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. 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. 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. 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. 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. 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. This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately.

Summary: 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. 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.