTANCE
------------------------------------------------------------ Letter :6

Almost all governments offer at least one flexible schedule or elder
care information option, and many governments offer several of these
options.  Experts and employees consider these options to be the most
useful for employed caregivers.\9 Many of these options, however,
were not designed specifically for elder care purposes.  Managers and
supervisors, therefore, may neither recognize their potential nor
encourage their use by employees for elder care purposes.  Other
elder care options, such as financial assistance, are offered by a
much smaller number of governments. 

--------------------
\9 Robyn Stone and Pamela Short, "The Competing Demands of Employment
and Informal Caregiving to Disabled Elders," Medical Care, Vol.  28,
No.  6, (1990) pp.  513-526; Andrew Scharlach, Eugene Sobel and
Robert Roberts, "Employment and Caregiver Strain:  An Integrative
Model," The Gerontologist, Vol.  28, No.  6, (1991) pp.  778-787;
Jeane Anastas, Janice Gibeau, and Pamela Larson, "Working Families
and Eldercare:  A National Perspective in an Aging America," Social
Work, Vol.  35, No.  5, (1990) pp.  405-411; Florence Glasser,
Solving The Workplace Puzzle-Fitting Work and Family Together in
Government Workplaces of North Carolina, North Carolina Equity,
(Raleigh, North Carolina, 1992) pp.  26-27. 

      FLEXIBLE SCHEDULES PREVALENT
      BUT NOT WIDELY RECOGNIZED OR
      PROMOTED AS ELDER CARE
---------------------------------------------------------- Letter :6.1

The federal government, state governments, and big-city governments
offer a variety of flexible schedule options that may be used for
elder care though not designed for that purpose.  These options vary
by government but may include paid sick leave, leave without pay,
compressed work schedule, flex-time, flex-place, and part-time
employment with partial or full benefits (see app.  II for a complete
list of schedule options).  The actual availability of these options
to employees differs, however, by agency and by unit within the same
agency.\10

Although not initially intended to address elder care needs, flexible
scheduling options, when available to employees, can be a key element
of employer-provided elder care assistance.  These options can enable
working caregivers to respond to the unpredictable, emergency needs
of the elderly, such as acute health care episodes, as well as
accommodate routine care requirements such as relieving another
caregiver in the home after work.  Employees can use these options to
change their work hours, work fewer hours, or take unpaid leave. 

Schedule options vary among governments.  OPM reports that 7 of the
10 options that we examined can be used for elder care purposes at
the federal level.  These include leave without pay, flex-time,
compressed work schedules, job sharing, flex place, allowing
temporary reduction in work hours, and part-time employment with
benefits.  The federal government does not, however, offer the use of
sick leave for elder care purposes, although many states and
localities do.  The Report of the National Performance Review has
called for all federal agencies to allow employees to use accrued
sick leave to care for sick or disabled dependents, including the
elderly.\11 This proposal is consistent with our recommendation that
federal employment practices should be modernized to help employees
balance work and family responsibilities.\12

Options for schedule flexibility that may be used for elder care
purposes are also widely offered by state and big-city governments,
although their actual availability varies by agency and by unit
within agencies.  All 47 states responding to our survey had at least
2 of the 10 schedule options we examined, 33 had 6 or more options,
and 2 had all 10 (see fig.  1).  Seventy-three of the 80 cities
responding had at least 2 options, 35 had at least 6 options, but
none had all 10 (see fig.  2). 

   Figure 1:  Number of States
   With Schedule Flexibility
   Options

   (See figure in printed
   edition.)

Information is based on the 47 state responses to GAO's survey of
states on elder care issues. 

   Figure 2:  Number of Large
   Cities With Schedule
   Flexibility Options

   (See figure in printed
   edition.)

Information is based on the 80 responses to GAO's survey concerning
elder care issues of the 100 cities with the largest work forces. 

The most common flexible scheduling practice among state governments
is flex-time, followed closely by leave without pay, paid sick leave
to care for an elderly person, and part-time employment with
benefits--all of which were offered by more than 40 states.  Among
large cities, leave without pay was the most prevalent flexible
schedule option (69 cities).  The next most prevalent flexible
schedule options were paid sick leave (54 cities) and flex-time (53
cities). 

Governments do not generally recognize and promote flexible schedules
for elder care purposes, in part, because they were intended for
broader purposes.  Experts and managers engaged in elder care in the
public and private sectors believe this diminishes the value of
flexible scheduling options for helping balance work and caregiving
responsibilities.  Specifically, they believe that supervisors and
managers must be aware and supportive of accommodating employees'
caregiving needs.  When employers identify and promote all elder care
options, employees may be more likely to use them to effectively
provide home care. 

--------------------
\10 GAO is completing a study of federal agencies' actual practices
regarding flexible schedules. 

\11 Creating a Government That Works Better & Costs Less, Report of
the National Performance Review, (Washington, D.C.:  1993), p.  85. 

\12 Management Reform:  GAO's Comments on the National Performance
Review's Recommendations (GAO/OCG-94-1 Dec.  3, 1993), p.  218. 

      ELDER CARE INFORMATION LESS
      PREVALENT
---------------------------------------------------------- Letter :6.2

Governments also offer elder care information options, but these are
not as prevalent as flexible schedules.  This is not surprising
because elder care is a relatively new workplace issue.  Some
information options are available, however.  These options are
especially valuable to working caregivers who need a ready source of
information to help them handle the changing needs of the disabled
elderly.  In addition, many caregivers live far from the elderly
person in need and provide long-distance assistance.  When new needs
arise, caregivers need to know what resources are available in the
elderly person's community.  Information and referral services reduce
the amount of time and stress spent on elder care by enabling
caregivers to more efficiently locate and use services even in other
states. 

According to a 1992 OPM study on work and family needs, only 2.6
percent of federal employees with elder care responsibilities
reported that their agencies offered information and referral
services; 2.3 percent, educational workshops; 1.8 percent, resource
libraries; and 1.5 percent, dependent care counselors.\13 Our state
and big-city survey data also show that elder care information
options are far less prevalent than work schedule flexibility. 

OPM and other federal agencies are taking important steps to improve
the availability of elder care information (see fig.  3).  The impact
of these practices, however, will depend on how well they are
implemented and on employee usage.  OPM has taken the lead federal
role in developing and promoting education and information options in
other federal agencies and for its own employees.  OPM has
established a Work and Family Program Center with elder care
responsibilities, sponsored regular Interagency Adult Dependent Care
Working Group meetings on elder care to which representatives of all
federal agencies are invited, held an elder care fair, and consulted
on elder care issues with other federal agencies.  OPM has also
mounted a campaign, in cooperation with the AOA, to increase federal
employees' awareness of the National Association of Area Agencies on
Aging toll-free Eldercare Locator Number available to the public.\14
Callers to this number may speak to an elder care information
specialist anywhere in the United States to identify the type of
community services and agencies available to help an elderly person
in his or her community.  Services may consist of meal delivery, home
chore services, or help with bathing and other personal care needs. 
In addition, some other federal agencies, such as the Department of
Defense (DOD), the Social Security Administration (SSA), and the
Animal Plant Health Inspection Service (APHIS) in the Department of
Agriculture (USDA), have developed customized or more elaborate
approaches to elder care for their own agencies. 

   Figure 3:  Some Governments Use
   Promotional Materials to
   Publicize Their Elder Care
   Programs to Employees

   (See figure in printed
   edition.)

We did not find evidence to suggest that states or large cities have
begun to implement comprehensive elder care, including flexible
schedules and information and referral, or initiate broader campaigns
to promote options for providing elder care as OPM has at the federal
level.  Some state and city governments reported, however, that they
are considering developing and promoting a comprehensive approach to
elder care. 

We did find that 15 state and 24 big-city governments offer at least
two education and information options.  Fourteen states and 27 cities
reported that they offer employees a specific option for locating
services for an elderly dependent.  Experts say that this is the most
useful information option needed by employed caregivers.  The most
prevalent information options among states in our survey are seminars
on aging issues (15 states), elder care reference materials (12
states), and in-house information on community services (12 states). 
For cities in our survey, the most prevalent options are seminars on
aging (29 cities), in-house provision of community service
information (23 cities), and elder care reference materials (21
cities). 

--------------------
\13 A Study of the Work and Family Needs of the Federal Workforce:  A
Report to Congress by the Office of Personnel Management, p.  17. 

\14 The Eldercare Locator toll-free number, 1-800-677-1116, is part
of AOA's National Eldercare Campaign. 

      CERTAIN ELDER CARE OPTIONS
      ARE RARE OR LESS USEFUL
---------------------------------------------------------- Letter :6.3

Employee support services and financial arrangements are other
employee options often associated with work and family issues.  These
options, however, are generally less prevalent than schedule
flexibility and information options in government, or their
usefulness in elder care is limited.  The availability of these
options also varies by level of government. 

Some federal agencies offer elder care services such as support
groups and individual counseling, but these activities are limited. 
The federal government offers none of the financial arrangements that
we examined such as a Dependent Care Assistance Plan (DCAP), cash
subsidies for services, and private long-term care insurance. 

State and big-city governments also offer support services to
employees with elder care responsibility; individual counseling,
available in 15 states and 28 cities, is the most frequent option. 
State and big-city governments also offer financial arrangements to
employees for elder care purposes.  The most common such financial
arrangement is a DCAP, offered by 29 states and 32 cities.  A DCAP is
a flexible spending arrangement that allows employees to exclude from
taxable income expenditures for care of dependent children or adults. 
A few states and cities offer other options such as private long-term
care insurance that covers dependents and cash subsidies for
services. 

Although offered by many states and cities, the use of a DCAP for
elder care is limited.  Experts and employers believe that employed
caregivers usually cannot use a DCAP for elder care because elderly
dependents often cannot meet two Internal Revenue Service (IRS) tax
code requirements--that they spend at least 8 hours a day with and
receive more than half their financial support from their caregiver. 

   FUTURE AVAILABILITY AND OTHER
   FACTORS WILL AFFECT MULTIPLE
   BENEFITS OF ELDER CARE
------------------------------------------------------------ Letter :7

Government elder care assistance has the potential to benefit
employers and caregiving employees by reducing conflicts between work
and family responsibilities.  Caregivers with access to flexible
schedules or elder care information may be better able to provide the
informal care generally preferred by the elderly.  Many factors,
however, will affect the degree to which such benefits are realized,
including the extent to which available elder care options are
effectively recognized, promoted, and used, as well as future
availability of elder care assistance. 

      ELDER CARE ASSISTANCE COULD
      BENEFIT CAREGIVERS,
      EMPLOYERS, AND ELDERLY
---------------------------------------------------------- Letter :7.1

Assistance currently available to working caregivers through their
government employers has the potential to help them provide care for
the elderly at home.  Such care helps prevent and postpone
institutionalization, allowing the elderly to stay at home as they
prefer.  According to recent analyses, informal caregiving can reduce
the risk of institutionalization for seriously disabled people by
almost one-third.  A spouse or adult child having the caregiving role
for 3 or more years is the lead factor in reducing risk of nursing
home admission.\15 At the same time, the burden on informal
caregivers, including a lack of social and other support, places
their care recipients at high risk for nursing home admission. 
Moreover, caregiver characteristics, including the quality of their
support systems, better predict institutional placement than patient
characteristics.\16

Providing elder care options could help governments enhance employee
recruitment, retention, and productivity.  For example, elder care
information can help employees with long-distance caregiving and
reduce absences from work that might otherwise be required for
travel.  In addition, some leave options such as leave without pay
may temporarily increase absence from work but allow employees to
return to the agency rather than have to resign.  This can reduce the
cost of additional recruitment and training to replace valuable
employees.  Government employers promoting all options that
facilitate caregiving could therefore enhance workplace performance,
support employees, and assist disabled elderly persons.  The ultimate
impact of elder care assistance, however, depends on the extent that
caregivers recognize and use it effectively. 

--------------------
\15 Deborah Pearlman and William Crown, "Alternative Sources of
Social Support and Their Impacts on Institutional Risks," The
Gerontologist, Vol.  32, No.  4, (1992), pp.  527-535. 

\16 Elizabeth Coleric and Linda George, "Predictors of
Institutionalization Among Caregivers of Patients with Alzheimer's
Disease," Journal of the American Gerontological Society, No.  34,
(1986), pp.  493-498; and Stephanie McFall and Baila Miller,
"Caregiver Burden and Nursing Home Admission of Frail Elderly
Persons," Journal of Gerontology, Vol.  47, No.  2, (1992), pp. 
S73-79. 

      SOME GROWTH IN ELDER CARE
      LIKELY
---------------------------------------------------------- Letter :7.2

Some governments plan to expand elder care options or introduce new
ones in the next 3 years.  Most, however, are uncertain if they will
increase elder care options.  At the federal level, OPM plans to
encourage more federal agencies to establish work/family and elder
care programs, provide technical assistance to agencies to sponsor
caregiver fairs, and provide information on expanding elder care
options available at agencies.  DOD expects to evaluate the
effectiveness of its elder care initiatives as part of its continuous
effort to improve troop readiness.  SSA also plans to continue
promoting elder care in the agency and using low-cost community
resources to help its employees.  The USDA's APHIS is sponsoring a
demonstration to determine the best way to provide information and
referral services by contracting for two different models of
services.  The IRS and the Environmental Protection Agency also are
considering elder care initiatives.  OPM encourages many of these
efforts through its Work and Family Program Center and through
information shared at the Interagency Adult Dependent Care Working
Group meetings, which OPM leads. 

Seven states and 22 cities reported that they would expand or
initiate their elder care efforts in the next 3 years.  The areas of
possible expansion that states reported include education and
information and private long-term care insurance to cover dependents. 
City governments reported possibly expanding flexible schedules,
education and information, support groups, and financial
arrangements.  Eleven states and 18 big cities reported no plans to
expand or initiate elder care options. 

Some government employers may also plan to expand awareness of
dependent elder care issues as a result of the federal Family and
Medical Leave Act of 1993, which became effective for their employees
on August 5, 1993.  The act mandates that employers, including
federal, state, and local government employers, provide leave without
pay to employees to care for immediate family members with serious
health conditions--including the elderly.  The employee may take up
to 12 work weeks of unpaid leave during any 12-month period for this
purpose.  The Family and Medical Leave Act will offer more schedule
flexibility to government employees who did not previously have
guaranteed access to leave without pay to care for elderly people.\17

--------------------
\17 States were the first to develop family leave laws, many of which
had provisions for leave to care for elderly relatives.  These laws
covered state government employees, many local government employees,
and certain private-sector employees in some states. 

      SEVERAL FACTORS MAY LIMIT
      EXPANSION, IMPACT OF
      ASSISTANCE
---------------------------------------------------------- Letter :7.3

While overall access to government elder care assistance will
probably increase, several factors will likely affect its growth and
impact.  In general, government officials do not believe that a great
or very great need exists for elder care assistance today; only 8
states and 13 cities reported this level of importance for elder
care.  We found this to be generally true in the federal government
as well.  Consequently, most government officials do not see
expanding elder care options as a top priority for the next several
years.  In fact, few governments have made any formal assessments to
gauge the need for elder care.  OPM stands out as an exception in
this regard, having conducted a survey of federal needs in 1992.  For
the long term, most governments expect elder care to become more
important as the population ages, but they have rarely assessed elder
care needs or considered how to meet those needs. 

Additionally, many government officials have concerns about the
perceived costs of offering elder care assistance.  Many elder care
options, however, such as publicizing the AOA's toll-free Eldercare
Locator Number or promoting flexible schedules, are generally
inexpensive.  Nonetheless, cost concerns are the most frequently
cited disincentives to initiating or expanding elder care assistance. 
Less common reasons for not expanding access to elder care assistance
include lack of assessment of elder care need, difficulty in
scheduling workers' hours, private long-term care insurance issues,
and employees' and managers' lack of awareness about elder care as a
work issue. 

   CONCLUSIONS
------------------------------------------------------------ Letter :8

Federal, state, and local governments have an opportunity to offer
enhanced elder care assistance to their employees, often at little
cost.  This assistance can benefit caregivers by easing work and
family conflicts; the elderly, by maintaining their independence at
home; and governments, by improving employee recruitment, retention,
and productivity. 

OPM has begun a campaign to promote elder care programs among federal
agencies.  However, it is too early to evaluate the campaign's
effectiveness in developing elder care in other federal agencies. 
When agencies develop elder care programs, their success will depend
on how well the programs are implemented and the degree to which
employees use them. 

Informal caregivers currently play a major role in caring for the
elderly in their homes and communities.  The prevalence and types of
elder care policies, programs, and practices that we found in
federal, state, and big-city governments have the potential to
strengthen this essential informal care network.  Employers that
actively promote those options that caregivers find
useful--especially schedule flexibility and information about elder
care services--can strengthen the capacity of employed caregivers to
balance their work and family roles, enabling them to continue
providing valuable care. 

---------------------------------------------------------- Letter :8.1

We have discussed a draft of this report with officials from OPM and
the Department of Health and Human Services, and they generally
agreed with our findings.  We are sending copies of the report to the
Director of the Office of Personnel Management, to the Secretary of
Health and Human Services, and to the state and city authorities who
responded to our survey.  Should you or your staff have any questions
concerning this report, please call me on (202) 512-7215.  Other
major contributors to this report are listed in appendix III. 

Sincerely yours,

Jane L.  Ross
Associate Director, Income Security Issues

OBJECTIVES, SCOPE, AND METHODOLOGY
=========================================================== Appendix I

This study is the first nationwide review of government elder care
practices focusing on all levels of government.  Our objectives were
to determine (1) the extent and nature of government practices
facilitating elder care, (2) planned changes in these practices, and
(3) their potential to further support informal caregivers. 

For this report, we defined elder care as an employer-sponsored
practice, policy, or program offered by federal, state, or local
governments that directly or indirectly helps their employees or
retirees care for elderly relatives and friends.  To meet our
objectives, we reviewed the literature on elder care and informal
caregiving, interviewed experts, and visited federal, state, and
local government agencies.  We reviewed other information from
federal, state, and local governments and conducted a mail survey of
the 50 states and of the 100 cities with the largest work forces to
get information on the options their employees can use in caring for
elderly people. 

   FEDERAL GOVERNMENT INFORMATION
--------------------------------------------------------- Appendix I:1

At the federal level, we collected information and documents from the
Office of Personnel Management's Work and Family Program Center and
from other federal agencies to determine what schedule flexibility
options federal employees are permitted to use to facilitate
caregiving to the elderly and what elder care information initiatives
federal agencies offer.  We also visited or collected and reviewed
additional information and documents from individual agencies that
either have or are planning elder care initiatives including the
Department of Defense, the Department of Agriculture's Animal Plant
and Health Inspection Services, the Social Security Administration,
the Environmental Protection Agency, and the Internal Revenue
Service.  In addition, we regularly attended the OPM-sponsored
federal Interagency Adult Dependent Care Working Group, which brings
together a wide range of federal agencies to discuss elder care
issues approximately every 2 months. 

On the basis of these contacts and our briefing of OPM and Department
of Health and Human Services officials at the conclusion of our work,
we believe that this work covers the major elder care options
available to federal employees.  The extent to which these options
are actually available to all employees, however, varies by agency
and by unit.  We are conducting a separate study to examine the
extent to which alternative work schedules are actually available to
federal employees for elder care and other purposes. 

   STATE AND LOCAL GOVERNMENT
   INFORMATION
--------------------------------------------------------- Appendix I:2

We used several different methods to collect information on state and
local government elder care options.  We visited the localities of
Montgomery County, Maryland; Wake and Durham Counties, North
Carolina; Baltimore, Maryland; Richmond, Virginia; Durham, North
Carolina; New York City; and the state government of North Carolina. 
We collected information on employee options that might have elder
care applications from 21 state personnel offices before we conducted
our 50-state survey.  We requested information from organizations
such as the National Association of Counties, the National League of
Cities, the National Governor's Association, the U.S.  Department of
Education, and the College and University Personnel Association.  In
addition, we mailed surveys to the 50 states and the 100 cities with
the largest work forces. 

Our nationwide study of state and local elder care options is more
comprehensive than any other study we found.  Our work, however, does
not include comprehensive information on county governments, school
districts, special districts, townships, and smaller municipalities,
which comprised about 8.7 million employees in 1987.  The level of
overall government employment grew to 18 million in 1992.  Based on
the information collected for these local governments, however, we
have no reason to believe that these localities have more elder care
options available to their employees than those governments for which
we have more comprehensive information. 

   GAO'S SURVEY METHODOLOGY FOR
   STATES AND LARGE CITIES
--------------------------------------------------------- Appendix I:3

      QUESTIONNAIRE DEVELOPMENT
      AND PRETESTING
------------------------------------------------------- Appendix I:3.1

In conjunction with a GAO study of elder care in the private sector,
we designed a questionnaire to obtain information about current and
future employer practices, policies, and programs that directly or
indirectly help state and big-city government employees or retirees
care for elderly relatives or friends.  We discussed development of
the questionnaire with academic experts at the University of
California - Berkeley, the University of Southern California, and
Portland State University.  We also discussed it with representatives
from organizations active in elder care research and consulting,
including the New York Business Group on Health, the Washington
Business Group on Health, the Families and Work Institute, the
Creedon Group, and North Carolina Equity.  In addition, some of these
experts reviewed draft copies of the questionnaire. 

We pretested our questionnaire with officials at three state
governments and three city governments.  Using the pretest results,
we reviewed the questionnaire to try to ensure that (1) respondents
could easily provide the information requested and (2) all questions
were relevant, clear, and free from bias. 

Our survey data show the general availability of various schedule
flexibility and elder care options to state and city employees. 
However, we did not determine if all employees in those governments
have access to these options.  The actual availability of these
options varies by and within departments or agencies.  In addition,
we did not independently verify the accuracy of governments'
responses.  Nor did we assess the quality of the elder care
assistance they offered or the extent of its use by employees. 

      SAMPLE DEVELOPMENT AND
      RESPONSE RATE
------------------------------------------------------- Appendix I:3.2

We surveyed all 50 states and the 100 cities with the largest work
forces as determined by data from The 1987 Census of Governments
(Washington, D.C., Department of Commerce, Bureau of the Census, Jan. 
1991) and City Employment:  1990 (Washington, D.C., Department of
Commerce, Bureau of the Census, Sept.  1991).  In December 1992, we
mailed the questionnaire to the states and cities selected.  We sent
a postcard follow-up to all nonrespondents 4 weeks later; additional
reminders were sent in late January 1993.  We sent a third reminder
to the cities in March.  In April, we called all those who had not
responded to encourage their participation.  Forty-seven of the 50
states responded.  Eighty of the 100 large cities shown in table I.1
responded. 

                                                                                      Table I.1
                                                                       
                                                                        GAO Elder Care Survey: 100 Cities With
                                                                                 Largest Work Forces

                                   Number of                                    Number of                                     Number of                                    Number of
City                               employees  City                              employees  City                               employees  City                              employees
------------------------  ------------------  -----------------------  ------------------  ------------------------  ------------------  -----------------------  ------------------
New York, New York                   416,799  Cleveland, Ohio                       9,453  Baton Rouge, Louisiana                 5,291  Tampa, Florida                        3,991

Washington, D.C.                      48,338  Honolulu, Hawaii                      9,284  Portsmouth, Virginia                   5,286  Huntsville, Alabama                   3,854

Los Angeles, California               45,566  San Diego, California                 9,097  Colorado Springs,                      5,285  Birmingham, Alabama                   3,814
                                                                                           Colorado

Chicago, Illinois                     41,282  Milwaukee, Wisconsin                  9,003  Newark, New Jersey                     5,056  Cambridge,                            3,770
                                                                                                                                         Massachusetts

Philadelphia,                         33,042  Rochester, New York                   8,966  Tucson, Arizona                        4,979  Sacramento, California                3,636
Pennsylvania

Baltimore, Maryland                   31,645  Jersey City, New Jersey               8,507  Portland, Oregon                       4,976  St. Paul, Minnesota                   3,491

San Francisco,                        23,338  Anchorage, Alaska                     8,483  Paterson, New Jersey                   4,917  Quincy, Massachusetts                 3,439
California

Memphis, Tennessee                    21,663  St. Louis City,                       8,311  Hampton, Virginia                      4,882  Lincoln, Nebraska                     3,378
                                              Missouri

Boston, Massachusetts                 21,167  Atlanta, Georgia                      7,891  Elizabeth, New Jersey                  4,781  Jackson, Mississippi                  3,265

Detroit, Michigan                     20,044  Columbus, Ohio                        7,026  Yonkers, New York                      4,719  Tacoma, Washington                    3,252

Houston, Texas                        19,381  Hartford, Connecticut                 6,873  New Haven, Connecticut                 4,572  Anaheim, California                   3,251

Nashville-Davidson,                   17,880  Albuquerque, New Mexico               6,845  Alexandria, Virginia                   4,501  Stamford, Connecticut                 3,244
Tennessee

Dallas, Texas                         14,912  Syracuse, New York                    6,777  Flint, Michigan                        4,453  Amarillo, Taxas                       3,191

San Antonio, Texas                    12,953  Springfield, Illinois                 6,727  Charlotte, North                       4,386  St. Petersburg, Florida               3,184
                                                                                           Carolina

Denver, Colorado                      12,580  Worcester,                            6,473  El Paso, Texas                         4,336  Toledo, Ohio                          3,151
                                              Massachusetts

Indianapolis, Indiana                 12,461  Cincinnati, Ohio                      6,389  Miami, Florida                         4,323  Fall River,                           3,150
                                                                                                                                         Massachusetts

Buffalo, New York                     11,991  Newport News, Virginia                6,236  Orlando, Florida                       4,318  Waterbury, Connecticut                3,122

Virginia Beach, Virginia              11,865  Pittsburgh,                           6,176  Louisville, Kentucky                   4,258  New Bedford,                          3,115
                                              Pennsylvania                                                                               Massachusetts

Norfolk, Virginia                     11,146  Kansas City, Missouri                 6,149  Roanoke, Virginia                      4,242  Lexington-Fayette,                    3,053
                                                                                                                                         Kentucky

Seattle, Washington                   10,589  Minneapolis, Minnesota                6,064  Tulsa, Oklahoma                        4,240  Omaha, Nebraska                       3,043

Phoenix, Arizona                      10,455  San Jose, California                  6,054  Oakland, California                    4,178  Portland, Maine                       2,981

Austin, Texas                         10,333  Chattanooga, Tennessee                5,650  Bridgeport, Connecticut                4,147  Wichita, Kansas                       2,975

Richmond, Virginia                     9,680  Chesapeake, Virginia                  5,633  Trenton, New Jersey                    4,041  Greensboro, North                     2,935
                                                                                                                                         Carolina

New Orleans, Louisiana                 9,814  Fort Worth, Texas                     5,531  Oklahoma City, Oklahoma                4,039  Manchester, New                       2,935
                                                                                                                                         Hampshire

Jacksonville, Florida                  9,482  Long Beach, California                5,326  Providence, Rhode Island               3,999  Dayton, Ohio                          2,934
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Source:  1987 Census of Governments, Department of Commerce, Bureau
of the Census (Washington, D.C.:  1991), pp.  78-151, and City
Employment:  1990, (Washington, D.C.:  1991), pp.  6-14. 

SURVEY INSTRUMENTS
========================================================== Appendix II

This appendix presents our survey instruments and a summary of the
responses.  Forty-seven of the 50 states responded to our state elder
care survey, and 80 of the 100 cities with the largest work forces
responded to our city survey.  The number of responses per question,
however, varies because all respondents did not answer all questions. 

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MAJOR CONTRIBUTORS TO THIS REPORT
========================================================= Appendix III

HEALTH, EDUCATION, AND HUMAN
SERVICES DIVISION,
WASHINGTON, D.C. 

Cynthia A.  Bascetta, Assistant Director, (202) 512-7207
Wayne Dow, Assistant Director
James C.  Musselwhite, Jr., Senior Social Science Analyst
Luann Moy, Senior Social Science Analyst
Benjamin C.  Ross, Evaluator-in-Charge
Edward J.  Murphy, Computer Science Analyst

OFFICE OF GENERAL COUNSEL

George H.  Bogart, Attorney-Advisor

DETROIT REGIONAL OFFICE

Sara Koerber Galantowicz, Evaluator

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