Performance Standards and Accountability
Technology/Information Highway
Home Is More Than Where You Hang Your Hat
- The aging network has a long and successful history of working for and with older adults—since the passage of the Older Americans Act in 1965. Its future depends on demonstrating that it can continue to respond effectively and efficiently to changes in funding, services administration, and in the makeup, needs, and interests of the older population.
- These changes present both challenges and opportunities for all levels and aspects of the aging network. Senior centers are an important part of the network that must be strengthened to remain an essential community focal point for older adults.
- Adequate and affordable housing and transportation remain some of the top needs of older adults that the network must help assure are met.
- Facing a complicated array of choices and decisions that affect their overall quality of life, older North Carolinians and their families need reliable and timely information and assistance. The aging network must move deliberately to meet their varied needs and interests, using state-of-the-art technology as well as the personal communications that have been the hallmark of the network.
- The aging network must plan and act now to consider the future of our “aging society” that is driven largely by North Carolina’s two million baby boomers.
The “aging network” refers to those agencies and organizations at the state, regional, and local levels who share responsibility for carrying out the mission of the federal Older Americans Act and related state interests and initiatives. This network includes the state Division of Aging (GS 143B-181.1), the Area Agencies on Aging (AAAs), and a wide array of more than 360 local service providers. It also involves other state divisions and their local counterparts, including health, social services, and mental health agencies. All of these organizations, and more (see figure 6-1), play a significant role in the planning and delivery of services and benefits to older North Carolinians and their families.
The future of the aging network will be influenced both by its history as well as its ability to respond to the changing landscape of issues, needs, and opportunities. The network began with the creation of the Older Americans Act (OAA) in 1965, the same year that the US Congress established Medicare and Medicaid. As we approach the thirty-fifth anniversary of the Older Americans Act, its ambitious objectives remain as relevant to aging boomers as they were to their grandparents (see appendix G for a list of these objectives).
The wide scope of the Older Americans Act’s charge to the aging network contrasts with the modest level of federal funding the network receives. The Division of Aging operates with a federal and state budget that supports 33 positions, nearly the same number employed when the division was established in 1977. The 18 Area Agencies on Aging function with an average of 5.5 full-time equivalent employees. Appreciating how the growing challenges and responsibilities are overwhelming existing capacity, in the 1998 Session, the State General Assembly appropriated an additional $900,000 in administrative funds for use by AAAs.
Local providers of aging services draw sharp contrasts in size and scope of activities. Many providers of aging services depend heavily on in-kind contributions and volunteers to meet local needs. This is especially true of nutrition programs and senior centers. Still, the aging network can boast that it reaches every community in North Carolina with information, services, and opportunities for involvement. There are very few parallels, especially in human services, to the long-standing and close relationship that the aging network enjoys with its primary constituents and consumers—older persons and their families.
The positive relationship that the aging network enjoys with its constituents is one that has developed largely because of the network’s responsiveness to their needs and interests. The future of the network depends on its continued ability to anticipate, understand, and react to the changes that older households are experiencing. Without question, the aging network’s role in assuring an adequate system of home and community-based services will remain its most fundamental task. Its performance in this area must remain strong. As outlined in the other chapters, the network also has substantive roles in the promotion of older workers, the support of good health and access to quality and affordable health care, and the protection of the rights of older adults, including those of persons living in long-term care facilities.
This final chapter of the plan considers some of the other ways in which the network has an opportunity and responsibility to lead. First, the network must do its current work more efficiently and effectively. There are four basic elements relative to raising the network’s level of performance:
Second, the network must show leadership in identifying and responding to emerging trends and issues, including the changing desires and preferences of the older population. In this role, the network must invite a wide range of community interests—public and private—to participate in planning and preparing for an aging society.
Figure 6-1. The Core of North Carolina's Aging Services Network
A theme of North Carolina’s aging plans of the 1990s is that “services organized and planned at the county level in partnership with the regional Area Agencies on Aging (AAAs) provide the greatest opportunity for being responsive to the needs of older adults and their families.” These plans identified important leadership roles for AAAs in their support of the development of county-based programs on aging. In one role, AAAs are to help county programs on aging assure that older adults and their family caregivers have access to a range of service choices of acceptable quality.
During the last decade, several changes have raised the relative importance of the performance of local aging services. These include the increasing number of older consumers who require effective targeting of resources; changing consumer expectations about services; the emergence of managed care; an intensified search for a user-friendly, seamless, unfragmented system of services; the need to maintain quality while minimizing costs; the pressures to increase consumer cost-sharing as a way to build revenues to expand services; and the considerable investment of state funding for home and community-based services. Collectively, these changes are forcing providers to make difficult decisions about whom to serve, with what services, for what expected outcomes.
An overriding challenge of the aging network is how to strengthen standards of performance in ways that promote continuous quality improvement and innovation to meet the changing needs of its consumers. While the education and training of the aging services workforce are essential, the presence of service standards is especially important to the quality of performance and the professionalism of the field. Working with other state organizations and professional associations, the Division of Aging has established standards for each of the services fundable under the Home and Community Care Block Grant. These standards must be updated periodically to reflect changes in service needs, the workforce, and the service system. The network must be able to demonstrate that it can effectively monitor, evaluate, and report on its performance relative to current consumer needs and interests. Not only is this the mark of an effective agent of public funds and trust, it is also now required by federal and state laws.
With the implementation of the federal Government Performance and Results Act in 1996, all levels of the aging network must apply a results-oriented approach to the management of services. In the future administration of OAA funds, agencies will be expected to go beyond such output measures as number of persons served to identify performance outcomes for their programs—how do clients benefit from their contact with the system. Encouraging service providers to set goals—for more timely service, for example—and to document the achievement of such a goal will likely provide a better measure of performance. Another important component of performance measurement is identifying and documenting the reasons that prevent goals from being met. Similarly, the North Carolina General Assembly passed legislation (GS 143-10.5e3) to require state agencies to submit annual performance reports for review and evaluation.
The following performance measures for the Division of Aging illustrate this movement toward greater accountability:
The Division of Aging has supported several initiatives with Area Agencies on Aging and local service providers designed to plan and measure performance better. First, in 1996 the North Carolina Association of Area Agencies on Aging established a set of voluntary performance standards, with assistance from the division and the Duke Long Term Care Resources Program. In consultation with their advisory councils, AAAs now use these standards as a framework for developing their Area Plans. Also in 1996, the division convened the Provider Performance Review Committee as a cooperative effort among the state, regional, and local levels to focus not only on compliance with state service standards but also on technical assistance and training, quality improvement, fiscal monitoring, cost analysis, and improved stewardship of federal and state funding.
The committee believes that the aging network can no longer feel confident in simply providing a service, but rather must assure that it is a quality, consumer-focused, and cost-effective service. The real challenge is how to accomplish this quality improvement with the existing resources of the network. The committee began with a review of nutrition services and is now field-testing several tools that will serve as a prototype for the other block grant services. The overall goal is to empower local aging service providers to conduct a self-assessment and then systematically improve their performance consistent with standards set by the state and their peers. The AAAs and the Division of Aging will provide training and technical assistance.
In a related initiative, in 1996 the division conducted the first statewide customer satisfaction survey of the home-delivered and congregate meals programs. An important finding of the survey was that about two-thirds of home-delivered meal participants and 44 percent of congregate meal participants were found to be at “high risk” of poor nutrition. This led the division to help secure a grant of $380,565 from USDA for an educational campaign to lower the risk of malnutrition among participants of the congregate meals program. The use of customer satisfaction surveys is simply one more way the aging network can respond to the changing needs and interests of consumers and maintain quality. In 1998, the division completed a statewide customer satisfaction survey of its Ombudsman Program, and it will conduct similar surveys of other services in the future.
As of November 1998, there were 135 senior centers in 91 counties in North Carolina. This means that there is about one senior center for every 10,000 older North Carolinians. Nationally, in 1995 there were reportedly 1.85 senior centers for every 10,000 persons aged 60 years and over. States with the highest percentage of senior centers, per 10,000 persons age 60 and over, were Alabama (52 per 10,000); New York, (27 per 10,000); and North Dakota (17 per 10,000).1
Promoting the establishment and development of multipurpose senior centers has been an integral part of the Older Americans Act since its enactment in 1965. The modern-day senior center can trace its roots back nearly 60 years ago to the Hodson Center in New York City, which focused on meeting the needs of older people with low incomes through nutrition and recreation services. While many of today’s senior centers in North Carolina are well recognized and respected as multipurpose, community focal points that offer a wide range of information, assistance, and involvement, others remain more narrowly focused on recreation and nutrition. Few, if any, centers have realized their full promise as active links to information, services, and programs, or as promoters of wellness.
The Division of Aging has undertaken an initiative to enhance the operation and programming of senior centers. This is requiring increased support for senior centers at both the state and local levels. The effort will be a major priority of the division and the aging network.
Considering the role of the aging network into the next century, the Division of Aging looks to senior centers to further their position as focal points for services to and activities for older adults. This past September the division established a State Task Force for Senior Center Development to design a model of senior centers to move them into the next millennium and to guide state and local efforts over the next five years. The division is also revising its standards for senior center operations. These standards stipulate the policies and procedures governing the operation of senior centers that receive funds under the Home and Community Care Block Grant. The senior center model is different from the service standards because it does not represent policy, but rather an ideal to which senior centers should aspire.
These initiatives come at an important time in the history of North Carolina’s senior centers. First, the General Assembly has shown renewed interest in and support of senior centers. In the 1997–99 state fiscal biennium, it appropriated $4.5 million ($1 million in recurring funds; $3.5 million in nonrecurring funds) for senior center development and operations—consistent with the recommendations of the Senior Tar Heel Legislature, the Governor’s Advisory Council on Aging, and the Legislative Study Commission on Aging. Second, the National Institute for Senior Centers recently revised the voluntary standards for senior centers and established an accreditation process that some centers will pursue. Third, there are an increasing number of changes under way that affect older adults and their families—to which senior centers must respond as community leaders in aging.
The State Task Force has identified a model that all senior centers should achieve—the Center of Merit. It also outlined a second model to which senior centers should aspire and grow—the Center of Excellence. A descriptive outline of these two models is included as appendix E. In creating this framework for future development, the task force considered the role of senior centers relative to the oldest seniors as well as the emerging boomers. These models are living documents, in that they will change with new thinking, developments, and opportunities.
The Division of Aging will use these models to support a more focused approach to senior center funding that encourages new centers to meet quality standards and provides existing centers with an incentive to improve their programs and operations. Currently, there are a number of different state and federal funding sources that support senior centers. This diverse funding is considered essential for their development, but because of the different program and facility requirements, there are no uniform standards that address program performance and outcomes. The use of these models should change this. The division will promote future state funding of senior centers based on these models.
The division will use the following objectives to measure progress for senior centers during the next four years. By 2003
Volunteer and Paid
Similar to any business, the effectiveness of the delivery of aging services rests largely on its workforce. Unlike many businesses, the workforce of the aging network depends as much on unpaid as on paid personnel. Volunteers and informal caregivers are essential to assisting older adults with their various needs.
Volunteerism and Informal Caregiving
Nearly all of the meals delivered to the homes of frail older adults depend on the conscientious service of volunteers, and few, if any, senior centers could function without the contributions of unpaid workers. Volunteers are essential to the congregate nutrition program, and some providers of home repair and transportation services also rely on volunteers. It should not be surprising that development of volunteerism ranks high as a significant need among aging programs, especially in our state’s most rural counties.
There are two basic issues for the future. First, how can programs that rely extensively on volunteers maintain or even expand this resource? Some report increasing difficulty in the recruitment and coordination of volunteers. It is becoming more complicated as potential volunteers have competing demands for their time, including participation in the paid workforce. Second, why have certain programs successfully tapped volunteers while others have not? The Division of Aging’s 1992 workforce survey found a variance, especially among home repair and transportation services.
The key to the effective use of volunteers is having the capacity to link volunteers to the needs of agencies and communities and to assure that the volunteers’ time and contributions are appropriately used. Currently, about three-quarters of our counties do not have a centralized program to recruit and manage volunteers. Additional resources—whether public or private—are needed to support volunteer development programs in all counties.
Volunteerism does not typically include the contributions that families and neighbors make on a daily basis to enable frail or isolated older adults to remain independent. Nonetheless, it is their personal care and concern that may tip the balance toward being able to stay living at home. Their valued contributions include the phone call to say hello, transportation to the doctor, grocery shopping, help with day-to-day chores, and around-the-clock caregiving. As discussed in chapter 3, the labor of love of informal caregivers remains the backbone of long-term care, without which the formal system would be overwhelmed and the public financing of it bankrupt. As there is growth in the older population, there will be increasing numbers of families called upon to be caregivers.
Older adults themselves are a vital part of the volunteer and caregiving network. As of January 1997, the Division of Aging estimated that 367,000 older adults were volunteers in various programs in North Carolina, including the Retired Senior Volunteer Program (RSVP), the Foster Grandparent Program, the Senior Companion Program, and the Senior Corps of Retired Executives (SCORE). While much of this volunteerism was on behalf of other older adults, these senior volunteers were also helping children and younger disabled persons. Another good example of older persons reaching out to children is the Senior Education Corps, which matches senior volunteers to the needs of schools.
While far too numerous to list here, some volunteer initiatives that are making valuable contributions to the quality of life of older adults include:
As we look ahead, we can be reassured by the commitment of North Carolinians to volunteer. This includes the large cohort of baby boomers who reportedly volunteer more than any other age group. Still there are concerns. First, the need for volunteers will rise as the number of frail older people increases, and we work to slow the rate of growth of public expenditures. Second, because the majority of volunteers are working people, the planning and coordination necessary to use these workers effectively is becoming more complicated. This points to the value of investing in volunteer program development and the use of state-of-the-art tools for matching human resources to service needs.
The Volunteer Coordinator Program of the Region D Council of Governments Area Agency on Aging provides an excellent example of the benefits of such an effort. Supported with a two-year grant from the Kate B. Reynolds Charitable Trust, each of the six counties in Region D—Alleghany, Ashe, Avery, Mitchell, Wilkes, and Yancey—has a county volunteer coordinator housed in its local senior center. From April to December 1998, 344 new volunteers added their support to aging services in the region, resulting in such new activities as pet therapy in an Alleghany nursing home; a mobile pharmacy in Ashe County, serving seniors quickly and at no charge; and formation of a support group for the visually impaired. It is estimated conservatively that the 25,601 hours of volunteerism amounts to about $153,606 in service dollars.
As we look to the future, we also must pause to consider demographic trends that are affecting social relations and informal caregiving. We must be especially sensitive to the fact that women provide most of the informal caregiving of children and elderly. The strength and stability of family caregiving, on which we have relied in the past, are being tested by several factors. Boomers, their parents, and their children have all been more mobile than previous generations. Children moving away (especially from some of our rural areas) has an effect on the whole community (i.e., population loss, loss of tax base, higher proportion of older adults). Long-distance caregiving is one of the personal consequences for families. While we expect that families—and especially the women within these families—will continue to shoulder responsibility for caregiving—it is clear that family dynamics are changing, and we must change with them to support this vital resource. We must develop policies and programs for caregiving—not as a children’s issue or seniors’ issue—but as a family issue.
The Paid Workforce
In the 1991 State Aging Services Plan, counties identified the inadequate supply of properly trained personnel as the major barrier to the provision of home and community-based services. The adequacy of the personnel providing health and human services to older adults is determined in terms of supply and preparedness. The chapter on long-term caregiving discussed issues of both supply and preparedness relative to the paraprofessional workforce. The future (supply and capability) of the paraprofessional workforce is vital to aging services, especially for older adults requiring long-term care at home, in the community, or in residential and nursing facilities.
Concern about the aging services workforce led the Division of Aging to commission a study in 1992 of local home and community care providers. Here are a few findings of this survey:
Since 1992, there have been several developments that should make a measurable difference over time, especially in the area of training. These include the establishment of the NC Institute on Aging in the University of North Carolina system, the commencement of an annual statewide Summer Symposium on Aging, and the ongoing work of the Duke University Long Term Care Resources Program.
In 1996 the North Carolina General Assembly approved funding for the creation of an Institute on Aging to advance public service, education, and research in aging. Evidence of the institute’s progress is its acquisition in 1998 of a federal grant to establish one of the nation’s six Resource Centers for Minority Aging Research. Minority workers, especially African Americans, assume a vital role in aging services.
In 1996, a group of practitioners and academics teamed to produce a collaborative, voluntary educational effort that resulted in an annual summer symposium to showcase how colleges and communities are working together for the benefit of aging in North Carolina. The Institute on Aging is now sponsoring this summer symposium as a means to integrate theory and practice and test the practical application of new ideas. The effectiveness of such an approach was previously demonstrated in the success of Duke University’s support of teaching and learning communities and its internships for graduate and undergraduate students and senior leaders.
Today’s older adults, like everyone else, have faced a number of difficult choices in their lives. To help them make these choices, most have sought information from a variety of sources. The complexity of choices that older people currently face presents them with what may be among their biggest challenges. Most contemplate whether to move or to stay put in retirement. Some became distressed over the contradictory information about the choice of whether to accept direct deposit of their Social Security or SSI check. The choices of an increasing variety of health care plans under Medicare will likely be even more difficult.
The choices that older persons must consider are many, and they can have significant consequences. Asked to take on more personal responsibility for the cost of long-term care and the security of their income, they struggle with making an informed decision whether to purchase private long-term care insurance, secure a reverse mortgage, or do something else. While North Carolina’s aging network takes pride in the success of its expansion of service alternatives, older households can face added questions about where and how to receive assistance based on preferences, finances, and eligibility.
With choice comes risk. Seniors may ask: Did I make the right decision about my health plan and supplemental coverage? Should I withdraw my pension funds as a lump sum or an annuity? Should I have accepted my employer’s incentive for early retirement? To what extent should I worry about getting to my doctor or a grocery store if I move outside the city? Should I retire to North Carolina?
The National Information and Referral Support Center of the National State Units on Aging has identified three fundamental questions for the aging network to consider as it prepares to serve older adults in the year 2000 and beyond.3
In response to these three fundamental questions, North Carolina’s aging network must become well equipped to continue empowering older consumers, caregivers, and advisors to make informed choices.
People need different levels and types of interventions to help them make informed decisions. The kind and level of assistance needed depends on the person’s capacity and confidence; on the quality and availability of information; and on the range, complexity, and acceptability of choices. The 1991 State Aging Services Plan outlined a framework for county-based programs for older adults to encourage development of the infrastructure to support the varied levels of assistance needed to help older adults and their families access services and programs, exercise self-care, and make informed decisions in matters of personal responsibility. The continuum shown in figure 6-2 expands upon this framework to identify the essential elements necessary for aging in the year 2000 and beyond.
Figure 6-2. A Continuum of Interventions
Everyone wants and needs access to reliable information from credible sources to help them make decisions. They want the information to be readily available and easily understandable. In addition to information, people want accurate referrals to resources, and depending on their situation or interests, they may also want education about some issue or topic and training in some skill or task. In some instances, one-on-one counseling is what is needed to enable the individual or family to understand and manage a crisis or handle a difficult situation.
A small number of people require more help, especially to identify and access services. Case assistance involves screening of requests for assistance to determine the level of help needed, making the referral to appropriate services, and following up to determine if needs were addressed satisfactorily. As needs become more complex, so must the response. Care management incorporates case finding, assessment, care planning, negotiation of services, care plan implementation, monitoring, and advocacy to assist people with complex needs to obtain appropriate services. When it is found that a disabled adult is at risk from abuse, neglect, or exploitation, the state is required to act to protect the adult’s health and safety through the provision of essential services, the counseling of caregivers, and the initiation of legal action. This is accomplished in North Carolina through a mandate to the Social Services system. The county departments of social services assist older adults who are at risk of abuse, neglect, or exploitation through the provision of At-Risk Case Management Services, a comprehensive case management program funded by Medicaid.
When people lose their ability to make important decisions and manage their everyday affairs, it may become necessary for another person to intervene and oversee their affairs. One way this is done is for the court to declare the person incompetent and appoint a guardian. Because of the substantial loss of rights, people are encouraged to consider alternatives to guardianship whenever possible, such as durable power of attorney and living will. These options require advance preparation and participation on the part of the person affected—another example of the choices that people make.
North Carolina enjoys a rich array of resources—public and private, paid and volunteer—to assist older persons and their families with understanding and exercising their options and rights. The network of Area Agencies on Aging, local councils and departments on aging, senior centers, county departments of social services, and other resources serves as the fundamental conduit of information and assistance. The many other resources that complement and supplement the network’s role include the Seniors’ Health Insurance Information Program (SHIIP) of the state Department of Insurance, the North Carolina Cooperative Extension Service, the county departments of social services, and various state and local consumer groups (e.g., AARP, NC Senior Citizens Federation, NC Association of Senior Citizens).
The state is witnessing increasing interest and activity toward creating an efficient and easily accessible system for information and referral. At locations all across the state, there are multicounty initiatives under way to pool resources, use the best of technology, and focus on consumer needs for information and assistance. These efforts include WNCHelpLink, a 27-county project in western North Carolina, involving five of the AAAs, and a special multicounty project at the Mid-East Commission AAA. Nationally, a goal of the Alliance of Information and Referral Systems and the United Way of America is to establish “211” as the universal telephone number for information and referral throughout North America. What is missing in all of this activity is a strong state presence to guide and coordinate these varied initiatives so that the end result will be an effective and efficient statewide system. The Division of Aging is working to fill this void.
For the most vulnerable of seniors, North Carolina has a variety of supports. The Division of Social Services oversees the provision of Adult Protective Services and North Carolina’s program for appointment of public agency guardians. For those residing in adult care homes and nursing homes, the Ombudsman Program of the Division of Aging and AAAs works to promote and protect their rights. For “heavy care” residents of adult care homes, the Division of Social Services, in cooperation with the Divisions of Medical Assistance and Mental Health, oversees the Adult Care Home Case Management Services program. This program serves to improve the overall quality of care of these residents by providing support to those who are seriously impaired and require more extensive assistance in order to have their needs adequately addressed. With additional personal care assistance, case management support, and other needed services, residents and residents’ families who want their relatives to be able to “age in place” can be allowed to do so.
Few, if any, persons reading this plan on the Internet (http://www.state.nc.us/DHR/DOA/plan.htm) had access to the World Wide Web just four years ago, at the time of the 1995 White House Conference on Aging. Interestingly, the 1995 State Plan did not mention use of computers as a way to reduce barriers to learning about and participating in life enrichment programs, to increase public education and awareness of elder rights, or to enhance access to health care or long-term care services.
Today consumers, providers and government officials are communicating via electronic mail and exploring the Internet for information about elder housing, advance directives, local tax aide counselors, and an endless range of other news and tips. Consumers are participating in on-line public polls and surveys designed to influence public opinion. They are part of chat groups to seek and offer support in the caregiving of family members with Alzheimer’s disease, to debate current policy questions, and to share other concerns and interests with people whom they only know by way of the Internet. An increasing number of seniors use electronic mail to stay in touch with children and grandchildren.
The Internet gives special meaning to 1999 as the International Year of Older Persons. For the first time in history, information about aging and aging programs around the world is literally at our finger tips, and we can learn from the experiences of others. When the Health Care Financing Administration announced its strategies for informing beneficiaries and providers of Medicare+Choice—the program’s new managed care initiative—at the top of the list was use of Medicare’s web site.
From a survey of more than 170 local aging services providers, conducted in July 1998, the Division of Aging learned that 60 percent of these providers have access to electronic mail and the Internet. All Area Agencies on Aging have e-mail. SeniorNet learning centers and other programs of computer training for older people are growing rapidly. This rapid expansion of the electronic transfer of information will enable providers and consumers to communicate at a frequency and speed never before imagined. To be effective, though, we must assure that the benefits of this aging information highway are available to all people, especially those living in outlying and depressed areas.
A primary reservation about the move toward relying on the Internet is that many of our state’s adults are not functionally literate,5 as was discussed in Chapter 5. The efforts of such national programs as Equipped for the Future are vital to our state. Wilkes Community College is one of 25 sites from across the country field testing this initiative. It is designed to give adults the tools they need to fulfill their responsibilities as members of families, communities, and workplaces, including the ability to access the information they need, voice their ideas and opinions effectively, act independently to solve problems and make decisions, and adapt to the world as it changes. The North Carolina Literacy Resource Center, within the Community College System, is leading this effort in partnership with public and private organizations.
Older adults are like all people in their desire to go wherever they want, when they want. This is evident in the fact that 82 percent of North Carolinians ages 65 to 74 are licensed drivers, as is the case with more than half (54 percent) of those age 75 and older.6 Because most older adults will continue to rely on their personal vehicles, we must continue to encourage and reward efforts to maintain safe driving skills. AARP continues to coordinate the 55 Alive driving course with the local support of senior centers, churches, hospitals, and other organizations. More than 3,000 persons age 50 and older passed the course this past year, and AARP hopes to double enrollment in the coming year. Nationally, 34 states (including South Carolina, Virginia, Tennessee, Georgia, and Florida) and the District of Columbia require a premium discount for persons who pass a state-approved improvement course, but North Carolina is not among them.8
Personal mobility is an important link to accessing information and services. In the 1991 State Aging Services Plan, transportation was the second-highest service priority among counties, only exceeded by the demand for in-home services. According to Area Agencies on Aging in their work with county planning committees, transportation is still near the top, with only in-home services and housing ranking higher. Transportation, especially for medical visits, remains a significant need for more than half of North Carolina’s counties.
The importance of transportation in the lives of older adults was emphasized in a recent report of the US Department of Transportation—Improving Transportation for a Maturing Society.9 As the report puts it, “Personal mobility is so taken for granted that for many its restriction becomes the true point at which the quality of life begins to deteriorate.” The basic elements of the department’s national goal of “Safe Mobility, for Life,” include
Over the next three years, the state Department of Transportation will assist counties and regions to develop Community Transportation Services Plans (CTSPs) to inventory resources and assess true community needs unique to each area. The new community transportation planning process will encourage communities to become brokers for meeting individual transportation needs, using all local resources, even private services, volunteers, and innovative solutions. Departments and councils on aging are considered to be one of the five core agencies (along with the departments of social services, mental health programs, the sheltered/vocational workshops, and county health departments) that are to help develop the CTSP. This is an important activity in which all levels of the aging network must participate.
Having a safe, secure, and familiar place to live is fundamental to independence. The home remains one of the most valued assets for older adults, both in emotional and financial terms. Housing-related concerns always rank near the top of expressed service needs. The cost of upkeep or rent, taxes, and waiting lists for affordable housing for older people are just a few of the concerns. Many of the state’s poorest older citizens live in substandard housing in dire need of repair or of modification to accommodate disabling conditions. As of June 1998, there were more than 800 identified needs on the waiting list for housing and home improvement services provided through the Home and Community Care Block Grant.
Much has been achieved relative to housing for older people, as noted in the list of accomplishments. Still, as we approach the new millennium, there are at least four housing-related goals that remain vital to the well-being of many older adults. First, the aging network must join with others to expand development of housing with services as a vital part of the home and community-based system of services for older adults. On a related note, the Division of Aging and North Carolina Housing Finance Agency must continue their support of service coordinators. These coordinators are hired by housing developments for older people to help link residents with supportive services.
Second, ample resources must be committed to the growing demand for home repair, maintenance, weatherization, and the installation of assistive devices (e.g., ramps, rails, grab bars) in existing housing. The state must continue to promote reverse mortgages as an option, to offer older homeowners a source of income from home equity. Reverse mortgages can help older consumers pay for home repair, modifications, health care, supportive services, and other needs. Third, for those seniors who have to change their living arrangements because of finances or personal care needs, there must be affordable housing options for older people with low and moderate incomes. Fourth, every county must have a central and well-organized source of information about housing and supportive services.
With each year new dynamics appear to which those working in aging services must respond. Sometimes, these are dynamics that affect all of society, such as the increasing presence of the Hispanic population within our ranks and the growth of managed care. Other changes are ones for which the aging network has particular responsibility or should have special interest. These include the aging of baby boomers, the inmigration of retirees, the aging of persons with developmental disabilities, the increasing number of grandparents with primary responsibility for raising grandchildren, and the aging of the institutionalized population in mental health facilities and the prison system.
The rapidity with which new issues arise is evident in the fact that some of these dynamics were of little consequence to the aging services community just four years ago when the 1995 State Plan was produced. It is inevitable that four years from now there will be new matters drawing our attention. The aging network must be alert to signs of change and respond with leadership.
Developmental Disabilities and Aging
The population of older persons with developmental disabilities is growing along with the general population of North Carolinians who are aging. With medical progress, we are seeing people with developmental disabilities living longer.11 It is not uncommon today for individuals with Down Syndrome to be eligible to join AARP or receive Older Americans Act services, when in 1960, it was uncommon to find many with this condition who survived beyond age 40. The same increase in longevity is true for people with cerebral palsy.
The vocational and residential services of the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services have served many of these individuals for a number of years. Others—the so-called “hidden population”—have had parents or other family members as caregivers. They only become known to the formal system when the aging caregiver is unable to continue this role or dies. The Aging and Developmental Disabilities Committee of the North Carolina Council on Developmental Disabilities believes that a change in the existing system is needed for both of these groups.
The committee thinks barriers within the developmental disabilities and aging networks prevent older persons with developmental disabilities and their families from tapping and blending the services and supports of both to obtain a higher quality of life. The magnitude of this issue will only increase in the years ahead as the large wave of boomers—including those with developmental disabilities—live to old age. Concerned about today and the future, the Aging and DD Committee has proposed the formation of the “North Carolina Developmental Disabilities and Aging Leadership Initiative,” to be funded by the North Carolina Council on Developmental Disabilities. Numerous groups—representing service providers and consumers—will participate in developing a plan for North Carolina. The Gerontology Program of Appalachian State University is providing technical assistance to the project.
Inmigration of Retirees
As reviewed in chapter 2 that profiles North Carolina’s demographic shift, we are a popular destination for people choosing to move in retirement. The Bailey case, which grants immunity to most public retirees from taxation of their retirement benefits, the increase in the homestead exemption, the elimination of the intangibles and food taxes, and the reduction of the inheritance tax combine to make North Carolina an even more attractive state for retirement. Without much marketing, people are selecting retirement here. If the state elects to undertake an active campaign to promote retirement in North Carolina, there could be a major escalation of this trend.
This is an important happening for all sectors of our communities. It has implications for economic development, education, health and human services, roads and other forms of transportation, and many other aspects of our public and private lives. Within communities, the aging network has a number of important roles relative to the inmigration of retirees. Here are a few of these:
The Aging of Boomers
In the years since preparing the 1991 State Aging Services Plan, the Division of Aging has been committed to evaluating the status and helping represent the concerns of North Carolinians who are aging, rather than just those who have attained a certain arbitrary age. Because there is time to plan and act now, the division has undertaken an initiative to make boomers more aware of what they can do to age securely and in good health and to spur the state’s public and private leaders to consider what effect an “aging society” might have on the state.
North Carolina was one of the first states to undertake a study of its baby boom population at mid-life (those ages 35 to 53 in 1999). The division’s report—Baby Boomers at Mid-Life: The Future of Aging in North Carolina—profiled the boomers. Some of its more significant findings are highlighted throughout this plan. The division’s companion report—The Future of Aging in North Carolina: Responding to the Challenges and Opportunities Presented by Baby Boomers at Mid-Life—presented a public-private policy framework and suggested possible strategies for individuals, families, businesses, communities, and government. The division is using these reports to stimulate interest among a diverse group of public and private organizations and to develop a “Boomer Agenda” to help lead the state’s future efforts.
The division has accepted two roles that it intends to expand: (1) assembling and presenting the best information available to help policymakers, businesses, communities, and citizens decide and act in ways that will benefit boomers and their families today and in the future; and (2) fostering and supporting cooperative and collaborative activities among all parties who can help make a positive difference in how the state responds to the aging of the boomers.
The division has already started to engage the rest of the aging network in recognizing the merits of this boomer initiative and helping to lead and facilitate local responses. Area Agencies on Aging and local organizations can
It is the last role—assessing readiness for the boomer population—that may be the most critical for the future of the network. While the youngest of the boomers are age 35 in 1999, the oldest boomers will be eligible to receive Older Americans Act services in 2006. In fact, boomers may be among our aging participants today—and not just in a caregiving role. The Older Americans Act allows the spouse of a person age 60 and older to participate in aging programs, just as younger spouses of people age 62 and older can live in some HUD-supported senior housing. The aging of the boomers raises important policy and service design issues. Will the service needs of boomers be similar or quite different from those of their predecessors? What do we know about their interests and expectations?
Generally, here are some of the services and activities that aging boomers might expect from the network
The “aging” of the aging network has produced a predisposition toward serving the oldest, not only in home and community-based care, but also in senior centers and congregate nutrition. The Older Americans Act has reinforced this pattern with the emphasis on targeting those most in need. It would be inappropriate for the network to abandon the population of consumers that grew old with the aging network during the 1970s, 1980s, and 1990s. Still, the network must begin to expand and redirect some of its attention and resources to its future constituents—the boomers—as it continues to serve the parents and grandparents of boomers. This will require working with a broader range of community groups and interests, including the new service delivery vehicles presented by managed care. It will also require improved cohesiveness and efficiency within the network. Ultimately, the future success of the network will depend on its ability to understand and meet the needs and interests of its consumers and potential consumers in an aging society.
A fundamental component of the 1991 State Aging Services Plan was the introduction of the “concept and vision of comprehensive, county-based programs for older adults, which will be an outgrowth of counties’ comprehensive strategic planning.” It was believed then, as it is now, that successful strategies require effective planning, development, and management of public and private resources at the state, regional, and local levels.
One of the outcomes was the establishment of the Home and Community Care Block Grant [GS 143B-181.1 (a) (11)], which was designed to consolidate certain federal and state funding to facilitate counties in planning and supporting services to best meet the needs of their local constituents. In the first few years of the Block Grant, counties experienced little growth in federal and state funding for home and community-based care. As a result, there was little change in decisions about which services to fund and at what level.
In the second half of the 1990s, several developments, especially relative to funding, should start to influence rather dramatically local decisions and the appearance of the local service system. Clearly, the generous support of the General Assembly for home and community-based care provides a compelling reason for having a local plan for aging. This plan should identify and prioritize service needs and outline strategies for service development, including an adequate workforce of professionals, paraprofessionals, and volunteers to deliver services. Counties that have a plan and an effective and representative advisory committee to assess needs, target resources, and evaluate performance and outcomes are better positioned to use the additional public funds for older people, whether or not they are eligible for Medicaid.
The demographic shift itself should cause local leaders—both public and private—to see the value of county and regional planning. Some counties can foresee tremendous growth in the number of older persons. Others are experiencing a major change in the age composition of their community. The increase in state funding for Area Agencies on Aging, appropriated in 1998, should support their role in helping counties develop local plans for aging. This planning must take place at two levels.
First, there must be a deliberate approach to the development of the funding plan for the Home and Community Care Block Grant. This approach should be informed by the best information that the Area Agency on Aging and others can bring to the table about demographic trends, service needs, the performance of local service providers, and the effect of changes to other funding sources (e.g., Medicaid’s increase in eligibility to 100 percent of poverty and Medicare’s narrowing of eligibility for home health care).
Second, Area Agencies on Aging can help stimulate interest and commitment to more comprehensive planning at the regional and local levels relative to the aging of the community that includes participation and support from business, civic groups, religious leaders, and many others. The work of the Cape Fear Area Agency on Aging in connection with Project R.O.A.R. demonstrates this role. In 1997 New Hanover County began an ambitious, community-wide dialogue to plan and act to meet the needs and protect the rights of its older population. As co-leaders of Project R.O.A.R. (Raising Older Adults Rights), the Cape Fear AAA and the New Hanover County Department of Social Services are facilitating a coalition of enthusiastic public and private interests that has emerged to accomplish four major goals: reduce the abuse, neglect, and exploitation of older adults, assure that the public is informed of available choices, improve the quality of care for older adults in New Hanover County, and to provide additional choices in health care for older adults.
As AAAs plan for aging, representative and well-functioning Regional Aging Advisory Councils can play an important role in helping them stimulate discussion and set priorities. Planning could take into account such issues as grandparents raising grandchildren and the inmigration of retirees. It could also examine questions about how the county and regional shifts in demographics are affecting and will affect the local tax structure and receipts, economic development and the local workforce, housing and land use, crime and law enforcement, transportation, fire and emergency services, health and human services, volunteerism, local education and recreation, and a host of other areas. There are few areas of county governance and interest that are unaffected by the aging of the population. The aging of the community must not just be a concern of the aging network, but rather a change that triggers broad-based and lively discussion and planning among all sectors and constituents.
1. US Administration on Aging, Fact Sheet on Senior Centers, available at http://www.aoa.dhhs.gov/factsheets/seniorcenters.html. See also "Older Shoppers Flock to the World Wide Web" Global Aging Report, 3(5), September/October 1998, p. 2. 2. Council on Aging of Cleveland County, Inc., Phase III: News, Views and Information, 7(4), April 1997. 3. National Information and Referral Support Center, National Association of State Units on Aging, Vision 2000: Toward an Aging Information Resource System for the Next Century, January 1998. 4. L. Zimmerman, A. Broughton, and S. Bratesman, North Carolina Area Agencies on Aging Information Technology Project [Site Visit Report], School of Social Work, University of North Carolina at Chapel Hill, 1998. 5. NC Literacy Resource Center and NC Community College System, "North Carolina's Basic Skills/Literacy Programs" [fact sheet]. See also the NC Literacy Resource Centers' website: http://www.nclrc.state.nc.us/NCLRC/home/nisulit2.htm. 6. Highway Safety Resource Center at the University of North Carolina at Chapel Hill. See http://www.unc.edu/depts/hsrc/faq/young2.html for statistics on accident rates. 7. Cited in AARP, "55 Alive/Mature Driving 1998," [pamphlet], PF 3798(198) . D934, Washington, DC. 8. AARP, "55 Alive/Mature Driving Program," 1998, available at http://www.aarp.org/55alive/. 9. US Department of Transportation, "Improving Transportation for a Maturing Society," January 1997, available at http://ostpxweb.dot.gov/policy/aging/FINAL-B2.PDF 10. NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, "The Thomas S. Population Is Many Populations," available at http://www.state.nc.us/DHR/DMH/thomass/pop01.htm#Geriatric. 11. NC Developmental Disabilities and Aging Leadership Initiative, "A Proposal from the Aging and DD Committee to the NC Council on Developmental Disabilities," Raleigh, NC, 1998. 12. Bill Tillman, reported in County Lines, to the NC Association of County Commissioners, October 22, 1997 13. April Thompson, "State and Counties Join Forces to Plan for an Aging Society," American Society on Aging, Aging Today, 19(1), January/February 1998, p. 4.
- Table of Contents
- Major Actions Related to the Aging Network since 1995
- Objectives and Strategies for the Aging Network, 1999 to 2003
- Appendix 1. Resources for Aging in North Carolina
- Division of Aging Home