Long-Term Care: Private Sector Elder Care Could Yield Multiple Benefits
(Letter Report, 01/31/94, GAO/HEHS-94-60).

Today, about 6 million older Americans need help living at home because
of their disabilities.  The demand for this kind of assistance is
expected to increase significantly in the future, with upwards of 10
million persons needing help by 2020.  Most disabled elderly receive
this care from family members and friends, primarily women.  Yet greater
geographic dispersion of families, smaller family sizes, and the large
numbers of women who work outside the home are straining the ability of
caregivers. Some companies are responding to the needs of their workers
with policies and programs, known as "elder care," to help ease work and
caregiving conflicts.  This report evaluates (1) the extent and nature
of company practices now offered to help employees who look after the
elderly, (2) planned changes in these practices, and (3) the potential
of company practices to further support informal caregivers.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-94-60
     TITLE:  Long-Term Care: Private Sector Elder Care Could Yield 
             Multiple Benefits
      DATE:  01/31/94
   SUBJECT:  Long-term care
             Elderly persons
             Productivity
             Working conditions
             Fringe benefits
             Labor-management relations
             Handicapped persons
             Non-government enterprises
             Emergency leave
IDENTIFIER:  Social Services Block Grant
             Supplemental Security Income Program
             Medicaid Program
             Medicare Program
             
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Cover
================================================================ COVER


Report to the Honorable
Olympia Snowe, House of Representatives

January 1994

LONG-TERM CARE - PRIVATE SECTOR
ELDER CARE COULD YIELD MULTIPLE
BENEFITS

GAO/HEHS-94-60

Private Sector Elder Care


Abbreviations
=============================================================== ABBREV

  DCAP - dependent care assistance plan
  EAP - employee assistance program

Letter
=============================================================== LETTER


B-249658

January 31, 1994

The Honorable Olympia J.  Snowe
House of Representatives

Dear Ms.  Snowe: 

Today, about 6 million older Americans living at home need assistance
in everyday activities as a result of their disabilities.  Population
aging will significantly increase demand for this assistance, as the
number of elderly needing long-term care reaches an expected 10
million or more by 2020.  Currently, most disabled elderly receive
their care informally from family members and friends, primarily
women.  However, greater geographic dispersion of families, smaller
family sizes, and the large percentage of women who work outside the
home are straining the capacity of this care source.  Employed
caregivers often face challenges balancing their work and caregiving
responsibilities, which can adversely affect both roles. 

Some companies are responding to the needs of their employees who
care for the elderly with assistance, known as "elder care," to help
alleviate work and caregiving conflicts.  In this report we define
elder care as any employer-sponsored practice, policy, or program
that directly or indirectly helps employees or retirees in caring for
elderly relatives or friends. 

Because little was known nationwide about the extent and content of
elder care assistance in the private sector, you requested that we
evaluate (1) the extent and nature of company practices currently
offered to assist employees who care for the elderly, (2) planned
changes in these practices, and (3) the potential of company
practices to further support informal caregivers.\1


--------------------
\1 A separate, forthcoming report will discuss availability of elder
care assistance to employees in the public sector. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

Currently, about 2 million working Americans are providing
significant unpaid care to their elderly relatives living in the
community who need assistance with everyday activities.  An
additional 6 million employed persons have parents or spouses who are
disabled and may also need assistance with these activities.  The
number of employed caregivers is expected to grow as the population
ages.  Work and family responsibilities often conflict, and many
caregivers provide assistance long distance.  To maintain both roles,
working caregivers identify both work schedule flexibility and
information about community services for the elderly as the most
useful options their employers could offer.  Many companies provide
flexible scheduling options, but they are often not promoted as being
available to assist employed caregivers.  At least 23 million
Americans work for medium and large companies (those with more than
100 employees) that already offer at least one flexible scheduling
option, such as flexible leave, alternative work schedules, and leave
without pay.  Companies' support for their employees who care for
elderly persons could be strengthened if managers identified and
actively supported the use of these options for elder care.  At least
9 million people work for companies that also provide assistance
specifically designed for elder care, such as information about
long-term care services and aging, and support groups for caregivers. 

Companies' elder care assistance offers benefits for caregivers and
their employers, as well as for the elderly.  Caregivers struggling
to balance work and family responsibilities may find useful those
services that offer them flexible schedules and needed information,
while employers may see reduced work disruption, such as turnover and
absenteeism.  The elderly may benefit by being able to remain in
their own homes and communities as they prefer. 

The number of employees with access to elder care assistance is
likely to increase, although the rate and extent of this growth is
uncertain.  More than 8 million people work for companies planning to
expand existing elder care options or offer new ones.  However,
companies' awareness of both employees' elder care needs and
employers' options for addressing them will affect the extent of
overall expansion. 


   BACKGROUND
------------------------------------------------------------ Letter :2

More and more Americans are facing the need for long-term care in
their families.  In most cases, long-term care needs are primarily
for nonmedical care provided outside of nursing homes.  Unpaid,
informal assistance from family and friends is the chief source of
care for most elderly Americans dependent on others for assistance in
the basic tasks of everyday life such as eating, moving around the
house, shopping, managing money, and completing other routine
activities.  This assistance is instrumental in allowing the elderly
to remain in their homes and communities.  About 2 million elderly
persons receive formal, paid, home and community-based long-term care
services, such as home health care, transportation, and meals.\2
These services are either purchased by the elderly and their families
or paid for with public funds, primarily Medicaid and Medicare. 

When families can no longer provide care, or when home and
community-based services are not available or sufficient to address a
disabled elder's needs, institutionalization may result.  About 1.5
million older Americans, generally those with the severest
disabilities, live in nursing homes each year.  Institutions are
generally an expensive source of long-term care.  About half of
nursing home costs are paid for by the elderly and their families and
half by public funds. 

While most care to the elderly is provided by unpaid family and
friends, federal involvement in providing long-term care to disabled
elders is nonetheless significant.  In 1991, state and federal
long-term care spending totaled more than $38 billion through the
Medicare and Medicaid programs, primarily spent on funding
institutional care.  Other federal long-term care funds are provided
through the Older Americans Act, the Social Services Block Grant, the
Supplemental Security Income program, and several Department of
Veterans' Affairs programs.  In addition, some proposals for health
care reform, including the administration's, include federal payment
for additional long-term care services. 


--------------------
\2 National Medical Expenditure Survey:  Use of Home and Community
Services by Persons Ages 65 and Older with Functional Difficulties,
Research Findings 5, Agency for Health Care Policy and Research,
Public Health Service, Department of Health and Human Services (Sept. 
1990). 


   SCOPE AND METHODOLOGY
------------------------------------------------------------ Letter :3

To respond to your request, we surveyed a nationally representative
random sample of companies with 100 or more employees,\3 interviewed
benefits and human resources managers, discussed our work with elder
care experts, and reviewed the relevant literature on corporate
involvement in elder care assistance and informal care-giving.  (See
app.  I for a full description of our methodology.) Our overall
survey response rate was 56 percent.  We did not independently verify
the accuracy of companies' responses.  Nor did we assess the quality
of the elder care assistance companies offered or the extent of its
use by employees.  Our employee estimates in this report represent
the minimum number of persons with access to certain options.  Unless
otherwise noted, sampling errors on attribute estimates do not exceed
plus or minus 12 percentage points.  (See app.  II for more
information on estimates and sampling errors.)


--------------------
\3 Our survey reflects the availability of elder care options to at
least 26 million Americans who work in these medium and large
companies.  According to the Census Bureau, there were 42 million
Americans working for all private sector companies with 100 or more
employees in 1990.  We did not survey small companies--those with
fewer than 100 employees--which employ about one-half of all private
sector workers. 


   INFORMAL CAREGIVING GROWING,
   CAN CONFLICT WITH WORK
------------------------------------------------------------ Letter :4

Women's growing participation in the workforce and the rise in the
number of disabled elderly have resulted in increasing numbers of
employees who care informally for older Americans in their homes and
communities.  Nearly three-quarters of all caregivers are women, many
of whom are employed outside the home.  Approximately 2 million
working Americans provide informal caregiving assistance to their
disabled elderly relatives, including help with eating, bathing,
moving around the home, housework, and financial management.  An
additional 6 million employed persons have a disabled spouse or
parent who may also require assistance with these or other
activities.  As the population ages, the number of employed
caregivers is expected to grow.  Potential caregivers--spouses and
children of disabled elders--currently represent about 9 percent of
the workforce with full-time employment.\4

Employees' caregiving demands can adversely affect their work
performance.  Caregiving problems may lead to increased absenteeism,
tardiness, work disruptions, turnover, and stress, with damaging
effects on employee productivity and morale.  Working caregivers
report making adjustments in both caregiving and employment to
accommodate their dual roles.  At work, many caregivers rearrange
their schedules, reduce their overall hours, take leave without pay,
and even forgo career opportunities or quit their jobs to fulfill
elder care responsibilities at home.  Companies we interviewed who
address these conflicts believe their elder care and work/family
programs improve their ability to recruit and retain employees. 


--------------------
\4 R.  Stone and P.  Kemper, "Spouses and Children of Disabled
Elders:  How Large a Constituency for Long-Term Care Reform?" The
Milbank Quarterly, Vol.  67, Nos.  3-4 (1989), pp.  485-505. 


   MOST USEFUL OPTIONS ARE
   PREVALENT, BUT OFTEN NOT
   IDENTIFIED AS CAREGIVER
   ASSISTANCE
------------------------------------------------------------ Letter :5

Most employees in our survey have access to at least one option of
the type employed caregivers report finding most useful in balancing
work and family responsibilities, namely schedule flexibility and
information about elder care services.  However, many flexible
scheduling options were not designed as elder care and may not be
recognized or supported by managers and supervisors for use by
employees caring for the elderly.  Other options designed especially
to assist caregivers, such as financial assistance, are available to
many fewer employees. 


      MANY EMPLOYEES HAVE ACCESS
      TO OPTIONS CAREGIVERS NEED
      MOST
---------------------------------------------------------- Letter :5.1

More than 23 million working Americans have access to flexible
schedules, elder care information, or both through their employers. 
These types of support are most valuable to working caregivers in
maintaining their work and family roles, according to caregiver
surveys.\5 Overall, a flexible work schedule is the most common elder
care option employees have (see fig.  1).  A minimum of 23 million
people work for companies that offer some type of leave policy or
alternative work schedule that employees could use when providing
care for an elderly relative or friend.\6 At least 8 million
Americans work for employers who provide some form of information
about elder care services and aging to their staff. 

   Figure 1:  Flexible Schedules
   Are the Most Common Form of
   Elder Care Assistance

   (See figure in printed
   edition.)

Notes:  Estimates are the minimum number of employees who work for
companies that offer at least one benefit in the categories shown.

Flexible schedules include paid sick and family leave, leave without
pay, flex-time, compressed schedules, flex-place, part-time with
benefits, temporary reduction of work hours, and job-sharing, if they
could be used for elder care.

Education and information and referral includes elder care reference
materials, seminars, caregiver information fairs, company promotion
campaigns, and in-house and contractual information and referral
services.

Financial arrangements include cash subsidies for elder care
services, including respite and in-home care, and long-term care
insurance for employees' spouse, parents, or parents-in-law.

Elder care support services include employee support groups, case
management for elderly dependents, and employer-sponsored adult or
intergenerational day care. 

The most common flexible scheduling practice that could be used for
elder care is leave without pay, which is available to at least 18
million working Americans.\7 Also prevalent are temporary reductions
in work hours, flex-time, and paid sick leave, each of which is
available to a minimum of about 6 million employees.  Other options
companies offer that allow their employees flexibility include
job-sharing and paid family leave. 

Although not initially intended to address elder care needs, flexible
schedules can be of significant assistance to caregivers. 
Flexibility is important to caregivers both in providing care during
traditional work hours and in responding to unexpected needs.  For
example, a midday physician's appointment or temporary bedrest after
hospitalization are easier to accommodate when a caregiver has a
flexible work schedule.  Surveys of working caregivers show that
caregivers use flexibility at work to accommodate elder care
responsibilities by rearranging their schedules or reducing total
work hours, and by taking unpaid leave. 

At least 2.6 million employees have access through work to elder care
information and referral services, which help them identify and
access community resources for the elderly.  Such services are either
provided in-house or operated by an outside contractor.  Other
informational resources range from elder care reference materials,
such as brochures, videos, and service directories, which are
available to more than 4 million employees, to seminars on aging or
elder care issues, available to 3 million workers, and to caregiver
information fairs, where service providers are invited to market
their services, available to 1 million employees. 

Elder care information is especially valuable to working caregivers
because of the often-changing needs of the disabled elderly. 
Furthermore, many caregivers live far from their elders and are
providing assistance long distance.  When new needs arise, caregivers
need to know what resources are available in their elders'
communities, or what situations to expect.  Information and referral
services allow employees to act efficiently to locate and use
services, even in other states, thus reducing the amount of time they
must spend on this task.  Some companies enhance their informational
resources by conducting campaigns to promote or publicize their elder
care program or by training managers about company practices and
employee eligibility (see fig.  2). 

   Figure 2:  Some Companies Use
   Promotional Materials to
   Publicize Their Elder Care
   Programs to Employees

   (See figure in printed
   edition.)


--------------------
\5 R.  Stone and P.  Short, "The Competing Demands of Employment and
Informal Caregiving to Disabled Elders," Medical Care, Vol.  28, No. 
6 (June 1990), pp.  513-26; A.  Scharlach, E.  Sobel, and R. 
Roberts, "Employment and Caregiver Strain:  An Integrative Model,"
The Gerontologist, Vol.  28, No.  6 (1991), pp.  778-87; J.  Anastas,
J.  Gibeau, and P.  Larson, "Working Families and Eldercare:  A
National Perspective in an Aging America," Social Work, Vol.  35, No. 
5 (Sept.  1990), pp.  405-11. 

\6 This leave does not include vacation days, but does include other
paid and unpaid absences, such as sick days and leave without pay, if
the benefit could be used to provide elder care. 

\7 Our survey data do not reflect the impact of the Family and
Medical Leave Act of 1993, which was implemented in August 1993.  The
act mandates leave without pay for employees to care for immediate
family members with serious health conditions--including the elderly. 


      MORE WIDESPREAD RECOGNITION
      AND PROMOTION OF FLEXIBLE
      SCHEDULES COULD ENHANCE
      EFFECTIVENESS AND USE
---------------------------------------------------------- Letter :5.2

While flexible scheduling options were common, they were often not
specifically developed to assist caregivers to the elderly, but for
broader purposes.  Companies generally do not recognize and promote
the use of these options for elder care.  Experts and managers we
interviewed who are engaged in promoting private sector elder care
believe that the failure to identify and promote flexible scheduling
options diminishes the value of these options for helping balance
work and caregiving responsibilities. 

Specifically, they believe that supervisors and managers must be both
aware and supportive of accommodating employees' caregiving needs. 
This awareness increases the likelihood that managers and employees
will know when and how to use the flexible scheduling options
available.  Some companies have found employees reluctant to discuss
elder care concerns at work because they question the legitimacy of
seeking caregiving assistance there.  According to an official we
interviewed at one company with a well-utilized elder care program,
"We have to continuously let people know what we have" to ensure that
such options are known and used.  When employers identify and promote
the use of all options that can assist caregiving by their employees,
they may be more likely to be used to provide continued home care. 


      OTHER ELDER CARE PROGRAMS
      ARE RARE OR LESS USEFUL
---------------------------------------------------------- Letter :5.3

Two commonly available employee benefits often associated with work
and family issues are dependent care assistance plans (DCAP) and
counseling.  Their usefulness to caregivers, however, is limited.  At
least 12 million people work for companies that offer DCAPs--flexible
spending arrangements allowing employees to exclude dependent care
expenses, for either elder or child care, from taxable income.  For
example, expenditures may be made under a DCAP to pay for child care
for young children.  Experts and employers believe, however, that
employed caregivers generally do not find DCAPs useful for elder
care.  This situation occurs because elderly dependents generally
cannot meet two Internal Revenue code requirements to qualify
expenditures on their behalf for exclusion under a DCAP:  the
dependents must spend at least 8 hours a day with and receive over
half their financial support from their caregiver. 

Counseling assistance, frequently through an employee assistance
program (EAP), is available to at least 5 million employees.  While
some companies use their EAPs to organize and deliver elder care
assistance, many EAP personnel have less knowledge about aging issues
than other employee family concerns. 

About 3 million employees have access through their employers to a
variety of other, less common elder care options, designed
specifically to address caregiving needs.  These options include
support groups for employed caregivers; case management services for
disabled elderly dependents; and long-term care insurance coverage
for an employee's spouse, parents, or parents-in-law.  A very few
companies sponsor adult or intergenerational day care centers. 


   FUTURE AVAILABILITY AND OTHER
   FACTORS WILL AFFECT MULTIPLE
   BENEFITS OF ELDER CARE
------------------------------------------------------------ Letter :6

Corporate elder care assistance has the potential to benefit
employers and their caregiving employees by reducing conflicts
between work and family responsibilities.  Caregivers with access to
flexible work schedules and/or elder care information may be better
able to provide the informal care generally preferred by elderly
persons.  However, many factors will influence this potential
benefit, including the extent to which available options are
recognized, promoted, and used, as well as the future availability of
elder care assistance. 


      CURRENT AND FUTURE ELDER
      CARE ASSISTANCE COULD
      BENEFIT CAREGIVERS,
      EMPLOYERS, AND THE ELDERLY
---------------------------------------------------------- Letter :6.1

Assistance currently available to working caregivers through their
employers has the potential to help them continue providing home care
for the elderly.  According to recent analysis, informal caregiving
can reduce the risk of institutionalization for seriously disabled
persons by almost one-third.  Having a spouse or adult child in the
caregiving role for 3 or more years was the leading factor in reduced
risk of nursing home admission.\8 At the same time, the burden on
informal caregivers, including the lack of social and other support,
places their care recipients at high risk for nursing home admission. 
Indeed, evidence shows that caregiver characteristics, including the
quality of their support systems, are better predictors of
institutional placement than patient characteristics.\9

We found elder care information and flexibility in balancing work and
family roles are available to a substantial portion of the workforce
in medium and large companies.  The ultimate impact of elder care
assistance on the prevalence of informal caregiving, however, depends
on the extent to which it is recognized and used effectively by
caregivers.  Promotion by employers of all options that can
facilitate caregiving could help assure that employees use elder care
assistance effectively to maintain their caregiving and help their
elders avoid or delay institutionalization.  National polls have
shown the disabled elderly prefer to live in their own homes and
communities as long as possible. 

While most employees represented in our survey work for companies
that are uncertain about increasing their support for elder care, at
least 8 million work for companies that are planning to make
additional support available or to expand the availability of
existing support.  Many companies that responded to our survey
reported that the perceived future benefits to their organization,
such as improved productivity and morale, motivated them to plan new
or expanded elder care assistance for their employees.  Companies
already offering elder care assistance most often cited these
business-related reasons as important factors in their decision to do
so.  Employee requests and corporate culture were also frequently
noted as key reasons for implementing elder care policies.  These
factors were often more influential than demographic ones, such as
the percent of women in the workforce or the average staff age, for
the one-third of companies in our study that offer specific elder
care assistance (see fig.  3). 

   Figure 3:  Business Factors Are
   More Important to Companies
   Than Demographic Ones in
   Offering Corporate Elder Care
   Assistance

   (See figure in printed
   edition.)

\a Percent of companies reporting the factor had a great or very
great impact on their decision to offer elder care assistance. 

\b Sampling error for this estimate is plus or minus 14 percent. 

A minimum of 1.6 million people work for companies with no plans to
expand or offer elder care options.  However, the federal Family and
Medical Leave Act of 1993, which became effective August 5, 1993,
requires all companies with a staff of 50 or more to allow employees
up to 12 work weeks of unpaid leave during any 12-month period to
care for family members or attend to a personal illness.  In
addition, at least nine states and the District of Columbia already
had laws mandating similar leave options for companies.\10 These
state laws, along with the Family and Medical Leave Act of 1993,
offer greater flexibility to American workers who previously could
not take leave without pay to care for relatives.  The new law may
also raise corporate awareness of dependent care issues as workers
take advantage of their increased schedule flexibility. 


--------------------
\8 Deborah Pearlman and William Crown, "Alternative Sources of Social
Support and Their Impacts on Institutional Risks," The Gerontologist,
Vol.  32, No.  4 (1992), pp.  527-35. 

\9 E.  Colerick and L.  George, "Predictors of Institutionalization
Among Caregivers of Patients with Alzheimer's Disease," Journal of
the American Gerontological Society, No.  34 (1986), pp.  493-98; S. 
McFall and B.  Miller, "Caregiver Burden and Nursing Home Admission
of Frail Elderly Persons," Journal of Gerontology, Vol.  47, No.  2
(1992), pp.  S73-79. 

\10 "The Changing Environment of Work and Family," EBRI Issue Brief
Number 138 (June 1993), pp.  14-15. 


      VARIATIONS BY COMPANY AND
      EMPLOYEE TYPE MAY AFFECT
      FUTURE GROWTH
---------------------------------------------------------- Letter :6.2

Currently, access to elder care policies designed specifically to
assist with informal caregiving varies with corporation type. 
Communication, utility, financial, real estate, and insurance
companies are most likely to have elder care assistance for their
employees.  Companies with more than 500 employees, and those
offering child care assistance, also are more likely to have such
programs.  Smaller companies, and trade, service, and manufacturing
firms, in contrast, are least likely to offer policies designed
specifically to address caregiving responsibilities (see fig.  4). 

   Figure 4:  Specific Elder Care
   Assistance Is Most Common in
   Larger Firms, Certain
   Industries, and Companies With
   Child Care Benefits

   (See figure in printed
   edition.)

Within companies, policies designed especially for caregivers are
frequently not available to all employees.  About two-fifths of
companies limit elder care assistance options to certain staff. 
These options are most likely to be available to all full-time and
permanent staff, and least likely to be open to part-time and
temporary employees.  Adoption of elder care programs by more
companies may not, therefore, assist all staff with elder care
responsibilities.  Conversely, there is room for growth in such
assistance among companies currently offering elder care options if
they expand these options to a larger portion of their workforce. 

The implications of current access trends for future employee access
to elder care assistance are unclear.  The greatest employment growth
in the next 10 years is predicted among service industries, which are
least likely to be providing elder care assistance to their employees
now.  In addition, the number of well-educated, professional workers
is expected to increase appreciably.  Traditionally, this group of
highly paid workers has had the greatest access to family support
options of all types, including elder care assistance.  Companies
currently providing child care benefits but not elder care options
are another likely source of future elder care assistance, because of
their orientation to work/family issues. 


      SEVERAL FACTORS MAY LIMIT
      EXPANSION AND IMPACT OF
      ASSISTANCE
---------------------------------------------------------- Letter :6.3

While overall access to corporate elder care assistance will probably
increase, its growth and impact are likely to be limited by several
factors.  The majority of employers represented in our survey, 87
percent, said that elder care issues were, at most, of only some
importance to their companies.  Companies are currently less focused
on employees' elder care needs relative to other work/family concerns
such as child care.  In general, many more employees have child care
responsibilities than elder care ones.  Generally, firms in our study
reported little or no need for elder care assistance among their
staff, although most firms had not assessed their employees' elder
care needs in the 24 months preceding our survey.  However, at least
4 million people work for companies represented in our survey that
had recently examined the elder care needs of their staff. 

Additionally, many companies have concerns about the perceived costs
of offering elder care assistance.  Many elder care options, however,
such as publishing the National Association of Area Agencies on
Aging's toll-free Eldercare Locator number\11 or promoting existing
flexible schedules, are generally very inexpensive.  Nonetheless,
cost concerns were the most frequently cited disincentive to
initiating or expanding elder care assistance (see fig.  5).  Less
common reasons that companies report for not expanding access to
elder care assistance include their view of elder care as separate
from work or their concerns about maintaining equitable benefits for
employees who do not have elder care responsibilities. 

   Figure 5:  Perceived Cost of
   Elder Care Assistance Is
   Leading Reason Companies Do Not
   Plan to Expand Benefits

   (See figure in printed
   edition.)

\a Percent of companies reporting the factor had a great or very
great impact on their decision not to expand elder care assistance. 


--------------------
\11 The Eldercare Locator number, 1-800-677-1116, is part of the
Administration on Aging's National Eldercare Campaign. 


   CONCLUSIONS
------------------------------------------------------------ Letter :7

Many companies have an opportunity to offer enhanced elder care
assistance to their employees, often at little cost.  This assistance
can benefit caregivers by easing work and family conflicts, the
elderly by maintaining their independence at home, and employers by
improving worker recruitment and retention. 

Informal caregivers currently play a central role in providing
informal care to the elderly in their homes and communities. 
Companies can benefit when they address work/family conflicts that
can adversely affect employees' work performance.  The magnitude and
types of elder care policies, programs, and practices our survey
found to be available have the potential to strengthen the informal
care network.  Actively promoting existing options that caregivers
find useful, especially those that provide flexibility and
information about elder care services, can further strengthen the
capacity of working caregivers to better balance their work and
family roles, thereby enabling them to continue providing care. 


---------------------------------------------------------- Letter :7.1

We discussed a draft of this report with officials from the
Department of Health and Human Services, and they generally agreed
with our findings.  We are sending copies of the report to the
Secretary of Health and Human Services and other interested parties. 
Copies will be made available to others on request.  Please call me
on (202) 512-7215 if you or your staff have any questions concerning
this report.  The major contributors to this report are listed in
appendix IV. 

Sincerely yours,

Jane L.  Ross
Associate Director,
 Income Security Issues


OBJECTIVES, SCOPE, AND METHODOLOGY
=========================================================== Appendix I

The Honorable Olympia Snowe asked us to determine (1) the extent and
nature of company practices currently offered to assist employees who
care for the elderly, (2) planned changes in those practices, and (3)
the potential of company practices to further support informal
cargivers. 

To meet these objectives, we conducted a nationwide mail survey of
medium and large companies with 100 or more employees.  Furthermore,
we interviewed benefits and human resources managers to obtain
additional information to supplement the questionnaire.  We also
reviewed literature on corporate involvement in elder care assistance
and informal caregiving, and discussed our work with elder care
experts. 

We conducted our work between February 1992 and September 1993 in
accordance with generally accepted government auditing standards. 


   GAO'S SURVEY METHODOLOGY
--------------------------------------------------------- Appendix I:1


      QUESTIONNAIRE DEVELOPMENT
      AND PRETESTING
------------------------------------------------------- Appendix I:1.1

We designed a questionnaire to obtain information about current and
future employer practices, policies, and programs that directly or
indirectly help employees or retirees in caring for elderly relatives
or friends, i.e., elder care.  We discussed development of the
questionnaire with academic elder care experts at the University of
California-Berkeley, the University of Southern California, and
Portland State University (OR).  We also discussed the questionnaire
with representatives from organizations active in elder care research
and consulting, including the New York Business Group on Health, the
Washington Business Group on Health, the Families and Work Institute,
and The Creedon Group.  In addition, some of these experts reviewed
draft copies of our survey. 

Our questionnaire was pretested with officials at six companies in
the Washington, D.C., metropolitan area.  These companies represented
a range of industry types.  Using the pretest results, we revised the
questionnaire to try to ensure that (1) respondents would easily be
able to provide the information requested and (2) all questions were
relevant, clear, and free from bias. 


      SAMPLE DEVELOPMENT
------------------------------------------------------- Appendix I:1.2

Using data procured from Database America, a company that sells
information about businesses in the United States, we constructed a
universe of 88,448 for-profit companies with 100 or more employees,
excluding to the extent possible companies that did not meet our
criteria.  Based on this information, we stratified our sample by
industry type and employee size (see table I.1).  We drew a random
sample of 1,200 companies--120 in each of 10 strata.  We developed
weights for estimation based on the ratio of the sample to the
universe in each stratum. 

In early November 1992, we mailed the questionnaire to the 1,200
companies selected.  A postcard follow-up was sent to all
nonrespondents 2 weeks later; additional reminders were sent in
January and February 1993.  In April 1993, we called all companies
that had still not responded to encourage their participation. 


      SAMPLE ADJUSTMENT AND
      RESPONSE RATE
------------------------------------------------------- Appendix I:1.3

Although the initial sample size was 1,200 companies, based on
returned questionnaires, telephone calls to company officials, and
database research, we adjusted our sample to 730 eligible
participants.  We excluded entities that were not eligible for the
survey, including those that (1) were nonprofit or government
agencies, (2) were out of business, (3) were branches or divisions of
larger companies, (4) were duplicate entries, or (5) had fewer than
80 employees.  We included those reporting between 80 and 99
employees because they reasonably may have had 100 at the time the
universe was constructed. 

Early analysis of these surveys revealed that several respondents had
appreciably more or fewer employees than their stratification
criteria indicated.  Allowing for some workforce growth or loss, we
excluded those companies classified as medium-sized (100-499
employees) but reporting 600 or more staff, and those classified as
large (500 or more employees) but reporting 400 or fewer staff to
eliminate the bias resulting from their misclassification.  Based on
these adjustments, our final valid number of respondents was 407. 
Initial and adjusted sample sizes are shown by stratum in table I.1. 



                          Table I.1
           
           GAO Sample of Medium and Large Companies


                                                       Final
                                          Adjusted  response
Strata                  Universe  Sample  sample\a         s
----------------------  --------  ------  --------  --------
Mining, Construction,      9,335     120        55        25
 Selected
 Transportation
 (100-499 employees)
Manufacturing             26,107     120        80        53
 (100-499 employees)
Communication and          1,805     120        47        21
 Utilities
 (100-499 employees)
Wholesale Trade and       33,245     120        53        22
 Services
 (100-499 employees)
Finance, Insurance,        4,375     120        68        31
 and Real Estate
 (100-499 employees)
Mining, Construction,      1,368     120        90        35
 Selected
 Transportation
 (500 or more
 employees)
Manufacturing              5,147     120       106        71
 (500 or more
 employees)
Communication and            335     120        93        68
 Utilities
 (500 or more
 employees)
Wholesale Trade and        5,550     120        56        24
 Services
 (500 or more
 employees)
Finance, Insurance,        1,181     120        82        57
 and Real Estate
 (500 or more
 employees)
============================================================
Total                     88,448   1,200       730       407
------------------------------------------------------------
\a Does not include companies with fewer than 80 employees;
government, or private, not-for-profit entities; those that are out
of business; or branches or divisions of larger companies. 

These 407 responses resulted in an overall response rate of 56
percent.  A telephone survey of selected nonrespondents did not
reveal any meaningful differences between respondents and
nonrespondents.  However, we obtained insufficient information to
generalize our findings to the universe of nonrespondents. 


EMPLOYEE ESTIMATES AND SAMPLING
ERRORS
========================================================== Appendix II

Table II.1 contains estimates, based on our survey data, of the
number of employees with access to various types of options that
could be used for elder care.  In order to be conservative, we
focused our report on the "minimum" estimates presented in the table. 
These minimum estimates were calculated so that there is only about a
5-percent chance that the actual number of employees with the option
is lower than the estimate. 



                          Table II.1
           
           Selected Estimates of Access to Employee
                           Benefits

                    (Numbers in Millions)

                            Estimate
                            of total                 Minimum
                           number of        One-   number of
                           employees      tailed   employees
                                with    sampling        with
Benefit type                  access       error      access
------------------------  ----------  ----------  ----------
Paid sick leave                 14.1         8.3         5.8
Paid family leave                 \a          \a          \a
Other paid leave,                2.6         1.6         1.0
 excluding vacation
Leave without pay               27.0         8.9        18.1
Flex-time                       12.4         6.0         6.4
Compressed work schedule         7.4         4.6         2.8
Flex-place                       4.7         4.3         0.4
Part-time employment            11.6         5.4         6.2
 with benefits
Temporary reduction in          13.7         7.2         6.5
 work hours
Job-sharing                      7.7         5.3         2.4
Elder care reference             7.0         2.8         4.2
 materials
Seminars on aging and            5.6         2.6         3.0
 elder care
Caregiver information            2.8         1.6         1.2
 fairs
Company campaign to              4.2         1.8         2.4
 publicize elder care
 program
In-house elder care              2.9         1.7         1.2
 information and
 referral services
Contracts with outside           4.8         2.0         2.8
 agencies to provide
 information and
 referral
Support groups for               5.8         3.3         2.5
 caregivers
Counseling on legal,            13.3         8.3         5.0
 personal, or financial
 elder care issues
Case management for the          1.8         1.2         0.6
 elderly
Employer-sponsored adult          \a          \a          \a
 or intergenerational
 day care
Dependent care                  20.9         9.0        11.9
 reimbursement plans
Cash subsidies for                \a          \a          \a
 respite care
Cash subsidies for in-            \a          \a          \a
 home services
Cash subsidies for other          \a          \a          \a
 elder care
Long-term care insurance         3.2         1.7         1.5
 for nursing home care
Long-term care insurance         3.1         1.7         1.4
 for home and community-
 based care
------------------------------------------------------------
\a Too few cases for valid statistical analysis. 


SURVEY INSTRUMENT
========================================================= Appendix III

In this appendix, we present our survey instrument and a summary of
the responses.  Each question includes the weighted summary
statistics and the unweighted actual number of respondents that
answered each question.  In each case, we use the format we believe
best represents the data, including frequencies, medians, and ranges. 
Because of the extreme variation among responses, means are not
shown. 



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MAJOR CONTRIBUTORS TO THIS REPORT
========================================================== Appendix IV

HEALTH, EDUCATION, AND HUMAN
SERVICES DIVISION,
WASHINGTON, D.C. 

Cynthia Bascetta, Assistant Director, (202) 512-7207
Wayne Dow, Assistant Director
James C.  Musselwhite, Jr., Senior Social Science Analyst
Luann Moy, Senior Social Science Analyst
Margaret Nicklas, Evaluator
Andrew Eschtruth, Evaluator
Amy Ward, Research Assistant

OFFICE OF THE GENERAL COUNSEL,
WASHINGTON, D.C. 

George H.  Bogart, Attorney-Adviser

DETROIT REGIONAL OFFICE

Donald P.  Ingersoll, Regional Assignment Manager
Sara Koerber Galantowicz, Evaluator-in-Charge
