Occasional LTC Policy Paper Series
Duke Long Term Care Resources Program Paper No. 8
The Aging at Home Program: A Successful
Partnership in Caring
Julie Prince Bell, MHA, MPP and Sandra
Crawford Leak, MHA
Overview
Through three Aging at Home initiatives, over forty projects
received 6,792 referrals and ultimately served 1,572 new
clients. |
From 1994 to 1999, the Aging at Home Program
of the Kate B. Reynolds Charitable Trust has assisted communities
across North Carolina to help frail older adults "age at home"
by encouraging the development and growth of home and community-based
services. Through three distinct initiatives of Aging
at Home, the Trust has invested over $2.5 million in not-for-profit
and governmental service agencies in forty projects in thirty-nine
North Carolina counties. Duke Long Term Care Resources Program,
a program of the Duke University Center for the Study of Aging
and Human Development, has managed the Aging at Home Program
for the Trust, and the Division of Medical Assistance of the
North Carolina Department of Health and Human Services has been
a key partner in its implementation.
Over the combined grant periods of the three initiatives, the
forty projects received 6,792 referrals and ultimately served
1,572 new clients. As a result of the targeting used by the
Program, most of those new clients were very frail, Medicaid
eligible older adults.
The three initiatives each had distinctive themes: Aging at
Home I went to "the marketplace of ideas" to ask
communities around North Carolina what was needed to
help frail older adults age in their own homes or the homes
of family members. Aging at Home II "took CAP statewide"
by offering seed money to the twelve remaining counties in
North Carolina that did not have a Community Alternatives
Program for Disabled Adults (CAP/DA), North Carolina's
Medicaid Waiver Program. Aging at Home III helped CAP
programs in underserved areas expand to meet unmet need.
The following report is primarily a summary of the
experience of the Aging at Home III initiative which ended on
December 31, 1998. But, because the end of Aging at Home
III coincides with the conclusion of the Aging at Home
Program, this report also reflects the composite Aging at
Home experience.
Aging at Home I: Going to the
Marketplace of Ideas
Aging at Home I initiatives included adult day care centers,
care management initiatives, and expanded hospice services.
Aging at Home I Programs met their goal of serving frail,
older adults at risk for institutional placement.
Timely technical assistance, tracking performance and
networking among sites makes a difference. |
Responsive grantmaking; an impressive
response from the marketplace. In 1994 the first initiative
of the Aging at Home Program (which later came to be known as
Aging at Home I) offered organizations in communities across
the state an opportunity to submit their ideas for what their
communities needed to help frail older adults age at home. In
less than a month, eighty-six organizations responded with letters
of intent. A panel of experienced reviewers from the public
and private sectors chose thirty-six organizations to submit
full proposals and from those proposals, eleven sites, from
the mountains to the coast, were funded.
Diverse, viable ideas. The successful
experience of the Aging at Home I initiative has been detailed
in a report issued by Duke LTC in 1996. In addition to the responsive
grantmaking and impressive response from the marketplace, Aging
at Home I was characterized by diverse, viable ideas, from adult
day health centers to care management to expanded hospice services,
which were sustained after grant funding was ended. Some of
the most successful Aging at Home I projects used grant funding
to develop (four sites) or expand (one site) CAP/DA Programs.
Promises made; promises kept.
Most importantly, Aging at Home I kept its original promises
by meeting its goal of serving substantial numbers of frail
older adults who were at risk for institutional placement. Over
the course of the two- year grant period, 2,726 referrals were
made to the eleven sites with 494 clients receiving ongoing
packages of services and another 391 clients receiving other
substantial services. Seventy-three percent of the clients receiving
packages of services were "at risk" for institutional placement
with at risk being defined by the widely accepted indicator
of having three or more impairments in activities of daily living.
Framework established for future initiatives.
Lessons learned under Aging at Home I established the framework
for Aging at Home II and III to come: Timely technical assistance
leads to sustainable programs. Tracking the performance outcomes
of projects can be done in a way that is useful for both sites
and funding sources. Encouraging sites to share information
with one another is a win-win endeavor. And involvement of diverse,
experienced advisors, including key state agencies, was essential
to the initial review and ongoing efforts of programs.
Aging at Home II: Taking CAP Statewide
The Aging at Home II Program was funded by the Kate B. Reynolds
Charitable Trust between July 1995 and June 1997. In November
1994, 12 North Carolina counties, mostly in underserved areas, still
did not have CAP programs. The Aging at Home II Program offered
these remaining counties seed money for start-up of CAP programs.
Thus, Aging at Home II encouraged the 12 remaining counties to
participate in CAP and expanded the ongoing service capacity in
North Carolina.
All twelve county governments decided to participate by
designating lead agencies for the CAP/DA Program to apply
for funding and by January 1996, all 100 North Carolina
counties had operational CAP Programs. Overall, the Aging
at Home II Program served 480 new clients over a two-year
grant period. (A more detailed discussion of Aging at Home
II results compared to the Aging at Home III experience may
be found later in this document.)
Aging at Home
III: Reaching the Underserved
The Aging at Home III program was designed to help provide
funding to disadvantaged counties where there was an unmet
need for CAP services.
Forty-four letters of intent were submitted and seventeen
programs (serving eighteen counties) were eventually funded.
The Aging at Home III Program had sites across North Carolina.
|
Aging at Home II succeeded in "Taking CAP
Statewide." However, there was still an unmet need in many counties
for CAP services due to a lack of resources to expand, particularly
in rural and economically disadvantaged areas of the state.
The Aging at Home III Program's goal was to reduce unmet need
for CAP in rural, economically disadvantaged areas of the state
through providing expansion grants for adding capacity (primarily
case management capacity). Also, under CAP, there was a high
potential that funding could be sustained beyond the grant period
through Medicaid.
The Community Alternatives Program for Disabled Adults (CAP/DA):
CAP/DA is a Medicaid-funded program which provides case management
packages of services to help older and disabled adults who have
nursing home care level needs remain in their homes or the homes
of relatives. Hence, all of the persons served are low-income
and frail. Most are older adults. An analysis by Duke LTC of
a sample of CAP/DA data aggregated by Medical Review of North
Carolina indicated that the CAP/DA Program is on target in that
it serves a very impaired population that closely resembles
NC's nursing home population.
The Need for Expansion Funds:
CAP programs receive their main support from Medicaid through
the North Carolina Division of Medical Assistance but require
supplemental funding as they grow. While Medicaid funds will
support on- going operations of CAP/DA programs, counties, or
the lead agencies designated by the counties, are left to provide
the funds to develop and invest in their expansion (particularly
in the form of funding additional case workers). In counties
where programs were not able to expand to meet the growing need
for services, potential clients often spend long periods of
time on waiting lists and some were placed in institutional
care or died before they could be served. The Aging at Home
III Program was designed to help provide funding to disadvantaged
counties where there was an unmet need for CAP services.
Aging at Home III was targeted to help CAP/DA programs
expand (1) where there was unmet need, (2) where it was
unlikely that funds were available within the county to invest
in expansion, and (3) where the management capacity to
expand the program existed. In order to operationalize this
targeting, Duke LTC staff developed groupings of counties,
using the NC Department of Commerce rankings of
economic distress as a base, but also taking into account
such factors as percent of older adults living in poverty and
rurality within the county. Lead agencies for CAP/DA in all
100 counties were eligible to apply, but these groupings
were used to focus technical assistance on counties with low
resources and high need and were incorporated into the
scoring system for applications.
Request for Proposals (RFP's):
With the cooperation of the NC Division of Medical Assistance
and the NC Association of County Commissioners, the RFP for
Aging at Home III was distributed to CAP/DA lead agencies and
county managers' offices in all 100 counties by early January
1997.
Role of County Government: Applicants
were required to submit a letter of support from county government
for expansion with their proposals. As with many human services
programs in NC, county government plays a key role in leadership
for CAP/DA programs. County commissioners make the initial decision
to participate in the program and designate the lead agency.
On an ongoing basis, the county is responsible for the county's
Medicaid "match" for the program and often directly controls
hiring decisions because most lead agencies are units of county
government. Hence, support for expansion
by the county was considered to be a key element of the proposal.
Overall Response: The response
to the initiative was exceptionally strong. CAP/DA programs
in at least 60 NC counties had some contact with Duke LTC related
to the initiative. Forty-four letters
of intent were submitted. Thirty- one CAP/DA programs submitted
full applications for consideration in Aging at Home
III.
The Review Process: The review
process for Aging at Home III focused on identifying programs
where there was demonstrable need and the basic management capacity
to use investment by the Trust to meet that need. As in previous
rounds of the Aging at Home Program, a panel of experienced
advisors from the public and private sectors were reviewers
for the proposals. Reviewers met to consider each application
based on the following criteria:
- Evidence of unmet need for CAP/DA services
- Track record, particularly with the CAP/DA program
- Management plan for the proposed project, including a budget
- Community support and infrastructure
- Professional judgement of the reviewers
The Funded Projects: Because of
substantial interest and the Kate B. Reynolds Charitable Trust's
generosity, 17 projects serving 18 counties were eventually
funded (instead of the ten to twelve originally planned). Programs
were eligible to receive up to $40,000 for the eighteen-month
grant period. The initiative was successful in reaching some
of the most economically disadvantaged counties in the state.
The 18 counties served, and their CAP lead agencies, were:
- Alexander County through the Alexander County
Department of Social Services
- Alleghany County through the Alleghany County
Memorial Hospital, Inc.
- Bladen County through Bladen County Hospital
- Cherokee County through the District Memorial
Hospital of Southwestern NC
- Duplin County through Duplin Home Care and Hospice,
Inc.
- Franklin County through the Franklin County
Department of Social Services
- Graham County through the Graham-Swain District
Health Department
- Greene County through the Greene County Department
of Social Services
- Hertford County through the Hertford County
Department of Social Services
- Jones County through the Jones County Department
of Social Services
- Nash County through the Nash County Health Department
- Northampton County through the Northampton County
Department of Social Services
- Pender County through the Senior Citizen Service
of Pender, Inc.
- Sampson County through the Sampson County Department
of Aging
- Scotland County through the Scotland County
Health Department
- Stanly County through the Stanly County Department
of Social Services
- Swain County through the Graham-Swain District
Health Department
- Yancey County through the Toe River Health District
Role of Duke LTC: As manager of the Aging at Home
Program, Duke LTC provided technical
assistance, networking and quarterly performance monitoring
activities for the Aging at Home III awardees.
Before grants were awarded, the overall goal of technical
assistance to the sites was to assist applicants to
communicate their program's needs and experiences
clearly and concisely. Specifically, Duke LTC made contacts
with target counties, conducted application development
workshops at four locations across the state (Asheville,
Hertford, Lumberton, and Durham) which were attended by
24 programs, and reviewed and commented on draft
applications submitted by programs. Additionally, Duke LTC
coordinated and staffed the review process described above.
After programs were selected for participation in the Aging at
Home III Program, Duke LTC monitored their performance.
Each quarter, sites were asked to briefly review their
progress toward their original goals, complete a performance
report on client activity which included information on
referrals, screens, assessments, and waitlists, and highlight
their challenges and successes. Duke LTC compiled the
data from Aging at Home III sites and communicated the
information to the sites, advisors, and other interested state
officials through a quarterly newsletter.
In addition, Duke LTC maintained close contact with sites
through sites visits, frequent telephone contact, newsletters
summarizing quarterly performance information and topics of
interest or concern to sites, and meetings of the Aging at
Home Network to further encourage sites to learn from one
another. Duke LTC also acted as a liaison with the Division
of Medical Assistance.
Results
of Aging at Home III
The Aging at Home III Program was designed as a service
program, not as a research project. However, data from
regular performance monitoring of sites provides useful
and unique insight into the CAP program.
Fifteen CAP/DA sites reduced their pre-grant waitlists
to zero during the grant period.
Aging at Home III sites had 2,166 new referrals during
the grant period, most of which (83%) were screened for
CAP/DA services.
By the end of the grant period, 463 new referrals had
become new CAP clients.
Aging at Home III programs gained 598 total new clients
during the grant period.
Overall, 80% of CAP clients who left Aging at Home III
Programs during the grant period did so because they died,
entered a nursing home, or were hospitalized. |
Performance Monitoring Methods:
The Aging at Home Program was designed as a service program,
not as a research project. However, the data collected during
regular performance monitoring of sites provides useful, and
to-date unique, insight into CAP/DA as the Medicaid Waiver Program
for North Carolina, particularly for rural and underserved areas
of the state. As with Aging at Home I and II, both the sites
and long term care leadership across North Carolina have found
the information on the "flow" of individuals through programs
(from referrals to served clients) particularly useful.
Aging at Home III sites were required to submit quarterly
reports to Duke LTC which included information on pre-grant
waitlisted clients, new referrals during the grant period,
screening, assessment, and outcomes. The analysis of the
Aging at Home III data includes 17 counties (16 CAP/DA
programs). Due to unavoidable delays in start-up, one
CAP/DA program is not included because that program is on
a different time schedule than the other Aging at Home III
sites.
Pre-grant Waitlists for CAP Services
Were Reduced: Reducing waitlists was a goal for all Aging
at Home III projects. When the grant period began on July 1,
1997, the Aging at Home III sites had a total of 622 potential
clients on the waitlist for CAP services. By the end of the
grant period (December 31, 1998) the Aging at Home III sites
had reduced the number of pre-grant clients on their waitlists
to only eight, or less than 1% of the original waitlist. All
eight pre-grant clients still on the waitlist were concentrated
in one county while the remaining fifteen CAP programs reduced
their waitlists to zero.
The most dramatic improvement in waitlist reduction
occurred during the first quarter of the grant, July 1, 1997 to
September 30, 1997. During this time, total waitlisted pre-
grant clients dropped from 622 to 348. This represented a
44% reduction in the number of waitlisted potential clients.
Part of the reason such a significant reduction occurred in
the first quarter was due to the working through of waitlists
by CAP staff who were able to take off names of potential
clients who no longer needed or wanted CAP services for a
variety of reasons.
Eventually, 135 pre-grant clients (22%) on the waitlist for
services received CAP services.
Outcomes of other pre-grant waitlisted clients: Two hundred
thirty, or 37%, of those waitlisted pre-grant for CAP services
were screened during the grant period. Two hundred two, or
88% of those screened, were assessed for CAP. Fifty-nine
percent (135 total clients) of those screened, or 67% of
those assessed, eventually received CAP services.
The remaining 392 people who did not go through a
screening process had various other outcomes:
- 93 of the pre-grant waitlisted potential clients died before
they were screened for CAP;
- 77 were declared financially ineligible;
- 46 were placed in a nursing home or rest home before they
were screened for CAP;
- 2 were hospitalized;
- 28 had other things happen;
- 8 were still on the waitlist at the end of the grant period;
- 138 no longer wanted CAP services (From discussions with
sites, we know that some of these referrals were served under
the Medicaid Personal Care Service Program (PCS) and
found that to be enough. However, the performance
monitoring process did not collect specific reasons for their
decline of service).
Tracking New Referrals During the Grant Period:
Between July 1, 1997 and December 31, 1998, CAP programs participating
in the Aging at Home III Program had 2166 new referrals. New
referrals during this time came primarily from family (37%),
home health agencies (24%), and hospitals (8%). Also of significance
are referrals from DSS sections, other than adult protective
services, (6%), physicians (5%), other community agencies (5%),
and self-referral (5%). The remaining 10% of referrals came
from "other" sources, adult protective services, aging agencies,
and friends.
Screening of New Referrals: Of the 2166 new referrals to the
CAP programs participating in the Aging at Home III
Program during the eighteen-month grant period, 1810
(83%) were screened for services. The remaining potential
clients were awaiting screening at the end of the grant period
(10%), had "other things happen" (4%), were found
financially ineligible before screening (2%), or died before
screening (1%).
Assessment of New Referrals: Of the 1810 new referrals
screened for CAP services during the grant period, 35%
were assessed for CAP. The remaining new referrals had
various outcomes:
- 569 (31%) were still waiting for assessment at the end of the grant period
- 207 (11%) were financially ineligible
- 102 (6%) had low risk needs
- 94 (5%) died while waiting for assessment
- 48 (3%) entered a nursing home
- 11 (<1%) entered a rest home
- 8 (<1%) moved out of the service area
- 2 (<1%) were hospitalized before assessment
- and 127 (7%) had "other" things happen
Outcomes of New Referrals Assessed for CAP: Four-
hundred-sixty-three new referrals eventually received CAP
services. These new CAP clients represent 72% of those
assessed, 26% of those screened, and 21% of those
referred to Aging at Home III programs during the grant
period.
Twenty-eight percent (28%) of new referrals assessed did
not receive CAP services for a variety of reasons:
- 8% were ruled inappropriate for CAP services (4% were not financially
eligible, <3% were too impaired, and <2% were not impaired enough)
- 9% were still waiting for development of their care plan at the
end of the grant period
- 5% declined CAP services for reasons not specified in the data
- 3% were awaiting DMA approval at the end of the grant period
the remaining 3% were waiting to be discharged from a hospital, did not
meet Medicaid limits, or had "other" things happen
The Big Picture: Combined Totals of Pre-Grant Clients and
New Referrals: Combining the pre-grant waitlisted clients
data with the new referral data shows the complete picture of
the Aging at Home III experience. Pre-grant, there were 622
people on the waitlist for services. During the grant period,
2166 people were referred to the sites for CAP services for
a total of 2788 individuals. Overall, 2040 people (73%) were
screened for CAP services under the Aging at Home III Program
(1810 from new referrals and 230 from pre-grant waitlisted clients).
Of those screened, 844 people, or 41%, were assessed for services.
Growth in the Number of CAP Clients During
the Grant Period
Aging at Home III CAP Programs gained 598 new clients
during the eighteen-month grant period -- 135 from pre-
grant waitlisted potential clients and 463 from new referrals
during the grant period. During that same period, 407
established clients left the program. Thus, the total net gain
in CAP clients under the Aging at Home III Program was
191. The largest gains in total clients came during the
second and third quarters. Total net client gain slowly
decreased after the third quarter. New clients served
followed the same pattern as net client gain. This is likely
due to turnover in case management staff positions which
several sites experienced midway through the grant period.
Filling a CAP vacancy in a rural area often takes three to six
months and some sites experienced even longer vacancy
periods. During such periods, net growth in caseload was in
a holding pattern for the effected sites. By the end of the
grant period, however, most sites were back to full staffing
which included the capacity added under the grant.
The 407 established clients who left CAP during the grant
period did so for varying reasons. The primary reasons why
clients left the program were through death at home or after
a short hospital stay, comprising 34% of those who left (22%
and 12% respectively), or because they were admitted to a
nursing home (34%). Overall, 80% of established clients that
left CAP during the grant period did so because they died,
were admitted into a nursing home, or were still hospitalized
at the end of the grant period. Only 3% left to enter a rest
home.
Declining Waitlist Time: After
the Aging at Home III Program began, participating CAP agencies
slowly saw their waitlist times decrease. Most reached their
lowest waitlist time in the fourth and fifth quarters. By the
end of the grant period, some sites had virtually no wait times,
while others were slowly beginning to build-up again. The rebuilding
of waitlists is most likely due to CAP/DA staff turnover. Additionally,
as the grant period ended on December 31, 1998, sites were anticipating
that demand for services would increase in January, 1999, as
a result of the Medicaid expansion of coverage to 100% of the
poverty level for aged and disabled individuals in North Carolina.
Qualitative
Insights From the Sites
Through "listening" to sites issues of aide availability,
information systems, and dedication to client service
were heard. |
In addition to the quantitative tracking
of individuals through their programs, staffs of the Aging at
Home III sites were encouraged to share qualitative narrative
information in their quarterly reports related to their progress.
From those vignettes we learned that:
- CAP programs continue to struggle with the issue of aide
recruitment and retention. A few sites were using a portion of
their grant funds to address this issue through additional
training, etc. with varying success. And at least one site
reported client service being delayed because of the lack of
aide capacity in the county to serve new clients.
- Several sites reported that "client tracking" through
performance monitoring for Aging at Home had helped staff
manage waiting lists more effectively. Some also indicated
that the information collected was useful to them to help
describe their programs to county commissioners and other
groups.
- Both through the narratives and during site visits, staff of sites
communicated the often poignant stories of clients and their
families for whom the CAP/DA Program makes the
difference in their ability to remain at home.
Comparisons of Aging at Home
II and III
Aging at Home II sites had only new referrals while Aging
at Home III had both new referrals and pre-grant waitlisted
referrals.
Most Aging at Home III sites met self-sustaining caseload
levels for expanded capacity by the end of the grant period.
|
Overall, the experiences of Aging at Home
II, with new CAP programs, and Aging at Home III, with existing
CAP programs that wanted to reduce waitlists and augment services
to underserved individuals, were similar. Both initiatives were
intended to increase delivery of services to frail older adults
in rural, underserved areas of North Carolina. It is difficult
to compare pre-grant waitlisted individuals in Aging at Home
III, however, with Aging at Home II data since Aging at Home
II sites had only new referrals. Thus, most comparisons will
be made based on new referrals only. New referrals came
from basically the same sources under both Aging at Home II
and III: family, home health, and hospitals.
Additionally, the grant periods for Aging at Home II and III
differed. The period for Aging at Home II was two years and
the period for Aging at Home III was eighteen months. The
hypothesis was that existing CAP programs could compress
the amount of time needed to build-up additional capacity.
Overall, the Aging at Home III Program experience
supported that hypothesis. Most of the sites had reached
self-sustaining levels for additional caseloads at the end of
the grant period, and all are expected to sustain expanded
capacity. However, the model for growth did not anticipate
fully the amount of time that existing CAP programs spend
helping clients with nursing home placement or death and
dying issues or the degree to which staff turnover would
effect expansion.
Overall, the twelve sites of Aging at Home II served 480 new
clients over a two year grant period, and sixteen of the Aging
at Home III sites served 598 new clients over an eighteen-
month grant period. During those grant periods, Aging at
Home II and III sites had 155 and 407 established clients to
leave their programs, respectively, making net capacity
growth for Aging at Home II 325 clients and for Aging at
Home III 191 clients. Roughly the same percentages of
potential clients were screened by both programs (85% in
Aging at Home II and 83% in Aging at Home III) and were
assessed under both programs (30% for both Aging at Home
II and III). Twenty-five percent (25%) of Aging at Home II
referrals were eventually given CAP services, while 21% of
Aging at Home III referrals had received CAP by the end of
the grant period.
Lessons Learned
CAP serves a very impaired population.
CAP programs provide I&R, case assistance, and waiting
list management.
Screening is an effective tool for waitlist management.
|
Several useful lessons emerge from the aggregate
experiences of the Aging at Home Programs:
1. CAP serves a very impaired population: Of the 407 established
CAP clients who left the CAP program during the Aging at Home
III grant period, 80% died, entered a nursing home, or were
still hospitalized on December 31, 1998. Only 3% of established
CAP clients who left the program entered a rest home. In addition,
of those assessed for CAP services during the grant period,
72% eventually received services and 9% are waiting careplan
development. Only 2% of those assessed were declined for CAP
services because they were not functionally impaired enough.
The clients in the Aging at Home II Program were similar to
those in Aging at Home III. Of the established CAP clients
who left Aging at Home II, 78% died, entered a nursing
home, or were still hospitalized at the end of the grant
period. Only 1% left CAP to enter a rest home and only 3%
progressed to the point where services were no longer
needed.
2. CAP programs provide I&R, case assistance, and waiting list
management: On average, only about one out of every four
referrals to CAP in Aging at Home II and III became a served
client: This means CAP programs provide information and
referral, case assistance, and waiting list management services
as well as their specific role in case managing CAP clients.
3. Screening is an effective tool for waitlist management and
helps both potential clients and case managers: Screening
diminishes the possibility that referrals who are unable to
meet CAP eligibility requirements will wait for long periods
of time on CAP waitlists only to be told they do not qualify
for CAP. It also reduces the time spent by CAP staff on
clients who will not be eligible for services and allows them to
suggest alternatives to the CAP program sooner to referrals
and their family members.
The Aging at Home III statistics show the usefulness of
screening: Of the pre-grant clients on the waitlist for CAP
services that were screened during the grant period, 88% of
those were eventually assessed for CAP. Of the new
referrals to the Aging at Home III sites during the grant
period, 83% were screened. Of those screened, 35% were
assessed for CAP. All in all, CAP staffs tend to be able to
recognize the people who have a high likelihood of qualifying
for CAP services, with the help of a screening instrument.
Challenges Remaining
Although Aging at Home III projects have increased the number of
CAP clients served in 18 counties and have reduced wait times for
services, challenges do remain for the sites which reflect challenges for
North Carolina CAP/DA Programs in general and rural programs in
particular.
- Case manager staffing issues: Over half of the Aging at Home
III sites have experienced some turnover in case management
staff since the projects began. Recruitment of replacement
staff has taken three to six months for several sites. In
addition to salary issues, other reasons frequently expressed
for turnover include a small pool of qualified applicants in
rural areas, competition with near-by more affluent counties
for employees, and high visibility of CAP case managers in
communities which leads to offers from other programs with
more advancement options. Currently, most CAP case
managers in these sites, who work for government agencies,
are classified as Social Worker IIs and have annual salaries in
the low to mid 20's.
- Increasing demand for CAP services: Through both increases in
the number of frail elderly who wish to age at home and
increases in the eligibility levels for Medicaid services, more
older adults will both seek and be qualified to receive CAP
services. This is good but challenging news for CAP/DA
Programs around the state.
- Consequences of unmet need: Of the 622 individuals on the
pre-grant waiting lists for the sites in Aging at Home III, 93
died and 46 were placed in a nursing home or rest home
while waiting to be considered for services. These numbers
can be expected to increase as more and more older adults
seek CAP services unless CAP programs are able to expand to
meet the need for services in a timely manner.
- Potential Clients and their families concerned about Medicaid
Estate Recovery: Several of the Aging at Home Program sites
indicated during site visits or in their narrative progress
reports that they are concerned that some potential clients
who could benefit from CAP services are not accepting
services because of perceived fears of Medicaid Estate
Recovery. Staff appear to be most concerned about older
adults with small rural homesteads. (Note: Because CAP/DA
services are an alternative to nursing home care by federal
Medicaid definition, Medicaid Estate Recovery provisions
apply as they do for nursing home care. However, the Estate
Recovery Provisions do not apply to Medicaid Personal Care
Services, the other primary program for in-home services
supported through Medicaid.)
- Aide availability: CAP/DA programs are impacted by the
availability of in-home aides to serve clients. With serious aide
shortages around the state, CAP/DA clients can become
waitlisted because there is no aide to provide care.
- Death and dying issues: The experience of all three of the
Aging at Home initiatives indicate that CAP/DA Programs
help substantial number of clients to remain at home as they
are dying, a goal of many older adults and their families. But
has been little formal attention given to the needs of CAP
staff, who deal with these death and dying issues.
Conclusion
About the Authors
While challenges remain for CAP/DA and related home and
community-based care programs in North Carolina, the Aging at
Home Program leaves a legacy of responsive grantmaking that
encourages sustainable growth. Through the Teaching Communities
Initiative, Duke Long Term Care Resources Program is continuing to
help communities to share information in productive ways, a lesson
learned from Aging at Home I. The members of the Aging at Home
Network will be consolidated into the Teaching Communities
Network where they will have opportunities to share their experiences
through events, list serves and hard copy and online publications.
Additionally, as a part of the Teaching Communities
initiative, Duke Long Term Care is encouraging communities
across North Carolina to analyze their home and community-
based care complements in ways that will assist them to
plan for reasonable growth. Important partners in this
planning for growth are county and state governments. The
Aging at Home Program experience indicates that, in
general, county governments are very receptive to the needs
of frail older adults. And, recent evidence, including
increases in Medicaid eligibility levels and in Home and
Community Care Block Grant funding, indicates that North
Carolina as a state is growing in its commitment to the
vulnerable elderly.
The lead author of this policy paper is Julie Prince Bell. As a
graduate intern with the Duke Leadership in an Aging
Society Program, she worked closely with the Aging at
Home III initiative. In May of this year, she received joint
masters degrees from the School of Public Health at UNC-
CH and the Sanford Institute of Public Policy at Duke
University and is currently employed with the Piedmont Triad
Area Agency on Aging in Greensboro, North Carolina. Co-
author is Sandy Crawford Leak, Associate Director of the
Duke LTC Resources Program.
Acknowledgements
We take this opportunity to warmly thank the many individuals and organizations which
have helped to make the Aging at Home Program successful. Key organizations and
individuals include:
- The leadership and staffs of the forty sites in thirty-nine North Carolina counties that
participated in the Program, as well as the county governments which endorsed their
participation.
- The North Carolina Division of Medical Assistance, particularly Bruce Steel, Mary Jo
Littlewood, Judy Walton, and the many CAP consultants who have worked with Aging at
Home sites over the past five years. We also gratefully acknowledge the support of DMA
director Dick Perruzzi and former director Barbara Matula.
- Aging at Home Advisors over the five years, in addition to Bruce Steel and Barbara Matula,
including Bonnie Cramer, Susan Harmuth, Anne Demaine, Dale Simmons, MD, Richard
Gottlieb, Tom Howerton, Judy Wright and Allan Richmond.
- The North Carolina Association of County Commissioners who helped us publicize the
initiatives to county government officials and the Divisions of Aging, Social Services and
Adult Health of the North Carolina Department of Health and Human Services and the
Area Agencies on Aging Administrators for assistance with publicizing and helping counties
respond to Aging at Home RFP's.
- Our colleagues at Duke LTC, both past and present, who had a hand in the development,
implementation, and assessment of the Aging at Home Program, including Jennifer
Hoffmann, MPP; Stuart Bratesman, Jr., MPP; Elise Bolda, PhD; Kathyrn Downer, EdD; R.
Turner Goins, PhD; and Julie Prince.
And finally, we thank the Kate B. Reynolds Charitable Trust whose generosity and
commitment to serving low-income frail older adults motivated this effort. Our special
thanks to the Health Care Advisory Board of the Trust which has overseen this effort
over the past five years and to Ray Cope, Executive Director, John
Frank, Director of the Health Care Division, and Vance Frye (retired) who exemplify the
commitment of the Trust.
George L. Maddox, PhD Sandra Crawford Leak
Program Director Associate Program Director
Occasional LTC Policy Paper Series
Paper 8 / July 1999
Duke University Center for the Study of Aging and Human Development
DUMC 2920
Durham, NC 27710
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