A Lifetime of Health and Dignity:
20 Actions Governors Can Take
Promote Community-Based Care
Promote elder-ready communities.
Older people want to live independently in their homes and neighborhoods for as long as possible. Key elements that are important to sustain older people in their communities include affordable housing, transportation, and necessary community supports. Governors can promote “elder-ready” communities through statewide initiatives and by working with local government. One example of a statewide initiative is Florida’s Communities for Lifetime Initiative. In addition, several states are working with local governments through the AdvantAge Initiative to help accommodate the needs of older residents. The initiative’s purpose is to help communities prepare for the growing number of older adults who are "aging in place" while creating livable neighborhoods for people of all ages. As part of the program, 10 communities in Arizona, California, Florida, Illinois, Indiana, New York, and Washington are working to address how communities can make a difference in the lives of the elderly.
Establish “fast-track” eligibility for home and community-based services.
People who need care following a hospital stay are routinely referred to nursing homes, instead of being offered community-based services. The nursing home referrals occur because hospital discharge planners are often more familiar with Medicaid nursing home eligibility rules and because institutional services are readily in place. To ensure that people leaving hospitals are offered community care options, states are establishing “fast-track” eligibility for Home and Community-Based Services (HCBS). Key program elements include streamlining the HCBS application processes, establishing presumptive Medicaid eligibility for community care, increasing resource levels, providing around-the-clock assistance, and making services available within 24 to 48 hours. In 1999, Coloradoconducted a fast-track demonstration project. More recently, Pennsylvania decided to take a two-site demonstration project statewide.
Improve access to long-term care options by developing Web-based information and assistance systems.
To ensure that consumers have accurate and timely information about long-term care options, states are developing information-rich Websites. For example, Virginia’s public-private partnership SeniorNavigator provides consumer information on a variety of aging-related topics. The program also includes counselors who assist older people without Internet access at SeniorNavigator neighborhood centers.
Include consumer direction in all state community-based service programs.
The term “consumer direction” describes programs and services where consumers have maximum choice and control over their care, often using vouchers or cash payments for the cost of services. In contrast to having care managers arrange services for clients, consumer directed care allows individual consumers to assess their own needs, determine how those needs should be met, and monitor the quality of the services they receive. Many states have incorporated consumer directed options in Medicaid and state funded long-term care programs. The “Cash and Counseling” demonstration project is a particularly successful model of consumer-directed care.
“One-stop shops” are community-level programs designed to help people make informed decisions about their long-term care service and support options. In the late 1990s, Wisconsin was among the first states toestablish one-stop shops. Since then, other states have developed one-stop shops, also known as Aging and Disability Resource Centers (ADRCs). These resource centers serve as the entry point to the long-term service and support system. States use ADRCs to better coordinate and redesign their existing systems of information, assistance, and access, which currently involve multiple federal, state, and local programs. Resource Center programs provide information and assistance to both public and private pay individuals. They also serve as entry points to publicly administered long-term supports, including those funded under Medicaid, the Older Americans Act, and state revenue programs.
Coordinate transit funding sources.
Finding transportation services remains a significant problem for community-based people of all ages with disabilities. However, collaboration among state transportation systems and between state and local systems is growing. Many states are linking transportation resources to health and social service programs. Coordination is particularly useful in areas with small populations where pooling program resources can make transportation available to participants in many programs. While many states are grappling with how to fund transportation services, Colorado, Missouri, and New York have each coordinated state funding with funds from other sources to establish or enhance transportation options for residents.
Support Family Caregivers & Home Care Workers
Improve the tax treatment of caregiver expenses.
Caring for a loved one can be expensive. Caregivers typically spend $12,500 annually on expenses related to their caregiving responsibilities. Typically, caregivers also spend about four years providing help. Providing dependent care tax deductions or tax credits can provide caregivers with financial relief. Some states offer a deduction for expenses, usually up to $2,400, but most offer a credit instead. Tax credits generally benefit low-income taxpayers and are often viewed as the most equitable way of providing caregiver tax incentives. State caregiver tax credits generally range from $500 to $1,500. These tax credit programs build on the federal tax credit, which reduces the amount of income taxes a family owes for dependent care. Many states have enacted laws to provide some financial relief for caregivers. At least 26 states and the District of Columbia have refundable or nonrefundable dependent care tax credits.
Expand Family and Medical Leave benefits.
Most caregivers work full-time. In order to fulfill their caregiving responsibilities, caregivers often have to take time off from work or be away from their jobs for extended periods. The federal Family and Medical Leave Act (FMLA) provides employees of businesses with at least 50 employees 12 weeks of unpaid leave each year to care for a newborn, seriously ill family member, or to recover from their own serious health conditions. To further support family caregivers, some states have expanded on the federal FMLA provisions by applying leave provisions to employees in workplaces with fewer than 50 employees; allowing leave for family medical needs that are not covered by the federal law; expanding the definition of “family”; extending the periods for family and medical leave; and offering paid leave benefits.
Home Care Workers:
Inform home care workers about eligibility for federal tax credits.
One way to support home care workers is to let them know that they may qualify for the federal Earned Income Tax Credit. Tax refunds under the program can be significant. For example, in New York City the maximum refund can be up to $4,200. To encourage home care workers to take advantage of federal tax provisions, Michigan enclosed a check stuffer about the earned income tax credit in the paychecks of state workers providing in-home personal care services.
Encourage and assist in developing employer health insurance purchasing pools.
Between 40 and 45 percent of all paraprofessional home care workers lack health care coverage. To address this problem states can provide in-home workers with access to health care coverage by encouraging and assisting the development of employer health insurance purchasing pools. Oregon and several counties in California have organized “public authorities” which serve as an employer-of-record for self-employed home care workers. The authorities serve as purchasing agents, making it possible to enroll individuals in a health insurance plan.
Connect in-home workers to existing supports for taxes, housing, health care, transportation, childcare, food, and other services for low-wage workers.
Supporting home care workers requires a full range of strategies. These strategies can include helping workers access low-income tax credits, childcare, transportation, and other community-based benefits. (Most home care workers have children under age 18.) States can help provide these services by linking direct care workers with existing supports. For instance, Pennsylvania is organizing a “Direct Care Worker Resource Center” targeted to paid home care workers that will centralize support and training services at the county level. The services are being offered at local agencies on aging. A similar program has been created in Tucson, Arizona by the Direct Caregiver Association and is supported by the Workforce Investment Act and other state and federal funds.
Encourage Personal Financial Planning for Long Term Care
Provide additional tax credits or deductions to encourage the purchase of long-term care insurance.
To encourage individuals to purchase long-term care insurance, many states offer limited income tax credits or deductions for LTC insurance premiums for policies purchased that benefit taxpayer spouse and dependents. However, some states also provide tax incentives for LTC insurance purchased for the benefit of other family members. Maryland, North Dakota, Oregon, and West Virginia provide LTC income tax credits for policies that cover parents and stepparents, and Montana provides a tax credit for policies that cover grandparents.
Promote the use of reverse mortgages for long-term care.
One way people can obtain additional income to pay for LTC expenses is by taking out a reverse mortgage. Reverse mortgages allow homeowners to stay in their homes while cashing in on the equity they have invested. Borrowers may receive income from the reverse mortgage or home equity conversion mortgage as a lump sum distribution, as monthly payments over a fixed period of years, as a lifetime annuity, or as a flexible line of credit. This tax-free money may be used without restriction and does not count as income toward Social Security, Medicare, or Medicaid benefits. The full loan amount, including principal and interest, is repaid to the lending institution when the borrower or borrower’s spouse sells the home, moves, or dies. States and the National Council on Aging (NCOA) are beginning to explore how reverse mortgages can be used to pay for long-term care expenses.
Promote the use of financial planning tools.
Studies show that individuals who use long-term care and retirement planning expense calculators to estimate their retirement expenses are far more likely to save for their LTC and retirement needs. Unfortunately, many consumers are unaware of the availability of such tools. States can promote new or existing calculators that encourage LTC and retirement planning. For example, several states and the U.S. Social Security Administration already include tools like the American Savings Education Council’s “Ballpark Estimate” on their Web sites. Examples of other useful tools include reverse mortgage and LTC expense calculators.
Develop a bare-bones long-term care policy for state employees.
To serve as a model for other employers and to help state employees plan for their own LTC financial needs, states are encouraging their employees and retirees to purchase LTC insurance. Some states offer low-cost group options that provide for limited benefits, while others offer LTC insurance through state self-funded retirement plans. Many other states offer LTC insurance policies through their employee benefit plans. Several states such as Alaska, Michigan, and Minnesota have created low-cost or “bare-bones” policies for state employees. As a result, 50 percent of Alaska’s retirees are enrolled in the state’s long-term care plan. Alaska’s plan is self-funded and most of Alaska’s retirees pay their LTC premiums through an automatic deduction taken out of their pension checks.
Promote Health and Wellness
Increase coordination between health and aging networks.
While most state units on aging (SUAs) and state health departments (SHDs) collaborate to varying degrees, collaboration is limited in many states. About one-half of these agencies reported collaborating on the joint planning or development of programs; and about three-fourths of SHDs and two-thirds of SUAs reported collaborating less than once a month. A federally funded project called the Aging States Project examines the obstacles that health and aging networks often encounter when attempting to work together. The Aging States report also provides examples from California, Delaware, Maine, Massachusetts, Missouri, New Jersey, New York, and Pennsylvania, where the public health and aging networks have successfully collaborated to improve the health and well-being of older adults.
Increase delivery of early detection and immunization services.
Flu and pneumonia pose substantially greater risks to senior adults than to younger adults. Yet, despite the proven benefits and cost-savings associated with vaccination, flu and pneumococcal vaccines are underutilized among seniors. New York has tackled this challenge by implementing a vaccination initiative for seniors, the goal of which is to vaccinate 60 percent of adults aged 65 years and over. The NY Department of Health and the Office for the Aging used the aging network to host flu clinics at senior centers, adult day health programs, and senior congregate housing sites. In three years, the immunization rates for influenza and pneumonia among New York residents aged 65 and older have improved by almost 24 percent, reaching 79 percent of the target population in the 2000-01 flu season.
Promote increased physical activity among seniors.
Every senior can benefit from physical activity. Older adults who engage regularly in physical activity experience physical and emotional improvements that exceed those of their younger counterparts. Seniors can experience dramatic increases in endurance after less than a year of moderate, regular activity. States are working to increase physical activity among seniors. In Texas, Texercise is a statewide fitness campaign to educate and involve older Texans and their families in physical activity and proper nutrition. Other states are promoting physical activity by creating bike paths, ensuring that sidewalks and walking trails are available, and sponsoring pubic education campaigns.
Launch a public awareness campaign for fall prevention.
Falls are the leading cause of injuries in seniors. More than a third of older adults fall each year. Of those that fall, 20 to 30 percent suffer injuries that reduce mobility and independence. The average health care cost of a fall injury for those aged 72 and over is almost $20,000. Arizona’s Fall Prevention Project targets residents of Pima County who are 60 years and older to reduce their risk of falls and injuries through education, home modification, and appropriate referrals. Nurses and fire district personnel jointly conduct home visits to assess environmental, medical, and behavioral risks for falls in clients’ homes to reduce health and safety hazards. Clients receive a “safety aids bag” that includes nightlights, double-sided carpet tape, installation grab bars, bathtub appliqués, reflective tape, and non-skid rugs. During the home visit, clients are educated about fall and injury hazards and receive recommendations about home improvements. Comprehensive fall prevention programs exist in 12 states.
Implement disease management programs.
Chronic diseases such as cardiovascular disease, cancer, diabetes, and arthritis are particularly prevalent in older people. Faced with tight fiscal constraints and soaring Medicaid budgets, states are pursuing new strategies to reduce the cost of caring for patients with costly chronic diseases. Chronic diseases such as cardiovascular disease, asthma, cancer, and diabetes are among the most prevalent, costly, and preventable of all health problems. Seventy-eight percent of the nation's total medical care costs, including almost 80 percent of total Medicaid expenditures, can be attributed to the treatment of chronic conditions. Disease management (DM) provides a strategy for states to improve patient health outcomes and limit health care spending by identifying and monitoring high-risk populations by helping patients and providers better adhere to proven interventions; engaging patients in their own care management; and establishing more coordinated care interventions and follow-up systems to prevent unnecessary health complications. More than 20 states are currently developing and implementing Medicaid disease management programs.