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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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