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.

2.

Older adults with physical limitations, cognitive impairments Older adults with chronic conditions – stabilize and improve health 3.

4.

Well Older adults – volunteers, mentors, entrepreneurs, community builders 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

1993 2002 2012 OAA Funding $90.6 million $102.5 million $100 million NYS $57 million $70.2 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 Ages 5 and over Ages 60 and over Ages 65 and over Ages 75 and over Ages 85 and over Ages 60-74 Ages 75-84 Minority Elderly, 60 and over Ages 65 and over Ages 75 and over Disabled (ages 5 and over) Ages 5 to 17 Ages 18 to 59 Ages 60 and over Poverty,(1) Age 60+ Below 150% Below 250% Housing (Own/Rent), 60+,(2)

Source: NYS Data Book, 2010, © NYSOFA

2000 19,000,135 17,763,021 3,211,738 2,452,931

1,180,878 314,771

2,030,860 866,107 736,742 506,282 198,537 3,606,192 257,194 2,206,913 1,201,431 352,835 652,365 1,201,110 158,860/92,900 2008 19,460,969 18,216,035 3,558,460 2,559,826

1,281,459 403,129

2,277,001 878,330 981,360 674,022 285,885 3,784,789 246,675 2,206,913 1,331,201 2010 19,566,610 18,314,451 3,677,891 2,588,024

1,259,873 417,164

2,418,018 842,709 1,062,919 716,078 303,764 3,831,083 244,978 2,210,226 1,375,879 2015 19,892,438 18,619,147 4,027,480 2,851,524

1,242,577 442,958

2,784,903 799,619 1,277,197 872,889 357,680 3,952,167 246,999 2,198,510 1,506,658 2020 20,266,341 18,985,160 4,499,549 3,191,141

1,332,145 454,298

3,167,404 877,847 1,552,380 1,058,974 426,448 4,096,932 252,089 2,161,587 1,683,257 2025 20,693,354 19,398,722 4,962,734 3,615,695

1,561,652 486,682

3,401,082 1,074,970 1,865,871 1,296,349 537,061 4,253,653 255,876 2,141,246 1,856,532 2030 21,195,944 19,874,195 5,302,667 4,020,308

1,815,879 566,423

3,486,788 1,249,456 2,180,775 1,574,537 672,261 4,400,598 260,507 2,156,392 1,983,699 8

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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

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.

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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.

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Why we should be ready to Retain retirees and older adults in our communities

Economic Development:   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.  Gray Gold

States court retirees as a "clean" growth industry – couple that leaves a state – for every 1.5 jobs associated with supporting an older couple.

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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Ages Less than 24 25 to 44

45 to 64 65 and over

Aggregate Income by Age - NYS

Aggregate Income % of Total $22,434,274,582 $204,658,371,951

$235,878,868,294 $75,498,394,809

4.17% 38.01%

43.81% 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.

Tot Population Age 45-64 Age 65+ Age 45+ Income Age 25-44 Age 45-64 Age 65+ Nassau 1,357,429 400,427 (30%) 206,727 (15%) 607,154 (44.8)%) $9 billion $9.5 billion $8.9 billion Income age 45+ $18.4 billion Home ownership 65+ Own Home No Mortgage Volunteers (65+) Hours 85 % 73% 53,896 983,387 Value(x$28 per hour) $27.5 million NYC 8,391,881 2,059,808 (25%) 1,017,555 (12%) 3,077,363 (37%) $108.5 billion $100 billion $36.3 billion $244.8 billion 29.3% 70% 265,288 4,840,443 $136 million Suffolk 1,518,475 433,870 (29%) 204,117 (13%) 637,987 (42%) $23.6 billion $22.6 billion $7.3 billion $30 billion 83% 69% 53,216 970,971 $27.2 million Westchester 955,962 267,218 (28%) 135,355 (14%) 402,573 (42%) $14.5 billion $22.1 billion $6.6 billion $28.7 billion 71% 70% 35,289 643,875 $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:

white. Older individuals and those who are non-Hispanic 

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 EISEP Personal Care level I and II Home Delivered Meals Average age – 81.2 Average age – 83.5 Average age 80.8

47% below 150% of poverty 58% below 150% of poverty 44% below 150% of poverty 85% difficulty in 3+IADL 91% difficulty in 3+IADL 30% difficulty in 3+ ADL 45% difficulty in 3+ ADL 77% difficulty in 3+IADL 23% difficulty in 3+ ADL 39% at nutritional risk 42% at nutritional risk 62% live alone 69% lived alone State Cost - $359 State Cost - $2,369 Local Cost - $119 Local Cost - $789 42% at nutritional risk 59% lived alone $6.49 per meal 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

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

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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.

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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

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EBI partner with large MCO to implement fall prevention

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 7

th grade students to teach and experience what its like to get older – physical impairments

Many, many more…….

Questions?