On April 26, Assistant Secretary for Aging Kathy Greenlee addressed the National Association of Area Agencies on Aging (n4a) at its spring policy conference. President Obama had just signed the Older Americans Act (OAA) reauthorization (P.L. 114-144) into law a week earlier—the culmination of a six-year effort. This is the major federal funding for the Aging Network, the community-based supportive services that many elderly people need in order to live at home with the limitations associated with age and illness. While many among the assembled Area Agency on Aging (AAA) representatives seemed inclined to reflect on and celebrate this achievement, Greenlee was already looking ahead. Noting that the current reauthorization of the OAA covers just three years—through FY 2019—the Assistant Secretary urged attendees to begin thinking in broader, bolder terms right away. “We need a major revision to the Older Americans Act,” she declared.
Figuring this out, Greenlee acknowledged, will “be very hard.” To begin, she urged advocates and local leaders to highlight the Aging Network’s “50 years of history” in serving seniors by providing cost-effective supports and helping lower their health care costs. She said that providers of community-based supportive services have to “be more willing to agitate” and to think creatively about how to restructure the relationship between the medical care and community services sectors. Greenlee observed that the Centers for Medicare & Medicaid Services (CMS) sees Medicaid as a “natural partner” for the Aging Network, but “in a Medicare world they don’t see that at all.” This plays out, she noted, in a “huge loss of opportunity” with regard to Medicare-financed post-hospital care—use of which she said should be “a signal that care transitions are needed.” To change the dynamic, she suggested that the Aging Network could “start with home care and skilled nursing facilities” and “talk to Medicare” about community-based “activity and functional support needs.” She asked attendees to consider, “Who are our champions in the medical world? We need to take doctors with us to these meetings to help make this case.”
In the last several months, several major reports examining new financing opportunities for long-term care have been published by the Bipartisan Policy Center, Leading Age and the Long-Term Care Financing Collaborative. By comparison, proposals for Medicare Alternative Payment Models that emphasize the importance of integrating comprehensive geriatric care and social support services have been slow to get started. There is also a clear need to accelerate work on cross-cutting initiatives that span Medicare, Medicaid and the OAA, together with parallel workforce and quality metrics improvements. A policy framework for thinking broadly about some of the interlocking possibilities for long-term services and supports can be seen here.
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More specifically concerning the next OAA reauthorization, certain consensus recommendations advanced by the Leadership Council on Aging Organizations in 2011 seem particularly relevant, including:
- “demonstration projects to assist AAAs and Aging Disability Resource Centers (ADRCs) to extend their expertise in supportive services planning and delivery to health/medical care entities that are involved in developing new models of care coordination”;
- “an Advanced Aide training curriculum for direct-care workers” and a new requirement for “state and area plans to…monitor direct care workforce supply and standards”;
- development of area “housing with services” plans;
- “greater collaboration” between the Administration for Community Living (ACL) and the Department of Transportation; and
- a “technology development program to...improve service delivery and more effectively track and report on OAA programs and services.”
To better address the challenge of scaling critical home-based services for millions more older adults both now and over the next few decades, Greenlee called for enhancing the Aging Network’s “flexibility” with regard to eliminating certain “silos.” One piece of additional flexibility that is needed, she said, concerns OAA-established planning and service areas (PSAs): “We have to change the restriction” that AAA’s “can’t also provide direct services” in PSAs, Greenlee asserted, adding that, as currently constructed, these areas are “too limited” for the “fluid nature of what we need to provide.” The OAA constrains the ability of individual AAA’s to deliver OAA-funded services in their own service area.
Greenlee characterized ACL’s Business Acumen project as a “matter of life and death” for the Aging Network, which has a mission to serve all elders in need in the community. Calling for a more proactive approach to expanding and scaling services, she noted that if existing AAA’s are not successful in contracting with health care organizations, “others will be.” Because “there will be competition” from new services providers that do not have a community mission, Greenlee urged advocates and allies to “watch the competitors…where do they pull things out of the Network?” And “what are they not doing?” In an important move to help extend and expand the Business Acumen initiative, the John A. Hartford Foundation recently awarded $2.9 million to n4a for development of a national aging and disability resource center, which is charged with providing technical assistance to AAA’s and partnering community-based organizations that are seeking to partner with medical care providers.
The Aging Network’s lack of health information technology (HIT) infrastructure remains a significant barrier to this work, and Greenlee was quick to note this. “We have significant trouble with technology,” she said. “No one is investing in our technology.” She cited the example of San Diego County, which received a grant through the Community-based Care Transitions Program (CCTP) and then found that communicating with hospital partners and CMS effectively required an investment of $284,000 in order to develop an HIT system. While San Diego was able to secure these funds, other CCTP sites did not have the resources to make a similar investment, causing Greenlee to wonder aloud, “Did CMS understand we don’t participate in meaningful use?” An Affordable Care Act demonstration, the CCTP was designed to link individuals at high risk of hospital readmission with Aging Network services providers using evidence-based care transition protocols. Questions have been raised about the methodology used by CMS to assess the program. Although successful CCTP sites calculate that they saved over $800 million in avoided Medicare hospital costs across all successful CCTP programs, CMS is ending the program this year.
Without a substantial investment in HIT that is designed for the Aging Network’s social services and supports, AAA’s and their contracting community-based organizations will have difficulty communicating with medical providers using electronic health records, and they won’t get appropriate credit for the outcomes of evidence-based chronic disease management programs that they conduct. For example, Greenlee observed, “the doctor needs to know” what a diabetes self-management program is doing for his or her patients, and the same applies to falls prevention and many other chronic disease programs that are designed to empower and assist seniors to live safely at home.
New metrics are needed for tracking and reporting “service consistency and service delivery.” This too requires investment in HIT. The Assistant Secretary noted, the “OAA is built on output [e.g., number of meals served], not on [individual health] outcome, and we live in an outcomes world.” To change this rapidly, and to start capturing reliable data on the impact of social services and supports for vulnerable older adults and overall care costs, requires a dedicated “investment in community-based technology.” Absent this, she predicted that the health care system will continue to “build closed systems” that will bypass communities and social services providers.
It’s not too late to figure this out. Here at Altarum Institute, we see how this needle can be threaded. Because social determinants of health should have equal standing alongside medical care, a new infrastructure is needed to capture person-focused information efficiently in an easy-to-access online format that is accessible to the older adult and family members, and which is also available to relevant service providers for amending and updating.
Anyone working toward that vision for the future of HIT? We’d like to hear from you and see how we might be able to work together.
And with regard to the OAA, all of us can step up and help create a context in which the next reauthorization can be designed to fully support an even more robust Aging Network—one that gives community-based organizations the authority and the tools they need to be effective partners with medical care providers. We can and should spend time talking with our elected national representatives about how to do this, and also organize conversations at the local and state level. It’s not too early to start: We have three years in which we can improve on the current OAA authorization, starting today!