SERVICES FOR THE ELDERLY IN
FACING THE FUTURE WITH A GREATLY EXPANDED SENIOR POPULATION
The anticipated exponential growth of Montgomery County's elderly population with its attendant social and financial costs has stakeholders and far sighted county officials worried. Census data in 2000 showed that the over 65 population in Montgomery County had grown by 26.7% during the previous decade--at a faster rate than any other age group. As "baby boomers" reach retirement age, the increases in the county's senior population will accelerate even more rapidly. (The 2000 data also showed growing cultural diversity among our elderly, a trend that is expected to continue.)
As the elderly population grows, the strains on public financial resources increase. The increasing cost of long-term care in nursing homes alone is staggering, especially since 60-70% of nursing home residents' care is publicly funded through the federal/state Medicaid program. The Secretary of the Maryland Department of Health and Mental Hygiene (DHMH), Nelson J. Sabatini, has said that the state cannot financially sustain the Medicaid program as it is currently constituted. "In Maryland," he said," the Medicaid bill is between 4.5 billion and 4.7 billion a year and goes up more than 12 percent each year--with nearly one third going to long-term care."
Montgomery County's Department of Health and Human Services (DHHS) Chief of Aging and Disability Services, Jay Kenney, sums up the needs of the county's seniors by saying, "They range from opportunities for civic engagement, life long learning and meaningful volunteer work, to affordable assisted living, and more single level housing."
He adds, "As older adults develop functional disabilities, their needs expand to include: affordable assistance with personal care and household chores, access to nutritious meals, the prevention of social isolation, home modification, transportation that will enable continued participation in social activities, caregiver support such as respite care and adult day services, protection from abuse and financial exploitation, and quality assurance in nursing homes and assisted living facilities."
Considering the serious problems of an aging population and the high cost of resolving them, how can the county best prepare to assist its seniors to live active, productive and -- where possible -- independent old age? The League's Aging and Social Policy, Housing, and Health Committees have looked at the issues and approaches presently in place and have attempted to ascertain what works -- and what remains to be done.
ORGANIZATION OF GOVERNMENT SERVICES
Since the department reorganization in 1996, all services and programs for seniors in Montgomery County are provided through the DHHS Aging and Disability Services. This integrated model has resulted in improved coordination and more seamless services to the elderly.
The Older Americans Act
Most of the programs for the elderly in Montgomery County are authorized by the Older Americans Act of 1965, re-authorized every two years, the latest in 2002. The act mandated that each state establish local planning and service areas, to be called Area Agencies on Aging (AAA). The area plan must ensure that preference will be given to providing services to the elderly in the greatest economic and social need, particularly low-income, minority and those in rural areas.
Area Agency on Aging
The AAA carries out its mission in several ways. It provides services directly to seniors, funds provision of services through contracts, provides technical assistance and leadership to organizations interested in seniors and provides advocacy for them. The AAA also administers the National Caregiver Support Program.
Commission on Aging
Most of the advocacy activities of the AAA are accomplished by the Commission on Aging. The commission is a 25-member volunteer, diversified group whose members are appointed by the County Executive and approved by the County Council to advise the county government on policies and programs that affect the county's 131,000 seniors aged 60 and over. The commission identifies programs that are vital to frail and/or low-income seniors to remain independent in the community and advocates for funding increases in the county budget for these programs.
Montgomery County Senior Vital Living Initiative, which operates under the Department of Health and Human Services, promotes policies and programs that encourage civic involvement, social engagement and successful aging in place. Believing that county and community institutions are the key to transforming our aging population into the civic resource they have the potential to become, it advocates for senior needs such as housing, transportation and having a role in county government.
GROWS (Grass Roots Organization for the Well-being of Seniors, Inc), an all volunteer not-for-profit membership organization of service providers, agencies, businesses, organizations and individuals especially concerned about the well-being of the frail elderly in the county serves as educator, advocate and catalyst on behalf of older adults and caring families.
HEALTH CARE COSTS AND WHO PAYS
For most seniors health is a key to happy, productive aging. However, the challenge of meeting the escalating costs of health care is daunting to many of the elderly and to the providers and public agencies that serve them.
Virtually every American citizen has a right to Medicare, the country's most comprehensive federal program, at the age of 65. This health insurance plan helps cover medically necessary inpatient care in a hospital, skilled nursing facility (after a related 3 day hospital stay) and part time or intermittent skilled nursing care at home. Inpatient psychiatric treatment is limited to 190 days in a lifetime. Hospice care is provided for people with a terminal illness and includes drugs for symptom control and pain relief. Medicare helps cover doctors' services and outpatient hospital care. While there is usually no premium for hospital care (Part A), a monthly premium is charged for Part B, doctors’ services ($58.70/month in 2003). Many important preventive services are now included in Part B.
Coverage is provided through the original Medicare plan, which is a fee-for-service plan, or through Medicare + Choice plans (to be called Medicare Advantage under the new law), which include Medicare Managed Care plans (HMOs) and Medicare Preferred Provider plans (PPOs). Kaiser is the only Medicare Managed Care plan in the area. All other HMOs dropped seniors from their programs over two years ago. Physicians are increasingly refusing Medicare patients because of the low reimbursement rates.
The major drawback to the Medicare plan to date has been the lack of prescription drug coverage. The Medicare Modernization Act of 2003 will begin offering some pharmacy benefits in June 2004. Under the law, drug discount cards will be available to help defray the cost of prescription drugs from 10-25%. Beginning in 2006, prescription drug benefits will be open to all Medicare recipients. There has been major concern both with the complexity of the program and the funding. Sen. Edward Kennedy (D-Mass) quoted in the Washington Post, April 9, 2004, stated "The single most irresponsible provision in the Medicare bill is the prohibition that prevents Medicare from negotiating lower-priced drugs." Some predict that Congress will revisit this law before it goes into effect in 2006.
The changes will provide the most help to individuals with low incomes and limited assets. Those with incomes below a certain limit won't have to pay the premiums or the deductibles for prescription drugs and will pay a small co-payment for each prescription. Income limits will be set in 2005.
Medicaid, also known as Medical Assistance, is a state and federally funded health insurance program that pays health care providers to care for indigent and "medically needy" persons. Those services funded by Medicaid include acute and primary care, long-term and chronic care and hospice care. Due to the high costs of health care and the growing rate of inflation, Medicaid costs often outstrip the budget. It is one of the costliest programs in each year's state budget. To qualify for services under Medicaid one must meet specific financial and medical criteria. For long-term care these criteria differ depending on whether care is provided in an institutional or community setting. In each case the recipient becomes indigent because of the burden of paying medical bills.
The Medicaid Waiver program, which was introduced in 2001, provides assisted living facility services, in-home personal care and other support services to maintain an elderly person in a community setting. Individuals are able to qualify for this program at a higher income level than those receiving Medicaid services in a nursing home. Increasingly, long-term care is being provided in community settings rather than institutional ones. This increase is, in part, the result of a Supreme Court decision, Olmstead v L.C., which requires states, under certain circumstances, to place qualified individuals in community settings rather than institutions. Secretary Sabatini is developing a program, New Vision for Long-term Care, with the following objectives:
The county has been affected by FY04 reductions in funding of state programs serving seniors as follows:
Long-term Care Insurance
Faced with the possibility of staggering costs of long-term care, many seniors and middle-aged Americans are turning to long-term care insurance as a hedge against future financial needs. (While charges vary, it is estimated that average assisted living costs are approximately $4,000 a month and nursing home costs considerably higher.) Premiums for long-term coverage vary depending on the purchaser's age.
NURSING HOMES AND ASSISTED LIVING
Montgomery County DHHS monitors the care of elderly and disabled persons in a variety of settings. They include 35 nursing homes with approximately 5,000 beds; 30 large assisted living facilities with 1,546 units -- 220 of which are subsidized; and approximately 100 small assisted living group homes caring for 3-16 residents each. Medicaid covers the cost for 60 to 70% of people in nursing homes, while the costs of assisted living are usually covered by long-term care insurance or private pay.
Nursing Homes and Large Assisted Living Facilities
Nursing homes are expected to meet some 500 regulations for licensure. Nine registered nurses working in Public Health Services of the DHHS conduct periodic unscheduled surveys of nursing homes and the large assisted living facilities, including those in "life care communities," such as Riderwood and Asbury. They make recommendations for improvement, and report results of nursing home inspections to the federal, state and county governments. Reports on surveys of assisted living facilities go to state and county governments, since no federal regulations apply. If nurse inspectors identify deficiencies, a plan of correction is due within ten days. The nurses also conduct complaint investigations and are in contact with the nursing home ombudsman, who visits homes on a regular basis.
Long-term Care Ombudsmen visit nursing homes and assisted living residences on a regular basis to identify, investigate and resolve problems; advocate for clients; and encourage self-advocacy. The county currently has 6.5 paid ombudsmen positions, and 70 volunteers, whom they have trained for this work. Volunteers spend approximately four hours per week in each nursing home. For smaller 5-16 bed group homes, volunteers visit once a month. Senior Care Advocates, a private contractor, manages the ombudsman program in all assisted living facilities.
In general, leadership, and staffing ratios (the numbers of patients for whom a care-giver is responsible) are the keys to quality of care in these facilities. Staff training is another important factor. Medicare requires that there be an RN on staff in nursing homes where skilled nursing care is provided. Nursing assistants and certified medicine aides, however, provide the bulk of the care. Educational requirements for staff are minimal. For example, a nursing home administrator must be a high school graduate, complete 100 hours of an administrative course, spend one year in an internship and pass two tests. A certified nursing assistant must have 75 hours of training. (In contrast, to be licensed, a manicurist must have 350 hours; a hair stylist, 1500.)
Small Assisted Living Group Homes
There are approximately 100 small assisted living group homes caring for 3 to 16 residents each. Low-income elderly can access state and county subsidy funds for placement in these. Some residents are on Medicaid Waiver. Qualifications to open a small group home are also minimal. The person must be a high school graduate with no criminal record. Aides receive a 60-hour course on administration of medications. An RN, hired by the group home, visits every 45 days to review records, assess changes in status of patients or changes in medications
Some improvements in standards are under way. The Maryland General Assembly, in the 2004 session, passed a bill requiring 80 hours of training for managers of large (17+) assisted living managers. The DHHS will develop training programs. The Maryland DHMH is also developing training requirements and quality standards for small assisted living facilities. Its report is due by January '05.
Currently the county does not have a "report card" for nursing home or assisted living deficiencies, but the information on nursing homes is available at the federal web site,
AGING IN PLACE AND HOUSING OPTIONS
While most of us are living longer and healthier lives, the problems associated with the rapid growth of our county's elderly population and its costs have caused planners to look for ways to help seniors to live independently in the community. Whether it is in their own homes or apartments, or in other independent living arrangements within the community, there is strong support for "aging in place." A recent AARP survey reported that 82% of respondents preferred to be cared for at home. It is understood that both governmental and private organizations will attempt to provide services that support the vital independent living for the elderly. But first they need "a place." Modifying one's home may be the answer, for example installing grab bars, a ramp, or first floor bathroom with shower are a few possibilities. What are other housing options for seniors in Montgomery County who want to age in place?
Active Adult Communities:
Age restricted communities with a variety of housing types for vigorous, active adults offer recreational activities such as golf, security, low maintenance and amenities. Little or no health care is provided to residents.
Independent Living Communities:
Independent housing, usually full apartments, is designed for healthy older adults who can live independently. Such housing offers a variety of services to residents. Most county-owned low-income housing for seniors fits into this category. Many offer nutritional programs to residents and neighboring seniors. Market- priced independent living units offer more services and amenities.
Continuing Care Retirement Communities (CCRC) and Life Care Communities (LCC):
CCRCs offer more than one level of care so that residents will be able to move freely from one level to another. Most are expensive and require a large up-front payment and negotiation of a contract. While necessary level changes are facilitated, they are not guaranteed. Residents of LCCs are guaranteed the ability to move from one level to another, often with little change in financial arrangements. The up-front payment is high and often not refundable for life care facilities.
Senior housing is spread throughout the developed areas of the county and is frequently located in older, mature communities, such as Rockville. Many county master plans already address the need for senior housing.
While Montgomery County appears to have more than enough long-term care facilities at the present time, affordability is a problem. With the anticipated growth of the county's senior population, the county will need approximately 1,500 additional age-restricted units by 2010. About 14% of senior households have extremely low incomes-30% of the median or less. Another 24% have low-incomes -- 30 to 60% of the median, requiring assistance to afford senior housing. The county needs an average of 200 to 250 new housing units each year for the next ten years to accommodate both growth and the needs of underserved segments of the population.
Community Resources That Encourage "Aging In Place"
The DHHS, through its Aging and Disability Services, administers a variety of programs and services that are supported by county, state and federal dollars. They include:
Health is a major focus. Registered nurses provide blood pressure screenings several times a month. Cholesterol screenings and counseling for persons with heart disease (or at risk) are conducted less frequently. Screening for other less common disorders are done at some centers. Lectures on health subjects are featured. Flu and pneumonia shots are administered in the fall. Exercise programs are popular, and a physical therapist does balance and fall assessments in some classes. Holiday Park and Rockville have well equipped fitness centers. An audiologist provides hearing screening periodically.
All centers feature classes for all levels in exercise, computer skills, arts and crafts, and more. Regular offerings include games, entertainment, lectures and day trips. Senior information and assistance provides health insurance information and helps seniors connect with appropriate county services. Legal and notary services are available periodically. Grocery shopping trips by bus from centers to super markets have been an essential service for many frail seniors.
The Montgomery County Recreation Department manages four senior centers: Holiday Park (Wheaton), Margaret Schweinhaut (Silver Spring), Damascus, Long Branch (Silver Spring.) The City of Gaithersburg operates its senior center with some funding from the Department of Recreation. The City of Rockville manages and funds its center. There, membership is required, and Rockville residents are given priority. Free transportation for Rockville residents is provided. A Master's prepared health educator serves as wellness coordinator, and is at the center most weekdays.
Aging and Disability Services: Two programs seem especially valuable if the goal is to keep the frail elderly in their homes. In Home Aide Services were provided to 544, seniors each of whom received an average of seven hours a week of service. Chore Services provided 50 seniors assistance with light housekeeping and other chores.
In addition to the above county subsidized and managed programs, a number of private, non-profit organizations provide valuable services that help or inspire seniors to remain independent. Some of those include:
Aging is accompanied by many changes, such as loss of family and friends to death, changes in professional identity, serious illness and changes in functional capacity. Although grief and bereavement often accompany loss, depression is not a normal part of aging and needs to be recognized and treated. It is important to note that older adults have the highest suicide rate of all populations, with older white males being at the highest risk. Social isolation is a major contributing factor, often leading to substance abuse and alcoholism in the elderly. In A Report on the Needs of Low Income Seniors, Montgomery County, Maryland 2002, it was noted that as income, social interaction and physical health declined, there was an associated increase in mental health impairment.
Several county programs are designed to address mental health problems in seniors. DHHS' Behavioral Health and Crisis Services provide evaluation, treatment, outreach counseling, provider training, caretaker support and referral services. The Mental Health Association through its Friendly Visitor Program matches volunteers with isolated or home bound seniors. The Senior Outreach Program (SORT) is a partnership between DHHS and Affiliated Sante Group. The program provides short term psychotherapeutic services to English and Spanish speaking seniors as well as peer counseling to homebound elders.
Alzheimer's disease: Although Alzheimer's disease (AD) was considered a rarity in the past, today it is the most common cause of dementia. In the year 2000 it was estimated that there were 14,000 residents in Montgomery County with AD. By 2010 the number is projected to increase to 20,000 and by 2030 a 150% increase is expected, bringing the total to 36,000. The disease begins gradually and the rapidity of progression varies with the individual. Confusion, personality and behavior changes and impaired judgment all occur. Today AD affects 10% of people over age 65 and nearly 50% of those over 85. While some promising treatments are being investigated, the search for a cause has eluded scientists. Age and family history are the most common factors but no one, it seems, is guaranteed immunity.
Caring for people with AD is exhausting and stressful. Currently 70% of patients are cared for at home by relatives at great personal and financial sacrifice. Eventually, many require institutional care. Neither in-home aides nor adult day care services are covered by Medicare or private insurance. Individuals with AD are not included in the Medicaid Waiver program because they often do not meet the strict medical criteria and because of cognitive impairment. Most transportation services to and from adult day care do not provide the direct hand-off from one responsible person to another. Without this guarantee, these vulnerable patients are at high risk of falling, wandering or other personal injury. Respite care, it has been said, is the caregiver’s lifeline.
PROGRAMS THAT SUPPORT FAMILIES
Other programs are available to support families who elect to keep their frail elderly at home.
National Family Caregiver Support Program (NFCSP)
The NFCSP, administered by the federal Department of Health and Human Services, Administration on Aging, was officially launched in February 2001 with the release of $125 million in funds to states to begin its implementation.
The program here is centered at Holiday Park Senior Center. Eligible family caregivers have access to information about available services. Those include: individual counseling, organization of support groups and training; respite care; and supplemental services on a limited basis, e.g. home modifications, and assistive technologies such as an emergency response system, equipment/supplies and transportation.
Adult Day Care Programs
Adult day center programs provide social activities and care for adults needing supervision. They are important for allowing families to keep older family members living at home while promoting activity and social stimulation. These centers provide an invaluable resource for caregiver families who are employed during the day but wish to provide recreation, exercise and healthful meals to their elderly frail, impaired or confused family member in a safe, enjoyable and supervised setting.
Montgomery County has 13 adult day care centers. Licensed centers may provide rehabilitation, nursing care and help with toileting and personal care. All provide nutritious meals and snacks and can accommodate to special dietary needs. Most are able to arrange transportation to and from the center.
The daily cost averages about $65 a day, including meals, and transportation is usually extra. Some seniors are subsidized through the Medicaid Waiver, and 20 are currently partly subsidized by the county from state funds. There are 70 seniors on the waiting list for county subsidy.
Respite care is temporary care provided to a frail, ill or disabled client to relieve the caregiver or caregiver family, for a defined period. Services may include in-home care by nursing, aide or companion personnel; temporary day care placement for one or more days a week; or out-of-home temporary placement in a group home, an assisted facility or nursing home. The option chosen is based on the needs of the client and the caregiver family.
Respite Services of Montgomery County is a joint program of Montgomery County Department of Health and Human Services and the Association for Retarded Citizens (ARC), a non-profit organization with a mission to support individuals of all ages with functional disabilities and their families. The ARC arranges for respite care for individuals of all ages including the elderly. Individuals receiving respite care services must either have a physical, mental or cognitive disability.
The program is flexible to meet the specific needs of clients and family caregivers. The cost of respite care is $7.50 an hour/$75 a respite day, or $25 an hour/$250 a respite day for a registered nurse. Income-eligible families may apply for a subsidy for up to 164 hours of care a year.
For most seniors, giving up driving a car is a huge adjustment. So it is not surprising that most surveys of the needs of the county's elderly place transportation near the top. The county has a good system of bus transportation, but learning the routes and accessing the buses are sometimes problematic for seniors. Taxis are not always reliable.
In addition to the bus transportation provided to seniors by the DHHS through its senior programs, the Department of Transportation and Public Works operates a program called Call 'N Ride. This allows low-income persons to buy coupons for taxi rides at discount. Seniors who are 67 and older and have incomes of less than $20,000 for a couple may purchase two $50 books of coupons per month for $5.00 each. They can use these to go anywhere. There are about 4,000 persons who have been approved for eligibility and about 3,800 coupon books are sold each month. Metro Access provides van transportation service for disabled persons, a service mandated by the Americans with Disabilities Act of 1990. They must be certified by Metro as unable to use public transportation to get to a station. Certified users are eligible to use the service for a very nominal fee, and personal care attendants ride free. Advance reservations are required.
In spite of the many services currently provided to the elderly in Montgomery County, the 2002 study on the "Needs of Low-Income Seniors" age 75+ conducted by the University of Maryland for Aging and Disability Services found that 62% of the elderly in the study had significant unmet needs in at least one area such as health, mental health and activities of daily living. The study points out that low-income elderly are often a neglected population and, in a community composed of many highly educated and economically comfortable older adults such as Montgomery County, the elderly with serious problems and few resources may become invisible. Jay Kenney of DHHS has stated, “It is clear that the needs of the elderly far exceed the scope of the Department of Health and Human Services, Aging and Disability Services. Their needs touch every sector of county government, the faith community, private for-profit and not-for-profit agencies and the community in general."
Given the present unmet needs, the long waiting lists and the expanding senior population, the following recommendations are offered to deal with this situation. Montgomery County should:
Interviews with: Meg Campbell-Kotler, Executive Secretary, Commission on Aging; Dr. Jay Kenney, DHHS, Chief of Aging and Disability Services; Phyllis Madachy, Director, Howard County Agency on Aging; Vivian Omagbemi, MC DHHS Long-term Care Ombudsman; Susan Quast, Nurse Manager, DHHS Public Health Services; Rosalie Silverberg, LWVMC; Carolyn Wanner, Mental Health Association.
This Fact Sheet was prepared by Health Committee members : Myrna Bernstein, Pat Dougherty, Eva Feder, Elaine Friedman, Priscilla Kaeser, Dorothy Millon-Ladd, Laura Ryan, Ruth Shevdoff, Ann Ruth Volin, and Mary Jane Zusy, as well as Donna Dahlgren of the Aging/Social Policy Committee and Melpi Jeffries, Housing Committee.