[Senate Hearing 108-108]
[From the U.S. Government Publishing Office]
S. Hrg. 108-108
BABY BOOMERS AT THE GATE:
ENHANCING INDEPENDENCE THROUGH INNOVATION AND TECHNOLOGY
=======================================================================
HEARING
before the
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
ONE HUNDRED EIGHTH CONGRESS
FIRST SESSION
__________
WASHINGTON, DC
__________
MAY 20, 2003
__________
Serial No. 108-11
Printed for the use of the Special Committee on Aging
88-497 U.S. GOVERNMENT PRINTING OFFICE
WASHINGTON : 2003
____________________________________________________________________________
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SPECIAL COMMITTEE ON AGING
LARRY CRAIG, Idaho, Chairman
RICHARD SHELBY, Alabama JOHN B. BREAUX, Louisiana, Ranking
SUSAN COLLINS, Maine Member
MIKE ENZI, Wyoming HARRY REID, Nevada
GORDON SMITH, Oregon HERB KOHL, Wisconsin
JAMES M. TALENT, Missouri JAMES M. JEFFORDS, Vermont
PETER G. FITZGERALD, Illinois RUSSELL D. FEINGOLD, Wisconsin
ORRIN G. HATCH, Utah RON WYDEN, Oregon
ELIZABETH DOLE, North Carolina BLANCHE L. LINCOLN, Arkansas
TED STEVENS, Alaska EVAN BAYH, Indiana
RICK SANTORUM, Pennsylvania THOMAS R. CARPER, Delaware
DEBBIE STABENOW, Michigan
Lupe Wissel, Staff Director
Michelle Easton, Ranking Member Staff Director
(ii)
C O N T E N T S
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Page
Opening Statement of Senator Larry E. Craig...................... 1
Statement of Senator John Breaux................................. 2
Panel I
Josefina G. Carbonell, Assistant Secretary for Aging, U.S.
Department of Health and Human Services, Washington, DC........ 3
Panel II
Maria Greene, Director, Georgia Department of Human Resources,
Division of Aging Services, Atlanta, GA........................ 28
Kevin J. Mahoney, Ph.D., National Program Director, Cash and
Counseling Demonstration and Evaluation Project, Chestnut Hill,
MA............................................................. 48
Ronald H. Aday, Ph.D., Director of Aging Studies, Middle
Tennessee State University, Murfreesboro, TN................... 69
Gregory D. Abowd, Ph.D., Associate Professor, College of
Computing, and GVU Center Director, Aware Home Research
Initiative, Georgia Institute, Georgia Institute of Technology. 83
APPENDIX
Statement from Center for Aging Services Technologies, American
Association of Homes and Services for the Aging................ 107
Statement from Tobey Gordon Dichter, Founder, CEO Generations on
Line........................................................... 113
(iii)
BABY BOOMERS AT THE GATE: ENHANCING INDEPENDENCE THROUGH INNOVATION AND
TECHNOLOGY
---------- --
TUESDAY, MAY 20, 2003
U.S. Senate,
Special Committee on Aging,
Washington, DC.
The committee convened, pursuant to notice, at 2:05 p.m.,
in room SD-628, Dirksen Senate Office Building, Hon. Larry
Craig (chairman of the committee) presiding.
Present: Senators Craig and Breaux.
OPENING STATEMENT OF SENATOR LARRY CRAIG, CHAIRMAN
The Chairman. The Senate Special Committee on Aging will
convene. Let me first of all thank our panelists for their
flexibility in meeting the scheduling change that we had that
pushed this hearing into the afternoon. I want to thank you for
that.
Also, I want to thank Senator Breaux for being here.
Yesterday, he held, I think, a very successful hearing by all
accounts dealing with senior access, and certain protocols and
other activities that relate to the formulation and development
of pharmaceuticals and other interests and issues.
Both John Breaux and I work to share this committee and its
authority. We think this is certainly an issue for all
Americans. It is not a partisan issue. The business of aging, I
think we find that Democrats and Republicans age at about the
same rate. [Laughter.]
Senator Breaux. I'm aging faster. [Laughter.]
The Chairman. Just wanted to check him out and see if he
was awake there. No.
But good afternoon to all of you. I am pleased to convene
this hearing in recognition of Older Americans' Month and to
explore a wide range of policy issues impacting older Americans
and their families. Such an ongoing dialog is imperative since
the first wave of baby boomers will turn 60 in less than 3
years.
Today, we will hear testimony from various innovative
thinkers. We will hear about the Older Americans Act and the
Family Careviger Program, a new approach to Medicaid service
delivery, plans for modernizing our nation's senior centers,
and the technological opportunities available to seniors.
It is estimated that in 2006, over three million baby
boomers will turn 60 and become eligible for older Americans
services. This new wave of seniors will have a very different
set of characteristics from the previous generation. It is,
therefore, critical that we in Congress review and design
national policies to address these new demands.
I believe the central strategy for meeting the new
challenges of the 21st century is that of innovation, new and
bold programs and technologies that enhance independence for
all older Americans. Today's testimony will highlight some of
these innovations.
We will hear about the Older Americans Act and its newest
addition, the National Family Caregivers Program. It is well
known that family caregivers are on the front lines of long-
term care for older persons in this country. It is important
that these programs continue to evolve and assist family
caregivers so they can meet the challenges of caring for loved
ones in their own homes. A new approach in providing these
services to caregiver will be shared with us today.
I look forward to the testimony on Medicaid consumer-
directed services pilot project, a new concept that allows
seniors and their families to direct their own care. An example
of a self-directed service is that of cash and counseling
program, which will allow older persons who have trouble
managing their finances to hire a financial manager of their
choice.
National Senior Center Week, which ended last Sunday, was a
national recognition of the importance of senior centers. Of
equal importance is the need to vigorously explore a new vision
for our nation's senior centers. Although senior centers are
created and funded at the local level, they serve as critical
delivery points for various Older Americans Act services. I
look forward to the testimony on how senior centers will evolve
to meet the interests and the demands of a new generation of
older Americans in the 21st century.
Finally, assistive technologies are also becoming a major
tool for older Americans. Promising areas of computers to human
interaction that will allow older Americans to live more
independently will be discussed.
So before I turn to and introduce our first witness of our
panel this afternoon, let me turn to my colleague from
Louisiana, the senior Senator, John Breaux. John.
OPENING STATEMENT OF SENATOR BREAUX
Senator Breaux. Thank you very much, Mr. Chairman. Thanks
again for holding today's hearing. I would just point out how
important it is to talk about where we are headed. We are truly
in a perfect storm, if you would, as far as the aging of
America is concerned in the sense that we are about to receive
a huge number, the largest in generations, of individuals who
will be becoming eligible for senior programs, 77 million baby
boomers. On top of the large number of people who are going to
become eligible, that large number of people are living a lot
longer than any other generation in American history. So we
have a double problem of having a lot more people who will live
a lot longer.
I have jokingly said many times said that good news and the
bad news is that people are living a lot longer, and the bad
news is that people are living a lot longer. How will we take
care of them? Who is going to pay the bills? How much is it
going to cost? How are we going to be able to do what we as a
society need to do with regard to allowing people to live not
just longer lives, but also healthier lives and happier lives
as they get older?
So that is the real challenge of America, among the most
serious challenges, and everything seems to be coming together
at one time, which is truly a perfect storm as far as the
geographics are concerned. So hopefully, we will hear some
ideas today about how to address these problems. Thank you.
The Chairman. John, thank you very much.
Our first panel today is Assistant Secretary Josefina
Carbonell. Josefina, welcome before the committee. The
Assistant Secretary will discuss issues related to the Older
Americans Act, will address the rebalancing of the long-term
care system, the importance of family caregiving and the
challenges the Older Americans Act programs face in the demand
of the new baby boomers, much as my colleague has referred to.
So with that, Assistant Secretary, welcome.
STATEMENT OF JOSEFINA G. CARBONELL, ASSISTANT SECRETARY FOR
AGING, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES,
WASHINGTON, DC
Ms. Carbonell. Thank you very much, Chairman Craig, Senator
Breaux, and members of the committee for inviting me to testify
at this very important hearing. It is especially important
during Older Americans' Month. This month, and this year's
theme, is ``What We Do Makes a Difference.''
As we have discussed before, both globally and here in the
U.S., we are witnessing one of society's greatest achievements,
an extension of longevity due to advancements in medicine,
public health, and technology. At the Department of Health and
Human Services, we are updating and reenergizing old programs
and developing new ones that empower and serve older Americans
in their communities.
Also I am pleased to announce that today, the Departments
of Labor and Health and Human Services have transmitted a
Report to Congress that examines the future supply of long-term
care workers in relation to the aging baby boom generation.
Ensuring the adequacy and the availability of direct care
workers is a critical goal of the Administration and we have
been taking steps to prepare for the increased demand for
direct care workers. Our report recommends how to retain
existing long-term care workers and attract new pools of them.
It urges continued support of many of the Bush Administration's
existing efforts to address the growing demand for long-term
care workers.
Let me begin with the Administration's initiative aimed at
rebalancing the long-term care system to create real choices in
home and community-based care. Currently, 75 percent of public
long-term care funding goes to institutional care, while many
people prefer to remain at home.
Our guiding principles for caring communities are that we
give seniors and family caregivers affordable choices and
options; that they have control over their consumer choices and
what kinds of programs they wish to access; that the
information is there for them to access the programs; that we
make sure that we support the family caregivers, one of our key
components of the rebalancing long-term care system initiative;
and that quality services be available.
In the 2004 budget, the President has proposed a $1.75
billion program titled ``The Money Follows the Person
Rebalancing Initiative,'' as well as State systems change
demonstrations that promote home and community-based care
alternatives. These initiatives represent an historic turning
point in Federal long-term care policy.
Shortly, the Administration on Aging and CMS will jointly
issue a competitive grant announcement to develop one-stop shop
resource centers. This program will make it easier for
consumers to learn about and access existing long-term care
options, including alternatives to institutional care.
Family caregivers are a key component to ensuring that
older Americans can continue to remain at home. More than 23
million Americans are providing assistance to a family member,
and interestingly enough, 30 percent of the current workforce
is caring for a relative. If we were to pay for these services,
it would cost $257 billion per year. This is more than the
amount spent on formal home care and nursing home care
combined.
According to our national data, one out of four caregivers
report difficulty providing care because of their own physical
limitation. More than six in ten take care of someone who is at
least 75 years old. Eighty-eight percent report that our
services have helped them provide care longer, and 95 percent
of our caregivers are very or somewhat satisfied with the
services that they have received.
At listening sessions in communities throughout the
country, I hear the recurring difficulties. Whether it is the
51-year-old son who is the sole caregiver for his blind mother,
the 80-year-old woman who is struggling to bathe, feed, and
care for her 102-year-old mother, or the grandmother who lives
on a working farm in Idaho and is struggling to take care of
her grandchildren, the message is the same. Just give me a
little help, a little hope, a little relief, and I can take
care of my loved one in my own home. Caregivers tell me that
the Family Caregiver Program is the best program that the
government provides and many people have thanked me with tears
in their eyes.
Let me just share a couple of other personal stories. A
disabled individual is caring for his wife with Alzheimer's and
in need of 24-hour care. With help from the Arkansas Caregiver
Program, she is bathed and gotten ready to attend adult day
care. This results in time for him to receive his own therapy
and attend to his own needs. Twice, an elderly Kentucky
grandmother had put off needed surgery because she would be
unable to care for her 11-year-old grandson. The program
arranged for home care and personal care for her own needs
following the surgery. The North Carolina program installed a
wheelchair ramp in the home of a daughter so that she could get
her father in and out of the house without having to carry him.
Technology is also playing a very important role in
addressing the two greatest concerns of caregivers, safety in
the bathroom and transporting the care recipient. Things from
non-skid surfaces to grab bars and other safety features are
being installed in bathrooms and in homes across this country.
Videos are instructing caregivers on the best way and the
safest techniques for getting disabled individuals in and out
of vehicles. Nurses are electronically monitoring frail elders
and their caregivers in between doctors' visits.
So you see that the caregiver program is really creating a
new way of doing business in the aging network by focusing on
caregivers while allowing consumers to have choices.
Our data further indicates that over 3.8 million caregivers
have been empowered with information in the last year and
approximately 436,000 caregivers have been served, far
exceeding our target of 250,000. Significant numbers have also
been reached with intensive direct services in counseling,
training, respite, and many other supplemental services.
We look forward to releasing the complete caregiver report
at our national summit in September, which is designed to
strengthen the capacity of State and community service
networks.
Today, I am delighted to release the new PSA called, ``Who
Cares for the Caregivers?'' currently being sent to over 3,000
stations throughout the country. We would like to let you be
the first to preview this 30-second spot following my
testimony.
As you see, the administration is taking comprehensive
action to prepare for the aging of the baby boom population. An
important component of this effort will be the National Aging
Services Network, which is well positioned with assets to shape
our future, including a deeply ingrained focus on the consumer;
on commitment to early intervention and the social model of
care; a national network grounded in the community and capable
of delivering an extensive array of low-cost services; a proven
track record in leveraging resources; and the capacity to reach
out and serve private-pay consumers as well as consumers who
are low-income, culturally diverse, and isolated.
We cannot afford to maintain the status quo. By working
together to create systems of care at home as well as
institutional settings, we can develop a comprehensive approach
to health and long-term care that truly reflects the needs and
preferences of older Americans.
Now is the time to join forces to ensure that the promise
of independence, choice, and dignity is fulfilled for all
Americans. Thank you very much, and I would be pleased to
answer any questions you might have.
The Chairman. Thank you. You had a video that you wanted to
show? We will watch this first. [A videotape was shown.]
Well, that was simple and straight forward. Thank you. That
obviously communicates a very clear message. Thank you very
much for your testimony, Madam Secretary.
[The prepared statement of Ms. Carbonell follows:]
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The Chairman. Currently, would an 80-year-old woman, say,
taking care of her 55-year-old disabled daughter be able to
receive family caregiving services?
Ms. Carbonell. Any person over the age of 60 can receive
any kind of benefits from the Older Americans Act, from 3(b)
supportive services in senior centers, adult day care, home
care, respite, to meals and other services that are provided
under the Act. So the answer is yes, Senator, an 80-year-old
woman can receive respite services and other supportive
services available through the entire service network provided
under all the titles in the Older Americans Act.
The Chairman. In your view, how will the Older Americans
Act need to evolve to meet the demands of this new wave of
boomers that we are talking about and the demographics of them,
I guess I would say, different from previous generations that
we hope are currently covered under existing law?
Ms. Carbonell. As indicated, of course, in our written
testimony and as we heard from both Senators speaking about the
tremendous challenge ahead of us, I think we are looking at a
future where the senior centers will look a little different
than the senior centers for my mother and my grandmother looked
20, 25 years ago.
So we are looking at how senior centers are evolving in
many communities across this country. We are looking at more a
comprehensive holistic approach to the scope and the
availability of services. We are looking at a transformation
from just serving an older population, to serving a multi-
generational population and becoming more like community and
family centers.
So, therefore, the appeal across generations is going to be
critical as the challenges of the baby boom generation evolve.
We are going to see the availability or the need to provide
better choices, to have better linkages, through technology, to
caregivers across the country. That is why the new Family
Caregivers Program has given us the ability to add an
additional component to our base programs to ensure that we are
serving the younger caregiver, or the caregiver aging with
multiple generational challenges.
We are looking at the possibility of many of the senior
centers having both health clubs and Starbucks coffee houses
and community houses where people will remain active within the
community for a multi-generational purpose.
We need to ensure that senior centers of the future,
obviously, continue to address many of the challenges of the
health needs to maintain people healthy and active in their
communities. We need to ensure that the nutrition program,
which is one of our key programs within the Older Americans
Act, continues to evolve and improve to ensure that we get
better outcomes on reducing malnutrition and improving health
outcomes for individuals. Also, the availability of leisure and
volunteer activities, employment opportunities, where they can
seek a homemaker that can assist them at home, but at the same
time maybe seek a part-time employment or volunteer opportunity
in their community.
The Chairman. I don't think there is any question. I have
had several discussions over the last couple of years about the
design of the new center as really a point of full contact for
seniors and the services that are provided for them and their
needs, certainly unique and different from the kind that we see
today.
Dominant in my State of Idaho in many senior centers is a
quilting room. Quilting, obviously a delightful art form and a
pastime of many older Americans and now has become almost a
modern art form again. But ironically, the newest request to go
in beside that quilting room is a computer room.
Ms. Carbonell. Absolutely.
The Chairman. With about 11 million seniors now online, I
think it demonstrates even more that kind of transition.
The Administration on Aging has been working on performance
outcome measures for services provided under the Older
Americans Act. Can you please give us an update on your
progress as it relates to those reviews?
Ms. Carbonell. We are very excited with the outcomes that
we are generating. We have taken a step back and really
readdressed our issues of reporting. So we have taken a first
job at ensuring that we reduce the reporting formats for
programs to ensure that we get the kind and the quality of data
that we need, not excessive data with no outcomes at the end.
Not only are we reaching the numbers of individuals that we
set our goals to reach, just in the actual production of the
numbers, as we saw with the National Family Caregivers
Programs, but we are making a difference, ensuring that we
target--a high percentage to those most at risk or those most
vulnerable.
For instance, 30 percent of the clients served in the Older
Americans Act programs are elderly poor. That means that we are
targeting our priority to those in most need. We also are over-
serving. Thirty percent of the clients are in rural
communities, compared to 24 on a national basis. In particular,
States where we know that the rural issues are critical, with
our new National Family Caregivers, we are expanding our
availability to have comprehensive collaborations with the
health care providers and others in the community that we had
not had the opportunity to do. We are serving a large
percentage of people that are from minority at-risk
communities.
We are leveraging some interesting dollars. Even with
States' economic downturn, overall States are leveraging about
$2 for every $1 of the AOA dollar put in many of the States.
For intensive services, like in-home care, we are leveraging $3
to every $1 AOA dollar.
We are seeing excellent increases in recruiting of
volunteers for the senior Medicare patrols, as well as who are
ombudsmen within the communities, and improving the outcomes of
the Ombudsman program by working together with CMS on their new
quality initiative, both in the nursing home and obviously in
the home health area.
The Chairman. Thank you. Will you do a white paper on those
findings, or how will they be reported to us?
Ms. Carbonell. They will be reported--we have an annual
report which is our own specific annual report----
The Chairman. It will show up in those?
Ms. Carbonell [continuing]. That we are proud to--it is hot
off the press.
The Chairman. OK.
Ms. Carbonell. It is not out. It will be out at the end of
this week, but we have brought a copy that we will leave with
you.
The Chairman. Fine.
Ms. Carbonell. In addition, the final outcome data of the
national surveys, which is a new survey that has been added to
the outcome measurements and performance data, will be ready
later this summer, and those will be released and we will be
glad to provide them to Congress and to the Chair.
The Chairman. Super. Thank you.
I am going to turn to my colleague, Senator Breaux. A vote
has just started. I am going to run and vote and come back and
we will do tag team here so that we can keep our hearing going.
John?
Senator Breaux. Thank you, Mr. Chairman. Thank you, Madam
Secretary.
You mentioned in your testimony that the President's budget
for 2004 requests for CMS a $1.75 billion program to encourage
a transition of people from nursing homes or other long-term
care institutions back to the community, and you correctly
point out that we really have an institutional bias in long-
term care in this country in keeping people in institutional
care. An awful lot of people, in fact, need long-term, 24-hour-
a-day, 7-day-a-week care, but there are an awful lot of them
that are in institutional care like nursing homes that don't
need to be there.
Yet, almost 75 percent of all the money we appropriate is
being used principally through the Medicaid program to put
people in nursing homes. It is really an embarrassment, because
you have got to spend yourself poor to get money to get long-
term care, which is a real embarrassment as a society, but that
is a whole other point.
How would the money that the President is proposing be used
to end this institutional bias that we are talking about?
Ms. Carbonell. Well, I think that--not only the rebalancing
initiative, but several other initiatives, including the New
Freedom and the systems change grants, have allowed and are
beginning to allow many States the opportunity to begin to
rebalance their systems. In the rebalancing proposal, the
opportunity, if they wish, to invest in shifting folks from a
nursing home into home and community-based care. It provides a
1-year, 100 percent Federal reimbursement for all costs to move
and to pay for services to move individuals from a nursing home
into home and community-based care. That is virtually how we
envision the framework that was proposed to Congress for the
2004 budget.
In anticipation of those changes, we have been working and
there have been system choice grants already given out to
States which have allowed States to begin to address removing
barriers, institutional and infrastructure barriers, that
prevent individuals from living independently in their own
homes. So it has addressed structural changes and
reimbursements at the State level for making those changes,
both policy and resource-wise.
Senator Breaux. Of course, the problem at the State level
is that the States can do that now simply by requesting a
waiver from HHS to use their State Medicaid funds for non-
institutional care, like assisted living facilities. The
problem has been that they don't want to do it. The problem has
been that they have a bias toward nursing homes, in many cases
because of the political strength of the nursing homes that
prevent legislators from allowing them to make the request.
My concern is I don't understand how this is going to help
the situation, because the problem is with the States not
wanting to do it. They can do it now.
Ms. Carbonell. Well, they can do it now, right now,
Senator, but the current reimbursement mechanism would be the
same match that the States have at the current time. With the
rebalancing proposal, it provides 100 percent Federal
reimbursement to States for one year, so they can begin to
shift it. That, coupled with the fact that the Administration
on Aging is partnering with CMS to create, again, the
involvement of a single-entry or one-stop-shop place where
people can turn for help and assistance, where there will be
one single entry point in the system to long-term care, that
will allow the individual better choices. Right now those
programs are fragmented.
So some States, a few of the States, have their long-term
care system, including their Medicare waiver programs, managed
by the aging network, the aging State unit. But the rest of the
States have, of course, their Medicaid waiver and long-term
care program managed by their State health or Medicaid agency.
Senator Breaux. So are we saying that under this proposal,
the State would get the same amount of money under Medicaid
plus the States would divide up $1.75 billion in addition to be
used for non-institutional care?
Ms. Carbonell. Correct. That means that it is an historic
investment, a change in the way that we offer incentives to
States to begin to shift policy and resources to home and
community-based care to create more balance.
Senator Breaux. This is not a subtraction from what they
would normally get under Medicaid?
Ms. Carbonell. This proposal is an addition and it is 100
percent for one-year. This one-year reimbursement at 100
percent for States wishing to pilot and to begin to shift
policy and programs to home and community-based care.
Senator Breaux. So a State will get 100 percent with no
State match to allow them to move out of a nursing home?
Ms. Carbonell. For the first year, sir, yes, and the rest
of the years, it comes back to the State match as stipulated.
Senator Breaux. Why are we doing a 100 percent match?
Aren't we just telling the States we are going to pay 100
percent of the cost if somebody moves out of a nursing home?
Ms. Carbonell. Well, this is an historic turning point----
Senator Breaux. It certainly is.
Ms. Carbonell [continuing]. We feel very confident that a
1-year, coupled with other supports will help. I am not CMS so
I defer that kind of question to my colleagues----
Senator Breaux. What happens, then, if we do it for 1 year
and a State moves 20 percent of their nursing home population
into an assisted living facility and the Federal Government
picks it all up? What happens to those people when the Federal
Government sunsets it after one year?
Ms. Carbonell. Well, in those States where we have seen the
experience of shifting resources, a consolidation of resources
and programs into one single entity for long-term care, the
experience and the studies and the data have shown that they
have actually reduced their costs in general, and have improved
the number of people being able to be served under home and
community-based services by mixing of services available both
in-home and community-based care and nursing home.
So that means that, No. 1, people have been able to
successfully be transitioned out of nursing homes into home and
community-based care programs. We know that the data shows that
those States that have invested dollars in shifting to home and
community-based care have done so cost effectively and have
been able to continue to do so.
Senator Breaux. I have no qualms with the principle that it
is cheaper and, I think, more convenient and a better degree of
care for a large number of people to be in non-
institutionalized care. I think that is what we ought to be
encouraging States to do, something that they can do now but
they don't in most cases.
I need to learn more about this $1.75 billion and how it
would actually work. I think it is the right thing to try and
ultimately accomplished. I am not certain that this is the best
way to do it because I am concerned about if we do it to them
for one shot and then the next year it is not there, they are
going to be left with an awful lot of people hanging in
facilities that they didn't think they were going there for one
year. All of a sudden, the money is not going to be there in
the second year and what happens to all of those people?
Ms. Carbonell. We would like to follow up with you,
Senator, and bring you additional information with my colleague
at CMS, Tom Scully. Obviously, that is not just the only thing
it involves. Obviously, our role at the Administration on Aging
is that the administration and the aging network is one of the
largest providers of home and community-based care throughout
this country and we are ready, we are experienced, we have
proven to be cost effective, and we are ready to take on the
next step, which means work collaboratively, partnering with
CMS, because you have got an existing structure that is evident
throughout 29,000 providers and communities. We are doing it
for the grant monies right now and in many cases, about 30
percent of the States, the aging network is managing and
operating the Medicare waiver home and community-based care
services in communities.
So we are--the one-stop-shop initiative will give us the
ability to partner with CMS to ensure that we integrate the
service systems at the community level and that we incentivize
and award competitive grants that will be released later on
this month to do just that, to begin to shift----
Senator Breaux. We will follow up on that.
Ms. Carbonell. Thank you.
Senator Breaux. You are aware, apparently, of our hearing
yesterday, because you reference it in your testimony. I think
that what we learned yesterday is that there is an enormous
bias in America, in our own country, against seniors in a lot
of areas. One of the most important areas is the general area
of health care.
Our medical schools do not have enough geriatric degrees.
Only five schools in the entire United States medical schools
out of 125 have full departments of geriatrics. Yet all of them
have full departments in pediatrics.
We have clinical trials for prescription drugs that are
ongoing that do not fully utilize, if hardly at all, seniors in
the testing, even though most of the people who take
prescription drugs, over half are seniors, but they are not
involved in the clinical trials to develop the drugs and to
ensure that they are safe.
We have a bias and a lack of utilization among seniors in
preventative care programs that are available to others. We
have, I think, a lack of understanding of depression among
seniors. The highest suicide rates in this country is not among
teenagers but among seniors, and we had testimony that doctors
don't recognize it because they haven't been trained. Too many
times, seniors are just dismissed as being, well, they are old
people. They are going to die anyway.
I think that we as a society need to be striving for not
just getting seniors to live longer, but to live better lives.
I have said it a million times. Part of living better lives is
to make sure that they have access to the same type of quality
preventative services and health services that someone who is
in their 20's or 50's or even younger.
So, I mean, what can the Administration on Aging, when you
look out over America and you see this discrimination against
aging and people who are seniors, what can the Administration
on Aging do to become a leader in this area, to eliminate these
biases that currently exist?
Ms. Carbonell. At the Administration on Aging, obviously is
the chief advocate for aging and older Americans across the
country, we not only are taking a chief advocacy role, but we
are actually running programs and collaborating with other
agencies to ensure that we begin to tear down those barriers
that ensure not only quality of care for our seniors, but a
better quality of life, obviously.
If you look at the report released today on, long-term care
workers in relation to the aging baby boom generation, you will
see substantial recommendations in to Congress based on the
kinds of urgency that there is to address not only the
shortages of professional workers, but also ensure that
paraprofessional quality training continues to happen.
We are working with HRSA inasmuch as the Health Resource
Services Administration is addressing geriatric education in
their 2003, spending approximately $12 million in continuing to
fund geriatric education centers across this country.
We are working with the Agency for Health Research and
Quality, AHRQ, to ensure that there is safety in medications
and that the medications' overuse is addressed and the safety
and products of the medication are there. FDA is expanding its
consumer information opportunities, and that includes the
working relationship between FDA and AOA, to improve that
consumer information education.
On mental health, we have just developed and are about to
launch by the end of this month a tool kit that SAMHSA has
provided to ensure that we address mental health, depression,
substance abuse, and other issues in older populations.
So we are taking active steps with our partners in CMS to
address prevention services and the expansion of prevention
services.
The whole Medicare proposal before you in the 2004 budget,
the President's 2004 budget, obviously not only aspires to
provide for prescription drug benefits for seniors, but it is
looking at a more comprehensive reform as we improve the
capacity to do prevention and screenings for all Medicare
beneficiaries.
So we are taking active steps with CDC in our aging State
programs. Our aging network providers are partnering in ten
specific communities across this country where there is high
incidence of risk behaviors and health disparities. We are co-
funding with CDC initiatives in this program with public health
providers and our community aging providers.
Senator Breaux. Thank you. Thank you, Mr. Chairman.
The Chairman. John, thank you.
One last question, Madam Secretary, before we turn to our
next panel group. I understand the administration has been
involved in a series of listening sessions. What exactly have
you learned from people out there receiving and providing older
Americans' services?
Ms. Carbonell. Well, the most important thing is that the
flexibility and the ability of many of our providers with the
new reauthorized Act has awarded us the flexibility needed to
address consumer choice at the local level. So the improved
capacity for program sharing, for having the new Family
Caregiver Program, has allowed us the opportunity to create new
partnerships and collaborations at the State level, whether you
are looking at private sector elder care programs or benefit
programs being matched together with many of our Area Agencies
on Aging and caregiver providers in the community.
I just came back from a town hall session in Orange County,
CA. We held that town hall meeting in collaboration with the
aging network and the disability advocates. We were able to
come together as one to address some of the barrier removals
and some of the challenges that we both have both in the aging
and disability communities to promote independence in
communities, and address better opportunities for home and
community-based care.
We are looking, obviously, at hearing from seniors, like I
mentioned, particularly in the area of grandparents. We see
that there are challenges in many of the grandparents raising
grandchildren that we need to continue to address as we move
forward, and the National Family Caregiver Program evolves and
there are obviously opportunities as the reauthorization of the
Older Americans Act becomes evident just in 2005.
The Chairman. Thank you. Thank you very much for your
testimony, the work you are doing, and all of the efforts well
underway. I think all of us kind of view, whether we are at the
policy level or the implementation of that policy, at your
level, kind of feel we are in that interesting transitional
time out there into a relatively known field, at the same time
with expectations and demands that are not yet known in many
respects as it relates to the aging of America.
But we thank you very much for that testimony and look
forward to our continued work with you.
Ms. Carbonell. Thank you.
The Chairman. Thanks for being here.
Let us ask, then, the next group of panelists to come
forward, please, Maria Greene, Kevin Mahoney, Ron Aday, and
Gregory Abowd.
Mr. Mahoney, we will try to deal with you in dispatch. We
understand you have a family problem or concern and we will
move you through as quickly as possible.
Let me thank our panelists for being with us. I recognize
Maria Greene, Director of the Georgia Division on Aging. She
will visit with us today about the features of Georgia's family
caregiving efforts, including a mobile day care program.
Maria, welcome, and we look forward to your testimony.
Ms. Greene. Thank you.
The Chairman. Please proceed.
STATEMENT OF MARIA GREENE, DIRECTOR, GEORGIA DEPARTMENT OF
HUMAN RESOURCES, DIVISION OF AGING SERVICES, ATLANTA, GA
Ms. Greene. Good afternoon, Senator Craig. Thank you for
the opportunity to come this afternoon. I am Maria Greene,
Director of the Georgia Department of Human Resources, Division
of Aging Services. Also with me today is Mr. Cliff Burt,
Caregiver Specialist responsible for Georgia's caregiver
program.
I would like to share information with you about five
innovative caregiver initiatives. They are caregiver research,
assessment, mediation, consumer-directed care, and mobile day
care.
Georgia conducted 11 focus groups to solicit input from
family and professional caregivers regarding needs and gaps in
services. We found that caregivers need more information, more
direct services, training for themselves, and better trained
non-ageist providers. The results of the focus groups have been
used to integrate the National Family Caregiver Program into
the existing delivery system, expansion of existing services,
and development of new programs and services.
Georgia was awarded grants from the Administration on Aging
to participate in the performance outcomes measurement project.
The Division participated in the development of instruments
that measure caregiver support and satisfaction, nutrition
risk, physical functioning, and emotional well-being. We tested
these instruments over a 3-year period. We are encouraging Area
Agencies on Aging to use the instruments in determining service
outcomes, quality and client satisfaction, and how best to
manage using data.
We understand, Senator Craig, that the committee has an
interest in mediation. Georgia is one of the three States
participating in a caregiver demonstration grant received by
the Center for Social Gerontology in Ann Arbor, MI. The goal of
the project is to use mediation to assist frail older persons
and their family caregivers to address and resolve problems and
disputes which all too frequently arise when families face the
physical, emotional, and financial demands of providing care.
Elder law attorneys using mediation skills have helped many
families resolve conflicts.
We value the philosophy of consumer-directed care.
Preliminary studies have found that 77 percent of caregivers
utilize funds to hire someone to provide care, and 80 percent
of the caregivers hired someone they know as opposed to agency
personnel. Caregivers who participate in the program are
considerably more satisfied with those services than those who
receive traditional services.
I will share with you a story told to me recently. The
caregiver for 94-year-old Mr. K called the local Area Agency on
Aging about using some of the fund from the self-directed care
program to make needed bathroom repairs. The caregiver utilized
some of the self-directed funds to purchase needed materials
and secured volunteers to make the necessary repairs.
Consequently, her father is able to bathe by himself for the
first time in many years. The caregiver stated that her dad
never had a tub and had to use a very small shower stall. Her
father, who last year would not bathe, has to be coaxed out of
the tub. She and her father would like to thank all of those
responsible for the program.
Given the well-documented long-term care staffing crisis in
the nation, the unavailability of services, and fewer workers
in rural areas, it should come as no surprise that our
preliminary findings show that family caregivers wholeheartedly
embrace self-directed care.
Through funding provided by the Administration on Aging,
Georgia developed the mobile day care program. Mobile day care
enables communities to have their own day care programs while
sharing staff who travel between locations. Mobile day care has
proved to be a great respite care alternative. Its flexibility
with part- and full-time staff positions helps to retain
qualified staff. Perhaps its greatest values is that it builds
trust in rural communities and thus becomes the precursor of a
full-time day care program.
Georgia's ability to do caregiver research, assessment,
mediation, consumer-directed care, and mobile day care has
enabled us to create new partnerships and paradigms to meet the
diverse and increasing needs of caregivers. One of the National
Family Caregiver Support Program's hallmarks has been the
component of supplement services, which has enabled the aging
network the flexibility needed to become more innovative. The
product of that flexibility is improved service delivery, new
services, and increased empowerment for caregivers. Also, the
demonstration grants have allowed States like Georgia to pilot
new delivery of care systems, gather consumer satisfaction
data, and to manage programs using those data.
Mr. Chairman, with your permission, may we show a short
clip of the mobile day care video.
The Chairman. Surely.
Ms. Greene. Thank you. [A videotape was shown.]
Thank you.
The Chairman. Thank you. Thank you very much for that
testimony and the video.
[The prepared statement of Ms. Greene follows:]
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The Chairman. Now, let us turn to Kevin Mahoney, Program
Manager for a demonstration project which highlights
innovations in consumer directed care. Would you please
proceed? Thank you.
Dr. Mahoney. If I might just have a second to get this set
up.
The Chairman. All right. Thank you. I want to also say that
you are a National Program Director at Cash and Counseling
Demonstration Project in Chestnut Hill----
Dr. Mahoney. At Boston College.
The Chairman. There we go. Thank you. Now we have it all
out.
STATEMENT OF KEVIN J. MAHONEY, PH.D., NATIONAL PROGRAM
DIRECTOR, CASH AND COUNSELING DEMONSTRATION AND EVALUATION
PROJECT, BOSTON COLLEGE GRADUATE SCHOOL OF SOCIAL WORKS,
CHESTNUT HILL, MA
Dr. Mahoney. Thank you, Mr. Chairman and members of the
committee. Today in most States, whether you are elderly or a
younger person with disabilities, if you are on Medicaid and
you need help with such basic things as bathing, dressing,
getting out of bed, you rarely have any choice over who helps
you, when they come, or what they do. But for years, people in
the disability community have been saying, if I had more
control over these services, my life would be a lot better and
I think I could do it for the same amount of money or less.
The Cash and Counseling Demonstration and Evaluation is, in
fact, a real major test of just that idea. It is a test of one
of the ultimate forms of consumer direction, where people are
given the choice between traditional services from agencies or
managing the equivalent amount of a cash allowance themselves
with supports. It is a major test, one that involves over 6,700
people in three States who have been randomly assigned for this
demonstration.
Janice Maddox is a perfect example of the desire of seniors
to have more control over who enters their home and who
provides intimate care. At 75, Mrs. Maddox does not have the
best health. She has diabetes and glaucoma and is confined to a
wheelchair possibly as a result of several strokes. But despite
her physical frailty, Mrs. Maddox possesses a tremendous asset,
an extensive support network of family and friends who want to
help her continue to live independently.
For 5 years, Mrs. Maddox received personal assistance
services from aides sent to her by an agency that contracted
with Medicaid. Then her daughter read about Arkansas's Cash and
Counseling Program in the newspaper. Mrs. Maddox enrolled and
her oldest daughter, Johnetta Thurman, became her
representative decisionmaker. Mrs. Maddox's monthly allowance
through Cash and Counseling pays her adult granddaughter to
spend at least 2 hours a day, 7 days a week, attending to Mrs.
Maddox's needs. Her allowance is also used to pay her grandson
$10 a week to do odd jobs around the house and helps cover the
cost of such things as over-the-counter medications and
toiletries.
Mrs. Maddox's daughter, who lives in Chicago and travels
frequently to Arkansas to make sure her mother's needs are
being met, believes the program has made an immense impact in
improving the quality of her mother's life. She says, ``There
is just something about having family look after her. She
doesn't get nearly as many allergic reactions or bedsores now,
and I think that's because when it's your own you're looking
after, you pay more attention.''
The Cash and Counseling Demonstration and Evaluation is
really a rather unusual creature. It is completely co-funded by
the Robert Wood Johnson Foundation and the Office of the
Assistant Secretary for Planning and Evaluation at HHS. It
operates under Medicaid waivers granted by the Centers for
Medicare and Medicaid Services. The quantitative evaluation
that I am going to present to you, the first results, was done
by Mathematica Policy Research. The qualitative evaluation that
is my favorite follows about 25 people close up and personal in
each of the three States and tells how this really affects
their lives.
The program takes place in three States, Arkansas, Florida,
and New Jersey. In all three States, it includes older people
and younger adults with disabilities. Florida is different.
They also include children with developmental services.
What I would like to do in these few minutes today is
present the first of our research results. they are from
Arkansas which was the first State to implement this. To
Arkansas's credit, they implemented the cash and counseling
option within a month of when they got the Federal waivers.
These particular findings that we get to share today are from a
controlled experiment, so in Arkansas, we had a little over
2,000 people enrolled. Half of them were randomly assigned to
the traditional system, half to managing the cash allowance.
When we looked at quality of care measures, we looked at
four: satisfaction, reduction in unmet need, health outcomes,
and affects on overall quality of life.
Just a key to sort of give a picture of this, the left side
are younger adults with disabilities. The right side are the
elderly. The red bars are the treatment group. Those are the
people that got to manage the cash allowance. The ``C'' is the
control, is the traditional system. Whenever you see an
asterisk, it is statistically significant. The more asterisks,
the more statistically significant. Rarely will you in your
lifetime as a researcher get a chance to see that kind of
results, over 20 percentage points improvement in some of these
measures of satisfaction.
When you turn to the second measure, unmet needs, you start
seeing reduction, major reductions there.
The results people were really looking for the most were
the health outcomes, and I am pleased to be able to report that
basically the health outcomes were either as good, or where
there were differences, they favored the people who managed
their own allowance. You can see the elderly had fewer
contractures while younger persons with disabilities had fewer
bedsores. Overall life satisfaction was also improved. The
final slide shows the schedule for the rest of our reports.
Each of these three States is looking at making cash and
counseling a permanent option. The Robert Wood Johnson
Foundation and HHS are looking at how we can expand this option
to other States. Thanks.
The Chairman. Thank you very much for that testimony. That
is exciting, you are right, to see those kinds of results,
Kevin, are very impressive.
[The prepared statement of Dr. Mahoney follows:]
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The Chairman. Now, let us turn to Dr. Ron Aday. Dr. Aday is
Director of Aging Studies, Middle Tennessee State University.
Welcome, Doctor.
STATEMENT OF RONALD H. ADAY, PH.D., DIRECTOR OF AGING STUDIES,
MIDDLE TENNESSEE STATE UNIVERSITY, MURFREESBORO, TN
Dr. Aday. Thank you, Senator Craig. It is a pleasure to be
here today to discuss the significance of senior centers and
the important role that they will play in meeting the diverse
needs of our nation's baby boomers.
The challenge, of course, centers around the diversity of
this population, as you mentioned earlier, in terms of
ethnicity, the well, the frail, and, of course, an age span
from 60 to 100 or more. So it is a tremendous challenge that we
are facing.
This year, senior centers are celebrating their 60th year
as an entity and are serving over ten million clients annually
at approximately 1,400 senior centers. They have a strong
infrastructure, a dedicated staff that certainly has
demonstrated an openness to exploring ways of how to meet the
upcoming challenges for serving the baby boomer generation.
There are several ways that senior centers might be able to
empower this group in the coming decades. I think it is very
important to provide what I refer to as survival skills for the
baby boomers and, of course, in many cases, their aging
parents, as well.
One of the research outcomes I have recently found in
surveying senior centers from seven States and approximately 20
senior centers, was that the senior center environment is
conducive to the establishment of social support networks,
where seniors feel responsible for each other and assist each
other in order to help maintain their independence. About 85
percent of the sample reported that friends they have made at
the senior center provided them with a sense of emotional
security and someone that they can depend on in time of need.
Eighty-five percent also said that they provided some type
of assistance to their friends that they had made at the senior
center. I think that is very significant as we look at how to
create a more independent baby boomer generation as they
progress in age. This social network, of course, combats
depression, loneliness, especially for those that live alone.
We have a large number of female senior center users in
particular that live alone.
Another, main area where senior centers can certainly
empower and help our baby boomers is through what has been
termed self-care initiatives. Most senior centers currently
provide health and wellness programming, which brings about
positive behavioral changes. In the future, chronic care
clinics will emerge as an even more important component of
senior centers.
The senior center that I have been serving on the board for
for the last 12 or 15 years, when we reconstructed the new
senior center that we opened 4 or 5 years ago, we actually
built within that construction a nurse-on-duty program. It was
actually in place, and so we have a nurse that comes there 2
days a week, provides a clinic. She also works at the
university where I do. It is a partnership between the
university and the senior center. They bring nursing students
to the senior center and provide assistance and screening, and
she has at the present time 400 open cases where she sees on a
regular basis, providing screening and drug management kinds
of--and information to them.
A third area that we see, I think, is really looking at the
baby boomers in the future, who many of them will want to
continue to work into their 70's. That is one of the things
that the literature tells us. But the senior center can evolve,
I think, to provide retirement counseling for those that may
choose to retire, but also retraining and employment for those
that want to continue. We know that based on advanced
technology, that many of us will phase in and out of several
careers over a lifetime and the senior center can certainly be
the environment where baby boomers in their 60's might be able
to come and get retrained. Senior centers in this way will
serve as continuing education centers, where they will provide
programming and innovations and it will be, I think, beyond
computer skills. We talk about computer skills today. While
computer labs are found in many senior centers today,
additional computer and other new information will be important
technological to baby boomers in order to remain current in the
21st Century.
Also, another, senior centers are now getting involved in
what we call civic engagement programming, and that is trying
to find a balance between leisure and recreational activities
as well as civic commitment. We know that we need to utilize
the services and the potential that baby boomers have as they
age and as they enter into the long-term care continuum. So we
want to utilize their services, and so attracting them to the
senior center for their education, for their skills, for
volunteer work, is going to be extremely important.
Finally, a connection to other generations is also very
important and senior centers can play a very important role in
this process, by providing adult day services, services for
helping family caregivers, grandparents' support groups,
latchkey children telephone assistance, and also mentoring for
juvenile diversion programs, to maintain a few examples.
While senior centers are now recognized as one of the most
widely utilized services created by the Older Americans Act,
they are in some ways still the very best kept secret based on
the outcome measures that are telling us we really can't afford
not to utilize the senior center network to its fullest in the
coming decades. If given the adequate resources, senior centers
will help make aging a new adventure for our baby boomers.
Thank you very much.
The Chairman. Thank you very much, Doctor. The concept of a
new or futuristic senior center was brought to my attention
some months ago when a group met with me in Boise, ID, to talk
about creating, if you will, a kind of model of a future
center. I think, clearly, with the dynamics of this aging
group, you are right. I have oftentimes thought how computer
centers are important today. All of these folks entering will
be mostly computer literate. They will simply be wanting to
advance themselves in those skills as that part of our
technology evolves, along with a lot of others.
I often have thought, yes, and they need an employment
center or an employment contact and maybe even some training.
So certainly what you have talked about seems to clearly be a
part of what others are visiting about and what some are
thinking about in a sincere and direct way. Thank you.
[The prepared statement of Dr. Aday follows:]
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The Chairman. Now, let us turn to Dr. Gregory Abowd,
Associate Professor, College of Computing at Georgia Institute
of Technology in Atlanta, GA. His research interests lie in
human-to-computer interaction--hmm, I need some of your
courses.
Dr. Abowd. We all do.
The Chairman. I don't interact well. [Laughter.]
Dr. Abowd. It is not your fault.
The Chairman. The smart home, or the aware home research
initiative, or the smart home project for aging Americans.
Thank you. Please proceed.
STATEMENT OF GREGORY D. ABOWD, ASSOCIATE PROFESSOR, COLLEGE OF
COMPUTING, AND GVU CENTER DIRECTOR, AWARE HOME RESEARCH
INITIATIVE, GEORGIA INSTITUTE OF TECHNOLOGY
Dr. Abowd. Mr. Chairman, thank you for giving me this
opportunity to speak about such an important topic and to allow
me to talk about how I think this country can use high
technology or advanced technology to meet the needs of an
increasing aged population.
I have a very simple message, and that is that advanced
technology holds great promise for promoting healthy and
independent aging, but we must be more proactive to realize
this promise. Aging is not a disease, and while there is
significant research exploring how technology can provide
assistance for individuals coping with disabilities or disease
as they grow older, the role of technology in enhancing the
lives of older but otherwise healthy Americans is not well
understood or appreciated.
I am a computer scientist and an expert in the area of
ubiquitous computing, meaning the spread of computing artifacts
throughout the physical world to support everyday activities.
Though my work presents great technical challenges, the
motivation to work in this area is largely the human-centered
agenda of providing assistance in our everyday lives.
Over the past 5 years, with support from the National
Science Foundation, the State of Georgia, and several major
computing companies, we have been exploring ubiquitous
computing in the home. We refer to our efforts as the Aware
Home Research Initiative, with the challenge of creating a home
that serves its inhabitants because it is empowered with an
awareness of their whereabouts and activities.
A major motivation for this work is that an aware home,
properly connected to trusted caregivers, can provide the
assistance needed for otherwise healthy individuals to cope
with the natural declines related to aging. Advanced
technologies can be pleasingly woven into the fabric of our
homes, allowing us to age in place. An aware home can promote
independence and quality of life for an aging population, and
there are tremendous social and economic incentives to do this.
Now, what do I mean by advanced technological supports? In
my written statement, I catalog a wide variety of technological
supports for an aging population. To summarize for you here,
there are three categories of interest. First, you have
assistive devices that compensate for motor, sensory, or
cognitive deficiencies. Then you have monitor and response
systems that provide both emergency response to crisis
situations as well as early warning for less critical and
emerging problems. Finally, we have communication aids that
provide a link between an individual and a network of formal
and informal caregivers.
The greatest promise for advanced technology lie with the
cognitive aids, the monitoring of trends, and novel
communication aids. I will demonstrate some of these
technologies at the end of my statement, with your permission.
Now, who will benefit from these technological supports?
First and obviously, we provide assistance directly to the
individual in an attempt to support their independence and
quality of life.
Second, this technology provides support for distributed
family members and other more formal caregivers who share the
financial and emotional burden of coping with the challenges of
aging.
Third, with the increase of broad-band networking into and
out of the home, we have greater capability to support the
activities of larger institutions providing medical, emergency,
or other social services.
Finally, scientific evidence of a quantifiable benefit of
advanced technology for healthy aging will encourage the
development of profitable business plans that drive private
investment and commercial success in this important market.
Now, what role does advanced technology research play? One
of the key indicators of independence is the measured
performance by an individual in activities of daily living. The
role for advanced technology, therefore, is the detection,
measurement, and even improvement of an individual's
performance with these various activities in their living
environment.
Until now, most assessment of independence has been done by
humans and this solution won't scale to provide proactive
support for a large population. Hence, advanced technology is
necessary. In my written statement, I have surveyed emerging
technological aids, but I must stress that there remain
significant advances in technologies of sensing and long-term
analysis of human behaviors that will not occur unless
sufficient funding is made available.
I want to make two recommendations to the committee. First,
we need basic technology research for sensing and measuring
these activities of daily living. The funding for these basic
technological advancements could be administered by agencies
such as the NSF that traditionally fund scientific and
engineering developments that eventually benefit society.
Second, we need large-scale test beds for evaluating
technology for healthy aging. Research into how best technology
serves the aging should be administered by groups whose
mandates focus on public health concerns. This funding will
make sure that the technology is well matched to the needs of
the community. It will also lay groundwork for a healthy aging
industry that will bring the research success to the
marketplace.
With the permission of the Chairman, I would like a few
minutes to demonstrate three separate projects that bring to
life some of the ideas I have been talking about that we have
been working on at Georgia Tech.
The Chairman. Please, go ahead.
Dr. Abowd. I want to demonstrate three separate projects
that are taking place at Georgia Tech as part of the Aware Home
Research Initiative.
In the first demonstration, we focus on the potential for
automatically detecting behaviors. Even with proper initial
training, people often misuse home health care devices, such as
the blood glucose monitor that is pictured here. I am sorry you
can't see on the monitor. Advanced computer vision algorithms
can observe the use of a device and automatically detect when a
sequence of actions is done incorrectly, providing an
opportunity to give immediate training advice. The video shown
here at the top demonstrates how our computer vision algorithms
track hands and various objects to label the actions as a user
attempts to calibrate the blood glucose meter.
An important form of cognitive aid is one that compensates
for near-term memory lapses. When an activity such as cooking
is interrupted, what visual cues provide the right information
to pick up where you left off? In the Aware Home, we have
instrumented the kitchen area with cameras looking down at the
countertop, shown in the bottom figure. An LCD panel is updated
with salient images of the cooking activity as it is occurring.
When interrupted, a simply glance at the display shows the most
recent activity.
Now, I am going to switch to a live demonstration. What you
see here is the image on the LCD panel that is being updated
occasionally with images being detected by a wizard sitting
outside the kitchen determining when a significant activity
occurs. The bottom right figure in this collage is updated to
show you the most recent activity, and the numbers in the
various panels indicate repeated activities, such as one, two,
or three cups of the same ingredient being placed in the bowl.
So that when someone glances at the collage, they can determine
where they would have left off, and frequently in our
controlled studies, it has been the repeated measures
activities that get forgotten. So you don't remember the number
of cups of flour that you have put in.
Now, we don't currently have the ability to automatically
detect the salient images to produce this collage, but we have
been simulating the collage in controlled studies to determine
its value, and given the progress on detecting simple
activities, as I showed on the previous example with the blood
glucose monitor, I hold very great hope that we will be able to
provide these kinds of visual reminders automatically in the
home of the future.
In my last example, I want to contrast with the previous
two. In the previous two examples, we showed services that
stayed within the home and serviced the individual. This last
demonstration is about connecting to caregivers, in particular,
the natural support group of family and friends who want to
maintain peace of mind for the well-being of older parents or
loved ones.
The digital family portrait shown here is an ordinary
picture of a loved one that has been augmented with information
in the frame to communicate how that person is doing over the
last month. This is an aesthetically pleasing way to keep in
touch with the everyday well-being of a loved one and it can be
modified to support the normal monitoring activities of
professional caregivers and assisted living facilities or
naturally occurring retirement communities, referred to as
NORCs. I can also demonstrate this, but for the sake of time, I
would like to thank you for your patience.
The Chairman. Doctor, thank you very much for that
testimony. I was telling staff, earlier in the day, I took a
tour of a smart home that a large software company in Seattle,
WA, developed. I guess for sake of not promoting advertising, I
won't mention the name.
Dr. Abowd. They don't sponsor us, either, so----
[Laughter.]
The Chairman. I found it very fascinating. It would do
about everything you asked it to do by just simply voice
command, and certainly could be adapted to someone with
disabilities or someone with problems. It could make their life
a good deal easier, including monitoring.
I think I was recalling the thing most fascinating about
it, in the evening before the person retired, they could go to
their laptop or their computer and activate an automatic in-
place e-mail to a loved one somewhere else telling them that
they were safe and retiring for the evening, the very similar
kind of thing that you see in retirement centers today in
individual apartments and living facilities that go to a
central station to monitor a person's activities. I thought,
hmm, a most useful approach.
Thank you for that testimony.
[The prepared statement of Dr. Abowd follows:]
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The Chairman. I am going to turn to Dr. Mahoney now, and
then if you wish, at the end of this--I have got a couple of
questions of you, Doctor--if you need to depart, please do so
and we thank you again for being here today and your patience
with us.
You were giving us a variety of work that is going on,
studies of comparatives. What percentage of the participants in
this demonstration project classify as older Americans?
Dr. Mahoney. In Arkansas, from which I just presented the
data----
The Chairman. Yes.
Dr. Mahoney [continuing]. About 72 percent of the
individuals that took part were elderly, and that certainly
dispels the myths that older people aren't interested in
managing services themselves. The percentages change in the
other States, but maybe 50 percent in New Jersey, and just by
nature of the demonstration, maybe about a third in Florida.
The Chairman. That is fascinating to hear, and absolutely,
they are concerned about that kind of management. It is a
matter of controlling their own lives or having some say in it
and feeling comfortable about it, I would guess.
Does the study you reference in your testimony consist of a
side-by-side comparison of older Americans receiving services
in the traditional fashion compared to those applying consumer-
directed choices?
Dr. Mahoney. If I understand correctly, exactly. People who
volunteered to take part in the demonstration were, in fact,
randomly assigned, so half of them went to the traditional
system, half of them got the chance to manage the cash
allowance, and with that kind of numbers, given that we had
about 6,700 people enroll in the three States, this is a very
powerful way of evaluating these impacts.
The Chairman. Does your study conclude that better services
can be achieved at the same costs? Is there a net cost savings?
Dr. Mahoney. I knew you would ask that. As I was showing,
the cost results will be our next effort.
The Chairman. OK.
Dr. Mahoney. We are hoping those will come out over the
summer. The good news is, at this stage, for instance, for
Arkansas, they are meeting the Center for Medicare and Medicaid
Service's budget neutrality requirements, so their research and
demonstration waiver has just been extended another 5 years,
and they have been able to get rid of the randomization, so at
this point, everyone who wants to be part of this demonstration
can be.
The Chairman. Excellent. As you know, rural areas often
face challenges accessing services. Has the demonstration
project been implemented in rural areas of the host States, and
if so, what has been the results?
Dr. Mahoney. The demonstration was in the whole State of
Arkansas, the whole State of New Jersey, and in Florida, for
elderly people and adults with disabilities, the lower two-
thirds of the State, children for the whole State. This is a
demonstration particularly helpful in rural areas and where it
is very hard for agencies to serve, where the worker shortage
was at its worst.
One of the things we found in Arkansas was if you
interviewed the people 9 months after they came in, for people
who were getting the cash allowance, 95 percent of them were
getting personal assistance services, whereas for those in the
traditional side, only about two-thirds of the adults with
disabilities and only about 80 percent of the elderly were
getting their care plans met. So in times of worker shortage,
and especially in rural areas, this is a wonderful, a wonderful
choice.
The Chairman. Back me up a bit. You are saying those that
were under the cash plan.
Dr. Mahoney. Right.
The Chairman. Actually were getting greater levels of
service than those under the traditional programs.
Dr. Mahoney. Right. Well, for instance, in the treatment
group the consumer got a cash allowance exactly equal to what
that person would have received under the traditional program,
but they got to decide how to spend it on meeting their
personal care needs. They had to develop a individualized plan.
They could hire friends, family, people who wouldn't have been
in the workforce. They could renovate their homes, or buy
assistive devices. Whereas in the traditional system, where
there was such trouble finding aides and workers, in many cases
people just didn't get the services that were called for in the
care plan.
The Chairman. I am treading into water that I will be a
little cautious on, because I have all the respect in the world
for professional, well-skilled, trained caregivers, but are we
suggesting by this that there are others capable of rendering
care and service to a given senior that they can seek out who
may not be as well trained or trained in some areas as a
professionally trained person, but certainly are capable of
delivering those services, and as a result, the service got
delivered?
Dr. Mahoney. Right. I think that is fair. I am involved in
caring for my mother. In so many cases, basic services that
families provide aren't skilled medical services.
The Chairman. No.
Dr. Mahoney. This is help bathing, dressing, toileting.
The Chairman. Exactly.
Dr. Mahoney. Remember what we found here. Those results
show that the health effects were either the same or where they
differed better for those who manage their own allowance. The
younger adults with disabilities had fewer bedsores when they
could choose people who really knew them and had a personal
relationship.
The Chairman. That is fascinating. Well, I trust you will
keep the committee and our staff abreast of your work and the
conclusions, the balance of the work you are doing. As our time
and our focus permits, we will have you back to give us an
analysis of the studies when they are completed.
Dr. Mahoney. We would very much enjoy that. Thank you.
The Chairman. Thank you. I find those findings fascinating.
I appreciate your time, and please feel free to leave if you
feel it necessary based on your schedule.
Dr. Mahoney. Thank you for your consideration. Thank you.
The Chairman. Now, let me turn to you, Ms. Greene. What you
are doing in the flexibility you are offering, is exciting.
What challenges has your agency faced in implementing the
Family Caregiver Support Program in Georgia, challenges and/or
obstacles?
Ms. Greene. Well, when we did our caregiver focus groups to
find out what our citizens or caregivers said they wanted or
didn't want, we recognized right away that we had some
challenges. They said that they wanted more information,
assistance and referral. They wanted more training for
themselves. They felt that our current providers needed more
training, that they were agist. They requested more respite
care.
Probably the most challenging, but the one that we had a
lot of interest from other organizations, was with the training
aspect. We have coordinated with AARP, the Georgia Gerontology
Society, a staffing solutions workgroup, the Alzheimer's
associations, all came together to address the issue of not
only training informal caregivers better, our personnel staff.
That has been very interesting and I have really enjoyed the
collaborative work with all the different associations to help
make that happen.
The Chairman. In what ways could the self-directed approach
you have mentioned be applied in the delivery of other aging
services?
Ms. Greene. We were talking most recently about we have a
dire need for transportation, especially most of the counties
in Georgia are rural counties. We were talking about the
possibility of hiring or making arrangements for friends and
neighbors also to transport people to services, and so that is
another consideration that we are looking for. But we have a
real need that we need to address in transportation that our
current level of fund sources, from all different fund levels,
is not an adequate amount to meet the transport needs.
The Chairman. Now, here is a question that dovetails with
the work that Dr. Mahoney is doing and it was a question
lingering in the back of my mind that I think, well, certainly
with the program you have established, Doctor--or let me ask
the question and feel free, if you would, to come in after Ms.
Greene to talk about this approach.
Some concerns have been expressed that allowing families to
hire relatives and friends to provide care might result in the
misuse of funds. What has been your experience in Georgia?
Ms. Greene. So far, we have not seen any misuse of funds,
probably better management of the funds. We have a service
coordinator in every region, so the family members and the care
receiver develop a plan or they decide how they can best use
the funds. Right now, there is an average of $1,200 to $1,500
spent a year. So they just call their service coordinator and
they say, ``This is what we really need.'' Mom has had another
stroke. Now she is in a wheelchair. We really need to build a
ramp, for example. The service coordinator then OKs the
expenditure of the funds and then they are reimbursed for the
service. So we really have not seen any misuse of the funds.
The Chairman. Doctor, do you wish to comment on that?
Dr. Mahoney. I will put it in this context. The Arkansas
project got underway in December 1998, New Jersey a year later,
and Florida in June of 2000. We have had no major instances of
fraud and abuse. In this context, of people who hired their own
personal assistance workers, I think about 75 percent hired
some level of family member and maybe another 17 percent hired
people they knew through church, through their neighborhood:
One of the things you end up finding is that they have hired
people that had a real personal relationship that made a
difference. That is not to say that we don't have important
monitoring and quality management processes in each of these
States, which again, I would be pleased to share.
The Chairman. Thank you. This February, I held a hearing on
the misuse of guardianships over the elderly. I was disturbed
by accounts that the wishes of older Americans and their
families are oftentimes ignored by persons bringing forth these
actions. How does Georgia's mediation program prevent this type
of undue control over a person's life?
Ms. Greene. The people who have been trained to be
mediators have worked actively with the Probate Judges'
Association, and in Fulton County, which is the largest probate
office in the State, they have agreed that prior to--when
someone comes to the court to petition that they become a
guardian of someone, that they are then provided information
and educated about the mediation process. It is not mandated by
the court, but it is strongly encouraged by the court that they
go through the mediation process.
So we are real excited about the relationships with the
probate judges and that we have the largest county agreeing to
work with us actively to seek mediation with families. So a lot
of it, I think, is education, not only to the families about a
mediation option, but also to the court system, that it is a
viable option that could work and also save a lot of grief and
financial cost.
The Chairman. Thank you very much for your being here and
your testimony and the work you are doing. I find all of that
very fascinating.
I had one other question as it related to mobile day care.
Does the program have a wellness screening component in it?
Ms. Greene. Yes, sir, it does. In fact, we have a statewide
wellness program and it is done in conjunction with all of our
other service components, and so they are screened to what
ability they might be able to participate in exercise,
nutrition education, medications management.
The Chairman. Good. Thank you. Thank you very much.
Dr. Aday, the work you are doing is fascinating to me
because it is always intriguing to me about anyone's ability to
successfully predict the future or at least to look outward and
determine what needs might be. For a baby boomer that has just
turned 60 and is relatively healthy and active, what would be
the appeal for this older American to attend a senior center? I
am assuming when I ask that question that this 60-year-old
would be attending a senior center of today.
Dr. Aday. Since I turn 60 next year, I will try to answer
that as best I can.
The Chairman. Oh, my goodness. We are getting truly
personal testimony here. Thank you.
Dr. Aday. Personal testimony. [Laughter.]
I think when we look at today as well as the future, I
think that the senior center certainly provides different
functions. Certainly, a 60-year-old could come to the center
for a very different reason than maybe that person's aging
parent. You might come to the senior center to bring your aging
parent, as we have adult day services in our center, to drop
them off, and you might want to go then engage in a day trip
and then return that evening, for example.
But as I mentioned earlier, I think some of the other
activities that we see already going on in senior centers do
include things like retirement counseling and retirement
training. We have lifelong learning that has been a steadfast
component of senior centers for a number of years. So those are
some of the kinds of activities, educational classes that might
be inviting. Basically, if you have partnerships with local
universities, they can offer topics that would attract a 60-
year-old.
I think some other factors that would also attract when you
are talking about coming into a senior center, would be the
opportunity to provide leadership skills on a community senior
center board. We know that if our senior centers are going to
become more sophisticated, the governing boards must also be
sophisticated, and so we have to attract really quality people
in leadership roles that can move senior centers forward in the
21st century. I have observed that very thing happen in my
community. It just so happened that the people on that board
and on our city council who were assigned to the advisory board
enabled us to do some very progressive things.
So I think that you have to have forward-looking people and
many of those are going to come from the young-old group.
Someone who can come and provide leadership and volunteer
services and assist with your other older clients that are also
participating in senior center programs.
The Chairman. How many senior centers in this country today
have that kind of appeal to them, from your understanding and
study?
Dr. Aday. The recent research that I did, and it wasn't a
random sample, but certainly 90 percent of the respondents
indicated they were very satisfied with the knowledge and
information that they were getting at their senior centers. We
know that senior centers, of course, are very diverse. Some of
them are open on a part-time basis. They may have just a
director and that is all that person does. They are very
limited in terms of funds.
On the other hand, you have multi-purpose senior centers,
and I don't know the exact number that would fall into that
category. I think we do need some additional research really to
look at where we are today as far as providing this myriad of
services and then also looking at what kind of projections,
what kind of plans these 1,300 or 1,400 senior centers have in
the future and what they have currently in place.
We know that NISC and other organizations are providing
leadership with getting senior centers accredited, so they will
become accredited entities which will, give senior centers a
much more professional kind of appeal and it also enables, I
think, the people that are funding senior centers to know that
they have a quality product. But I don't know the exact number
that are certainly in what we call the progressive mode now as
far as providing these kind of services.
The Chairman. The one thing that I often hear from 65-year-
olds is, well, I don't go to senior centers. They are for old
folks. But the kind of center you are talking about, with those
kinds of dynamics and services and opportunities in them,
wouldn't classify in that sense. So 10 or 15 years down the
road, should we be calling them senior centers?
Dr. Aday. That is certainly an issue that is being
discussed in the network at the present time. I don't think
there are really any conclusions that have been drawn, whether
you want to call them centers for vital aging or even taking
the term ``senior'' out of it.
I was very excited when I became a senior in high school
because I had seniority. [Laughter.]
When I became a senior in college, likewise. When I became
a senior professor. So it seems like we like to be a senior
executive, but when it comes to equating the term senior we
have difficulty accepting it with age. It goes back to what I
think Senator Breaux was talking about. We have kind of
implanted this ageism, well, now, I can't be a part of that
group and rather look forward to it. So I think it really
speaks to our society when we have trouble embracing where we
are chronologically.
So I think each center or each community will have to make
that decision, since senior centers are built and primarily
funded at the local level. They will determine what they are
going to be termed and what will be the best way of getting
people there.
It could be marketing. I think one of the issues we have
here is just the stereotype that senior centers provide
congregate meals and bingo. So it is just a lack of knowledge
of what really goes on in senior centers.
The senior center campus that I work with is really more
like a high school. If you go into it, you have a computer lab
and you have classrooms and you have all these classes. So
inside, the decor looks more like an educational unit than it
would what we call the traditional senior center. Now, not all
senior centers, of course, are at that particular stage, but I
think part of it is going to be dealing with how we market
ourselves and how we can appeal and attract that younger person
coming in.
We do know that the baby boomers are going to be much more
educated than today. I think by 2030, twice as many will have a
college diploma as today. The research that I conducted in
seven States, 20 percent had college degrees that were coming
to the senior center. So we are seeing a different kind of
clientele and they are going to be demanding different kinds of
services. I think when you get more of those people to come
they tell their friends about it. Word of mouth in many cases
is the best way that you can market a good product. I think
what we are talking about today is evolving, and so this is not
going to happen overnight, but I think over a period of time.
We should see an evolvement and a change in the clientele and a
new mission for senior centers.
The Chairman. Thank you very much for your testimony and
the work you are doing. I find it fascinating, because it
really is a part of the quality of life that these baby boomers
are going to be moving toward, and I think they are going to be
a group of our citizens who are going to be a good deal more
demanding simply by their level of entry into that community of
interest and their uniquenesses that will be very different
from their parents.
Dr. Aday. They have had an impact at every stage.
The Chairman. Oh, yes.
Dr. Aday. This will be no different.
The Chairman. Now, how, Doctor, can we move technology into
that senior community? Let us talk about the home that you are
talking about and the sophistication involved. In your opinion,
how long will it be before the average person will have access
to the sophisticated technologies like the awareness home that
you have demonstrated here?
Dr. Abowd. It depends on what kind of service you are
talking about. Some of the demonstrations that we have done and
technology we have built, for example, the digital family
portrait, is all done with technology and capability that we
have today. There is no real magic behind a project like that.
What we are lacking with something like that is a business
plan that would encourage people to invest in and provide this
kind of service to distribute to family members, for example,
although on that note, we have had a number of people who have
seen the digital family portrait and have on their own
essentially mocked up their own version of sensing in their
parents' home, with a way to dial up and produce information to
a central server that then can provide information at any place
the individual desires.
The best way to leverage off the kind of existing
technology we have in the homes today is to not require
identity to be part of the sensed equation. So if you were to
use the basic motion-detecting sensors that are in home
security systems right now and you used that information for a
household that has one or two family members, you can make very
good inferences about where an individual is, or even more
importantly, how much that individual is moving around, so you
can communicate to someone else in a secure way about that. So
for those kinds of applications, we could do that today.
For some of the more sophisticated applications that
require understanding of an activity, like the blood glucose
meter example I gave, where you are trying to understand where
someone is in a relatively simple and straightforward
sequential process, that is possible to do today in the
laboratories, but in very controlled settings. It wouldn't work
if I just deployed that in anyone's home without any control
over the ambient lighting. So there needs to be a significant
amount of advances in making those algorithms more robust, and
I think we are talking a 5- to 10-year horizon before the
research is robust enough to be able to produce those kinds of
services.
But before we have those kinds of capabilities, we want to
be able to get a glimpse of what that future would be like and
to evaluate what services would be important and which ones
would not. That is why a project--why I showed you the cook's
collage, the reminder system in the kitchen. It is being done
with smoke and mirrors, but it is being used to conduct
controlled studies to find out if we could get the technology
to do that automatically, would it be a valuable memory service
in the home, so that we can inform the advanced technology
research about what kinds of problems they do need to solve in
the next 5 to 10 years because we see the value in terms of
helping an older population.
The Chairman. I recently reviewed a technology that would
have to have a cooperative effort of the food manufacturer with
certain software programs, but there was a code on the back of
a given container of food that when moved across a scanner
could project up on a screen a large read-out of how to prepare
that food, or the simple instructions that might be beyond the
visual capability of the person. It would simply plant out on
the kitchen screen that could be used for a multitude of other
purposes as to how to program the--or it may even program the
microwave itself, preparing it for that particular food. Have
you looked at any of those or seen any of those kinds of
technologies?
Dr. Abowd. Yes, I have. What is very interesting about the
kind of technology you are talking about is it is becoming very
affordable to essentially tag all items with--in the past, we
have used bar codes, so we can use optical scanning to be able
to read them. But there are problems with line of sight, being
able to see the code.
With the kind of technology you are referring to, one of
which is radio frequency identification tags, or RFID, you
don't need line of sight and you can essentially fashion a
region of space that can read a code on any tagged item that
comes near it. So, for example, placing something on the
countertop, the counter then knows what is placed on top of it
and there are a lot of activities or possibilities you can
leverage on top of that.
So it is because these kinds of simple sensing technologies
are now commodity technologies that work very reliably that we
can provide these kind of services. One simple example we have
done in the aware home, and we are one of the first to do this
kind of activity, is we have used that RFID technology in a
slightly different way, to provide location information for
individuals and objects within the house. So we fashioned floor
mats that sit at various strategic points in the house and
individuals wearing non-powered tags somewhere below the knee,
usually attached to the shoe or around the ankle, then just
need to walk in the aware home and it will pick up what room or
what location they are in.
That information feeds directly into something like the
digital family portrait. It also feeds into a variety of other
kinds of applications that can leverage off that room level
awareness. So it is a very exciting time from the sensing
perspective, because we can now realize these kinds of
applications in the living environments like a home.
The Chairman. You have mentioned several technologies. Any
others that you see that are going to be a direct asset to this
kind of home?
Dr. Abowd. I think a critical kind of technology, I talked
about doing a purpose-built laboratory like the aware home.
Also, there are continuing care retirement communities that are
being special built for which you can, at the time you
construct the building, can put in special kinds of
technologies.
But the real problem is being able to retrofit existing
communities. So these naturally occurring retirement
communities with the technology to provide the same kind of
capabilities, and there, I think, wireless technologies are
advancing to the point where we will be able to retrofit
relatively easily lots of sensing and communication
capabilities that won't require you to tear down the walls and
won't be all that difficult to be able to put into homes. So
that is when you will start to see the real mass market effect.
The Chairman. Well, I concur with you. Obviously, the
rather simple process now of creating wireless technology for
your home, for your laptop and all of that, is really
phenomenally simple and relatively inexpensive. Of course, all
new--not all, many new homes are now being wired with that kind
of capability, so that is very positive.
The interesting thing about the new technologies is that
the baby boomers won't be as hostile to them, obviously, as the
generation before them, and quite understandably so. Also, the
best part about it is if they don't understand them, they can
just ask their grandkids. [Laughter.]
They will give them a rather simple explanation of how to
do it, because they will have figured it out a long time before
that.
Doctor, we thank you very much for your testimony and your
work. Those are exciting new opportunities, I think, as we move
along, and we appreciate it very much.
Dr. Abowd. Thank you for the opportunity to present it.
The Chairman. To all of you, thank you very much for being
with the committee today and helping us build a record in these
areas. We believe it is extremely important as we look at
especially the opportunity and the challenge of this baby
boomer generation that is about to be upon us, and as a member
of that generation, I am going to be as demanding as any of the
rest of us, I suspect. But I also want our public policy to be
prepared for us when we get there.
Thank you all very much for being with the committee today.
The committee will stand adjourned.
[Whereupon, at 3:53 p.m., the committee was adjourned.]
A P P E N D I X
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