Older Americans Act: Preliminary Observations on Services Requested by Seniors and Challenges in Providing Assistance
Published: 2010-09-07T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Administered by the Administration on Aging (AoA) in the Department of Health and Human Services (HHS), Title III of the Older Americans Act (OAA) is intended to assist individuals age 60 and older by providing supportive services. Title III, Medicaid and Medicare, state, and other sources of funding provide for several types of services, including congregate and home-delivered meals, transportation, and support for caregivers. This testimony reports on ongoing GAO work in preparation for the reauthorization of the OAA and a full report to be issued by GAO in 2011. Based on preliminary findings, GAO describes (1) Title III services most requested by seniors and how state and local agencies reach those most in need, and (2) how agencies have coped with increasing requests in the current economic environment. To do this, GAO reviewed aging plans from the 50 states and District of Columbia; conducted site visits to 4 states; interviewed national, state, and local officials; and analyzed preliminary responses to a Web-based survey of 125 Local Area Agencies on Aging for fiscal year 2009. The survey data used in this document reflect a 54 percent response rate as of July 30, 2010. The survey is still in progress and our results are not generalizable at this time. GAO shared its findings with AoA and incorporated their comments as appropriate.
section_title: What GAO Found
paragraphs: Seniors frequently requested home-delivered meals and transportation services, and based on preliminary responses to GAO's survey and information from site visits, demand for some Title III services may be increasing. Some agencies said they were unable to meet all requests for services in fiscal year 2009. For example, 13 of 67 survey respondents said they were generally or very unable to serve all seniors who requested home-delivered meals, and 15 of 63 said they were generally or very unable to serve all who requested transportation assistance. Local officials cite seniors' desire to remain in their homes as they age, and the economic downturn as possible reasons for increased requests. Given this demand, providers must make decisions about which applicants will receive services. OAA requires providers to target those with the greatest economic and social need,--low-income, minority, lacking proficiency in English, and rural residents--and local officials said they advertise, conduct outreach, and coordinate with other local organizations to identify and serve these groups. Additionally, most local agencies reported screening potential clients to assess level of need, for example, to determine those most at risk of hospitalization due to poor nutrition. In addition to these known service needs, an unknown number of other seniors may need services but not know to contact OAA providers, some officials told GAO. Local agencies who responded to GAO's survey reported using the flexibility afforded by the OAA to transfer funds among Title III programs to meet increased requests for specific services. Twenty-eight of 61 local agencies said they transferred funds in fiscal year 2009, most often removing funds from congregate meals to home-delivered meals or other services. Although the American Recovery and Reinvestment Act (Recovery Act) provided an additional $97 million specifically for meal programs, Title III programs are heavily reliant on state funds, and 44 of 64 local agencies responding to our survey said their state funding was reduced for fiscal year 2010. To cope with funding reductions, some reported cutting services to seniors. Twenty-seven of 65 local agencies said they cut administrative expenses in fiscal year 2010; others relocated offices or left agency positions vacant. Some state and local officials said they provided less service to individuals so that more could get some amount of assistance. Some agencies said they used Recovery Act funds to replace lost state and local funding or created new programs, but the funding was restricted to meal services and was a relatively small percentage of total OAA allocations. The proportion of Americans age 60 and over will continue to grow over the coming decades, and demand for Title III services also will likely grow. Therefore it will be increasingly important for service providers to focus services on those most in need.

section_title: Letter
paragraphs: Thank you for inviting me here today to discuss the preliminary results of  our work that you requested on services and funding provided under the  Older Americans Act of 1965 (OAA). Title III of OAA provides for a broad  range of home- and community-based services for older Americans and  their caregivers, including providing meals, transportation, assistance with  personal care and housekeeping, and time off (respite) for seniors’  caregivers. About 10 million seniors age 60 and older, or about 18 percent  of the national 60 and over population, benefited from these programs in  fiscal year 2008, the most current year for which these data were available.  In fiscal year 2009, Congress provided $1.2 billion for grants to states for  home- and community-based services under Title III of the OAA. Future  funding will be determined in the reauthorization process in 2011.
Demographic studies show that older Americans will make up a larger  proportion of the country’s population in coming decades, with those aged  65 and older projected to increase from 40 million in 2010 to 72 million in  2030. Delivery of services related to long-term care, nutrition, and other  needs of seniors will likely be increasingly in demand as well, particularly  services that help individuals remain in their homes and communities.
Currently, an economic downturn has challenged many seniors’ ability to  meet basic needs as well as the resources of agencies that provide  assistance. The American Recovery and Reinvestment Act of 2009  (Recovery Act) provided a one-time addition of $97 million for Title III  home-delivered and congregate meals for seniors. The Administration on  Aging (AoA) requires states to expend these funds by December 30, 2010.
For today’s testimony, we focused on the following questions: (1) Which  Title III services are most requested, and how do state and local agencies  reach those seniors most in need? (2) How have agencies coped with  increasing requests in the current economic environment?
Our analysis is based on preliminary responses to a GAO Web-based  survey of a random national sample of 125 local area agencies on aging.  As of July 30, 2010, our response rate was 54 percent. These agencies are  the frontline administrators of Title III services for seniors, and our survey  asked them about fiscal year 2009. We also reviewed 51 aging plans from  states and the District of Columbia, reviewed relevant statutory  provisions, conducted site visits to 4 states, and interviewed national,  state, and local officials involved in Title III programs. This testimony is  part of ongoing work for a report requested by the Special Committee on  Aging and scheduled to be issued in early 2011 in which we intend to  estimate need for and potential gaps in Title III services, and provide  results from our completed survey. We discussed our preliminary results  with AoA and incorporated their comments as appropriate. For more  information on our scope and methodology, see appendix I.
We conducted this performance audit from December 2009 to August  2010, in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions.
subsections: section_title: Background
paragraphs: The purpose of Title III of the OAA is to help seniors maintain  independence in their homes and communities by providing appropriate  support services and promoting a continuum of care for the vulnerable  elderly. The OAA laid the foundation for the current aging services  network. This network is comprised of 56 state units on aging (SUA), 629  area agencies on aging (AAA), 244 tribal and Native American  organizations, and 2 organizations serving Native Hawaiians, as well as  nearly 20,000 local service provider organizations. These organizations  are responsible for the planning, development, and coordination of a wide  array of home and community-based services within each state under Title  III of the OAA. This testimony focuses on three categories of services— those provided under parts B, C, and E of Title III of the OAA. Part B  covers, among other things, supportive services and senior centers,  including transportation, help with homemaker tasks and personal care,  and adult day care. Part C covers nutrition services, including home- delivered and congregate meals. Part E authorizes the National Family  Caregiver Support Program, which provides counseling, support groups,  and relief from caregiver duties (respite services) for caregivers. (See  table 1.)
AoA at the Department of Health and Human Services provides grants to  the states through the SUAs. Grant amounts are based on funding formulas  weighted to reflect a state’s age 60 and over population, which is generally  the group eligible for services. For example, in fiscal year 2009, the state  of Florida received about $87 million in Title III dollars compared to the  state of Montana, which received $6 million, because more seniors reside  in Florida. SUAs then typically allocate funds to Area Agencies on Aging  (AAA) to directly provide services or to contract with local service  providers. In a few states, the SUA directly allocates funds to local  providers or provides services. (See fig. 1.)
A significant amount of program funding is also provided to state and local  agencies by other sources, such as federal Medicare and Medicaid, states,  private donations, and voluntary contributions from seniors for services  they receive. According to a 2009 study published by the National  Association of Area Agencies on Aging and Scripps Gerontology Center of  Miami University, 99 percent of AAAs secure funds from additional  sources, and the average AAA utilized funding from six sources to provide  services in their communities. The amount secured by AAAs varies.
OAA services are available to all people age 60 and older who need  assistance. The law did not, however, establish an open-ended entitlement  available to all seniors, nor was it intended to meet all of seniors’ needs.  OAA requires providers to target, or place a priority on reaching, seniors  with the greatest economic and social need, and defines them as  individuals who have an income at or below the poverty level, or who are  culturally, socially, or geographically isolated, face language barriers, or  have physical and mental disabilities. Targeting these seniors who are  most in need may include a local agency locating a congregate meal site in  a low-income neighborhood or working collaboratively with organizations  that represent minority seniors. In addition, some services are targeted to  vulnerable groups by definition. Examples of these include the long-term  care ombudsman program, family care-giver support services, and assisted  transportation to those with limited mobility. OAA gives state and local  agencies flexibility in determining which populations to target.
The recent health care reform legislation—the Patient Protection and  Affordable Care Act—contains new provisions for senior health care,  including one removing barriers to home- and community-based services  under Medicaid. While these changes may shift the provision of some  services for seniors from OAA to Medicaid, the extent of this shift is  unknown; nevertheless, seniors will likely continue to look to OAA-funded  providers for a range of assistance.
section_title: Agencies Report Increased Requests for Meals and Transportation and Varied Efforts to Reach Those Most in Need
paragraphs: Local agencies who responded to our survey identified home-delivered  meals and transportation as frequently requested services in fiscal year  2009. These agencies also said they receive many requests for information  and assistance services—help locating resources and programs—and for  respite for caregivers. In preliminary responses to our survey, 49 of those  61 local agencies said more seniors requested home-delivered meals than  congregate meals. Forty-four of our 67 survey respondents thus far cited  transportation and 43 cited information and assistance as the support  services requested most frequently. One local official we spoke with in  Wisconsin highlighted the importance of transportation services for his  rural clients, while an agency official in Massachusetts said OAA  transportation services can be important in urban settings because seniors  often prefer them to mass transit options. In addition, 36 of the 63 local  agencies who have responded to our survey and track such requests said  respite services were most frequently requested by caregivers in fiscal year  2009. Respite care provides temporary caregiving for seniors so that a  family member can take a break or engage in other activities.
Some agencies responding to our survey said they are currently unable to  meet all requests for services. Thirteen of 67 agencies said they are  generally or very unable to serve all clients who request home-delivered  meals; 15 of the 63 agencies that provide transportation services said they  are generally or very unable to meet all transportation requests. Of the 64  agencies that provide respite care, 17 said they were generally or very  unable to meet all requests.
State and local officials we spoke with also said requests for some OAA  services are increasing. Specifically, officials at several local agencies we  visited described increased requests for home-delivered meals,  transportation, or home-based services. Officials attributed these  increases to several factors. First, some agency officials said there are  increasing numbers of Americans who are age 60 and older and eligible for  services. According to U.S. Census data, more than 9 million more  Americans were 60 years and older in 2009 than in 2000, and the Census  Bureau projects that population group will continue to grow. Secondly,  some agency officials told us requests for OAA services such as home- delivered meals and home-based care are increasing as more seniors stay  in their homes longer rather than move to assisted living facilities or  nursing homes. For example, state officials in Wisconsin said their client  population is increasingly older and those who remain in their homes less  likely to go out, leading many to request home-delivered meals.
Lastly, most agencies who responded to our survey said requests for  services have increased since the economic downturn began. Forty-eight  of 61 said they have received increased requests for home-delivered meals,  44 of 62 for support services such as transportation, and 40 of 61 agencies  for caregiver services since the downturn began. Twenty-five of 60  agencies said they had increased requests for congregate meals, even as  long-term trends show a decline in use of this service. A survey  conducted by the National Association of State Units on Aging to  determine the impact of the economic crisis on state-provided services  also found requests for the types of services provided by OAA increased,  particularly for home-delivered meals, transportation, and personal care.  Some researchers have concluded that older Americans have been hard hit  by the economic recession for reasons such as depreciating home values  and retirement accounts. These increasing economic challenges may lead  to increased need for services like those provided by OAA programs.
Given the number of agencies that cannot meet all requests for services  and the increasing demand for certain services, agencies must make  decisions about which applicants to serve. To reach and serve seniors with  the greatest economic or social need, local agencies responding to our  survey reported a range of strategies. Over 50 of 67 agencies said they  advertise, conduct outreach, and coordinate with other local organizations  to reach and provide services to seniors who are targeted by OAA: seniors  who are low-income, minority, or live in rural areas. At least 47 of 67 said  they use these approaches to reach seniors who speak limited English,  another group targeted by OAA. Additionally, most local agencies reported  screening potential clients to assess, whether seniors requesting home- delivered meals or respite care had physical limitations that made these  types of services particularly beneficial. For example, at one local agency  where demand often exceeds supply, an official said preference may be  given to those most at risk for hospitalization due to diagnosed  malnutrition or chronic diseases managed through nutrition, such as  diabetes. Most local agencies did not screen for congregate meals or  transportation services.
Some officials we spoke to said there are additional seniors who need  services but do not contact OAA providers to request them. For example,  one local official in Illinois said needs assessments and anecdotal  information indicate a much greater need for services than requests to the  agency indicate. Similarly, researchers from one organization we spoke  with surmised that if more seniors knew about the types of services  available through Title III, the requests for such services would be    greater.
section_title: Agencies Often Move Funds among Programs to Meet Requests and Cut Costs to Cope with Reduced Funding
paragraphs: Local agencies have adopted a number of coping mechanisms to address  seniors’ requests and decreased funding. Preliminary responses to our  survey indicate agencies utilize the flexibility provided by the OAA to  transfer funds among Title III programs to meet requests from seniors for  services. Twenty-eight of 61 local agencies responding to our question  said they transferred funds among programs in fiscal year 2009, most often  removing funds from congregate meals, which are less requested, to home- delivered meals or other services. On a national level, nearly 20 percent of  OAA funding for congregate meals in fiscal year 2008 was transferred out  of the program by states and split almost evenly between home-delivered  meals and support services, AoA data show. (See fig. 2.) As a result,  support services and home-delivered meal programs experienced an 11  percent and 20 percent net increase, respectively, in Title III funds. On the  state level, 34 states transferred funds from congregate meals to home- delivered meals in fiscal year 2008, according to AoA data.
The ability to transfer funds offers states flexibility, yet some officials have  questioned the need for meal funding to arrive in two streams. For  example, Wisconsin state officials said maintaining separate funding for  congregate and home-delivered meals creates a cumbersome process in  which the state has to deal with multiple rules to allocate funds to services  that are most needed. Similarly, Rhode Island state officials said they  would like to see a single Title III, Part C, meal program because requests  for congregate meals have decreased. In addition, in fiscal year 2008, 32  states transferred funds from the congregate meal program to Title III,  Part B, services such as personal care, homemaker assistance, and  transportation services. Local officials in Wisconsin told us federal funding  for Part B services is not sufficient to meet requests.
In addition to receiving federal funding, the programs created by Title III  of OAA receive funding from other sources as well. (See fig. 3.) OAA funds  to states and local agencies increased in fiscal year 2009 by $97 million due  to Recovery Act funding explicitly for meal programs. But many of the  local agencies responding to our survey reported overall decreases in  funding from fiscal year 2009 to fiscal year 2010. Forty-four of 64 local  agencies said state funding – the second largest source of funding for these  programs nationally—decreased for fiscal year 2010. This is consistent  with information reported by the National Association of State Units on  Aging (NASUA). NASUA found that most states reported state budget  shortfalls in fiscal year 2010 and reduced budgets for aging services. Local  agencies also use funds from local governments, voluntary client  contributions, and private sources, and our preliminary survey results  indicate these funds also declined in fiscal year 2010.
Some local agencies responding to our survey reported reducing services  as a result of funding cuts. Twelve of 64 local agencies said they reduced  support services, an additional 12 of 63 reported reducing nutrition  services, and 9 of 64 reported reducing caregiver services.
To replace lost state and local monies and maintain service levels to  seniors, just under half of those responding to our survey said they took  some steps to reduce administrative and operations costs and used  Recovery Act funds to fill budgeting gaps. In our preliminary survey  results, 27 of 65 agencies reported cutting administrative expenses, 22 of  54 reported cutting capital expenses, and 26 of 62 reported cutting  operating expenditures in fiscal year 2010. Local agencies responding to  our survey said they cut expenses in many ways such as by relocating to a  smaller building with lower overhead costs, stretching meal service  supplies, decreasing travel expenses, and limiting raises for employees.  Additionally, 29 of 63 said they did not fill vacant positions. These  preliminary survey data are consistent with what we heard from state  officials on our site visits. State officials in Wisconsin, for example, told us  that as a result of the state’s budget deficit, the agency was unable to fill  vacant positions and had cut planning, administration, and monitoring  activities in order to avoid cutting services to seniors. Illinois state officials  told us the last budget cycle included a 10 percent decrease in state funds  for aging services, and there were layoffs, required furlough days, and  positions left vacant as a result.
Some state and local agencies we visited also told us they adapt to limited funding or increased requests for services by providing less service to all  rather than full service to only some. For example, a local official in  Massachusetts said that some seniors are given fewer transit rides so  others can be accommodated. A state official in Illinois said some local  areas resolve the funding shortfalls by reducing the number of hours they  provide respite services for each caregiver.
Local agencies said they used Recovery Act funds to fill meal budget gaps  or to expand existing nutrition programs or create new ones. Nationw ide,  the Recovery Act provided $65 million for congregate meals and $32  million for home-delivered meals, or about 13 percent of the total OAA allocation for meals in fiscal year 2009. Unlike regular Title III meal  funds, Recovery Act meal funds could not be transferred among prog Thirty-nine of 61 local agencies said it was moderately to extremely  challenging that Recovery Act funds could not be transferred among meal  programs.  rams.
section_title: Concluding Observations
paragraphs: OAA Title III programs are an invaluable support mechanism for many  seniors, providing a varied network of care and services as they age.  Seniors’ needs for the types of services provided through these programs  will only increase over time since demographic studies show a larger  proportion of Americans will be age 60 and older over the next few  decades. Programs that allow seniors to remain in their own homes and  communities afford seniors the independence and dignity they desire. As  current fiscal stress and looming deficits continue to constrain available  resources, it will be increasingly important for all elements of the home  and community-based service network to focus services on those in  greatest need.
Mr. Chairman, this concludes my prep answer any questions you may have.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: To determine the Title III services requested most often, local agencies’  use of federal funds, and steps agencies take to deliver resources to those  most in need, we conducted a web-based random national sample survey  of 125 Area Agencies on Aging (AAA). The survey included questions  about: (1) utilization of OAA Title III services, (2) requests for OAA Title III  services, (3) approaches for measuring unmet need to target resources to  areas of greatest need, (4) use of OAA Title III funds, and (5) the economic  climate and use of American Recovery and Reinvestment Act (Recovery  Act) funds. We drew a simple random sample of 125 agencies, from a pool  of 638 agencies. This included all 629 area agencies on aging (AAA) that  operate in the 50 states and District of Columbia, as well as nine State  Units on Aging (SUA) in states that do not have AAAs. We included these  nine state agencies in our pool for sample selection because the SUA  performs the function of AAAs in those states. We conducted four pretests  to help ensure that survey questions were clear, terminology was used  correctly, the information could be obtained, and the survey was unbiased.  Agencies were selected for pre-testing to ensure we had a group of  agencies with varying operating structures, budget sizes, and geographic  regions of the country. As a result of our pretests, we revised survey  questions as appropriate. In June 2010, we notified the 125 AAAs that were  selected to complete our survey and e-mailed a link to complete the Web  survey to these agencies beginning July 1, 2010. The survey is on-going,  and the information included in this testimony presents preliminary  results, based on the 67 responses (54 percent) we received as of July 30,  2010. Some individual questions have lower response rates. The practical  difficulties of conducting any survey may introduce nonsampling errors.  For example, difficulties in interpreting a particular question, sources of  information available to respondents, or entering data into a database or  analyzing them can introduce unwanted variability into the survey results.  We took steps in developing the questionnaire to minimize such  nonsampling error. Due to the preliminary nature of the results, the  information presented in this testimony is not intended to be generalizable  to all AAAs.
We also reviewed relevant statutory provisions and used site visit  interviews and Administration on Aging (AoA) State Program Report data  to answer our two research questions. In March 2010, we visited Illinois,  Massachusetts, Rhode Island, and Wisconsin. These states were selected  due to varying sizes of the population age 60 and over and Title III  expenditures. Additionally, we considered geographic region, proximity to  AoA regional support centers, and a desire to interview at least one state  without AAAs (Rhode Island). We interviewed officials from the SUA,  AAAs, and AoA regional support centers. We also analyzed AoA State  Program Report data available on the agency’s Web site and at  www.agidnet.org. We assessed the validity and reliability of this data by  interviewing AoA officials, assessing official’s responses to a set of  standard data reliability questions, and reviewing internal documents used  to edit and check data submitted by states. We determined the data were  sufficiently reliable for purposes of this review.
To determine steps agencies take to deliver resources to those most in  need, we also analyzed the most recently available state aging plan for the  50 states and District of Columbia. Each state is required to submit a state  aging plan to AoA for review and approval covering a two, three, or four  year period. The aging plan should include state long-term care reform  efforts with an emphasis on home and community-based services,  strategies the state employs to address the growing number of seniors, and  priorities, innovations and progress the state seeks to achieve in  addressing the challenges posed by an aging society.
subsections: section_title: GAO Contact and Staff Acknowledgments
paragraphs: For future contact regarding this testimony, please contact Kay Brown at  (202) 512-7215 or e-mail brownke@gao.gov. Key contributors to this  testimony were Kimberley M. Granger-Heath, Susan Aschoff, James  Bennett, Ramona Burton, Andrea Dawson, Justin Fisher, Luann Moy,  Barbara Steel-Lowney, and Craig Winslow.
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