Aging Services Environmental Scan - What System In in Place?

2001 Aging Services Environmental Scan

WHAT SYSTEM IS IN PLACE TO CARE FOR OLDER ADULTS?

People are living longer and needing increasingly complex levels of care as they age. Originally, caring for the aged was primarily a concern of family, neighbors and friends. Today this responsibility is borne by a complex system involving government, private businesses and community based organizations in addition to the original caregivers. As with any large system, the best interests of the individual are at risk of being overlooked.

This chapter of the report considers the formal and informal systems that are in place to help older adults access the services and supports they need as they age. Initially the discussion is about the formal Long Term Care System - the mechanism for financing and providing community based and institutional care across all areas. The discussion focuses on how individuals access care and the changes and trends at the national and state levels that impact access. This is followed by a discussion about the informal long term care system - family and friends that provide the vast majority of care for older adults. Lastly, this chapter covers information about the local investment in care and services for older adults.

THE LONG TERM CARE SYSTEM

The formal system that has developed over the years to address the needs of older adults is commonly known as Long Term Care (LTC) and refers to a range of services including medical, social, personal care and supportive services that are used by individuals who do not have the ability to care for themselves or maintain their households due to some type of chronic condition, such as a physical disability or health problem. It is not possible to discuss here all aspects of the long term care system. Rather, the point is to provide an understanding of the key parts of the system and how it impacts older adults and the community as a whole

Long term care services can help individuals who, without help, may require institutionalization. As discussed, some individuals need only minimal assistance to maintain their independence while others need a wider array and more intense level of care (NAELA, 2000; THHSC, Jan. 1998).

Historically, public dollars have supported institutionalization over community based care. However, in recent years expenditures are shifting to community based support. The current LTC financing system favors acute care over chronic care and historically has focused on the most expensive, and possibly least effective, methods of care. For example, Medicare, the most significant health care protection

Types of LTC assistance:

skilled nursing care

sub-acute care

physical/occupational therapy/rehabilitation

respite for caregivers

adult foster care

home modifications

nursing home care

medical devices

home delivered meals

for older adults, covers bypass surgery (acute) but not care for diseases such as Alzheimer's (chronic). Dependence is supported over independence in that significantly more resources are allocated for institutional care than home care (NAELA, 2000).

In the last 10-15 years, several changes on the national level have occurred that are impacting the long term care system. These changes are having a significant impact on the ability of older adults to maintain independence and age in their own homes.

Changes on the National Level Impacting Long Term Care

Changes in Medicaid Spending. Medicaid, the number one government source for financing LTC, has traditionally been used to pay for institutional care. However, federal policy has changed such that states can apply for Medicaid waivers1 (HCBC waivers) that allow them to use Medicaid funds to pay for alternatives to hospital and nursing home care. Between 1987 and 1997, the percentage of Medicaid funds spent on home care nationally increased from 10.8% to 24% while the proportion of Medicaid funds spent on nursing home and intermediate care declined 15% (Coleman, 1999; NAELA, 2000). While states only spent 22% of Medicaid funds on Home and Community Based Care (HCBC) waiver programs in 1987, by 1997, 60% of funds were spent on these programs (Coleman, 1999).

Rights for the Disabled. In 1997, the Supreme Court ruled in Olmstead vs L.C. that under the Americans with Disabilities Act (ADA) it is discriminatory to place persons with disabilities in institutions without justification. As a result, Texas established the Promoting Independence Advisory Board to oversee the implementation of the Olmstead decision and how Texas would respond to the challenges it presented. The mission of the Board is "to provide guidance to the Health and Human Services Commission in the evaluation and implementation of the system of services and supports for people with disabilities in order to assure that Texans with disabilities have access to alternatives to institutional care when community care is preferable" (THHSC, July 2000).

Balanced Budget Act of 1997. This federal act made significant changes in the Medicaid and Medicare programs. The intent of the BBA, in part, was to stem the rapid growth in cost of these two programs. The complex changes made by the BBA cannot be addressed here, however, it is important to note some consequences of this legislation. First, Medicare managed care service and home health care providers are choosing to opt out of renewing Medicare contracts because the reimbursement rates for services are too low. This year, the primary local Medicare provider in Travis County, Seton Healthcare Network, announced that it would no longer provide Medicare funded managed care or home health services. Additionally, the BBA created additional financial burdens for physicians who accept Medicare/Medicaid assignment. As a result, more physicians are choosing not to accept Medicare/Medicaid patients or limiting the number they serve (Schneider, 1997).

Medicare Home Health Benefit. This warrants special consideration because of the important role it plays in meeting the needs of older adults. Originally, this benefit was intended for short term use for individuals recuperating from acute illness and to provide a less expensive option to institutional care. Legislative changes resulted in a huge increase in usage of the benefit during the 1990's and a huge growth in the number of private home health agencies. For example, the average number of visits per client increased 220% in Texas between 1990 and 1997. Federal changes to the benefit have resulted in a decline in its use and closure of hundreds of home health agencies in Texas (Health Care Financing Administration, August 1999).

1States apply to the federal government for Home and Community Based Care (HCBC) waivers which give states the flexibility to spend Medicaid funds for community based services, not just institutional care.

As our society continues to age, the need for long term care services will continue to rise as the problems associated with aging become more prevalent. Medicaid expenditures for elderly LTC are projected to more than double between 1993 and 2018 due to both the aging of the population and the increase in cost of care (Wiener and Stevenson, 1998).2

Nationally, it is estimated that 60% of all persons will require long-term care sometime in their lives (NAELA, 2000). Some 23% of all people aged 65+ are functionally disabled or currently need LTC (Tennstedt, 1999). It is estimated that in the year 2000 more than 13,000 Travis County residents ages 65 and older have difficulty with some ADL's (Texas Health and Human Services Commission, 1999, Selected Information).

Despite the high level of need, the vast majority of individuals are not adequately prepared to access LTC when they might need it and are confused about the financing of long term care. Most believe that Medicare covers LTC

services but in reality Medicare covers only a small part of LTC costs. Medicare primarily covers home health care related to acute care. (See Appendix E for more detailed information on Medicare and Medicaid).

Medicaid is the number one payer for LTC in the U.S., covering 40% of nursing home and home care expenditures in 1998. The next most common source is personal or family finances, accounting for 26% of nursing home and home care expenditures in 1998 (Feder, et. al., 1999). Another financing option is long term care insurance, but it is estimated that only 6% of individuals in the U.S. have purchased long term care insurance policies in the past (Coleman, 1999; NAELA, 2000).

Most common financing options for individuals needing LTC:

Medicaid - Many individuals must spend down personal financial resources in order to qualify for benefit.

Personal financial resources § Medicare Parts A & B and Medigap Supplemental Insurance

Long term care insurance - Primarily an option for people who have assets they want to protect.

NAELA, 2000

In Texas, the majority of resources for LTC go to residential services such as those provided in nursing homes. As is shown in Figure 22, of the individuals age 60 and older receiving LTC through the State, 299,000 receive community based services at a cost of $551 million while 59,000 receive residential services at a cost of $1.2 billion (THHSC, Dec. 1998). That means that 16.5% of those receiving services are using 68.5% of the resources.

Figure 22.
Long Term Care Resource Allocation in Texas

Source: THHSC, December 1998

Of the approximately $1.8 billion allocated to LTC for individuals age 60 and older, 61% comes from the federal government and the remainder from State general revenue (THHSC, December 1998). Although Texas expends a substantial amount on community based services, the demand for these services is greater than the supply. The federal government has approved Texas to serve more clients through the HCBC waivers but the State has not allocated the resources necessary to serve additional clients (Weiner, et. al., 1998).

Beginning in the 1990's, Texas increased its effort to improve the current delivery and administration of long term care services. Current state efforts include:

Changes at the State Level Impacting Long Term Care

STAR+Plus Pilot Project - Currently operating in Harris County, this Medicaid managed care pilot is designed to integrate delivery of acute and long-term care services covered under Medicaid and Medicare. This project is partially funded by a grant from the Robert Wood Johnson Foundation as part of the Medicare/Medicaid Integration Program (University of Maryland 2000). A status report on this project will be presented to the Legislature in January, 2001. If successful, the program could be expanded to additional service areas or implemented statewide.

HCBC Waiver Consolidation - The State is currently seeking approval from the federal government to start a pilot project that would consolidate 8 HCBC waivers. The goal is to streamline administration of the programs under these waivers which are currently administered by three separate state agencies. This process is also intended to improve service delivery. The state is applying to the federal government to start a consolidation pilot project in 2001.

Integration of LTC Services (SB 374 -76th Legislature) - In 1999 the State Legislature passed SB 374 which seeks the consolidation of all state LTC programs and the administration of these programs under a new agency on aging and disability services. The intent of the legislation is to improve the delivery and administration of services. Additionally, the Health and Human Services Commission, the Department of Human Services and the Texas Department on Aging are directed to assist local communities in developing systems for the delivery of LTC services (Broden and Angel, 1999).

For older adults, the most significant action the state could take is to increase the funds for services provided through HCBC waivers. This would enable more individuals to receive services that support independent living.

Although the federal and state governments play a significant role in making services available to older adults through financing and service systems, they cannot match the contribution of the individuals discussed in the next section.

Table 15.
Findings and Recommendations

FINDINGS	RECOMMENDATIONS
LTC resources are shifting from institutional care to community based care. However, the vast majority of resources still go to institutional care.	Support federal and state efforts to shift resources to community based services. Lobby the state to increase the slots available through HCBC waivers.
Many individuals do not understand the financing of LTC and are not adequately prepared to access the services they need. Sixty percent of all individuals will at some time need LTC services.	Educate older adults and their families about the options for paying LTC services and how to prepare in advance to protect resources and ensure that sufficient resources are available to purchase services.
Changes in federal financing of Medicaid and Medicare services are negatively impacting the ability of individuals to access community based and in home services.	Lobby the federal government to increase the reimbursement levels and allowable expenditures under various programs. Expand and leverage state and local resources to fill the gaps.

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THE ROLE OF CAREGIVERS

Caregivers are the backbone of the long-term care system. Yet, it is only recently that the term "caregivers" has become integral to the discussions about older adults and long-term care. Caregivers assist older adults with all types of needs, including transportation, house cleaning, cooking, personal care, and health care, for example. There are two types of caregivers: formal and informal. Formal caregivers include individuals who are employed by an agency or take on a formal volunteer commitment through an agency. Informal caregivers are family members or other laypersons (friends or neighbors) who provide assistance without pay. The focus will be on informal caregivers, as the contribution they make is not considered in the valuation of the formal LTC system.

Traditionally, as individuals aged and were no longer able to care for themselves, family members, friends and neighbors stepped in to help. Chances were that adult children lived nearby and that the daughter or daughter-in-law began to provide help to the older family member in need. Additionally, neighbors knew each other and people generally had stronger ties to their communities. Overall, a solid network of individuals who could provide help to an aging adult existed within a community. Often, elderly parents moved in with their adult children and their families. This was the expectation supported by our cultural and societal norms and our living situations.

A number of transformations in our way of life have changed the nature of providing care. Family and community ties have weakened. Families are spread across the country or the world, unable to readily provide help. In more families than not, both parents work. There are more single parent families juggling work and child rearing. People are working more hours. Despite these changes, family members are still the people most likely to care for older adults, but with greater consequences.

CHARACTERISTICS OF INFORMAL CAREGIVERS

In 1997, there were an estimated 24 to 27.6 million caregivers in the U.S. (Arno, Levine, & Memmott, 1999). There are roughly over 50,000 informal caregivers in Travis County. Caregivers are spouses, adult children, other relatives, friends, and neighbors. If an individual is married, the spouse is the one most likely providing care followed by adult children, usually daughters.

Individuals from racial and ethnic minority groups report a higher incidence of caregiving than the general population, with Asian-Americans reporting the highest (31.7%), followed by Blacks (29.4%), and Hispanics (26.8%) (Tennstedt, 1999).3

Twenty-five percent of caregivers are between 65 and 75 years of age and another 10% are over 75.

Figure 23.
Caregivers in the United States by Relationship to Older Adult

Source: American Society on Aging, 2000

Twenty percent of caregivers reside with the care recipient, while another 55% live within 20 minutes of the care recipient (Tennstedt, 1999). Twenty (20%) to forty (40%) percent of caregivers are in the "sandwich generation", caring for both children under 18 and disabled older adult(s) (ASA, 2000).

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PATTERNS OF CAREGIVING

Possibly, the most important pattern to recognize is that, in general, caregiving is reactive, not proactive. Caregivers typically do not anticipate and plan for the need to provide care, and as a result, are caught off guard when the need arises. Additionally, they underestimate the time commitment required. Those expecting to spend six months providing care spent one year, and those expecting to spend one to two years spent four or more years providing care (National Alliance for Caregiving, 1999; Tennstedt, 1999).

One person, the primary caregiver, assumes the majority of caregiving. Support may be provided by a secondary caregiver but this tends to be sporadic and less consistent, or offered only when the primary caregiver is unavailable (Tennstedt, 1999).

Overall, the majority of care is provided by informal caregivers with only a minority using any formal care. Research indicates that care provided by families is stable and that the overwhelming majority of caregivers do not voluntarily exit their caregiving roles. Institutional or community based care may be used to replace informal care in the absence or loss of the primary caregiver, but only temporarily. Most families will resume responsibility for the care when possible (Tennstedt, 1999).

Figure 24 shows the number of hours caregivers spend per week providing care. The majority spend less than 8 hours per week, but almost one-quarter spend more than 40 hours per week.

Figure 24.
Distribution of Caregiving Hours Per Week in the U.S. - 1996

Source: Arno, et. al., 1999

Johnson and LoSasso (2000) found that children are more likely to help parents when the parent is in poor health and lacks other social supports, such as a spouse or other adult children. The financial situation of the parent does not appear to impact whether or not children provide assistance. Adult children are more likely to provide care to mothers than they are to fathers.

The type of care provided is correlated to gender. Women are more likely to provide personal care, tend to housekeeping tasks, and prepare meals while men are more likely to provide transportation, attend to home repairs and manage the money (Tennstedt, 1999).

Research shows that the majority of expenditures for both informal and formal care go towards housekeeping, personal care and meals, in that order. This suggests that formal care purchased by caregivers is used to augment the care they provide informally rather than to add more types of support (Tennstedt, 1999).

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COSTS OF CAREGIVING

Nationally, it is estimated that informal caregivers provided 22 to 26 billion hours of caregiving in 1997 with an estimated value of $196 billion. In comparison, national expenditures for formal home care total $32 billion and nursing home care $83 billion. For Texas, it is estimated that 1.79 million informal caregivers provided 1.667

million hours of care valued at $13.6 billion in 1997 (Arno et. al., 1999). Published estimates of the cost of caregiving are not available for Travis County. However, a rough estimate was derived for this assessment. For Travis County, the estimated number of hours of work hours lost due to caregiving is 360,570 with an estimated value of $2,621,342.5

In 1997, informal caregivers in Texas provided 1.7 million hours of care valued at $13.6 billion.

Arno, et .al., 1999

Many caregivers are employed outside the home - between a third and two-thirds. However, caregiving impacts employment with 9% leaving employment because of caregiving demands (ASA, 2000). In fact, research shows that employed caregivers adjust employment to accommodate caregiving rather than the other way around (Tennstedt, 1999).

According to Juggling Act, a study on the caregiving and work dilemma (National Alliance, 1999), 84% of respondents made at least one adjustment to their work schedule to accommodate caregiving. Adjustments include using sick leave or vacation time, decreasing work hours, taking a leave of absence, moving from full to part time work, leaving employment and retiring early. For example, Johnson and LoSasso (2000) found that for men and women between the ages of 53 and 65, 100 hours of assistance to parents in a twelve month period

Informal caregiving costs the United States $11-29 billion annually in lost productivity.

National Alliance, 1999

translated into a reduction in annual labor supply of 460 hours. Additionally, many reported passing up career enhancing opportunities such as training or promotions. Consequently, caregiving impacts earnings. Although no definitive number exists, the Juggling Act study estimated that the average loss in total

wealth over a lifetime was $659,139 which includes lost wages, Social Security and retirement contributions (1999 dollars). Employees are not the only losers in this deal. It is estimated that employers lose $11-29 billion annually in lost productivity (National Alliance, 1999).

Caregiving can also exact a toll on physical and mental health. Research indicates that caring for a disabled older adult can increase stress, depression, and morbidity. A study reported in JAMA in 1999 found that caregivers who provide support to their spouse and report stress from providing care are significantly more likely to die earlier than non-caregivers (Schulz & Beach, 1999).

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CARING FOR CAREGIVERS

In the last couple of decades, it has become apparent that caregivers need support along with the older adults. Because caregivers are such an important resource, it is essential that any plan that addresses the issues facing older adults includes the issues of caregivers.

Public policy has begun to shift in support of caregivers. The most important change in policy is the passage of the Family and Medical Leave Act (FMLA) of 1993. This federal law requires that certain employers provide 12 weeks of unpaid leave for eligible employees to take care of family members with a serious health condition. Most recently, Congress reauthorized the Older Americans Act which included a new program, the National Family Caregiver Support Services Program. The initial authorization is $125 million (Email from Francisco Acosta, November 2000).

Additionally, employees may receive help from employers through employee benefit programs. However, the 1998 Business Work-Life Study found that only 23% of companies with 100 or more employees offer resource and referral for elder care. Nine percent (9%) offer long term care insurance, and only 5% make financial contributions to community based elder care programs (Galinsky & Bond, 1998).

TRENDS AND THE FUTURE OF CAREGIVING

A number of societal trends are impacting the ability of families to provide care for older adult relatives. These issues are important to consider in planning for the future.

Trends Impacting Caregiving

Rise in the number of divorces and remarriages - Increases the complexity and obligation of familial relationships - more parents have responsibilities to more than one set of children. Increases the likelihood that those starting a second family will be caring for both young children and older adults concurrently.

Increase in geographic mobility and long distance caregiving - Relatives are less likely to live close by and may not be familiar with resources in the community where older adult resides. Managing the care of older adult from long distance is much more difficult. May necessitate increased reliance on formal caregiving that, in turn, may increase the personal financial burden.

Decrease in family size - Fewer relatives available to care for older adults. If primary caregiver is unavailable, there are fewer options for a secondary helper to assume responsibilities.

Increase in delayed child bearing - Contributes to the rise in number of sandwich generation caregivers with responsibility for both young children and older adults.

Increase in the number of women in the workforce - As most caregivers are women, this will serve to increase the strain as women try to balance work, family, and caregiving. It also means that more families may have to turn to formal caregiving to meet their needs (ASA, 2000; Johnson, et.al., 2000).

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CURRENT EFFORTS

Respite - The Texas Department of Human Services (TDHS) and the Area Agency on Aging (AAA) of the Capital Area currently offer respite care, allowing caregivers to take a break from caregiving. An exact number of Travis County residents receiving services is not available. However, in 1998, TDHS served 8,800 individuals per month (includes those caring for older adults and disabled individuals in Region 7, a 30 county area, which includes Travis County). In 1999, the AAA served two people.6

Caregiver Support Groups - Four groups serve the Austin/Travis County area, some of which are specifically for individuals caring for those with Alzheimer's.

Other Services - A number of other non-profit agencies provide services that assist caregivers by providing direct client services. Such services include transportation, home delivered meals, home health aides, and homemakers. (See Appendix A for more information.)

Table 15.
Findings and Recommendations

FINDINGS	RECOMMENDATIONS
Many caregivers of older adults are older adults themselves. Caregiving stress for older adults can be life threatening.	Recognize the needs of older adult caregivers. Ensure that sufficient programs are available to provide support and assistance such as in home and respite care.
Caregiving is reactive not proactive and caregivers underestimate the amount of time required and the impact on their lives.	Provide information to potential caregivers about planning for the need to provide care to an older adult. Planning should include recognizing the impact on employment and family life and the need to anticipate necessary adjustments.
Caregiving exacts a high cost on employment resulting in lost work time and wages.	Encourage employers to offer more family friendly benefits including support related to eldercare.
A number of societal trends are impacting the ability of families to provide care for older adults. As the number of older adults increases the need for caregiving will increase accordingly.	Community planning should address the changes in population size and societal trends when developing plans for providing services to ensure that the capacity is available to meet the need.

Best Practices

Several programs around the country are considered "best practices" in providing support to family caregivers.

California: Caregiver Resource Center

New Jersey: Statewide Respite Program

New York: Consumer and Family Support Services

Oregon: Lifespan Respite Care Program

Pennsylvania: Family Caregiver Support Program

These programs all share certain key characteristics that are considered essential to supporting caregivers:

The term caregiver is recognized in state statute

Each program offers a range of service options

The caregiver is the client

Assistance is available to middle and low income families

Programs employ wide eligibility criteria (Feinberg and Pilisuk, 1999)

Caregivers have identified services that are helpful:

Information about and referral to available services

Individual counseling

Support groups

Training to help families with decision making and problem solving related to caregiving (AOA, 2000, Caregiver Support)

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THE ROLE OF THE LOCAL COMMUNITY

The contribution at the local level to care and support for older adults is a critical piece of the system. The funds and services described in this section help fill in the gaps in services that are not covered by other resources.

A comprehensive assessment of the community's investment in services for older adults is not available. Most agencies collect information by type of service provided, not by population served. Also, many times, services for older adults are combined with services for individuals who are disabled. Thus, the information provided here does not provide the complete picture.

Table 16 shows a sample of public and private non-profit investments totaling more than $2.8 million during the 1999-2000 fiscal year (includes both amounts for services provided directly to individuals and those purchased from other service providers). Despite this seemingly large investment, providers must turn away individuals needing services due to a lack of capacity. Many providers have waiting lists for services.

Table 16.
Older Adult Services Investments by Selected Major Investors - 1999 to 2000

Funding Agencies	Annual Expenditures	Percent
City of Austin Direct Services (Parks & Rec Senior Svcs*)	$2,207,763	77%
Austin and Travis County Joint Social Service Contracts**	$128,680	5%
Travis County Direct Services (RSVP)	$284,191	10%
United Way/Capital Area***	$234,000	8%
TOTAL	$2,854,634	100%

*Includes Senior Activity Centers, Transportation Services, Congregate Meals Program, Old Bakery and Emporium, and Employment Program.
**Contracts with Family Eldercare and Services for the Elderly - 12 months. ***Includes Meals on Wheels and Family Eldercare.

These funds purchase a range of services that address the needs of older adults, including respite care, employment assistance, guardianship, transportation, and social activities. This figure does not reflect the millions of dollars worth of volunteer time that is dedicated to programs that serve older adults. In addition, many programs are not specifically designated as "elderly" programs, even though a percentage of the population they serve includes the older adult population. For example, Austin/Travis County MHMR Center does not have programs that specifically target the older adult, although some of their clients are older adults. The figures shown represent programs that are specifically for older adults in Travis County.

Additional investors include State and Federal agencies, as well as local non-profit, faith based, and public/private partnerships. These include, but are not limited to:

Area Agency on Aging of the Capital Area - The Agency on Aging receives funds from the Texas Department on Aging (through Title III of the Older Americans Act), the USDA, and some state General Revenue funds. The total amount that they spend in Travis County is $777,417. This includes funding for transportation, home delivered meals, case management, personal assistance, legal assistance, and benefits counseling, all of which are services provided through contracts with local providers (This does not include rural transportation services provided by CARTS).

Capital Metro -Special Transit Services spent $7,754,000 in FY2000, providing 500,824 trips for elderly and disabled City of Austin residents. Capital Metro also spent approximately $63,892 in 1999 for half-priced transportation passes, and gave away approximately $206,280 in free transportation passes to clients of all ages (distributed through the United Way/Capital Area).

Meals on Wheels and More - Provides a variety of in home services to home bound individuals and older adults including home delivered meals, daily phone calls, rides to medical appointments, grocery shopping assistance and minor home repair. In 2000, approximately $2,087,000 was budgeted for all services.

Family Eldercare - Family Eldercare operates a variety of community-based services and develops partnerships supporting older adults and people with disabilities. In 1999, they spent $2,071,769 on Guardianship, In-Home Care, Aging in Place, Eloise's House, the Summer Fan Drive, Consultation and Referral, Elder Shelter, and Texas Money Management Programs.

Faith based organizations - faith-based organizations also provide assistance to older adults. It is not possible at this time to identify the amount of aid they provide.

Services for the Elderly - Homemakers or home health aides assist in cooking, cleaning, personal care and medication reminders for low-income clients. Services for the Elderly had a total annual budget of $2,013,000 in 1999. Approximately 49% of this total budget is budgeted for the Primary Home Care/Family Care program, which is devoted primarily to serving the elderly population.

Housing Authority of the City of Austin (HACA) - Approximately 15% (388) of HACA Section 8 housing vouchers are used by people age 62 and over. Older adults live in approximately 20% (300) of HACA's family public housing units. Of these 300 units, one-third are in apartment complexes designated for elderly & disabled individuals. HACA's annual budget for Section 8 vouchers is $19,286,920 and $7,997,204 for Public Housing Units.

Again, this is just a sample of the investment being made in Austin and Travis County. As evidenced in the current efforts sections throughout this report, numerous organizations and services exist to support this group. For a comprehensive list of organizations and services, see Appendix A. The Current Efforts Table offers information about community based, governmental and private programs that are serving older adults. One large group of providers not included is faith based organizations. They play a significant role in providing basic needs such as food and clothing to older adults and others in the community.

2 While LTC applies to individuals who are younger than 65, such as those with mental retardation or developmental disabilities, 60% of the individuals using LTC services are aged 65 and older. The vast majority of LTC funds (80%) go to care for individuals with MR/DD (Coleman, 1999). Care for individuals with MR/DD is substantially more expensive than care for non MR/DD elderly.
3 Although numerous resources on caregiving are available, the bulk of the information provided here comes from one source, a report on caregiving by Sharon Tennstedt that was presented at the U.S. Administration on Aging Symposium: Longevity in the New American Century, in March of 1999. Tennstedt's report is an up to date detailed review of the research on caregiving.
4 This estimate is based on the assumption that there were 25.8 million caregivers providing care valued at $8.18/hour. The low range estimate for total value is $115 billion and the high estimate is $288 billion - depending on assumptions about the number of caregivers and the per hour value of care.
5 Please see Appendix D for the calculation of this estimate.
6 The Area Agency for the Agency stated that the low number served is not due to funding or a lack of need, but rather the fact that caregivers are sometime wary of hiring someone, even for a few hours, to care for their loved one. Outreach and education may increase the numbers, as may the recent passing of the Older Americans Act, which contains an initiative on caregiving.

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