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Department of Health and Human Services
The National Advisory Committee on Rural Health and Human Services
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May 2010 Letter on the Reauthorization of the Older Americans Act

May 10, 2010

Kathy Greenlee
Assistant Secretary
Administration on Aging

U.S. Department of Health & Human Services
One Massachusetts Avenue, NW
Fifth Floor
Washington, D.C. 20001

Dear Assistant Secretary Greenlee,

I have the honor of chairing a Federal Advisory Committee which focuses on rural health and human service issues. The National Advisory Committee on Rural Health and Human Services (NACRHHS) is a citizens' panel of nationally recognized rural experts that provide recommendations on health and human services issues to the Secretary of the Department of Health and Human Services (HHS). I’d like to express my appreciation for the ongoing staff support that the Administration on Aging (AoA) has provided to the Committee.

We understand that you are conducting public listening sessions and soliciting input on the upcoming reauthorization of the Older Americans Act (OAA) and applaud you for your initiative. The reauthorization of the OAA is significant to the Committee as rural areas tend to have higher proportions of elderly citizens than urban areas. It is important to identify rural citizens as a distinct population with unique challenges for the purposes of program planning and funding. Urban models do not always translate successfully to rural areas because of increased distances to health and human services and difficulty accessing transportation. Rural areas tend to have a weaker infrastructure for delivery of services while residents experience geographic isolation and higher rates of poverty and chronic illness. There is also a challenge in providing services to a lower volume of clients which creates higher service unit costs.

The Committee recognizes that general language is in place in consideration of rural residents in the OAA. We support continuation of this language in the reauthorization and encourage a stronger emphasis on serving rural communities when prioritizing those with the greatest social and economic needs, because poverty level is correlated with the degree of rurality of an area.

Over the years, the Committee has examined many services provided for older Americans and urged for better integration of health and human services for the rural elderly. While the Aging and Disability Resource Centers are not authorized through the OAA, they are an especially important resource to rural areas because they provide a single entry point to many of its programs. When considering changes to the OAA, alignment and coordination of programs with ADRCs should be kept in mind.

We would like to share with you some recommendations from the Committee to consider that are specific to particular citations of the current OAA. These recommendations are primarily from our past Reports to the Secretary, which are prepared through a combination of research, field meetings, and site visits to rural communities. We believe that adoption of these recommendations will increase the effectiveness of OAA programs in assisting rural populations.

As the Committee analyzed the OAA, we examined Title IV, Part A, Section 414 for Health Care Service Demonstration Projects in Rural Areas. The Committee supports the reauthorization of this Section 414 and recommends that the eligibility requirements outlined in Section 414(b)(2) be reexamined to be more consistent with the rural definitions used by other programs and to allow for greater participation. The current eligibility location requirements allow grants to be awarded in frontier areas within five States (Alaska, Montana, North Dakota, South Dakota, and Wyoming). The Centers for Medicare and Medicaid and Health Resources and Services Administration's Office of Rural Health Policy have definitions for rural eligibility that could be adopted for this program.

We appreciate your continuing efforts towards collaboration between health and human services delivery through the OAA reauthorization and in upcoming health care reform discussions. Thank you for the opportunity to provide our input and recommendations for the reauthorization.

Sincerely,

David M. Beasley
Chair

Older American Act Reauthorization Recommendations:

Title II, Section 206 (a) – Administration on Aging, Evaluation

The Secretary should require the Administration on Aging, (the Center for Medicare and Medicaid Services and the Health Resources and Services Administration) programs to capture rural-specific data.
The Committee recommends that all survey instruments within HHS be required to collect and evaluate data in a way which identifies rural characteristics. The [National Aging Program Information Systems] NAPIS database, specifically, should begin to capture data on rural caregivers. The Committee is aware that no Department-wide definition of "rural" exists. As long as this situation persists, researchers, program administrators and policy-makers will be unable to truly determine and report the extent of rural need because the key federal organizations do not evaluate programs with a uniform rural geographic standard. The health-related components of HHS are slowly changing their data structures to illuminate urban/rural differences. The Committee would encourage the Secretary to require that all survey instruments within the Department collect, evaluate and report data in a geographically-specific way which identifies rural characteristics….

Support Research that Examines How Rural Seniors Access the Services Provided under the Older Americans Act
The Secretary should support research that examines how rural seniors access key services provided under the Older Americans Act to determine if there are any service gaps particular to rural communities.

Title III, Part E – Grants for State and Community Programs on Aging, National Family Caregiver Support Program

  • The Secretary should authorize a study to determine adequate funding requirements for rural family caregiver services under the [National Family Caregiver Support Program] NFCSP.

The Committee commends the work of the NFCSP and recognizes its success; however, the Committee realizes that the program is in great need of enhanced funding. Since it was authorized, the range and scope of NFCSP services have expanded but program funding, though increased annually, has not kept pace. Gaps in service and variation of availability of caregiver services in rural areas across States remain problematic due to inadequate funding.

The Secretary should expand eligibility for Family Caregiver Support services to include persons 50 and older.
In recognition that the major cohort of caregivers is between the ages of 40 and 70 years, the Committee favors expanding Title III program eligibility for caregiver services to individuals 50 and older.

  • The Secretary should ensure that best practices in rural family caregiving be identified, studied and publicized in a number of areas.

The NFCS programs should specifically identify and promote rural best practices. Rural best practice models for State home-based family caregiver waiver programs should also be widely distributed.…

  • The Secretary should encourage timely assessment of rural caregiver needs as part of the NFCS program.

“Caregiver assessment was identified in State of the States in Family Caregiver Support as one of the top five needed technical assistance and training areas. Screening of caregivers should be done in the primary care setting as it has been shown that early assessment of caregivers needs helps prevent institutionalization of the care receiver upon crisis.”

  • The Secretary should establish a research grant program to study the rural application and impact of the five required NFCSP service areas.

The Committee supports the expansion of the Family Caregiver Support Act for many reasons, including the proven cost-effectiveness of caring for sick or disabled family members at home, as opposed to institutional facilities. The Committee encourages the establishment of three-year research grants to learn more about the rural application of the five service areas.

Title IV, Part A – Activities for Health Independence, and Longevity, Grant Programs

  • The Secretary should develop data tracking systems for the health and human services workforce.

Workforce data should be periodically collected and analyzed so that rural areas can identify their current and projected workforce needs. The workforce data and analysis should be disseminated in a timely manner to employers, Workforce Development Boards, training centers, and educational institutions, so that they may better predict workforce oversupplies and shortages. Based on this data, the Secretary should target resources and develop training programs for appropriate health and human services professions in “high-need” geographic areas.

  • The Secretary should continue to work to eliminate the persistent health and human services workforce shortage in rural areas.

The need for more providers and the limited access to services in rural areas were cited as two of the top five needs listed in State of the States in Family Caregiver Support.

  • The Secretary should [continue efforts to] develop innovative approaches to providing transportation to rural elderly.

The Secretary should continue efforts to develop a demonstration project through Title IV, Part A, Section 416 to explore innovative approaches to providing transportation to rural elderly and would examine current Federal and State regulations and opportunities to use existing systems operated through Area Agency on Aging programs, Head Start and State and local transportation systems, such as school buses.