Network in Aging of Western New York
“Aging Services in the 21st Century: National, State and Local
Perspective
Greg Olsen, Executive Deputy Director
New York State Office for the Aging
Thursday November 6, 2014
Williamsville, New York
The PAST
The Older Americans Act
“Countervailing Force” to Medicare and Medicaid
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Passed in 1965
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The primary federal discretionary funding
source for home and community based services
for older adults
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The goal: keep older adults healthy and
independent, and living in the community.
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Established the Aging Services Network
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Focused on multi-disciplinary partnerships
at community level
 Adjusted/Amended 12 times, about once
every 4 years
 Evolution of the role of the
network over time
The Past
 Older adults are a drain on resources
 Older adults not valuable
 Care and assistance focused primarily on clinical/skilled
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care
Prevention not priority
Direct Line – Hospital to NH instead of home first
Social determinants of health not
understood/incentivized/valued Role of caregivers not
recognized
Major issues preventable and manageable
 Chronic conditions
 Falls and injury related falls
Results of “The Past”
 policies focused on paying for interventions that address medical
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needs, not social needs
Payers had little incentive to cover social interventions that
provide long term clinical and financial rewards
Payments based on procedures/tests, visits and discharges – not
clinical outcomes
Community supports lacking
Innovation stymied
Silos created
Accountability lacking
Waste and fraud
Prevention not priority
High expenses, poor outcomes
Quality of care poor
The Present
 3.7 million people 60+ - rank #3 nationally
 Very diverse group – physically, culturally, ethnically, economically,
educationally, health status, etc.
 1.8 million people age 75+ - fastest growing cohort in NYS
 330,000 with Alzheimer’s Disease
 700,000 individuals age 60+ contribute 119 million hours of service at economic
value of $3.35 billion
 64% of individuals age 60+ own their own homes, 64% have no mortgage
 4.1 million caregivers at any time in a year – economic value if paid for at market
rate is $32 billion, average age is 64
 $90 Billion in lost productivity to businesses due to caregiving
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The Present - Aggregate Income by Age - NYS
Ages
Aggregate Income
Less than 24
$22,434,274,582
4.17%
25 to 44
$204,658,371,951
38.01%
45 to 64
$235,878,868,294
43.81%
65 and over
$75,498,394,809
14.02%
TOTAL
% of Total
$538,469,909,636
In addition to the billions in income generated from this age group, according to the AARP,
persons over the age of 50 control half of the country's discretionary spending.
 Hold over $7 trillion in wealth
Source - Current Population Survey, March Supplement, 2011.
Erie and Niagara Counties
Erie
Niagara
Total Population
2015
907,099
2025
884,405
2015
214,450
2025
211,625
0-17
18-44
45-59
60+
45+
189,803
308,485
196,268
212,543
408,811 (45%)
185,537
298,633
152,034
248,201
400,235 (45%)
44,638
67,923
49,297
52,592
101,889 (48%)
44,160
64,816
37,905
64,744
102,649 (49%)
Own
75%
No Mortgage
66%
Own
77%
No Mortgage
70%
Home Ownership
Volunteers
# 60+
37,548
Hours
2,627,804
Value
$73,578512
# 60+
2,462
Hours
172,315
Value
$4,824,820
Erie and Niagara County - Economics
Erie
Niagara
Social Security (annual)
$2.9 trillion
$742 million
Personal Income Generated Total
$24,917,804,500
$5,385,440,700
25-44
$7,672,822,000
$1,673,449,300
45-64
$12,213,372,800
$2,679,181,400
65+
$4,565,454,000
$962,465,200
45+
$16,778,826,800 (67%)
$3,641,646,600 (68%)
The Present
Family Structure . . .
United States
Married couple families
Married couple families with children
Single parent households
Single person households
Non-traditional households
County Data
New York State
62 Counties
Change in Population Aged 60 and Over
2010 to 2020
Proportion of County Population Aged 60 and
Over
Number of Counties with Specified
percent of Older Persons
2010
2020
Less than 20%
33
4
20% to 24%
26
32
25% to 29%
1
22
30% and over
2
4
Source: Woods & Poole Economics, Inc., 2011 State Profile
Demographic Change
 Foreign Immigration
 100,000 each year come to NYS
 1.4 million legal, permanent since 2000
 2.4 million people not proficient in speaking English
 Race and Ethnic Diversity
 Growth in all categories
 Migration
 Young workforce
 New retirees
 Frail older adults
 Young people
 Minorities
out of state
out of state
back to NY
out of rural areas
into suburban and rural areas
What We Know - Social Factors Directly Impact Health Spending
 Income, access to food, educational status, housing, employment
affect health and longevity.
 Research attributes as much as 40% of health outcomes to social and
economic factors (University of Wisconsin Population Health
Institute)
 Food insecurity and diabetes related admissions
 Living conditions and asthma
 Physical activity and obesity
 Health policy has focused on paying for interventions that address
medical needs, not social needs
 Payers had little incentive to cover social interventions that provide long
term clinical and financial rewards
 Payments based on procedures/tests, visits and discharges – not clinical
outcomes
Social Supports and Health Care
 Older Adults – largest consumers of health care
 65+ population spends 2x more than 45-64
 Spends 3-5x more than all adults under 65
 Medical Care – controlled by insurers, doctors, hospitals, drug companies
and skilled nursing facilities
 Social Supports – community and family assistance, good nutrition,
exercise, transportation, safe housing, volunteering – not reimbursed
 Medical Community - have not traditionally seen the benefit in social
supports and don’t understand their importance
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Social Supports
Older adults
 80% have at least one chronic condition
 50% have at least 2
 Means more visits to health professionals, more medications,
decline in overall wellbeing and quality of life
 Means limited mobility, social isolation and need for LTSS more
common
 Health care cannot solve the problem
 Need Communities to plan for and accommodate, map assets
and opportunities and design a new paradigm
 Livable/Age Friendly Communities - Erie
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Other Costs Associated with Chronic Conditions
• Cost of an individuals independence and quality of life??
• Costs for long-term care – exceed $500 billion nationally
• Out of pocket costs for individuals
– Co-pays, premiums, deductibles
– Prescriptions, then run risk of adverse interactions
– Spend-down
– DME
• Business costs – loss productivity and health spending
• Economic costs – local and state economy, income,
assets
The Future
Retain and attract boomers/retirees in our
communities
Economic Development:
 Gray Gold
States court retirees as a "clean" growth industry– for every couple that
leaves a state – 1.5 jobs associated with supporting an older couple.
 25,000 retirees leave NYS annually – 12,000 come to NY = (-13,000)
 The "graying" of the U.S. population creates substantial opportunities for
businesses that target their products and services at older consumers.
Increasingly, economic development experts - regard affluent, mobile
retirees as a key customer base with a stable stream of income to be spent
on local purchases and investments.
 Just as states have competed in "smokestack chasing" for years, many have
begun to focus on attracting and retaining retirees.
http://www.window.state.tx.us/comptrol/fnotes/fn9611.html
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What do We Really Want?
 To make our own decisions or, at least, be empowered to be active
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part of decisions about us
To stay in our homes/communities
To be as independent as possible
To have choices
To maintain relationships, have purpose
To be able to assume personal risk, be in control
To receive assistance as needed, on our terms and schedules
Not be vilified for asking for and receiving help
To access support services– transportation, snow removal, lawn
mowing, home modifications, etc.
To have help maneuvering various systems that are complex – i.e.,
bills, health plan/Medicare info, application assistance
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What Services Meet that Goal
 Case management
 Home delivered meals (HDM)
 Congregate meals
 Nutrition counseling & education
 NY Connects (ADRC) - LTSS I&A/R, options counseling, benefits
and application assistance
 Health Insurance Information , Counseling and Assistance
(HIICAP)
 Personal Care Level I and II (non-Medicaid)
 Senior center programming
 Health promotion and wellness
 Evidence Based Interventions – CDSMEs, fall prevention, etc
 Volunteer opportunities
 Caregiver support services for those caring older adults, older adults
caring for adult children with disabilities, grandparents raising
grandchildren
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What Services Meet That Goal?
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Respite
Support groups
Public education and outreach
Information and Assistance, benefits application
assistance
Ancillary services such as PERS and assistive devices
Social adult day services
Transportation to needed medical appointments,
community services and activities
Employment – Title V
Legal Services
Home modifications, repairs
Bill paying
Long Term Care Ombudsman
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Changes Are Occurring
 ACA covering more low income via Medicaid and middle income via subsidy
 New payment models holding providers accountable for patient health and
treatment costs (i.e. capitated, global, bundled, shared savings, penalties for
hospital readmissions, etc.) – social determinants
 CMMI – Innovations fund - $10 billion over 8 years to test innovative
payment and service models
 Patient centered medical homes – must integrate social supports into their
care models – triggers higher levels of reimbursement
 BIP – Balanced Incentive Payment Program – rebalance LTSS, break down
silos
 Stronger business case to invest in social interventions
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Changes Are Occurring - Federal and State
Direction – Rebalance LTSS – Stay in Community
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Olmstead Plan
Medicaid Redesign Team (MRT)
Health Homes
Fully Integrated Dual Advantage (FIDA)
Managed Long Term Care (MLTC)
Community First Choice Option (CFCO)
Money Follows the Person (MFP)
Center for Medicare and Medicaid Innovation (CMMI)
Delivery System Reform Incentive Payment Program
(DSRIP)
 Accountable Care Organizations, etc.
Managed Long Term Care
WHICH SERVICES ARE PROVIDED BY THE MLTC PLANS - Benefit Package of "Partially Capitated" Plans
MLTC Benefit Package (Partial Capitation) (Plan must cover these services, if deemed medically necessary.
Member must use providers within the plan's provider network for these services).
 Home Care, including:
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Adult Day Health Care (medical model and social adult day care)
Personal Emergency Response System (PERS),
Nutrition -- Home-delivered meals or congregate meals
Home modifications
Medical equipment such as wheelchairs, medical supplies such as incontinent pads, prostheses,
orthotics, respiratory therapy
Physical, speech, and occupational therapy outside the home
Hearing Aids and Eyeglasses
Four Medical Specialties:
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Personal Care (Home attendant or Housekeeping)
Certified Home Health Agency Services (home health aide, visiting nurse, visiting physical or occupational
therapist)
Private Duty Nursing
Consumer Directed Personal Assistance Program
Podiatry
Audiology + hearing aides and batteries
Dental
Optometry + eyeglasses
Non-emergency medical transportation to doctor offices, clinics (ambulette)
Nursing home care
Balancing Incentive Program
What Will a NWD Hub Do?
NWD Hub will:
 Assist individuals of all ages and populations over the
phone or in-person;
 Provide information about LTSS;
 Conduct NWD Screen as appropriate;
 Coordinate and share information with Specialized NWD
through secure database as needed;
 Coordinate applications for public benefits and other services;
and
 Provide information to Specialized NWDs for comprehensive
assessments and care planning.
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How to Access the NWD Hub?
 Any individual will be able to access the NWD Hub by:
 NY Connects website,
 1-800 Number, or
 In-person.
 The NY Connects website will have an expanded
resource directory where an individual can search for
services by county without assistance.
 NY Connects website will also have an optional online
questionnaire which will help determine what services
an individual may need.
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DSRIP
Medicaid Waiver designed to reinvest $6.4 billion for the
purpose of promoting multi-systems community
collaborations that achieve the goal of 25% reduction in
avoidable hospital use over 5 years.
 Includes health care, behavioral health and social services
public private partnerships.
 PPS – Performing Provider Systems
 Are required to engage all relevant stakeholders
 Required to develop an integrated delivery systems
 May implement 5-7 projects each in appropriate domains
 Can apply to become Accountable Care Organizations
 May apply for regulatory relief (waivers of regs)
DSRIP
DSRIP Projects
 All projects must be derived based on a Community Needs Assessment
(CAN)
 A comprehensive assessment of health care resources and community based
resources currently available in the service area and the demographics and
health needs of the population to be served
 Identifies gaps
 Identifies excesses
Community Resources Supporting PPS Approach – includes
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Community outreach agencies
Transportation services
NFP health and welfare agencies
Self-advocacy and family support agencies
Community service agencies
Local government social service programs
Family support and training
Caregiving
The National Caregivers Library
(http://www.caregiverslibrary.org/Portals/0/Business_Caregiving_Bottom_LineJune2009NATIONAL.pdf ) estimates
that the costs exceed $90 billion because the MetLife study only included caregiving for individuals age 60 and older.
Recruitment, Retention and Training
 At any given time, more than 20% of the workforce is dealing with a caregiving situation.
 33% of caregivers decrease the number of hours they work
 29% quit their job or retire early
 22% take a leave of absence
 20% change their job status or go part-time
Lost Productivity
 53% of caregivers admit that their job performance is negatively affected
 84% make caregiving related phone calls during business hours
 68% arrive late or leave early
 67% take time off from work during the day
Increased Healthcare Cost
 Even when your employees are caring for someone not covered by your health plan, the employers healthcare
cost can go up.
 75% of working caregivers report an adverse affect on their own health
 50% report 8 additional visits per year to a health care provider (for themselves) as a result of their caregiving
responsibilities
 22% report a significant impact on their own health (Statistics taken from National Caregivers Library)
JAMA – March 12, 2014 – Caregiver Burden
Clinical Review
 Highlights the despair that family and friends (caregivers) can
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feel when supporting frail or disabled relatives and the failure of
the US Healthcare system to recognize and support them.
Highlights need for support due to advanced age and change
drivers
Health care has not adapted to the needs of Aging Americans
Unpaid and untrained caregivers must handle medical devices,
medications and treatments that were once restricted to
clinicians.
Family caregivers provide most of the hands-on-care – often for
years without a break, without pay, without a vacation, without
recognition, without backup, without help.
The result – widespread and unnecessary suffering, isolation,
fear, error, and at times, bankruptcy, affecting the care receiver
and the family
Did You Know
The Network of Aging Service Providers
 Served almost 600,000 people last year
 Served over 13,000 Medicaid clients (duals)
 Served more than 7,200 older adults with a diagnosed
mental health condition
 Served more than 3,000 older adults with
alcohol/substance abuse problem
 All AAA’s now screen for alcohol/drug use and misuse
(CAGE)
 Many screen for depression (PHQ9) and anxiety
(GAD7)
 Dementia screen will be rolled out in 2014
 Caregiver screen rolled out in 2014/2015
The Future - What We Need To Do
 Recognize the social, intellectual and economic capital of
older adults - -plan for it and put it to use
 Better integrate social supports with medical care
 Take seriously the role of caregivers – screen and support
 Develop new and innovative financing models not solely
based on health interventions
 Finance social supports
 Finance offices for the aging
 Community Planning – aging in place
 Livable NY
 Age Friendly neighborhoods
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How to Fund Social Supports
1.
Non-profit hospitals are required to provide a community
health benefit usually equal to the value of their tax exempt
status – estimated at $13 billion annually (GAO)
Since much of this money was spent on care for the poor, and given that ACA
is covering man of these individuals now– might be able to shift funds to
social supports
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ACA requires tax-exempt hospitals to conduct a community
needs health assessment and develop an implementation
strategy for addressing the needs once every 3 years
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US Center for Disease Control and Prevention recommended that the
assessment include information on social determinants of health
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IRS requires (Schedule H-990) tax-exempt hospitals to report spending on
activities benefitting the community.
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How to Fund Social Supports
 Offices for the Aging and other human/social service agencies can and are contracting with:
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managed care
Managed long term care
Accountable Care Organizations
Health Homes
VA
Hospitals – care transitions
Health systems for EBI’s
Could be for:
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Medicare (FIDA)
DSRIP (delivery system reform incentive payment)
Commercial Insurance
Businesses
 Relationship building and trust – demonstrate value
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How do We Increase Service Capacity – Non-Medicaid/PreMedicaid?
o Current Tools
o Long term care insurance/ Partnership
o Reverse mortgages
o Savings
o Trusts and other legal tools
 New Financing Mechanisms for Network
 Independence Savings Accounts/Family Accounts
 Independence Insurance
 Independence Credit – Tapping Home Equity for network services
 Private Pay Development
 Cost Sharing for OAA
Cost-Sharing & Private Pay
 NYSOFA is exploring cost-sharing for OAA programs
as well as state funded programs
 Model could be similar to EISEP
 Target is middle income older adults/family
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members/caregivers
Additional revenue generated folded back into programs
to expand services and reduce waiting lists
Nutrition programs not allowable under federal costsharing but could be allowable using state and local
funding
Looking at developing policies, protocols and standards
in 2015
Would like it to be optional for counties
Cost-Sharing & Private Pay
 NYSOFA is developing policies, procedures and protocols
on developing private pay models in NYS
 Large number of middle income older adults, families and
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caregivers
Limited state/federal funding
Current waiting lists
Demand will increase with implementation of BIP and
SFY2014-15 language directing all health care practitioners in
NYS to provide NY Connects phone number if they believe
their patients would benefit from LTSS
Goal is to ensure some standardization of how private pay
models work
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Protect individuals
Value
Reduce exploitation/scams
Summary
 Older adults are valuable – economically, intellectually and
socially – tap them
 Care models must move away from strictly medical models – they
don’t work
 Financing models must include social supports and non-medical
LTSS
 New Financing models must be developed to focus on types of
services offered by OFA’s
 Communities are in best position to plan for and develop livable
and healthy communities for all ages
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Thank you