With a fast-expanding older adult population, public policy makers can no longer talk about public health issues without considering the impact retiring baby boomers will have on the nation’s health and long term systems of care, as well as the fiscal soundness of the federal budget. Furthermore, with the vast majority of older adults (90%) aging in place, even as they grow frail, the discussion must reflect on community-based aging, in particular. As was editorialized in a 2003 article in the American Journal of Public Health, today’s communities can be “un-navigable” for elderly persons, who are often challenged by chronic illness and disease and are in need of communities where elderly persons can function well and contribute to society. Through creative planning, a shift to communities that facilitate physical and mental wellbeing of older persons must be effectuated. In this vein, the following analysis is intended to promote the consideration of aging in place, NORC Supportive Service Programs, and the new Older Americans Act program, Community Innovations for Aging in Place, as matters of public health policy and fiscal responsibility.
Aging In Place
In many cases, older adults cannot afford to move. But even for those who have the means to move to areas that cater to retirees, the desire to age in place near family and friends runs deep. And even though today’s baby boomers are generally wealthier than previous generations, studies show that the new generation of retirees is expected to follow the long-standing trend of staying close to home. Nearly 75% of all Americans 50 and older want to remain in their current homes for as long as possible, and this desire increases with age. This means that as 79 million baby boomers start to retire, the number of people aging in place will swell as never before.
This phenomenon alone raises implications for future public policies as the country approaches an unprecedented demographic shift, which begins next year with the retirement of the first baby boomers.
From a budgetary perspective, the status quo can not remain. According to a 2007 Congressional Research Service report, the older adult population is expected to reach close to 90 million by 2050, and the costs associated with their health care is expected to overwhelm the federal budget. This will place at-risk public spending for other national priorities, and could lead to economic stagnation, should spending continue unchecked.
Chronic illnesses are critical budget busters that factor into this assessment. Today, 42% of people age 65 and over report at least one functional limitation. Conditions, such as hearing and sight loss; hip-fractures; arthritis; obesity; and Alzheimer’s disease are expected to jump precipitously and exponentially with the retirement of the baby boomers in concert with the growth of this population.
Furthermore, the leading cause of death among people age 65 and over are chronic conditions, such as heart disease, cancer, cardiovascular disease, stroke, lower respiratory diseases, Alzheimer’s disease, diabetes mellitus, influenza, and pneumonia. Many of these conditions can be prevented or modified with behavioral interventions.
These budgetary drivers are directing policy makers to rethink the delivery model of long-term care for older adults. In 2002, then-Comptroller General of the United States David M. Walker made particularly prescient remarks before the Senate Special Committee on Aging on the impact of the Baby Boom generation on long-term care in America.
He testified that the Baby Boom generation will subsume an increasing “and ultimately unsustainable share of the federal budget and economic resources,” and that federal policies disproportionately favoring nursing homes must be reformed in favor of community-based care, which has been proven to be cost-effective and necessary to avoid institutionalization.
Walker further testified that Congress needs to recognize that long-term care for seniors is more than “traditional” health care. It comprises multiple supportive services (e.g., housing, mobility, nutrition, personal care, socialization, education, health care, financial management, and others) to assist seniors with their daily needs and to maintain their independence, quality of life, and dignity while aging. He recommended that in considering necessary reforms for long-term care, Congress must take into account preferences and lifestyles, such as where seniors want to live and the activities and services they want to pursue.
Walker’s position, which is moving more into the mainstream since he delivered his testimony, is very practical. First, the vast majority of older Americans are and will continue to age in place for the foreseeable future. Today, most people (nearly 80%) who need long-term care live at home or in community settings and not in institutions, while only 3.5% of people age 65 and older live in nursing facilities. Despite this discrepancy, only 18.2% of long-term care expenditures for the elderly are for community-based care.
Furthermore, the average expenditures per elderly person in a nursing home were four times greater than the average expenditures for those receiving paid care at home, according to Walker’s testimony. Today, the national average for a private nursing home room is $209 per day (or $76,460 annually), as compared to the national average for home health services, which are calculated at an hourly rate of $19. Thus, this balance of resources clearly needs to shift to more cost effective community-based care.
Second, now that older adults are living longer, public policies need to support extending their quality of life rather than simply prolonging life, and recognize the strong connection between an older adult’s quality of life and their ability to remain independent and in their own homes for as long as possible. These strong ties to the home necessitate health policies that support aging in place and prevent the relocation of older adults to institutional settings. These are among the strongest needs of older adults.
Consequently, both the delivery of human and social services that empower older adults to make decisions about their care and the building of “livable” communities where they can thrive must become a part of the health care lexicon for long-term care for older adults.
The U.S. Administration on Aging concurs with this assessment. In its national message celebrating this year’s Older Americans Month (May 2008), AoA called on the nation to take responsibility to ensure the well-being of an expanding older adult population. To this end, AoA published proclamations and supportive materials that urged all U.S. communities to become “supportive communities” for older adults by modernizing systems of care, by providing consumers with more control over their lives, and by improving the overall quality of life of older adults to ensure that they “remain at home as long as possible.” In its message, AoA underscored that the fulfillment of this mission requires collaborations of the Aging Network, which is largely made up of nonprofit and public health and supportive services agencies and volunteers.
NORCs (Naturally Occurring Retirement Communities)
In 2002, Congress began to support the development and testing of the innovative community-based NORC-Supportive Service Program (NORC-SSP) model through Title IV, Activities for Health, Independence, and Longevity, of the Older Americans Act (OAA). Title IV, authorizes the award of funds, including to private nonprofit agencies and organizations, for training, research, and demonstration projects in the field of aging. Funds can be used to expand knowledge about aging and the aging process and to test innovative ideas about services and programs for older adults.
The Jewish Federations of North America, whose system developed some of the country’s earliest NORC-SSP programming 25 years ago, brought the model to the attention of Congress around the same time then-Comptroller General Walker was making his arguments before the Senate Special Committee on Aging. In response, with bi-partisan and bi-cameral support, Congress initiated the first of 48 NORC-SSP demonstration projects that were established in 26 states between fiscal years 2002 and 2009.
Defining elements of the NORC-SSP model include:
Organizing and locating a range of coordinated health care and social services and group activities on site (core service components are case management and social work services; health care management, assistance, and promotion; education, socialization, and recreation; and volunteerism);
Drawing strength from partnerships that unite housing entities and their residents, health and social service providers, government agencies, and philanthropic organizations (rebuilding the social fabric of communities through coordination and cooperation of key stakeholders);
- Promoting independence and healthy aging by engaging seniors before a crisis and responding to their changing needs over time;
- Providing seniors with vital roles in the development and operation of the program (both in governance and volunteer roles); and
- Filling the gaps where Medicare, Medicaid, or Older Americans Act services are insufficient or inadequately coordinated, but not duplicating them.
According to AARP, NORCs are communities that were built decades ago and originally served a mix of families and young households, where low turnover of households has led to the transformation of neighborhoods consisting largely of older residents who are aging in place. They can be a building or buildings, a single-family neighborhood or a section of a neighborhood, and they exist in urban, suburban, and rural areas. The common denominator is that NORCs house large populations of older adults in close proximity to one another. In a nationwide survey conducted in 2005, AARP found that as many as 36% of respondents (55 and older) could be viewed as living in NORCs. Other reports place the percentage of NORC-residing older adults as high as 50%.
Leading national organizations on aging, such as AARP, the National Academy on Aging, and the National Council on Aging, believe that the vast aging in place of large concentrations of older adults living in NORCs can facilitate supportive communities. In this regard, a 1996 study sponsored by the Robert Wood Johnson Foundation and conducted by the Florence Heller Graduate School for Advanced Studies in Social Welfare at Brandeis University found:
- Older people want to age, and are aging, in place.
- A substantial number of older people live in naturally occurring retirement communities.
- Interest in programs supporting naturally occurring retirement communities as a strategy to promote aging in place is increasing, and the number of programs is growing.
- Naturally occurring retirement communities provide singular opportunities to:
- Deliver health and supportive services cost-efficiently.
- Increase service availability.
- Organize cooperative health promotion, crisis prevention, and community improvement initiatives.
- Develop new human, financial, and neighborhood resources for the benefit of older residents.
The OAA Title IV NORC-SSP demonstration projects put into practice, these findings.
An Institutional Review Board-approved study of nearly 500 participants in 24 of the longest-running Title IV NORC demonstration projects found the model to be an effective way to increase socialization and reduce social isolation among NORC-residing older adults. Social isolation has been associated with increased risk for cardiovascular disease and Alzheimer’s disease in older adults, and tackling social isolation and loneliness to improve older adults’ well-being and quality of life is increasingly recognized in policy and health strategies. In addition, the vast majority of respondents reported that they spoke to more people; knew more people; participated in more group activities and events; left the confines of their home more often; and felt healthier than they used to as a result of their participation in the NORC demonstration programs.
Community Innovations for Aging in Place (CIAIP) Program
Leading up to the reauthorization of the Older Americans Act in 2006, the federal NORC demonstration projects were considered during three hearings held by the Senate Subcommittee on Retirement and Aging. On May 15, 2005, then-Assistant Secretary of Health and Human Services for Aging, Josefina Carbonell, testified that the NORC Supportive Services Program model provides a “perfect” example of improved coordination of care and support that comes to bear on the quality of life of older Americans.
In a follow up hearing involving Aging Network stakeholders, held on February 14, 2006, Jo Reed, AARP’s National Advocacy Coordinator for Federal Livable Communities and Consumer Issues, testified that AARP has taken great interest in Congress’ NORC demonstrations, as there is an evolving awareness in the Aging Network that NORCs exist and present opportunities to achieve economies of scale by bringing services to where people live and want to remain.
A third hearing held on May 16, 2006, focused on the merits of establishing a new program within the Older Americans Act dedicated to promoting NORC-SSPs and to spurring development of similar innovative aging in place models. Witnesses from four of the NORC demonstration projects testified. During this hearing, then-Chairman Mike DeWine (R-OH) stated that we know that our current infrastructure will not be able to handle the magnitude of the aging baby boomer population and that is why we need to look to new models, such as NORC-SSPs, which will allow older persons to thrive while remaining in their own homes. Similarly, then-Ranking Democrat (now the Chairman) Barbara Mikulski (D-MD) stated during the hearing that as our nation anticipates the retirement of 78 million baby boomers, we must look at model programs that help keep seniors at home and independent, and that this is why she is a champion of NORC-SSPs.
These hearings served as a catalyst for the establishment of the Community Innovations for Aging in Place program within the Older Americans Act (OAA) Amendments of 2006, with the critical support of Senator Mikulski, then-Senator DeWine and Representatives George Miller (D-CA) and Howard McKeon (R-CA). These Members of Congress were the central negotiators of the reauthorization legislation. Then-Senator Hillary Rodham Clinton (D-NY) and Representatives Rush Holt (D-NJ) and Pat Tiberi (R-OH) also played key supporting roles in securing the new provision within the amendments package.
According to a Congressional Research Service report on the OAA Amendments of 2006, Congress created this Community Innovations for Aging in Place program in recognition that many communities around the country are experimenting with ways to assist older people who have aged in place and now need a variety of supportive services to assist them to continue to do so. The new program, according to the report, provides the Assistant Secretary on Aging with added authority to award Title IV grants to promote model aging in place projects, including NORC-SSPs, with the intent of building supportive communities to help sustain the independence and quality of life of older adult residents.
With particular leadership from Senators Mikulski and Norm Coleman (R-MN) and Representatives Henry Waxman (D-CA) and Rush Holt, Congress allocated $5 million to commence the Community Innovations for Aging in Place program in the fiscal year 2009 Omnibus Appropriations Bill (H.R. 1105/Public Law No: 111-8).
In July 2009, the Administration on announced the first year’s grant opportunity. AoA received more than 400 inquiries from interested parties throughout the Nation’s Aging Services Network, and considered more than 200 grant applications made. The level of interest and response made this grant opportunity the most popular in the history of AoA. On September 30, 2009, AoA announced the grant awards to establish 14 demonstration grants and a technical assistance center. The results can be viewed at: http://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/CIAIP_web_page.pdf.
In enacting Community Innovations for Aging in Place, Congress took a ground breaking step towards building supportive communities for the vast majority of older Americans who are and will be aging in place for decades to come. As a matter of public health policy and fiscal responsibility, the program invests in the development of innovative models of service, such as NORC-SSPs, to help older adults maintain their independence, health, and quality of life, while maximizing efficiencies in the delivery of supportive services and shifting federal resources to the community level.
Once funded, the Administration on Aging embraced the program. In her message commemorating National Aging in Place Week (October 12 -18, 2009), the Assistant Secretary for Aging, Kathy Greenlee, stated that helping older individuals age in place – at home – is one of her highest priorities. In support of this commitment, she highlighted the new Community Innovations for Aging in Place initiative. Subsequently, Congress provided second- and third-year program funding of a combined $10 million for fiscal years 2010 and 2011, which allowed for the continuation and completion of the 14 original grants and the technical assistant center through the three-year cycle.
While the President’s FY 2010 Budget recommendation to Congress included funding for CIAIP, neither his FY 2011 nor FY 2012 requests did – a consequence of fiscal austerity in the federal Budget that began in FY 2011. Presently, neither the House nor Senate draft Labor-Health and Human Services-Education Appropriations bills for FY 2012 contain a specific allocation to commence a second round (RFP) of CIAIP demonstration grants. However, the Senate version includes nearly $13 million in discretionary funding within the Innovations for Aging Services account (aka, Older Americans Act Title IV), which the Administration on Aging could designate all or a portion to continue the CIAIP program. The House bill on the other hand would actually zero-out the entire Innovations for Aging Services account, ensuring the end of CIAIP in FY 2012. Given the ensuing Aging tidal wave and the strong interest of CIAIP to the Aging Services Network, JFNA has met with senior domestic issues staff at the White House, program and leadership staff at the Administration on Aging, and with champions in Congress in the pursuit of CIAIP funding for FY 2012 and FY 2013.
The fiscal year for 2012 commenced on October 1st. However, having been unable to complete the appropriations process on time, Congress approved a temporary spending measure to keep the Federal government operating through November 18, 2011. Under these circumstances, we expect that the results for CIAIP, for better or worse, will most likely be determined in a combined year-end spending measure Congress will approve between now and the New Year.
AARP, “Beyond 50.05, A Report to the Nation on Livable Communities: Creating Environments for Successful Aging,” May 2005.
Bedney, B., Schimmel, D., Goldberg, R. (2007), “Rethinking Aging in Place: Exploring the Impact of NORC Supportive Service Programs on Older Adult Participants,” 2007 Joint Conference of the American Society on Aging and the National Council on Aging.
Butrica B., and Uccello, C. (2004), “How Will Boomers Fare at Retirement,” Washington, DC: AARP Public Policy Institute.
Cattan, M., White. M., Bond, J., and Learmouth, A. (2005), “Preventing Social Isolation and Loneliness Among Older People: A Systemic Review of Health Promotion Interventions,” Aging in Society (25: 41-67).
Congressional Research Service, “Health Care Spending and the Aging of the Population,” March 2007, (RS22619).
David M. Walker, Comptroller General of the United States, Testimony before the Special Committee on Aging, U.S. Senate. “Long-Term Care: Aging Baby Boom Generation Will Increase Demand and Burden on Federal and State Budget,” March, 21, 2002 (GAO-02-544T).
Family Caregiver Alliance. Selected Long-Term Care Statistics. San Francisco, CA: Family Caregiver Alliance.
Federal Interagency Forum on Aging Related Statistics (2008). Older Americans 2008: Key Indicators of Well-Being. Washington, D.C.: Government Printing Office; American Hospital Association (2007). When I’m 64: How Boomers will Change Health Care. Chicago, IL: American Hospital Association; Alzheimer’s Association (2007). Alzheimer’s Disease Facts and Figures 2007. Chicago, IL: Alzheimer’s Association.
Florence Heller Graduate School for Advanced Studies in Social Welfare at Brandeis University, “Naturally Occurring Retirement Communities Offer Opportunities for Delivering Health Care and Related Services,” 1996.
Genworth Financial 2008 Cost of Care Survey, April 2008.
Hansen, C. (2005). No Place Like Home: AARP’s View on Livable Communities. Washington, D.C.: AARP Public Policy Institute.
Hausner, A.N., Fox-Grage, W., and Gibson, M.J. (2006). Across the States 2006: Profiles of Long-Term Care and Independent Living. Washington, D.C.: AARP Public Policy Institute.
Hearing: Examining the Administration’s Recommendations for the Older Americans Act Reauthorization. Before the Subcommittee on Retirement Security and Aging of the Senate Committee on Health, Education, Pensions, and Education, 109th Cong., 1st Sess., May 17, 2005 (S. Hrg. 109-132).
Hearing: Examining the Reauthorization of the Older Americans Act. Before the Subcommittee on Retirement Security and Aging of the Senate Committee on Health, Education, Pensions, and Education, 109th Cong., 2nd Sess., February 14, 2006 (S. Hrg. 109-437).
Hearing: Examining Naturally Occurring Retirement Communities and What Impact They May Have on the Ability to Create Livable Community Options for All Americans. Before the Subcommittee on Retirement Security and Aging of the Senate Committee on Health, Education, Pensions, and Education, 109th Cong., 2nd Sess., May 16, 2006 (S. Hrg. 109-599).
Iwarsson, S., et al. (2007), “Importance of the Home Environment for Healthy Aging: Conceptual and Methodological Background of the European ENABLE-AGE Project,” The Gerontologist (Vol. 47, No. 1, 78-84)
Jackson, R. (2003), “The Impact of the Built Environment on Health: An Emerging Field,” American Journal of Public Health (Vol. 93, No. 9, 1382-1383).
O’Shaughnessy, C. and Napili, A., “The Older Americans Act: Programs, Funding, and 2006 Reauthorization (P.L. 109-365),” CRS Report for Congress, CRS-17, (Updated December 11, 2006 (RL31336).
Shapiro, A., and Taylor, M. (2002), “Effects of a Community-Based Early Intervention Program on the Subjective Well-Being, Institutionalization, and Mortality of Low-Income Elders,” The Gerontologist (Vol. 42, No. 3, 334-341).
Title 42 — The Public Health and Welfare, Chapter 35 – Programs for Older Americans, Subchapter IV – Activities for Health, Independence, and Longevity (formerly, Training, Research, and Discretionary Programs).
U.S. Administration on Aging: http://www.aoa.gov/press/oam/oam.asp