[Senate Hearing 118-362]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 118-362

                        THE OLDER AMERICANS ACT:
                    THE LOCAL IMPACT OF THE LAW AND
                      THE UPCOMING REAUTHORIZATION

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

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                    ONE HUNDRED EIGHTEENTH CONGRESS


                             SECOND SESSION

                               __________

                             WASHINGTON, DC

                               __________

                              MAY 23, 2024

                               __________

                           Serial No. 118-19

         Printed for the use of the Special Committee on Aging
         
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]         


        Available via the World Wide Web: http://www.govinfo.gov
        
                              __________

                   U.S. GOVERNMENT PUBLISHING OFFICE                    
56-166 PDF                  WASHINGTON : 2024                    
          
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                     SPECIAL COMMITTEE ON AGING

              ROBERT P. CASEY, JR., Pennsylvania, Chairman

KIRSTEN E. GILLIBRAND, New York      MIKE BRAUN, Indiana
RICHARD BLUMENTHAL, Connecticut      TIM SCOTT, South Carolina
ELIZABETH WARREN, Massachusetts      MARCO RUBIO, Florida
MARK KELLY, Arizona                  RICK SCOTT, Florida
RAPHAEL WARNOCK, Georgia             J.D. VANCE, Ohio
JOHN FETTERMAN, Pennsylvania         PETE RICKETTS, Nebraska
                              ----------                              
               Elizabeth Letter, Majority Staff Director
                Matthew Sommer, Minority Staff Director
                         
                         C  O  N  T  E  N  T  S

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                                                                   Page

Opening Statement of Senator Robert P. Casey, Jr., Chairman......     1
Opening Statement of Senator Mike Braun, Ranking Member..........     3

                           PANEL OF WITNESSES

Janet Billotte, Home-Delivered Meal Participant, West Decatur, 
  Pennsylvania...................................................     5
Laura Holscher, Executive Director/Assistant Vice President, 
  Generations, Area 13 Agency on Aging, Vincennes, Indiana.......     7
Leslie Grenfell, Executive Director, Southwestern Pennsylvania 
  Area Agency on Aging, Charleroi, Pennsylvania..................     9
Mairead Painter, Connecticut State Long-Term Care Ombudsman, 
  State of Connecticut, Hartford, Connecticut....................    10

                                APPENDIX
                      Prepared Witness Statements

Janet Billotte, Home-Delivered Meal Participant, West Decatur, 
  Pennsylvania...................................................    33
Laura Holscher, Executive Director/Assistant Vice President, 
  Generations, Area 13 Agency on Aging, Vincennes, Indiana.......    34
Leslie Grenfell, Executive Director, Southwestern Pennsylvania 
  Area Agency on Aging, Charleroi, Pennsylvania..................    38
Mairead Painter, Connecticut State Long-Term Care Ombudsman, 
  State of Connecticut, Hartford, Connecticut....................    41

                        Questions for the Record

Janet Billotte, Home-Delivered Meal Participant, West Decatur, 
  Pennsylvania...................................................    47
Laura Holscher, Executive Director/Assistant Vice President, 
  Generations, Area 13 Agency on Aging, Vincennes, Indiana.......    48
Leslie Grenfell, Executive Director, Southwestern Pennsylvania 
  Area Agency on Aging, Charleroi, Pennsylvania..................    50
Mairead Painter, Connecticut State Long-Term Care Ombudsman, 
  State of Connecticut, Hartford, Connecticut....................    53

                       Statements for the Record

National Council on Aging Testimony..............................    57
American Association of Retired Persons Testimony................    65
Meals on Wheels Testimony........................................    70

 
                        THE OLDER AMERICANS ACT:
                    THE LOCAL IMPACT OF THE LAW AND
                      THE UPCOMING REAUTHORIZATION

                              ----------                              


                         Thursday, May 23, 2024

                                        U.S. Senate
                                 Special Committee on Aging
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 9:30 a.m., Room 
106, Dirksen Senate Office Building, Hon. Robert P. Casey, Jr., 
Chairman of the Committee, presiding.
    Present: Senators Casey, Gillibrand, Blumenthal, Kelly, 
Fetterman, Braun, Rick Scott, Vance, and Ricketts.

                 OPENING STATEMENT OF SENATOR 
                 ROBERT P. CASEY, JR., CHAIRMAN

    Chairman Casey. Good morning. The Senate Special Committee 
on Aging will come to order. Welcome to today's hearing, which 
is entitled, "The Older Americans Act: The Local Impact of the 
Law and the Upcoming Reauthorization." we call it around here--
just like, everything has an acronym--OAA, that this act has on 
communities all across the country.
    OAA was passed into law in 1965, to establish a network of 
social services to support older Americans, complementing 
Medicare and Medicaid. By all measures, the Older Americans Act 
has succeeded.
    Since its passage, OAA has served as the foundation for 
community social services for older adults, providing nutrition 
services, legal support, and social networking, among other 
services. The Act has a tangible impact on local communities. 
Funding flows from the federal government to states and to 
communities to allow programs to be delivered in a way that 
works best for the locality.
    This law supports countless older adults and nearly 20,000 
service providers around the country, 20,000. In Pennsylvania, 
an estimated 27 percent of older adults served by OAA are under 
the federal poverty line. The Law's nutrition programs alone 
serve approximately 85,000 older Pennsylvanians.
    Today, I am releasing a brochure, which I am holding up and 
you would not be able to see from the distance of your seats, 
but it is a brochure that highlights the impact of the Older 
Americans Act on Pennsylvanians. This brochure is entitled 
"Federal Policy on a Local Level: The Impact of the Older 
Americans Act Across Pennsylvania," and it just has some 
examples of the individuals from different parts of our State 
and the services that are provided to them. It provides 
information on those eight Pennsylvanians who are receiving 
services from Older Americans Act programs across nine 
different counties.
    Over time, the OAA has evolved to meet the unique 
challenges that older adults face. In recent years, by way of 
work that I have done and others, Congress added language to 
expand support to grandparents raising grandchildren.
    Flexibility, of course, is the key. The COVID-19 pandemic 
required programs to innovate service delivery. We should be 
learning from this innovation as we move forward.
    This year, I am privileged once again to be the leader in 
negotiations to reauthorize the Older Americans Act. I am 
committed to building on my work in the last reauthorization to 
bolster support for older adults throughout Pennsylvania and 
throughout the Nation. I will be prioritizing both funding and 
programming that helps the Older Americans Act keep pace with 
our rapidly aging population.
    Just to name a few of my priorities: I am working to pass 
the Strategic Plan for Aging Act along with Senator Gillibrand 
to incentivize states to bolster public-private partnerships 
and build communities that work for the older adults of today 
and for future generations.
    In addition, I am dedicated to uplifting the tireless work 
of long-term care ombudsmen. As the Committee has shown 
throughout its history, some older adults experience tremendous 
hardship in nursing homes and assisted living facilities. Long-
term care ombudsmen are advocates for residents in nursing 
homes and other long-term care facilities, dealing with 
everything from no-notice evictions and theft to serious 
neglect.
    However, the program is stretched very thin, operating on a 
grossly inadequate budget, struggling to recruit and retain 
staff and volunteers. In some cases, one ombudsman may be 
serving 10,000 beds, well exceeding national recommendations of 
one to every 2,000 beds. Today, the GAO is releasing a report, 
which I requested, that shows the real impact these funding 
challenges have on residents.
    We will hear today from Mairead Painter, the State 
Ombudsman from Connecticut, who can discuss these struggles in 
much more detail. We will also hear today from two Area Agency 
on Aging directors, including Leslie Grenfell representing 
Washington, Greene, and Fayette Counties in Southwestern 
Pennsylvania, who will discuss the very real challenges they 
face in delivering services to rural communities with limited 
funds. The Aging Services network deserves to be elevated and 
supported by the federal government.
    I am especially looking forward to hearing today from Janet 
Billotte, a meal delivery recipient from Clearfield County, in 
central Pennsylvania. I am so grateful she is using her voice 
here today to share how OAA has helped her.
    Finally, May is Older Americans Month, a time when our 
Nation comes together to honor the contributions of older 
Americans. I want to be clear. I will not support any attempts 
to undermine vital programs that support older adults in 
Pennsylvania and across the country. Our Nation's older adults 
have fought our wars, raised our children and our 
grandchildren, they have built our communities, and they 
deserve support as they age.
    I will now turn to Ranking Member Braun for his opening 
comments.

                 OPENING STATEMENT OF SENATOR 
                   MIKE BRAUN, RANKING MEMBER

    Senator Braun. Thank you, Chairman Casey, and to all the 
witnesses who have come here today.
    Under the current Administration, we have seen sky-high 
inflation, and probably 20 percent higher now than it was when 
the Administration came in. That is an invisible but yet very 
palpable tax that makes everything we are talking about here 
even more difficult.
    All Americans are struggling, but perhaps no one more so 
than Older Americans, finding it harder and harder to stretch 
their dollars to afford even basic groceries.
    The spending of borrowed money, almost anything we do new 
here, is 100 percent borrowed, and it is now averaging into 
what we already do, 30 cents on every dollar we spend is 
borrowed. It is a bad business plan for the younger Americans, 
who are going to have to shoulder that burden, and especially 
for older Americans, so we need to do something about that, 
Republicans and Democrats guilty of it.
    This reckless spending is forcing more and more seniors to 
seek support to make ends meet, while simultaneously making the 
programs that are there for them even harder to be effective.
    The Older Americans Act provides this support, including 
nutrition, transportation, health promotion, and many other 
things. We need to make sure they stay vital.
    As a member of the working group leading the 
reauthorization of the Older Americans Act, I am committed to 
preserving flexibility for localities and states, because they 
generally do things with more effectiveness, and they make sure 
the bills get paid without borrowing the money.
    Every community is different. Seniors are best served, I 
think, when providers on the ground can be entrepreneurial. You 
do not want a one size fits all. You do not want it being 
dictated from the top down. That does not work anywhere. I was 
an entrepreneur for 37 years, and I can tell you in the real 
world, in a business, that never works. You want choice, you 
want transparency, you want new ideas to accomplish the same 
old thing.
    Every community is different, like I said. The Biden 
Administration, though, has put rules out there that want to 
try to make everyone adhere to the same guidelines. Some of the 
final rules are being looked at and litigated currently. All I 
can tell you is when it happens, it removes flexibility from 
local area agencies, adds administrative burden, more cost, 
changes the definition of greatest social need to prioritize 
certain social groups for OAA's nutrition programs. That just 
does not make sense to me.
    I am working to push back against some of these things they 
want to do. This includes ensuring that any senior in need of a 
meal has a fair chance, regardless of which social group they 
belong to. That should not be a parameter. I am also working on 
new proposals to empower AAAs and senior centers to serve older 
Americans without the need for additional funding. We have got 
to find a way to spend less than we take in and get more bang 
for our buck if this place is going to be around and be part of 
the solution.
    We should allow states and local service providers to 
innovate to meet growing nutrition needs, encourage business 
acumen in the aging network, and invest in cost-effective, 
evidence-informed programs.
    I would like to bring much needed transparency by requiring 
the Administration to summarize state ombudsman long-term care 
annual reports for Congress and publish a list of all resource 
centers that it funds. This will allow Congress to have better 
oversight over long-term care facilities and ensure that tax 
dollars are being stewarded effectively.
    Finally, a recurring theme I hear when traveling throughout 
Indiana--I visit all 92 counties every year; they all are 
trying to find those best practices, that right mix--is the 
lack of broadband access in rural communities, and Indiana, for 
example, is a state that is putting a high priority on it, 
investing in state funds, not waiting for the Feds to do it, 
and we are now getting that into every nook and cranny. Other 
states need to be enabled in the same way. They ought to 
probably look to see how they do that themselves rather than 
the cumbersome way of maybe involving this place.
    I hope that we can address this issue by doing more to 
connect existing resources to these communities.
    I look forward to working with my colleagues and 
stakeholders to advance these priorities in the Older Americans 
Act.
    I yield back.
    Chairman Casey. Thank you, Ranking Member Braun, and I want 
to thank the Ranking Member for his work on the reauthorization 
that we are working together on.
    I will introduce our witnesses now. I will introduce each 
of our witnesses before their testimony. I will start with our 
first witness, Janet Billotte. Janet, thank you for being here. 
She is from West Decatur, in Clearfield County in the middle of 
our State, kind of the northcentral part of our State, and she 
receives meal deliveries and other services from her Area 
Agency on Aging. She will share how meaningful the meals and 
services she receives have been for her.
    I want to thank you, Janet, for being here today and for 
making the trip from Clearfield County. It is not an easy ride.
    I will turn to Ranking Member Braun to introduce our second 
witness.
    Senator Braun. It is my pleasure to introduce Laura 
Holscher. She is the Executive Director and Assistant VP of 
Generations, which is an Indiana's Area 13 Agency on Aging, 
located in Vincennes, Indiana, very near where I live. In fact, 
we are rivals, I think, in a lot of sporting events and so 
forth, so it is that close.
    She has served with Generations for almost 30 years, 
including the past 14 years as Executive Director. Under her 
supervision, her team has received the highest level of 
accreditation through the National Committee on Quality 
Assurance. Kudos to you for that. She has served as a Board 
President of the Indiana Association of Area Agencies on Aging, 
and now serves as the Chairman of the Public Policy Committee.
    Thank you for making the trip to D.C. to be here today.
    Chairman Casey. Thank you, Ranking Member Braun. Our third 
witness is Leslie Grenfell. Leslie is the Executive Director of 
the Southwestern Pennsylvania Area Agency on Aging, or AAA as 
we call them. She will share her experience as the AAA's 
Executive Director, the challenges they face, and the 
innovative ways that AAAs handled service delivery during the 
COVID-19 pandemic.
    Ms. Grenfell, thank you for being here and thanks for your 
service to older Pennsylvanians and sharing your experiences 
with us today.
    Our fourth and final witness, I will turn to my colleague 
from Connecticut, Senator Blumenthal, to introduce that 
witness.
    Senator Blumenthal. Thanks, Mr. Chairman, and thank you for 
having this hearing on this very important topic. I am very 
honored to introduce Mairead Painter, of Connecticut. She is 
Connecticut's Long-Term Care Ombudsman, and she has done really 
magnificent work in that job. I am very proud to be here with 
you.
    Ms. Painter was appointed to this position of Connecticut 
Long-Term Care Ombudsman in 2018. She has had this position 
during some of the worst times in our long-term care 
facilities, during COVID. She promotes and protects the quality 
of life for older adults and individuals with disabilities 
across the State. She serves more than 30,000 Connecticut 
residents in skilled, long-term care nursing facilities, 
residential care homes, and assisted living and managed care 
residential communities. She also oversees the program's 
advocacy work and is committed to furthering person-centered 
care and informed choice for all individuals.
    Recently, she received the Administration for Community 
Living's first Community Living Director Care Award, 
highlighting the work that she and her team have done in 
advocating and protecting the rights and well-being of 
individuals in long-term care facilities.
    I want to thank Ms. Painter for all you have done to 
protect those 30,000 people in facilities across the State of 
Connecticut, and especially you making the trip down here to 
D.C. and sharing your thoughts on this very important topic 
with us. I know you have a lot of experience, a lot of insight, 
and we really welcome and express our thanks to you. Thank you.
    Chairman Casey. Thank you, Senator Blumenthal. We will turn 
to our first witness, Ms. Billotte.

       STATEMENT OF JANET BILLOTTE, HOME-DELIVERED MEAL 
            PARTICIPANT, WEST DECATUR, PENNSYLVANIA

    Ms. Billotte. Chairman Casey, Ranking Member Braun, and 
members of the Committee, thank you for having me here today at 
your Older Americans Act hearing. My name is Janet Billotte. I 
live at the Village of Hope. I am 78 years old, and I live in 
West Decatur, Pennsylvania, which is a rural town in Clearfield 
County. Before retiring, I worked as a nursing aide. I am here 
to share my experiences as a recipient of Meals on Wheels and 
other services from the Clearfield County Area Agency on Aging.
    I have been receiving Meals on Wheels for four years. My 
husband Richard and I started receiving meals in August 2020, 
when he had five stents placed in his heart and two years later 
open-heart surgery, during the pandemic. I was very happy to 
receive these meals. Every time I received a meal, it always 
feels like I am getting a present each meal. I would like to 
invite you to have lunch with me today. The meal is kielbasa, 
mashed potatoes, sauerkraut, a fruit cup, brown bread, and it 
is a special day--we get strawberry shortcake.
    Last year, I was diagnosed with Stage three colon cancer, 
and I was also caring for my husband Richard, who had been sick 
with many issues for a long time. I also just had an operation 
for my cancer and had chemotherapy three times every other 
week. Many days, I did not feel well, and it was very helpful 
to have these meals delivered to us.
    I love talking to Fred. Fred is my meal delivery person. 
Every day he comes he asks me how I am. Lots of times I don't 
see anyone except Fred to see or talk to each day, so I am 
thankful when he checks in on me. If he doesn't hear from 
someone, he calls the Area Agency on Aging and asks to make 
sure we are okay. A lot of older people don't have family. I 
don't have family. I have a son, Clint, who is autistic, a 
daughter, Sarah, who passed away, and my husband recently 
passed away. Now the Area Agency on Aging has become my family.
    Today, my cancer is in remission. I am still receiving 
deliveries from Meals on Wheels and other services from the 
Area Agency on Aging. I am very glad that they give us vouchers 
through the Senior Farmers Market Nutrition Program run by the 
Agriculture Department so that we can go to the farmer's 
market, and I can get fresh produce. I can get tomatoes, 
lettuce, and all kinds of fresh foods from the market. It is 
good nutrition, and it is helpful in preventing cancer.
    During bad weather, they also receive "blizzard boxes", 
where they send us a box of frozen and shelf-stable food so we 
have something to eat when we are stuck in bad weather to 
prepare. I am thankful for these services, and I'm not sure 
what I would do without them.
    Beyond meal deliveries, I also participated in events at 
the senior center. They took us on a field trip to a mushroom 
farm, where we learned about all the different types of 
mushrooms and how to prepare them, how bees pollinate herbs, 
and we went to a flower garden. I love flower gardens and 
gardens.
    The Area Agency on Aging also helped coordinate 
transportation for me when I had to go to the clinic to get 
chemotherapy. I had to get chemotherapy and blood work every 
week, and this was not good, because I live in a rural area, it 
was very hard to find transportation to the clinic, but Adam 
was very kind to help drive me to my doctor's appointment and 
to chemotherapy.
    I was very grateful to receive these services, and grateful 
for the friendship I have with my Area Agency on Aging. Kathy 
Gillespie, who is with the Area Agency on Aging, is like family 
to me. I know many older adults receive Meals on Wheels are 
thankful like I am. I also understand that there are many more 
older adults on the waiting list for these services. I ask you 
to please help more people get into the program and be able to 
receive these great services.
    Thank you again for the opportunity to share my story.
    Chairman Casey. Ms. Billotte, thanks so much for your 
testimony and for sharing your own personal experience. We are 
grateful.
    Ms. Holscher, you may begin.

             STATEMENT OF LAURA HOLSCHER, EXECUTIVE

        DIRECTOR/ASSISTANT VICE PRESIDENT, GENERATIONS,

          AREA 13 AGENCY ON AGING, VINCENNES, INDIANA

    Ms. Holscher. Senator Braun, Chairman Casey, and members of 
the Senate Special Committee on Aging, I am Laura Holscher. For 
30 years it has been my honor to serve older adults at 
Generations Area Agency on Aging. Generations is a program of 
Vincennes University and is designated by the Indiana Division 
of Aging's Commission on Aging as the Area 13 Agency on Aging 
and as the Aging and Disability Resource Center. I want to 
thank Senator Braun for inviting me today.
    Under the Older American Act, Generations' role is to 
develop, fund, and implement a broad range of programs and 
services to meet the needs of older adults and caregivers. We 
serve six counties in southwestern Indiana--Daviess, Dubois, 
Greene, Knox, Martin, and Pike Counties. We impacted the lives 
of more than 35,000 individuals last year. Our entire planning 
and service area is considered rural. We have four hospitals, 
but in some of our cities there is not even one primary care 
physician and 22.7 percent of the population in our service 
area is living below 150 percent of the federal poverty level.
    Some of the challenges we face as a rural community include 
lack of broadband internet and limited access to 
transportation, both of which limit access to health care and 
social opportunities. Under Title III-B of the Act, our AAA 
offers in-home services for frail older adults, senior 
transportation, information and referral/assistance, options 
counseling, home modification and repair, legal services, the 
Long-Term Care Ombudsman Program, and other person-centered 
approaches.
    The flexibility of this funding stream gives AAA the means 
to meet the needs of older adults in the community, eliminating 
the need for expensive nursing home care.
    Our Older Americans Act clients inform our work. Since many 
have cognitive impairments, we pulled together a dedicated 
action team to help form partnerships like the one with Mi 
Patio, a local restaurant, to provide dementia-friendly dining 
hours. This was achieved by using some of our Title III-B 
funding and supplementing it through our University of Southern 
Indiana Geriatric Workforce Enhancement Program workforce 
development grant. I am proud to say this county was recently 
designated as a Dementia Friendly Community by Dementia 
Friendly America.
    Another essential part of Older Americans Act is Title--C 
nutrition services. In the past, Generations has provided daily 
hot and home-delivered meals to homebound older adults. As the 
economy shifted, gas prices rose, and the cost of food 
increased, it became apparent that our operations would need to 
shift from daily hot, home-delivered meals to frozen meals. As 
we made the shift to frozen meal providers we searched locally 
for partners who would be willing to contract with us to 
provide hot meals. We now have partnership with a nursing home 
and two senior centers to provide hot meals in their 
surrounding area.
    Today, we operate a hybrid program. A client can choose 
from up to six different frozen, home-delivered meal service 
providers or from a hot meal if they live in a covered area. 
Last year we provided over 106,000 meals to nearly 1,000 older 
adults.
    Our hope was to expand these local partnerships for hot 
meal delivery, but the funding is not sufficient. Need is 
growing in our community. Over the past two years, we have seen 
a 20 percent increase in calls for meals and have more people 
accessing our services because they just cannot afford 
groceries or other necessities. Due to the continued rising 
cost of food, freight, delivery, and labor costs, the same 
amount of money simply cannot stretch to meet higher costs.
    In addition, donations, grant support, and community 
support are down as donors themselves are tightening up their 
purse strings and prioritizing their own budgets. This has 
forced us to triage calls and provide meals only to the most 
at-risk individuals and put others on a waiting list. In the 
meantime, our trained counselors work with clients to provide 
alternatives, such as enrollment assistance for Supplemental 
Nutrition Assistance Program, referrals to food banks, food 
pantries, and local churches.
    Under Older Americans Act Title III-D we run several 
evidence-based health and wellness programs, such as A Matter 
of Balance, Bingocize, and the Chronic Disease Self-Management 
Program. Through additional partnerships we have more than 
doubled in what we were able to offer.
    There are also ways to make these dollars go further. 
Generations and other rural AAAs around the country would 
benefit from flexibility to use Title III-D moneys to fund 
evidence-informed programs, which are lower in cost and more 
adaptable.
    Generations was created as a result of the Older Americans 
Act. These are just a few examples of how we innovate and adapt 
to meet the needs of older adults in our rural area. Please 
keep the Act's inherent flexibility and locally driven 
structure in mind as you update the law this year.
    I have four recommendations for the reauthorization.
    First, increase Older Americans Act funding, which has not 
kept pace with the growing number of older adults or inflation.
    Second, continue some of the nutrition flexibilities that 
were extended to AAAs during COVID or allow for the flexibility 
to fund innovative ideas in the nutrition program.
    Third, allow Title III-D health and wellness programs to be 
evidence-informed, and finally, we support USAging's 
recommendations for reauthorization.
    Thank you for the opportunity to testify today.
    Chairman Casey. Ms. Holscher, thanks for your testimony and 
for being here today.
    Ms. Grenfell. Thank you.

       STATEMENT OF LESLIE GRENFELL, EXECUTIVE DIRECTOR,

                 SOUTHWESTERN PENNSYLVANIA AREA

            AGENCY ON AGING, CHARLEROI, PENNSYLVANIA

    Ms. Grenfell. Chairman Casey, Ranking Member Braun, and 
members of the Senate Special Committee on Aging, thank you for 
the opportunity to testify before you today to discuss the 
Older Americans Act.
    My name is Leslie Grenfell. I am the Executive Director of 
Southwestern Pennsylvania Area Agency on Aging, serving older 
adults residing in Fayette, Greene, and Washington Counties. It 
has been an honor for me to serve as the Executive Director for 
the past 23 years.
    In terms of population, our agency is the largest rural 
Area Agency on Aging in the Commonwealth. Its service and 
planning area encompasses 2,223 square miles. The agency acts 
as a community focal point, providing information and 
assistance, protecting vulnerable older adults, assisting 
caregivers and their families, reducing food insecurity, and 
empowering older adults to live independently and to age well.
    The Nutrition Program is the cornerstone of the Older 
American's Act, and includes congregate, home-delivered, and 
grab-and-go meals, which were introduced during the COVID-19 
pandemic. The flexibility of the grab-and-go meal option, where 
older adults can pick up a meal to take home, has been well-
received by our consumers.
    Our home-delivered meal providers, however, are struggling. 
High costs, long distances between homes, and traveling on 
winding back-country roads, can make delivery difficult. One of 
our most demanding routes is in the Laurel Highlands of Fayette 
County, which requires travel through State Game lands and is 
32 miles long.
    Although challenging, providers have successfully developed 
and sustained a service delivery system using volunteers who 
not only deliver hot, well-balanced nutritious meals five days 
a week, but also provide wellness checks to each older adult, 
ensuring their safety and well-being. Last fiscal year, 
approximately 700 dedicated volunteers delivered over 400,000 
in-home meals to at-risk consumers.
    The challenges identified by our 34 home and community-
based agencies who provide personal care services in rural 
communities are the costs associated with transportation due to 
the distance between consumer homes, the recruitment and 
retention of direct care workers, and the need for increased 
reimbursement.
    Last fiscal year, our agency received $591,073 in American 
Rescue Plan Act funds, which provided a necessary infusion of 
financial support, permitting us to help a growing number of 
older adults.
    Despite the growing number of older adults and the 
corresponding need for services projected to increase, no 
appreciable amount of additional Older Americans Act funding 
has occurred for over a decade.
    Increasing Older Americans Act funding and increasing its 
flexibility is a cost-effective financial investment which 
would enable older adults to stay healthy longer, living in 
their own homes and communities where they want to be, whereby 
reducing the need for more costly long-term care interventions, 
such as skilled nursing care.
    In 2023, the Pennsylvania Department of Aging began 
development of a 10-year Multisector Plan for Aging called 
Aging Our Way, PA. It is a state-led and stakeholder-driven 
strategic plan designed to help transform the infrastructure 
and coordination of services for older Pennsylvanians and 
persons with disabilities. The network of AAAs was essential to 
the stakeholder process, which yielded over 20,000 responses 
from across the State. Each AAA engaged their local 
communities, encouraged community participation, and 
facilitated listening sessions, at least one in each of the 67 
counties and over 200 sessions in total.
    The AAAs are integral to many of the recommendations 
developed through this process, and we are looking forward to 
working with the Pennsylvania Department of Aging in 
implementation.
    In conclusion, I would like to especially thank Senator 
Casey for inviting me to provide testimony today. On August 
5th, I will be retiring after 48 years in the Aging Network. It 
has been an honor and a privilege for me to share my insights 
with you and it is truly a wonderful capstone of my career. 
Thank you.
    Chairman Casey. Well, Ms. Grenfell, thank you, and thanks 
for those--you said 48 years?
    Ms. Grenfell. Yes, sir.
    Chairman Casey. You started in second grade.
    Ms. Grenfell. Thank you.
    Chairman Casey. You have dedicated your life to this work. 
Thanks so much for that.
    Ms. Grenfell. You are welcome.
    Chairman Casey. Ms. Painter, you may begin.

        STATEMENT OF MAIREAD PAINTER, CONNECTICUT STATE

               LONG-TERM CARE OMBUDSMAN, STATE OF

               CONNECTICUT, HARTFORD, CONNECTICUT

    Ms. Painter. Thank you, Chairman Casey, Ranking Member 
Braun, and distinguished members of the Senate Special 
Committee on Aging for inviting me here today, and Senator 
Blumenthal for that welcome.
    My name is Mairead Painter, and I am honored to serve as 
the State Long-Term Care Ombudsman in Connecticut. As long-term 
care ombudsman, we serve as independent advocates for older 
adults and individuals who reside in residential care settings.
    The Long-Term Care Ombudsman Program was established in the 
1970's by President Nixon in response to widespread concerns 
over pervasive abuse, neglect, and mismanagement of nursing 
homes. Over the following years, the program was statutorily 
formalized as part of the Older Americans Act, or the OAA.
    My team in Connecticut, although small, is dedicated and 
strong. It is comprised of 12 staff members, including myself, 
and we serve approximately 30,000 residents in about 400 long-
term care facilities. The ombudsman's activities are performed 
on behalf of, and at the direction of, residents, and is 
strictly confidential. We provide direction for services, 
information about residents' rights, including consultation, 
investigation, and complaint resolution.
    Our non-mandated reporter status reassures residents that 
their communication with us is confidential. This is 
encouraging to them because they can speak to us and get our 
guidance without fear of reprisal.
    Our office frequently receives complaints concerning 
general care issues. These complaints can be adversely 
affecting to them, about their basic care needs. For example, 
in some cases residents are informed that they must choose what 
days they can get out of bed because they lack available staff 
to assist them. Other complaints might pertain to involuntary 
discharges, where residents receive notices that they are being 
discharged from the facility or instructed that they might have 
to leave immediately, and that they are being sent to a 
homeless shelter or a hotel. In these cases, our team works 
closely with the residents to try to ensure that their rights 
are upheld and that proper procedures are followed.
    Despite an increase in care settings over the years, 
ombudsman programs have not seen the corresponding increase in 
funding. Many programs receive minimal state funding, and some 
programs, like in Tennessee, only receive enough funding to pay 
for the state ombudsman's salary. This lack of investment in 
the state funding, coupled with stagnant funding at a federal 
level, hampers our ability to meet increased demand.
    Half of the states do not have adequate staff to meet the 
1995 Institute of Medicine staffing ratio, which recommends one 
ombudsman for every 2,000 long-term care beds. This report, 
while outdated, provides the most reliable staffing standard 
for the program to date. Connecticut's program currently 
operates with one regional ombudsman to almost every 3,800 
long-term care beds. Additionally, the increased number of 
residents with complex care needs who depend on our advocacy 
underscores the necessity for ombudsmen to be able to 
responsive.
    The original program relied heavily on volunteers, but 
today demands often exceed what volunteers feel equipped to 
handle. We need to reevaluate our reliance on volunteers while 
adding more trained and paid ombudsmen across the Nation.
    Most critical is funding limitations impede our ability to 
educate individuals, respond promptly to complaints, and 
monitor facilities before crisis happens. This critical funding 
would also result in cost savings to the greater health care 
system. Although ombudsmen may work as state employees, our 
roles require independence.
    In addition to monitoring and responding to complaints, our 
program engages in education and outreach, both at a facility 
level and in the broader community. We also undertake rigorous 
systemic and legislative advocacy.
    Once I got to know other state ombudsmen I began to realize 
that in Connecticut, while federally mandated under the Older 
Americans Act to have autonomy, it is not upheld in all the 
other states. Many of my peers cannot speak out about the 
interference that they experience as it might jeopardize their 
jobs. This is unsettling because ombudsmen must have the 
autonomy to advocate in a bipartisan way in order to advocate 
on behalf of the people that we serve.
    This leads me to one of the reasons that it is essential 
that the National Director position for Long-Term Care 
Ombudsman be refilled. It is necessary to have that independent 
voice advocating for our role. As a representative of the state 
ombudsmen across the country, I strongly urge you to reinstate 
the National Director for the Ombudsman Program.
    I want to thank you for allowing me to offer you this 
testimony today, as many individuals are still unaware of our 
role, their rights, and the standards of care that they should 
expect when receiving long-term services and supports. As 
ombudsmen our goal is to continue to protect the health, 
safety, welfare, and rights of all individuals receiving long-
term services and supports. Thank you.
    Chairman Casey. Ms. Painter, thanks very much for your 
testimony and for your good work.
    We will turn next to questions, and I often say at this 
point in the hearing how challenging Thursdays can be around 
here with a lot of conflicting hearings. That challenge applies 
to me today, so I am going to have to step out to get to a 
hearing and then come back, but the Committee will be in the 
capable hands of the Ranking Member, and I think we will start 
with, in my place for questions, we will start with Senator 
Blumenthal, and then we will turn to Ranking Member Braun. 
Thank you.
    Senator Blumenthal. Thank you, Mr. Chairman, and I 
appreciate your yielding to me, and I want to thank all the 
witness for your excellent, insightful testimony.
    Ms. Painter, I am particularly interested in your comments 
about the need for autonomy and independence, and also adequate 
funding. Connecticut may be doing better than other states, but 
still your point about needing additional resources I think is 
extremely important, and perhaps you can tell us how those 
resources would be used in Connecticut and by other similar 
ombudsmen or offices around the country.
    Ms. Painter. Yes. Thank you, so the staffing that we need 
is trained, paid staff in order to meet the demand when the 
calls come in. We do not want to have to triage calls. We want 
to be able to answer the calls when individuals say that there 
is a need. We want to be able to go out and meet with them 
directly. It is important that they have the confidentiality 
and the ability to meet with us face to face.
    When you are talking about having to choose or only being 
able to represent some of the residents, my team right now is 
almost double the amount of individuals that they serve. We try 
to get out to everybody within two to three days, but sometimes 
that is taking up to a week, and like I said, we have one of 
the better staffing ratios in the country. For some I think it 
was, Senator Braun brought up, it was almost 10,000. We are 
almost 4,000; some are 10,000, so that is a major difference 
there.
    Senator Blumenthal. I understand your point about the need 
for independence so you can speak out.
    Ms. Painter. Yes.
    Senator Blumenthal. At the same time, it is important, is 
it not, that ombudsman offices be supported by the 
Administration in Connecticut and around the country. Do you 
find that support less robust than it should be?
    Ms. Painter. I have the support at a state level, so 
different ombudsmen offices are set up differently. They are 
either housed within a state agency, which is centralized, or 
decentralized, which is outside of a state agency, so I am 
within a state agency. However, I am independent, so I have 
autonomy. They support me in the ways of a fiscal office and 
HR. However, I can advocate on behalf of the residents in the 
way that the residents or family members direct me to do so.
    It is challenging for my peers because when something, for 
instance staffing levels or other issues, come up at a federal 
level for them to be able to testify either at a state or 
federal level. They do not always have the ability, or there 
may be a manager if they are decentralized, or someone that 
tells them they are either not able to speak out against that 
or to speak to a reporter. I am able to independently speak to 
reporters, the media, anyone who contacts me, and I do not have 
interference at a state or federal level.
    Senator Blumenthal. Do you have authority to go to court, 
to take action in court?
    Ms. Painter. If I see necessary, yes, I do.
    Senator Blumenthal. Do you do that commonly, or is it a 
rare instance?
    Ms. Painter. It is a rare instance.
    Senator Blumenthal. Would you do more of it if you had more 
resources?
    Ms. Painter. Potentially. If there was a need and I felt I 
needed to, yes.
    Senator Blumenthal. That would provide a stronger deterrent 
as well as remedies for the individuals who may be suffering 
unfairly or painfully in facilities that are not doing their 
job right.
    Ms. Painter. Potentially, if we had the ability to work on 
the cases and to have the staff out there to work the cases in 
those ways, we may have the ability to get the information 
necessary to move cases forward.
    Senator Blumenthal. You mentioned a couple of instances 
that you found where perhaps residents or patients were not 
treated well, being unable to get out of bed when they wanted 
to do so, involuntary discharge. Are those the two most common 
kinds of complaints? What are the most common kinds of 
complaints that you receive?
    Ms. Painter. I believe the two highest complaints that we 
heard this past year were related to individuals' care plans 
being honored, some of them having a say in their individual 
plans of care and those being honored, and that was directly 
linked back to staffing. When we really looked at why their 
care plans were not being honored it was because they did not 
have the staff to be able to do that. It was not that the staff 
did not want to. They were not able to complete those things 
that the residents wanted done because the staff were not there 
to do that and the other highest area is involuntary discharge.
    Senator Blumenthal. Thank you. My time has expired. This 
area is of great interest to me and very important in the State 
of Connecticut. Again, I appreciate your very significant work 
and the need for more resources. Thank you.
    Senator Braun. Thank you, Senator Blumenthal. We will go 
next to Senator Ricketts.
    Senator Ricketts. Great. Thank you, Ranking Member.
    As the Nation's population ages, communities face 
increasing demand and challenges in providing comprehensive 
systems for the care of older Americans. The Older Americans 
Act funds programs and services that enable older adults to 
enjoy healthy, productive, and independent lives in their homes 
and communities.
    Services authorized by the OAA include, but are not limited 
to, family caregiver support, health and wellness promotion, 
job training, nutrition programs, transportation, and programs 
to prevent and address elder abuse, neglect, and exploitation. 
The OAA provides states not only to target services to people 
with the greatest social or economic need but also to make 
programs available to all people in the community.
    The Older Americans Act has been the primary federal 
legislative source supporting social and nutrition services to 
Americans aged 60 and older since 1965. OAA programs are vital 
for seniors who are at significant risk of hunger, isolation, 
and losing their ability to live independently. We have heard 
about the Meals on Wheels and the great work they do providing 
home-delivered nutrition services to older Americans, and the 
Older Americans Act helps fund this critically important 
program.
    When considering care for older Americans, loneliness if 
often overlooked. Studies undertaken during the COVID-19 
pandemic demonstrated significant increase in reported 
loneliness among older adults. A study conducted at the 
University of Nebraska Omaha found that 39 percent of older 
Nebraskans reported feelings of loneliness, and 35 percent 
reported feeling lonelier due to the impacts of the pandemic.
    That was my experience as Governor of Nebraska. One of my 
concerns was in our skilled nursing facilities and assisted 
living facilities due to the restrictions that were placed on 
those facilities. There was concern about the folks in those 
facilities being isolated and the loneliness that goes along 
with that, not being able to get access to their families, and 
that sort of thing.
    As a result, last November I introduced the Improving 
Measures for Loneliness and Isolation Act with my First 
District Congressman Mike Flood. This would direct the 
Secretary of Health and Human Services to establish a working 
group to formulate recommendations for standardizing the 
measurements for loneliness and isolation.
    Ms. Holscher, you mentioned in part of your remarks that 
lack of broadband actually limited social interactions. In 
general, what are your thoughts with regard to loneliness and 
finding a way to come up with uniform measurements for 
loneliness? Would this be something potentially beneficial? I 
mean, everybody, I think, mentioned about the wellness checks 
that the Meals on Wheels do.
    Tell me a little bit, what are kind of your thoughts on 
this?
    Ms. Holscher. During COVID obviously we did the wellness 
checks, as you mentioned. Some of the other activities that we 
engaged in during COVID included porch drop of activities. We 
created a manual, so to speak, that had activities and games 
and trivia, and we were able to porch-drop those to individuals 
that we were concerned about, that we knew were at high risk of 
social isolation and loneliness. We continued that for a while 
with the COVID relief funding, but since that money is gone we 
are struggling to be able to continue that.
    We have done some other things to get folks out of their 
houses since COVID kind of opened back up. We are providing 
Coffee and Canvas programs. They are art programs, and we 
provide those in senior centers, and they are a more relaxed 
activity than an evidence-based program, because you can come, 
you can participate in the activity, and it is just a lot more 
relaxed than a classroom type activity.
    We have done some of that. Again, funding is an issue, and 
we would like to be able to continue that.
    One of the other things that we think is very important is 
we would like to see the National Resource Center for Engaging 
Older Adults codified in the Act. This is a valuable resource 
for AAAs. It provides training and technical assistance on 
social engagement.
    Senator Ricketts. Would you think it would be helpful, 
because you mentioned the evidence-based programs and 
flexibility to use that, would it be helpful then to have some 
way to measure loneliness, for example, to be able to determine 
who is most at risk, establish baselines, who would be the 
folks that you would need to focus on, as a first priority for 
some of the programs you talked about?
    Ms. Holscher. I think that it would definitely be helpful, 
but I would not want to add an additional mandate to what we 
are already doing. We have been doing this for 50 years, and we 
are able to recognize those individuals that we think are most 
at risk. That does not mean that we will not miss some, but I 
think what would be helpful--I would not want an additional 
mandate, because when you add a mandate, it increases our 
costs.
    Senator Ricketts. Finding a way to be able to maybe 
establish a baseline but do it in a way that is not going to 
impact, or mandate you do extra stuff without actually 
providing the funding to be able to do it.
    Ms. Holscher. Right.
    Senator Ricketts. Right. We tend to do that a lot in 
government. Okay, great.
    Hey, well, my time is up but thank you very much, Ms. 
Holscher. I appreciate your insights on it.
    Ms. Holscher. Thank you.
    Senator Braun. Thank you, Senator Ricketts. Senator 
Gillibrand.
    Senator Gillibrand. Thank you, Mr. Chairman.
    State and local governments need resources and planning 
assistance to comprehensively address the needs of our aging 
loved ones. I am proud to lead the Strategic Plan for Aging 
Act, with Chair Casey, which would establish a grant program 
for states, territories, and Tribes to create or continue 
developing a Multisector Plan to transform the infrastructure 
and coordination of services for their aging population.
    Ms. Grenfell, thank you for your testimony and your 48 
years of work in the aging network. Could you please describe 
the ways in which legislation like the Strategic Plan for Aging 
help a state like Pennsylvania with continuing to develop its 
10-year Multisector Plan for Aging?
    Ms. Grenfell. Thank you, Senator. That is an excellent 
question. Regarding Pennsylvania's work, there was considerable 
effort to ensure that we received input from a multiple number 
of stakeholders. There was effort made also to have a vast 
majority of older people, as I mentioned.
    I think that legislation that you are referring to would be 
extremely helpful, not only to the work that we are continuing 
to do in Pennsylvania but to incentivize other states to 
possibly move into a direction of a Multisector Plan. I think 
it would be extremely helpful. I think what we are hearing 
today is that states and local Area Agencies on Aging are 
struggling, and if there would be a way to incentivize such 
planning on a national level. We already know that other states 
have implemented such plans, and Pennsylvania is in the 
implementation stage. I think it would go a long way to 
ensuring that older adults across the Nation receive that same 
type of respect in terms of the planning process, so I thank 
you for that question.
    Senator Gillibrand. What, Ms. Grenfell, do you think is 
most misunderstood or overlooked as part of the Older Americans 
Act, and what does Congress need to know about it?
    Ms. Grenfell. Well, I think what is most misunderstood is 
the provision about the state units on aging having oversight 
over contracting that local Area Agencies on Aging are involved 
in to help ensure that the constituents that live in their 
geographic area are able to receive a number of services. There 
seems to be some confusion on whether or not the state units 
are to have oversight over all types of contracting or just the 
contracting that would leverage potentially Older Americans Act 
funds, as opposed to non-Older Americans Act funds.
    In Pennsylvania, we are very involved in the level of care 
determinations, so that contract, for us, the Southwest Area 
Agency on Aging, allows us to bring over $1 million. That 
funding then helps to reduce other funding that we might need 
but allows us to use more services and programs, provide more 
services and programs, if you will, to the population that we 
serve.
    Senator Gillibrand. Great. Since 1972, the Older Americans 
Act Nutrition Program has been successfully meeting its purpose 
to reduce hunger, promote socialization, and support health 
amongst older adults. During Fiscal Year 2025 appropriations 
process I am proud to have called for $1.8 billion in funding 
for this vital program to fund congregate and home-delivered 
food services for older adults.
    Ms. Billotte, thank you for sharing your story. It is vital 
that older Americans can age in place. Could you please explain 
the ways in which home delivery food services impacts your 
ability to live in the setting of your choice?
    Ms. Billotte. It is helpful for me to receive services at 
home because that way I don't have to go to the nearest grocery 
store, which would be eight miles to Philipsburg, 10 miles to 
Clearfield for my doctor's appointments. It helps me to be in 
my home and be secure that I can have Fred, my deliveryman, 
deliver Meals on Wheels to me, and also that I can receive 
someone to take me to my doctor's appointments, and for the 
nutrition part, I believe that through the Senior Farmers 
Nutrition Act that also is very helpful for my cancer.
    Senator Gillibrand. What would happen to you if you were 
unable to receive home-delivered meals?
    Ms. Billotte. I would have to go to someone and hire them 
to take me to the grocery store, and then to learn how to cook 
all over again.
    Senator Gillibrand. Yes. It is a lot. Well, I just want to 
thank all of our panelists for their dedication and their 
strong support for our older Americans. Thank you for all the 
hard work you have done and thank you for your testimony.
    Chairman Casey. Thank you, Senator Gillibrand. We will turn 
next to Ranking Member Braun.
    Senator Braun. Thank you, Mr. Chairman. I want to start 
with Ms. Holscher. In the OAA Final Rule the Administration 
expanded the definition of "greatest social need." These 
criteria are used to determine which seniors should get 
priority for meals. With waiting lists and challenges in food 
delivery is it justified to expand the definition of greatest 
social need?
    Ms. Holscher. I think the definition needs to remain broad 
and allow the local AAA to determine who is in the greatest 
need through their local area plans and their needs assessment. 
My area does not look like Juneau, Alaska, or Indianapolis, 
Indiana, for that matter, and we need the flexibility to plan 
for and meet the needs of the older adults at the local level.
    Senator Braun. We have heard about how partnering with 
other aging service providers can magnify your reach while 
making each dollar go further. I applaud this local 
entrepreneurship. Our national debt, as I said earlier in my 
opening statement, is ballooning to the tune of a trillion 
dollars every six months. To put that in perspective, that was 
just, well, it is a lot of zeroes after a one. It was a 
trillion dollars annually just five and a half years ago. We 
are now $35 trillion in debt, and five and a half years ago, 
18, which was approaching a record.
    What steps should we take to support entrepreneurship in 
the aging network, and do you think this will bring costs down 
and yet still be more effective?
    Ms. Holscher. We would ask that the flexibility and control 
of business arrangements, such as contracting with health care 
entities to deliver home and community-based services under 
Medicaid be restored to the local AAA level. We have been 
charged with building comprehensive systems of services by 
leveraging local and private funding, and we need to be nimble 
to do that without delay.
    We have a long history of preventing conflict of interest 
and managing multiple funding sources, and it is important that 
we maintain our independent status without the restrictions or 
barriers.
    Senator Braun. One more question for you. In your testimony 
you called for more flexibility in the Older American Act's 
Health and Wellness Programs. Currently, and by the way, health 
and wellness and prevention and all that is what I wove into my 
health care plan, back many years ago, in my company, and 
pretty well, when you do that right you can halt your health 
care costs and insurance costs, so it can be done, and I know 
that it hurts in places where you have got communities that are 
already strapped for resources.
    Can you explain how allowing evidence-informed programs 
would expand the reach and effectiveness of services?
    Ms. Holscher. The flexibility in Title III-D to incorporate 
evidence-based programs would allow the network to reach older 
adults with emerging innovations and enhance our ability to 
stretch the limit on Title III dollars and reach more people.
    In my area we would like the opportunity to try a program 
called Building Better Caregivers. It is a six-week, online 
workshop for caregivers of veterans, and this flexibility would 
allow us to do that. Right now that is not a program we would 
be able to offer because we do not have the funding.
    Senator Braun. Thank you. Ms. Painter, the Long-Term Care 
Ombudsman Program exists to identify, investigate, and resolve 
complaints made at long-term care facilities. State ombudsmen 
submit reports to the Administration on the cases they handled 
each year. However, it is unclear how this information is being 
utilized. How would summarizing this data and making it public 
improve transparency at long-term care facilities?
    Ms. Painter. We agree that this information should be 
available to the public and to policymakers. We think that it 
is important that transparency is available to everyone.
    There are millions, billions of dollars going out to long-
term care facilities, and that in many cases individuals are 
spending down their private dollars and going on Medicaid, and 
if it is federal dollars that are being spent in these 
facilities that there should be good policies for oversight and 
transparency about how those dollars are being spent, and if it 
is our programs that are looking at those cases and doing those 
investigations, and by you all having access to that 
information and what we are seeing would give you better 
ability to make policies, then that should be available.
    Senator Braun. Yeah, an ombudsman service is a portal of 
feedback, and I think any business, any entity ought to welcome 
it. In your experience, do you get a lot of it, and do you 
learn a lot from it?
    Ms. Painter. Yes, we do have a lot of information. We 
would, of course, want to make sure that it remains 
confidential--people's names, information in that way--so that 
they continue to feel confident in giving us that information, 
but the actual data related to cases of mistreatment, abuse, 
neglect, the amount of times that people go to the hospital, 
involuntary transfers and discharges, because I do believe that 
that directly impacts cost savings, and when individuals are 
not given information about informed choice, to return a less 
restrictive setting or encouraged to stay in the nursing home 
versus go to a less restrictive setting, I think that is very 
costly to our long-term care system.
    Senator Braun. It makes sense. Thank you. I yield back.
    Chairman Casey. Thank you, Ranking Member Braun. I will do 
my questions now that I am back.
    I wanted to start with Ms. Billotte. Janet, I am noting in 
your testimony you shared how not only that you have enjoyed 
receiving a meal but you also have enjoyed seeing your meal 
delivery driver, Fred, and you have become friends, and that is 
just such an important part of the services, as you made 
reference to.
    A critical piece of the home-delivered meals, the program 
itself and OAA programs, in general, not only are you receiving 
important services but you are able to make friends and build 
relationships. In fact, toward the end of the first page of 
your testimony you say, "The Area Agency in Aging is my 
family," which I think speaks volumes of what we are talking 
about.
    In this brochure that I made reference to earlier about 
these Pennsylvanians, one of them is from Erie, Pennsylvania, 
Doris Philhower, and she talks about her experience, and I am 
quoting her here from the brochure, she says, "It has filled my 
life with new friends over the years. It's my home away from 
home." I think that says it all, so this is obviously an 
important part of the benefit that you derive from these 
services. Can you share more about the social connections you 
have been able to build through the Clearfield County AAA?
    Ms. Billotte. With the AAA services I have been able to 
receive doctor's appointments, and we become friends with many 
people that deliver the Meals on Wheels and also that we can 
depend on those people checking in on us each day, so that we 
have someone to support us and that will know how we are and 
what we are doing that day, so I think it is very important to 
do that.
    Chairman Casey. It is obviously part of life that we have 
relationships and we are able to see people. I think one of the 
more remarkable pieces of evidence the last number of years, 
especially during COVID, was sometimes when someone was 
receiving a meal, that person delivering the meal was the only 
person they saw----
    Ms. Billotte. Right.
    Chairman Casey [continuing]. for days at a time, if not to 
include, as well, the Postal Service worker, but I think we all 
understand what you are talking about.
    Ms. Grenfell, I wanted to make reference to your testimony, 
as well, that Pennsylvania is currently working to develop and 
implement a so-called Multisector Plan for Aging. These plans 
help states and localities come together to collaborate on ways 
to make communities work for older adults. The response 
throughout our commonwealth from community stakeholders is 
really impressive. You have lived this, and I want you to know 
how important it is for us to try to pass the Strategic Plan 
for Aging Act, Senator Gillibrand and I and others, to 
incentivize states to start their own planning processes. How 
can we ensure that state governments are hearing the voices of 
older adults and nontraditional aging partners across the 
state?
    Ms. Grenfell. Thank you, Senator. The process that 
Pennsylvania undertook involved multisector planning, as I 
mentioned, so what we attempted to do was to reseed the 
nontraditional type of input from departments, state 
departments, as well as local planning areas, as well as the 
elected officials that were local, the American Legions, all 
the infrastructures that were available locally, so the plan 
that we are developing will entail the opportunity to have 
diverse input and will allow Pennsylvanians to have the breadth 
of a larger plan that takes all of their considerations and 
their input into practice, so we are really excited about 
moving forward on this plan.
    It is very transparent. That is the other important part of 
the plan, and as I said, we are looking forward to its 
implementation stage, which is coming up.
    In terms of having any incentives to do that, if that is an 
opportunity for other states, I think it would be well 
received. Pennsylvania could certainly use additional funding 
if it was available and thank you for presenting that 
opportunity as a legislation attempt. We appreciate it.
    Chairman Casey. Well, I think funding is a big part of this 
equation. We appreciate you making reference to that.
    I will turn next to Senator Kelly.
    Senator Kelly. Thank you, Mr. Chairman, and thank you for 
having this hearing today.
    Since I have been in the Senate three and a half years now 
I have been very grateful for my senior advisories, my seniors 
advisory group that I meet with often to discuss issues 
impacting Arizona seniors, and most of the group is made up by 
representatives of the Arizona Area Agencies on Aging, and 
because of that I have gotten to understand the essential role 
that the Area Agencies on Aging play in their communities, from 
providing meals to helping somebody find a direct care aide, to 
connecting older adults to benefit programs, to make the most 
out of a fixed income.
    These organizations are, in many areas of my State, the 
backbone of the aging services community, and they call 
themselves the best-kept secret in Arizona until folks turn 60, 
so I want to make sure we all understand why it is so important 
that we successfully reauthorize and fund programming in the 
Older Americans Act.
    Ms. Painter, your role is authorized under the OAA, but you 
are also deeply immersed in the rest of the aging network. 
Could you speak to how the OAA and Area Agencies on Aging fit 
into the aging ecosystem and why they are so important, not 
only to Arizonans but to all Americans?
    Ms. Painter. Thank you. That is a great question. I think 
working in partnership in order to support individuals at the 
lowest level of need, so that they are able to age in a healthy 
way, and to support them before they have the highest level of 
need. That way we are giving them--we spoke about good 
nutrition, access to programming, information about health and 
wellness, and we want to encourage individuals to be a part of 
their communities.
    Senator Kelly. Would those be examples of the lowest level 
of need?
    Ms. Painter. Those are the lowest level of need, and doing 
that on an individual level, so the Area Agencies on Agencies--
I can speak for Connecticut, that I know--they meet with their 
communities and they talk to the individuals that they serve 
about the programs that they want in their areas, and so it is 
really about ensuring that they are meeting the needs of the 
individuals that they serve, because it could be different 
district to district, and so we want to make sure that if it is 
an ombudsman program that is decentralized they may also house 
some ombudsmen within the Area Agency on Aging, so they could 
be having information about what services are needed from the 
Ombudsman's Office, they could be speaking about what they are 
seeing related to long-term care, home and community-based 
services, as well as meal delivery services or even 
transportation services. We know that comes up a lot for 
individuals and how they are reaching doctor appointments or 
access to food and other resources.
    I think if we are not able to do that we would see people 
needing higher levels of care, which is more expensive, more 
quickly.
    Senator Kelly. All right. That is true, I think, in a lot 
of areas of health care, as well, is trying to tackle the 
problem earlier can be less costly.
    Ms. Billotte, thank you for being here today and thank you 
for sharing your story, and I am sorry for your loss. Your 
testimony about your local Area Agency on Aging, about how they 
made sure you were fed and looked after during your illness was 
very powerful. You mentioned your interaction with Fred, who 
delivers your meals.
    As we work to reauthorize the OAA, Arizona's Area Agencies 
on Aging have requested that we allow them one unified 
nutrition program so they can determine how best to split the 
congregate meals and home-delivered meals to folks who qualify, 
and the Arizona agencies have said that that would make it 
easier to fill the needs of their local communities. Nearly all 
of them have a waitlist for home-delivered meals, but they are 
not seeing the same demand for in-person congregate meals.
    I think some folks up here are a bit hesitant to create one 
single nutrition program because socialization is such an 
important part of the meal program within the OAA.
    Ms. Billotte, do you feel like your home-delivered meals 
were the right fit for you when you needed them, both for your 
physical and mental health?
    Ms. Billotte. They were. It was very helpful when my 
husband was sick and I also was sick that we received these 
meals and we were able to understand that they were nutritional 
and that they did help us, that we were able to receive them.
    I also understand that there were many more Americans that 
are on this waiting list for the Meals on Wheels and would 
appreciate that you would speak to people that would be able to 
put this program into service so that we could receive 
services, and I think that it is very helpful to us, as 
American citizens.
    Senator Kelly. Right. Well, thank you, Ms. Billotte, and 
thank you, Mr. Chairman.
    Chairman Casey. Thank you, Senator Kelly. We turn next to 
Senator Fetterman.
    Oh, I am sorry. Senator Vance.
    Senator Vance. Thank you, Mr. Chairman. I appreciate 
Senator Fetterman for pushing back against your Pennsylvania 
bias there, but thanks to both of you, and thanks to you and 
the Ranking Member for hosting this hearing, and thanks to all 
of you for being here and giving us some sense of what you are 
working on and how we can make things a little bit easier for 
people.
    You know, I come at this with some personal experience with 
Meals on Wheels program. My grandmother, who I lived with for a 
very long time, benefited from the program. It was a very, I 
think, critical part of keeping her healthy and happy during a 
pretty tough time for our family.
    I want to sort of direct my questions to Ms. Holscher--am I 
pronouncing that right? Okay, great. I am sort of interested in 
the two sort of meal programs in the Older Americans Act and 
how they sort of can provide flexibility or take some away if 
we do not do this right way, so maybe, Ms. Holscher, given your 
extensive work in Indiana, what factors inform seniors when 
they are choosing between congregate meals, going to a place 
for a meal, versus things like Meals on Wheels?
    Ms. Holscher. Well, some of it has to do with 
transportation and if they have access to a senior center. In 
some of our very rural areas there are not senior centers, so 
there is no choice. They would have to access home-delivered 
meals.
    Some of it has to do with some of our senior centers have 
been around for 50 years, and they are in older buildings, in 
basements, and they are outdated, and the seniors today want 
choices, and they want places that they can go that will engage 
them in activities. We have one senior center that is in the 
basement, and I personally feel like it is haunted, and I have 
heard that from other older adults.
    They want choices, not just, "Here is the senior center." 
They want places that they can go where they can engage in 
today's activities, such as like our Coffee and Canvas project 
that we do, and sometimes it is about, just because you are 
isolated does not mean you are lonely, and some older adults 
prefer to eat at home, alone, but we still try to find ways to 
engage them in other activities.
    I hope that answered your question. Thank you.
    Senator Vance. It does, and I guess on this, if I 
understand it correctly, and please correct me if I am wrong, 
is that you saw, understandably, during COVID especially, in 
that summer of 2020 time period, a really massive increase in 
demand for things like Meals on Wheels. We are now close to, 
well, it is exactly four years after that. Where do you think 
we stand? Has demand fallen? Has it stayed the same? Are we 
seeing seniors less interested or more interested in that 
service?
    Ms. Holscher. In our area we have seen a 20 percent 
increase in requests for services, nutrition services, so while 
I think it has stabilized a little bit after COVID, the 
increase is definitely there in the last two years, a 20 
percent increase that probably has more to do with they can't 
afford their basic necessities and so they are reaching out to 
us for help with nutrition to offset some of those other costs.
    Senator Vance. Got it, and could you just explain to me, 
when the money is coming to an agency like yours, that I 
believe you have worked with for close to 30 years, right, does 
it come in as--are there separate buckets?
    Ms. Holscher. Yes.
    Senator Vance. There is money for congregate, there is 
money for Meals on Wheels, and am I correct, you have 
flexibility in moving them between the two programs, depending 
on the demand for seniors in your area?
    Ms. Holscher. We do not. We had that flexibility during 
COVID and it was very helpful, obviously because most of our 
congregate sites were closed during COVID, but since the public 
health emergency has ended we no longer have that flexibility.
    Senator Vance. I see, and so I guess I am probably asking 
the obvious here, but am I right that you would prefer to have 
more flexibility in how you actually provide these services?
    Ms. Holscher. We would definitely prefer to have more 
flexibility at the local level. We want to meet the needs in 
our area, and we can only do that with flexibility between 
funding sources.
    Senator Vance. Yes, and I can imagine, too, just between 
rural and urban areas, you could have a small town that might 
have one set of preferences, you could have a bigger city that 
might have a different set of preferences. Obviously, maybe a 
little easier to get to a senior center if you are in 
Indianapolis or Columbus or Cincinnati.
    I appreciate your testimony here and I certainly share your 
view that flexibility would be a good thing here, and maybe we 
can work on that. Thank you.
    Ms. Holscher. Thank you.
    Chairman Casey. Thank you, Senator Vance. I am sorry about 
the mess-up in the order. I will now turn to my colleague from 
Pennsylvania, Senator Fetterman, with that long buildup.
    Senator Fetterman. Thank you, Mr. Chairman. Ms. Grenfell, 
can you speak to the barriers that exist to the LGBTQ+ older 
adults and aging individuals with HIV in accessing programming 
established through the OAA?
    Ms. Grenfell. Thank you for that question, Senator. As we 
know, the LGBTQ+ community has faced many barriers over the 
years--discrimination, difficulty accessing health care. The 
Older Americans Act programs are based on need, and so our job 
is to ensure that we are creating an inclusive environment that 
is welcoming to all communities. Our agency is certified 
platinum, stays informed, and so our staff has made sure that 
we are all in the position to be able to understand exactly 
what their history has been, how we can ensure that we have 
welcoming senior centers, how we can ensure that we have 
services and programs that meet their particular needs and are 
sensitive and inclusive of their needs.
    Senator Fetterman. You are able to confirm that the special 
kinds of needs and other issues to those kinds of communities 
are being fully addressed?
    Ms. Grenfell. Well, Senator, to the extent that we are able 
to include, and are welcoming----
    Senator Fetterman. Sure, so that language seems specific. 
What are you referencing then?
    Ms. Grenfell. Well, I am specifically referencing the 
training that our staff has undergone, and that there are 
particular questions that are part of the assessment process 
that are identifying if the individual is willing to self-
identify. That is not necessarily everybody is willing to do 
that, but those that will, then we are able----
    Senator Fetterman. In other words, somebody might be--they 
might not be--not comfortable to identify as a member of that 
community. They would be actually missing those kinds of 
critical services then, right?
    Ms. Grenfell. They could, yes. Yes, they could. Yes, they 
could. However, I think that, in general, it is important that 
there be adequate training for staff and that Area Agencies on 
Aging are well-informed of the need to be inclusive, to have 
environments, have policies in place, which allow for all types 
of individuals to receive the services at that level.
    Senator Fetterman. Okay.
    Ms. Grenfell. Thank you, Senator.
    Senator Fetterman. Okay and now, currently the OAA is up to 
serve Americans 60 and older. Other federal programs do not 
kick in until 65. There are a lot of Pennsylvanians between 60 
and 65 who rely on these critical programs. OAA bridges this 
gap.
    Ms. Painter, can you speak about the importance of offering 
these programs before the eligibility kicks in on the other 
federal programs?
    Ms. Painter. Thank you. Yes, I believe, again, the earlier 
we can intervene and support individuals and offer them the 
ability to stay healthy, have access to supports, the better we 
will be able to maintain their health and well-being and 
enhance their wellness in order to prevent them from needing 
higher levels of care at earlier ages and stages of their life.
    Senator Fetterman. Finally, ensuring Pennsylvanians can 
have food on the table, I mean, that is a top priority, 
personally for me, but of course, for the commonwealth as well, 
and about five percent of older Pennsylvanians are food 
insecure. Recipients of OAA-provided meals report that this is 
half or more of the food for that day.
    Ms. Billotte--is that correct? How important are these 
kinds of home-delivered meals for overall, and for your 
nutritional meals?
    Ms. Billotte. I believe that our Area Agency of Clearfield 
County has obtained a chef that will help each individual meal 
be characterized, like what the need is. We all have a menu we 
go through each day, and they provide meals to us. The 
nutrition meal, for me, for my cancer, was very helpful to help 
me get through cancer.
    Senator Fetterman. Mr. Chairman, about 30 more seconds?
    Chairman Casey. Sure.
    Senator Fetterman. It is also another point of contact for 
some seniors that may not have any other kinds of contact, 
essentially a well check on there, like making sure everything 
is still okay.
    Ms. Billotte. That is very correct, because my meal 
deliveryman, Fred, is my only contact during the day many times 
to talk to and to see each day, so that is very helpful that he 
checks in on me to see how things are.
    Senator Fetterman. Yes, and also my own grandmother, she 
fell, and she did not have a situation like this, and she was 
not able to get contact for several days, so the horror of all 
of that, so only the critical food but just also just kind of 
that interaction, but also like it is a well check, just how 
critical it is to make sure that everyone is going to still be 
okay.
    Ms. Billotte. That is correct, and with my transportation 
issue it was for my cancer, to go to the chemotherapy and to my 
doctor, and it was very critical because there is no Ubers, no 
taxis, and no transportation in my area because we live in a 
rural county, so that is very helpful if I can have 
transportation to and from my doctors.
    Senator Fetterman. That seems almost beyond helpful. I 
mean, that is critical to maintain your health and your way of 
life.
    Ms. Billotte. At that time, I did not drive while I had 
cancer for the year, so not driving for a year it is critical 
in finding someone to help.
    Senator Fetterman. Thank you, all of you. Thank you. Mr. 
Chairman.
    Ms. Billotte. Thank you.
    Chairman Casey. Thank you, Senator Fetterman.
    I just have maybe two more questions and then we will have 
to wrap up. I wanted to ask a question of Ms. Painter. In your 
testimony you spoke about the Long-Term Care Ombudsman Program 
desperately needs more federal funding to account for the sheer 
number of older adults who are now residing in long-term care 
settings, especially assisted living facilities. Many of these 
residents may worry about retaliation if they raise issues 
themselves. Others may not have the ability to self-advocate. 
That is why the Long-Term Care Ombudsman Program is so 
important in your voice for older adults who may be both 
uncomfortable or unable to advocate for themselves.
    However, you cannot do this essential job without the 
funding. I released a report last year entitled "Uninspected 
and Neglected." The report revealed that lack of investment in 
ombudsmen and nursing home surveyors leave nursing home 
residents at risk. Today, at my request, the GAO is releasing 
new findings on the increased complexity of cases and the 
impact that limited budgets have on ombudsmen. In fact, 
Connecticut is one of five states highlighted by GAO. Based on 
this data, I am advocating to triple the amount of funding for 
Long-Term Care Ombudsmen Programs in the Older Americans Act 
reauthorization, so here is the question. If it is clear that 
additional funding would help ombudsmen stay afloat, can you 
describe how additional funding would directly impact and 
improve the lives of older adults living in long-term care 
facilities?
    Ms. Painter. Yes. Well, thank you for advocating for us to 
have that increased stable funding. We so appreciated the 
funding that we received during COVID, and realized how much we 
could do. Even though we were not able to access the buildings 
initially, once we had that funding and we were able to do more 
outreach that we were seeing an increase in cases, and we have 
seen a steady increase in cases.
    I think with additional funding that would continue, 
because when we were able to meet that mandate of being in 
long-term care facilities on a regular basis it is not 
necessarily that individuals know to reach out to us. As I said 
in my testimony, individuals do not know what their rights are 
always related to quality of care, and so when you have the 
access to regular ombudsman who is in the building, on at least 
a quarterly basis, going around, introducing themselves to 
people, explaining their rights, and ensuring that they know 
what quality of care looks like, talking with them, explaining 
to them the grievance process, explaining to them that they 
have the right to transfer to a less restrictive environment, 
to attend a care plan meeting with them and talk to them about 
what their plan of care can look like and what they should be 
expecting, that they do not have to just decide to get out of 
bed every other day. The expectation should be that they get 
out of bed when they want to get out of bed. They should be 
able to get to the bathroom or have nutritional support when 
needed.
    I think that is when we will see those changes, and I think 
that will impact cost savings as well, because we will not have 
those visits to the hospital, where people have wounds or 
infections and those types of things, because the interventions 
that the ombudsmen are able to provide one-to-one with the 
nursing homes, when residents allow us to, and sometimes it 
means multiple visits. When you have that rapport with a 
resident, sometimes initially they do not want us to do 
anything. We just have to go back a few times and reassure them 
that we can have that conversation with the long-term care 
community, and when we talk with them they put those 
interventions in place, and the resident sees that benefit, and 
I think that is where we will see the biggest change in care.
    Chairman Casey. Ms. Painter, thanks for that response.
    The last question I have is really for the panel, but I may 
ask Ms. Grenfell and Ms. Holscher to address it first, but if 
anyone else wants to add to the conversation.
    As I mentioned earlier we have got a bipartisan group of 
Senate colleagues that are leading the effort to reauthorize 
the Older Americans Act. We are not only working to reauthorize 
the Act, we are also working to modernize it, to make sure that 
we are meeting the needs of today's older adults and the needs 
of future generations of older adults.
    The reauthorization provides us with an opportunity to look 
at what has changed in the last four years since the 2020 
reauthorization, what innovations were critical throughout the 
COVID-19 pandemic, and what needs are still not being met.
    How have you seen the needs of older adults evolve over 
your careers, and where is modernization needed most within the 
Older Americans Act? Maybe Ms. Holscher, and then we can go 
from there.
    Ms. Holscher. The needs have changed, I guess over the 
years, is today's older adults want choices. They want to be 
able to choose from a list of meals. They do not want, here is 
a cookie-cutter meal, everybody gets it, and that is true in 
all six counties that we serve, so what the folks in Pike 
County might want is different than what the folks in Dubois 
County, and they want those choices, and we need the 
flexibility to be able to provide those choices to them.
    As well as we need the flexibility to come up with new 
ideas. We need to be able to pilot programs, and the funding 
right now does not really allow for us to get out of our box, 
so to speak, so we would really like to see more flexibility so 
that we can implement new ideas, emerging innovations, and be 
more entrepreneurial.
    Chairman Casey. That is great. Thank you. I might reframe 
the question a little bit for Ms. Grenfell because of her 
impending retirement, so I guess the question for you would be 
what is your hope for the Older Americans Act moving forward?
    Ms. Grenfell. Well, I certainly agree with my colleague, 
Laura, from Indiana, because those are critical issues for the 
Older Americans Act.
    I would also say that our national USAging organization has 
really spent a lot of time and effort with the Older Americans 
Act and has excellent recommendations for moving forward and I 
think for modernizing it.
    It is not always just about money either. I mean, money is 
important, and we have all mentioned that, but it also, as 
Laura mentioned, it is really important that we are able to do 
some innovation. Southwestern Pennsylvania has certain meals 
that they love, and they do not necessarily meet the 
nutritional requirements exactly.
    I think we have to update a lot of that in terms of the 
whole nutrition program to make it more available. The COVID-19 
grab-and-go meals have been extremely successful. We are 
finding that our population likes the fact that they are 
available, and they are flexible, and they can come to the 
center when they have time, or if they are caring for somebody 
at home then they can pick up a meal for their loved one and 
them and get a little bit of respite.
    We are also looking at trying to do some innovation, 
because of the ruralness of our service area, of a cafe, a pop-
up cafe, where we would be able to take the meals in more rural 
parts of our service area and have them available as opposed to 
an infrastructure like a senior center that is a lot more 
costly, so we are looking for innovation and cost-efficient 
ways to provide the program. That type of innovation is what I 
think both Laura and I are looking for, and that would be 
something I would hope for.
    Thank you, Senator.
    Chairman Casey. We are grateful for that, and I think that 
innovation is going to be important, and obviously giving 
seniors choices is also important. Who wants to be locked into 
one choice for a meal? That should be part of the opportunities 
we provide.
    I will move to our closing statement. I will have a closing 
statement and then I will turn to Ranking Member Braun, and 
then we will have to wrap up.
    As we heard today from our witnesses, the Older Americans 
Act is a landmark piece of legislation that has been providing 
lifesaving services to older adults for nearly 60 years. To put 
it simply, these programs authorized through the Older 
Americans Act are working well. The Area Agencies on Aging, 
senior centers, Meals on Wheels programs, and other provide 
services tailored to the unique needs of their communities.
    The individuals who make up the aging network are dedicated 
to this work, with many having devoted their entire careers to 
improving the quality of life for many older adults. Ms. 
Grenfell, I am making reference to you here. They are the 
trusted partners in our communities.
    I think everyone on both sides of the aisle can recognize 
the importance of the Older Americans Act in preventing chronic 
diseases and reducing social isolation and loneliness, and 
enabling older adults to remain at their home, in their 
communities, where they would like to be.
    However, we cannot expect the aging network to continue to 
work for older Americans and their communities if we are not 
willing to provide the programs with adequate funding. As we 
heard today, due to funding limitations there are thousands of 
older adults waiting--waiting--for services across the country, 
from meal services to ombudsman assistance. Waitlists and wait 
times will only grow of Congress fails to act.
    Folks like Janet should not be forced to wait for needed 
meals and services, and that is why, through the 
reauthorization I will be pushing for increased funding for 
Older Americans Act programs, and I encourage my colleagues to 
join me. I will also continue to advocate for changes to the 
statute that will better enable AAAs and local service 
providers to do their work.
    The Older Americans Act plays a critical role in the health 
and success of older adults in local communities from 
Pennsylvania to Connecticut to Indiana, and everywhere in 
between. It is critically important the Senate invest the 
necessary resources to fulfill the intent of the Act.
    I will now turn to Ranking Member Braun for his closing 
remarks.
    Senator Braun. Thank you, Mr. Chairman. We always have 
prepared remarks that we can default to. Since I have been 
here, I like to listen, hear what everybody says, and then 
sometimes just chuck the prepared remarks.
    This is a Committee that I had to be recruited to get onto, 
back when I came to the Senate, and it is one that we cannot 
legislate out of, but for the time I have been here we have had 
more pertinent discussions in this Committee that other 
committees end up legislating off of, and in this place it is 
always frustrating in that we have all heard what we need. We 
have got future older Americans that have to pay all the bills 
and shoulder the debt, so we are kind of between that rock and 
hard place, and it is not only here. It is across our 
government. You know, sure, we need more funding. Everybody 
needs more funding, but when you are borrowing 100 percent of 
it, remember, we are asking our kids and grandkids to pay for 
it. We have got to get smarter than that. No other place does 
that work, and that is why being entrepreneurial, maybe turning 
more of the responsibility over to all the places that have to 
live within their means.
    It was refreshing to hear from Ms. Grenfell that maybe it 
is not all about money. Federal level, that is what this place 
is about. That is okay if you have it. If we are borrowing it 
from our future older Americans, our kids and grandkids, we 
have to step back and figure out how to be smarter and better, 
because then we are defeating the whole purpose of what this is 
about in this discussion.
    Thank you all for coming in. It is food for thought. Maybe 
we will find a way to have our cake and eat it too, be smarter 
about it in the long run. Thank you.
    Chairman Casey. Well, thanks everyone for being here today. 
We are grateful for the witnesses, for your testimony, and for 
bringing your own life experience as well as your professional 
experience to bear.
    If any Senators have additional questions for the witnesses 
or statements to be added, the hearing record will be kept open 
until May 30th.
    Thank you all for participating today. Have a great rest of 
your day.
    [Whereupon, at 11:10 a.m., the hearing was adjourned.]

                                APPENDIX

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


                      Prepared Witness Statements

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

                 U.S. Senate Special Committee on Aging

       "The Older Americans Act: The Local Impact of The Law and 
                     The Upcoming Reauthorization"

                              May 23, 2024

                       Prepared Witness Testimony

                             Janet Billotte

Chairman Casey, Ranking Member Braun, and Members of the 
Committee, thank you for having me here today at your Older 
Americans Act hearing. My name is Janet Billotte, I am 78 years 
old. I live in West Decatur, Pennsylvania, which is a rural 
town in Clearfield County. Before retiring, I worked as a 
nursing aide. I am here to share my experiences as a recipient 
of Meals on Wheels and other services from the Clearfield 
County Area Agency on Aging.

I have been receiving Meals on Wheels for four years. My 
husband, Richard, and I started receiving meals in August of 
2020, during the pandemic. Let me tell you, it is so nice to 
receive these meals. Every time I get a box, it always feels 
like I get a little present. You always get milk, sometimes 
cookies, and if it was summer, sometimes we get a strawberry 
shortcake. Last year, I was diagnosed with Stage three colon 
cancer and I was also caring for my husband who had been sick 
with many issues for a long time. I also just had an operation 
for my cancer and had chemotherapy three times a week. Many 
days, I didn't feel well and it was very helpful to have these 
meals delivered to us.

I love talking to Fred, the meal delivery person. Every day he 
comes in and always asks me how I am. Everywhere he delivers, 
he checks on everyone it is wonderful that he does these check 
ins. If he doesn't hear from someone, he calls the Area Agency 
on Aging and they make sure we are okay. A lot of older people 
don't have family around. I don t have family around. I had two 
brothers, but they passed away and my husband just passed 
recently. The Area Agency on Aging is my family.

Today, my cancer is in remission. I am still receiving 
deliveries from Meals on Wheels and also use other services 
from the Area Agency on Aging. They do this very nice thing 
where they give us vouchers through the Senior Farmers Market 
Nutrition Program run by the Agriculture Department so that we 
can go to the farmer's market and I can get fresh produce. I 
get tomatoes, lettuce, and all kinds of fresh foods from the 
market. It is good nutrition, and it's good for preventing 
cancer. During bad weather, they also do a blizzard box, where 
they send you a box of frozen and shelf-stable food so we have 
something to eat when we are stuck in bad weather. I really am 
thankful for these services because I'm not sure what I would 
do without them.

Beyond meal deliveries, I also participated in events at the 
senior center. One time, I went on a field trip to a mushroom 
farm, where we learned about all the different types of 
mushrooms. We also went to a flower farm. I love flowers and 
have always had a flower garden. The Area Agency on Aging also 
helped coordinate transportation for me when I had to go to the 
clinic to get chemotherapy. I had to get chemo and blood work 
every week, and that was terrible, because I live in a rural 
area, it was very hard to find transportation to the clinic but 
they were very kind to help drive me to my doctor's 
appointment.

I'm very grateful to be receiving these services, and grateful 
for the friendship I have with my Area Agency on Aging. Kathy 
Gillespie, who is with the Area Agency on Aging, is like family 
to me. I know many older adults who receive Meals on Wheel are 
thankful like I am. I also understand that there are many more 
older adults on the waiting list for these services. I ask you 
to please help more people get into the program and be able to 
receive these great services. Thank you again for the 
opportunity to share my story.

                 U.S. Senate Special Committee on Aging

       "The Older Americans Act: The Local Impact of The Law and 
                     The Upcoming Reauthorization"

                              May 23, 2024

                       Prepared Witness Testimony

                             Laura Holscher


I am Laura Holscher. For 30 years it has been my honor to serve 
older adults at Generations Area Agency on Aging, the past 14 
years as the Executive Director. Generations is a program of 
Vincennes University and is designated by the Indiana Division 
of Aging's Commission on Aging as the Area 13 Agency on Aging 
serving Daviess, Dubois, Greene, Knox, Martin and Pike counties 
in southwestern Indiana. Generations is also designated as the 
Aging and Disability Resource Center (ADRC). I want to thank 
Senator Braun for inviting me to speak with you today on a 
topic that I am very passionate about, the Older Americans Act 
(OAA) programs and services that support older adults and 
caregivers in Indiana and nationwide.

As an Area Agency on Aging, Generations' role is to develop, 
fund and implement a broad range of programs and services to 
meet the needs of older adults and caregivers, all of which are 
based on demonstrated need in the communities we serve. We 
develop an area plan that is based on those identified needs, 
the changing preferences of older adults and the input of local 
stakeholders, such as our provider partners. As a AAA, we also 
leverage additional local dollars to support the Act's efforts, 
operate an information and referral/assistance system so that 
consumers can access resources, select community providers to 
deliver services and then provide oversight, and much more.

Generations serves six counties in southwestern Indiana. Our 
entire planning and service area is considered rural. We have 
four hospitals, but in some of our cities, there is not even 
one primary care physician. Our public transportation system 
runs Monday through Friday between the hours of 6:00 a.m. and 
6:00 p.m. with reservations requiring at least 24-hour advance 
notice. Additionally, 22.7% of the population in the 
Generations planning and service area is living below 150% of 
the federal poverty level.

Some of the challenges we face as a rural community include 
lack of broadband internet and limited access to 
transportation, both of which lead to increased risk of social 
isolation. Broadband internet is nonexistent in some rural 
areas or unaffordable. This limits access to online 
opportunities that our AAA offers such as social engagement 
activities or virtual evidence-based classes on healthy aging.

Through our work with community partners and contracted 
providers Generations staff and volunteers impacted the lives 
of more than 35,000 individuals last year. To respond to the 
needs of older adults and caregivers in our planning and 
service area, we offer all the core OAA services.

Under Title III B of the Act, our AAA is able to offer in-home 
services for frail older adults, senior transportation 
programs, information and referral/assistance services, options 
counseling, home modification and repair, legal services, the 
Long-Term Care Ombudsman Program and other person-centered 
approaches to helping older adults age well at home. Services 
provided through Title III B are a lifeline for older adults 
living in the community, and they also connect older adults to 
other OAA services-for example, transportation services funded 
by Title III B ensure older adults can reach congregate meal 
sites funded by OAA Title III C.

The critical flexibility of this funding stream gives AAAs 
greater means to meet the needs of older adults at home and in 
the community, thereby eliminating the need for more expensive 
nursing home care-which usually leads to impoverishment and a 
subsequent need to rely on Medicaid to meet critical health 
care needs.

Many of our OAA clients have cognitive impairments, including 
those living with dementia, and so this informs our OAA work as 
well as other projects we take on. Recently one of our counties 
was designated as a Dementia Friendly Community by Dementia 
Friendly America. This was achieved by using some of our Title 
III B funding and supplemented through our University of 
Southern Indiana (USI) Geriatric Workforce Enhancement Program 
(GWEP) workforce development grant. A dedicated action team was 
pulled together that consists of a diverse group of community 
members who volunteer their time and energy to create an 
inclusive community that is welcoming, mindful and 
inspirational for people living with dementia (PLWD) and their 
caregivers through education and action. Our action team 
membership includes representation from the faith community, 
local nursing facilities, local United Way, Chamber of 
Commerce, several local nursing facilities and, most 
importantly, Genevieve and Carmen (someone who is living with 
dementia and her caregiver daughter). A few of the highlights 
from our team's dementia friendly work include partnering with 
Mi Patio, a local restaurant, to provide dementia friendly 
dining hours. These hours are set aside specifically for people 
living with dementia and their care partners; a special menu 
was created for these dining hours which includes a limited 
menu, to make decision making less stressful, and pictures of 
each food item so that these customers can see what they are 
ordering. Other events/activities include Coffee and Crafting 
activities for PLWD and their caregivers; these activities 
provide opportunity for fun quality time for the person living 
with dementia and their caregiver.

In the near future we will be reaching out to first responders 
in our service area in an effort to provide dementia education 
and awareness to these individuals who are often first on the 
scene in the event of an emergency. By educating this group to 
be able to recognize the signs and symptoms of dementia and 
instructing them on techniques to interact with someone living 
with dementia, we hope to reduce stress in an already stressful 
situation for both the person living with dementia and the 
first responder.

The flexibility of OAA Title III B also allows AAAs to meet new 
and emerging needs in their communities. During the COVID-19 
pandemic, we were able to transition to new and modified 
programs such as wellness checks for homebound older adults, 
activity packets that we were able to porch drop to help older 
adults stay socially engaged, and a new virtual version of our 
evidence-based programs. This was in addition to our work 
supporting vaccine outreach and assistance. To further support 
older adults' access to social engagement and healthy aging 
opportunities, we have also started offering basic technology 
classes geared toward older adults. However, years of eroded 
funding prior to COVID-19 have resulted in local rural AAAs 
like my own losing ground in their ability to provide critical 
Title III B Supportive Services. Without bold investment in FY 
2025, the expiration of the COVID-relief funding will create 
gaps and elimination across a range of OAA programs, but 
especially Title III B and Title III C.

Another essential part of the OAA is Title III C Nutrition 
Services. In the past, Generations had provided daily hot home 
delivered meals to homebound older adults for many years. Under 
our old model of services, meals were prepared out of our 
centralized kitchen, plated, packaged and delivered on hot or 
cold trucks door to door to nearly 1,000 older adults five days 
a week. Generations prioritized this service by diversifying 
funding with local donors to ensure that all individuals who 
met qualifications were provided a daily hot meal. As the 
economy shifted, gas prices rose and the cost of food 
increased, it became apparent that our day-to-day operations 
were going to have to change. We slowly made minor changes such 
as reducing routes, reducing delivery days, reducing food costs 
by changing vendors, and closing some of our sites. Ultimately 
by 2016, we had to make the very difficult decision to shut 
down local meal production and secure partnerships with home 
delivered meal providers for frozen/cold meals. We could no 
longer support the cost of providing daily, hot meals to all 
the rural communities in our six-county area due to stagnant 
federal funding that hasn't kept up with inflation-nor the 
growing need as our country's aging population has grown.

As we were progressing to the shift to frozen meal providers 
and Fed Ex/UPS meal delivery, we searched locally for partners 
who would be willing to contract with us to continue to provide 
hot meal preparation and delivery, even if we couldn't cover 
all of our planning and service area. We looked at hospitals, 
community centers, senior centers, long-term care providers, 
and restaurants. We were fortunate that three local 
organizations shared our passion for serving older adults in 
their community. We now have partnerships with a nursing home 
and two senior centers to provide hot meals in their 
surrounding area. All three of these sites offer home cooked, 
hot meals prepared daily to local residents who are homebound 
and over age 60.

Today we operate a hybrid program that is person centered and 
designed to meet the needs of the individual. A client can 
choose from up to six different frozen/cold home-delivered 
service providers, or, if they live in an area covered by a hot 
meal provider, they have that option as well. Last year, we 
provided over 106,000 nutritious meals to nearly 1,000 older 
adults in our planning and service area.

Our hope was to expand these local partnerships for hot meal 
delivery, but the funding isn't sufficient. This is even though 
need is growing in our community: over the past two years, we 
have seen a 20% increase in calls for meals and have more 
people accessing our services because they just can't afford 
groceries or other necessities.

Due to the continued rising cost of food, freight, delivery, 
and labor cost, it became apparent that we would need to 
increase reimbursement to our providers by 30% if they were 
going to continue to provide meals to our current clients. 
Increasing the reimbursement rate to keep qualified providers 
decreases our overall budget for the number of clients we can 
serve. The same amount of money simply cannot stretch to meet 
higher, necessary costs without reducing the numbers of people 
served, and it certainly cannot meet the increased need.

In addition, donations, grant support, and community support is 
down as donors themselves are tightening up their purse strings 
and prioritizing their own budgets. This has forced us to 
triage calls and provide meals only to the most at-risk 
individuals and put others on a waiting list, which is not 
something we have had to do historically. When older adults sit 
on a waiting list for nutrition services, it increases the risk 
of malnutrition, health deterioration and social isolation, in 
addition to the continued pain of hunger.

In the meantime, our trained and skilled AAA options counselors 
work with callers to provide alternatives to OAA home delivered 
or congregate meals, such as offering enrollment assistance for 
Supplemental Nutrition Assistance Program, or SNAP, benefits 
and referrals to food banks, food pantries, and local churches 
and other charities. However, those latter community resources 
are also under financial strain given increased need, leaving 
few options for the older adults in our area.

As a way to supplement the work we were doing with evidence-
based health and wellness programs under Title III D we entered 
a partnership with USI on a GWEP grant which covers 12 counties 
in southern Indiana designated as a Health Profession Shortage 
area, rural and medically underserved. Other partners included 
three Deaconess primary care clinics, a family medicine 
residency program, two AAAs and two chapters of the Alzheimer's 
Association. Goals included to improve health outcomes for 
older adults through information, education, support and 
medical services. Falls, chronic illness, increasing incidence 
of dementia with longer longevity, nutrition, and mobility 
issues majorly affect this population.

As a result of the partnership, we have expanded our outreach 
for evidence-based programs under OAA Title III D. Programs 
such as A Matter of Balance (MOB) and the Chronic Disease Self-
Management Program (CDSMP) have more than doubled in what were 
able to offer prior to the partnerships. We have increased the 
number of master trainers for both programs to five and lay 
leaders to almost 70. This has allowed us to provide education 
to more than 500 participants in the last five years. Outcomes 
from MOB analyzed in May 2023 show significant improvements, 
with individuals stating they are steadier, are walking more 
and have decreased fear of falling, which is in alignment with 
national statistics. CDSMP outcomes from post surveys indicated 
that all individuals had increased knowledge from the program 
and would refer a friend.

We also added another evidence-based fall prevention program, 
Bingocizer, which successfully reaches a different older adult 
audience. While we are proud to be able to offer these 
evidence-based programs through Title III D, the partnership 
with USI has allowed us to increase the scope of the 
programming. As the grant with USI comes to an end though, we 
are concerned that we will not be able to continue all the 
programs with the very limited funds we receive through Title 
III D. Generations and other rural AAAs around the country 
would benefit from new flexibility to also use Title III D 
monies to fund evidence-informed programs, which have the 
benefit of being lower in cost to operate and more adaptable to 
community needs or cultural factors.

Generations was created as a result of the Older Americans Act 
for the purpose of planning, pooling resources and coordinating 
services at the grassroots level. These are just a few examples 
of how we innovate and adapt to meet the needs of older adults 
in our rural area. As an organization, we encourage active 
participation in our communities. We live where we work and 
that makes a real difference in terms of local access and 
networking abilities, and that's true of our fellow AAAs and 
our service providers nationwide. Please keep the Act's 
inherent flexibility and locally driven structure in mind as 
you update the law this year.

To that end, I have several recommendations for the 
reauthorization of the Older Americans Act.

  1. Increase OAA funding, both authorized funding levels and 
actual funding for FY 2025 and beyond. OAA funding has not kept 
pace with the growing number of older adults or inflation and 
funding is inadequate to meet even a fraction of the needs of 
those older adults most at risk.

  2. Continue some of the flexibilities that were extended to 
AAAs during COVID such as flexibility between Congregate and 
Home Delivered meals which allowed AAAs to use the funding 
provided based on client needs. Or allow for the flexibility to 
fund innovative ideas in the nutrition program that meet the 
needs at the local level.

  3. Allow Title III D health and wellness programs to be 
evidence-informed-not just evidence-based-to expand the Aging 
Network's ability to reach older adults with emerging 
interventions and to extend the reach especially in rural areas 
and other areas which have limited funding for this important 
work.

  4. We also support USAging's reauthorization recommendations.

Thank you for the opportunity to testify today.

                 U.S. Senate Special Committee on Aging

       "The Older Americans Act: The Local Impact of The Law and 
                     The Upcoming Reauthorization"

                              May 23, 2024

                       Prepared Witness Testimony

                            Leslie Grenfell

Chairman Casey, Ranking Member Braun, and members of the Senate 
Special Committee on Aging, thank you for the opportunity to 
testify before you today to discuss the Older Americans Act.

My name is Leslie Grenfell. I am the Executive Director of 
Southwestern Pennsylvania Area Agency on Aging, Inc., serving 
older adults residing in Fayette, Greene and Washington 
Counties. It has been an honor for me to serve as the Executive 
Director for the past twenty-three years.

In terms of population, Southwestern Pennsylvania Area Agency 
on Aging is the largest rural Area Agency on Aging, or AAA, in 
the Commonwealth. Its three-county service and planning area 
encompasses 2,223 square miles. The Agency acts as a community 
focal point providing information and assistance about services 
and programs, protecting older adults who are most vulnerable, 
assisting caregivers and their families, reducing food 
insecurity, and empowering older adults to live independently 
and age well.

Having worked in the Area Agency on Aging Network since 1976, I 
have witnessed the transformation and development of the Older 
Americans Act Programs and Services which have evolved from its 
early days as a nutrition program into a comprehensive and 
coordinated service delivery system for older adults who may be 
at risk of losing their independence.

Older Americans Act Programs

The Older Americans Act Nutrition Program is the cornerstone of 
the Older Americans Act and includes congregate, home-
delivered, and grab-n-go meals, which were introduced during 
the COVID-19 pandemic. The flexibility of the grab-n-go meal 
option, where older adults can pick up a meal to take home, has 
been well-received by our consumers, especially those who are 
providing caregiver services to a loved one.

Our home-delivered meal providers are struggling. High costs, 
due to the increased cost of food, supplies, packaging, and 
staffing, the long distances between homes, and traveling on 
winding back-country roads or in mountainous areas, especially 
during inclement weather, can make delivery difficult. One of 
our most demanding routes is in the Laurel Highlands of Fayette 
County, called Kentuck Knob, which requires travel through 
State Game lands, is 32 miles long, and takes 54 minutes to 
complete.

2Although challenging, the home-delivered meal providers have 
successfully developed and sustained a service delivery system 
utilizing dedicated volunteers who not only deliver hot, well-
balanced nutritious meals five days a week, but also provide 
wellness checks to each older adult ensuring their safety and 
well-being. Last fiscal year, a total of 691 volunteers 
provided 97,638 hours of service and delivered 434,872 in-home 
meals to at-risk consumers.

The major challenges identified by our thirty-four home and 
community-based agencies who provide personal care services in 
rural communities are the costs associated with transportation 
due to the distance to consumer homes, the recruitment and 
retention of direct care workers, and the need for increased 
reimbursement.

Funding

Last fiscal year, the Southwestern Pennsylvania Area Agency on 
Aging received $591,073 in American Rescue Plan Act (ARPA) 
funds which provided a necessary infusion of financial support 
for the OAA nutrition program and the home and community-based 
program, permitting us to help a growing number of older 
adults.

With the number of older adults projected to continue to 
increase, there will be a corresponding growth in the need for 
services, and yet, no appreciable amount of additional Older 
Americans Act funding has occurred for over a decade. 
Increasing Older Americans Act funding and increasing its 
flexibility is a cost-effective financial investment which 
would enable older adults to stay healthy longer, living in 
their own homes and communities, whereby reducing the need for 
more costly long-term care interventions.

Looking Ahead

In 2023, the Pennsylvania Department of Aging began development 
of a 10- year Multisector Plan for Aging called Aging Our Way, 
PA. It is a state-led and stakeholder-driven strategic plan 
designed to help transform the infrastructure and coordination 
of services for older Pennsylvanians and persons with 
disabilities to reflect the needs and preferences of this 
population to live where they choose and to access the supports 
they need to thrive and age in place.

The network of AAAs was essential to the stakeholder process, 
which yielded over 20,000 responses from across the state. Each 
Area Agency on Aging engaged their local communities, 
encouraged community participation, and facilitated listening 
sessions at least one in each of the 67 counties and over 200 
sessions in total.

From that engagement and those 20,000 responses, state 
government agencies, state experts in different areas of 
livability, and members of the Long-term Care Council developed 
Aging Our Way, PA's five priorities, and a number of 
strategies, and tactics. The AAAs are integral to many of the 
recommendations developed through this process and are looking 
forward to working with the Pennsylvania Department of Aging 
and other stakeholders.

In conclusion, I would like to especially thank Senator Casey 
for inviting me to provide testimony today. On August 5th, I 
will be retiring after 48 years in the Aging Network. It has 
been an honor and a privilege for me to share my insights with 
you and it is truly a wonderful capstone of my career!

                        Attachment to Testimony:

Aging Our Way, PA is Pennsylvania's ten-year Multisector Plan 
for Aging (MPA). This Plan is designed to address the needs and 
preferences of older adults and their caregivers in 
Pennsylvania and support the Commonwealth's preparedness as 
this older adult population grows dramatically over the next 15 
years.

On May 25, 2023, Governor Shapiro signed Executive Order 2023-
09, which directed the Pennsylvania Department of Aging (PDA) 
and agencies under his jurisdiction to develop this 10-year 
strategic plan that has been designed to help transform the 
infrastructure and coordination of services for Pennsylvania's 
older adults. Aging Our Way, PA defined by six key traits 
including:

  Necessary: The investments and improvements outlined in the 
Plan are needed for Pennsylvania to grow alongside its aging 
population.

  Stakeholder-Driver: community members were invited from 
across the state including Pennsylvanians over 60, caregivers, 
families, subject-matter experts, and community members to 
recommend improvements to the services and infrastructure in 
their communities.

  Collaborative: Drawn from stakeholder input, state agencies 
and community expert partners worked together to articulate the 
priorities, strategies, and tactics (initiatives) included in 
the plan.

  Achievable: To guarantee achievability, each Tactic has been 
refined in active partnership with the agencies responsible for 
its implementation.

  Responsive: The Plan is designed to adapt alongside shifting 
needs and resources over its ten-year timeframe.

  Effective: The Plan presents an opportunity for 
Pennsylvania's government to work smarter.

Pennsylvania's network of Area Agencies on Aging (AAAs) was 
essential to the stakeholder process that yielded over 20,000 
responses from across the state. The AAAs engaged their local 
communities, encouraged community participation, and 
facilitated listening sessions at least one in every county and 
over 200 sessions in total. The AAAs structured these listening 
sessions around the AARP's eight Domains of Community 
Livability. These domains organize the holistic older adult 
experience related to transportation, engaging with government, 
volunteerism, employment, the need for navigation and getting 
information from trusted sources, respect and having a sense of 
belonging, social engagement and the challenges of social 
isolation and loneliness, access to health care including 
behavioral health and long-term care, and most broadly, 
challenges with housing. From that engagement and those 20,000 
responses, state government agencies, state experts in 
different areas of livability, and members of the Long-term 
Care Council drew out Aging Our Way, PA's five priorities, 
strategies, and tactics. The AAAs are integral to many of the 
recommendations developed through this process and are eager to 
work with the PDA and other Commonwealth agencies. The Plan's 
five priorities include:

  Unlocking Access: Eliminate barriers preventing equitable 
ability of older Pennsylvanians to live healthy, fulfilling 
lives.

  Aging in Community: Enable older Pennsylvanians to maintain 
secure housing, active community involvement, and familiar 
surroundings.

  Gateways to Independence: Promote older adults unhindered 
mobility and safe, convenient, and autonomous use of 
transportation.

  Caregiver Supports: Provide support, training, respite, and 
navigation tools to paid and unpaid caregivers.

  Education and Navigation: Streamline the resolution of 
complex problems faced by older adults through improvements to 
the connection, reach, and delivery of the services network.

                 U.S. Senate Special Committee on Aging

       "The Older Americans Act: The Local Impact of The Law and 
                     The Upcoming Reauthorization"

                              May 23, 2024

                       Prepared Witness Testimony

                            Mairead Painter

Thank you, Chairman Casey, Ranking Member Braun, and 
distinguished members of the Senate Special Committee on Aging 
for inviting me here today. My name is Mairead Painter, and I 
am honored to serve as the State Long-Term Care Ombudsman for 
Connecticut. I appreciate the opportunity to offer this 
testimony to you regarding the critical role of Long-Term Care 
Ombudsman programs in protecting the health, safety, welfare, 
and rights of residents' in long-term care settings.

The term "ombudsman" originates from Sweden, where it means 
"representative." This concept has been adopted by several 
countries, including the United States, to ensure transparency 
and accountability within the government and organizations. As 
Long-Term Care Ombudsmen, we serve as independent advocates for 
older adults and individuals with disabilities who reside in 
nursing homes, assisted living facilities, and other small home 
settings, such as residential care homes many of whom cannot 
advocate for themselves.

My team in Connecticut, though small, is dedicated and 
formidable. It includes eight Regional Ombudsmen, two Intake 
Coordinators, one Administrative Assistant, and myself as the 
State Ombudsman, serving approximately 30,000 residents in 209 
nursing homes and about 200 board and care facilities these are 
inclusive of residential care homes and assisted living 
communities. Additionally, we have recently expanded our 
program with state funding to serve approximately 50,000 
individuals receiving home and community-based services. This 
expansion includes one Manager and one Regional Ombudsman.

Looking back, the Long-Term Care Ombudsman Program was 
established in the 1970s by President Nixon in response to 
widespread concerns over the conditions in nursing homes. Media 
reports and investigations at that time revealed pervasive 
abuse, neglect, and mismanagement. President Nixon's plan aimed 
to improve the quality of care in these facilities and address 
systemic issues such as inadequate care, poor conditions, and 
lack of accountability. From this initiative, the Long-Term 
Care Ombudsman Program was born in 1972 as a demonstration 
program.

In 1973, authority for the long-term care ombudsman 
demonstration was transferred to the Administration on Aging 
(AoA), which oversaw the project in several states, and in 
1978, the long-term care ombudsman program was statutorily 
formalized through amendments to the Older Americans Act. In 
the following years, the ombudsman program was provided a 
separate authorization of appropriations, incorporated into 
Title VII of the Older Americans Act, and expanded to cover 
additional long-term care facilities.

In 2016, nearly 40 years after the functions of the LTCOP were 
delineated in the Older Americans Act, final regulations went 
into effect, providing more clarity and additional authority to 
the Long-Term Care Ombudsman Program in several areas.

All Ombudsman activities are performed on behalf of and at the 
direction of residents, with strict confidentiality. We provide 
direct services, including consultation, information about 
residents' rights, and investigation and resolution of 
complaints, contingent upon residents' consent. Additionally, 
we serve as a continuous resource for support. Our non-mandated 
reporter status reassures residents that their communications 
with us are confidential encouraging them to seek our guidance 
without fear of reprisal.

Our office frequently receives complaints concerning general 
care issues arising from insufficient staffing, which adversely 
affects residents' ability to have their basic needs met, such 
as assistance with getting out of bed to use the bathroom. In 
some cases, residents are informed that they must rotate which 
days they can get out of bed at all due to the lack of 
available staff to assist them daily.

Other complaints pertain to involuntary transfers and 
discharges. Residents may receive notices indicating they are 
being discharged from the facility or are instructed to leave 
immediately and are sent to a homeless shelter or hotel. 
Additionally, there are instances where residents are sent to 
the hospital, and when the hospital is ready to discharge them, 
the facility refuses to readmit them.

In all these cases, our team works closely with the residents 
to ensure their rights are upheld and that proper procedures 
are followed. We strive to ensure that any discharge is 
conducted safely and appropriately. If residents wish to remain 
in the facility, we attempt to resolve the issues to maintain 
their facility as their home.

Despite an increase in additional care settings and models over 
the years, the Ombudsman program has not seen the corresponding 
increase in funding to manage this new workload. Many programs 
receive minimal state funding some programs, like Tennessee s, 
only receive enough state funding to pay the state ombudsman 
salary. This lack of investment on the state level, coupled 
with stagnant federal funding, hampers our ability to grow and 
meet increased demand resulting from older adult population 
growth and additional care settings. Without sufficient and 
stable funding, our capacity to fulfill the program's original 
intent identified as a critical need since its establishment in 
1972 continues to decline.

Inadequate resources directly impact our ability to support and 
protect hundreds of thousands of older adults living in our 
communities and to respond to complaints. For example, half of 
the states do not have adequate staffing to meet the 1995 
Institute of Medicine staffing ratio, which recommended one 
ombudsman per 2,000 beds. This report, while outdated, provides 
the most reliable staffing standard for the program to date. 
Although Connecticut is fortunate to have a relatively higher 
level of state support, our team members still manage caseloads 
nearly double the recommended standard. Currently, our program 
operates with approximately one Regional Ombudsman for every 
3,800 long-term care beds. Despite these financial constraints, 
Ombudsman programs have expanded services to cover additional 
settings like assisted living facilities and small homes, 
further straining our resources.

Additionally, the increasing number of residents with complex 
care needs who depend on our advocacy underscores the necessity 
for Ombudsmen to be present and responsive. The original 
program relied heavily on volunteers, but today's complex care 
demands and cases often exceed what volunteers feel equipped to 
handle. Consequently, many volunteer-based programs have been 
diminished or eliminated. It is no longer feasible to run 
Ombudsman programs using volunteers as the program's backbone. 
We need to reevaluate our reliance on volunteers and how to 
best utilize their skills while adding more trained, paid 
Ombudsmen across the nation. Sufficient funding is required to 
make these staffing changes.

Most critical: funding limitations impede our ability to 
educate individuals, respond promptly to complaints, and 
monitor facilities to prevent crises

To begin to properly fund Ombudsman programs, we respectfully 
request the following funding for Fiscal Year 2025 for the 
benefit and safety of long-term care residents across our 
nation: $65 million for ombudsman services in assisted living 
facilities under Title VII of the Older Americans Act and $70 
million for our current core funding under Title VII of the 
OAA. Increased and stable funding would enable us to hire 
additional staff, enhance our education and outreach programs, 
and provide stronger protections for elder justice.

This critical funding would not only improve residents' quality 
of life and well-being but also results in cost savings to the 
greater health care system. The Long-Term Care Ombudsman 
Program reduces the risk of individuals requiring Medicaid 
preemptively and reduces unnecessary trips to the hospital 
emergency room. Significant data show that when individuals 
feel they have a high quality of life, they report being in an 
overall better medical condition.

Although Ombudsmen may work as state employees or under the 
direction of a state Agency Director, our role requires 
independence and autonomy to effectively advocate on behalf of 
residents. This includes the ability to speak out on residents' 
behalf, regardless of where the program is housed, whether 
within a state agency or decentralized outside of one.

In addition to monitoring and responding to complaints, our 
program engages in education and outreach both at the facility 
level and within the broader community. We undertake rigorous 
systemic and legislative advocacy at state and federal levels 
to continuously improve and expand long-term care services and 
supports for your constituents. Our goal is to empower 
residents to have a direct voice in policies and legislation 
that affect them. When this is not feasible, we advocate on 
their behalf before governmental agencies or policymakers.

Until I became the State Ombudsman in Connecticut, I did not 
realize how fortunate I was to be part of this ombudsman 
program. Once I got to know other state ombudsmens, I began to 
realize that I have an independence and autonomy that is not 
only federally mandated under the Older Americans Act but is 
not possible for some of my peers in other states. For example, 
at a recent conference, as a Board Member of the National 
Association of State Long-Term Care Ombudsman Programs, I 
raised questions related to interference with the Ombudsman 
office. This inference directly impacts state ombudsmen's 
efforts to advocate for changes to state or federal laws, 
comment to the media, or talk with legislators about concerns 
constituents face.

I can ask these questions because in my state I have the 
autonomy and support to speak freely on behalf of the 
individuals I serve. However, the conference was being 
livestreamed, and I know other state ombudsmens would be 
concerned someone from their state might see them ask the 
question; it could result in consequences when they return to 
their home state. Some State ombudsmen have reported that in 
their state, their comments are controlled by their managers or 
senior officials, or they are told they cannot make comments to 
the media or speak to legislators independently at all. This is 
unsettling because Ombudsmen must have the independence and 
autonomy this position was intended to have and advocate in a 
bipartisan way on behalf of the people we serve and truly be 
their voice. This is foundational to our position as State 
Ombudsmen, which was created to represent them and inform all 
of you.

This leads me to one of the reasons it is essential that the 
National Director position for the Long-Term Care Ombudsman 
Program be refilled. Although the current leadership at the 
Administration for Community Living has been extremely 
supportive of the program, it is necessary to have an 
independent voice advocating for our role and needs without any 
conflict of interest. At the state level, Ombudsmen are not 
able to be housed within the same agency as Adult Protective 
Services due to concerns over conflict of interest. However, at 
the federal level, we report to the same Director. This 
inherently creates a conflict when trying to advocate for the 
interests of both programs related to funding and support. As 
the representative of state ombudsmen across the country, we 
strongly urge you to reinstate the National Director of the 
Ombudsman Program. It is crucial that we have an independent 
national director who can represent ombudsmen without any 
potential conflicts of interest.

I want to thank you for allowing me to offer this testimony. 
Many individuals are still unaware of our role, their rights, 
or the standards of care they should expect when receiving 
long-term services and supports. As Ombudsmen, our goal is to 
continue to protect the health, safety, welfare, and rights of 
all individuals receiving long-term services and supports.

Respectfully,
/s/
Mairead Painter,
Connecticut State Long Term Care Ombudsman


                        Questions for the Record

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

                 U.S. Senate Special Committee on Aging

       "The Older Americans Act: The Local Impact of The Law and 
                     The Upcoming Reauthorization"

                              May 23, 2024

                        Questions for the Record

                             Janet Billotte

                        Senator Raphael Warnock

Question:

According to research from 2020, Georgia ranks in the top 10 
worst states for food insecurity among seniors.\1\ However, in 
the most recent government funding bill, the Older Americans 
Act's (OAA) Title III nutrition programs were funded at $8.1 
million less than the previous year.\2\ We owe it to our 
seniors to increase funding and strengthen nutrition programs.
---------------------------------------------------------------------------
    \1\ Key Statistics on Seniors Hunger, Georgia Department of Human 
Services Division of Aging Services, https://aging.georgia.gov/key-
statistics-senior-hunger.
    \2\ Kirsten Colello and Angela Napili, Older Americans Act: 
Overview and Funding, Congressional Research Service, (May 6, 2024), 
https://www.crs.gov/Reports/R43414.

Ms. Billotte, how have nutrition programs authorized under the 
---------------------------------------------------------------------------
OAA, like Meals on Wheels, helped you?

Response:

I would be happy to answer questions of the nutrition balance 
of the Meals on Wheels. For protein, chicken, fish, ham, pork, 
and turkey are on a monthly menu. A balance of vegetables like 
broccoli, brussels sprouts, carrots, green beans, potatoes and 
sweet potatoes, spinach and tomatoes are delivered with meals. 
Wheat bread or a muffin or a dinner roll. Fruit or pudding or 
cookies. Milk of 2% is delivered with each meal.

                 U.S. Senate Special Committee on Aging

       "The Older Americans Act: The Local Impact of The Law and 
                     The Upcoming Reauthorization"

                              May 23, 2024

                        Questions for the Record

                             Laura Holscher

                     Chariman Robert P. Casey, Jr.

Question:

In 2021, Democrats passed the American Rescue Plan Act, which 
provided significant funds and flexibility for federal 
programs, including those authorized through OAA. This funding 
was critical to the success of Area Agencies on Aging (AAAs) 
during the pandemic. It was especially crucial because funding 
through annual appropriations has not matched the levels 
authorized in the 2020 reauthorization of OAA. In fact, in 
Fiscal Year 2024, Older Americans Act programs should have 
received $450 million more in funding than was appropriated.

Ms. Holscher, how did the American Rescue Plan funds assist 
service delivery at your Area Agencies on Aging? How does the 
expiration of those funds affect the older adults you serve and 
the people you employ?

Response:

As a result of the American Rescue Plan funds, we were able to 
provide over 18,000 additional meals ensuring no one would go 
on the waiting list, and we provided 8,000 additional respite 
hours for caregivers; we doubled the number of evidence-based 
programs we were able to offer and provided some much-needed 
one-time services such as home modifications, durable medical 
equipment and pest control services allowing older adults to 
remain safely in their homes. We used the funds to kick off 
some new projects such as technology 101 classes, art programs 
for people living with dementia and activity packets for those 
that are homebound and at risk of becoming socially isolated.

We have used all the additional funds made available through 
the American Rescue Plan and are now looking at scaling back 
these programs. We are currently only providing meals and 
respite to the most at-risk individuals, and the waiting list 
is growing. We have scaled back our new initiatives and may 
have to eliminate one or more of the evidence-based programs we 
provide. Finally, we had to decrease our workforce by three 
FTEs to accommodate the loss of funds.

Allowing AAAs to pilot new projects such as online payments to 
Uber Eats or partnering with local food trucks to set up in 
rural communities would enhance our ability to meet the needs 
of older adults in small communities. We need the flexibility 
to come up with new ideas that allow us to make the best use of 
the dollars to meet the needs that best serve our communities.

It goes without saying we could use funding at the same levels 
we received from the American Rescue Plan, but continuing the 
flexibility in Older Americans Act TIII-C that was extended to 
the AAA's during the public health emergency would increase our 
ability to utilize current funding to best meet the needs in 
our local communities.

Question:

The Older Americans Act is intended to target those with the 
greatest social need and greatest economic need, which includes 
many rural older adults. However, rural populations, while 
older, poorer, and sicker, are often left out of many social 
safety net programs, including OAA meal programs. This is a 
population that has seen a lot of other supports in their 
community move away-including hospitals, grocery stores, and 
community centers. There is a need to provide targeted support, 
particularly nutrition services and transportation, to rural 
older adults.

Ms. Holscher, what are some of the challenges that rural 
providers face when trying to reach rural older adults? What 
can we do within OAA to ensure this population has access to 
the same services as urban and suburban older adults?
Response:

Some of the challenges we face as a rural community include the 
lack of broadband internet and limited access to 
transportation, both of which limit access to healthcare and 
social opportunities.

While TIII-B is the most flexible of the Titles under the Older 
Americans Act, additional funding and/or increased flexibility 
would go a long way to help us address the challenges of rural 
communities. Increased flexibility would allow us the 
opportunity to subsidize service connectivity, provide digital 
literacy training and increase access to telemedicine for older 
adults.

Affordable, accessible transportation has always been a 
challenge in rural communities, and in many areas, public 
transportation systems such as buses, subways etc. will never 
be an option. We would like the flexibility to include 
reimbursement for ride-share services and mileage expense for 
privately owned vehicles as an eligible activity under TIII-B 
services.

Additionally, we would benefit from the flexibility of using 
TIII-D for evidence-informed programs which are lower in cost 
and more adaptable to our local communities.

To sum it up, I would recommend an increase in OAA funding, 
which has not kept pace with the growing number of older adults 
or inflation. I would also strongly encourage enhanced 
flexibility in transfers between Titles and allowable services 
within the Titles.

                 U.S. Senate Special Committee on Aging

       "The Older Americans Act: The Local Impact of The Law and 
                     The Upcoming Reauthorization"

                              May 23, 2024

                        Questions for the Record

                            Leslie Grenfell

                     Chariman Robert P. Casey, Jr.

Question:

In 2021, Democrats passed the American Rescue Plan Act, which 
provided significant funds and flexibility for federal 
programs, including those authorized through OAA. This funding 
was critical to the success of Area Agencies on Aging (AAAs) 
during the pandemic. It was especially crucial because funding 
through annual appropriations has not matched the levels 
authorized in the 2020 reauthorization of OAA. In fact, in 
Fiscal Year 2024, Older Americans Act programs should have 
received $450 million more in funding than was appropriated.

Ms. Grenfell, how did the American Rescue Plan funds assist 
service delivery at your Area Agencies on Aging? How does the 
expiration of those funds affect the older adults you serve and 
the people you employ?

Response:

The American Rescue Plan Act (ARPA) funds were critical to 
meeting the needs of older adults in our planning and service 
area as we began recovering from the COVID-19 pandemic. Serving 
as a lifeline, the ARPA funds provided the flexibility needed 
to ensure local needs such as increased requests for home-
delivered meals and community-based services were met during 
those uncertain and challenging times. However, Area Agencies 
on Aging continue to struggle with the recruitment and 
retention of staff and providers, cost inflation and the 
rapidly growing elderly population who are in need of OAA 
services and programs. With the ARPA funds expiring, additional 
OAA financial support is now critical to offset staff 
reductions in force, long waiting lists for in-home services 
and the creation of a waiting list for home-delivered meals. 
While funding levels have not increased over the past two 
decades, the cost of labor, food, supplies and infrastructure 
has continued to escalate. Significant increases in authorized 
funding levels is urgently needed to meet the rising costs of 
service delivery.

Question:

The Older Americans Act is intended to target those with the 
greatest social need and greatest economic need, which includes 
many rural older adults. However, rural populations, while 
older, poorer, and sicker, are often left out of many social 
safety net programs, including OAA meal programs. This is a 
population that has seen a lot of other supports in their 
community move away-including hospitals, grocery stores, and 
community centers. There is a need to provide targeted support, 
particularly nutrition services and transportation, to rural 
older adults.

Ms. Grenfell, what are some of the challenges that rural 
providers face when trying to reach rural older adults? What 
can we do within OAA to ensure this population has access to 
the same services as urban and suburban older adults?

Response:

By highlighting the challenges that rural older adults face in 
accessing necessary services in the OAA, we can work to ensure 
that rural older adults have the same access as their urban and 
suburban counter parts. The Older Americans Act places emphasis 
on prioritizing populations with the greatest economic and/or 
greatest social need. According to the Office of Policy 
Development and Research, rates of poverty among rural older 
adults is higher than metro and suburban areas. This 
exemplifies the need for highlighting rural older adults as 
part of those in greatest economic need.

The federal final rule assisted in clarifying what should be 
considered for the "greatest social need", including physical 
and mental disabilities, language barriers and cultural, social 
or geographical isolation. Providing a definition of social 
isolation as it relates to rural older adults and greatest 
social need would encourage State Units on Aging to reevaluate 
their intrastate funding formulas (IFF) to prioritize rural 
populations that have often been forgotten. By underscoring the 
importance of addressing rural older adult population in the 
Older Americans Act, state units can begin to focus on some of 
the disparities seen between urban and rural communities and 
provide the access rural older adults need to quality services 
and programs.

A significant challenge that rural providers face is difficulty 
recruiting direct care workers. While challenging in any 
setting, recruitment in rural communities is especially 
difficult due to many direct care workers not having access to 
a vehicle to reach remote areas or the inability of providers 
to reimburse for mileage and other expenses, making rural 
service provision cost prohibitive. As a result, many rural 
elders are not receiving the care they need, leaving them 
socially isolated and at increased risk of self-neglect. Others 
are not obtaining consistent care, resulting in frequent and 
costly emergency room visits, hospital admissions and nursing 
facility stays.

Any efforts to strengthen the direct care workforce through the 
OAA will increase rural older adult access to these much needed 
services and also enhance support to rural caregivers of older 
adults. A suggestion is to support the National Council on 
Agency's Direct Care Workforce Strategies Center.

Question:

The National Family Caregiver Support Program, authorized 
through Title III-E of the Older Americans Act, provides 
critical support to family caregivers across the Nation. Many 
of these caregivers include older adults caring for a 
grandchild, great-grandchild, or other loved one-this is 
especially true as a result of the COVID-19 pandemic and the 
ongoing opioid crisis. In the last reauthorization of the Older 
Americans Act, I ensured the resources provided through the 
National Family Caregiver Support Program would reach those 
families.

Ms. Grenfell, as a AAA director, what additional supports 
within OAA would be most helpful for the older adults you serve 
who are also raising grandchildren, other relatives, or close 
family friends?

Response:

Over the last several years, our Agency has encountered, but 
has not been able to serve, many elders caring for related 
children who are younger than the minimum eligible age of 55. I 
recommend consideration of lowering the minimum age of 
eligibility in the National Family Caregiver Support Program 
(NFCSP) for older adults caring for related children to 50 
years old.

In our experience, some children receiving support from older 
adult relatives enrolled in the NFCSP have aged out of the 
program while they are still in need of assistance.

I recommend extending the age limit to twenty-one or twenty-two 
years of age in extenuating circumstances such as:

  If the child is enrolled in the school system with an 
Individualized Education Plan (IEP) and can remain in the 
school system until age 21.

 If the child has an intellectual disability, is physically 
disabled, or has a behavioral health diagnosis that limits 
their ability to obtain employment.

Question:

Ms. Grenfell, throughout your career, you've helped tens of 
thousands of older adults, maybe even more, access services 
that enable them to live healthy, independent, and full lives. 
You've seen the direct impact that OAA programs have on older 
adults in your community. One of the defining factors of the 
Older Americans Act is the age of eligibility. Older adults 
ages 60 and older, and for some programs, ages 55 and older, 
can receive the services they need.

Ms. Grenfell, why is it so important, especially in rural 
communities like yours, that Older Americans Act programs 
continue to serve those 60 years and older?

Response:

As previously noted, rural older adults face unique challenges 
in accessing the same services as their urban counterparts. 
Older Americans Act programs are vital to ensuring rural older 
adults continue to live in their homes and communities.

With the number of rapidly growing older adults, it is 
important that the OAA continues to be primarily focused on the 
needs of older adults aged 60 and older especially in rural 
areas where there is a lack of community resources and the OAA 
funding is often necessary to fill the service gap.

                        Senator Raphael Warnock

Question:

According to research from 2020, Georgia ranks in the top 10 
worst states for food insecurity among seniors.\1\ However, in 
the most recent government funding bill, the Older Americans 
Act's (OAA) Title III nutrition programs were funded at $8.1 
million less than the previous year.\2\ We owe it to our 
seniors to increase funding and strengthen nutrition programs.
---------------------------------------------------------------------------
    \1\  Key Statistics on Seniors Hunger, Georgia Department of Human 
Services Division of Aging Services, https://aging.georgia.gov/key-
statistics-senior-hunger.
    \2\  Kirsten Colello and Angela Napili, Older Americans Act: 
Overview and Funding, Congressional Research Service, (May 6, 2024), 
https://www.crs.gov/Reports/R43414.

Ms. Grenfell, how can Congress modernize the Title III C 
nutrition funding stream\3\ to improve meal services for 
seniors?
---------------------------------------------------------------------------
    \3\  See Nutrition Services, Administration for Community Living, 
https://acl.gov/programs/health-wellness/nutrition-services.

---------------------------------------------------------------------------
Response:

Obtaining adequate nutrition can be challenging for rural 
seniors due to limited financial resources and the lack of 
available transportation, as well as access and proximity to a 
grocery store.

Congress has the opportunity to modernize the Title III C 
Nutrition Program by consolidating the funding streams to 
enable increased flexibility at the local AAA level. Such an 
action would increase innovation and creativity necessary to 
revitalize the nutrition program to address the requests of 
current consumers for more culturally appropriate menus and to 
serve the next generation of elders who are seeking more 
person-centered service options such as medically tailored 
meals.

One overreaching goal of the OAA is that the services for older 
persons must be delivered through a comprehensive plan which is 
based upon an assessment of the local planning and service area 
and its resources. Toward that end, the aging network should 
have the flexibility necessary to determine the programs and 
supports that most effectively and efficiently address the 
needs of older adults and caregivers in their communities.

Question:

Area Agencies on Aging (AAAs) offer critical services for 
seniors across the country. Georgia's 12 AAAs do exceptional 
work providing resources and care to older Georgians.\4\ 
However, the aging population is growing rapidly, and AAAs 
across the country may need increased funding to meet the real 
and urgent needs of their community.\5\
---------------------------------------------------------------------------
    \4\  Aging & Disability Resource Connection, Georgia Department of 
Human Services, https://dhs.georgia.gov/aging-disability-resource-
connection.
    \5\  Becky Kurtz, Request for Information - Older Americans Act 
Reauthorization, Atlanta Regional Commission (Mar. 21, 2024).

Ms. Grenfell, can you explain how AAAs could benefit from 
---------------------------------------------------------------------------
increased funding levels in this year's OAA reauthorization?

Response:

The fastest growing segment of the older adult population is 
older adults aged 85 and older. In our planning and service 
area, the number of older adults aged 85 and older is predicted 
to nearly double between 2030 and 2050. These older adults are 
the most likely to need the services and supports provided by 
AAAs in order to continue to live independently in their own 
homes and communities. Already, about 45% of the older adults 
our Agency serves are aged 80 and older. Many AAAs, including 
ours, are forced to maintain a waiting list for in-home 
services. Increased funding levels would allow AAAs to increase 
the number of older adults served and the amount of services 
provided, which would allow older adults to "age in place" and 
prevent or delay costly institutionalization.

                 U.S. Senate Special Committee on Aging

       "The Older Americans Act: The Local Impact of The Law and 
                     The Upcoming Reauthorization"

                              May 23, 2024

                        Questions for the Record

                            Mairead Painter

                     Chariman Robert P. Casey, Jr.

Question:

Ombudsmen are uniquely positioned to understand resident needs 
and to get to know the residents they serve and the facilities 
they monitor. This, in turn, allows ombudsmen to effectively 
identify issues and to advocate for their needs.

Ms. Painter, can you explain why ombudsmen are unique in 
providing this service? How does their status allow them to 
identify issues more easily than other agencies?

Response:

Residents direct the actions of an Ombudsmen. All conversations 
with ombudsmen are completely confidential unless the resident 
grants consent to proceed with taking action. This 
confidentiality allows residents to speak freely, gain 
perspective on their concerns, and decide how they wish to 
address issues without fear of real or perceived retaliation. 
Additionally, ombudsmen regularly visit long-term care 
facilities to engage with residents who may be unaware of the 
program. These visits provide an opportunity to inform 
residents of their rights and address issues before they 
escalate and to help individuals learn how to make their needs 
known and advocate for themselves. This support offered by 
ombudsmen is unparalleled by any other agency. As the only 
oversight agency that has a regular presence in facilities, 
ombudsmen can identify systemic concerns through their 
observations and resident interactions. These issues can then 
be addressed directly with the facility by the ombudsman and 
resolved in a timely manner. When this occurs, resident care 
and satisfaction can be quickly improved, while potentially 
lessening the risk of costly citations. Ombudsman intervention 
and support helps to improve the quality of care and quality of 
life for individuals living in long term care and can be a cost 
saving on many levels of the greater health care system by 
resolving care concerns before they escalate.

Question:

The Older Americans Act reauthorization process provides us 
with an opportunity to look at what has changed in the last 
four years since the 2020 reauthorization, what innovations 
were critical throughout the COVID-19 pandemic, and what needs 
are still not being met.

Ms. Painter, how have you seen the needs of older adults evolve 
over your careers and where is modernization needed most within 
the Older Americans Act?

Response:

Over my career, I have observed many ways in which the needs of 
older adults have evolved but believe there are three 
significant areas where modernization is necessary in relation 
to the Older Americans Act.

First, the complexity of care needs for older adults has 
increased. Advances in modern medicine have led to longer 
lifespans, resulting in more complex health needs. 
Additionally, there has been a rise in individuals facing 
health-related conditions due to lifestyle choices, substance 
use diagnosis or seeking mental wellness as they age. This 
trend is evident not only in the broader community, where 
issues such as loneliness and poor health are prevalent, but 
also within long-term care facilities. We are also seeing an 
increase in residents diagnosed with traumatic brain injuries, 
cognitive related deficits, mental health diagnoses, and 
physical limitations resulting in the need for staff that are 
highly skilled and trained to serve a population with complex 
physical and psychosocial needs.

Second, the Olmstead Act has brought positive changes by 
allowing individuals to choose where they receive their long-
term services and supports. Many ombudsman programs spend a 
great deal of time supporting individuals working to transition 
to the least restrictive environment. It is crucial to ensure 
that these individuals have access to the protection of their 
rights regardless of where they choose to receive their long-
term services and supports. Currently, the Older Americans Act 
does not permit Ombudsman funding to support individuals who 
opt for long-term services and supports in the greater 
community beyond six months after transitioning from a nursing 
home. Only a few states even offer this level of support 
individuals, so this identifies a significant gap in rights 
protections while resulting in a potential significant cost 
savings to states and the federal government.

Ombudsmen oversee Residential Care Facilities for older adults, 
and individuals with disabilities that are often not regulated 
or licensed to the same level of Skilled Nursing Facilities. In 
these facilities there are no minimum staffing requirements, 
training requirements are weak, and in these communities, 
ombudsmen often identify cases of significant abuse and 
neglect. Examples of people who live in residential care 
facilities could be individuals who want to stay in their local 
community but require either financial or independent living 
support but are not in need of a skilled nursing facility. They 
could be a veteran or other community members, for example in 
CA there are over 8,000 residential care facilities that house 
over 200,000 residents and members of their community on a 
daily basis.

Third, the Elder Justice Act has introduced additional 
protections for older adults, including many individuals served 
by Ombudsmen. However, the expansion of these protections has 
increased the demands and scope of work for our program. The 
OAA should be modernized by authorizing funding at levels 
proportionate to the numbers of older Americans in need so that 
we are able to provide services to all eligible older Americans 
without delay. When we don't respond quickly to complaints and 
routinely monitor resident care, residents are at risk of 
dangerous outcomes.

                        Senator Raphael Warnock

Question:

Georgia has some of the highest rates of people living with 
human immunodeficiency virus (HIV) in the country.\1\ In 2021, 
nearly 32 percent of Georgians living with HIV were over the 
age of 55.\2\ Because of advancements in treatment, people with 
HIV are living longer.\3\ We must invest in services for the 
aging population of those with HIV.
---------------------------------------------------------------------------
    \1\  Sofia Gratas, Georgia Has Some of the Highest HIV Rates in the 
Country, but Treatment Has Never Been Easier, Georgia Public 
Broadcasting (Jul. 1, 2022), https://www.gpb.org/news/2022/07/01/
georgia-has-some-of-the-highest-hiv-rates-in-the-country-treatment-has-
never-been.
    \2\  Local Data: Georgia, AIDSVu, https://aidsvu.org/local-data/
united-states/south/georgia.
    \3\  Brian Altman, Older Adults with HIV/AIDS: A Growing 
Population, Administration for Community Living (Sept. 18, 2021), 
https://acl.gov/news-and-events/acl-blog/older-adults-hivaids-growing-
population.

Ms. Painter, can you elaborate on the unique health needs of 
the aging population of people with HIV? How could new 
---------------------------------------------------------------------------
investments in the OAA benefit this population?

Response:

The ombudsman program supports individuals residing in long 
term care facilities, residential care homes and assisted 
living communities and individuals with HIV most likely live in 
these communities that we serve. HIV, like any other infectious 
diseases, requires long-term care providers to be inclusive of 
the person, meet their individual needs, have knowledge of and 
apply good infection prevention and control practices.

I think it is important that all members of our community know 
that they are welcome, that they deserve and are entitled to 
high quality care, not matter where they receive it. For this 
reason, I think that it is important that the OAA provide 
access to programs that reduce isolation and loneliness, 
keeping people connected to their greater community and 
providing education and outreach. Individuals with HIV who live 
in long-term care facilities or residential care communities 
would benefit from ombudsmen with adequate stable funding to 
hire staff ombudsmen that are highly skilled and trained to 
help them achieve this. No matter what an individual's 
diagnosis is, Ombudsmen need to be able to serve anyone with 
complex physical and psychosocial needs, offering them support 
when needed and protecting their rights. 
      
=======================================================================


                       Statements for the Record

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

  
                 U.S. Senate Special Committee on Aging

       "The Older Americans Act: The Local Impact of The Law and 
                     The Upcoming Reauthorization"

                              May 23, 2024

                        Statement for the Record

                  National Council on Aging Testimony

Introduction

Chairman Casey, Ranking Member Braun, and members of the Senate 
Committee, thank you for convening this hearing to highlight 
the local impact of the Older Americans Act (OAA) as you engage 
in this year's reauthorization process.

The National Council on Aging (NCOA) is the nation's oldest 
organization focused on serving older adults. For nearly 75 
years, we have worked to improve the lives of older Americans, 
especially vulnerable and underserved populations. From 
advocating for passage of the original Older Americans Act, 
Medicare, and Medicaid, to helping end mandatory retirement, 
NCOA has operated under the principle that aging well in 
America should be a right for all, not a privilege for a few.

NCOA's goal is to improve the health and economic security of 
40 million older adults by 2030, especially women, people of 
color, LGBTQ+, low-income, and rural individuals. Working with 
thousands of national and local partners, we provide resources, 
tools, best practices, and advocacy to ensure every person can 
age with health and financial security. Every day, our team 
works to help individuals secure job training and placement, 
enroll in programs that help with the cost of food and 
medicine, better manage their chronic conditions like diabetes 
and hypertension, and prevent falls. All our insights from our 
direct service delivery inform our reauthorization 
recommendations.

The OAA is integral to achieving NCOA's vision of a just and 
caring society in which each of us, as we age, lives with 
dignity, purpose, and security. First enacted in 1965, the OAA 
establishes priorities and operations for key programs and 
services that help keep our nation's adults ages 60 and older 
healthy and independent.

The OAA is the designated vehicle to plan for and provide 
professional assistance to older Americans and their families, 
providing the many nonmedical care services that older adults 
often need and complementing the support provided by Medicare, 
Medicaid, and Social Security. The Act provides the blueprint 
that encompasses the full range of services and supports that 
address vital social determinants of health and allow all of us 
to age well in community and at home as desired. Further, OAA-
funded services and supports have been shown to reduce health 
care costs and delay nursing home placement.\1\ Given that 
greater than 90% of older adults live in communities,\2\ we 
must recognize the OAA's critical role in supporting family 
caregivers who are the backbone of long-term care for older 
adults.
---------------------------------------------------------------------------
    \1\  https://www.liebertpub.com/doi/10.1089/pop.2017.0199
    \2\  https://aspe.hhs.gov/reports/understanding-characteristics-
older-adults-
---------------------------------------------------------------------------
different-residential-settings-data-sourcestrends-0#exhibit2

Today's realities demand that we examine the OAA with fresh 
eyes and with innovation at the forefront. The OAA must be 
modernized to better address the needs of the diverse and 
growing older adult population, which includes not only the 
Silent Generation and Baby Boomers, but also Generation X, 
whose members start to turn 60 in 2025.

NCOA Reauthorization Priorities

Investing in the Aging Services Network, including the 
thousands of multipurpose senior centers and other community 
organizations, is crucial to the Act's success now and in the 
future. While demand for OAA services is growing and 
diversifying, OAA funding is not keeping pace. This financial 
reality has made it increasingly difficult for the Aging 
Network to maintain existing services, let alone expand. The 
supplemental funding Congress provided to the Aging Network 
during the COVID-19 pandemic was critical to helping older 
adults most at risk and in greatest need and sharply 
underscored the value of and critical need for additional 
investment in OAA programs. Ten leading national advocates for 
the OAA have praised bipartisan efforts to reauthorize the 
statute in 2024 and called for authorizing increased funding 
for these critical programs at the highest possible levels to 
ensure that all older people can thrive.\3\
---------------------------------------------------------------------------
    \3\  https://www.ncoa.org/older-americans-act-reauthorization

NCOA has several additional priorities that we believe should 
be included in this year's OAA reauthorization. Our proposals 
focus broadly on senior centers, healthy aging, and economic 
---------------------------------------------------------------------------
security.

Seniors Centers

For more than 80 years, senior centers have provided access to 
support services and opportunities for healthy aging in a 
highly social setting in towns and neighborhoods across the 
nation. The OAA has recognized their importance for 50 years by 
including multipurpose senior centers in 1973 and by 
establishing the senior nutrition program. In the establishment 
of the Aging Network, senior centers were to be given special 
consideration as community focal points to deliver OAA services 
on a local level. Today, an estimated 11,000 senior centers 
operate locally, sometimes hyper-locally, as gathering places 
for generations of older adults to stay active, healthy, and 
connected.

Research shows that older adults who participate in senior 
center programs experience better mental health across several 
measures compared to non-participants, including perceived 
social and health benefits,\4\ depression,\5\ friendship,\6\ 
and stress levels.\7\ Compared to their peers, senior center 
participants have higher levels of health, social interaction, 
and life satisfaction.
---------------------------------------------------------------------------
    \4\  Gitelson, R., McCabe, J., Fitzpatrick, T., & Case, A. (2005). 
Factors that influence perceived social and health benefits of 
attendance at senior centers. Activities, Adaptation & Aging, 30, 23-
45.
    \5\  Choi, N., & McDougall, G. (2007). Comparison of depressive 
symptoms between homebound older adults and ambulatory older adults. 
Aging Mental Health, 11, 310-322.
    \6\  Aday, R., Kehoe, G., & Farney, L. (2006). The impact of senior 
center friendships on aging women who live alone. Journal of Women & 
Aging, 18, 57-73.
    \7\  Farone, D., Fitzpatrick, T., & Tran, T. (2005). Use of senior 
centers as a moderator of stress-related distress among Latino elders. 
Journal of Gerontological Social Work, 46, 65-83.

Senior centers are a time-tested model to deliver on the 
promise of the Older Americans Act. They provide for the -
maximum co-location of services, which differentiates them from 
other community-based organizations. A visitor to a senior 
center can come to exercise and also get screened for benefits, 
take an art class and get a hot meal, or learn a new language 
and find purpose through volunteering. At their core, senior 
centers are places that foster social connection and belonging, 
addressing the epidemic of loneliness\8\ identified by the U.S. 
Surgeon General.
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    \8\  https://www.hhs.gov/sites/default/files/surgeon-general-
social-connection-advisory.pdf

Senior centers also serve as critical lifelines for many older 
adults in the community. This was never more evident as during 
the pandemic that brought a disproportionately harsh impact on 
older adults. Senior centers across the country sprang into 
action, ensuring that older adults, especially the most 
vulnerable, had credible information; access to nutrition 
through meal delivery, grab-and-go meals, and grocery shopping 
services; and social engagement through online programs, 
parking lot parties, drive-through programs, and thousands upon 
thousands of phone calls. With deep knowledge of their 
communities, senior centers creatively pivoted to meet ever-
changing needs. Many moved programs from in-person to virtual. 
Today, their in-person participation is rebounding, and those 
with capacity continue to offer virtual options for older 
adults who cannot attend the center due to transportation or 
health issues. When vaccines became available, senior centers 
stepped in to facilitate appointments, provide transportation, 
---------------------------------------------------------------------------
and host clinics.

While they provide these critical services, senior centers, in 
general, are chronically underfunded. They rely on municipal 
dollars, philanthropy, and fundraising. While some are operated 
by Area Agencies on Aging (AAAs), especially when the AAA is 
part of county government, most are not. They are part of 
municipal government or nonprofit community-based 
organizations. In 1978's Older Americans Act reauthorization, 
senior centers were placed in the consolidated Title III-B, 
Supportive Services and Senior Centers. In the allocation of 
scarce resources and without a requirement that any percentage 
of the appropriation for III-B be directed to senior centers, 
senior centers generally are not funded by the OAA. They might 
receive funding on a service unit reimbursement rate (e.g., for 
meal delivery) but not for general programs, operations, or 
facility needs. Senior centers that received investments from 
the American Rescue Plan (ARPA) saw innovations that were not 
possible before. ARPA was an infusion of funding that supported 
innovations like grab-and-go meals, allowed communities to make 
renovations or purchase equipment (for exercise, technology, 
kitchens, etc.), and shored up the senior nutrition program. 
ARPA showed us what was possible with better support. However, 
once ARPA funds are expended, those innovations will not likely 
be funded, and the programs that were supported will, again, 
face budget shortfalls.

NCOA has been the national voice for senior centers for more 
than 50 years. We have over 2,300 senior centers in our 
affiliate network and, through a three-year cooperative 
agreement with the U.S. Administration for Community Living 
(ACL), we have established a Resource Center for the 
modernization of senior centers. Through this work, we see some 
senior centers that are modernizing and thriving with new or 
renovated facilities that support today's technological needs, 
fitness programs, evidence-based programs, meal options, and 
services to address complex issues like homelessness and 
behavioral health. These centers also provide support for 
economic security through information and referral and benefits 
enrollment. They have collaborative partnerships with 
organizations and businesses in their communities, with aging 
network partners like AAAs, and with community partners like 
libraries, parks and recreation, and public health. New models 
of senior centers, including public/private partnerships, 
wellness centers, and intergenerational centers have been 
developed.

2023 Programs of Excellence

Among the senior centers receiving a 2023 Programs of 
Excellence award from NCOA is the Veterans Coffee Club 
administered by the Muncie/Delaware County Senior Citizens 
Center in Muncie, Indiana.\9\ This special military suicide 
prevention program was created with support from the VA 
Delaware County Indiana. The goal is not only to create and 
design a program to help prevent military suicides, but to 
develop, with the cooperation of the Veterans Administration, a 
suicide prevention program that can be introduced to the 
10,000+ senior centers across the country.
---------------------------------------------------------------------------
    \9\  https://www.ncoa.org/article/nisc-programs-of-excellence-
veterans-coffee-club

Initiated in response to staggering rates of suicide, the 
program started out with four veterans from the center, and 
currently, there are 237 registered members. A wives support 
group meets at the same time for those veterans who will only 
attend if their wife goes, and for Gold Star and Blue Star 
wives. The program continues to grow, with a club established 
in Anderson, Indiana, and two more clubs in the works one in 
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Marion and one in New Castle.

All these efforts aim to find a way to reach veterans where 
they are, not just reach out and hope they come get help. 
Typical attendance is 80-100 veterans on the first Saturday of 
every month, and several of the veterans now attend programs at 
the senior center on a regular basis, but not all senior 
centers are thriving. NCOA conducted an environmental scan, 
which identified the successes and challenges of senior centers 
today. Inadequate support, both in recognition of their value 
and in the allocation of resources, is at the top of the list 
of challenges.\10\ Centers do not have the funding and 
direction needed to upgrade their facilities, to access 
technology, and to ensure a skilled workforce. The centers that 
struggle the most are those in areas of greatest need.
---------------------------------------------------------------------------
    \10\ https://www.ncoa.org/article/the-state-of-todays-senior-
centers-successes-
---------------------------------------------------------------------------
challenges-and-opportunities

Through OAA reauthorization, Congress has an opportunity and 
obligation to provide the focus and funding that will ensure 
that a modern senior center one that addresses the needs of 
current and future generations of older adults in a way that is 
culturally meaningful is available in every ZIP code.

Senior centers are also an integral part of the OAA senior 
nutrition program. The OAA created two delivery systems for 
nutrition congregate meals (Title III-C1) and, for those unable 
to access a congregate meal, home-delivered meals (Title III-
C2). The pandemic demonstrated the importance of elevating both 
home-delivered meals and congregate meals as equally important 
vehicles for fighting senior hunger and addressing social 
isolation. These proven and effective community-based programs 
have more than 50 years of experience, expertise, and trust to 
serve those in greatest need. However, with rising costs and 
increasing demand, merely maintaining current funding levels is 
not enough. We need to increase the authorization level and 
provide greater parity to support both approaches at scale.

Senior centers are the most common site for congregate meals. 
During the pandemic, we saw innovation in meal delivery such as 
grab-and-go meals and virtual options for dining with friends. 
The flexibility to implement innovative solutions should be 
maintained and encouraged, as should local flexibility, with 
limits, to shift funds to the most-needed services. However, 
the OAA should continue to recognize and prioritize them as 
distinct programs and fund each one adequately. Sharing a meal 
is one of the most treasured traditions of social connection. 
We must support the modernization of the congregate meal, in 
conjunction with senior centers, to ensure current and future 
generations of older adults have this opportunity.

OAA reauthorization should:

  Address lessons learned from the pandemic related to 
promoting equitable access to senior center services, 
addressing diverse needs, and pursuing innovation in nutrition 
programs.

  Ensure strong congregate settings in the community by 
reinstating a separate title for senior centers and updated 
language that retains the special consideration of senior 
centers as designated focal points and by strengthening support 
for multipurpose senior center infrastructure and services, 
while allowing for the flexibility capacity for virtual 
connections.

  Strengthen the authorization for modernizing senior centers.

  Increase the authorization level of senior nutrition 
programs to allow for greater parity for both home-delivered 
meals and congregate meals approaches to be equally funded at 
scale.

Healthy Aging

Title III-D Health Promotion

Chronic conditions are the leading cause of frailty, 
disability, and death in the United States. They lead to 
declining activities of daily living (ADLs), causing affected 
individuals to lose their independence, require help from 
family and/or paid caregivers, and need long-term services and 
supports. Yet, there are evidence-based health promotion and 
disease prevention programs that we know can help and work.

NCOA has been a leader in expanding access to health promotion 
and disease prevention programs, many of which have been shown 
through research to reduce or delay expensive hospital or 
nursing home admissions. Through education, outreach, and 
community programs, NCOA provides older Americans with the 
tools and resources they need to age well physically, 
cognitively, and mentally. Through our ACL-funded National 
Chronic Disease Self-Management Education and Falls Prevention 
Resource Centers, NCOA provides broad support and technical 
assistance to state agencies and community-based organizations 
delivering these programs.

These health promotion and disease prevention programs result 
in positive health outcomes related to managing chronic 
disease, preventing falls, increasing physical activity, and 
reducing symptoms of depression and social isolation. These 
well-researched programs have resulted in health care cost 
savings for participants:\11\
---------------------------------------------------------------------------
    \11\  https://www.ncoa.org/article/falls-prevention-programs-
saving-lives-
---------------------------------------------------------------------------
saving-money-infographic

  A Matter of Balance, a falls prevention program, reduces 
total annual medical costs by $938 per participant.

  The Otago Exercise Program reduces falls by 35%, resulting 
in net savings of $429 per participant.

  The Community Aging in Place Advancing Better Living for 
Elders Program (CAPABLE) provides home modifications to reduce 
falls risks resulting in more than $30,000 in medical costs 
savings.

  The Chronic Disease Self-Management Program (CDSMP) shows 
participants saved $714 in emergency department visits and 
hospital utilization. If 10% of Americans with one or more 
chronic conditions were reached by CDSMP, there is potential 
for $6.6 billion in savings.\12\
---------------------------------------------------------------------------
    \12\  Lorig K, Ritter P, Stewart AL, et al. Chronic Disease Self-
Management Program: 2-Year Health Status and Health Care Utilization 
Outcomes. Medical Care. 2001;39:1217-1223.

Given that 80% of older adults experience two or more chronic 
conditions, NCOA believes CDSMP should be offered in every ZIP 
code across the U.S. in an effort to save lives and decrease 
health care costs. CDSMP is a workshop for adults with at least 
one chronic health condition, which may include diabetes, heart 
disease, or arthritis. Given that chronic conditions are the 
primary drivers of health care costs and disability, as well as 
declines in quality of life, we must ensure that anyone with a 
chronic illness has access to this program. CDSMP focuses on 
critical disease management skills, including decision making, 
problem solving, and action planning. The program increases 
confidence, physical and psychological well-being, knowledge of 
ways to manage chronic conditions, and motivation to manage 
challenges associated with chronic diseases. Interactive 
educational activities include peer discussions, brainstorming, 
action-planning and feedback, behavior modeling, problem 
solving techniques, and decision making. The program also 
results in behavior change, such as more exercise and 
relaxation, better communication with health care providers, 
healthy eating, medication management, and better management of 
---------------------------------------------------------------------------
fatigue.

The delivery of these programs to older adults is funded by OAA 
Title III-D. Funding amounted to $26.3 million in the FY23 
federal budget; this funding is shared across all states, 
territories, and the District of Columbia. Beginning in 2012, 
ACL required that programs funded by Title III-D meet strict 
evidence-based criteria defined as proven effective for 
improving the health and well-being or reducing disease, 
disability, and/or injury among older adults; and proven 
effective with older adult population, using experimental or 
quasi-experimental design; and results published in a peer-
review journal; and fully translated in one or more community 
site(s); and includes developed dissemination products that are 
available to the public.

However, not all these programs are reaching older adults in 
need, especially in rural and diverse communities. This lack of 
access is due in part to inadequate funding under OAA Title 
III-D, which has not kept pace with growing needs and costs to 
deliver evidence-based programs. Congress and the 
Administration must address lessons learned from the pandemic 
related to promoting equitable access to services, addressing 
diverse needs, and expanding healthy aging programs that are 
offered both in-person and virtually. For example, the costs 
associated with delivery of virtual programs are significantly 
higher in most cases than in-person programs due to greater 
technology and staffing needs.

NCOA recognizes that evidence-based programs have some 
implementation challenges and inequities. Most have not been 
tested with a full diversity of populations, communities, or 
contexts. Some communities struggle to implement them as 
designed. Therefore, we advocate for expanding the continuum of 
programs funded under the OAA to include those that are 
evidence-informed, defined as an approach in which 
practitioners are encouraged to be knowledgeable about findings 
coming from all types of studies and to use them in an 
integrative manner, taking into consideration experience with a 
program or intervention and judgment, clients' preferences and 
values, and context of the interventions.\13\
---------------------------------------------------------------------------
    \13\  Adapted from: Nevo, I., & Slonim-Nevo, V. (2011). The myth of 
evidence-based practice: towards evidence-informed practice. British 
Journal of Social Work, 41(1), 1-22.

NCOA is proud to be leading the Innovation Lab through funding 
from ACL's Center for Performance and Evaluation. We are 
partnering with researchers to take a core-components approach 
to identify what is truly necessary to achieve the ultimate 
goal better outcomes for people and communities. This broader 
approach gives communities the flexibility to deliver programs 
that match their capacity and meet the needs of their 
culturally diverse populations. This core components 
methodology is being applied to falls prevention interventions, 
and we believe it has significant potential across other areas 
of aging services such as nutrition and chronic disease 
management.
OAA reauthorization should:

  Double authorized funding levels for OAA Title III-D to 
support the licensing, training, technology, and other costs 
required for implementation of evidence-based programs.

  Expand the continuum of programs funded under the OAA to 
include those that are "evidence-informed."

Jane's Story

One of our participants, a 76-year-old woman, initially relied 
on a walker for mobility. However, as she diligently engaged in 
the exercises taught in our sessions, her progress was 
remarkable. By the third session, she entered class confidently 
using only her cane, brimming with pride at her newfound 
ability. Her excitement was palpable as she shared how these 
exercises had significantly improved her mobility and daily 
activities. Her husband, who accompanied her to class, echoed 
her joy, thrilled to engage in activities together that had 
been out of reach for a while.

Direct Care Workforce

Between 2021 and 2031, the direct care workforce is projected 
to add more than one million new jobs, resulting in a total of 
9.3 million direct care jobs need to be filled,\14\ according 
to PHI. Low wages, lack of full-time employment, and the 
pandemic have caused fewer workers to enter direct care at the 
exact time the need for their services is growing.
---------------------------------------------------------------------------
    \14\  https://www.phinational.org/resource/direct-care-workers-in-
the-united-states-
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key-facts-2023/

Funded by ACL, the Direct Care Workforce Strategies Center, 
housed at NCOA, is addressing this challenge by supporting 
state systems change through the provision of resources, 
technical assistance, and training to state systems, providers, 
and stakeholders to improve direct care workforce recruitment, 
training, and retention.

This Center addresses the charge of OAA and its National Family 
Caregiver Support Program (enacted as part of the 2000 OAA 
reauthorization) to build and strengthen the care 
infrastructure needed to address the pressing challenges that 
threaten the independence, health, and economic security of 
older adults who rely on the support of family caregivers.

OAA reauthorization should:

  Strengthen authorities for sustained funding for the Direct 
Care Workforce Strategies Center beyond five years to increase 
dissemination of state technical assistance and training 
opportunities to ensure an adequate and well-trained direct 
care workforce.

Economic Security

Older adults are more likely to face economic insecurity as 
they age. In 2023, poverty among older adults rose for the 
third consecutive year to 14%.\15\ An analysis conducted by 
NCOA and the LeadingAge LTSS Center at the University of 
Massachusetts, Boston found that of people age 60 and older, 
80% (47 million) do not have the financial resources to cover 
long-term care services or another financial shock, nearly 20% 
of older households have no assets to draw upon to withstand a 
financial shock, and 21-80% of older adults have modest assets 
but would still be unable to afford more than two years of 
nursing home care or four years in an assisted living 
community.\16\
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    \15\  https://www.ncoa.org/article/older-adult-poverty-continues-
upward-trend-reaching-an-unacceptable-14-percent
    \16\  https://www.ncoa.org/article/80-percent-of-older-americans-
cannot-pay-for-long-term-care-or-withstand-a-financial-shock-new-study-
shows

An important factor in determining older adults? Economic 
security is the geographic location of their primary residence. 
Regions such as the Northeast and the West Coast have a higher 
cost of living compared to states in the Sunbelt region. NCOA 
urges Congress and the Administration to modernize and increase 
flexibility in the determination of economic need with proven 
tools such as the Elder Index\17\, which is a more accurate 
measure of the income older adults need to meet their basic 
needs and age in place with dignity. It includes household 
size, geographic location, housing, and health status in 
determining costs of living. The Elder Index is updated 
annually to include the latest Consumer Price Index data to 
account for inflation costs. Elder Index data show that nearly 
half of older adults live alone, and one in five older couples 
is economically insecure and cannot pay for necessities.\18\ 
The costs of necessities in every state exceeds the federal 
poverty thresholds used in eligibility requirements for 
benefits programs.
---------------------------------------------------------------------------
    \17\  https://elderindex.org/
    \18\  Mutchler, Jan; Su, Yan-Jhu; and Velasco Roldan, Nidya, 
"Living Below the Line: Economic Insecurity and Older Americans, 
Insecurity in the States, 2022" (2023). Center for Social and 
Demographic Research on Aging Publications. 66.

The Elder Index also shows that the average Social Security 
benefit does not cover the cost of basic expenses. Researchers 
from the University of Massachusetts, Boston reported that the 
average Social Security benefit only covers 68% of the costs 
for basic necessities for a single person living alone and 81% 
for couples living together.\19\ This gap identifies the 
reality that many older adults must use other means to cover 
their basic costs either by working, withdrawing from savings 
and other retirement accounts, or relying on social safety net 
programs such as the Supplemental Nutrition Assistance Program 
(SNAP) or Medicare Savings Programs.
---------------------------------------------------------------------------
    \19\  https://kffhealthnews.org/news/article/elder-index-aging-
costs-seniors-basic-necessities/

---------------------------------------------------------------------------
OAA reauthorization should:

  Modernize and increase flexibility in the determination of 
economic need with proven tools such as the Elder Index to 
ensure the local cost of living are addressed as future 
generations are expected to age with limited financial 
resources.

Christian's Story

Christian, 61, lives with disabilities and relies on a fixed 
income of $1,156 monthly. He relocated to Windsor, Vermont, to 
assist his 93-year-old father with his care. Christian 
previously paid $148.50 for Medicare, along with co-pays for 
medications, without receiving assistance for food, fuel, or 
prescriptions. Unfamiliar with available resources in Vermont 
due to being a nonnative, Christian faced financial strain when 
prescribed a new medication with a $500 copay. With the help of 
a local benefits enrollment center, Senior Solutions, Christian 
received a tablet for telehealth, facilitating his connection 
with family in New York and easing access to medical services. 
Additionally, Christian applied for food benefits, fuel 
assistance, and pharmacy aid programs, promptly receiving a 
SNAP card with $202 for food, $56 for fuel assistance, and 
relief from his Medicare Part B premium, qualifying him for 
Medicaid after a $60 spend-down. Thrilled by these benefits, 
Christian anticipates saving for a car, resulting in monthly 
savings exceeding $500. These supports allow Christian to 
continue to care for his father and himself, both remaining 
independent.

Older Workers

For millions of Americans, aging well means having the 
opportunity to work in the years leading up to and beyond the 
traditional retirement age. The reasons older adults want or 
need to work are the same as at any age. Work provides meaning, 
social connections, and much needed income to pay for daily 
needs. As longevity continues to climb and many Americans 
struggle to save enough for retirement, work is also essential 
to affording a longer life. This is especially true for older 
adults of color, who experience higher rates of poverty than 
white older adults, and among rural and LGBTQ+ older adults who 
face access barriers and discrimination in employment.

Since 1968, NCOA has served as one of several national 
administrators for the Senior Community Services Employment 
Program (SCSEP). Today, we provide SCSEP services in 11 states 
and Puerto Rico, including Georgia, New York, North Carolina, 
and Pennsylvania. This work has given us clear insight into the 
value older workers contribute to our economy.

A Department of Labor program that is authorized and funded 
under OAA, SCSEP is the only federal job training program 
focused exclusively on helping older Americans return to the 
workforce. It prioritizes services to veterans, individuals 
with disabilities, those living in rural communities, and other 
most-in-need older adults who have low job prospects and 
significant barriers to employment. Significant majorities of 
participants have incomes below 125% of the federal poverty 
line, are women, and are people of color. The program enables 
them to develop new skills and add work experience through 
subsidized community training assignments with local nonprofit 
organizations.

SCSEP incorporates benefits coordination and access to 
wraparound services. Older workers particularly low-income 
individuals with significant barriers to employment have 
traditionally been left behind by public workforce systems and 
strategies. Many have been out of the workforce due to 
caregiving responsibilities, health and disability challenges, 
and age discrimination. For many, the traditional 40-hour week 
and year-round employment placement envisioned in Workforce 
Innovation and Opportunity Act (WIOA) and other public 
workforce programs are not appropriate. These systems lack the 
targeted, one-on-one counseling and assistance many older 
workers require for successful training and re-employment.

However, the impact on ageism starts much before age 55. We 
advocate for lowering SCSEP eligibility to age 50, so we can 
broaden the impact of the program by helping people retool 
their skillset earlier in life. Similarly, we recommend 
broadening the income eligibility to at or below 200% of the 
federal poverty level to recognize that those who are slightly 
over the current cap still need the help of a program like 
this. If we focus on younger individuals with slightly more 
income initially, we will be able to further decrease the curve 
of individuals falling into a position that requires federal 
benefits and Medicaid.

OAA reauthorization should:

  Update SCSEP eligibility to make it available to adults 50 
years and older.

  Adjust income eligibly guidelines to allow for individuals 
with incomes at or below 200% of the federal poverty level to 
improve access for older workers struggling with financial 
security and employment.

Susan's Story

At age 75, Susan learned of the NCOA SCSEP program while 
waiting at her doctor's office. Unsure of what to expect, but 
in dire need of work, she took a chance and dialed the number 
listed on the flyer, hoping for assistance. At the Crawford 
County Read Program, Susan found fulfillment in helping people 
of all ages improve their literacy and basic math skills. 
However, when the program faced closure due to funding issues, 
Susan feared returning to financial uncertainty.

Thankfully, another opportunity arose swiftly, and Susan 
embarked on training as a receptionist at an organization 
dedicated to mental health awareness. As Susan's tenure in the 
program approached its conclusion, her colleagues recognized 
her value and advocated for her to join the team permanently. 
In a remarkable show of support, Susan's coworkers collectively 
urged management to hire her full-time.

Now secure in her job and an active taxpayer, Susan expresses a 
newfound sense of relief, stating that she can finally relax 
knowing she has stable employment. She passionately shares her 
experience with others, emphasizing the vital role of SCSEP in 
assisting older adults facing employment obstacles, noting that 
the program can be a lifeline for many.

Conclusion

The OAA provides our nation with a blueprint for ensuring we 
have the infrastructure in place to support individuals across 
the full spectrum of domains related to aging in community and 
at home as we all desire. The various titles of the Act 
intentionally and thoughtfully support an ecosystem for 
deploying services and supports that reflect the needs of 
states and communities, prioritizing the most vulnerable.

With nearly 12,000 people turning 65 each day this year and for 
the next several years, we applaud ACL's leadership in updating 
the Act with the recently released OAA regulations, largely 
building upon lessons of the pandemic, and we also recognize 
that demographic trends require us to further align Federal, 
State, and local programs with the needs of today and tomorrow. 
We appreciate this opportunity to offer our priorities to 
reauthorize, modernize, and fund the Older Americans Act to 
ensure every American can age well.

For more information, please contact: Marci Phillips 
[email protected].

                 U.S. Senate Special Committee on Aging

       "The Older Americans Act: The Local Impact of The Law and 
                     The Upcoming Reauthorization"

                              May 23, 2024

                        Statement for the Record

           American Association of Retired Persons Testimony

AARP, which advocates for the more than 100 million Americans 
age 50 and older, thanks the Committee for holding the hearing, 
"The Older Americans Act: The Local Impact of the Law and the 
Upcoming Reauthorization." We appreciate the opportunity to 
work with you to advance support for older adults and their 
family caregivers through the Older Americans Act (OAA). The 
OAA has a powerful legacy. Since 1965, the OAA has supported 
older adults so they can live at home with independence and 
dignity, deferring or eliminating more costly institutional 
services and hospitalizations. Our research shows that people 
overwhelmingly want to age at home in their own communities, 
but as the population of older adults rises exponentially, it 
puts a greater strain on services provided by OAA.

Meeting this increasing demand is a significant challenge. In 
2000, adults age 65 and older made up approximately 12 percent 
of the US population; today, the proportion is estimated at 17 
percent and is expected to rise to 23 percent by 2050. The 
number of people age 80 and older, who are the most likely to 
need help to live independently in their homes and communities, 
is projected to nearly double from 2023 to 2040.

America is on the brink of a serious national crisis. Right 
now, nearly 48 million family caregivers are filling in the 
gaps, providing $600 billion in uncompensated care to their 
loved ones. Many, especially women, are dropping out of the 
workforce or cutting back hours to care for their loved ones, 
exacerbating labor shortages across the economy. As the 
population ages, the number of family caregivers is not likely 
to keep up with the demand.

As OAA's funding levels have declined relative to the 
population demanding these services, more and more is falling 
on the backs of these caregivers - and they are already at the 
brink. When adjusted for inflation, total OAA funding has 
declined by 18 percent since 2001. Without sufficient funding, 
critical OAA programs are often unable to meet rising demand, 
and many have been forced to implement waiting lists. For 
example, according to Meals on Wheels, one in three of their 
programs currently have a waitlist, with older adults waiting 
an average of three months for vital meals.

In a typical year, thanks to the OAA, 11 million older adults 
receive help to stay in their homes, receive congregate and 
home-delivered meals, case management, family caregiver 
support, transportation, adult day care, legal services, elder 
abuse prevention, and job training and employment opportunities 
for low-income older adults. Additionally, OAA Native American 
programs provide nutrition, support and caregiver services to 
older American Indian, Alaska Native and Native Hawaiian 
people. The OAA plays a critical role in making sure people in 
this country can age at home, where they want to be. OAA 
programs are cost-effective investments that serve the needs of 
older Americans while deferring or eliminating the need for 
costly institutionalization. Now more than ever, OAA is 
essential for our country.

As we approach OAA reauthorization, we look forward to 
continuing to work with you to improve upon OAA's many existing 
programs. Our recommendations for ways OAA can be improved to 
meet the needs of our aging population are outlined below.

OAA Reauthorization Priorities

AARP supports a number of proposals that will help to improve 
OAA, including:

  Strengthening support for family caregivers;
  Improving food security and social isolation through the 
Nutrition Services Programs;
  Supporting housing stability among older adults;
  Addressing direct care workforce shortages; and
  Protecting and strengthening the reach of OAA programs.
Strengthen Support for Family Caregivers

  Connect Caregivers to the needed resources through caregiver 
assessments

OAA's National Family Caregiver Support Program (NFCSP) 
includes a range of services to support family caregivers and 
older relative caregivers. One of AARP's 2019 OAA 
reauthorization priorities was to ensure caregivers were being 
connected to the right resources and support for their 
particular caregiving situation. The final bill included 
provisions to allow for and encourage the use of caregiver 
assessments under NFCSP, which AARP supported, but it did not 
require their use as we had urged. The Administration for 
Community Living (ACL) furthered this effort in their recently 
finalized OAA regulations by including language to allow "an 
evidence-informed or evidence-based caregiver assessment."

We understand that due to the COVID-19 pandemic and 
availability of resources, some caregiver assessment-related 
provisions have not been completed or fully implemented at this 
time. This includes the technical assistance to promote and 
implement the use of caregiver assessments, an analysis and 
report on the use of caregiver assessments by the Aging 
Network, the inclusion of caregiver assessments used in the 
states in data and reports from states to ACL, and identifying 
and making available best practices relating to NFCSP and 
Native American Caregiver Support Services. It is important for 
these activities to be completed as soon as possible so family 
caregivers, the Aging Network and others can benefit. We 
understand that agreements awarded by ACL to provide technical 
assistance and capacity building to support the aging and 
tribal services networks with implementing the National 
Strategy to Support Family Caregivers will help with 
implementation of some of these provisions.

In addition to completing work from the last reauthorization 
period, it is important to strengthen caregiver assessments and 
expand their use so that more caregivers can get the support 
they individually need. The assessments should be used to 
provide a no wrong door approach to help connect caregivers 
with any supports they may need - including programs outside of 
OAA authority.

We recommend multiple improvements to the current OAA caregiver 
assessment provisions that AARP supported and were successfully 
enacted in 2020, including:

  Ensure caregiver assessments are:
      *culturally appropriate;
      *person-and family-centered; and
      *evidence-informed or evidence-based.

  Amend OAA so that services provided under the NFCSP must be 
informed by a caregiver assessment starting two years after the 
date of enactment. Currently, this is permitted but not 
required. The two-year timeframe would allow time to complete 
caregiver assessment activities from the 2020 reauthorization 
and build on those activities.

These changes are consistent with the National Strategy to 
Support Family Caregivers. We note that Outcome 2.2 in the 
National Strategy is, "Where appropriate, identifying services 
and supports needs for caregivers consistently starts with a 
review of family caregiver strengths and preferences using 
evidence-based assessments." The Strategy also states, 
"Accurately assessing the needs of family caregivers with 
evidence-based tools and protocols is critical to providing 
services that make a difference for the caregiver and empower 
them to better meet the needs and preferences of the person 
they are supporting."

  Increase awareness of and education about existing family 
caregiver supports

Too often, family caregivers are not aware of support in their 
communities and how to find it. To help make it easier for 
caregivers to learn about existing available support, we 
propose adding language to OAA Sections 305, 306, and 373 to 
help increase awareness of and education about existing family 
caregiver supports.

  Improve Counseling in the National Family Caregiver Support 
Program (NFCSP) and Native American Caregiver Support Services

To help improve consistency, improve OAA family caregiver 
counseling services, and incorporate an element from the 
National Strategy, we recommend adding language to help ensure 
that counseling under NFCSP and within Native American 
Caregiver Support Services is person-centered and trauma-
informed. This could also help increase caregiver engagement 
with caregiver support services, consistent with the National 
Strategy.

  Measure the caregiver navigation experience and impact of 
caregiver supports

Caregivers say they are stressed emotionally (72%), overwhelmed 
by responsibilities (60%), and financially strained (55%). Time 
is also a top challenge for them. They do not have the time to 
spend unnecessary and inefficient efforts navigating to get the 
help, information, and support they need. To help ensure that 
family caregivers receive the navigation support/customer 
service experience they need and deserve, we recommend 
requiring ACL to develop and implement family caregiver 
experience and outcome measures for the NFCSP, Native American 
Caregiver Support Services, and Aging and Disability Resource 
Centers (ADRCs) within two years of enactment.

This would help focus additional attention on caregiver 
experience and outcomes, as measures have traditionally been 
more focused on the number of people served or processed. There 
are measures, such as "Maintain at 75% or higher the percentage 
of caregiver services clients who report that services enabled 
them to provide care for the care recipient for a longer time 
than would have been possible without these services" and 
"Increase the likelihood that the most vulnerable people 
receiving Older Americans Act Home and Community-based 
Supportive Services and Caregiver Support Services will 
continue to live in their homes and communities." However, more 
outcomes and experience measures can help improve caregivers' 
overall experience.

  Ensure access to flexible respite services that meet the 
specific needs of each family caregiving situation

As with other recommendations to the NFCSP, AARP recommends 
authorizing language be added to ensure a person- and family-
centered approach to respite care. Ensuring flexible options 
will help meet the specific needs of individual family 
caregiver situations.

According to a 2024 AARP report, while family caregivers often 
feel their role provides meaning in their lives, they also face 
significant challenges. Caregivers can feel stressed, 
overwhelmed, and lonely. They may also have physical and 
financial stressors related to taking care of children, keeping 
up with their jobs, and managing finances. Some care 
recipients, especially those with cognitive impairment or 
dementia, need a caregiver to be on call 24 hours a day.

Many family caregivers need respite care-that is, short breaks 
from their responsibilities. Respite is most often defined as 
care provided to an older adult or person with disabilities so 
that their family caregiver can get a short break from their 
care responsibilities.

OAA provides respite services through the Title III National 
Family Caregiver Support Program. These supports help family 
caregivers balance caregiving with other responsibilities 
which, in turn, helps ensure more older adults can remain in 
their homes and communities. Evidence shows that respite 
services are helpful to family caregivers, including those who 
care for people with dementia.

AARP research shows tailored communications, flexible and 
accessible services, and trained staff delivering high-quality 
care are important and respite programs that take this into 
account will be better able to meet the needs of family 
caregivers and their care recipients. Family caregivers could 
benefit from a range of services that are tailored to their 
needs, as different caregiving situations may necessitate 
different types of respite services.

Improve Food Security and Reduce Social Isolation by Ensuring 
Flexibility in the Nutrition Services Programs

In 2022, nearly 11.8 million (or about 1 in 10) Americans age 
50 and older faced food insecurity and the threat of hunger. 
Food insecurity among this age group increased 25 percent 
between 2021 and 2022, reversing a decade-long decline. While 
only part of the solution, OAA nutrition programs are a 
critical component of addressing senior hunger.

Congregate nutrition services and home-delivered nutrition 
services provided by the OAA Nutrition Services Program reduce 
hunger and support older adults' health and independence, 
including their ability to remain in their homes. A 2017 
evaluation found that 42 percent of congregate meal 
participants and 61 percent of home-delivered meal participants 
reported they would skip meals or eat less without the program. 
The majority of participants report that the program helped 
them to eat healthier and continue to live independently.

Furthermore, OAA-funded senior nutrition programs also provide 
more than a meal; they provide opportunities for social 
engagement, offer nutrition screening and counseling, and link 
participants to other home- and community-based supports. A 
2017 AARP Public Policy Institute study found social isolation 
costs Medicare $6.7 billion per year. Congregate meals 
participants report seeing friends more often due to the meals 
and the home-delivered meal program is associated with reduced 
loneliness among new participants, with delivery individuals 
often being the only human contact of the day for homebound 
clients. The improved social connections among participants can 
lead to improved health and lower associated health care costs 
among program participants.

We recommend permanently implementing several COVID-era 
flexibilities for the nutrition services program. AARP believes 
the following changes would improve efficiency and allow local 
providers to tailor services to best meet the needs of their 
communities.

  Grant nutrition service providers funding flexibility to 
meet the specific needs of their individual communities

Title III-C Nutrition Programs are currently funded separately, 
meaning providers have limited flexibility to transfer funds 
from one to another should demand or need differ between the 
programs. Local providers say combining the home-delivered 
meals and congregate meals programs into one funding stream or 
allowing the transfer of funds between the two programs, will 
improve efficiency and allow the providers to better tailor 
services to the needs of their participants.

AARP recommends agencies within the Aging Network be given the 
funding flexibility to offer services based on the needs of the 
participants and communities, while ensuring they continue to 
address the program's three goals of reducing hunger, promoting 
socialization, and promoting the health and well-being of older 
adults. While this flexibility is key, participants must 
continue to have the option to receive either congregate or 
home-delivered meals.

  Codify flexible nutrition service models allowed during 
COVID-19 and included in the most recent OAA Regulations

Pandemic flexibilities allowed for alternative meal options, 
such as carry-out, grab-and-go and drive through meals, through 
the congregate meals program. While included in the most recent 
OAA regulations, these flexibilities should be permanently 
extended in statute not only to address hunger but to reach 
older adults struggling with social isolation.

Protect and Strengthen the Reach of OAA Programs

OAA is a major delivery system of a variety of services for 
older adults and their family caregivers. In addition to the 
policy areas addressed above, we are also focused on finding 
ways to strengthen other critical OAA programs, including - but 
not limited to - the following:

  The Senior Community Service Employment Program (SCSEP)

SCSEP is the only federal program specifically created to 
assist low-income workers age 55 and older to regain entry into 
the workforce. The program provides part-time community service 
assignments for low-income persons age 55 or older who would 
otherwise have poor employment prospects because older 
jobseekers continue to face barriers to employment, often due 
to age discrimination. SCSEP-funded services are available in 
nearly all 3,000 U.S. counties and territories.

Grantees include public workforce agencies and national 
nonprofit organizations. Participants are unemployed, 
disadvantaged older workers who work an average of 20 hours a 
week at minimum wage. Work experience is gained typically in 
community service activities at nonprofit and public 
facilities, serving as a bridge to unsubsidized employment 
opportunities. SCSEP has helped thousands of older jobseekers 
into jobs providing them work-based training and the 
opportunity to use their skills. According to the recent 
Department of Labor Workforce GPS survey, participants strongly 
believe that the program helped prepare them for success in the 
workforce (8.4 on a 10-point scale). SCSEP adds needed value as 
the only federal program targeted at lower income older 
jobseekers.

  The Long-Term Care Ombudsman Program (LTCOP)

LTCOP is the most effective program to advocate and act as a 
resource for older adults and people with disabilities who live 
in nursing homes, assisted living, and other licensed adult 
care homes. Every state - plus Puerto Rico, Guam and the 
District of Columbia - has a long-term care ombudsman office. 
These offices work to resolve problems related to the health, 
safety, welfare, and rights of individuals who live in long-
term care facilities, and help residents understand and 
exercise their rights to good care in an environment that 
promotes and protects their dignity and quality of life.

Data from the 2022 National Ombudsman Reporting System (NORS), 
shows that LTCOP's nearly 2000 full time staff and 
approximately 4000 certified volunteers investigated more than 
182,000 complains nationwide and provided assistance to more 
than 400,000 individuals looking for information about long-
term care.

The COVID-19 pandemic highlighted the critical role these 
ombudsmen play in the long-term care system and the challenges 
they face, including significant workload with limited staff 
and funding.

Support Housing Stability Among Older Adults

Through nutrition assistance, in-home care services and support 
to family caregivers, OAA is providing a vital resource for 
millions of older adults who want to age in their homes. In 
addition to food and caregiving assistance, OAA also provides 
assistance for home repair and modifications to ensure the home 
is safe and updated with accessibility features to make the 
home easier to navigate. However, rising costs to remain in the 
home, everything from rent and insurance to taxes, is also 
making it harder for older adults to age in place. According to 
the Department of Housing of Urban Development's (HUD) recent 
2023 Annual Homelessness Assessment Report, there has been a 12 
percent increase in homelessness in the last year, with eight 
percent of all people experiencing homelessness over the age of 
64, and almost 30 percent elderly or near elderly (55 years or 
older).

OAA could play a larger role in supporting local partnerships 
between Area Agencies on Aging (AAA) and housing providers and 
enabling access to services and supports for older adults 
residing in HUD-assisted housing, as well as funding, to 
support housing stability with service coordination and 
delivery.

Strengthen the Direct Care Workforce

AARP supports efforts to bolster the direct care workforce, 
including through additional support and investments in the OAA 
Direct Care Workforce Demonstration.

Around 12.6 million adults in the US need long-term services 
and supports (LTSS). Despite the increased demand for direct 
care workers as the population continues to age, job quality 
for all members of the direct service workforce remains low. 
About 38 percent of direct service workers leave their 
positions in less than six months, and approximately 21 percent 
leave within six to 12 months. According to a 2023 AARP report 
on the direct care workforce, major challenges contributing to 
a high turnover rate within the direct care workforce include:

  low wages and lack of benefits;
  minimal or insufficient training and career development 
opportunities;
  physically and emotionally demanding positions, with high 
rates of occupational injury;
  high rates of burnout; and
  racial and gender discrimination that causes, compounds, 
and/or exacerbates other challenges.

OAA's Direct Care Workforce Demonstration provides funding for 
a national technical assistance center for federal, state, and 
private entities to access model policies, best practices, and 
training materials for recruiting and retaining direct care 
workers.

Conclusion

AARP appreciates the opportunity to share our OAA 
reauthorization priorities with the Committee. We look forward 
to working with you on a bipartisan basis to build upon the 
success of the OAA as the 2024 reauthorization process moves 
forward. If you have additional questions, feel free to contact 
me or have your staff contact Lauren Ryan on our Government 
Affairs team at [email protected] or (202) 434-0351.

Sincerely,

/s/
Bill Sweeney
Senior Vice President
Government Affairs

                 U.S. Senate Special Committee on Aging

       "The Older Americans Act: The Local Impact of The Law and 
                     The Upcoming Reauthorization"

                              May 23, 2024

                        Statement for the Record

                       Meals on Wheels Testimony

Dear Chairman Casey, Ranking Member Braun, and Members of the 
Senate Special Committee on Aging:

Thank you for the opportunity to submit this statement for the 
record for the recent hearing, "The Older Americans Act: The 
Local Impact of the Law and the Upcoming Reauthorization." On 
behalf of Meals on Wheels America, the nationwide network of 
more than 5,000 community-based senior nutrition providers and 
the older adults they serve, we urge you to prioritize our 
recommendations to strengthen and improve the Older Americans 
Act (OAA) Nutrition Program. Please reference the provided 
materials for detailed information about Meals on Wheels 
America's priorities and recommendations for the OAA 
reauthorization:

  Ellie Hollander, President and CEO of Meals on Wheels 
America, Testimony before the Senate HELP Committee hearing, 
"The Older Americans Act: Supporting Efforts to Meet the Needs 
of Seniors" on March 7, 2024

  Meals on Wheels America's response to the Request for 
Information from the HELP Committee, submitted March 21, 2024

  Meals on Wheels America's Older Americans Act priorities

We look forward to continuing to work together toward the 
successful reauthorization of the Older Americans Act. The 
reauthorization process presents an important opportunity to 
strengthen and preserve the Act's original intent and core 
purpose to reduce hunger, promote socialization and improve 
health and well-being for older adults in greatest social and 
economic need.

We hope that you will consider Meals on Wheels America a 
trusted partner as we collectively address the growing issues 
of senior hunger and social isolation. Please don't hesitate to 
reach out whenever we may be of service.

/s/
Ellie Hollander
President and CEO

Contact Information:
Josh Protas
Chief Advocacy and Policy Officer
[email protected]

Good morning, Chairman Sanders, Ranking Member Cassidy, and 
esteemed Members of the Committee. Thank you for the 
opportunity to testify before you at this critical hearing. I'm 
Ellie Hollander and am proud to present before you as the 
President and CEO of Meals on Wheels America. Meals on Wheels 
America is the national leadership organization representing 
over 5,000 local nutrition programs committed to addressing 
senior hunger and isolation in virtually every community across 
the country and working toward a vision in which all seniors 
live nourished lives with independence and dignity.

With the support of hundreds of thousands of committed 
volunteers and staff members, local community programs deliver 
nutritious meals in a variety of ways, including in group and/
or grab-and-go settings, as well as to individual homes, where 
they also provide friendly visits and social interaction, 
safety checks, and connections to other health and wellness 
services to support older Americans in greatest need, and the 
underpinning of all this work and impact is a direct result of 
the support, policies and funding provided through the Older 
Americans Act (OAA).

For more than 50 years, the OAA has supported millions of our 
nation's seniors and caregivers through a network of state, 
regional and local community-based programs. The local 
providers that we represent at Meals on Wheels America serve as 
a direct lifeline to those struggling with food insecurity, 
malnutrition, mobility, loneliness, and countless other 
difficulties of aging. We frequently say the service starts 
with the meal and opens the door to so much more. It's the 
purposeful and unique combination of nutritious meals and 
social connection that fosters a relationship with the 
individual senior, enabling Meals on Wheels providers to 
identify and deliver valuable services that promote 
independence and well-being. The impact not only saves lives 
but also saves taxpayer dollars by ensuring that our nation's 
seniors live safer, longer and more nourished in their own 
homes and out of other more costly healthcare settings. In 
fact, we can serve a senior Meals on Wheels for an entire year 
for roughly the same cost as one day in the hospital or ten 
days in a nursing home.\1\
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    \1\ Meals on Wheels America (2024), special analysis of ACL and 
Mathematica's estimated meal cost (OAA Nutrition Programs Evaluation: 
Meal Cost Analysis), Kaiser Family Foundation's daily hospital expense 
data (State Health Facts: Hospital Adjusted Expenses per Inpatient 
Day), and Genworth's cost of semi-private nursing home room (2021 Cost 
of Care Survey) adjusted for inflation. Sources and methods available 
at: https://www.mealsonwheelsamerica.org/docs/default-source/fact-
sheets/2023/what--we--deliver--2023--national--snapshot--sources--
methods.pdf

The OAA is considered the gold standard of a successful public-
private partnership, having delivered on its original intent 
and shown great resiliency and adaptability through challenging 
times, including a global pandemic. As its reauthorization 
approaches, Meals on Wheels America is focusing on several key 
legislative recommendations that further enhance the support 
and services provided to older adults. Given the significant 
need, changing demographics, and inflationary pressures, we are 
pushing for increased authorized funding levels across all OAA 
programs, with an emphasis on closing the existing needs gap 
for nutrition services and establishing incentives and funding 
for medically tailored and culturally appropriate meals. An 
important strategic proposal we are recommending involves 
unifying the Congregate and Home-Delivered Nutrition Services 
with the Nutrition Services Incentive Program (NSIP) under a 
single Title III-C Nutrition Program and funding stream. This 
shift would improve efficiency at all levels of the aging 
network and enable local service providers to tailor their 
offerings to meet the diverse needs of seniors in their 
community far more easily. Additionally, we believe there 
should be a concerted effort to prioritize community-based 
organizations for nutrition services contracts, as local 
providers are delivering a holistic service and not just a 
meal. Finally, this reauthorization is also an opportunity to 
continue to modernize the OAA to incorporate innovations, 
flexibility, and successful practices that were leveraged 
during the pandemic, ensuring that the Act is adaptable and 
---------------------------------------------------------------------------
responsive to the evolving needs of America's older population.

The Foundation of the Older Americans Act

As we look toward this year's reauthorization of the OAA, we 
first and foremost want to protect the core purposes of the Act 
and underscore the significance of it as a solution to ending 
senior hunger and social isolation in our country and why it 
must be sufficiently resourced.

The Older Americans Act of 1965 (OAA) was signed into law on 
July 14, 1965, as an answer to improving access to social 
services and supports for older adults living in the community. 
Since then, the Act has served as the primary federal 
legislation supporting community-based social services for 
adults 60 and older and the bedrock of federal support to the 
nationwide network of senior nutrition programs that rely on 
federal funding.

The OAA has evolved and grown over time through prior 
reauthorizations and consists of seven titles today. Of the 
seven titles, all but one is administered by the Administration 
on Aging (AoA), a federal sub-agency established by the OAA 
within the U.S. Department of Health and Human Services (HHS) 
Administration for Community Living (ACL). At the state and 
local levels, OAA activities are carried out by 56 State Units 
on Aging (SUA), over 600 Area Agencies on Aging (AAA), and 
thousands of community-based organizations. AoA, housed within 
ACL, is tasked with advocating for older adults and persons 
with disabilities and supporting them in securing and 
maintaining their health, well-being, and independence in the 
community.

The largest title of the Act, accounting for 72% of the OAA's 
total funding in FY 2023, is Title III Grants for State and 
Community Programs, which provides grants to states to help 
carry out a variety of supportive service and health promotion 
programs for older adults and their caregivers.\2\ The Title 
III Nutrition Program, which includes congregate (Title III-C1) 
and home-delivered (Title III-C2) nutrition services, and the 
Nutrition Services Incentives Program (Title III-C), is a 
federal program that supports the health and well-being of 
older adults through nutrition services. We are proud and 
thankful and want to underscore the significance of the OAA 
Nutrition Program, which is the only federal program designed 
specifically to meet older adults' nutritional and social 
needs. The OAA Nutrition Program is a successful public-private 
partnership, with the critical federal dollars provided 
leveraging an impressive funding match of approximately three 
to one, from additional state, local, and private sources.\3\
---------------------------------------------------------------------------
    \2\ Congressional Research Service (2023), Older Americans Act: 
Overview and Funding. https://crsreports.congress.gov/product/pdf/R/
R43414
    \3\ ACL (2019), Written Statement by Administrator and Assistance 
Secretary for Aging Lance Robertson for the Senate Special Committee on 
Aging. https://acl.gov/news-and-events/announcements/asa-robertson-
testified-senate-hearing-oaa-today

Again, we believe that the Act successfully fulfills its 
purpose, and that reauthorization efforts and modifications 
should be primarily focused on improving the ability to reach 
---------------------------------------------------------------------------
more seniors.

The Pervasive Problem of Senior Hunger

Since its inception, the OAA Nutrition Program has provided 
billions of meals to seniors in need, improved countless lives, 
and saved considerable taxpayer dollars through well-
established trust built at both the community and national 
levels. While this program has worked as it was designed for 
decades, it is not reaching all those in need. Eight out of ten 
(80.3%) low-income, food insecure older adults are not 
receiving the congregate or home-delivered meals that they are 
eligible for and likely need.\4\ From a national survey, we 
found that one in three local Meals on Wheels programs maintain 
waiting lists, with seniors waiting on average three months for 
vital meals-an increase of 10% for program waitlists from 
2021.\5\ The same survey found an overwhelming majority of 
programs, 78%, have already or would need to add seniors to 
waitlists due to funding cuts. These are only the individuals 
we are aware of and know that it is an underrepresentation of 
the true need across the country. In fact, 97% in our survey 
indicated they believe that there is unmet need in their 
communities.
---------------------------------------------------------------------------
    \4\ U.S. Census Bureau (2022), Current Population Survey (CPS) Food 
Security Supplement, Meals on Wheels America calculation of dataset 
available at: https://www.census.gov/data/datasets/time-series/demo/
cps/cps-supp--cps-repwgt/cps-food-security.html
    \5\ Meals on Wheels America (November 2023), #SaveLunch Member 
Pulse Survey. Internal report.

Additional research has found that older adults who seek Meals 
on Wheels services are already more vulnerable than the average 
American seniors, with poorer self-reported health, higher 
levels of depression and anxiety, greater fears of falling and 
more.\6\ Simply put, while older adults are on waiting lists 
and struggling to have their nutritional and social needs met, 
their health is continuing to decline and are more likely to 
end up in a hospital or nursing home prematurely and at 
significantly higher cost to the individual and taxpayers.
---------------------------------------------------------------------------
    \6\ Meals on Wheels America (2015), More Than a Meal Pilot Research 
Study, commissioned report prepared by Thomas & Dosa. https://
www.mealsonwheelsamerica.org/learn-more/research/more-than-a-meal/
pilot-research-study

The OAA Nutrition Program is an essential linchpin in 
supporting the healthy aging process for millions of Americans, 
but its effectiveness in making a dent in the national dual 
crises of senior hunger and social isolation depends on being 
adequately funded. The reality of senior hunger and isolation 
in our country is sobering. 12 million older adults aged 60+ 
worry about having enough food (i.e., are marginally food 
insecure). This was an increase of 2.2 million over 2021.\7\
---------------------------------------------------------------------------
    \7\ See note 4.

While daunting, even one individual struggling with hunger is 
far too many. With the issue being pervasive in American 
communities and additional challenges fast approaching with the 
growth of our senior population, there is no time to wait for 
action. The number of OAA meals and seniors we are able to 
serve nationwide, however, has failed to keep pace with 
demographic shifts, growing demand, and the rising costs of 
food, transportation, and other expenses. While we currently 
serve 251 million nutritious home-delivered and congregate 
meals annually to the 2.2 million older adults facing hunger 
and isolation, we have the infrastructure and know how to reach 
millions more, especially through increased appropriations and 
a strong and timely reauthorization.\8\
---------------------------------------------------------------------------
    \8\ Administration for Community Living/Administration on Aging 
(2023), State Program Report (SPR) 2021, available on ACL's Aging, 
Independence, and Disability Program Data Portal (AGID) at: https://
agid.acl.gov/

The Costs and Consequences of Senior Hunger and Social 
---------------------------------------------------------------------------
Isolation

Today, millions of seniors are experiencing some degree of food 
insecurity and/or social isolation, leaving them at risk for a 
multitude of adverse health issues. Food-insecure older adults 
experience worse health outcomes than food-secure seniors, with 
greater risk for heart disease, depression, and decline in 
cognitive function and mobility.\9\ Some of the most vulnerable 
seniors that the OAA serves - those who are frail, homebound, 
and socially isolated - rely on the home-delivered meal 
program. Despite the well-founded, inextricable link between 
healthy aging and access to nutritious food and regular 
socialization, millions of seniors struggle to meet these basic 
human needs. The infrastructure and cost-effective 
interventions to address these consequences already exist 
through the OAA network. As stated above, local, community-
based organizations serve a critical role in addressing the 
nutritional and social needs of our nation's older adults. The 
impact of these services on seniors' lives is powerful.
---------------------------------------------------------------------------
    \9\ Ziliak and Gunderson (2021), The Health Consequences of Senior 
Hunger in the United States: Evidence from the 1999-2016 NHANES, report 
prepared for Feeding America. www.feedingamerica.org/research/senior-
hunger-research/senior

Most seniors receiving OAA nutrition services from senior 
nutrition programs consistently report that participating in 
the program helps them feel more secure, helps them eat 
healthier foods, prevents falls or fear of falling, and allows 
them to stay in their own homes. In turn, this helps avoid 
preventable emergency room visits, hospital admissions and 
readmissions, and extended rehab stays, preventing premature 
institutionalization and ultimately reducing our nation's 
health care costs. The cost of not providing these services and 
---------------------------------------------------------------------------
increasing funding is clear.

Currently, almost 95% of older adults have at least one chronic 
condition, while nearly 80% have two or more chronic 
conditions.\10\ Increasingly, older adults need access to 
nutritious meals and comprehensive services that can help them 
manage their chronic conditions.
---------------------------------------------------------------------------
    \10\National Council on Aging (April 2022), Chronic Inequities: 
Measuring Disease Cost Burden Among Older Adults in the U.S. A Health 
and Retirement Study Analysis. https://ncoa.org/article/the-inequities-
in-the-cost-of-chronic-disease-why-it-matters-for-older-adults

Malnutrition, senior falls, and social isolation tell a similar 
story. The economic burden of senior malnutrition alone costs 
$51.3 billion annually (in 2010 dollars), while senior falls 
account for $50 billion (in 2015 dollars).\11\,\12\ Studies 
show the highest rates of social isolation are found among 
older adults, putting seniors at risk for high blood pressure, 
heart disease, obesity, a weakened immune system, anxiety, 
depression, cognitive decline, Alzheimer's disease, and even 
death. Research demonstrates that social isolation among older 
adults leads to an extra $6.7 billion in Medicare spending a 
year (in 2012 dollars) similar expenditures to that of having 
high blood pressure or arthritis.\13\
---------------------------------------------------------------------------
    \11\  Snider, et al. (2014), Economic Burden of Community-Based 
Disease-Associated Malnutrition in the United States. Journal of 
Parenteral and Enteral Nutrition, 38(2S), 77S-85S. https://doi.org/
10.1177/0148607114550000
    \12\  Thomas, et al. (2018), Home-Delivered Meals and Risk of Self-
Reported Falls: Results From a Randomized Trial. Journal of Applied 
Gerontology, 37(1), 41-57. https://doi.org/10.1177/0733464816675421
    \13\ Meals on Wheels America (September 2023), The Case for Meals 
on Wheels: An Evidence-Based Solution to Senior Hunger and Isolation. 
https://www.mealsonwheelsamerica.org/learn-more/research/the-case-for-
meals-on-wheels-sept23

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The Case for Meals on Wheels and the Older Americans Act

As noted throughout this testimony, Meals on Wheels is a proven 
solution that addresses the escalating issues of senior hunger 
and isolation. We know this not only through the daily 
anecdotes we hear of how Meals on Wheels has impacted people's 
lives, but through decades of research. Our recently released 
report, The Case for Meals on Wheels: An Evidence-Based 
Solution to Senior Hunger and Isolation, showcases consistent 
findings that Meals on Wheels improves senior health, safety, 
social connection, and more while saving taxpayer dollars.13

The Case for Meals on Wheels analyzed a total of 38 studies, 
spanning 1996 to 2023, and found they consistently reported 
that Meals on Wheels programs reduce healthcare utilization and 
costs, falls, nursing home use, social isolation and loneliness 
while improving food security, diet quality, and nutritional 
status and seniors' ability to age in place. These remarkable 
outcomes, highlighted below, underscore the life-changing 
impact that Meals on Wheels services have on the lives of the 
older adults we serve:

1. Reduced use of costly health care services: Several studies 
found Meals on Wheels program participants needed fewer visits 
to the emergency room or experienced fewer hospital stays or 
readmissions.

2. Reduced nursing home use and increased ability to age in 
place: Access to medically tailored and home-delivered meals 
allowed individuals to stay in their homes rather than transfer 
to a nursing facility for nutritional support. Nearly all (92%) 
home-delivered meal participants said the meals help them 
continue to live independently, according to the 2022 national 
survey of Older Americans Act Title III home-delivered meal 
participants.

3. Reduced health care costs attributed to reduced hospital and 
nursing home spending: In line with outcomes one and two, their 
reduced health care and nursing home use also meant Meals on 
Wheels participants spent less on health care. One study found 
that among individuals receiving medically tailored meals, 
average medical expenditures were 40% lower per month for those 
receiving meals than for a matched group not receiving meals 
($843 vs. $1,413).

4. Increased food security: Several studies concluded that 
home-delivered meal participants worried less about having 
enough to eat. Those individuals who received breakfast and 
lunch deliveries, rather than just lunch, benefited even more.

5. Improved diet quality: Home-delivered meals led to higher-
quality diets among participants, as measured by nutrient 
intake, calories, vitamins, and other indicators. Participant 
feedback reinforced that meal delivery helped them eat 
healthier, more nourishing foods.

6. Reduced or slow decline in nutritional risk: Program 
participants threatened by malnutrition saw improvement in 
their nutritional risk scores. Individuals benefited from both 
improved dietary intake and improved food security.

7. Reduced social isolation and loneliness: Several studies 
found a link between home-delivered meals and reduced social 
isolation or loneliness, particularly among participants who 
lived alone. These benefits resulted from contact with drivers 
during meal deliveries and opportunities for social connection 
via other Meals on Wheels programs.

8. Reduced falls and increased home safety: Several studies 
found Meals on Wheels participants experienced fewer falls and 
minimized exposure to hazards in the home, outcomes 
attributable to safety checks provided at meal delivery, and a 
reduced need to cook in the kitchen.

This research alone cannot bring these evidence-based programs 
to the older adults who desperately need them. Seniors' access 
to these critical services is only possible with the support of 
Congress and sufficient federal funding. This report 
illuminates the impact that Meals on Wheels has and the 
necessity to protect and increase federal funding to meet the 
current needs of our growing senior population.

Older Americans Act Reauthorization Priorities

While the need for far greater federal funding is the primary 
key to serving more seniors, especially in the years following 
the COVID-19 pandemic, there are opportunities to ease 
administrative burdens and improve our insight into the 
performance and operations of the network at all levels. The 
Act, including the Nutrition Program, must continue to be 
robust and successful and fulfill its original intent and core 
purpose to reduce hunger, promote socialization, and improve 
health and well-being for older adults in greatest social and 
economic need. Any policy changes must, first and foremost, do 
no harm to the aging services network and the seniors they 
support. Instead, they must address the pervasive and growing 
challenges of senior hunger and social isolation. We believe 
reauthorization should also build on the newly updated OAA 
regulations by modernizing the law and reflecting the on-the-
ground needs of service providers, older adults, and their 
families and caregivers. Accordingly, Meals on Wheels America 
urges Congress to enact the following recommendations:

1. Increase authorization funding levels for all OAA programs 
and provide additional resources for enhanced nutrition 
services.

  Increase authorized funding, including sufficient funding 
for Title III Nutrition Services, to address existing waiting 
lists and reach the ever-growing number of older adults who 
would benefit from OAA programs.

  Authorize new funding streams and establish incentives for 
senior nutrition programs to offer medically tailored and/or 
culturally appropriate meals and expand reach in underserved 
areas.

  Improve and clarify authorization of funding for senior 
nutrition programs to maintain and invest in the infrastructure 
and resources needed to prepare and deliver services, including 
kitchen equipment, delivery vehicles, labor, etc.

2. Unify OAA Congregate, Home-Delivered and the Nutrition 
Services Incentive Program into a single Title III-C Nutrition 
Program.

  Create one authorized funding stream to remove 
administrative burden, improve efficiency, and enable 
community-based organizations to tailor nutrition services to 
seniors' needs more easily.

  Codify alternative nutrition services models, such as grab-
and-go and drive-thru meals, proven to reach more older adults 
struggling with hunger and social isolation.

  Modernize the Nutrition Services Incentive Program through 
enhanced partnership and coordination with USDA, HHS, states, 
Area Agencies on Aging (AAA), and local providers to procure 
commodity foods for preparing OAA meals and coordinate other 
important federal benefits and programs for seniors.

3. Prioritize community-based nutrition programs and 
experienced network providers in OAA grant awards and 
contracts.

  Encourage states and AAAs to partner more closely with and 
leverage senior nutrition programs' established infrastructure, 
dedicated volunteer base, and experience serving their 
communities to deliver nutritious meals, socialization 
services, and safety checks to more older adults.

  Ensure timely payment and reimbursement processes for 
nutrition services provided.

4. Expand senior nutrition program capacity and infrastructure 
support for further integration into the health care system.

  Reduce administrative and regulatory burdens on local 
nutrition and aging services providers seeking to establish 
contracts and partnerships with health care providers and 
payors.

  Provide additional resources and promote incentives for the 
aging services network to build the capacity, including 
infrastructure and technology, to meet the compliance and 
privacy standards for providing covered health care benefits.

5. Promote innovations and successful practices learned during 
the COVID-19 pandemic.

  Facilitate continued innovation and implementation of many 
successful practices leveraged during the COVID-19 public 
health emergency, including new partnerships, programming, 
emergency preparedness and outreach.

  Support the expansion of evidence-informed and/or 
technology-based solutions that can help meet the needs of 
seniors, including their preferences for meals and social 
connectedness.

In addition to improvements through reauthorization, our 
organization and network of senior nutrition providers are 
pleased with the recent effort to update federal regulations 
for OAA policies and programs for Titles III, VI, and VII for 
the first time in 36 years.\14\ As a result, they are now 
better aligned with language and additions from recent 
reauthorizations and better reflect the needs of today's 
growing and diversifying older adult population.
---------------------------------------------------------------------------
    \14\ ACL (February 2024), Final Rule [89 FR 11566]: Older Americans 
Act: Grants to State and Community Programs on Aging; Grants to Indian 
Tribes and Native Hawaiian Grantees for Supportive, Nutrition, and 
Caregiver Services; Grants for Supportive and Nutritional Services to 
Older Hawaiian Natives; and Allotments for Vulnerable Elder Rights 
Protection Activities. https://www.federalregister.gov/documents/2024/
02/14/2024-01913/older-americans-act-grants-to-state-and-community-
programs-on-aging-grants-to-indian-tribes-and

Among the several updated policies we look forward to being 
implemented, we remain supportive of the following nutrition-
related provisions that are included and/or clarified per ACL's 
---------------------------------------------------------------------------
final rule (effective Friday, March 15, 2024):

  Home-delivered meals - and a certain amount of congregate 
meals - may be provided via home delivery, pick-up, carry-out, 
or drive-through.

  Eligibility for home-delivered meals is not limited to 
people who are "homebound;" criteria may depend upon many 
factors (including ability to leave home unassisted, ability to 
shop for and prepare nutritious meals, mental health, degree of 
disability or other relevant factors about their need for the 
service, including social and economic need).

  Requirements regarding the use and transfer of funding for 
Title III programs, including clarification under Title III C-1 
and C-2 that funds can be used for nutrition education, 
nutrition counseling, and other nutrition services, as well as 
cautioning against transitioning money away from Title III-B 
and Title III-C services for which they were appropriated and 
intended by Congress.

  States have the option to receive NSIP allocation grants as 
cash, commodities or a combination of both, and that funds can 
only be used to purchase domestically produced foods used in 
meals.

We are encouraged to see much consideration and modernization 
of OAA regulations through this regulatory process. 
Nonetheless, regulatory updates and guidance can only achieve 
so much and look forward to addressing remaining policy 
priorities and making further legislative improvements during 
this OAA reauthorization process.

Conclusion

Thank you for holding this timely hearing and inviting me to 
testify before you. I appreciate the chance to share how the 
OAA improves the lives of senior citizens, communities, and our 
nation. I would like to extend a special thanks to Chairman 
Sanders for his leadership on the OAA in past reauthorizations 
and in seeking increased funding, and I want to thank all 
members of the Committee for sharing the belief that no senior 
in America should be left hungry or isolated. I hope the 
information I provided today is helpful as you consider the 
next reauthorization and look forward to working together to 
make this vision a reality for our older adults. Thank you 
again for your time, and I am pleased to answer any questions 
you might have.

Dear Committee Chairmen Sanders and Casey, Ranking Members 
Cassidy and Braun, and Senators Kaine, Collins, Markey, and 
Mullin:

On behalf of Meals on Wheels America, the nationwide network of 
community-based senior nutrition programs and the seniors they 
serve, thank you for the opportunity to provide input and 
submit responses to this bipartisan Request for Information 
(RFI) regarding the upcoming Older Americans Act (OAA) 
reauthorization. There is a great urgency for strong 
legislation that meets our aging population's current and 
future needs. The upcoming reauthorization deadline comes 
during a critical period of rapid growth in the senior 
population. With this population boom comes an even greater 
need for long-term care solutions like Meals on Wheels - a 
trusted, tested, and cost-effective solution to senior hunger, 
malnutrition, isolation and loneliness - instead of costly and 
preventable health care utilization among the 60+ population.

Responses to the general and targeted questions identified in 
the RFI are below:

Question:

1. What are the biggest challenges currently facing the older 
adult population? How have OAA programs performed historically 
in addressing these challenges? How can OAA programs be 
improved upon to better address these challenges?

Response:

Our nation is ill-prepared for the massive growth in the older 
adult population. The in community services and supports 
necessary to enable seniors' independence, health, well-being 
and dignity are not keeping pace with need. However, if 
properly resourced, the OAA network is poised and ready to 
deliver lifesaving services to America's seniors.

Biggest Challenges:

Unmet Need and Population Increase

The reality of senior hunger and isolation in our country is 
sobering. 12 million older adults aged 60+ worry about having 
enough food (i.e., are marginally food insecure). This is a 
devastating increase of two million over 2021. While daunting, 
even one individual struggling with hunger is far too many. 
With this pervasive issue affecting so many American 
communities and additional challenges fast approaching due to 
the growth of our senior population, there is no time to wait 
for action. The number of OAA meals and seniors we are able to 
serve nationwide fails to keep pace with demographic shifts, 
growing demand, and the rising costs of food, transportation, 
and other expenses. While we currently serve 251 million 
nutritious home-delivered and congregate meals annually to the 
2.2 million older adults facing hunger and isolation, we have 
the infrastructure and know-how to reach millions more, 
especially through increased appropriations and a strong and 
timely reauthorization.

While this program has worked as designed for decades, it is 
not reaching all those in need or who would benefit due to the 
lack of adequate funding. Eight out of ten (80.3%) low-income, 
food insecure older adults are not receiving the congregate or 
home-delivered meals for which they are eligible and likely 
need. These are only the individuals we are aware of, and we 
know it is an underrepresentation of the true unmet need across 
the country. Nearly all (97%) programs in our national survey 
indicated they believe there is an unmet need in their 
communities.

Unmet Need and Waitlists

Due to insufficient funding, our local programs have 
regrettably been forced to place some older adults on 
waitlists. From the aforementioned national survey, we found 
one in three local Meals on Wheels programs maintain waiting 
lists, with seniors waiting an average of three months for 
vital meals. The same survey found an overwhelming majority of 
programs (78%) have already or would need to add seniors to 
waitlists due to funding cuts. In 2023, 33% of programs 
reported having a waitlist for their home-delivered meal 
services, higher than the 23% of programs that reported 
maintaining a waitlist in 2021.\15\ In response to the surge in 
demand and growing unmet need among seniors exemplified by 
increased program waitlist for services, our Meals on Wheels 
network is urging increased funding for the OAA as part of its 
reauthorization.
---------------------------------------------------------------------------
    \15\  Meals on Wheels America (November 2023), #SaveLunch Member 
Pulse Survey. Internal report.

Additional research has found that individuals who seek Meals 
on Wheels services are already more vulnerable to adverse 
health outcomes than the average American older adult, with 
poorer self-reported health, higher levels of depression and 
anxiety, greater fears of falling, and more. Simply put, while 
seniors on waiting lists struggle to have their nutritional and 
social needs met, their mental and physical health declines, 
and they are at greater risk of hospitalization or premature 
nursing home placement-at a significantly higher cost to the 
---------------------------------------------------------------------------
seniors, their families, and taxpayers.

Cost of Food Insecurity, Malnutrition and Social Isolation

Today, as millions of seniors are experiencing food insecurity 
and/or social isolation, they are at greater risk of serious 
health issues. Food-insecure older adults experience worse 
health outcomes than food-secure seniors, with a higher risk 
for heart disease, depression, and decline in cognitive 
function and mobility. Almost 95% of older adults have at least 
one chronic condition, while nearly 80% have two or more.\16\ 
Some of the most vulnerable seniors the OAA serves - those who 
are frail, homebound, and socially isolated - rely on the home-
delivered meal program. Increasingly, older adults need access 
to nutritious meals and comprehensive services that can help 
them manage their chronic conditions and ease the economic 
burden for our clients and taxpayers alike.
---------------------------------------------------------------------------
    \16\ National Council on Aging (April 2022), Chronic Inequities: 
Measuring Disease Cost Burden Among Older Adults in the U.S. A Health 
and Retirement Study Analysis. https://ncoa.org/article/the-inequities-
in-the-cost-of-chronic-disease-why-it-matters-for-older-adults

The economic burden of senior malnutrition alone costs $51.3 
billion annually (in 2010 dollars), while senior falls account 
for $50 billion (in 2015 dollars). Studies show the highest 
rates of social isolation are found among older adults, putting 
seniors at risk for high blood pressure, heart disease, 
obesity, a weakened immune system, anxiety, depression, 
cognitive decline, Alzheimer's disease and even death. Research 
demonstrates that social isolation among older adults leads to 
an extra $6.7 billion in Medicare spending a year (in 2012 
dollars), similar expenditures to that of having high blood 
---------------------------------------------------------------------------
pressure or arthritis.

Meals on Wheels Historical Impact and Ways to Face these 
Challenges:

For more than 50 years, the OAA has consistently demonstrated 
how access to nutritious food and regular socialization have 
enabled millions of our seniors to remain healthier, safe, and 
independent in the comfort of their homes. Despite such cost-
effective interventions, these basic human needs are out of 
reach for hundreds of thousands of American seniors. Community-
based organizations are critical to addressing the nutritional 
and social needs of our nation's older adults-and keeping our 
healthcare costs in check-but they can only reach their full 
potential when they have the resources to do so. Nationally, 
research shows that participation in home-delivered meal 
programs is associated with lower medical spending and 
emergency department visits.

In addition to decreasing health care costs, home-delivered 
meal clients consistently self-report positive and improved 
health outcomes as a result of participating in the program:

  92% say services help them live independently

  77% say meals help improve their health

  79% say meals help them eat healthier foods

  85% say services help them feel more secure

As discussed below, Meals on Wheels is an intervention to 
reduce these kinds of costs. The local providers Meals on 
Wheels America represent serve as a direct lifeline to those 
struggling with food insecurity, malnutrition, mobility, 
loneliness, and countless other difficulties of aging. The 
Meals on Wheels service begins with the meal and opens the door 
to so much more. The purposeful and unique combination of 
nutritious meals and social connection fosters a relationship 
with the individual senior, enabling Meals on Wheels providers 
to identify and deliver valuable services that promote 
independence and well-being. The impact not only saves lives 
but also saves taxpayer dollars by ensuring that our nation's 
seniors live safer, longer, and more nourished in their own 
homes and out of other more costly healthcare settings. In 
fact, we can serve a senior through Meals on Wheels for an 
entire year for roughly the cost of one day in the hospital or 
ten days in a nursing home.\17\
---------------------------------------------------------------------------
    \17\  Meals on Wheels America (2024), special analysis of ACL and 
Mathematica's estimated meal cost (OAA Nutrition Programs Evaluation: 
Meal Cost Analysis), Kaiser Family Foundation's daily hospital expense 
data (State Health Facts: Hospital Adjusted Expenses per Inpatient 
Day), and Genworth's cost of semi-private nursing home room (2021 Cost 
of Care Survey) adjusted for inflation. Sources and methods available 
at: https://www.mealsonwheelsamerica.org/docs/default-source/fact-
sheets/2023/what--we--deliver--2023--national--snapshot--sources--
methods.pdf

---------------------------------------------------------------------------
The Case for Meals on Wheels

Meals on Wheels is a proven solution to the escalating issues 
of senior hunger and isolation. We know this through decades of 
research and the daily anecdotes we hear about how Meals on 
Wheels has impacted people's lives. Our recently released 
report, The Case for Meals on Wheels: An Evidence-Based 
Solution to Senior Hunger and Isolation, showcases consistent 
findings that Meals on Wheels improves senior health, safety, 
social connection, and more while saving taxpayer dollars.\18\
---------------------------------------------------------------------------
    \18\  Meals on Wheels America (September 2023), The Case for Meals 
on Wheels: An Evidence-Based Solution to Senior Hunger and Isolation. 
https://www.mealsonwheelsamerica.org/learn-more/research/the-case-for-
meals-on-wheels-sept23

This analysis of 38 studies, spanning 1996 to 2023, found that 
Meals on Wheels programs are consistently reported to reduce 
healthcare utilization and costs, falls, nursing home use, 
social isolation, and loneliness while improving food security, 
diet quality, nutritional status, and seniors' ability to age 
in place. The significant outcomes of this research highlighted 
below underscore the life-changing impact that Meals on Wheels 
---------------------------------------------------------------------------
services have on the older adults we serve:

  1. Reduced use of costly health care services: Several 
studies found Meals on Wheels program participants needed fewer 
visits to the emergency room or experienced fewer hospital 
stays or readmissions.

  2. Reduced nursing home use and increased ability to age in 
place: Access to medically tailored and home-delivered meals 
allowed individuals to stay in their homes rather than transfer 
to a nursing facility for nutritional support. Nearly all (92%) 
home-delivered meal participants said the meals help them 
continue to live independently, according to the 2022 national 
survey of Older Americans Act Title III home-delivered meal 
participants.

  3. Reduced health care costs attributed to reduced hospital 
and nursing home spending: In line with the first and second 
outcomes identified above, the reduced health care and nursing 
home use by Meals on Wheels participants also meant less was 
spent on health care. One study found that among individuals 
receiving medically tailored meals, average medical 
expenditures were 40% lower per month for those receiving meals 
than for a matched group not receiving meals ($843 vs. $1,413).

  4. Increased food security: Several studies concluded that 
home-delivered meal participants worried less about having 
enough to eat. Those individuals who received both breakfast 
and lunch, rather than just lunch, benefited even more.

  5. Improved diet quality: Home-delivered meals led to higher-
quality diets among participants, as measured by nutrient 
intake, calories, vitamins, and other indicators. Participant 
feedback reinforced that meal delivery helped them eat 
healthier, more nourishing foods.

  6. Reduced or slower decline in nutritional risk: Program 
participants threatened by malnutrition saw improvement in 
their nutritional risk scores. Individuals benefited from both 
improved dietary intake and improved food security.

  7. Reduced social isolation and loneliness: Several studies 
found a link between homedelivered meals and reduced social 
isolation or loneliness, particularly among participants who 
lived alone. These benefits resulted from contact with drivers 
during meal deliveries and opportunities for social connection 
via other Meals on Wheels programs.

  8. Reduced falls and increased home safety: Several studies 
found Meals on Wheels participants experienced fewer falls and 
minimized exposure to hazards in the home, outcomes 
attributable to safety checks provided at meal delivery, and a 
reduced need to cook in the kitchen.

Improvements to the OAA:

Despite such remarkable improvements to health and well-being 
as the evidence-base shows, not the chasm is widening between 
those who need access to these critical services and those we 
are able to reach. That's why we are imploring Congress to 
boost federal funding to sufficient levels to not only maintain 
current utilization but also to expand and bridge the growing 
gap of unmet need. Additional resources are essential to enable 
the Meals on Wheels network to meet the evolving needs of our 
growing senior population and continue delivering the powerful 
and proven return on investment their services provide. The OAA 
is a foundational law that continues to function exceptionally 
well, consistent with its original, intended purposes. It has 
withstood the test of time. Any changes made to the legislation 
through the reauthorization process should maintain the 
integrity of the enacted OAA and support community-based aging 
programs as the backbone of service provision to older adults 
across the country. Especially as the older adult population 
skyrockets, the next reauthorization must allow the OAA network 
to evolve and expand in tandem with the increasing need/demand 
that will occur through this authorization period. In the 
following question, our priorities and improvements for the OAA 
are listed in greater detail.

2. What are your top priorities for OAA reauthorization? Please 
explain why.

Response:

As reauthorization approaches, Meals on Wheels America is 
focusing on several key legislative recommendations that 
further enhance the services and supports provided to older 
adults. Given the significant need, changing demographics, and 
inflationary pressures, we are pushing for increased authorized 
funding levels across all OAA programs, with an emphasis on 
closing the existing needs gap for nutrition services and 
establishing incentives and funding for medically tailored and 
culturally appropriate meals.

To ensure that any changes enacted through the upcoming OAA 
reauthorization do not harm older adults or the existing aging 
network, Meals on Wheels America has developed legislative 
priorities based on input from our diverse senior nutrition 
network. This network has decades of experience delivering 
services in their communities, in addition to Area Agencies on 
Aging (AAAs) and several State Units on Aging. We believe 
reauthorization should improve efficiencies and remove 
administrative burdens - such as complex funding transfer 
protocols and requirements - in the implementation of funding. 
As well, it should also build on the newly updated OAA 
regulations by reflecting the on-the-ground needs of service 
providers, older adults, and their families and caregivers. 
Ultimately, the goal is to continually address the growing, 
pervasive issues of senior hunger and isolation.

Top Priorities:

Meals on Wheels urges Congress to enact the following 
recommendations:

  1. Increase authorization funding levels for all OAA programs 
and provide additional resources for enhanced nutrition 
services.

    Increase authorized funding, including sufficient funding 
for Title III Nutrition Services, to address existing waiting 
lists and reach the ever-growing number of older adults who 
would benefit from OAA programs.

    Authorize new funding streams and establish incentives for 
senior nutrition programs to offer medically tailored and/or 
culturally appropriate meals - which are more costly to 
prepare/procure - and expand reach in underserved areas.

    Improve and clarify authorization of funding for senior 
nutrition programs to maintain and invest in the infrastructure 
and resources needed to prepare and deliver services, including 
kitchen equipment, delivery vehicles, labor, etc.

  2. Unify OAA Congregate, Home-Delivered and the Nutrition 
Services Incentive Program into a single Title III-C Nutrition 
Program.

    Create one authorized funding stream to remove 
administrative burden, improve efficiency, and enable 
community-based organizations to tailor nutrition services to 
seniors' needs more easily.

    Codify alternative nutrition services models, such as 
grab-and-go and drive-thru meals, which have been proven to 
reach more older adults struggling with hunger and social 
isolation.

    Modernize the Nutrition Services Incentive Program through 
enhanced partnership and coordination with USDA, HHS, states, 
Area Agencies on Aging (AAAs), and local providers to procure 
commodity foods for preparing OAA meals and coordinate other 
important federal benefits and programs for seniors.

  3. Prioritize community-based nutrition programs and 
experienced network providers in OAA grant awards and 
contracts.

    Encourage states and AAAs to partner more closely with and 
leverage senior nutrition programs' established infrastructure, 
dedicated volunteer base, and experience serving their 
communities to deliver nutritious meals, socialization 
services, and safety checks to more older adults.

    Ensure timely payment and reimbursement processes for 
nutrition services provided.

  4. Expand senior nutrition program capacity and 
infrastructure support for further integration into the health 
care system.

    Reduce administrative and regulatory burdens on local 
nutrition and aging services providers seeking to establish 
contracts and partnerships with health care providers and 
payors.

    Provide additional resources and promote incentives for 
the aging services network to build the capacity, including 
infrastructure and technology, to meet the compliance and 
privacy standards for providing covered health care benefits.

    Promote innovations and successful practices learned 
during the COVID-19 pandemic.

    Facilitate continued innovation and implementation of many 
successful practices leveraged during the COVID-19 public 
health emergency, including new partnerships, programming, 
emergency preparedness and outreach.

    Support the expansion of evidence-informed and/or 
technology-based solutions that can help meet seniors' needs, 
including their preferences for meals and social connectedness.

3. The demographics of the older adult population are changing 
rapidly: Please describe changing needs and how the aging 
network (including area agencies on aging, senior centers, 
state units on aging, aging and disability resource centers, 
centers for independent living, etc.) plans to address them?

Response:

The OAA Nutrition Program is the essential linchpin to 
supporting the healthy aging process for millions of Americans. 
While this program continues to make inroads in addressing the 
national dual crises of senior hunger and social isolation, its 
ability to scale to the magnitude of the need and have the 
impact that is warranted (and that it is capable of) requires a 
concomitant level of investment.

As the population diversifies further, the types of meals and 
how meals are provided are also changing and adapting. More 
programs are offering medically tailored and culturally 
appropriate meals. They are tailoring nutrition to meet the 
unique health needs of their clients, treating food as 
medicine. Enabling seniors to have flexibility in when and 
where they enjoy their meals is yet another evolving trend 
borne out of the pandemic. There are key ways the aging network 
through the OAA is addressing the growing and changing needs of 
older adults.

Since its inception, the OAA Nutrition Program has provided 
billions of meals to seniors in need and improved countless 
lives. Our local programs do this through the more than a meal 
service model, such as daily safety checks, opportunities for 
socialization to prevent loneliness, phone calls to ensure the 
well-being of the most isolated individuals, monitoring of 
change of condition, caregiver support and connections to other 
critical community services that support the health and well-
being of seniors. One of the ways our local programs are 
adapting to the changing needs of older adults is by offering 
medically tailored and culturally appropriate meals, which 
allow for increased access to nutritious meals.

4. What changes could Congress make to improve the efficiency 
and effectiveness of OAA services and programs?

Response:

While greater funding is the primary key to serving more 
seniors and improving the efficiency and effectiveness of the 
OAA, especially in the years following the COVID-19 pandemic, 
the OAA Nutrition Program must also continue to evolve and 
fulfill its original intent and core purpose to reduce hunger, 
promote socialization, and improve health and well-being for 
older adults in greatest social and economic need.

Unifying the Congregate and Home-Delivered Nutrition Services 
with the Nutrition Services Incentive Program (NSIP)

An important strategic proposal we recommend for the upcoming 
reauthorization, which we mentioned earlier, involves unifying 
the Congregate and Home-Delivered Nutrition Services with the 
Nutrition Services Incentive Program (NSIP) under a single 
Title III-C Nutrition Program and funding stream. This shift 
would improve efficiency at all levels of the aging network and 
would provide local service providers with the flexibility they 
require to tailor their offerings to meet seniors' preferences 
and the diverse needs of individuals across local communities 
far more easily. The OAA Nutrition Program is effective at 
supporting healthy aging because of the combination of proper 
nutrition and social connection that enables older adults to 
remain healthier and independent in their own homes, where they 
want to be; however, the current structure of the OAA Nutrition 
Program has inevitably contributed to disproportionate funding 
between different types of delivery models and creates a 
fragmented approach to delivering the spectrum of service 
offerings. Local nutrition programs consider the currently set 
percentage limits and reporting requirements on transfer 
authority between the nutrition services to be arbitrary and 
unnecessarily burdensome as they further complicate the 
movement and use of resources for nutrition providers to meet 
seniors' needs and preferences to age at home.

While we believe this legislative priority could be achieved in 
various ways and statutory language, we are recommending a 
proposal to restructure the program similarly to Sec. 321 of 
the Act, where allowable activities that are eligible and 
funded under Title B Supportive Services are outlined in a 
codified list of services. Further, funding traditionally 
allocated to NSIP would be redistributed into the consolidated 
Title III Nutrition Program funding. As a recommended example, 
under an amended section for a unified program, state and local 
agencies could have the flexibility to allocate nutrition 
service funds towards any of the following activities without 
caps limiting funding distribution of various subprograms/
allowable services currently authorized under Title III-C of 
the Act and per the finalized regulations:

  1. Congregate meals

  2. Home-delivered meals

  3. Grab-and-go, carry out and/or curbside meals

  4. Nutrition counseling, assessments, and education related-
services (provided in tandem with congregate, home-delivered, 
and/or eligible alternative meal

Encouraging and Incentivizing Greater Partnership and 
Coordination

We believe there is further opportunity to modernize NSIP by 
encouraging and incentivizing greater partnership and 
coordination in the OAA Nutrition Program among USDA, HHS, 
states, and Area Agencies on Aging (AAAs). The envisioned 
collaboration between these entities would allow them to be 
better poised and connected to help local providers procure the 
commodity foods needed to prepare and provide balanced Title 
III meals.

As these federal departments and agencies and their state and 
local affiliates are heavily involved with the administration 
and implementation of many other benefits and direct services 
that support seniors, we propose language and/or requirements 
encouraging greater partnership in connecting local providers 
with commodities to reduce procurement costs and connect 
eligible older adults with all of the federal nutrition, social 
and financial support from which they may benefit.

Prioritize Community-Based Organizations

Additionally, we believe there should be a concerted effort to 
prioritize community-based organizations for nutrition services 
contracts, as local providers deliver a holistic service, not 
just a meal. The Act has the potential to go further in 
supporting the long-serving community-based senior nutrition 
programs that are experts in addressing these interconnected 
issues by prioritizing them for limited federal grant funding 
and the OAA contracting process. Nonprofit community-based 
organizations (CBOs) are uniquely positioned to meet the needs 
of individuals in their own community as they understand the 
interplay of resources and connection to other local services 
and coalitions. Encouraging contracts with these entities helps 
ensure that the services provided include the more than a meal 
service model, such as daily safety checks, opportunities for 
socialization to prevent loneliness, phone calls to ensure the 
wellbeing of the most isolated individuals, monitoring of 
change of condition, caregiver support and connections to other 
critical community services that support the health and well-
being of seniors. Currently, many long-time OAA providers risk 
or face the loss of critical resources to contracts being 
awarded to for profit nutrition services as the lowest cost 
meal provider. These company models may not provide the same 
level and breadth of service and coordination that Meals on 
Wheels provides to holistically meet the needs of seniors 
living independently at home.

There is also wide variation in the amount reimbursed for each 
meal provided through OAA funding between states and geographic 
regions and limited information on the processes used to 
determine this per meal reimbursement. The overwhelming 
majority of reimbursement rates do not cover the total cost of 
the meal and services provided, and many have not increased in 
years. Further, better public information on reimbursement 
rates would help to improve understanding of how reimbursement 
rates are determined and the role they might play in creating 
waiting lists and exacerbating unmet need in local communities.

This recommendation helps ensure that funding explicitly 
appropriated to the OAA Nutrition Program assists the seniors 
it is designed and intended to serve. It continues to support 
the community-based organizations that have built the 
community's trust and are the "eyes and ears" for those they 
serve.

Finally, as we expand upon our responses to the Targeted 
Questions below, this reauthorization is also an opportunity to 
further modernize the OAA by incorporating innovations, 
flexibility, and successful practices that were leveraged 
during the pandemic and ensuring that services authorized under 
the Act remain adaptable and responsive to the evolving needs 
of America's older population.

Targeted Questions:

A. Legislation passed by Congress in response to the COVID-19 
pandemic made temporary changes to some OAA programs, including 
flexibility for nutrition services funding and adjustments to 
eligibility for home-delivered meals.

    1. What impact did these changes have on older adults and 
program operations?

Response:

Enhanced flexibility has been extremely beneficial and remains 
a top priority for many OAA nutrition service providers.

During the pandemic, the flexibilities enabled local programs 
to adjust on the fly, as they encountered situations they never 
faced before and needed the space to innovate and reach as many 
people as possible. In particular, the ability to transfer 100% 
of funding between Congregate and Home-Delivered meals during 
the Public Health Emergency was essential. It allowed OAA 
nutrition providers to serve each person individually and 
ensure the strategic and cost-effective use of federal funding 
to provide people with the services they required as needs 
evolved.

As one senior nutrition program representative recently noted 
to us regarding the ACL's final rule:

        "[OAA policies] must include as much flexibility as 
possible for funding of congregate and home delivered funds. 
The 'boots on the ground' who are providing services should be 
allowed to make decisions based on the people they serve."

    2. How should Congress consider these changes outside of a 
public health emergency?

Response:

We would like Congress to make permanent the ability to direct 
nutrition funding to where it is needed most in each community, 
rebalancing and streamlining to accommodate flexibility is 
critical. As previously noted, we consider the authorized 
percentages and limits on transfer authority between the 
nutrition services to be arbitrary and unnecessarily burdensome 
as they further complicate the movement and use of resources 
for nutrition providers at the state and local levels. As such, 
we strongly support a permanent combination of the C1 and C2 
nutrition programs and the Nutrition Services Incentives 
Program (NSIP) into a single Title III-C program (or at a 
minimum, permanently allow 100% transfer authority between the 
nutrition funds).

Currently, State Units on Aging have the ability to transfer up 
to 40% of allocated funding between Title III C1 (Congregate) 
and Title III C2 (Home-Delivered). However, our network of 
community-based providers reports that the rationale for the 
levels and timing of transfer at the state level is not always 
clear, and the reporting and administrative requirements to 
initiate and complete funding transfers between their funding 
services can be onerous.

We have long advocated for greater parity in budget allocations 
between the congregate and home-delivered meal programs. In FY 
2023, only 40% of the total nutrition funding was appropriated 
to home-delivered meals. To allow full flexibility of transfer 
between these programs or by eliminating the separate subparts 
entirely, programs with limited capacity and resources at their 
disposal will be able to direct funding toward the specific 
needs and preferences of older adults in their communities.

Further, in our proposal to eliminate NSIP and redirect 
appropriations toward the unified Title III-C Nutrition 
Program, we believe the program's resources would be better 
utilized as direct funding for the network.

    3. What changes made during the COVID-19 pandemic but not 
mentioned above should Congress examine for this 
reauthorization?

Response:

Supplemental funding provided through the various emergency 
COVID-19 relief packages in 2020 and 2021 was absolutely 
critical. It allowed organizations to respond rapidly with the 
reassurance that resources were coming and that seniors in 
communities would not be going without nutritious meals. It 
also allowed our network to begin addressing the services and 
unmet needs gap before the pandemic started.

While it's our understanding that only a few states have 
expended all COVID-relief funding, a growing majority (75%) 
have expended half or more. Under the statute, states have 
until September 30, 2024, to expend American Rescue Plan Act 
funds. Our hypothesis is that resources are not flowing to 
local service providers more quickly due to fears about annual 
appropriations cuts that could occur because of what is 
happening right now in Congress. The Aging Network again needs 
reassurance that more funding will be coming so that older 
adults don't begin services and then be forced off the program 
when there's no longer adequate funding.

Investments in the Older Americans Act had declined well before 
the COVID-19 pandemic and has neither kept pace with a rising 
age 60+ population nor inflation. Adjusted for inflation, 
regular federal funding (excluding emergency supplemental 
funding) appropriated to the OAA Nutrition Program decreased by 
$20 million (1.9%) between FY 2019 and FY 2023. Before the 
influx of emergency supplemental funding in FY 2020-2021, about 
18 million fewer OAA meals were served in 2019 than in 2009 due 
to inflation, rising costs, and inadequate funding. Without 
increasing both the authorization and appropriation levels on 
which these programs depend, local programs must attempt to 
fill the ever-growing gap in other ways. Or worse, Meals on 
Wheels programs will be forced to reduce services, add more 
food insecure seniors to wait lists or turn them away 
altogether.

    4. How should Congress consider the impact of the pandemic 
when working to reauthorize OAA?

Response:

Increased federal funding and extended flexibility within the 
nutrition program following the COVID-19 pandemic are essential 
to help ensure that programs have the resources needed to 
continue providing a wide range of services that meet the 
unique needs of their communities. Local senior nutrition 
providers recognize the importance of providing a range of 
appropriate nutrition options to older individuals and should 
be used as experts in this field, but they need more resources 
to do so. The response of the senior nutrition program network 
in the wake of COVID-19 proved that this model of service is 
not only effective at working with limited resources but also 
highly adaptable and able to address unmet needs as they arise.

B. During the COVID-19 pandemic, OAA partners, including 
congregate meal providers, adapted to new ways of delivering 
services, such as providing grab-and-go meals.

    1. In the absence of a public health emergency, is it 
appropriate to retain flexibility in meal delivery services for 
the congregate meals program? If so, why? What effect would 
changes in meal delivery services have on older Americans?

Response:

Since the onset of the pandemic, local senior nutrition 
providers have experienced a drastic increase in demand for 
home-delivered services and alternative delivery models such as 
grab-n-go, carry-out, and curbside meals. Greater flexibility 
in providing these alternative delivery methods in the OAA 
statute would provide greater balance and flexibility for 
programs to tailor their services better and support older 
adults in the coming years. We believe it is important to give 
local programs the freedom to respond to their diverse and 
evolving local needs.

Meals on Wheels programs also play a critical role in providing 
regular meals and socialization opportunities. For countless 
individuals participating in the program, the staff members and 
peers at a congregate dining facility, or the volunteer 
delivering a meal and visit to the home, may be the only 
person(s) an older adult sees that day, providing critical 
occasions for social connection. Therefore, we believe that any 
flexibility in service delivery must be assured not to reduce 
and/or prevent access to opportunities for vital social 
connection provided through the nutrition program. In any 
capacity and especially through home-delivered meal services, 
Meals on Wheels volunteers and/or staff are additional eyes and 
ears in seniors' homes, often serving as first responders if an 
emergency has occurred or preventing them from occurring 
altogether. As many local programs have described, without 
greater flexibility to provide home-delivered and alternative 
delivery models, older adults' safety and well-being would be 
at greater risk:

        "We consistently hear from HDM [home-delivered meal] 
clients that our driver is the only individual they see each 
day. Social isolation is a crisis in our country, and we are 
battling it on a daily basis, one delivery at a time. In 
addition, delivery drivers frequently find clients in distress 
and needing immediate assistance. Clients have fallen and have 
been lying on the floor for hours, unable to get up on their 
own. Clients have been found on the verge of a diabetic coma or 
having breathing problems. Without our safety check, we can 
only imagine the outcome." - Meals on Wheels program in Ohio

        "One example of how important the home-delivered meals 
program is a driver found a female who had fallen out of her 
wheelchair and was stuck between it and a table. She was unable 
to call for help and he was able to call 911. She had been in 
that situation for approximately two hours." - Meals on Wheels 
program in West Virginia

The consequence of not allowing flexibility and the ability to 
provide nutritious meals and meet the needs of the community 
include harm, loss of quality of life, and financial cost to 
our clients, their families, and taxpayers for preventable 
healthcare costs incurred.

    2. Should Congress consider any requirements related to 
different ways of providing congregate meals?

Response:

Our primary position and recommendation regarding congregate 
meals is to unify the nutrition services under one Title III-C 
program so that providers have the flexibility to deliver 
services in a way that meets the needs of their communities. 
Again, this reauthorization should modernize the OAA by 
consolidating the OAA Nutrition Program, which would simplify 
operations and increase the local programs' abilities to 
provide person centered services that still focus on enhancing 
nutrition and reducing social isolation. By unifying the 
nutrition services under a single program and line item, this 
modification would protect the core purpose of the OAA 
Nutrition program, which is to reduce hunger, promote 
socialization, and promote health and well-being. Furthermore, 
it would better help programs respond to seniors' evolving and 
diverse needs across communities and enable more decision-
making at the local level, which is best positioned to address 
their communities' needs.

Without full 100% transfer authority between all service 
delivery models or a consolidated Title III-C Nutrition 
Program, we believe the congregate meal program should be 
established as the prioritized/mandated funding stream for 
grab-and-go, take out and/or curbside meals. As this level of 
flexibility within the nutrition program was not achieved in 
the newly finalized regulations, we maintain the urgent need to 
address the disproportionate budget allocations between 
congregate and home-delivered nutrition programs. Similarly, 
while we strongly support flexibilities established and granted 
through the regulations, terms like "grab-and-go," "carry-out" 
or "drive through" are not technically home-delivered meal 
models in name or practice, so we urge careful consideration of 
terms - as well as the appropriate funding streams - that are 
selected so that it is not confusing to the people for whom it 
is designed to serve.

C. Congress made several changes to OAA through the Supporting 
Older Americans Act of 2020, including adding caregiver 
assessments to the National Family Caregiver Support Program as 
well as efforts to improve social isolation.

    1. Have these policies better informed resources needed by 
caregivers or older Americans? Please explain why or why not, 
and if yes, how.

Response:

We are supportive of the several provisions, including 
requiring a report on social isolation and the effect of the 
OAA program included in the last reauthorization to increase 
focus and understanding of social isolation and the evidence-
based practices to prevent and address loneliness, The final 
reauthorization's provisions to expand and improve screening of 
and long-term planning and coordination to address social 
isolation are especially beneficial for older adults receiving 
these services as these issues and the negative outcomes 
associated with them are historically overlooked and under-
addressed.

The importance of focusing on social isolation and loneliness 
in the last reauthorization was realized almost immediately 
upon enactment during the COVID-19 pandemic.

    2. How can Congress improve these efforts?

Response:

Leveraging the network of senior nutrition providers to combat 
social isolation and loneliness is a crucial focus at Meals on 
Wheels America. While we believe these OAA amendments have 
brought much-needed awareness of the issues and strengthened 
the capacity for OAA programs and resources to address them 
better, additional support is necessary beyond the critical 
work already done to ensure the safety and social connectedness 
of our nation's seniors. As with other OAA services and 
programs, these activities remain underfunded, and much more 
investment of resources to address social isolation and 
loneliness among older adults is urgently needed.

As recommended above, we believe the Act can further support 
the long-serving community based senior nutrition programs that 
are experts in addressing these interconnected issues by 
prioritizing them for limited Federal Grant Funding and the OAA 
contracting process. For decades, and now more than ever, 
seniors are relying on Meals on Wheels programs to provide 
services, including essential socialization, through various 
creative and resourceful ways that meet the growing needs in 
their communities. Below are a few examples of these activities 
that programs are able to offer to support social connection 
and wellness among participants:

  Telephone reassurance services are designed to have a 
volunteer or staff member make consistent phone calls to 
isolated older adults.

  Friendly visitor or senior companion programs designed to 
offer human connection by providing companionship and emotional 
support to older adults who are socially isolated or lonely.

  Pet assistance and food delivery programs often leverage 
partnerships with shelters, veterinarians, pet food stores, 
and/or boarding and sheltering services to provide holistic 
animal care and encourage animal companionship. Seniors with 
pets are less likely to exhibit depression, report feelings of 
loneliness and experience illness.

Unfortunately, many long-time OAA providers are at risk of 
losing critical resources to contracts with for-profit 
nutrition services. Meals on Wheels provides a more holistic, 
service-oriented approach to meeting the needs of seniors 
living independently at home than many for-profit models. When 
these models are selected and prioritized for OAA meal service 
delivery over traditional local Meals on Wheels programs and 
senior nutrition providers, far fewer individuals receive the 
social connection they need with their meals. For this reason, 
we have long advocated for greater prioritization, utilization, 
and support for the network of community-based programs that 
specialize in nutrition services and are already delivering 
nutritious meals with trusted human connection.

    3. What changes made in the Supporting Older Americans Act 
of 2020 but not mentioned above should Congress examine for 
this reauthorization?

Response:

We remain highly supportive of changes in the last 
reauthorization that highlighted the importance of addressing 
and mitigating the negative impact of issues pertaining to 
senior hunger and nutrition, such as malnutrition, chronic 
diseases, older adult falls, and home safety, as well as social 
isolation and loneliness described above.

We believe this reauthorization can build upon the advances 
made in the Supporting Older Americans Act of 2020 with 
language and authority regarding Food is Medicine (FIM) and 
medically tailored meals, which are burgeoning practices in the 
nutrition and healthcare field. Health providers and insurers 
are increasingly looking to work with the aging services 
network and Meals on Wheels providers to support and execute 
their FIM/medical meal strategies; however, many barriers 
remain in forming and sustaining these partnerships, including 
restrictive policies and resources.

Several state Medicaid plans offer Home- and Community-Based 
Services (HCBS) waivers to provide home-delivered meals as a 
covered service, which is particularly relevant to elderly and 
disabled beneficiary populations. Additionally, with guidance 
under the Centers for Medicare and Medicaid Services (CMS), 
Medicare Advantage (MA) Special Need Plans (SNP) for 
beneficiaries with chronic conditions are now able to cover 
additional supplemental benefits, including meals delivered to 
the home, that are tailored specifically to the patient's 
conditions and health needs. Greater contracting with Meals on 
Wheels programs that can also provide efficient, cost-effective 
health monitoring in the home setting is critical, though, to 
scale and unlock the true cost-saving advantages of these 
benefits. To be able to offer many of these services through 
healthcare partnerships, additional investments must be made to 
enable senior nutrition programs to meet the requirements and 
protocol for such infrastructure and operations.

Similarly, we often hear from local senior nutrition providers 
how special meals, such as medical or cultural meals, are more 
costly to produce and deliver and may differ based on the 
community. As evidence shows promising outcomes for these types 
of special meals in certain communities and in certain 
healthcare interventions, we believe the next reauthorization 
should recognize the value of and appropriately resource these 
enhanced nutrition services. By providing additional targeted 
funding that is structured in a way that allows for flexible, 
age-appropriate implementation and promoting opportunities for 
programs to access alternative revenue streams for special 
meals, the aging network will be better supported and have the 
capacity to cater to the health and medical needs and/or 
preferences of older adults they serve. For example, securing 
more resources for senior nutrition programs to establish and 
manage partnerships with local farms would assist older adults 
actively seeking out easily peelable and digestible fruits and 
vegetables.

D. ACL recently finalized regulations regarding OAA. Should 
Congress consider any changes in response to the new rule?

Response:

Our organization supports the recent effort to update federal 
regulations for OAA policies and programs for Titles III, VI, 
and VII for the first time in 36 years.\19\ We appreciated the 
opportunity to provide comments on the rule and ACL's 
partnership. As a result, they are better aligned with language 
and additions from recent reauthorizations and better reflect 
the needs of today's growing and diversifying older adult 
population.
---------------------------------------------------------------------------
    \19\  ACL (February 2024), Final Rule [89 FR 11566]: Older 
Americans Act: Grants to State and Community Programs on Aging; Grants 
to Indian Tribes and Native Hawaiian Grantees for Supportive, 
Nutrition, and Caregiver Services; Grants for Supportive and 
Nutritional Services to Older Hawaiian Natives; and Allotments for 
Vulnerable Elder Rights Protection Activities. https://
www.federalregister.gov/documents/2024/02/14/2024-01913/older-
americans-act-grants-to-state-and-community-programs-on-aging-grants-
to-indian-tribes-and

We are especially supportive of the final rule as it contains 
clarifying language around the home-delivered meals for 
seniors, including clarification that eligibility for home-
delivered meals is not limited to people who are "homebound" 
and that criteria for home-delivered meals may depend upon many 
factors (including ability to leave home unassisted, ability to 
shop for and prepare nutritious meals, mental health, degree of 
disability or other relevant factors pertaining to their need 
---------------------------------------------------------------------------
for the service, including social and economic need.

While we are encouraged to see much consideration and 
modernization of OAA regulations through this process, 
regulatory updates and guidance can only achieve so much, and 
we look forward to addressing remaining priorities and making 
further legislative improvements during reauthorization. 
Federal level, these include:

  Unifying - or authorizing permanent 100% funding transfer 
authority between - the home delivered, congregate, and NSIP 
into a single Title III Nutrition Program.

  Increasing funding authorization levels for all OAA 
programs, particularly as current funding and reimbursement 
rates are not keeping pace with increasing demand for nutrition 
services and sustained higher operating costs.

  Providing additional resources for enhanced nutrition 
services and requiring that state agencies, AAAs, and local 
providers be aware of the definitions, uses, and importance of 
culturally appropriate meals, medically tailored meals, fresh 
produce, and locally sourced food, as included in the statute.

  Prioritizing community-based organizations and public 
entities, such as AAAs, county governments, tribes, nonprofit 
service providers, or volunteer organizations, to receive grant 
awards and/or enter contracts to provide Title III services.

Thank you again for the opportunity to submit these comments 
and for considering our concerns and recommendations for the 
forthcoming OAA reauthorization. A strong reauthorization of 
the Act is critically needed to improve the delivery, access, 
and long-term sustainability of services and supports for 
seniors. Local Meals on Wheels and other OAA programs are 
essential, effective, and work well to meet the nutritional, 
health, and social needs of older adults, but they need more 
support from Congress to better serve older adults in need. 
Please do not hesitate to reach out with any questions as you 
continue this critical work for older Americans, their 
families, and caregivers.

Sincerely,

/s/
Ellie Hollander
President and CEO

Contact Information:
Julia Martinez Harrington
Senior Director, Government Relations 
[email protected]
(303) 514 5751

1550 Crystal Drive, Suite 1004
Arlington, VA 22202
571-339-1622
www.mealsonwheelsamerica.org 
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