As North Carolina’s population ages, an increasing number of elderly individuals will need long-term care. Fortunately, a variety of options are available for older adults, including nursing homes, assisted living, and home- and community-based resources. This issue of the NCMJ also covers topics such as fall prevention, advance care planning, caregiver support, adaptive leadership and person-directed care, and behavioral interventions for dementia.
There’s No Place Like Home
Dorothy in The Wizard of Oz said it best: “There’s no place like home!” However, as people age and slowly become more dependent on others, they may question the idea of remaining in the home where they have lived for many years. Many believe that they have few options for securing the necessary support and services they need to gracefully and safely age in place. As a result, individuals and families often default to institutional settings such as nursing homes or assisted living facilities. Although such facilities are a necessary part of the array of services available for senior citizens and people with disabilities, these facilities may not be the best choice for everyone. In North Carolina, there are many community-based options and organizations that provide a full array of services designed to support individuals who wish to remain in their homes. The rapid growth of the older adult population is increasing the demand for these services.
Home and Community Care Block Grant Programs
In 1965 Congress passed the Older Americans Act (OAA)  as a response to a grave lack of community social services for senior citizens. The law established the Administration on Aging to administer grant programs and to serve as the federal focal point on issues concerning older adults. Today the OAA is the major pipeline for the delivery of social and nutrition services to older adults and their caregivers. An array of services is provided by a national network of 56 state agencies on aging, 629 area agencies on aging, nearly 20,000 service providers, 244 tribal organizations, and 2 Native Hawaiian organizations representing 400 tribes.
Federal dollars originating with the OAA are distributed to each state based on a funding formula. North Carolina rolls these funds into the Home and Community Care Block Grant (HCCBG), which is supported by approximately 34% federal OAA funds, 3% Social Service Block Grant funds, and 52% state funding. A local match (cash or in-kind) of at least 10% is required to secure HCCBG funding. Recent figures show that local matching was 11.5% (written communication from Heather Burkhardt, North Carolina Division of Aging and Adult Services; August 13, 2014). The North Carolina Division of Aging and Adult Services allocates HCCBG funds to all 100 counties in North Carolina based on a weighted funding formula. All 100 counties are a part of the Aging Network and work with Area Agencies on Aging for administrative support, quality assurance, and technical assistance. The Aging Network is a strong, well-structured network that has been in place for over 40 years. This network is made up of 1 state unit on aging, 16 Area Agencies on Aging, and more than 400 funded partners across North Carolina. More information on these agencies is available from the North Carolina Association of Area Agencies on Aging (www.nc4a.org).
There are 18 services available under the HCCBG program, although not all services are available in all areas of the state. These services include congregate nutrition, home-delivered meals (Meals on Wheels), adult day care, adult day health care, care management, skilled home (health) care, housing and home improvement, information and case assistance/options counseling, in-home aides (levels I–IV), senior companions, transportation, group respite, health promotion and disease prevention, health screening, institutional respite care, mental health counseling, senior center operations, and volunteer program development.
Meals on Wheels is perhaps the best known and most broadly available of these services. (A current list of meal providers can be accessed at http://www.ncdhhs.gov/aging/services/hdm.htm.) Many such programs use volunteers to deliver hot meals up to 5 days a week, making the program much more than just a meal. A recent study by Brown University public health researchers estimated that if all of the lower 48 states in the United States were to expand the number of senior citizens receiving meals by just 1%, then 1,722 more Medicaid recipients could avoid living in a nursing home, and most states would experience a net annual savings from the expansion .
Adult day service programs may be one of the best-kept secrets in the array of services included in the HCCBG program. A study by a research team at Penn State University  found that people with Alzheimer disease and other types of dementia showed improvements in behavior, mood, and sleep when they participated in an adult day service program, and their family caregivers experienced decreased daily stress. According to this study, the activities and social interaction provided by adult day service programs are an effective nonpharmacological way of treating people with dementia:
Adult Day Service programs engage people in stimulating and therapeutic activities during the day. The positive benefits of these activities carry over when clients go home. They are more relaxed and sleep better after a day of meaningful activity.
According to the Penn State study, the improvement in behavior and mood achieved by adult day service program is similar to, or greater than, the improvement provided by available medications for persons with dementia, without the adverse effects .
This study also found that being able to send a spouse or parent to an adult day service program reduced family caregivers’ daily stress levels by about 40% . “Adult day services create a win-win situation for everyone involved,” said Elia Femia, a codirector of the research and coauthor of the article. “The person with dementia benefits by participating in engaging activities, while the family caregiver gets a helpful break” . Family caregivers sometimes report that it is difficult to get their relative ready in the morning to go to an adult day service program. However, this study found that morning routines were not, on average, more challenging for caregivers on mornings when their relative went to an adult day service program . A complete list of currently licensed adult day service programs in North Carolina is available on the North Carolina Division of Aging and Adult Services Web site .
Waiting lists. Although the list of services available through the HCCBG program is impressive, flat or decreasing funding has led to growing waiting lists for these services. In addition, due to the increasing cost of providing services, flat funding actually equates to a decrease in the volume of services available. According to a survey of HCCBG providers conducted in April 2013 , about 16,000 senior citizens were on the waiting lists for HCCBG services, 66% of whom were waiting for an in-home aide or home-delivered meals. The third-longest waiting list was for housing/home repair, followed by adult day services, transportation, and congregate nutrition. More than half of providers said that county funds were being reduced or eliminated, and more than one-third of providers said that they had fewer volunteers and that those volunteers were working fewer hours. Of providers that offer information and assistance, 71% reported increased requests for their help, but 46% said they had fewer community resources to which they could refer people. Additionally, 81% of senior centers in the state reported increased demand and attendance . These statistics are the result of dramatically increasing demand during a period of flat or decreasing funding.
Private-payment services. Many providers across North Carolina have waiting lists for most or all of their services that are funded through the HCCBG program. As a result, many are branching out into a new business model and are offering services on a private-payment basis—meaning they charge a fee for services, and this fee is paid by the recipient and/or his or her family. Private-payment rates vary by location and provider. Aging, Disability and Transit Services of Rockingham County has taken this concept a step further through the creation and implementation of their new @Home Assisted Living program. @Home Assisted Living bundles 4 core services—in-home aide, Meals on Wheels, transportation, and adult day care—into various packages designed to meet a wide variety of needs. Seniors can also design their own packages with any of the aforementioned services at whatever level meets their unique needs. Many long-term care insurance policies cover some of these services. To access these private-payment services, families can contact their local senior services agency or visit www.nc4a.org for a complete list of Area Agencies on Aging.
Volunteer services. Many local communities have been able to meet their needs by using teams of dedicated volunteers, although not all communities have volunteer programs. Churches, synagogues, and other community groups can make a real difference by organizing volunteers to extend the reach of HCCBG services. Information about volunteering can be obtained from a local senior services agency or the local Area Agency on Aging. A complete listing of Area Agencies on Aging can be found at http://www.ncdhhs.gov/aging/aaa.htm.
The Community Alternatives Program for Disabled Adults
The Community Alternatives Program for Disabled Adults (CAP/DA) is a Medicaid Home and Community-Based Services Waiver authorized under section 1915(c) of the Social Security Act. (A description of these services can be found in section 440.180 of Title 42 of the Code of Federal Regulations . Federal regulations governing such waivers are in Part 441 Subpart G of Title 42 of the Code of Federal Regulations .) The CAP/DA program waives certain North Carolina Medicaid requirements and furnishes an array of home- and community-based services to adults with disabilities who are 18 years of age or older and are at risk of institutionalization. The services are designed to provide an alternative to institutionalization for beneficiaries in this target population who prefer to remain in their primary private residences. Services provided through the CAP/DA waiver program include adult day health; personal care aide; home accessibility and adaptation; meal preparation and delivery; institutional respite services; noninstitutional respite services; personal emergency response services; specialized medical equipment and supplies; participant goods and services; community transition services; training, education, and consultative services; assistive technology; case management; care advisor (available only to patients in the Community Alternative Program for Choice [CAP/Choice]); personal assistant (CAP/Choice only); and financial management services (CAP/Choice only) .
The Home and Community-Based Services Waiver allows the state to offer home- and community-based services to individuals who meet the following criteria: they require a level of institutional care under the North Carolina State Medicaid Plan; they belong to a target group included in the waiver; they meet applicable Medicaid eligibility criteria; they require more than 1 waiver service, including case management, in order to function in the community; and they are voluntarily choosing to enter the waiver in lieu of receiving institutional care. Eligibility for the CAP/DA waiver is limited to Medicaid beneficiaries who are adults with disabilities (18 years of age or older) who are in the aged, blind, or disabled Medicaid eligibility categories .
As with HCCBG services, there are currently waiting lists for CAP/DA services. In Rockingham County, the waiting list averages around 140 people, and individuals can wait 9–12 months to receive services. As an interim measure, many people apply to receive limited services through the Personal Care Services (PCS) program.
The PCS program, which took effect on January 1, 2013, is a Medicaid State Plan benefit designed to provide personal care services to individuals who reside in one of the following settings: a private living arrangement, a residential facility licensed by the state as an adult care home, a combination home (a nursing home offering any combination of skilled nursing, intermediate care, and adult care home services ), or a group home licensed by the state as a supervised living facility for 2 or more adults whose primary diagnosis is mental illness, developmental disability, or substance abuse dependency .
PCS services are available to individuals who have a medical condition, disability, or cognitive impairment and who meet one of the following criteria: they need limited hands-on assistance with 3 of the 5 qualifying activities of daily living (ADLs); they need extensive assistance with at least 1 ADL and some type of assistance with 1 other ADL; or they need assistance at the full dependence level with at least 1 ADL and some type of assistance with 1 other ADL. The 5 qualifying ADLs are eating, dressing, bathing, toileting, and mobility. PCS program eligibility is determined by an independent assessment conducted by the North Carolina Division of Medical Assistance or its designee, and services are provided in accordance with an individualized plan of care .
Essential Services for Safe Transitions
With an increasing national focus on successfully transitioning patients from hospitals to their homes, community-based services are now more important than ever. Unfortunately, much of the medical community seems to lack awareness and recognition of the value of these services. There are several ongoing demonstration projects in North Carolina looking at ways of encouraging a smooth transition from health care facilities to homes, as well as supporting people so that they can remain at home once they have made this transition.
Services such as those mentioned previously are often essential to ensuring a successful transition. Rockingham County conducted a 15-month pilot project in 2012 and 2013 and found that people were often rehospitalized because of social isolation, hunger, or an inability to understand medication changes. The services discussed in this article are an integral part of the solution, but there is a need for additional funding from all levels—local, state, and federal. The recently approved state budget included a 3% cut to HCCBG funds ($969,549).
Potential conflicts of interest. T.L.C. is an employee of Aging, Disability and Transit Services of Rockingham County.
1. The Older Americans Act of 1965. Pub L No. 89-73, 79 Stat 218.
2. Thomas KS, Mor V. Providing more home-delivered meals is one way to keep older adults with low care needs out of nursing homes. Health Aff (Millwood). 2013;32(10):1796-1802.
3. Zarit SH, Whetzel CA, Kim K, et al. Daily stressors and adult day service use by family caregivers: effects on depressive symptoms, positive mood and dehydroepiandrosterone-sulfate [published online ahead of print February 2, 2014]. Am J Geriatr Psychiatry. doi:10.1016/j.jagp.2014.01.013.
4. Provider Directory by Service. Adult Day Care. North Carolina Division of Aging and Adult Services Web site. http://www.ncdhhs.gov/aging/services/adult_day_care.pdf. Accessed June 19, 2014.
5. North Carolina Department of Health and Human Services (NCDHHS). HCCBG Survey Results—June 2013. Status of Home and Community Block Grant Services for Older Adults. NCDHHS Web site. http://www.ncdhhs.gov/aging/pub/HCCBG-State2013.pdf. Accessed June 20, 2014.
6. 42 CFR §440.180. http://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol4/xml/CFR-2011-title42-vol4-sec440-180.xml. Accessed June 20, 2014.
7. Home and Community-Based Services, Waiver Requirements. 42 CFR Part 41, Subpart G, §441.300-441.310. http://www.law.cornell.edu/cfr/text/42/part-441/subpart-G. Accessed June 20, 2014.
8. North Carolina Division of Medical Assistance, North Carolina Department of Health and Human Services (NCDHHS). CAP/DA. NCDHHS Web site. http://www.ncdhhs.gov/dma/services/capda.htm. Accessed May 19, 2014.
9. North Carolina Division of Medical Assistance. Community Alternatives Program for Disabled Adults and Choice Option (CAP/DA-Choice). Medicaid and Health Choice Clinical Coverage Policy No. 3K-2. Revised March 12, 2012. http://www.ncdhhs.gov/dma/mp/3K2.pdf. Accessed June 20, 2014.
10. NCGS §131E-101. http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/BySection/Chapter_131E/GS_131E-101.pdf. Accessed June 20, 2014.
11. North Carolina Division of Medical Assistance, North Carolina Department of Health and Human Services (NCDHHS). Personal Care Services. NCDHHS Web site. http://www.ncdhhs.gov/dma/pcs/pas.html. Accessed May 19, 2014.
T. Lee Covington, MPA executive director of Aging, Disability and Transit Services of Rockingham County, Reidsville, North Carolina; president, Meals on Wheels Association of North Carolina; immediate past president, North Carolina Association on Aging, Raleigh, North Carolina.
Address correspondence to Mr. T. Lee Covington, PO Box 1915-105, Lawsonville Ave, Reidsville, NC 27323 (email@example.com).