The Kate B. Reynolds Charitable Trust committed $1 million to be allocated to sites across North Carolina to develop or enhance home and community care programs to serve the frail elderly who were at high risk of institutionalization. Duke LTC agreed to manage that investment for the Trust including the selection process for sites and technical assistance and performance monitoring for funded programs.

This report summarizes the composite experience of the eleven sites from around North Carolina which received funding through what is now known as "Aging at Home I" from January 1, 1994 through December 31, 1995.

Based on the initial success of Aging at Home I, the Kate B. Reynolds Charitable Trust subsequently funded "Aging at Home II" beginning in 1995.

The Approach: Going To The Marketplace Of Ideas
The Aging at Home I Program was a model of public/private partnership intended to promote infrastructure development through grantmaking that was responsive to the specific needs and capabilities of local communities. Early on, the Board of the Trust made the decision to "go to the marketplace of ideas" from communities rather than to fund programs specified by the Trust. Particular emphasis was also attached to funding projects viewed by communities as viable programs to be sustained in the long term.

While no model was specified, proposals that sought to develop or enhance Medicaid Community Alternative Programs (CAP) were encouraged because CAP programs provide an umbrella of services for high-risk older and disabled adults who are also low- income and Medicaid is a source of funds for continuing support.

A Diverse Response From The Marketplace
The enthusiastic response from communities across North Carolina was impressive in its diversity and its quality. Eighty-six letters of intent were submitted from across North Carolina proposing a wide range of projects (see Chart A).

A panel of experienced reviewers from the public and private sectors considered each idea proposed with a particular emphasis on potential sustainability (see Exhibit 1). Thirty-six organizations were chosen to submit full proposals from which eleven sites, including four CAP development sites and one CAP expansion, were recommended to the Trust and all recommended sites were approved for funding for two years, beginning January 1, 1994.

Chart A
Aging at Home I Program Site Selection Process Managed by the Duke Long Term Care Resources Program

The Funded Projects: Considerable Diversity
The eleven funded Aging at Home projects represented considerable diversity along the lines of geographic distribution, organizational auspices and type of project. (See Exhibit 2 for a Summary of Funded Projects.)

Geographical Diversity. The counties served spanned the state from Haywood County to Currituck County. It is important to note, as illustrated in Exhibit 2, that the geographical distribution of the pool of potential awardees at both the letter of intent phase and the final selection phase was so broad that geographical diversity was achieved without any intentional adjustments on the part of the reviewers.

Organizational Diversity. In terms of organizational auspices, four county departments of social services, three aging agencies, two health departments, one hospital and one retirement community with community-based services received awards.

Idea Diversity. The types of projects funded included four new Medicaid Community Alternatives Programs (CAP); one CAP expansion; the development or expansion of three adult day care/day health programs, including the first one in northeastern North Carolina; the development of case-managed service packages as alternatives to institutionalization in two projects; and a program to expand respite care to hospice patients and their families.

• Establishment of the Aging at Home Network which included the sites and advisors to the program;
  
  
• Site visits and frequent telephone contact;
  
  
• Quarterly publication of "Progress Notes", a newsletter for the Aging at Home Network which summarizes quarterly performance information; and
  
  
• Annual statewide meetings of the Aging at Home Network to further encourage sites to learn from one another.

• Aging at Home I served substantial numbers of frail, older adults and their families. Over the two-year period (1994-1995), the eleven sites received a total of 2,716 referrals and screened 1,658 older adults for functional status. One thousand and eighty potential clients received full assessments for services; and 885 clients went on to receive direct services from sites.
  
  
• Of the 885 clients who received direct services from sites, 494 received ongoing packages of services and 391 received other substantial services (most often through coordination of volunteer services.) Additionally, many of those referred who were not served directly received informational, educational or support group services from sites.
  
  
• Families were the most frequent (19%) single source of referrals to sites followed by hospitals (16%) (Chart B). This finding suggests what much of the case experience of Aging at Home I indicates: Many North Carolina families are deeply committed to helping their older relatives stay at home.
  
  
• As expected, females, minorities and the oldest-old are over-represented in the overall client group. Of the 885 clients receiving direct services, 69% were female; 29% were minority and 13% were 85 or over. For the clients who received ongoing packages of services, 71% were female, 35% were minority and 20% were 85 or over.
  
  
• Frail, at-risk older adults were reached. Observed levels of Activity of Daily Living (ADL) impairment indicate adults served were very impaired (see Chart C). Nationally, institutional populations of frail adults average around 4 ADL impairments, and having 3 or more ADL impairments indicates an individual in the community is at risk of institutionalization.
  
  
• Overall, 73% of clients who received ongoing packages of services from the 11 sites were "at risk" as indicated by 3 or more ADL impairments. The reasons why established clients left the Program also suggest that a frail, high-risk population was being served. The most frequent reason for ongoing clients leaving the program was death and most of those deaths (94 clients) occurred at home. The second most frequent reason for leaving was nursing home placement (45 clients).

• Communities across NC have "good", viable ideas, which can lead to sustainable programs, to help frail older adults age in their own homes or the homes of relatives. Spurred by the growing need for such services at the local level and by county-based planning for aging services, most communities in the state know where the gaps in services are and what infrastructure is needed to fill those gaps. The challenge for the communities is to develop programs which can be sustained in uncertain times.
  
  
• All of the programs which were begun through the Aging at Home I investment completed the initial two-year grant period and are positioned to survive the transition period to other funding sources. All sites faced serious challenges at some point during their development, and some challenges remain to be resolved. Where challenges have been overcome, the successes seem best explained by a community's abiding commitment to provide options for frail older people. The dedicated staff and leadership of the Aging at Home I sites have implemented that commitment.
  
  
• Timely technical assistance linked to seed money from the Trust enhances the viability and sustainability of "good ideas." Beginning with proposal development, Duke LTC staff not only provided technical assistance to sites through educational meetings, site visits and many telephone contacts, but sites also were encouraged through the "Aging at Home Network" to provide support to one another, and later, to the Aging at Home II sites.
  
  
• The most significant challenge for all eleven sites was, and remains, financing for on-going service delivery for older adults. Sites were effective in targeting services to reach those most functionally impaired, but both performance reporting data and case experience indicate that it was, and remains, a constant challenge for sites to fund service delivery. Obtaining and maintaining service funding for clients was a challenge for both sites funded primarily by limited programmatic resources (such as the Home and Community Block Grant) and sites receiving Medicaid funding because many poor older adults do not qualify for Medicaid without complex "spend downs." While grant support alone cannot provide continuing, basic support for services, such support in the form of timely technical assistance and the development of infrastructure that involves a broad range of community leadership helps to use limited resources more effectively and to compete for external support.