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Monday, November 17, 2014

Home and Community Based Services: A Broader View

Navigating the myriad of resources available to older adults in need of special services can be daunting. This article covers them in detail.

Those who are new to the aging industry often find themselves confused by the world they have entered. Even experienced service providers have difficulty understanding how to weed through the labyrinth of the “continuum of care.” As a professional advisor, you know your clients wish to remain active, healthy, and independent but are unsure how to find resources to assist them with that goal. 

To make things more complicated, older adults have different needs based upon their stage of life. You may be working with older seniors (not boomers) who deal with issues such as: Should I still be living in my current home? If not, where should I be living? Am I safe in my environment? Should I be driving? How do I get to the doctor? Will I have enough money to survive through my final years? These same questions and others may be initiated from the family member or caregiver.

Boomers may be in a different phase of life, but still be unsure where to go to get help. They may be unemployed when it is difficult to find a job and are not old enough to qualify for Medicare.  Sometimes they find themselves members of the “sandwich generation” who are still supporting children while taking care of their older parents. Perhaps they are looking for a way of reinventing themselves by finding opportunities that allow them to apply their skills and talents in a new  environment. How do they deal with these challenges in meaningful ways? 

With the growing numbers of older adults, it is important for advisors to be aware of the resources available in their communities to help these individuals. These services are defined by the public sector as Home and Community-Based Services (HCBS). However, it is important that service providers understand there are many public and private resources available for their clients. To better serve older adults, providers should consider realigning their existing paradigms of what services are available and developing a broader knowledge of home and community-based services.

The Common Perception of Home and Services

HCBS allow people of all ages who have limitations to remain independent in the least restricted settings possible, and to be connected with their communities. Both of these defined goals are critical to an older person’s quality of life. They need to be independent and they need to feel connected to the community in order to have balance and meaning. 

Some people identify HCBS as publicly supported services serving the low-income, older adult population. Although there may be some services under publicly supported HCBS that are paid for with private-funding, the majority of publicly-funded services are paid for through publicly funded sources. These services are available to all older adults, but typically are provided based on the greatest need. 

The National Association of States United for Aging and Disabilities (NASUAD) defines HCBS as “services or other supports to help people with disabilities of all ages to live in the community.” Each state has a mix of public programs and funding sources. The Medicaid program pays for many of these public services in all states. There are also other federal, state, and local dollars that fund home and community-based services, including the Social Services Block Grant (SSBG), Older Americans Act (OAA), Education and Rehabilitation funds, and State General Funds (NASUAD Clearinghouse). 

In 1965, Congress passed three important pieces of legislation that, over time, would shape and define the nation’s approach to its growing older population: Medicare, Medicaid and the Older Americans Act (OAA) (Niles-Yokum and Wagner 2011).

Over the last forty-eight years, the OAA has been largely responsible for the development of the public aging network and services. These services are administered and overseen by fifty-six State Units on Aging and 629 Area Agencies on Aging (AAAs) across the nation. The Congressional authors viewed the role of AAAs to include identifying the priority service needs of the age sixty-plus population in their communities, developing plans of action to address those needs, and serving as visible advocates with and on behalf of older Americans. 

Each AAA has evolved in the context of a unique social, economic, and political environment. Further, AAAs are flexible and take advantage of emerging opportunities and “climates for success” to mount new initiatives or expand services that support the health and independence of those sixty and older, especially the most frail and vulnerable, and their caregivers. Consequently, no two AAAs are alike. Yet, the OAA provides the umbrella uniting them in a common mission with a common set of roles and responsibilities (National Association of Area Agencies on Aging 2011). Existing programs and services provided through the aging network have been categorized as follows (Niles-Yokum and Wagner 2011):
  • Home-based and community-based long-term care
  • Elder rights protection 
  • Health, prevention, and wellness 
  • Special projects
AAAs either provide these services directly or contract with providers to provide the services identified in Figure 1. AAAs often serve as the pass-through for Older Americans Act funds, contracting with local service providers to provide the actual services for older adults. Many of these services are provided through the network of senior centers across the country. The National Institute of Senior Centers states there are over eleven thousand senior centers nationally. These entities are either nonprofits or run through local governments, providing services that include meal programs, transportation to and from the centers, case management and assistance programs, as well as social and fitness activities.

The Broader Picture of HCBS

It is clear that the publicly provided HCBS are an important resource to assist older adults. However, a relatively small proportion of the older population receives services directly funded by the Older Americans Act (O’Shaughnessy 2011). Most older adults receive care from family, friends, public and/or private agencies. These existing networks provide services for older individuals in most communities around the country. Service providers, working in what is called the “continuum of care,” meet many people’s needs (Tenenbaum 2010).

In addition to publicly funded home and community-based services, many are paid for with private monies and service fees. Demand for services in the private sector have grown annually an average of 5.1 percent from 2009-2014 resulting in an industry revenue total of $14 billion (IBISWorld 2014). This trend supports the growth of the private service sector including services such as adult day care, non-medical home care or homemaker services, social activities, group support and companionship services. The U.S. Bureau of Labor Statistics states jobs for home-care workers (home-health aides and personal-care aides) are projected to increase 70 percent—1.3 million from 2010-2020, much faster than average. In fact, these are two of the projected fastest growing occupations in the United States (currently at 1.9 million nationally). 

Privately-funded services are typically found in senior resource directories under varying categories, but some can list up to fifty categories of senior resources. For example:
  • Living Arrangements: adult day care, assisted living facilities, nursing homes, hospice care, independent living, continuing care retirement communities, active adult living, housing referral service, moving and relocation services.
  • Estate Services: elder law, estate planners, financial planners, funeral services, reverse mortgages, insurance providers.
  • Health, Prevention and Wellness: hospitals, physicians, non-medical home care, medical home health, geriatric care management, companion services, health clubs, fitness programs, chiropractors, personal trainers, nutritionists, dietitians, physiotherapists, occupational therapists.
  • Medical Supplies: assistive devices, health products, foods & supplements, medical equipment.
  • Home Maintenance and Delivery: home maintenance, home modification, house cleaning, grocery delivery, meal delivery.
  • Transportation: medical and non-medical transport services.
  • Employment: jobs for seniors, civic organizations, training organizations.
  • Volunteering: senior volunteering programs, community volunteering organizations.
  • Education: aging advocacy, education for seniors, lifelong learning programs.
  • Information and Resource Referrals: resource centers, care managers, and others.
Why Understanding the Broader Picture is Important: Silos of HCBS Services

Though many services may be available, piecemeal development of HCBS over a long period of time largely explains why the services do not always work in coordination with each other. Additionally, programming and funding have emerged from an array of congressional appropriations, state programs, nonprofit grants, private enterprise, and community initiatives. The service providers’ inspirations and intentions, background, mission, and purpose are equallyvaried. Neither funding nor providers are developed for comprehensive care on an at-home basis (Tenenbaum 2010).

Public funding for home and community-based care comes from different departments, agencies, and levels of government, sometimes described as “silos” because operationally they are self-contained and vertical. Funding and services from non-profits and foundations are organized around missions, goals, and funding priorities. Private-pay providers organize their services around a skill set or resources they can manage well. This is fair because all of these provider organizations are meeting their purposes, charters, and goals to provide a program or service. However, none are mandated to consider or provide the whole continuum to match client needs, which is the optimal situation for a service consumer (Tenenbaum 2010). As a result, people are often unaware of available resources to help them address their needs.

Resources to Find HCBS

As an advisor to older adults, connecting your clients with resources to help them remain independent can be confusing. Questions you may need to ask yourself include: What specific services does my client need to remain independent? Does my client qualify for publicly-supported programs and services? If so, is there a waiting list for these services? How accessible are existing aging resources for my client? How affordable are privately-developed services for my client? You may not feel comfortable addressing these issues with your clients. If so, consider referring them to a geriatric care manager or a local AAA. Many AAAs have Aging and Disability Resource Centers (ADRC), which can help them find existing services.

Aging and Disability Resource Centers

Information and referral resources are available from multiple public and private organizations. As a result of the 2006 amendment called “Choices for Independence,” Aging and Disability Resource Centers (ADRCs) are growing across the nation. Tied to Area Agencies on Aging, ADRCs look to better coordinate services and assist consumers across the age spectrum to access them.

The ADRC program, a collaborative effort of the Administration for Community Living (ACL), formerly Administration on Aging or AoA, the Centers for Medicare and Medicaid Services (CMS), and now the Veterans Health Administration (VHA), supports state efforts to streamline access to long-term services and support (LTSS) options for older adults and those with disabilities. ADRCs simplify access to LTSS, and are a key component to long-term care systems reform (ACL 2013). ADRCs are known to be “No Wrong Door (NWD)” or “Single Entry Point (SEP)“and are designed to serve as highly visible and trusted places available in every community across the country where people of all ages, incomes, and disabilities go to get information and one-on-one counseling on the full range of LTSS options. Nationally, ADRC programs have taken important steps towards meeting AoA (now ACL) and CMS’s vision by:
  • Creating a person-centered, community-based environment that promotes independence and dignity for all.
  • Providing easy access to information and one-on-one counseling to assist consumers in exploring a full range of long-term support options.
  • Providing resources and services that support the needs of family caregivers.
As a CSA, you should locate one of the 629 national Area Agencies on Aging in your region to ensure you are connecting your clients with available aging resources and services through the ADRC program. In addition, you should educate those connected with AAAs and ADRCs about your services. 

The HCBS resource chart lists home and community-based resources that will help you connect your clients and their family members with solutions. •CSA

Erika T. Walker, MBA, MSeD, CSA, is owner and CEO of SAGE WAVE Consulting, LLC, in Gainesville, Georgia. She conducts strategic planning with businesses and
communities across the country, helping them to prepare for the growing aging population. With over twenty-five years of experience, she has served as Director of the SAGE Institute and Director of Geriatrics at Greenville Hospital System. She may be contacted at 678-971-4778,, or at

Home and Community Based Services: A Broader View was recently published in the Summer 2014 edition of the CSA Journal.

Blog posting provided by Society of Certified Senior Advisors