    [House Hearing, 116 Congress]
    [From the U.S. Government Publishing Office]

                       EXAMINING THE OLDER AMERICANS ACT:
                       PROMOTING INDEPENDENCE AND DIGNITY
                               OF OLDER AMERICANS

    =======================================================================

                                     HEARING

                                   BEFORE THE

                SUBCOMMITTEE ON CIVIL RIGHTS AND HUMAN SERVICES

                             COMMITTEE ON EDUCATION
                                   AND LABOR
                         U.S. HOUSE OF REPRESENTATIVES

                         ONE HUNDRED SIXTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                  HEARING HELD IN WASHINGTON, DC, MAY 15, 2019

                                   __________

                               Serial No. 116-23

                                   __________

          Printed for the use of the Committee on Education and Labor

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

               Available via the World Wide Web: www.govinfo.gov
                                       or
                  Committee address: https://edlabor.house.gov

                                   __________

                        U.S. GOVERNMENT PUBLISHING OFFICE
    36-598 PDF                  WASHINGTON : 2020

    --------------------------------------------------------------------------------------

                        COMMITTEE ON EDUCATION AND LABOR

                 ROBERT C. ``BOBBY'' SCOTT, Virginia, Chairman

    Susan A. Davis, California           Virginia Foxx, North Carolina,
    Raul M. Grijalva, Arizona            Ranking Member
    Joe Courtney, Connecticut            David P. Roe, Tennessee
    Marcia L. Fudge, Ohio                Glenn Thompson, Pennsylvania
    Gregorio Kilili Camacho Sablan,      Tim Walberg, Michigan
      Northern Mariana Islands           Brett Guthrie, Kentucky
    Frederica S. Wilson, Florida         Bradley Byrne, Alabama
    Suzanne Bonamici, Oregon             Glenn Grothman, Wisconsin
    Mark Takano, California              Elise M. Stefanik, New York
    Alma S. Adams, North Carolina        Rick W. Allen, Georgia
    Mark DeSaulnier, California          Francis Rooney, Florida
    Donald Norcross, New Jersey          Lloyd Smucker, Pennsylvania
    Pramila Jayapal, Washington          Jim Banks, Indiana
    Joseph D. Morelle, New York          Mark Walker, North Carolina
    Susan Wild, Pennsylvania             James Comer, Kentucky
    Josh Harder, California              Ben Cline, Virginia
    Lucy McBath, Georgia                 Russ Fulcher, Idaho
    Kim Schrier, Washington              Van Taylor, Texas
    Lauren Underwood, Illinois           Steve Watkins, Kansas
    Jahana Hayes, Connecticut            Ron Wright, Texas
    Donna E. Shalala, Florida            Daniel Meuser, Pennsylvania
    Andy Levin, Michigan*                William R. Timmons, IV, South
    Ilhan Omar, Minnesota                    Carolina
    David J. Trone, Maryland             Dusty Johnson, South Dakota
    Haley M. Stevens, Michigan
    Susie Lee, Nevada
    Lori Trahan, Massachusetts
    Joaquin Castro, Texas
    * Vice-Chair

                       Veronique Pluviose, Staff Director
                     Brandon Renz, Minority Staff Director
                                     ------

                SUBCOMMITTEE ON CIVIL RIGHTS AND HUMAN SERVICES

                      SUZANNE BONAMICI, OREGON, Chairwoman

    Raul M. Grijalva, Arizona            James Comer, Kentucky,
    Marcia L. Fudge, Ohio                  Ranking Member
    Kim Schrier, Washington              Glenn ``GT'' Thompson,
    Jahana Hayes, Connecticut                Pennsylvania
    David Trone, Maryland                Elise M. Stefanik, New York
    Susie Lee, Nevada                    Dusty Johnson, South Dakota

                                C O N T E N T S

                                  ----------
                                                                       Page

    Hearing held on May 15, 2019.....................................     1

    Statement of Members:
        Bonamici, Hon. Suzanne, Chairwoman, Subcommittee on Civil
          Rights and Human Services..................................     1
            Prepared statement of....................................     3
        Comer, Hon. James, Ranking Member, Subcommittee on Civil
          Rights and Human Services..................................     4
            Prepared statement of....................................     5

    Statement of Witnesses:
        Archer-Smith, Ms. Stephanie, Executive Director, Meals on
          Wheels of Central Maryland, Inc............................    13
            Prepared statement of....................................    15
        Ducayet, Ms. Patricia, LMSW, Texas State Long-Term Care
          Ombudsman, Texas Health and Human Services.................    30
            Prepared statement of....................................    32
        Girard, Ms. Lee, Director, Multnomah County Aging, Disability
          and Veterans Services......................................     7
            Prepared statement of....................................     9
        Whiting, Ms. C. Grace, J.D., President and CEO National
          Alliance Caregiving........................................    22
            Prepared statement of....................................    24

    Additional Submissions:
        Chairwoman Bonamici:
            ADRC Business Case: Final Report.........................    59
        Questions submitted for the record by:
            Chairwoman Bonamici

            Schrier, Hon. Kim, a Representative in Congress from the
              State of Washington....................................   106
        Responses to questions submitted for the record by:
            Ms. Archer-Smith.........................................   107
            Ms. Ducayet..............................................   109
            Ms. Girard...............................................   112
            Ms. Whiting..............................................   114

                       EXAMINING THE OLDER AMERICANS ACT:.
                           PROMOTING INDEPENDENCE AND
                           DIGNITY OF OLDER AMERICANS

                                  ----------

                            Wednesday, May 15, 2019

                            House of Representatives

                       Committee on Education and Labor,

                Subcommittee on Civil Rights and Human Services

                                Washington, DC.

                                  ----------

        The subcommittees met, pursuant to notice, at 10:18 a.m.,
    in room 2175, Rayburn House Office Building. Hon. Suzanne
    Bonamici [chairwoman of the subcommittee] presiding.
        Present: Representatives Bonamici, Schrier, Hayes, Trone,
    Lee, Comer, Thompson, Stefanik, and Johnson.
        Also present: Representatives Scott, and Foxx.
        Staff present: Nekea Brown, Deputy Clerk; Ilana Brunner,
    General Counsel Health and Labor; Brutrinia Cain, HHS Detailee/
    Health Fellow; Emma Eatman, Press Aide; Alison Hard,
    Professional Staff; Carrie Hughes, Director of Health and Human
    Services; Ariel Jona, Staff Assistant; Stephanie Lalle, Deputy
    Communications Director; Katie McClelland, Professional Staff;
    Richard Miller, Director of Labor Policy; Max Moore, Office
    Aide; Veronique Pluviose, Staff Director; Banyon Vassar, Deputy
    Director of Information Technology; Cyrus Artz, Minority
    Parliamentarian, Courtney Butcher, Minority Director of Member
    Services and Coalitions; Bridget Handy, Minority Communications
    Assistant; Amy Raaf Jones, Minority Director of Education and
    Human Resources Policy; Kelley McNabb, Minority Communications
    Director; Jake Middlebrooks, Minority Professional Staff
    Member; Casey Nelson, Minority Staff Assistant; Brandon Renz,
    Minority Staff Director; Mandy Schaumburg, Minority Chief
    Counsel and Deputy Director of Education Policy; Meredith
    Schellin, Minority Deputy Press Secretary and Digital Advisor;
    and Heather Wadyka, Minority Operations Assistant.
        Chairwoman BONAMICI. The Subcommittee on Civil Rights and
    Human Services will come to order. I note a quorum is present.
    This meeting will hear the testimony on examining the Older
    Americans Act, promoting independence and dignity for older
    Americans.
        Pursuant to committee rule 7c opening statements are
    limited to the Chair and ranking member. This allows us to hear
    from our witnesses sooner and provides all members with
    adequate time to ask questions.
        I recognize myself now for the purpose of making an opening
    statement.
        We are here today to examine the Older Americans Act, a
    critically important pillar of our efforts to improve the
    quality of life for older Americans and their families.
        In 1965, Congress passed the Older Americans Act, or OAA,
    to provide basic supports to aging Americans. Since then,
    Congress has repeatedly updated and strengthened the OAA in a
    bipartisan manner to fulfill its mission of helping more
    Americans live independently and age with dignity.
        OAA programs have been consistently successful, which has
    led to a gradual expansion of the services it provides. The Act
    now supports a range of community-based programs that target
    assistance to those who need it most.
        Of the many vital OAA programs, one of the most recognized
    is nutrition assistance offered through both congregate meal
    sites and home-delivered programs such as Meals on Wheels.
    OAA's nutrition assistance programs provide more than 900,000
    healthy meals to older Americans each day.
        OAA also supports elder justice activities and funds
    programs to prevent elder abuse. Additionally, the Act offers
    community service employment opportunities to low-income
    seniors, allowing them to access part-time work that both
    supports them economically and provides purpose and social
    engagement.
        OAA also provides family caregivers with much needed
    training, respite, and support. And based on my own experience
    caring for my 90-year-old mother, who has Alzheimer's, I can
    particularly appreciate the importance of the National Family
    Caregiver Support Program.
        Collectively, OAA programs serve about 11 million older
    adults, 3 million of whom regularly look to OAA services for
    basic needs. Importantly, OAA programs work together to make
    sure that aging adults retain independence and avoid costly
    institutionalized care for as long as possible.
        Despite the success of the Older Americans Act, in recent
    years our investment has not kept pace with inflation and has
    not recognized the rising number of older Americans and the
    challenges they continue to face.
        Although the population of Americans age 60 and over has
    grown more than 60 percent since 2001, OAA funding has only
    grown by roughly 20 percent. And, accounting for inflation, OAA
    funding has steadily declined by 16 percent.
        The disinvestment has weakened OAA programs at a time of
    growing demand for the services they provide. Nearly 1 in 10
    Americans over the age of 65 lives in poverty, and they are not
    getting the support they need. A 2015 Government Accountability
    Office study found that 83 percent of food insecure, low-income
    older Americans did not receive any meal services, and 2 in 3
    older Americans who struggle with daily activities received
    limited or no home-based care.
        As the number of older Americans continues to increase,
    Congress must strengthen our support for OAA's proven, long-
    standing programs. We must recommit to providing basic services
    and compassionate care to vulnerable members of our
    communities.
        Not only is this the right thing to do, but the economics
    also make sense. OAA allows older Americans to delay or
    altogether avoid costlier care by promoting healthier--healthy
    behaviors, such as chronic disease management, and by providing
    the supportive services that allow seniors to age in place.
        That is the responsibility and the opportunity facing this
    committee and the 116th Congress. We are in a position to
    advance a reauthorization of the Older Americans Act that will
    allow millions of Americans across the country to age with
    dignity.
        This hearing is an important first step. Today, we will
    discuss the challenges facing older Americans, what OAA
    programs look like across the country, and how the OAA supports
    millions of seniors and their families.
        Today we are also continuing the law's tradition of strong
    bipartisan support. I was honored to be involved in the 2016
    reauthorization when both the House and Senate unanimously
    supported the legislation and I look forward to once again
    working with Ranking Member Comer, Ranking Member Foxx, and of
    course Chairman Scott, and all my colleagues on both sides of
    the aisle to advance a robust Older Americans Act
    reauthorization bill this year.
        Thank you to the distinguished witnesses for being here
    today. I look forward to this discussion.
        And I now recognize the distinguished ranking member for
    the purpose of an opening statement.
        [The statement of Chairwoman Bonamici follows:]

     Prepared Statement of Hon. Suzanne Bonamici, Chairwoman, Subcommittee
                       on Civil Rights and Human Services

        We are here today to examine the Older Americans Act, a critically
    important pillar of our efforts to improve the quality of life for
    older Americans and their families.
        In 1965, Congress passed the Older Americans Act, or O-A-A, to
    provide basic supports to aging Americans. Since then, Congress has
    repeatedly updated and strengthened OAA in a bipartisan manner to
    fulfill its mission of helping more Americans live independently and
    age with dignity. OAA programs have been consistently successful, which
    has led to a gradual expansion of the services it provides. The Act now
    supports a range of community-based programs that target assistance to
    those who need it most.
        Of the many vital OAA programs, one of the most recognized is
    nutrition assistance offered through both congregate meal sites and
    home-delivered programs such as Meals on Wheels. OAA's nutrition
    assistance programs provide more than 900,000 healthy meals to older
    Americans each day. OAA also supports elder justice activities and
    funds programs to prevent elder abuse. Additionally, the Act offers
    community service employment opportunities to low-income seniors,
    allowing them to access part-time work that both supports them
    economically and provides purpose and social engagement. OAA also
    provides family caregivers with much-needed training, respite, and
    support. And based on my own experience caring for my 90-year-old
    mother, who has Alzheimer's, I can particularly appreciate the
    importance of the National Family Caregiver Support Program.
        Collectively, OAA programs serve about 11 million older adults 3
    million of whom regularly look to OAA services for basic needs.
    Importantly, OAA programs work together to make sure that aging adults
    retain independence and avoid costly institutionalized care for as long
    as possible.
        Despite the success of the Older Americans Act, in recent years our
    investment has not kept pace with inflation and has not recognized the
    rising number of older Americans and challenges they continue to face.
        Although the population of Americans age 60 and over has grown more
    than 60 percent since 2001, OAA funding has only grown by roughly 20
    percent. And, accounting for inflation, OAA funding has steadily
    declined by 16 percent.
        This disinvestment has weakened OAA programs at a time of growing
    demand for the services they provide. Nearly one in ten Americans over
    the age of 65 lives in poverty, and they are not getting the support
    they need. A 2015 Government Accountability Office study found that 83
    percent of food insecure, low-income older Americans did not receive
    any meal services. And two in three older Americans who struggle with
    daily activities received limited or no home-based care.
        1
        As the number of older Americans continues to increase, Congress
    must strengthen our support for OAA's proven, long-standing programs.
    We must recommit to providing basic services and compassionate care to
    vulnerable members of our communities.
        Not only is this the right thing to do, but the economics also make
    sense. OAA allows older Americans to delay or altogether avoid costlier
    care by promoting healthy behaviors, such as chronic disease
    management, and by providing the supportive services that allow seniors
    to age in place.
        That is the responsibility and the opportunity facing this
    Committee and the 116th Congress. We are in a position to advance a
    reauthorization of the Older Americans Act that will allow millions of
    Americans across the country to age with dignity.
        This hearing is an important first step. Today, we will discuss the
    challenges facing older Americans, what OAA programs look like across
    the country, and how the OAA supports millions of seniors and their
    families. Today we are also continuing the law's tradition of strong
    bipartisan support. I was honored to be involved in the 2016
    reauthorization when both the House and Senate unanimously supported
    the legislation. I look forward to once again working with Ranking
    Member Comer, Ranking Member Foxx, Chairman Scott, and all my
    colleagues on both sides of the aisle to advance a robust Older
    Americans Act reauthorization bill this year.
        Thank you to the distinguished witnesses for being here today. I
    look forward to this discussion and now yield to the Ranking Member,
    Mr. Comer, for the purpose of an opening statement.
                                     ______

        Mr. COMER. Thank you, Madam Chairman, for yielding.
        Today's life expectancy in our Nation is at a historic
    high, which is great news and it means we need to be doing all
    we can to ensure that Americans have access to quality, timely
    services which allow them to live in their homes as long as
    possible.
        This hearing will help us better understand what might be
    done to ensure the law is aging as well as the people it saves.
        Since 1965 the Older Americans Act, or OAA, has governed
    the organization and delivery of services for senior citizens
    throughout the country. With more than 41 million Americans 65
    and older, the social and nutritional programs offered by OAA
    are critical to helping them maintain independence. The reach
    of this law is substantial and covers many aspects of elder
    care.
        In addition to well known programs like Meals on Wheels,
    OAA support services provided by more than 300 State, tribal,
    and native Hawaiian organizations and approximately 200,000
    local providers. Some of these services include nutrition
    programs, providing meals for senior citizens, schools, and
    churches, care to prevent the abuse, neglect, and exploitation
    of seniors, family care giver support systems, and community
    service employment opportunities for older Americans.
        These types of programs offer valuable assistance for
    American seniors and the Federal Government should continue to
    support them. I know that I do.
        As our committee considers reauthorization of OAA, I am
    confident that we can work together on bipartisan legislation
    to support our Nation's seniors through effective policy.
        I thank the witnesses for being here today and hope today's
    discussion will offer insights into how we can build upon OAA's
    flexible policies to promote consumer driven independent living
    for older Americans.
        Madam Chairman, I yield back.
        [The statement of Mr. Comer follows:]

    Prepared Statement of Hon. James Comer, Ranking Member, Subcommittee on
                        Civil Rights and Human Services

        Thank you for yielding.
        Today's life expectancy rate in our Nation is at a historic high,
    which is great news, and it means we need to be doing all we can to
    ensure that Americans have access to quality, timely services which
    allow them to live in their homes as long as possible. This hearing
    will help us better understand what might be done to ensure the law is
    aging as well as the people it serves.
        Since 1965, the Older Americans Act, or OAA, has governed the
    organization and delivery of services for senior citizens throughout
    the country. With more than 41 million Americans 65 and older, the
    social and nutritional programs offered by OAA are critical to helping
    them maintain independence.
        The reach of this law is substantial and covers many aspects of
    elder care. In addition to well-known programs like Meals on Wheels,
    OAA supports services provided by more than 300 State, Tribal, and
    Native Hawaiian organizations and approximately 20,000 local providers.
    Some of these services include: nutrition programs providing meals at
    senior centers, schools, and churches; care to prevent the abuse,
    neglect, and exploitation of seniors; family caregiver support systems;
    and community service employment opportunities for older Americans.
    These types of programs offer valuable assistance for America's
    seniors, and the Federal Government should continue to support them.
        As our committee considers a reauthorization of OAA, I am confident
    that we can work together on bipartisan legislation to support our
    Nation's seniors through effective policy. I thank the witnesses for
    being here and hope today's discussion will offer insights into how we
    can buildupon OAA's flexible policies to promote consumer-driven,
    independent living for older Americans.
                                     ______

        Chairwoman BONAMICI. Thank you very much to the ranking
    member.
        Without objection, all other members who wish to insert a
    written statement into the record may do so by submitting them
    to the committee clerk electronically in Microsoft Word format
    by 5 p.m. on May 29, 2019.
        I will now introduce our witnesses. I am honored to
    introduce Lee Girard, who is the director of Multnomah County
    Aging, Disability, and Veterans Services Division, the
    federally designated Area Agency on Aging, or AAA, from
    Multnomah County, Oregon, and the largest AAA in the State of
    Oregon. Multnomah County Aging, Disability, and Veterans
    Services Division serves approximately 40 percent of the
    State's caseload in long-term services and supports.
        The Division operates Older Americans Act programs, State
    funded programs, adult protective services, and Medicaid
    eligibility for long-terms services and supports for older
    adults, people with disabilities, and veterans. Lee has a staff
    of 465, with 10 community centers and 11 meal sites, reaching
    more than 136,000 consumers annually.
        Lee currently serves as the chair of the Oregon Association
    of Area Agencies on Aging, the member association representing
    the area agencies in the State of Oregon. She is also a board
    member of the National Association of Area Agencies on Aging,
    or n4a.
        We are going to come back to Ms. Archer-Smith.
        Next is Christina Grace Juno Whiting. She is the president
    and chief executive officer at the National Alliance for
    Caregiving, where she continues her tenure from previous roles,
    including chief operating officer and the director of strategic
    partnerships.
        Grace led the launch of the Caregiving in the U.S. 2015
    research study with AARP and directed the first national public
    policy study of rare disease caregivers with Global Genes.
        She has contributed to several national reports on
    caregiving, including Cancer Caregiving in the U.S., with the
    National Cancer Institute and Cancer Support Community, and
    Dementia Caregiving in the U.S., with the Alzheimer's
    Association.
        She is also a member of the American Society on Aging and
    the Gerontological Society of America.
        Next we have Patty Ducayet. She is a licensed master social
    worker. She became the State long-term care ombudsman at the
    Texas Department of Health and Human Services in January of
    2007. As the State long-term care ombudsman, Patty oversees 28
    local ombudsman programs, certifies and trains ombudsmen, and
    advocates for policy and legislative change to positively
    impact Texans living in nursing and assisted living facilities.
        Patty has served on the Board of the National Association
    of State Long-term Care Ombudsman Program since 2009, including
    serving as president from 2014 to 2018. She currently serves as
    chair of the Association's advocacy committee.
        Mr. Trone is not here, so. Mr. Trone was going to introduce
    Ms. Archer-Smith, but I am going to introduce her.
        She is from his home State of Maryland. Stephanie Archer-
    Smith is executive director of Meals on Wheels of Central
    Maryland, a community based, nonprofit organization providing
    congregate and home-delivered meals and support services to
    individuals primarily age 60 and older through the Older
    Americans Act nutrition program in Baltimore City and County,
    as well as six surrounding counties.
        Ms. Archer-Smith has 35 years of experience working with
    vulnerable populations through the life cycle in private,
    public, and not for profit human services organizations.
    Stephanie has served on the board of directors for the
    Baltimore Homeless Services and was a contributing author to
    Journey Home, Baltimore's 10-year plan to end homelessness.
        We appreciate all of the witnesses being here today and we
    look forward to your testimony.
        Let me remind the witnesses that we have read your written
    statements and they will appear in full in the hearing record.
    Pursuant to committee rule 7d and committee practice each of
    you is asked to limit your oral presentation to a 5-minute
    summary of your written statement.
        Let me remind the witnesses that pursuant to Title 18 of
    the U.S. Code section 1001, it is illegal to knowingly and
    willfully falsify any statement, representation, writing,
    document, or material fact presented to Congress or otherwise
    conceal or cover up a material fact.
        Before you begin your testimony please remember to press
    the button on the microphone in front of you so it will turn on
    and the members can hear you. As you begin to speak the light
    in front of you will turn green. After 4 minutes the light will
    turn yellow to signal that you have 1 minute remaining. When
    the light turns red your 5 minutes have expired and we ask that
    you please wrap up.
        We will let the entire panel make their presentations
    before we move to member questions. When answering a question,
    please remember once again to turn your microphone on.
        I will first recognize Ms. Girard.

      STATEMENT OF LEE GIRARD, DIRECTOR, MULTNOMAH COUNTY AGING,
                    DISABILITY AND VETERANS SERVICES

        Ms. GIRARD. Chair Bonamici, Ranking Member Comer, and
    members of the subcommittee, I am Lee Girard, Director of
    Multnomah County Aging, Disability, and Veterans Services.
        Thank you for this opportunity to share our experiences and
    recommendations for the Older Americans Act as you work toward
    reauthorization.
        In Oregon, we have set forth in statute the values of
    independence, dignity, and choice as the foundation of our work
    in supporting older adults. These values are also foundational
    in the Older Americans Act. Area Agencies across the Nation
    have worked to build a strong and dynamic network of services
    and supports that allow older adults to have the kinds of
    choices we all wish for, living in the communities of our
    choosing in ways that are responsive to our diverse needs and
    preferences.
        When my agency conducted our last area plan community needs
    assessment we talked to almost 500 older adults from diverse
    communities across our county. The need for flexibility in
    planning local services was highlighted by the variety of needs
    that were raised in these community sessions. Based on these
    listening sessions, our agency has continued to prioritize
    expansion of services for older adults with the greatest
    economic and social needs, with particular focus on LGBT and
    racial and ethnic communities in our area.
        Oregon is no different than the national trend. We now
    enjoy a longer lifespan than previous generations. By 2025, it
    is estimated that 20 percent of Oregon's population will be age
    65 and over. Oregon's person-centered system prioritizes the
    needs of the individual to provide better care, lower costs,
    and a better quality of life for older adults and people with
    disabilities.
        Information and assistance and person-centered options
    counseling are foundational services within the Older Americans
    Act. As an individual finds that they need more help to remain
    independent, these services provide the support to meet that
    goal.
        Several recent studies in Oregon have demonstrated the
    impacts of this work. A recent business case study found an
    11:1 return on investment for these services. The benefits that
    were found included finding and keeping long-term services and
    supports and housing, helping with basic needs to remain
    independent, avoiding homelessness--which is a growing issue
    for older adults--preventing abuse, and averting falls and
    other debilitating situations.
        A second study also found a distinct correlation between
    avoiding preventable hospitalizations and the availability of
    Older Americans Act funded information assistance and options
    counseling services. These are significant numbers and
    demonstrate the high value and return on investment for the
    services provided via the Older Americans Act. Social
    determinants of health can influence up to 60 percent of an
    individual's health.
        The Older Americans Act funds health promotion programs,
    elder justice and abuse prevention, family caregiving support,
    and nutrition services. It really is this holistic approach
    that made the Older Americans Act truly ``ahead of its time''
    when it was created in 1965.
        As you begin your work on reauthorization, we encourage you
    to consider important adjustments that could be made to the Act
    to bring it into this new era of services and supports. We also
    know that the needs of older adults' experiences can vary
    widely and be significantly impacted by a variety of factors
    and barriers. The Older Americans Act is founded on targeting
    services to individuals with the greatest social and economic
    needs. We ask that LGBT communities be specifically recognized
    as one of those populations to be targeted.
        Local flexibility is also a key program strategy for the
    Older Americans Act. This provision has enabled Area Agencies
    to meet the needs of their local communities in ways that makes
    the most sense with the most efficient use of funds.
        Supporting innovation and best practices must also be
    another key priority. The Aging Network continues to evolve
    through local planning and development efforts to expand a
    network of services focused on interventions that lower the
    overall cost curve in long-term care and healthcare.
        Finally, a commitment for bipartisan support to increase
    authorization levels as well as reauthorizing the Older
    Americans Act is absolutely necessary to meet the goals of the
    Older Americans Act going forward.
        I would like to thank you for your time today and would be
    happy to answer any questions later from the committee.
        Thank you.
        [The statement of Ms. Girard follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Chairwoman BONAMICI. Thank you for your testimony.
        And next I will recognize Ms. Archer-Smith for 5 minutes
    for your testimony.

    STATEMENT OF STEPHANIE ARCHER-SMITH, EXECUTIVE DIRECTOR, MEALS
                  ON WHEELS OF CENTRAL MARYLAND, INC.

        Ms. ARCHER-SMITH. Good morning, Chairwoman Bonamici,
    Ranking Member Comer, and members of the subcommittee. Thank
    you for the opportunity to testify today.
        My name is Stephanie Archer-Smith and I am the executive
    director for Meals on Wheels of Central Maryland, a community-
    based nonprofit that provides congregate and home-delivered
    meals through the Older Americans Act nutrition program.
        Each year we serve over a million nutritious meals; 800,000
    of those are delivered to the door of nearly 3,000 homebound
    seniors in Baltimore City and the surrounding counties.
    Federally supported senior nutrition programs like ours are
    leading the fight to improve senior health by combating hunger
    and isolation. This unique combination of nutritious meals,
    companionship, and other person-centered services is only made
    possible by the Older Americans Act.
        Title III-C of the Older Americans Act, the nutrition
    program, is the only Federal program designed specifically to
    meet both the nutritional and social needs of older adults in
    order to reduce hunger and food insecurity, promote
    socialization, and improve the health and wellbeing of older
    individuals. In 2017 the Older Americans Act delivered on that
    promise to 2.4 million seniors nationwide.
        The Older Americans Act nutrition program is perhaps the
    best example of the power of a successful public-private
    partnership. At Meals on Wheels of Central Maryland, the Older
    Americans Act funding we receive makes up 60 percent of our
    budget. The remaining 40 percent is comprised of private
    donations, other private and local government grants, and other
    healthcare partnership programs. We mobilize more than 1,800
    volunteers who provide over $2 million of in-kind contribution
    annually to support our daily operations.
        The reality of senior hunger and isolation in our country
    is sobering. In Maryland more than 140,000 seniors face the
    threat of hunger each day, often making difficult choices
    between eating properly or paying for medication. Nationwide
    nearly 9 million seniors struggle with hunger, and almost twice
    as many live alone, leaving them at risk for negative health
    outcomes associated with food insecurity, malnutrition, and
    social isolation. Feelings of loneliness in particular are
    associated with negative health effects comparable to smoking
    15 cigarettes a day.
        The economic burden associated with senior malnutrition
    costs $51 billion annually, while senior falls account for $50
    billion in medical costs. The good news is the infrastructure
    to address these consequences already exists through the Older
    Americans Act network. The majority of seniors receiving Older
    Americans Act nutrition services report that participating in
    the program helps them feel more secure and prevents falls,
    avoiding hospitalization and reducing healthcare costs. One
    year of Meals on Wheels services can be provided for the
    approximate cost of 1 day in the hospital.
        In Maryland the impact is clear. Ninety-four percent of our
    participants report increase food security, ninety-eight
    percent believe our services have extended the length of time
    they can remain living at home, ninety-four percent report that
    Maryland Meals on Wheels has improved their quality of life,
    and one hundred percent report better medication compliance.
        But it is best illustrated by the story of the seniors
    themselves. Frederick, who is a 69-year-old Navy veteran, lives
    alone in a mobile home in Harford County. He has been receiving
    Meals on Wheels since 2015 because of his limited mobility.
    Frederick also receives food for his dogs, who are always by
    his side when we deliver.
        During his annual home assessment, something all Meals on
    Wheels clients receive, it was discovered that he had a roof
    leak so severe that he was no longer able to use his bedroom
    and mold was growing. Our case management team immediately
    intervened, identifying resources for his roof replacement.
        Today Frederick enjoys his home free of leaks and dangerous
    mold due to a complete roof replacement, which was finished
    earlier this month at no cost to him.
        Ruth lives alone on a narrow street in Baltimore. During a
    big snow storm last winter she wondered how the mobility van
    that picks her up for dialysis would make it down her narrow
    street. Despite the snow, her Meals on Wheels volunteer was
    there. The Meals on Wheels team reached out to the police to
    ask for their help in getting Ruth safely to her treatment.
        Ruth shared her gratitude with me, stating ``I thought my
    life depended on dialysis, but that day my life depended on
    Meals on Wheels.''
        Were it not for Meals on Wheels these seniors would be
    hungry and alone and disconnected from their community. The
    unacceptable truth is that for these seniors we are unable to
    serve this is their reality.
        A 2015 Government Accountability report found that 83
    percent of low-income food insecure adults are not receiving
    the meals they need. We currently have 186 people waiting for
    space on the Older Americans Act funded program. How do you
    tell a senior who needs your help that you cannot help them?
        I urge this committee to keep a strong and on-time
    reauthorization of the Older Americans Act a priority and
    support local nutrition providers like me as we work tirelessly
    to meet the unmet needs of seniors today and in the future.
        Again, I thank you for holding this timely hearing during
    Older Americans Act month, and for the opportunity to testify.
    I stand ready to support this process in any way I am able and
    look forward to answering any questions you might have.
        [The statement of Ms. Archer-Smith follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Chairwoman BONAMICI. Thank you for your testimony.
        And I recognize Ms. Whiting for your 5 minutes for your
    testimony.

        STATEMENT OF C. GRACE WHITING, J.D., PRESIDENT AND CEO,
                    NATIONAL ALLIANCE FOR CAREGIVING

        Ms. WHITING. Thank you so much, Chair Bonamici and Ranking
    Member Comer, and members of this subcommittee. Chair Bonamici,
    thank you especially for sharing your own personal experience
    as a caregiver for your mother. We need champions like you on
    these issues.
        I appreciate the time today to talk about the Older
    Americans Act, Title III-E, National Family Caregiver Support
    Program.
        My name is Grace Whiting and I am the President and CEO of
    the National Alliance for Caregiving, a 501(c)(3) nonprofit
    organization dedicated to advancing family caregiving through
    research, innovation, and advocacy. We believe that OAA
    programs, including the National Family Caregiver Support
    Program, support our long-term care ecosystem in three key
    ways.
        First, healthcare providers rely on caregivers to fill gaps
    in care and Older Americans Act's programs help caregivers
    become better care providers.
        Second, employers who face productivity losses due to
    caregiving can use OAA programs as a resource to help
    caregivers who are in the work force.
        And, third, OAA programs can protect the health, wealth,
    and wellbeing of aging caregivers themselves.
        We believe that family caregiving is a public health issue.
    In national research with AARP we estimate that there are
    approximately 44 million people caring for older adults and
    people with disabilities across a lifespan. That is one in five
    Americans, roughly the same size as the population of the
    country of Argentina. And when supported, caregivers can
    improve the quality of care offered to individuals. They
    support activities of daily living, such as helping people eat
    and bathe, instrumental activities of daily living, such as
    managing finances, and more than half are conducting medical
    nursing tasks that would normally be provided through formal
    care providers. Activities like giving injections, tube
    feedings, catheters, and colostomy care, often without any
    prior education on how to do these activities and no prior
    support. Most help with transportation, which helps address
    social isolation and allows people to stay engaged in their
    communities longer. And we know that when supported, caregivers
    can improve the health of populations and reduce health system
    costs.
        When surveyed, program participants in the Administration
    for Community Living program, almost nine out of 10 caregivers
    said that these services help them to be a better caregiver,
    and more than half said that if they did not have the National
    Family Caregiver Support Program, the person they care for
    would be in a nursing home. In fact, if we replaced every
    caregiver in America with a direct care worker, it would cost
    our economy $470 billion a year. Health care providers are
    aware of this cost savings and emerging trends in managed care
    rely on caregivers to bridge gaps, to reduce health system
    costs, and to improve shared savings.
        In our written testimony we speak to the impact of
    caregiving on the work force, including an estimated $36.5
    billion a year in productivity losses to employers. Title III
    programs can help employers offset the cost of caregiving. For
    example, nutrition programs provide support when a caregiver
    may not be available to make dinner, senior centers offer an
    additional form of respite. Transportation support for seniors
    can make it possible for caregivers to use that time for other
    needs.
        As family size shrinks, the number of available people to
    care is shrinking too, meaning that we must act now to protect
    caregivers.
        More than half of the caregivers in America are 50 years
    old or older, 7 percent are 75 years old or older, and
    caregivers of adults with disabilities are aging too. Think,
    for example, of the aging parents of an adult child with Down
    Syndrome, or the aging wife of a wounded warrior from Desert
    Storm. Yet the current program only supports 700,000
    caregivers. Based on our prevalence estimate, this means that
    the current program serves only 2 percent of America's
    caregivers.
        One quick personal story before I end. About 6 years ago I
    had the honor of being invited to the White House for a
    ceremony to celebrate caregivers of veterans, the Hidden Heroes
    Initiative, led by former Senator Elizabeth Dole. And I was
    standing in the green room talking to this caregiver whose
    husband had been wounded in Iraq and I said I grew up in
    Louisiana, I went to High School in Mississippi, I never in a
    million years thought that I would be standing in the White
    House looking outside at the tourists. And she looked at me, at
    this celebration to honor the work that she was doing for her
    husband, in a room that most Americans are never going to have
    the chance to be able to stand in, and she said all I can think
    about is my husband back at his hotel room and whether he is OK
    without me. That is the type of person that this program
    serves, people who are too tired, too overwhelmed, and too busy
    to advocate for themselves. We know that family is the basic
    unit of society, and our society needs these families to
    survive.
        Thank you.
        [The statement of Ms. Whiting follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Chairwoman BONAMICI. Thank you for your testimony.
        And now I recognize Ms. Ducayet for 5 minutes for your
    testimony.

    STATEMENT OF PATRICIA DUCAYET, LMSW, TEXAS STATE LONG-TERM CARE
               OMBUDSMAN, TEXAS HEALTH AND HUMAN SERVICES

        Ms. DUCAYET. Thank you, Chair Bonamici and Ranking Member
    Comer, thank you to the subcommittee. It is my pleasure to
    testify today on behalf of the Texas State Long-Term Care
    Ombudsman Program.
        Title VII of the Older Americans Act authorizes State
    ombudsman programs to protect the health, safety, welfare, and
    rights of residents, people who live in nursing facilities and
    assisted living facilities.
        In Texas over 92,000 people live in a nursing home and over
    45,000 live in an assisted living facility. Last year we
    resolved 78 percent of our complaints that we received; that
    was over 16,000 complaints in the State of Texas. We did that
    through the use of 100 staff and over 400 volunteers in our
    program.
        Today you recognize the ombudsman program and the work we
    do to prevent abuse and protect residents' rights. And you see
    that as part of the system to protect independence and promote
    dignity. Many Americans don't think of an assisted living as a
    place where you can be independent, but it should be. And many
    Americans don't think of a nursing facility as a place where
    you can live a dignified life, but it must be.
        Our program volunteers and staff are onsite in facilities
    to the maximum extent possible, to ensure that residents have
    independence and to address instances of indignity. Essential
    elements of the ombudsman program include our confidentiality
    provisions, systems advocacy, resolving complaints, and
    preventing abuse and neglect. Confidentiality requirements are
    specifically outlined in the Act and include strict
    confidentiality of our ombudsman program records, so no
    resident identifying information can be released by our program
    without the permission of the person to which it pertains.
        Based on the problems we observe in facilities our program
    represents the interests of residents to decisionmakers in
    Congress, to the State legislatures, and to Federal and State
    agencies. We make recommendations and provide comments, which
    we call systems advocacy, and aim to improve quality of life
    and quality of care for residents, most of whom are Medicare
    and Medicaid eligible.
        In 2017, State ombudsman programs across the Nation
    investigated almost 200,000 complaints, complaints ranging from
    the use of chemical restraints to neglect to insufficient
    staffing in facilities. But the most common complaint we
    receive is about discharge. Because a nursing home is a
    person's residence, a resident has a right not to be discharged
    without cause. To protect this right, a resident can appeal to
    the State Medicaid agency and nursing homes are required to
    notify every resident and the ombudsman each time there is a
    discharge. Ombudsmen help residents who want to stay in their
    home file an appeal and represent them in a hearing. Ombudsmen
    also negotiate with the facility to find solutions that are
    other than discharge.
        So as an example, I want to share with you a brief story
    from Texas. A resident in a dementia unit was issued a
    discharge notice for being a threat to others. The resident had
    recently fallen, had limited mobility and vision, and had a
    diagnosis of dementia. The facility was discharging him for one
    incident of disrobing in public, which is a relatively common
    symptom of dementia. His guardian appealed the discharge, and
    while awaiting the hearing received a call at 6 p.m. on a
    Friday night from the nursing home informing the guardian that
    the resident had been discharged to a behavioral health
    hospital.
        The nursing facility refused to take the resident back. So
    the resident remained in this behavioral health hospital for a
    month before being transferred to a new nursing facility and
    living only 1 week longer.
        While the resident's case prevailed in the fair hearing,
    because it was an improper discharge, the result came too late
    to benefit him. So the guardian has given us permission to
    share his story to honor him and to inform you of the effects
    of improper discharge.
        To prevent abuse, neglect, and exploitation, ombudsmen
    train residents, family members, and facility staff on how to
    prevent, identify, and report abuse. Each onsite visit that we
    make also prevents abuse. And 2017 nationwide, ombudsman
    programs made over 29,000 routine visits for that purpose.
    Ombudsman programs also investigated over 5,000 cases of abuse,
    neglect, and exploitation in an assisted living facility and
    over 11,000 cases of abuse, neglect, or exploitation in a
    nursing home.
        Thank you for preserving the independence and dignity of
    older Americans across the continuum, thank you for recognizing
    that people who live in institutions and victims of abuse also
    need dignity and independence.
        On behalf of the Texas Ombudsman Program and my colleagues
    around the country, I want to thank you. Thank you for your
    support of the Older Americans Act and with it, ombudsmen will
    be here in the future and are here today to prevent harm and
    protect residents' rights.
        Thank you very much.
        [The statement of Ms. Ducayet follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Chairwoman BONAMICI. Thank you so much to each of our
    witnesses for your excellent and comprehensive testimony.
        Under committee rule 8a we will now question witnesses
    under the 5-minute rule. As chair I will go first and then
    yield to the ranking member. We will then alternate between the
    parties.
        And I yield myself 5 minutes.
        Ms. Girard, you discussed research that has been conducted
    in Oregon regarding the return on investment for OAA programs.
    I ask you unanimous consent to enter into the record the 2018
    report commissioned by the Oregon Department of Human Services.
        So how have you been able to achieve--you talked about an
    11:1 return on investment you mentioned. And based on this
    research and from your professional experience, are OAA
    programs a good investment for the Federal Government and the
    taxpayer?
        Ms. GIRARD. Yes, I would say that they are an excellent
    investment. The foundation for the return on investment that
    was studied in Oregon is really person-centered options
    counseling, and that really entails individuals who have been
    trained on how to do motivational interviewing and really
    person-centered care planning and work with individuals, meet
    with individuals, and really focus in on their long-term
    services and support needs, and really develop a very focused
    plan that is person-centered to what that person and individual
    needs and the very unique needs that they have.
        Through the study what we were able to do is actually do
    both a qualitative and quantitative analysis really looking at
    what were the outcomes that were gained for each individual.
    And then we used either State or national data around things
    like if we were shown that we were able to prevent future
    falls, we could--you can actually cost that out. You know what
    the cost is when somebody falls and breaks a hip and ends up in
    the hospital. And we were able to show that we were reducing
    hospital readmissions. We know what the cost of that is in our
    community.
        And then able to do other things like helping somebody to
    avoid homelessness. We know what the expense is for somebody
    being homeless. So doing that we were able to really show that
    this is a comprehensive service that really helps to connect
    people to just a wide variety of very person-centered services
    that results in a significant cost savings.
        Chairwoman BONAMICI. Thank you for that work. And
    continuing, Ms. Girard, you discussed tailoring your
    department's services and supports to meet the distinct needs
    of individuals from diverse communities, including the LGBT
    community. We know that LGBT older adults often face structural
    inequalities, including greater social isolation and higher
    rates of poverty. But they also encounter barriers to accessing
    culturally competent aging services and supports and in many
    cases are less likely to have supportive family members and
    more likely to face discrimination.
        So I want to ask you, and then I will ask the others, how
    does your department address the unique needs of the LGBT
    community and why should LGBT older adults be designated a
    population of greatest social need?
        Ms. GIRARD. Thank you, Chair Bonamici.
        One of the things that is really a challenge for us locally
    is that there are not really good data sources around what is
    the prevalence of folks that are LGBT in our community. And
    there is actually a fear for people reporting. So one of the
    things that we have done is we have a great network in our
    area,--we do, we actually participate in both regional and
    Statewide advocacy coalition to really raise awareness and to
    really try to identify what the needs are. And one of the
    things we really have done is we have actually met one-on-one
    with individuals in our communities. We have done things like
    we know that there are specific types of social events, so we
    actually go and meet. We went to a dinner party with a group of
    folks and really sat down and talked about what are the unique
    issues and needs that you are experiencing. And when we did
    some of that as part of our area plan, what we really found was
    that the needs do differ across different populations.
        Chairwoman BONAMICI. And what would the designation of
    greatest social need mean? And I am going to ask the others as
    well.
        Ms. GIRARD. I really think it helps to--one of the things
    that it does is it really focuses our area plan efforts. So we
    have to do--it makes us really reach out into the community,
    hear from communities, and then really be conscientious about
    how we program for those needs.
        Chairwoman BONAMICI. Thank you.
        Does anybody else--please weigh in on that issue. Ms.
    Whiting, did you have--
        Ms. WHITING. So I would second the recommendation that
    there needs to be more research. We know that there is
    approximately 9 percent of caregivers in America identified as
    LGBT and I have heard from the field that particularly people
    who are transgender sometimes feel that the people they care
    for get worse care from formal providers because of biases. So,
    for example, a gentleman who is transgender said that his
    mother received worse care in the nursing facility she was at
    because the staff was uncomfortable with him and his identity.
        So I think it is an area that needs more research. We had
    in our written testimony, included some recommendations for OAA
    reauthorization and one piece of that is to collect more data
    in particular on caregiving and these OAA programs broadly.
        Chairwoman BONAMICI. My time is expired, so I am going to
    ask the others--well, we will submit a question for the record.
        And I now yield to Dr. Foxx, the ranking member of the full
    committee for 5 minutes for your questions.
        Ms. FOXX. Thank you, Madam Chairman. And I want to thank
    our witnesses for being here today to discuss this important
    subject.
        Miss Girard, I was pleased to hear that you appreciate the
    value of local flexibility in the Older Americans Act. Can you
    give us some examples of the differences between services you
    provide to seniors in Portland versus some of the more rural
    areas of Oregon?
        Ms. GIRARD. Thank you, Representative Foxx.
        I think probably a really key example is the provision of
    transportation. We hear from older adults across Oregon that it
    is a significant need, but it looks very different in Portland
    than it does out in places like Ontario or Malheur County.
        In our area we have a robust transit system and we can
    purchase transportation services through that network. In rural
    counties, the AAA is the transportation network. So that is
    probably a really good example.
        Ms. FOXX. Great.
        This question is for all of you, and I will start on this
    end of the panel so you are not always last. One of the
    purposes of the Older Americans Act is to help people age 60
    and older maintain independence in the home. Why is this
    important and how does this goal potentially save taxpayer
    dollars? And do keep in mind there are four of you to answer,
    so.
        Ms. DUCAYET. Well, as the representative of providing
    services to people who live in an institutional setting, I will
    make my answer quick to you and say I know that people want to
    live in their home and prefer to. There will be a need
    continuously for long-term care facilities, but emphasis does
    need to be where people want to get their services at home.
        Ms. WHITING. I would say it is in the title of the hearing
    today, it is about dignity and independence. Our family sizes
    are getting smaller, we have got I think roughly one out of
    five Americans are over 60, and so we want people to be able to
    thrive and to be cared for by their families in the setting
    they choose.
        Ms. FOXX. Ms. Archer-Smith.
        Ms. ARCHER-SMITH. Yes, I would echo that the people that we
    work with want to stay--they want to stay in their home and in
    their communities, they want to age in place. It is more
    economical to age in your home and I would argue that
    intergenerational communities are stronger.
        Ms. FOXX. All right.
        Ms. GIRARD. In our community only 14 percent of people
    getting long-term services and supports are in a nursing
    facility. The Older Americans Act is the foundation of helping
    people identify and figure out what additional kinds of
    resources and services are available so that they don't have to
    rely on nursing facility services unless it is absolutely
    necessary.
        Ms. FOXX. And let me ask a clarifying question, because I
    have for years--I think, Ms. Archer-Smith, you mentioned that
    it is less expensive--one of you mentioned it is less expensive
    for people to remain in their homes. And I have also read over
    the years that people are healthier, more alert, and in
    better--generally in better health and better able to be
    involved with activities the longer they are able to stay in
    their home.
        I am sure there is associations with having the ability to
    do it, but also using the facility that you have while you are
    in your home. Does the research continue to show that?
        Any of you can respond.
        Ms. WHITING. Especially in Alzheimer's and dementia, where
    someone who is changing settings but might have mild cognitive
    impairment, it can be very hard for both that person and the
    family to continue to care for them.
        Ms. GIRARD. And I would just add that in Oregon, because we
    do have such a broad array for people that are often at the
    same level of need, we are able to show that people can
    function quite well at home and have pretty significant care
    needs as long as you have a system that supports them.
        Ms. FOXX. Great. Thank you all.
        I yield back, Madam Chairman.
        Chairwoman BONAMICI. Thank you, Dr. Foxx.
        I now recognize Representative Lee from Nevada for 5
    minutes for your questions.
        Ms. LEE. Thank you, Madam Chair, for hosting this important
    hearing on such an important issue.
        Having a father who passed away after spending 4 years in a
    nursing home and now dealing with a mother who is suffering
    from--is an assisted living facility and having experienced her
    struggles as a caregiver, I think that addressing these issues
    is incredibly important.
        I appreciate the question that Representative Foxx just
    asked about the benefits the tax benefit and financial benefit
    of allowing people to age in place.
        I wanted to ask Ms. Girard, you know, as we know, these
    supportive services and preventative health programs are
    essential for older Americans in need of care. And in Nevada,
    my home State, $3.5 million went to support that.
        Can you please elaborate on how home healthcare services
    can serve as preventive healthcare for older Americans?
        Ms. GIRARD. Yes. We have had--In Oregon we have had a
    foundation of both State and Older Americans Act funded in-home
    service supports for older adults since 1981. Well, the Older
    Americans Act actually before that. And we have been able to
    show that it really helps people to avoid further decline, it
    helps them to avoid spending down to have to go on Medicaid and
    use more expensive Federal supports, and actually keeps them
    more engaged in their communities.
        Ms. LEE. Thank you.
        Miss Whiting, one of your recommendations was to develop a
    national resource center for caregiving. Can you explain what
    the benefit of establishing that would be?
        Ms. WHITING. Absolutely. And that recommendation builds on
    some of the language in the RAISE Family Caregivers Act that
    was enacted last year, which talks about finding efficiencies
    between different Federal agencies. So, for example, there is
    the VA Caregiver Support Program, there is the National Family
    Caregiver Support Program under Older Americans Act, there were
    supports across CMS, looking at different types of caregiver
    supports within Medicaid and community-based service models.
        So the idea here is let us put all that information in one
    place and make it more efficient for caregivers to navigate
    across these different centers, as well as identify other
    community-based supports that might be available to families
    across the country.
        Ms. LEE. Yes that--Speaking from a personal point of view,
    my father broke his hip and because of Medicare requirements
    and Medicaid requirements, was really forced--you know, they
    quit--we quit rehab, which led him to unfortunately go into a
    nursing home. So I find that sort of looking across all of
    these issues and doing as much as we can to keep someone in
    home is really important.
        So I look forward to working with you on that.
        I wanted to turn real quickly to nutrition. In Nevada
    80,000 older Americans were deemed to be food insecure in 2016.
    Estimated by 2025 17,000 more older Nevadans will need
    nutrition services than those today, totaling almost 100,000
    older Nevadans.
        And we all know the great work that Meals on Wheels
    accomplishes carrying out home-delivered services.
        I would like to ask Ms. Archer, can you please speak a
    little bit about the other option, congregate nutrition option,
    and how it is important to fulfilling the social needs of many
    of our older Americans?
        Ms. ARCHER-SMITH. Yes, thank you.
        The congregate meal program as I see it, it is kind of a
    continuum of service. So the congregate meal program is really
    good for people who might be able to get to it, either they
    have transportation provided for them or they are still a
    little bit more mobile. So they don't quite need the home-
    delivered meal program yet. So it is a good continuum of
    service. That opportunity to socialize with your peers is
    invaluable. And what often happens is they come for the meal
    and then they engage in other programs and other activities
    that will keep them healthier, more mobile, stronger, things
    like that. So it is a really important part of the continuum of
    service.
        Ms. LEE. Great.
        I will yield the rest of my time. Just thank you all for
    the important work you do.
        Chairwoman BONAMICI. Thank you for your questions. And as I
    am yielding to Ranking Member Comber, I want to encourage all
    of my colleagues to do what I have done, which is to deliver
    Meals on Wheels and to visit a congregate meal site, because I
    think you will really appreciate everything that happens there.
        And now I yield to Ranking Member Comer for 5 minutes for
    your questions.
        Mr. COMER. And I agree with that, Madam Chair. I have done
    that as well.
        Miss Ducayet--did I pronounce that right? I am from rural
    Kentucky, it is hard for me to pronounce a name like that, but
    so glad you are here. You mentioned the importance of
    flexibility in the location of a State long-term care ombudsman
    program. Can you expand on what factors might play into this
    decision?
        Ms. DUCAYET. Thank you for the questions. And, yes, I know
    I have a difficult last name and career name as well--it is
    hard to pronounce.
        Yes, so we are in, in Texas, the State unit on aging, a
    pretty traditional setting for the State Ombudsman Program. And
    we coordinate with the Area Agencies on Aging in our State to
    deliver ombudsman services locally. That is a fairly standard
    practice in many States, but not all States operate in the same
    manner, and they do so successfully. The flexibility is needed
    because of different State structures and the different jobs
    that are done in a State unit on aging, or in an Area Agency on
    Aging, because ombudsman programs need to be free of any
    conflicts of interest so that we are sure we are assured that
    we are serving the needs of the resident first and foremost and
    that none of our work is compromised by the location that we
    operate within.
        And so my placement within my State agency, for example,
    ensures that I have independence from other functions that are
    performed by the State Medicaid agency, for example. And it
    works very well for us.
        Mr. COMER. Great.
        Ms. DUCAYET. Thank you.
        Mr. COMER. Great.
        Miss Girard, how do the agencies on aging, senior citizens,
    and other providers of elderly services work together to
    deliver services?
        Ms. GIRARD. I think the foundation is we start with our
    area plan. Every Area Agency on Aging needs a robust area plan
    that really engages all of the community. And then we actually
    in our area have an aging and disability resource connection
    network, and so we really are able to have a no wrong door
    system. We fund a wide variety of services out in community-
    based organizations, some of which are culturally responsive,
    some are culturally specific, and it is really that aging and
    disability resource connection network that allows the
    consumer--it doesn't really matter where they show up, we are
    going to be able to help them.
        Mr. COMER. Great.
        This question is for everyone on the panel. As Ms. Foxx
    said, we have limited time, but are there any provisions in the
    current law or regulations that are particularly burdensome to
    your efforts that we in Congress need to address this year? Can
    anyone think of anything?
        Well, I will--before I yield back I will say this, of all
    the government programs that I am aware of, and there are many,
    in my opinion in my district there is nothing more popular that
    Meals on Wheels. Very popular district and anytime there is
    mention of potential cuts to that we get a lot of calls and
    messages in my office on that. So I appreciate everything that
    you all do and we look forward to working with you as we
    continue to try to make life better for you and for the great
    people that you serve.
        Madam Chairman, I yield back.
        Chairwoman BONAMICI. Thank you very much, Mr. Comer.
        I now recognize Representative Hayes from Connecticut for 5
    minutes for your questions.
        Ms. HAYES. Good afternoon, everyone, and thank you for
    having this very important hearing and for you all coming here.
        I am struggling a little this morning because I have this
    lovely binder with these prepared questions and all I can think
    about is my grandma right now. And so I really have to shift
    gears and just go in a different direction just for a minute,
    if you would indulge me.
        I was raised by my grandmother. My mom struggled with
    addiction and my grandmother raised my brother and I, and
    really was the backbone of our family. And I would say that,
    you know, this is over 30 years ago, but in my experience,
    recently as a teacher and even seeing it every week in my
    church, there are so many aging adults who are over 60 who are
    now raising their grandchildren. So I know we are talking a lot
    about, you know, our elderly community receiving care, but
    there are so many of them that are still giving care.
        So I guess what I want to first start with, the Senate held
    a similar hearing last week and they talked about the National
    Family Caregiver Support Programs.
        I guess, Ms. Whiting, has the opioid crisis impacted the
    rate of aging Americans, especially grandparents, who are
    having to be the de facto guardians and in fact raising their
    grandchildren?
        Ms. WHITING. Thank you for the question. It is incredibly--
    something that has been on our minds as we look out at the
    field and we interact with people, that the rate of substance
    abuse--even I would say other populations, such as military
    veterans where you have wounded warriors coming home and they
    are not able to care for their own children and so sometimes
    their parents take on care of those minor children. So I think
    you have hit on something that is critically important and, of
    course, is recognized within the Older Americans Act program
    overall.
        I would say that some have proposed flexibility in allowing
    States to, you know, put some of the caregiver funding into the
    kinship care, the grandparents raising grandchildren. We would
    just encourage you to think about expanding authorization and
    appropriations for the program as a whole, because there are
    many people over 50 who are also caring for other adults and
    kids with disabilities.
        Ms. HAYES. Thank you. And I think that is exactly where I
    was going, because currently there is a proposed 10 percent cap
    on the NFCSP programs that fund older adults caring for
    children in this country. And I don't want to us to get caught
    up addressing one problem, but not addressing the flip side of
    that problem because fast forward 30 years and the same
    grandmother who I just told you was the backbone of our family
    went through stages of dementia, Alzheimer's, hospice, at home
    in bed. My aunt didn't leave the house for a year because she
    had to take care of my grandmother.
        So I want to make sure that we are addressing all aspects
    of this problem. It is not just about providing nutrition and
    supports and getting health care services, but really the
    entire family is affected when this happens. You know, whether
    they are the children, who now the only reliable person in
    their life can no longer care for them, or the adults who are
    now tasked with caring for their parents and have to put their
    careers on hold, their families, their lives on hold.
        So I guess my question for--and this is the same thing that
    everyone here has kind of said--how can we provide supports
    to--what is it that we need to be asking for when we are
    legislating programs to ensure that we are touching all of
    those needs and not just pinpointing one area? Because I
    recognize how broad those things are.
        Ms. DUCAYET. Thank you for the question and your personal
    story.
        One thing that occurs--
        Ms. HAYES. Everything is personal here, I swear.
        Ms. DUCAYET. One thing that occurs to me is the need for
    person-centered services. And the Older Americans Act actually
    does an incredible job of emphasizing that. But I think there
    is always room for improvement in terms of how we coordinate
    those person-centered services across the different Older
    Americans Act services. So that is something I would recommend
    to look at and see if that is a point where we could improve
    upon.
        Ms. WHITING. I would also just thank you for your personal
    story and for talking about that. My grandmother had dementia
    and my aunt was her primary caregiver, and it was very
    difficult for her to access services because some of the
    restrictions in these laws around ages. So, for example, in the
    caregiver program, you know, it is caring for people over 60
    and then caring for people with dementia of any age. And it is
    sometimes difficult for people to understand how those programs
    could be administered. So that is an area where, you know,
    thinking about how the program aligns and making sure people
    understand at the State level how the program can be
    administered.
        Ms. HAYES. Thank you, Madam Chair. That is all I have.
        Chairwoman BONAMICI. Thank you very much, Representative.
        I now recognize Representative Thompson from Pennsylvania
    for 5 minutes for your questions.
        Mr. THOMPSON. Chairwoman, thank you so much. Thank you for
    this session. As someone who worked a career for almost 30
    years serving mostly older adults, therapists, previously a
    licensed nursing home administrator, the Older Americans Act is
    incredibly important.
        I was pleased when a few years back here we did the last
    reauthorization, we made some really good improvements, tried
    to focus on some of the chronic and disabling conditions, did
    some investment in our senior centers. A lot of good things.
    But this is the reason we do periodic reauthorizations, so we
    make sure that we are always getting it better and getting it
    right.
        And thank you for what each of you do and the perspectives
    that you bring here. You know, one of the covered--and this was
    mentioned briefly--one of the covered populations under the
    Older Americans Act obviously are those who are living with
    Alzheimer's disease. I experienced that. My mother lived with
    Alzheimer's for 10 years. It stole her identity, her memories,
    and then her life eventually. You know, these individuals
    receive the vital care and assistance needed to help maintain
    their independence. However, there is an estimated 200,000
    Americans under the age of 60 that are now living with
    Alzheimer's disease, or more commonly referred to as early
    onset Alzheimer's. Kind of an area I worked on when I practiced
    rehabilitation.
        Now, those with early onset Alzheimer's face difficult
    challenges when it comes to family and work and finances.
    Things kind of compound. It is almost like an accelerated aging
    to some extent.
        So starting with Ms. Whiting, you know, what are your
    thoughts as we look forward to reauthorization--and I know that
    we have got an age group of 60 that we define with the Older
    Americans Act, but quite frankly, when you look at things like
    Medicare, we do make accommodations for certain disabling
    conditions, end State renal disease--there may be more--you
    know, where folks are younger than that normal eligibility age.
    Any thoughts on what we should do in terms of early onset
    Alzheimer's? Any revisions or thoughts for changes as a result
    of the next reauthorization of the Older Americans Act?
        Ms. WHITING. So under the current Family Caregiver Support
    Program my understanding is that if you are caring for someone
    with Alzheimer's or related dementias of any age that you can
    receive services. But I would say when we look at other places
    in the Federal Government where they are providing support to
    caregivers, this is an area that is definitely underserved.
        So, for example, there is an estimated 5.5 million people
    caring for military veterans and the support for those programs
    is over $1 billion. Likewise, with Alzheimer's and dementia,
    you know, that community was able to reach an appropriation and
    authorization level to support it.
        I think the other piece, though, is just looking at
    research and where is it that we don't know what we don't know.
        Mr. THOMPSON. And there was an early onset bill that has
    been introduced in the House and the Senate that I think would
    be perfect to incorporate into any future Older Americans Act
    reauthorization.
        I want to kind of revisit just briefly, to anyone that
    wants to comment further, on the whole issue of just everywhere
    I go, you know, obviously the public health crisis of our
    lifetime is substance abuse. Maybe it is opioids, maybe it is
    crack, maybe it is prescription drugs--it changes based on a
    host of factors, but it is the underlying substance abuse. And
    a tremendous number of--I don't want to call them older adults
    because I put myself in that category of, you know,
    grandparents who find themselves now back in a primary care
    role. And there is a reason we have our kids when we are
    younger, we have the endurance for it. And when you, you know,
    assume those roles say in your 50's and 60's and 70's, it is a
    challenge.
        And I heard some general responses, but are there any
    concrete, any specific at this point recommendations that you
    would have for--I am not one that just likes to throw money
    into a program and hope that good people do good things, I like
    to have clear direction. And maybe it is more study that we
    need to do to figure out what are the supports that folks--I
    guess technically it would be 60 and older because the Older
    Americans Act, of how can we help those grandparents that find
    themselves in a parenting role once again?
        Ms. GIRARD. I think That is a really, really great
    question. There are--I think there are some really good
    evidence-based programs that some communities are really
    starting to utilize that are helping to destigmatize and bring
    resources for older adults who are experiencing many behavioral
    health issues, including substance use disorders, because they
    are often co-occurring with other issues. And I know in our
    State we have actually been looking at studying what some of
    the barriers are for people getting the support that they need.
    And it is actually more challenging for somebody that is older,
    somebody 65 and older to get the supports that they need
    because of issues around how Medicare is structured. So if we
    can be looking at ways that we can use evidence-based programs,
    that we can use peer supports, where peers can actually support
    other people that are going through the same thing, I think
    that would be excellent.
        Mr. THOMPSON. Thank you, Madam Chair.
        Actually, let me just say if any other witnesses have any
    thoughts on inputs or specific strategies, if you wouldn't mind
    forwarding to the committee. I think that would be very
    helpful, how do we help these grandparents who find themselves
    in--
        Chairwoman BONAMICI. Yes, Representative Thompson, if you
    put that in writing as a question for the record we will make
    sure that happens and we have a full record.
        Thank you.
        I now recognize Representative Trone from Maryland for 5
    minutes for your questions.
        Mr. TRONE. Thank you, Madam Chairman. Thank you all for
    coming out today. This is a really important subject.
        I want to talk a little bit about social determinants of
    health, SDOH. It is a new term in health. I wasn't that
    familiar with it whatsoever. For the Older Americans Act, has
    been way ahead of the curve in recognizing the importance in
    addressing the social determinants of health through community
    interventions. Category under the SDOH that is starting to get
    more attention is loneliness and social isolation. It is a
    growing concern and one that has serious health consequences.
        A 2010 study at Brigham Young University found that
    loneliness can shorten a person's life by 15 years. Another at
    Rush University found connection between loneliness and a whole
    wide range of health problems, especially increased risk of
    Alzheimer's.
        So Ms. Archer-Smith, first of all I want to thank you again
    for coming out. You are a--You work in my district in
    Montgomery County, so it is great. You serve over 40,000
    seniors throughout Maryland, and we really appreciate the help
    with Meals on Wheels. But a quarter of our seniors are living
    alone. And, you know, I know the fantastic volunteers are
    serving many of these seniors nutrition, and that is the only
    human interaction they get often, and those connections are so
    important to have during the day.
        So you spoke about the benefits of home-delivered meals and
    reducing isolation among these homebound adults. Can you share
    some examples of individuals who particularly benefit from
    social contact provided by the program and how this program is
    doing more than just substance, but performing other duties on
    isolation?
        Ms. ARCHER-SMITH. Yes, and thank you for the question.
        So I can give countless examples of volunteers who tell us
    about the person who they wait for the end of the route so that
    they can spend more time with them, play cards with them, talk
    with them about, you know, what is in the news.
        I can share with you a personal experience that was in my
    written testimony of a woman named Doreen who was 92 years old
    and lived alone. And I actually delivered to her personally. I
    was covering for someone and I liked to do that periodically
    to, you know, engage with our clients. And she didn't know me
    when I came in, but her face was so excited to see me and her
    eyes lit up so, you know, so wide and she wanted to know
    everything about me, what was my name and what did I do at
    Meals on Wheels and why was I there today and where was her
    other volunteer. And those are the questions. She was just
    hungry for someone to talk to. And I think is true of many of
    the people that we serve, but many of the things that we do, we
    call ourselves more than a meal because we are delivering more
    than just a meal, and that goes beyond that interaction with
    the volunteer. We also have other services that act as other
    touch points for them. So if it is a companion visit or if it
    is a phone pal, or something like that. That is another touch
    point. If it is someone to help them with some grocery shopping
    and household things that we don't deliver, those are other
    touch points and those are opportunities for them to interact
    more. And we have many, many stories of people who receive our
    full offering of services.
        Mr. TRONE. Yes, I was with a friend of mine last night, he
    has worked with Meals on Wheels for probably four or 5 years
    and he had a lot of similar stories about, you know, saving one
    person toward the end of the route to spend some time with them
    and one-on-one, and that made their day.
        So I think it is really great work that you guys are doing.
        What are the limitations that you are facing right now to
    be able to cover everybody appropriately, and, you know, what
    are the barriers?
        Ms. ARCHER-SMITH. So the barriers obviously are the
    funding. I mean, you know, that is the easy answer. But, you
    know, there are so many other things that our clients need. So
    being able to create those services and a plan for them that is
    unique to their individual needs is important. So being able to
    be creative about how we can deliver those services, whether it
    is grocery shopping through volunteers or companion visits, or
    whether it is professional case management and care
    coordination services.
        Mr. TRONE. And what is your volunteer stream? Do you have
    an adequate number of volunteers?
        Ms. ARCHER-SMITH. We have an aging group of volunteers, so
    we have some very, very loyal volunteers that have been with us
    for many, many years. And so we are able to recruit a lot of
    volunteers by way of word of mouth because they are so loyal to
    us and they tell their friends about it.
        But we are struggling to keep volunteers with growth. So
    there needs to be a more intentional approach with that, which
    we are addressing.
        Mr. TRONE. Well, it is very rewarding work. Thank you.
        Ms. ARCHER-SMITH. Thank you.
        Chairwoman BONAMICI. Thank you, Mr. Trone.
        I now recognize Mr. Johnson from South Dakota for 5 minutes
    for your questions.
        Mr. JOHNSON. Thank you, Madam Chair.
        Ms. Ducayet, maybe start with you. Of course, as we talk
    about reauthorizing the Act we want to make sure that it is
    well positioned for the future. I feel like I have read in a
    number of different places that number of older Americans,
    seniors, will double like in the next 30 or 40 years. And I
    think despite our best efforts to help people age in place, I
    assume that will mean a lot more folks who will call nursing
    homes, long-term care facilities, home.
        No. 1, is my assumption right about the data from what you
    know?
        And then, No. 2, will that place a burden on the
    ombudsman--ombudspeople across the country?
        Ms. DUCAYET. Thanks. Yes. So absolutely we know that the
    numbers are really skyrocketing in terms of our aging
    population, and that is going to affect our need for long-term
    care facilities.
        Where we are really seeing the biggest boom, and it has
    really been happening for decades now, is in assisted living
    facilities. If we can make those affordable everywhere, and
    that is a big question in all States, then people will choose
    assisted living facilities instead of a nursing home if they
    could at all possibly have it. It gives you more freedom and
    independence. It is less expensive to provide services in that
    setting. That boom has completely overwhelmed our ombudsman
    programs across the country.
        And so we hope to see a new appropriation for us to serve
    people in assisted living facilities, frankly because we have
    never seen that given to us in reauthorizations before and we
    have been very overwhelmed by the addition of assisted living
    facilities to our responsibilities.
        Mr. JOHNSON. Yes, of course, resources are a big part of
    the equation. I mean nationally do we see a change in how
    services are deployed in a way that provides for more
    efficiency or effectiveness in meeting the mission?
        Ms. DUCAYET. Well, I think big States like mine tend to use
    localized services and don't have a State operation hub for all
    services to be provided, and that makes sense for us to have
    localized offices of our program so that we can get to the
    residents quickly and visit facilities frequently. We need to
    use volunteers and we are allowed to use volunteers. That is a
    cost savings to the government. Our volunteers do a lot for our
    program, but our volunteer work force is aging as well and that
    has been a challenge for us too as we need to replenish those
    services.
        So another thing that would help the ombudsman program with
    volunteers is to be able to recognize the role of the volunteer
    more specifically in the Act, be able to reimburse volunteers
    specifically for mileage costs and training costs that are
    associated with it. Because volunteers save money for the Older
    Americans Act, but it isn't entirely free to have a volunteer
    in your program either. You have got to have a well trained
    force.
        Mr. JOHNSON. So I just want to make sure I am tracking,
    more specific language making it clear that those volunteer
    expenses could be reimbursed as a part of the program would be
    helpful?
        Ms. DUCAYET. Yes, yes. Yes, it would.
        Mr. JOHNSON. Okay, very good.
        So then, Ms. Whiting, as we look at--we talked about aging
    in place, and I thought you did a nice job of outlining the
    value proposition. When we have effective caregivers that
    allows people to maybe put off going to a long-term care
    facility or assisted living.
        So a similar question, if we have this many more older
    Americans in the future, and you mentioned that we are only
    providing supports to 2 percent of the caregivers out there,
    are there ways that we should be looking nationally to deploy
    services in a different way that can help meet the goals, meet
    the mission?
        Ms. WHITING. I think, Congressman, the ultimate goal here
    is that we would have people taking care of each other and we
    would be fostering that, not just through the appropriations
    process and expanding the program, but just to bring to your
    attention the RAISE Family Caregivers Act advisory council has
    yet to meet and it is on a 3-year sunset and will end in 2021.
    And that council, you know, proposes an opportunity to examine
    those exact kind of questions. And so we would encourage you to
    think about extending the life of that so we can actually get a
    plan that has employers, providers, older Americans, and others
    putting in what they really need, and where there could be more
    efficiencies in the system.
        I think the other piece of this is--if I can respectfully
    call it the Golden Girls model--where we have peers living
    together because increasingly we have younger generations of
    caregivers who are not having as many kids, they are more
    isolated, and so how can we help people age in healthy ways,
    using things like respite and senior centers and these other
    types of OAA programs so that they can care for each other as
    peers.
        Mr. JOHNSON. Yes. So and then Ms. Archer-Smith, Ms. Girard,
    I just wanted to give you an opportunity briefly to comment on
    anything it is we are talking about, increasing number of
    seniors and if there are different deployment mechanisms to
    provide supports, allow for aging in place. Any other thoughts?
        Ms. GIRARD. Well, I don't know if it is an opportunity, it
    is definitely a challenge. One of the things that families need
    is they need respite care and they actually often can be a
    better caregiver if somebody else is coming in to do
    caregiving, like giving somebody a bath. And what we are really
    experiencing is a challenge in the availability of the work
    force.
        So I think work force development for people so that there
    are people that view this as a viable option for them for
    employment would be really, really beneficial. And I know that
    there are both many State and national efforts looking at work
    force issues, but that is going to be a big one.
        Mr. JOHNSON. Thank you very much.
        Madam Chair, I yield back.
        Chairwoman BONAMICI. Thank you very much.
        I now recognize Representative Stefanik from New York for 5
    minutes for your questions.
        Ms. STEFANIK. Thank you, Chairwoman, and thank you to our
    panelists for being here today on such an important topic.
        I represent New York's 21st district, which is one of the
    most rural districts on the East Coast, but it is also one of
    the most aged districts if you look at the percentage of
    seniors that I represent. So your programs and the great work
    that you do has a direct impact on my constituents.
        I wanted to followup on Mr. Thompson's line of questioning
    related to Alzheimer's. As we know, there are approximately
    200,000 Americans suffering from early onset Alzheimer's
    disease and too often people living with this disease in their
    30's, 40's, and 50's can have young children, new homes, or
    growing careers. They are shut out of vital services just
    because they are young and the disease hits them earlier.
        Alzheimer's forever changes people's lives. It has impacted
    my family and we have heard from stories on both sides, both
    individuals in the audience here today, witnesses, as well as
    Members of Congress who have been impacted. I introduced the
    Younger Onset Alzheimer's Act this year, that was the
    legislation Mr. Thompson was referencing, that would amend the
    Older Americans Act to ensure the availability of programs and
    services for those impacted by Alzheimer's by allowing patients
    younger than 60 to access them.
        So my question, Ms. Whiting, this legislation would allow
    the National Family Caregiver Support Program and the Long-term
    Care Ombudsman Program to serve this population, but can you
    shed more light on how expanding these programs to those under
    the age of 60 would greater support family caregivers,
    especially those in the work force or those caring for young
    children? I am really interested in the caregiver piece aspect
    of this.
        Ms. WHITING. Thank you for that question.
        I think Alzheimer's is probably one of the biggest threats,
    for lack of a better word, facing us. In particular for
    caregivers, we know from research that it impacts their health,
    it impacts their ability to stay engaged in the work force, and
    we know that employers are starting to think about the impact
    of Alzheimer's. So actually in Kentucky the ranking member's
    home State, the Louisville Healthcare CEO Council has been
    trying to come up with business solutions for caregivers at
    work.
        I think where Older Americans Act programs can be most
    helpful to people with Alzheimer's, one would be respite,
    expanding the availability of respite. The second is, you know,
    really being a State laboratory to test Alzheimer's
    interventions that work. So, for example, the REACH
    intervention is an amazing intervention in New York, Mary
    Mittelman's program that she has done, hospital to home, that
    helps educate caregivers at discharge is also an excellent
    program. So thinking about how the AAA network can test that in
    different types of communities and then use that to spread
    those best practices.
        Ms. STEFANIK. Thank you.
        Ms. Girard, I wanted to followup on your recommendation
    about work force development when it comes to caregivers. The
    issue of caregivers is something that not only I have engaged
    on this committee, but also on the House Armed Services
    Committee when it comes to military caregivers. There was a
    program through the VA for military caregivers, but they did
    not anticipate just how many applications there would be. So it
    was underestimated.
        You talk about work force development specifically for
    caregivers. What can we do to ensure that we have a trained,
    qualified, and well paid work force when it comes to
    caregiving?
        Ms. GIRARD. That is a really great question as far as what
    kind of infrastructure is needed. I think we need to be looking
    at making sure that it is seen as a viable career, that it pays
    a living wage. That can be a challenge where sometimes the in-
    home caregivers are actually receiving public benefits. So the
    more we can promote a living wage for folks where they might be
    able to get some benefits.
        I had the opportunity to be on our Oregon Home Care
    Commission and they really have developed Statewide a strategic
    plan. So I think encouraging communities to develop strategic
    planning that really looks at their work force and how they can
    really boost it, because really we are funding that work force
    in our area through both Medicaid, through State funds, and
    Older Americans Act funds. And it impacts really all the
    individuals getting those services. So it is a real vital
    thing.
        Ms. STEFANIK. Absolutely. Any other feedback on those
    questions from other panelists? Ms. Archer-Smith?
        Ms. ARCHER-SMITH. Yes. I would just encourage the
    reauthorization at levels that help meet the unmet need,
    because when you are providing the meal for the person with
    Alzheimer's, you are supporting that caregiver. When you are
    bringing other resources into the home, you are supporting that
    caregiver.
        We have stories, of you know, people that we have been able
    to help navigate a very complicated system of resources that
    are out there. And without the support of a case manager or a
    client support specialist, they may not have known how to get
    that, those extra hours of in-home care that they were eligible
    for. So making sure that we are meeting the unmet need is
    serving both the participant and the caregiver.
        Ms. STEFANIK. Thank you.
        My time has expired.
        Chairwoman BONAMICI. Thank you. I now recognize the
    chairman of the full committee, Representative Scott from
    Virginia, for 5 minutes for your questions.
        Mr. SCOTT. Thank you.
        Miss Whiting, I wanted to followup on one of the things you
    talked about, respite care. Can you talk about the value of
    respite care, both to the senior and to the caregiver?
        Ms. WHITING. Absolutely, and thank you for the question.
        So respite care is one of those evidence-based benefits
    that we know improves the ability of the caregiver to actually
    be a provider of care and it provides the individual who is
    receiving care a chance to essentially take a break. I mean one
    of the challenges is we think about caregiving in these real
    tactical terms, but there is research coming out that shows
    that if you are going to improve the relationship and the way
    that the caregiver and recipient communicate with each other,
    you cannot only improve the health of the older person or the
    person with disabilities, but you can improve the health of
    that caregiver as well.
        So being able to give people a break from each other and a
    chance to just be the sister, the wife, the brother, the
    friend, has a tremendously positive benefit on families.
        Mr. SCOTT. Thank you.
        Ms. Girard, you talked about the cost of caregiving. Is it
    realistic to think that you could provide funding for
    caregivers without subsidy?
        Ms. GIRARD. Well, I do know a good example. I am probably
    actually a good example because I am doing caregiving for my
    father. He lives about 30 miles from me and I have been
    searching for a caregiver that I am willing to pay in my
    community and I can't find anybody. So it is a struggle. I mean
    there are many families who are willing to cover the cost of
    that, and especially when you look at a return on investment of
    they get a break if you can have somebody come in 5 hours a
    week to just do some of the really heavy work.
        So I think looking at how we can encourage families to do
    that, individuals to do that. But then also I do think we have
    to look at a bit of a safety net for people that really can't
    afford to pay for caregiving and if you look at the return on
    investment.
        Mr. SCOTT. If you are going to pay the caregiver a living
    wage, most of the seniors can't pay someone else a living wage
    because they are hardly making it themselves.
        Ms. GIRARD. That is true. So that is where really we do
    have to subsidize that. But if you look at the cost of the in-
    home caregiving and compare it to the cost of either a
    community-based care, like assisted living or a nursing
    facility, it is still much, much cheaper. We have some State
    funded programs where it is really only costing the State, and
    Older Americans Act actually, about $300 a month. But if that
    person was in an assisted living, it would be probably $3,000 a
    month. And if they were in a nursing home it would be closer to
    $6-8,000 a month. So if you look at it that way, it is actually
    very cheap.
        Mr. SCOTT. Thank you.
        The Older Americans Act supports a number of evidence-based
    health interventions. Ms. Girard, one of these is fall
    prevention, where evidence shows that fall prevention programs
    can reduce problems. Can you say a word about that?
        Ms. GIRARD. Yes. For our Area Agency on Aging we look at
    the development of those programs at multiple levels. We
    participate in a network that includes us, it includes public
    health, it includes health care providers, and it includes our
    community partners, like our nutrition programs. We develop a
    plan in our area and then we look at different ways that we can
    all pool funding to start really developing a network of fall
    prevention programs, evidence-based fall prevention programs.
    And some of the funding is coming from Older Americans Act, but
    some of the funding is coming from other sources. And we really
    try to embed it in local community-based organizations because
    then it is more likely to get out to the folks that actually
    need it.
        Mr. SCOTT. When you talk about evidence-based, do the fall
    prevention programs prevent falls?
        Ms. GIRARD. Yes, the evidence-based--they have been
    studied, they have been compared to control groups where people
    have not been getting the program, and has shown a really
    significant return in reduction of falls. And I know that in
    our area falls is actually, for older adults, one of the
    biggest disease injury kind of issues in our county.
        So it is something that our whole health network is really
    looking at.
        Mr. SCOTT. Thank you.
        And, finally, Ms. Ducayet, can you say a word about the
    ombudsman model addressing problems of elder abuse?
        Ms. DUCAYET. Yes, thank you. So I would say that our model
    includes surprise visits, frequent visits to facilities where
    our eyes and ears are in those buildings. And I think that
    absolutely prevents abuse. It is something different far and
    away from a regulatory function that is there to cite a
    facility and bring them into compliance. Our focus is on the
    resident and being person-centered and finding a resolution
    that the resident wants and seeks to feel safe and secure after
    abuse, neglect, or exploitation.
        I think those are really key factors. We resolve 73 percent
    of complaints to the satisfaction of the resident or the
    decisionmaker of the resident every year.
        Mr. SCOTT. Thank you.
        Ms. DUCAYET. Thanks.
        Mr. SCOTT. Thank you, Madam Chair.
        Chairwoman BONAMICI. Thank you, Mr. Chairman.
        And I see no other members.
        I want to remind my colleagues that pursuant to committee
    practice, materials for submission for the hearing record must
    be submitted to the committee clerk within 14 days following
    the last day of the hearing, preferably in Microsoft Word
    format. The materials submitted must address the subject matter
    of the hearing. Only a member of the committee or an invited
    witness may submit materials for inclusion in the hearing
    record. Documents are limited to 50 pages each. Documents
    longer than 50 pages will be incorporated into the record via
    an internet link that you must provide to the committee clerk
    within the required timeframe, but please recognize that years
    from now that link may no longer work.
        So, again, I want to thank the witnesses for their
    participation today. What we have heard is incredibly valuable
    and I know members of the committee may have some additional
    questions for you. We ask the witnesses to please respond to
    those questions in writing. The hearing record will be held
    open for 14 days to receive those responses.
        And I remind my colleagues that pursuant to committee
    practice, witness questions for the hearing record must be
    submitted to the majority committee staff or committee clerk
    within 7 days. Questions submitted must address the subject
    matter of the hearing.
        I now recognize the distinguished ranking member for his
    closing statement.
        Mr. COMER. Thank you, Madam Chairman. And I just want to
    again thank the witnesses for being here today and thank you
    for everything that you do in the people that you serve. Your
    knowledge and experience and testimony today will help us
    better serve older Americans as we move forward.
        It is crucial that we hear from people on the front lines,
    like yourselves, and I think this committee hearing has been
    very beneficial to us. We must acknowledge the challenges
    facing the Older Americans Act given the rapidly growing senior
    population and constraints of a limited Federal budget.
        As we explore ways to further empower seniors, we must
    enhance coordination within the program to effectively serve
    those with the greatest social and economic needs. A critical
    aspect of this is maintaining and strengthening the local
    flexibilities within the law to meet the needs of individual
    communities.
        We have the opportunity today to begin the committee's
    process of improving the law to better provide care for older
    Americans.
        Again, thank you for being here today and I look forward to
    working with you in the future.
        Madam Chairman, I yield back.
        Chairwoman BONAMICI. Thank you.
        I now recognize myself for making a closing statement.
        Thank you, again, to the witnesses for providing such
    insightful testimony. And I think I also want to thank my
    colleagues who shared--and you heard the intensely personal
    stories--because this is an issue that affects us all and
    affects our constituents.
        People in the United States of America should be able to
    retire and age with dignity. And by passing the Older Americans
    Act in 1965, Congress did make a commitment to provide
    Americans the support they need to age independently in their
    homes and communities for as long as possible. And today, as
    our witnesses testified, the Older Americans Act programs
    empower millions of adults every day to remain independent
    while avoiding or significantly delaying costly
    institutionalized care.
        The population of older Americans continues to grow, but
    unfortunately commitments--investments by Congress in OAA
    programs have not sufficiently kept pace. And this has reduced
    our ability to meet the increased demand for these effective
    and widely used services.
        Just Monday at home in Oregon I heard about an 80-year-old
    woman who was living in the back seat of her car. And I think
    far too many Americans continue to live in poverty across our
    districts, face discrimination, face barriers to basic
    necessities in part because OAA programs are underfunded and
    not well enough supported.
        So today's hearing has underscored our responsibility. We
    can help stop this cycle of disinvestment which is eroding the
    original purpose of the Older Americans Act and creating
    additional challenges for too many older Americans, and
    actually costing us more in higher cost care.
        As this committee considers the OAA reauthorization I hope
    we can work together so its programs have the support and
    resources needed to provide essential services and
    compassionate care to all aging Americans.
        Just 3 years ago both parties came together in each chamber
    of Congress to reauthorize and improve the OAA programs. Today,
    I appreciate my colleagues joining me in renewing that
    commitment to honoring the promise made to older Americans more
    than a half a century ago. By continuing the Older Americans
    Act tradition and bipartisan support we can make clear that
    this committee and this Congress will continue to stand up for
    older Americans.
        So thank you, again, to the witnesses for being here. I
    look forward to working with you and all of my colleagues on
    both sides of the aisle as we move forward.
        And if there is no further business, without objection,
    this committee stands adjourned.
        [Additional submission by Chairwoman Bonamici follows:]
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        [Questions submitted for the record and their responses
    follow:]
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        [Whereupon, at 11:49 p.m., the subcommittee was adjourned.]

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