Addressing the Needs of Diverse New York City Elders:
Multidisciplinary Perspectives
Perspectives on the State of Aging in New York State
Greg Olsen, MSW
Executive Deputy Director
Wednesday, April 9, 2014
Fordham University
Cafeteria Atrium
NYSOFA Mission – Why We Exist
• The mission of the New York State Office for the Aging is to
help older New Yorkers to be as independent as possible
for as long as possible through advocacy, the development
and delivery of person-centered, consumer-oriented, and
cost-effective policies, programs and services which
support and empower older New Yorkers and their
families, in partnership with the network of public and
private organizations which serve.
NYSOFA
 Medicaid spend-down and nursing home diversion programs
 Cost effective community-based services
 Local network of providers
 59 AAA’s – network of over 1,200 community providers and growing
 Innovators
 Economic Development
Targets
1. Older adults with physical limitations, cognitive impairments
2. Older adults with chronic conditions – stabilize and improve health
3. Well Older adults – volunteers, mentors, entrepreneurs, community builders
4. Caregivers
The Older Americans Act
“Countervailing Force” to Medicare and Medicaid
• Passed in 1965
• The primary federal discretionary funding source
for home and community based services for older
adults
• The goal: keep older adults healthy and
independent, and living in the community.
• Established the Aging Services Network
• Focused on multi-disciplinary partnerships at
community level
• Adjusted/Amended 19 times, about once
every 3.5 years
• Evolution of the role of the network
over time
Historical Funding - NYS
OAA Funding
NYS
1993
$90.6 million
$57 million
2002
$102.5 million
$70.2 million
2012
$100 million
$113.9 million
With County, participant contribution, fundraising, cost sharing, etc –
add an additional $250 million
Network leverages funds, volunteers and creates sustainable
partnerships to survive, grow and meet evolving needs
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
Many screen for depression (PhQ9) and anxiety (GAD7)
Dementia screen will be rolled out in 2014
Caregiver screen rolled out in 2014/2015
NYSOFA Priorities
Overarching Theme:
Comprehensive consumer program to assist older persons to
continue living independently
 Community Empowerment Strategies – Community Building
 New York Connects/HCBS
 Health Promotion/Wellness
 Civic Engagement, Volunteerism, Workforce
 Caregiving – supporting those who provide the bulk of services
in America
WHY?
New York State
Trends in Demographics (2010)
Population Trends
Total Population
2000
2008
2010
2015
2020
2025
2030
19,000,135
19,460,969
19,566,610
19,892,438
20,266,341
20,693,354
21,195,944
Ages 5 and over
17,763,021
18,216,035
18,314,451
18,619,147
18,985,160
19,398,722
19,874,195
Ages 60 and over
3,211,738
3,558,460
3,677,891
4,027,480
4,499,549
4,962,734
5,302,667
Ages 65 and over
2,452,931
2,559,826
2,588,024
2,851,524
3,191,141
3,615,695
4,020,308
Ages 75 and over
1,180,878
1,281,459
1,259,873
1,242,577
1,332,145
1,561,652
1,815,879
Ages 85 and over
314,771
403,129
417,164
442,958
454,298
486,682
566,423
Ages 60-74
2,030,860
2,277,001
2,418,018
2,784,903
3,167,404
3,401,082
3,486,788
Ages 75-84
866,107
878,330
842,709
799,619
877,847
1,074,970
1,249,456
736,742
981,360
1,062,919
1,277,197
1,552,380
1,865,871
2,180,775
Ages 65 and over
506,282
674,022
716,078
872,889
1,058,974
1,296,349
1,574,537
Ages 75 and over
198,537
285,885
303,764
357,680
426,448
537,061
672,261
3,606,192
3,784,789
3,831,083
3,952,167
4,096,932
4,253,653
4,400,598
257,194
246,675
244,978
246,999
252,089
255,876
260,507
Ages 18 to 59
2,206,913
2,206,913
2,210,226
2,198,510
2,161,587
2,141,246
2,156,392
Ages 60 and over
1,201,431
1,331,201
1,375,879
1,506,658
1,683,257
1,856,532
1,983,699
Poverty,(1) Age 60+
352,835
Minority Elderly, 60 and over
Disabled (ages 5 and over)
Ages 5 to 17
Below 150%
652,365
Below 250%
1,201,110
Housing (Own/Rent), 60+,(2)
Source: NYS Data Book, 2010, © NYSOFA
158,860/92,900
8
9
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
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
Family Structure . . .
United States
Married couple families
Married couple families with children
Single parent households
Single person households
Non-traditional households
Economics of Aging
The growth of the older population and the
baby boomers
=
opportunities
Does not have to equal high cost, loss of
independence, loss of choices
Why Should We Care?
Over the next 25 years, as the American Baby Boomer Generation ages,
communities across the country will face growing burdens of care and
need unless they begin planning for changes that will make their
communities enabling environments for lifelong growth. The vast majority
of communities have failed to confront this challenge
Older Adults are growing in numbers and as a proportion of their
communities.
Older Adults are an economic driver in their communities
Older Adults are contributing thousands of hours of time in a variety of
capacities in their communities
Older Adults overwhelming state they want to stay and grow old in their
communities
Older Adults face many challenges as well including health, chronic
conditions, isolation, economic security, etc.
14
Why we should be ready to - Retain retirees and older
adults in our communities
 $50 billion a year is paid to New Yorkers through Social Security, 65% of this is received by
our older residents and they receive billions in retirement pension benefits, a majority of
which are used to purchase goods and services.
 In New York according to the U.S. Census Bureau - 72 percent of persons over 60 own their
own homes - pay real property taxes and do not create additional demands on a community’s
local school system.
 In New York, over 143,014 grandparents are caring for their grandchildren (300,000) – who
would otherwise need placement in the state’s foster care system at an average annual cost
of $47,000.
 80% of long-term care is provided by over 4.1 million informal caregivers in New York –
average age of a caregiver, 64.
 Helping Communities become Livable Communities through a process of thoughtful planning
and engagement that by design supports seniors so that they can safely live independently.
AARP membership survey revealed that 90% of their members want to stay in their homes and
communities as they age – i.e. not move.
15
Why we should be ready to - Retain retirees
and older adults 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.
 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
16
Aggregate Income by Age - NYS
Ages
Aggregate Income
% of Total
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
$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.
In New York according to the U.S. Census Bureau, 2005-07 American Community Survey 72
percent of persons over 60 own their own homes - pay real property taxes and do not create
additional demands on a community's local school system.
Source - Current Population Survey, March Supplement, 2011.
Nassau
NYC
Tot Population
1,357,429
8,391,881
Age 45-64
400,427 (30%)
Age 65+
206,727 (15%)
Age 45+
Suffolk
Westchester
1,518,475
955,962
433,870 (29%)
267,218 (28%)
1,017,555 (12%)
204,117 (13%)
135,355 (14%)
607,154 (44.8)%)
3,077,363 (37%)
637,987 (42%)
402,573 (42%)
Income
Age 25-44
$9 billion
$108.5 billion
$23.6 billion
$14.5 billion
Age 45-64
$9.5 billion
$100 billion
$22.6 billion
$22.1 billion
Age 65+
$8.9 billion
$36.3 billion
$7.3 billion
$6.6 billion
Income age 45+
$18.4 billion
$244.8 billion
$30 billion
$28.7 billion
65+ Own Home
85 %
29.3%
83%
71%
No Mortgage
73%
70%
69%
70%
Volunteers (65+)
53,896
265,288
53,216
35,289
Hours
983,387
4,840,443
970,971
643,875
$136 million
$27.2 million
2,059,808 (25%)
Home ownership
Value(x$28 per hour) $27.5 million
$18 million
What do People Really Want
•
•
•
•
•
•
•
•
•
To make their own decisions
To be a part of decisions made about them
To be empowered
To have choices
To be able to assume risk
To stay in their homes
To maintain relationships, have purpose
To receive assistance as needed, on their terms, on their schedules
To feel ok about asking for and receiving help
• More human service focused – transportation, snow removal, home
modifications, etc.
• Help maneuvering various systems that are complex – i.e bills,
health plan info, application assistance, rules
•
•
•
•
•
•
•
•
•
•
•
•
•
Home delivered meals
Congregate meals
Nutrition counseling & education
Long Term Care Ombudsman
Health Insurance Counseling and Assistance (HIICAP)
Employment – Title V, DOL one stops
Medicare prevention, screening and wellness
Options counseling, benefits and application assistance
Legal Services
Senior center programming
Evidence Based Interventions – CDSMP, fall prevention, etc
Volunteer opportunities
ADRC – aging and disability resource center
– No wrong door – objective info and assistance on LTC
• Caregiver support services
– Support groups
– Training
– Respite
Services Provided by the Aging Network
•
•
•
•
•
•
•
•
Case Management
Help understanding, navigating complex systems and application support
Personal Care Level I and II (non-Medicaid)
Ancillary services such as PERS, those that maintain or promote the individual’s independence such
as:
(i) purchasing/renting of equipment or assistive devices
(ii) purchasing/renting, maintaining and repair of appliances
(iii) personal and household items
social adult day services
transportation to needed medical appointments, community services and activities
those that maintain, repair or modify the individual’s home so that it is a safe and adequate living
environment, such as:
(i) home maintenance and chores
(ii) heavy house cleaning
(iii) removal of physical barriers
those that address everyday tasks, such as:
(i) house cleaning
• (ii) laundry
• (iii) grocery shopping, shopping for other needed items and other essential errands
• (iv) bill paying and other essential activities
Systems Changes/reorganization in health care (Affordable Care Act) and long-term services
and supports delivery (Olmstead, MRT, managed care for all, health homes, OAA
reathorization) may provide an opportunity for aging services network to contract with:
– Medicaid Managed LTC
– Medicare Advantage
– Traditional Managed Care
– Veterans Administration
– Health Homes
– Private Insurers
– Private Pay Customers
– Businesses/Chambers of Commerce
– Other non-profits in human services
Systems Integration is Key
• 20% of older adults have a diagnosable mental disorder such as
dementia, depression and anxiety
– Medicare now pays for annual wellness visit, a variety of screenings,
depression screening and alcohol and substance abuse screening
• Primary care physicians are key
– Virtually all of them have a chronic health condition
• 75% of ALL health care spending is spent on chronic conditions
– Those ages 65 + - 91% have at least 1 Chronic condition
• 73% have two or more
The next set of older adults – baby boomers
68% have at least one chronic condition
43% have at least 2
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
• USA funds the most expensive settings and services – attention not paid to
role of social/human services, housing, nutrition, socialization, etc.
AAA’s and Network Providing Services WHERE PEOPLE ARE
• Have a strong ground game – 59 AAA’s and over 1,200 subcontractors
• Have extensive experience in working in and navigating complex systems
• Operate/administer myriad of programs and services – not a one trick
pony
• Understand the valuable role caregivers play and work to maximize
family support
• Understand public benefits, counseling and are seasoned in helping
individuals and families with diverse applications for a myriad of
programs
• Are mobile and can “go to” the client’s home/other community setting
• Are adept at leveraging resources and building sustainable partnerships
• Have a culture of helping and are trusted locally
• Are positioned to be an important part of a new system that will:
–
–
–
–
Focus on prevention and preventive services and screenings
Manage chronic conditions through EBI’s
Reduce reliance on Medicaid, maximize private pay
Better target those at risk and coordinate their care
• Are an important part of economic development/sustainability
Nursing Home Placement Indicators
To understand cost efficient programs and services, it is important to understand
the risk factors associated with higher levels of care, particularly nursing home
placement.
 Demographic characteristics: Older individuals and those who are non-Hispanic
white.
 Socioeconomic status: Individuals with low incomes
 Health status and physical functioning: Those with certain health conditions
(such as cognitive impairment, cancer, high blood pressure, diabetes, and a
history of strokes and falls) and those who have difficulty performing activities
of daily living (ADLs
 Prior health care utilization: Individuals who have spent time in the hospital or
in a nursing home. In 2009, about 7 percent of state residents 65 or older had
one nursing home stay and 23 percent of state residents 85 or older had one
nursing home stay. (Source: Nursing Home Compendium 2010 from CMS)
 Living arrangements and family structure: Those who live alone (including
widowed and divorced individuals), do not own their home, and have fewer
children than their peers not in nursing homes.
 Availability of support: Individuals who lack caregiver support
NYSOFA Programs serve individuals at risk of nursing
home placement and Medicaid spend-down
EISEP Case Management
Average age – 81.2
47% below 150% of poverty
85% difficulty in 3+IADL
30% difficulty in 3+ ADL
39% at nutritional risk
62% live alone
State Cost - $359
Local Cost - $119
EISEP Personal Care level I and II
Average age – 83.5
58% below 150% of poverty
91% difficulty in 3+IADL
45% difficulty in 3+ ADL
42% at nutritional risk
69% lived alone
State Cost - $2,369
Local Cost - $789
Social Adult Day Services
Average age - 81.5
32% below 150% of poverty
80% difficulty in 3+IADL
47% difficulty in 3+ ADL
22% at nutritional risk
24% lived alone
$9.72 an hour
Home Delivered Meals
Average age 80.8
44% below 150% of poverty
77% difficulty in 3+IADL
23% difficulty in 3+ ADL
42% at nutritional risk
59% lived alone
$6.49 per meal
How do We Increase Service Capacity – Non-Medicaid?
Federal appropriators hostile towards discretionary funds
NYS closing multi-year structural deficits
•
Expand Access to SNAP and other federal benefit (LIS/MSP, etc) – avg benefit $175/month = 27 meals
per month full pay, 44 meals if paying $4 contribution
•
Formalized Volunteer Recruitment Campaign– HIICAP, LTCOP, AAA, home delivered meals, congregate,
CDSMP, etc.
•
Vendors for managed care, Medicare, Private Insurance, Veterans, Businesses
•
New Financing Mechanisms for Network
•
•
•
•
•
•
Independence Savings Accounts/Family Accounts – i.e. ITN
Independence Insurance
Independence Home Equity Line of Credit
Private Pay Development
Cost Sharing for OAA
Medicaid Administration Pursuit
• NY Connects
• LTCOP
• System for reimbursement for allowable activities under Medicaid – applications, case management
JAMA – March 12, 2014 – Caregiver Burden
Clinical Review
• Highlights the despair that family and friends (caregivers) can 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
What is New Out There?
Systems Integration – SI
• 51 Counties, 6 Alzheimer's Chapters and 1 Alzheimer's
Community Based org
• Bring distinct, core components to scale across NY Connects
(ADRC) and enhance dementia capability through consistent
screening, staff training and linkages to available services
•
•
•
•
•
•
•
•
Information and Assistance
Options Counseling
Dementia Screening
Care Transitions
Expand EBIs – Chronic Disease Self Management for dementia
Caregiver Supports
Consumer Directed Programming
Streamlined eligibility for public services/programs
Balanced Incentive Payment Program (BIP)
The Balance Incentive Program (BIP) is a funding opportunity
offered under section 10202 of the Affordable Care Act:
• Provides enhanced FMAP (+2%) to participating states to
rebalance Medicaid Long Term Services and Supports (LTSS) by
increasing access and expanding community services as an
alternative to institutional care.
• Requires 3 structural changes:
• No Wrong Door/Single Entry Point network (NWD/SEP)
• Core Standardized Assessment Instruments
• Conflict-Free Case Management
BIP
No Wrong Door/Single Entry Point (NWD/SEP):
• Consistent information must be delivered about LTSS options
whether an individual seeks information from a 1-800 number,
a website, or a local office that is part of the state’s NWD/SEP
network.
• Provides assistance in enrolling the individual in services.
• The State plans to:
• expand NY Connects statewide;
• add an interactive screen to allow individuals to self-assess their
LTSS needs prior to a comprehensive assessment; and
• develop tools and training to ensure consistent information about
the LTSS available in communities across New York.
Innovations
Westchester Care Circles – provides respite and caregiver support – teams
of volunteers matched with clients to meet family needs.
Orange – Partnership with School of Occupational Therapy and Nursing to
provide home assessments for safety, fall prevention
P2 Collaborative – multi-county effort in western New York to reduce
preventable hospital readmissions using area agencies on aging and New
York Connects as partners with discharge planners and connect to
community resources
St. Lawrence – Partners with Red Cross and local university to implement
disaster preparedness programs at nutrition sites
Broome, Oneida, Onondaga – saved Medicaid $7.7 million by targeting
older adults at imminent risk of spend-down and nursing home placement
– used AAA services and offered consumer direction
AAA and local partners – developing and implementing chronic disease
self management programs
Wayne– partnership with rural health network to support older adults and
families – provides in home geriatric assessments, acts as liaisons to
medical providers and insurance carriers, coordinates care transitions,
counseling and entitlement benefits, assistance with advance directives
Innovations
NY Connects - local long term care councils – over 1,600
members statewide – gaps analysis, service needs, problem
solving – action
Broome – partner with large MCO to implement fall prevention
EBI
Livingston – partnership with AAA, University of Rochester,
county health, rural health network, emergency management
and Tri-county family medicine to identify unmet medical and
social needs of rural older adults
Erie – NY Connects is no wrong door for older adults needing
behavioral health services
Madison – Age simulator for 7th grade students to teach and
experience what its like to get older – physical impairments
Many, many more…….
Questions?