Tuesday, February 23, 2016

Aging NetworkMost American families and even health policy experts have never heard of the Aging Network (AN), a loosely organized, community-embedded aggregation of service organizations that provide elders with vital services such as housing repairs, food, and transportation. Yet this network is essential and fundamental to the health of our grandparents, parents, and, eventually, all of us as we grow older and need a bit of assistance to continue living in our communities. It is also about to be overwhelmed: A 2015 report by the Government Accountability Office found that 83 percent of older adults who are likely to be food insecure did not receive meal services, and it estimated that up to 78 percent of older adults needing home-based care do not receive help with all of their difficulties.

A major reason is that appropriations for the Older Americans Act (OAA), which funds the Aging Network, have declined for decades in inflation-adjusted terms. If current patterns hold, the needs of a rapidly growing population of older adults will soon overwhelm the capacity of the OAA to provide a meaningful level of support in communities across the country. This budgetary squeeze is not benign neglect; it has a real-world impact in the form of tens of thousands of seniors who, each year, unnecessarily wind up malnourished, dehydrated, unable to care for themselves, and, ultimately, cycling into and out of hospitals and other high-cost care settings.

In fact, there is growing evidence that low-cost Aging Network services actually save the health care sector money. For example, research has shown that every $25 increase in home-delivered meals is associated with a 1% decrease in the low-care nursing home population. In this regard, it is good news that the Obama Administration’s FY 2017 budget proposal includes significant increases in nutrition assistance, as well as $10 million in proposed new funding for community-based support services.

Created by the OAA reauthorization in 1973, the Aging Network has played a fundamental role in the development of community-based long-term services and supports (LTSS) systems over the past 40 years—and demand for LTSS in the form of personal care and other in-home assistance is projected to grow by 50% between now and 2050. There are 56 State Units on Aging, 623 Area Agencies on Aging (AAAs), and more than 20,000 community-based organizations (CBOs) across the country that provide LTSS and other health-related social services and supports, including congregate- and home-delivered meals, transportation needed to help elders move around the community, legal assistance and help figuring out programs and benefits, and respite for family caregivers.

However, the past decade has brought significant change to the AN and to the vulnerable older adults it serves. Research indicates that growing gaps in services can result in higher hospital admissions and higher health care costs. Just for comparison, Medicare spending has doubled during the past decade, as beneficiaries increase in number and those with functional limitations and multiple chronic conditions wind up in crisis repeatedly.

Figure 1

From “The Older Americans Act at 50 — Community-Based Care in a Value-Driven Era,” by R. B. Parikh, A. Montgomery, and J. Lynn, New England Journal of Medicine, 373, p. 399.  © 2015 Massachusetts Medical Society. Reprinted with permission.

Policy changes have also challenged the AN. One of the foremost has been a rapid increase in managed LTSS programs across the country. Twenty-two states are now operating managed long-term services and supports (MLTSS) programs and another 11 are preparing to contract for delivery of MLTSS programs to either some or all of their Medicaid-covered populations in part of the state or statewide. In some states, the AN has maintained some of its traditional roles, such as providing care coordination and building provider networks. However, working in a managed care environment has necessitated that the AN evolve almost overnight, particularly in its capacity to contract, bill, and provide data on the value and quality of its services. A number of initiatives seek to build the business acumen of the AN, including the Administration for Community Living’s Business Acumen Learning Collaborative, the SCAN Foundation’s Linkage Lab, and the National Association of Area Agencies on Aging (n4a)–led Aging and Disability Partnership for Managed Long-Term Services and Supports.

Thanks to these efforts, the Aging Network is developing relationships with a diverse array of health care organizations. For example, AAAs in some states are seeking to acquire provider status in the Medicaid and Medicare programs. Doing so involves the development of and investment in expanded skills and capacities to meet new requirements, such as clinical supervision for diabetes education and other chronic disease management programs; requirements to design, price, negotiate and bill for services; and requirements to establish or interface with health care systems that collect and report data to payers on performance metrics. There is also the question of whether smaller AN providers can devise strategies for brokering services across sizable areas and large populations. The ease of contracting may make it more appealing to Medicaid managed care and other health care organizations to partner with the Aging Network for an array of services, rather than attempting to establish parallel new capacity.

Recent years have also seen a proliferation of efforts to launch, test, and evaluate better-coordinated delivery models in the health care sector that can demonstrate improved care for Medicare beneficiaries at a lower cost. While most of these models do not explicitly require or incentivize a connection to community-based services, policymakers are increasingly recognizing the necessity of these supports to keeping Medicare beneficiaries and dual-eligible beneficiaries stable and out of high-cost health care settings. The Senate Finance Committee’s Chronic Care Working Group, for example, is considering new flexibility to encourage Accountable Care Organizations and Medicare Advantage plans to connect beneficiaries with social supports. In doing so, policymakers should ensure that the deep community experience and expertise of the Aging Network is preserved and built upon as payment models are created and adapted, as health information technology is expanded and metrics are improved, and as social services become more integrated into the health care sector.

In summary, the services of the AN have never been more important. The major source of direct federal funding is the Older Americans Act, which has not been reauthorized since 2011 and which is so underfunded that the capacity of communities to meet very basic needs is at risk. Get in touch with your Congressional representatives in the House of Representatives to push for reauthorization and supplemental funding, so that your community has these critically needed services into the future for you and yours!

Read more in The Aging Network in Transition: Hanging in the Balance.  

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