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NORTH CAROLINA STUDY COMMISSION ON AGING REPORT TO THE GOVERNOR AND THE 2004 REGULAR SESSION OF THE 2003 GENERAL ASSEMBLY A LIMITED NUMBER OF COPIES OF THIS REPORT IS AVAILABLE FOR DISTRIBUTION THROUGH THE LEGISLATIVE LIBRARY. ROOMS 2126, 2226 STATE LEGISLATIVE BUILDING RALEIGH, NORTH CAROLINA 27611 TELEPHONE: (919) 733-7778 OR ROOM 500 LEGISLATIVE OFFICE BUILDING RALEIGH, NORTH CAROLINA 27603-5925 TELEPHONE: (919) 733-9390 North Carolina Study Commission On Aging April 27, 2004 To: Governor Michael Easley Lieutenant Governor Beverly Perdue, President of the North Carolina Senate Senator Marc Basnight, President Pro Tempore of the North Carolina Senate Representative James Black, Speaker of the North Carolina House of Representatives Representative Richard Morgan, Speaker of the North Carolina House of Representatives Members of the 2003 General Assembly, Regular Session 2004 Attached is a report from the North Carolina Study Commission on Aging submitted to you pursuant to North Carolina General Statute §120-187. The North Carolina Study Commission on Aging presents to you findings and recommendations based on study conducted after the adjournment of the 2003 Regular Session of the 2003 General Assembly. Proposed legislation is contained within this report. Respectfully submitted, ___________________________ ___________________________ Senator A.B. Swindell, IV Representative Debbie A. Clary Co-Chair Co-Chair ___________________________ Representative Edd Nye Co-Chair i North Carolina Study Commission On Aging 2004 Membership List President Pro Tempore's Appointments Speakers' Appointments Senator Albin B. Swindell IV, Co-Chair Representative Debbie A. Clary, Co-Chair Senator Austin M. Allran Representative Edd Nye, Co-Chair Senator Charlie S. Dannelly Representative David R. Lewis Senator Tony P. Moore Representative Jennifer Weiss Senator Joe Sam Queen Representative William Eugene Wilson Mr. Brad Allen Ms. Katherine Fox Price Ms. Jan Elliot Ms. Florence Gray Soltys Mr. Sam Marsh Ms. Linda Howard Ex Officio: Mr. Jackie Sheppard, Assistant Secretary, Long Term Care and Family Services, Department of Health and Human Services Clerk: Jo Bobbitt 919/733-5477 Staff: Theresa Matula Dianna Jessup Research Division 919/733-2578 Susan Morgan Fiscal Research Division 919/733-4910 ii North Carolina Study Commission on Aging 1 Report to the Governor and the 2004 Session of the 2003 General Assembly TABLE OF CONTENTS LETTER OF TRANSMITTAL ................................................................................................. i MEMBERSHIP LIST ................................................................................................................ ii PREFACE ................................................................................................................................. 4 EXECUTIVE SUMMARY......................................................................................................... 5 OLDER ADULTS IN NORTH CAROLINA: A PROFILE .................................................... 7 COMMISSION PROCEEDINGS.............................................................................................. 11 COMMISSION RECOMMENDATIONS................................................................................. 16 APPENDICES APPENDIX A ............................................................................................................................. 27 North Carolina Demographics of Aging APPENDIX B ............................................................................................................................ 31 Commission Recommendations to 2003 General Assembly, 2003 Regular Session Summary of Substantive Legislation Related to Aging, 2003 Session Studies and Reports Related to Aging APPENDIX C ............................................................................................................................ 44 Overview of Aging Services and the State Aging Plan Presentation APPENDIX D ............................................................................................................................ 48 Guardianship Reform in the Twenty-First Century APPENDIX E ............................................................................................................................. 53 Tax Treatment of Long-Term Care Insurance in Selected States Long-Term Care Credits Claimed for TY 2002 AAHP-HIAA State Tax Incentives for Purchase of LTCI APPENDIX F.............................................................................................................................. 58 Mentally Ill Population in Adult Care Homes In NC Geriatric Mental Health Specialty Teams Presentation Geriatric Mental Health Specialty Team Model and Guidelines APPENDIX G............................................................................................................................. 66 Summary of Presentations by Organizations Representing Older Adults North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 2 APPENDIX H............................................................................................................................. 72 Home and Community Care Block Grant Presentation Facts about the Home and Community Care Block Grant Summary of Home and Community Care Block Grant Budgeted Funding APPENDIX I.............................................................................................................................. 85 Adult Day Services in Brief Types of Programs and Geographic Location in North Carolina Staffing Ratios Adult Day Services Program Closings 2001-2003 Adult Day Services Funding Fact Sheet APPENDIX J: LEGISLATIVE PROPOSALS ......................................................................... 95 (SWz-32) AN ACT TO REPEAL THE SUNSET ON THE LONG-TERM CARE INSURANCE TAX CREDIT, AS RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON AGING. (SHz-13) AN ACT TO PROVIDE SUPPORT AND TRAINING FOR LONG-TERM CARE PROVIDERS CARING FOR RESIDENTS WITH MENTAL ILLNESSES, AS RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON AGING. (SHz-16) AN ACT TO DIRECT THE DEPARTMENT OF HEALTH AND HUMAN SERVICES TO STUDY ISSUES RELATED TO MENTALLY ILL RESIDENTS IN LONG-TERM CARE FACILITIES, AS RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON AGING. (SWz-37) AN ACT TO ESTABLISH A PILOT PROGRAM TO CONDUCT NATIONAL CRIMINAL HISTORY RECORD CHECKS OF PERSONS SEEKING EMPLOYMENT TO PROVIDE DIRECT CARE IN ADULT CARE HOMES AND CONTRACT AGENCIES OF ADULT CARE HOMES, AND TO MAKE CONFORMING CHANGES, AS RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON AGING. (SHz-6) AN ACT TO APPROPRIATE FUNDS FOR SENIOR CENTER DEVELOPMENT AND OUTREACH, AS RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON AGING. (SHz-7) AN ACT TO APPROPRIATE FUNDS FOR SENIOR ADULT HOUSING, AS RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON AGING. (SHz-8) AN ACT TO APPROPRIATE FUNDS FOR THE HOME AND COMMUNITY CARE BLOCK GRANT, AS RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON AGING. (SWz-34)AN ACT TO DIRECT THE DEPARTMENT OF HEALTH AND HUMAN SERVICES TO STUDY WHETHER AN INSTITUTIONAL BIAS EXISTS IN THE STATE'S MEDICAID PROGRAM, AS RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON AGING. North Carolina Study Commission on Aging 3 Report to the Governor and the 2004 Session of the 2003 General Assembly (SWz-33) AN ACT TO ESTABLISH THE LEGISLATIVE STUDY COMMISSION ON STATE GUARDIANSHIP LAWS, AS RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON AGING. (SHz-11) AN ACT TO APPROPRIATE FUNDS AND TO REQUIRE THE SOCIAL SERVICES COMMISSION TO ADOPT A RATE INCREASE FOR ADULT DAY SERVICES, AS RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON AGING. North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 4 PREFACE As outlined in Chapter 120, Article 21 of the North Carolina General Statutes, the North Carolina Study Commission on Aging is charged with studying and evaluating the existing system of delivery of State services to older adults and recommending an improved system of delivery to meet the present and future needs of older adults. The Commission consists of 17 members. Of these members, eight are appointed by the Speaker of the House of Representatives, eight are appointed by the President Pro Tempore of the Senate, and the Secretary of the Department of Health and Human Services or the Secretary’s designee serves as an ex officio, non-voting member. This report represents the work performed by the North Carolina Study Commission on Aging from the conclusion of the 2003 Session of the 2003 General Assembly until the convening of the 2004 Session of the 2003 General Assembly. The Study Commission on Aging met on five occasions to study a variety of topics concerning older adults including: guardianship, a long-term care insurance tax credit, caring for the mentally ill in long-term care facilities, prescription drug assistance, disease management, elder care housing, the long-term care workforce, adult day services, the Home and Community Care Block Grant, and criminal history record checks of long-term care employees. During the course of its study, the Commission also heard presentations by representatives from fourteen (14) organizations advocating on behalf of older adults in North Carolina. North Carolina Study Commission on Aging 5 Report to the Governor and the 2004 Session of the 2003 General Assembly EXECUTIVE SUMMARY North Carolina General Statutes Chapter 143B, Article 3, Parts 14A. and 14B. establish North Carolina's Policy Act for the Aging, and Long-Term Care. The principles of the Policy Act for the Aging are to effectively utilize the resources of the State, to provide a better quality of life for senior citizens, and to assure older adults the right of choosing where and how they want to live. The Long-Term Care policy recognizes that traditional caregivers are increasingly employed outside the home and create a growing demand for improvement and expansion of home and community-based long-term care services to support and complement the services provided by informal caregivers. The long-term care policy provides that the public interest would best be served by a broad array of long-term care services that support persons who need services in the home or in the community whenever practicable, and that promote individual autonomy, dignity and choice. The provision also provides that institutional care will continue to be a critical part of the State's long-term care options and that services should promote individual dignity, autonomy, and a home-like environment. The current size of North Carolina's older adult population, and trends indicating that this segment of the population will increase, indicate the importance of an intense and sustained focus on the support systems and services that North Carolina has in place for older adults. Study efforts undertaken during the 2003-2004 interim by the North Carolina Study Commission on Aging, sought to evaluate the existing system of services to older adults and to recommend improvements. In response to this study, the North Carolina Study Commission on Aging makes the following recommendations to the Governor and the 2004 Session of the 2003 General Assembly: Recommendation 1 The North Carolina Study Commission on Aging recommends that the General Assembly repeal the sunset on the Long-Term Care Insurance Tax Credit. Recommendation 2 The North Carolina Study Commission on Aging recommends that the General Assembly require the Department of Health and Human Services to continue to provide support and training for long-term care providers caring for residents with mental illnesses by conducting a study on expanding the mission of Geriatric Mental Health Specialty Teams; and by standardizing criteria across the Teams and tracking utilization and expenditure data. Recommendation 3 The North Carolina Study Commission on Aging recommends that the General Assembly require the Department of Health and Human Services to work with long-term care providers and advocates for the elderly and the mentally ill to study issues related to mentally ill individuals residing in long-term care facilities. Recommendation 4 The North Carolina Study Commission on Aging recommends that the General Assembly establish a pilot program to conduct national criminal history record checks of persons seeking employment to provide direct care in adult care homes or contract agencies of adult care homes. North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 6 Recommendation 5 The North Carolina Study Commission on Aging recommends that the General Assembly support Senior Center development and outreach, and restore funding to the 2002 level, by appropriating $281,000 for the 2004-2005 fiscal year. Recommendation 6 The North Carolina Study Commission on Aging recommends that the General Assembly appropriate $1,000,000 to the Housing Trust Fund for the 2004-2005 fiscal year to be used for independent housing with services. Recommendation 7 The North Carolina Study Commission on Aging recommends that the General Assembly appropriate $1,000,000 for the Home and Community Care Block Grant for the 2004-2005 fiscal year. Recommendation 8 The North Carolina Study Commission on Aging recommends that the General Assembly require the Department of Health and Human Services to study whether the State's Medicaid Program has a bias that favors support for individuals in institutional settings over support for individuals living at home; and to recommend ways to alleviate this bias, if such a bias exists. Recommendation 9 The North Carolina Study Commission on Aging recommends that the General Assembly establish a Legislative Study Commission to study State guardianship laws. Recommendation 10 The North Carolina Study Commission on Aging recommends that the General Assembly appropriate funds and require the Social Services Commission to adopt a rate increase of no less than five dollars ($5.00) per day for adult day and adult day health services. North Carolina Study Commission on Aging 7 Report to the Governor and the 2004 Session of the 2003 General Assembly OLDER ADULTS IN NORTH CAROLINA: A PROFILE Prepared by the Department of Health and Human Services, Division of Aging and Adult Services Older Population Today North Carolina ranks tenth among states in the number of persons age 65 and older and eleventh in the size of the entire population.i The fast pace of growth of the State’s older population is evident in a recent US Census Bureau’s release in which North Carolina was ranked fourth nationally in the increase of the number of older persons age 65+ (47,198 in NC) between April 2000 to July 2003. Only three other states (California, Texas, and Florida) reported a greater increase among their older populations. Even so, when combined with the equally strong growth in other age groups, the State continues to maintain an overall healthy demographic balance among the generations. Currently, North Carolina ranks thirty-third nationally in the percentage of the population that is 65 years of age and older (65+). § North Carolina population age 65+ in 2004: 1,016,214 (12.1% of total population) § North Carolina population age 85+ in 2004: 118,511 (1.4% of the total population) North Carolina is rich in diversity, but its citizens face challenges because of the disparity that exists among all populations, including older adults. Some important differences among the State's older adults relate to gender, marital status, race/ethnicity, residence, rurality, disability, health status, and veteran status. § Gender: Older women represent 59.8% of the 65+ age group and 74.0% of the 85+ age group.ii The higher rate of poverty among older women remains a primary issue today. For example, women age 75+ are twice as likely to be poor as men the same age.iii § Marital Status: At age 65 and older, women are more than twice as likely to be unmarried as men in their age group.iv Data show that being unmarried (widowed, divorced, separated, or never married) increases a woman’s vulnerability to poverty. According to the Social Security Administration, 50% of unmarried women rely on Social Security for 80% of their income and 25% rely on Social Security as their sole source of income.v Age 65-74 Age 75-84 Age 85+ Unmarried Women in NC 45.4% 65.8% 76.5% Unmarried Men in NC 18.7% 25.2% 39.4% Source: NC Division of Aging and Adult Services (2003). The Aging of North Carolina: The 2003-2007 North Carolina Aging Services Plan § Ethnicity/Race: Altogether 18.1% of persons age 65+ are members of ethnic minority groups in North Carolina.vi Compared to the nation as a whole, North Carolina’s population age 65+ includes a larger proportion who are African American (15.3% in NC to 8.3% nationally) and a smaller proportion of Latinos (0.6% in NC to 4.7% nationally). American Indians, Asian Americans, and other ethnic groups each account for 1% or less of the age group 65+. The statistics for African American and other older adults who are minority group members, in North Carolina as well as nationally, show both a higher poverty rate and a lower life North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 8 expectancy when compared with the white population. 65+ White Minority Total Male Female Male Female Below Poverty 13.2% 6.5% 12.9% 21.7% 30.3% “Near Poor”(101-200% Poverty) 23.2% –* –* –* –* Life Expectancy at Birth (years) 75.6 73.8 79.6 68.0 75.8 Life Expectancy at Age 65 (years) 17.1 15.4 18.9 13.8 17.8 *Information currently not available. Source: NC Division of Public Health (2002). Healthy Life Expectancy in North Carolina, 1996-2000. § Residence: In North Carolina, 23.8% of all homeowners are age 65+, yet among older homeowners, over 61,000 reported incomes for 1999 that were below poverty.vii This figure represented 38% of the homeowners of all ages with income below poverty and exceeded the national average of 32.7%. Among renters age 65+ who provided information, 53%, or almost 48,000, spent more than 30% of their household income on rent. Furthermore, 5,000 North Carolina homeowners and renters age 65+ lacked complete plumbing facilities in their homes.viii Even more disturbing news is found in the statistics of emergency shelters—where the largest increase among the homeless between 2001 and 2002 in North Carolina were among those 55+.ix While the total population of homeless reported by shelters increased by 5% during this period, the elder homeless grew by 71% (totaling 3,494 persons in 2002). § Rurality: Although the United States Census Bureau has not yet released figures specifically for the older population residing in rural areas, it is expected to easily exceed 39.8%, the rate for the total population.x In 2000, North Carolina's rural population (3,199,831) was almost as large as the one in Texas (3,647,539), the state with the largest number of rural residents in the nation. Not only was North Carolina's rural population among the largest in terms of numbers, but the state also reported the highest proportion (39.8%) of rural population among the 20 most populous states in the nation. While 11 other states reported higher proportions of rural population, ranging from 40.7% to 61.8%, all of these states are much smaller in total population than North Carolina. Thus, North Carolina is unique among more populous states in having so large a rural contingent. A 2002 report highlights a long list of challenges rural residents and their communities face—isolation by distance, lagging infrastructure, sparse resources that cannot adequately support education and other public services, and weak economic competitiveness.xi § Disability: In North Carolina, 45.7% of the non-institutionalized civilian population age 65+ reported having one or more disablities•47.5% of women and 43.2% of men, according to the 2000 Census.xii The Census defines disability as “a long-lasting physical, mental, or emotional condition. This condition can make it difficult for a person to do activities such as walking, climbing stairs, dressing, bathing, learning, or remembering. This condition can also impede a person from being able to go outside the home alone or to work at a job or business.” § Health Status: In a statewide survey, over one third of people age 65+ say that their general health status is fair or poor, ranging from 34.1% for white women to 49.3% for minority women.xiii In the same survey, 18.4% (highest) of minority women and 4.4% (lowest) of white men age 65+ said that there was a time they could not see a doctor due to medical cost. North Carolina Study Commission on Aging 9 Report to the Governor and the 2004 Session of the 2003 General Assembly § Veteran Status: Of the 779,393 veterans living in North Carolina, 263,102, or 34%, were age 65 and older in 2000. Another 34% were Vietnam-era veterans (between 43 and 57 years old in 2000). The population of veterans of the Vietnam-era contains proportionally more disabled members than the veterans’ populations of earlier wars.xiv The Veterans Administration cites the aging of the veterans as a major challenge to its health care system in coming years.xv North Carolina’s Demographic Shift Older adults are North Carolina’s fastest growing population. By 2030, our senior population should exceed more than 2.2 million, comprising 17.9% of total population.xvi The median age climbs from 35.3 years in 2000 to 38.4 years in 2030. Projected Growth of Population Age 65+ (2000 – 2030) 969,048 1,183,243 1,652,288 2,221,470 0 500,000 1,000,000 1,500,000 2,000,000 2,500,000 2000 2010 2020 2030 Year Population Age 65+ Why This Demographic Shift A combination of improved life expectancy and lower birth rates contributes to a society’s “aging”. In North Carolina, as anywhere in the nation, the aging of the “Baby Boomers” (born between 1946 and 1964) will greatly accelerate this societal aging in coming years. Another factor in the State’s aging is migration. North Carolina ranked sixth among the states with a net migration rate of 22.1 per 1,000 among persons age 65+, in the five-year period between 1995 and 2000. [Note: A positive net migration indicates that more older adults moved to North Carolina than left during that time.] Along with other Sunbelt states, North Carolina remains a popular destination for people of all ages, including seniors. Other southern states with high positive net migration among older adults include: Florida (56.9); South Carolina (33.6); Georgia (18.1); and Tennessee (15.2). There are other important factors influencing the diverse experiences in demographic shifts among the State’s 100 counties.xvii In 83 counties, the rate of increase among citizens age 65+ (22%) is expected to exceed the growth of the total population (18%). § Rural-to-urban migration of young adults continues to age rural counties. § Large metropolitan counties attract large numbers of persons from outside the State as well as from rural counties. § The large metropolitan counties are experiencing greater growth among younger adults than North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 10 they are among older adults. § A large number of older adults with higher incomes are retiring in some western and coastal counties. What Are the Implications of This Shift? The aging of the population is a national and international trend, and North Carolina, like the rest of the world, must be prepared to reap the benefits and face the challenges of an older population. Government faces decisions about the allocation of public resources from a tax base that may experience slowed growth, especially in many aging rural counties. People must consider living and caregiving arrangements in light of smaller nuclear and extended families. The health, human service, employment, and education systems must adapt to the changing needs and interests of seniors of today and tomorrow. The business, faith communities, and others must identify and respond to the challenges and opportunities of these demographic shifts. In the 2003-2007 State Aging Plan, the North Carolina Division of Aging and Adult Services introduced a new initiative–Senior-Friendly Communities–to raise awareness of the aging of our population and to promote the North Carolina communities becoming senior-friendly through collaboration among citizens, agencies, organizations, and programs, in both the public and private arenas. A senior-friendly community in North Carolina will draw on the talents and resources of active seniors while enhancing services for those are vulnerable because of their health, economic hardships, social isolation, or other conditions. A senior-friendly community will bring together a wide range of issues and concerns (e.g., air quality, housing, long-term care services, employment, enrichment opportunities) that, as a whole, affect the quality of life of seniors and others in the community. Also, a senior-friendly community will assure stewardship of its resources to meet the needs of today’s seniors, while helping baby boomers and younger generations prepare for the future. For additional information on North Carolina aging demographics, please refer to Appendix A. Sources of Information 1 US Census Bureau (2004). Annual Estimates of the Resident Population by Selected Age Groups for the United States and States: July 1, 2003 and April 1, 2000. 1 NC State Data Center (2004). County/State Population Estimates. 1 Institute for Research on Women & Gender (2002). Difficult Dialogues Program Consensus Report: Aging in the Twenty-first Century. 1 US Census Bureau (2002). PCT 7 (Summary File 3). 1 US Social Security Administration (1998). Fast Facts & Figures about Social Security. 1 US Census Bureau (2003). P12 (Summary File 1). 1 US Census Bureau (2002). HCT 8 (Summary File 2). 1 NC State Library (2003). Special tabulation from the Census 2000 data as requested by the NC Division of Aging. 1 NC Office of Economic Opportunity (2002). Comparison of Beneficiary Characteristics: Emergency Shelter Grants Program (FY 2000 and FY 2001). 1 US Census Bureau (2003). P2 (Summary File 1). 1 MDC (2002). State of the South 2002. 1 US Census Bureau (2003). PCT 26 (Summary File 3). 1 NC Department of Health and Human Services (2003). A Health Profile of Older North Carolinians. 1 US Department of Veterans’ Affairs (2002). VA History in Brief. 1 US Department of Veterans’ Affairs (2002). Data on the Socioeconomic Status of Veterans and on VA Program Usage. 1 NC State Data Center (2004). County/State Population Projections. 1 NC Division of Aging and Adult Services (2003). The Aging of North Carolina: The 2003-2007 North Carolina Aging Services Plan. North Carolina Study Commission on Aging 11 Report to the Governor and the 2004 Session of the 2003 General Assembly COMMISSION PROCEEDINGS February 10, 2004 The North Carolina Study Commission on Aging met on Tuesday, February 10, 2004 at 10:00 a.m. in Room 643 of the Legislative Office Building. Representative Edd Nye was the presiding Co-Chair. Following Commission member introductions and approval of the budget, Theresa Matula, Commission staff, provided an overview of the statutory basis for the Commission and its charge. By law, the Commission is required to study and evaluate the existing system of delivery of State services to older adults and to recommend an improved system of delivery to meet the present and future needs of older adults. Mrs. Matula pointed out the specific duties of the Commission as they appear in G.S. 120-181, and the reporting requirements contained in G.S. 120-187. Theresa Matula and Dianna Jessup, Commission staff, reviewed the status of the Commission's recommendations to the 2003 Session of the 2003 General Assembly and presented an overview of other legislation of interest to older adults Appendix B. Karen Gottovi, Director, Division of Aging and Adult Services, Department of Health and Human Services (DHHS), presented an overview of the services available for older adults in North Carolina Appendix C. Mrs. Gottovi also presented The Aging of North Carolina, the 2003-2007 North Carolina Aging Services Plan. The Plan was submitted to the North Carolina General Assembly on March 1, 2003. Mrs. Gottovi pointed out that the 2003-2007 Plan builds upon the achievements of the 1999-2003 Plan as well as three other earlier plans developed in the 1990s (1991, 1993, and 1995) and provides a foundation for new developments. The Aging Services Plan is required by G.S. 143B-181.1A and the federal Older American Act. John Saxon, Professor of Public Law and Government, University of North Carolina at Chapel Hill gave a presentation on guardianship laws. Appendix D. The presentation outlined the legal history of guardianship reform, the current law and issues that may need to be addressed, as well as and overview of the Uniform Guardianship and Protective Proceedings Act (UGPPA). The North Carolina tax credit for long term care insurance expired for taxable years beginning on or after January 1, 2004. As a result, the Commission heard from Carla Obiol with the Department of Insurance's Seniors' Health Insurance Information Program (SHIIP), who gave an overview of long term care insurance. Her handouts included: A Shopper's Guide to Long-Term Care Insurance and Facts About Long-Term Care Insurance In North Carolina . Additionally, Karl Knapp from the Tax Research Division, and Nancy Pomeranz from the Personal Taxes Division, of the North Carolina Department of Revenue, made presentations on the tax treatment of long-term care insurance in selected states, and on the number of long-term care tax credits claimed in North Carolina Appendix E. Ms. Pomeranz discussed the error rate experienced on the long-term care tax credit and the Department's efforts to reduce that error rate. Some of the Department's efforts include informing taxpayers who made errors, and working with software vendors to improve the long-term care tax credit information in their programs. The final item on the agenda concerned adult care home rules and caring for the mentally ill. The Commission heard presentations from Jim Upchurch, Division of Facility Services, Department of Health and Human Services Appendix F; Dottie Harrison, Board Member, NC National Alliance for the Mentally Ill (NAMI); and Lou Wilson, NC Association of Long Term North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 12 Care Facilities. Ms. Harrison addressed the consequences of the lack of appropriate housing for mentally ill individuals and her concerns for adequate staffing and training to care for mentally ill individuals in long-term care facilities. Ms. Wilson mentioned the use of the Geriatric Mental Health Specialty Teams and provided recommendations for improvement. March 9, 2004 The North Carolina Study Commission on Aging met on Tuesday, March 9, 2004 at 10:00 a.m. in Room 643 of the Legislative Office Building. Senator A.B. Swindell was the presiding Co- Chair. Topics of this meeting included brief remarks by organizations advocating on behalf of older adults in North Carolina; disease management; NC Senior Care; the new Medicare prescription drug program; and geriatric mental health specialty teams. The Commission heard from fifteen (15) individuals that represent, or advocate on behalf of, older adults in North Carolina. Each representative was allowed approximately three minutes to make a brief presentation on the issues affecting older adults in North Carolina. Staff presented the Commission members with a Summary of Presentations by Organizations Representing Older Adults Appendix G during the March 23, 2004 meeting. The legislative priorities/issues of concern that were mentioned with the greatest frequency were: Access to National Criminal Record Checks (6 responses); Restoration of the LTC Insurance Tax Credit (4 responses); Support for and/or Restoration of Funding for the home and Community Care Block Grant (HCCBG) (3 responses); Support for/and or Restoration of Funding for Senior Centers (3 responses); and Maintaining the Viability of the Community Alternatives Program for Disabled Adults (CAP/DA) (3 responses) Appendix G. Alan Dobson, Chairman of Cabarrus Community Care; Chairman of Physician Advisory Group; and President/CEO of Cabarrus Family Medicine delivered a presentation on disease management. Community Care of North Carolina focuses on improved quality, utilization and cost effectiveness with thirteen (13) networks with more than 2,000 physicians and 417,000 enrollees. Dr. Dobson indicated that the primary goals of Community Care of North Carolina are to: Improve the care of the Medicaid population while controlling costs; and to Develop community based networks capable of managing populations. He pointed out that these goals are achieved by making sure people get the care when they need it; increasing local provider collaboration; obtaining quality care; implementing best practice guidelines; and managing Medicaid costs. Key program efforts for the aged and disabled include: diabetes, poly-pharmacy in skilled nursing facilities, poly-pharmacy for the disabled, and therapy services. Michael Keough, from the Department of Health and Human Services, gave a presentation on the North Carolina Senior Care program. He first gave an overview of the program, which is designed specifically to provide assistance to North Carolina seniors (age 65 or older), diagnosed with one of three diseases (diabetes mellitus, cardiovascular disease, and chronic obstructive pulmonary disease); have an annual household income at or below 200% of the federal poverty level and no other prescription drug coverage. As of March 2004, there were 32,600 enrollees, representing all 100 counties. Outreach efforts include the distribution of 400,000 enrollment applications and an outreach grant with the General Baptist State Convention. Mr. Keough also presented information on the Medication Assistance Program in which 23 grantees cover 60 sites in 60 counties. The key components of the Medication Assistance Program include: Prescription Assistance (facilitating use of pharmaceutical manufacturers' free and low cost drug programs), and Medication Management including pharmacist evaluation of individual senior's drug North Carolina Study Commission on Aging 13 Report to the Governor and the 2004 Session of the 2003 General Assembly regimens. NC Senior Care is reviewing options to coordinate coverage with the recently enacted changes to the Medicare program. Carla Obiol, Deputy Commissioner, Seniors' Health Insurance Information Program (SHIIP) made a presentation to the Commission on the Medicare Prescription Drug Improvement and Modernization Act of 2003 (Act). Ms. Obiol gave an overview of the timetable of benefits, information on the Medicare Prescription Drug Discount Card and the Transitional Assistance Program, the discount card sponsor qualifications, Medicare Part D: Prescription Drug Plan (PDP), and outreach efforts by SHIIP and the Centers for Medicare & Medicaid Services (CMS). Provisions of the Act include a Medicare-approved Prescription Drug Discount Card, a Transitional Assistance Program, and Medicare Advantage from 2004-2005. It is anticipated that Medicare Part D: Prescription Drug Plan will be in place by 2006. Details are continuing to evolve and Ms. Obiol recommended the following resources: the Medicare Program: http://www.medicare.gov/ or http://www.cms.gov/ or 1-800-MEDICARE; and SHIIP http://www.ncshiip.com./ (see Senior Citizens heading). This meeting concluded with a presentation on Geriatric Mental Health Specialty Teams from Dr. Bonnie Morell, Division of Mental Health, Developmental Disabilities and Substance Abuse Services, Department of Health and Human Services. According to Dr. Morell, the Geriatric Mental Health Specialty Teams were developed to provide expertise and services throughout the State in recognition of the need for greater local capacity to address and serve the needs of older adults with mental illness. According to information presented, "The purpose of these teams is to increase the ability of older adults with mental illness to live successfully in their communities by: 1) assisting with the successful reintegration of older adults into the community when they are discharged from State psychiatric hospitals, and 2) providing holistic support services and technical assistance to nursing homes, adult care homes, and other agencies and caregivers that serve older adults who have mental health treatment needs and who may be at risk of psychiatric hospitalization." Appendix F March 23, 2004 The North Carolina Study Commission on Aging met on Tuesday, March 23, 2004 at 10:00 a.m. in Room 643 of the Legislative Office Building. Representative Debbie Clary was the presiding Co-Chair. Presentation topics for this meeting were elder housing, the long-term care workforce, adult day services, the Home and Community Care Block Grant (HCCBG), a report on CAP/DA, and criminal history record checks. Bob Kucab, Executive Director of the North Carolina Housing Finance Agency, spoke to the Commission about the work of the agency. The purpose of the agency is to finance housing for persons who are not served by the private market. The agency helps seniors by improving their existing housing and by working to develop new apartments where seniors can have affordable rents, good living environments, and connections to community services. While the agency is involved in a number of projects, applications for funding exceed available capital by 3 to 1. Mr. Kucab requested an increase in the $3 million State appropriation for the Housing Trust Fund to aid the agency in its efforts. Susan Harmuth from the Office of Long Term Care and Family Services, Department of Health and Human Services (DHHS), updated the Commission on the Department's long-term care workforce initiatives. She reported that employee turnover has been decreasing since 2000, but it is still high. The Department is working on a variety of projects to combat this turnover. One North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 14 of these projects is The Better Jobs/Better Care Demonstration. Under this demonstration, the State's Better Jobs/Better Care Partner Team is working to develop a uniform (and voluntary) set of expectations and criteria for use across home care, adult care homes and nursing facilities that relate to issues impacting the recruitment and retention of direct care workers. Major domain areas include safe and balanced workloads, training and career advancement opportunities, supportive workplaces, worker empowerment, peer mentoring, orientation, management support, coaching supervision, and reward and recognition. Following Ms. Harmuth's presentation, the Commission heard several presentations concerning adult day and adult day health services. Nancy J. Cox, Director of Partners in Caregiving, Wake Forest University School of Medicine, presented information concerning the predictors of success for adult day programs from a marketing, financing, and programming perspective. Created in 1987 by The Robert Wood Johnson Foundation, Partners in Caregiving is a national adult day services program. The focus of Partners in Caregiving is to teach non-profit adult day centers the principles of business and marketing to be financially self-sufficient and not rely on grants. She presented the results of a recent national study of adult day services that showed the need for adult day service capacity building at the State level in three areas: increased public awareness in underutilized areas, increased availability in areas where the service is not currently an option for caregivers, and increased knowledge at the provider level regarding predictors of success. Suzi Kennedy from the Life Enrichment Center of Cleveland County, Inc. spoke about the challenges of operating a successful adult day program. Ms. Kennedy showed pictures of the facilities in her area and presented the "Menu for Financial Success for the Life Enrichment Center." This Menu included: 1) a strong Board with effective committees; 2) diversified revenue streams (operating and non-operating); 3) a diversified population; 4) unbundling the services (i.e. transportation, personal care services, hair care); and 5) pre-billing for enrollment rather than attendance, for the levels of care, and for ancillary services. Ms. Kennedy stated that, "Without financial stability there can be no social good," and she pointed out that public reimbursement rates are often insufficient to cover the costs of running a program. Steve Freedman from the Division of Aging and Adult Services, DHHS, was the final speaker on the subject of adult day services Appendix I. Mr. Freedman stated that there are currently 113 certified adult day and adult day health programs in the State, a decrease from the peak of 125 programs in 2000. The programs are currently located in 60 counties. The Division of Aging and Adult Services has been working with the North Carolina Adult Day Services Association to develop fiscal training for adult day programs. According to the Division, the aim of this project is to assist adult day programs with budgeting and help increase their understanding of service costs. Mr. Freedman also addressed reimbursement rates. Currently, the maximum reimbursement rate for adult day services is $26.07 per day, and $33.00 per day for adult day health services. According to the North Carolina Adult Day Services Association, the average cost to operate an adult day program is $31.00 per day, and for adult day health programs it is $44.00 per day. In the 2003 budget bill, the General Assembly directed the Social Services Commission to consider adopting rules to increase these rates within existing funds. A rate increase has not occurred. Next, Dennis Streets from the Division of Aging and Adult Services, DHHS presented information concerning the Home and Community Care Block Grant Appendix H. The Home and Community Care Block Grant (HCCBG) was established by the General Assembly in 1992. North Carolina Study Commission on Aging 15 Report to the Governor and the 2004 Session of the 2003 General Assembly By consolidating several funding sources (i.e. the Older Americans Act, the Social Services Block Grant in support of respite care, portions of the State In-Home and Adult Day Care funds, and other relevant State appropriations), the HCCBG helps to coordinate the service delivery system to meet the needs of seniors. The focus of the HCCBG is to support the frail elderly at home, assist with access to services and information, provide family caregiver relief and help seniors remain active. While there have been some increases in federal funds, State support has decreased. According to Mr. Streets, there are more than 6,500 unmet service needs, especially for home-delivered meals and in-home aide services. Gary Fuquay, Division of Medical Assistance, DHHS, presented a report on the Community Alternatives Program for Disabled Adults (CAP/DA), required by S.L. 2003-284, Sec. 10.29B(b) and (c). The section basically required the Department to conduct a cost analysis of CAP/DA and the State/County Special Assistance In-Home program in relation to the per client cost of nursing homes and adult care homes. While the report attempted to provide cost comparisons, Mr. Fuquay warned that it is difficult to draw conclusions from the data because one cannot compare level of care indicators. The Commission next heard from various speakers concerning national criminal history records checks of long-term care workers. John Aldridge from the North Carolina Attorney General's Office gave an overview of current law regarding who can receive the results of national criminal history records checks and for what purposes. Jackie Sheppard from the Office of Long-Term Care and Family Services, DHHS, gave an overview of what the state of Mississippi is doing to address this issue. Roger Manus, representing Friends of Residents in Long-Term Care, urged the Commission to look at Florida's system for conducting background checks. Stacy Flannery, representing the NC Health Care Facilities Association, presented the providers' concerns about this issue. Finally, the meeting concluded with a brief presentation summarizing Appendix G the association presentations from the March 9 meeting. Chief among the issues raised by the associations was the current moratorium on national criminal history records checks of long-term care workers. April 13, 2004 The North Carolina Study Commission on Aging met on Tuesday, April 13, 2004 at 10:00 a.m. in Room 643 of the Legislative Office Building. Senator A.B. Swindell was the presiding Co- Chair. During this meeting, the Commission heard a presentation from Jackie Franklin with the Division of Aging and Adult Services, Department of Health and Human Services, on the State/County Special Assistance In-Home program. The Commission discussed and initially approved recommendations to the Governor and the General Assembly. The Commission also directed the staff to prepare a draft report for review at the final meeting. April 27, 2004 The North Carolina Study Commission on Aging met on Tuesday, April 27, 2004 at 10:00 a.m. in Room 643 of the Legislative Office Building. Members discussed and approved the Commission’s Report to the Governor and to the 2004 Session of the 2003 General Assembly. North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 16 COMMISSION RECOMMENDATIONS The North Carolina Study Commission on Aging makes the recommendations presented in this section to the Governor and the 2004 Session of the 2003 General Assembly. Each recommendation is followed by background information, and corresponding legislative proposals appear in Appendix J of this report. Recommendation 1 The North Carolina Study Commission on Aging recommends that the General Assembly repeal the sunset on the Long-Term Care Insurance Tax Credit. Background In 1997, the North Carolina Study Commission on Aging recommended that the 1997 General Assembly enact a 15% tax credit, up to a maximum of $350, on the premiums paid by the purchaser of long-term care insurance policies. According to the 1997 Commission report, the Office of State Budget and Management estimated that a 15% tax credit up to a maximum of $350 may result in a revenue loss of $17 million. The report further stated that, the average premium was $1,600, thus a 15% credit would be equal to $240. The report acknowledged that it was difficult to estimate the offsetting benefits of the tax credit in terms of reduced Medicaid payments, but that the cost of a year's stay in a North Carolina nursing home was $40,000. The Commission recommended this tax credit again in 1998, and the credit became Section 29A.6 of Session Law 1998-212. The tax credit was effective for taxable years beginning on or after January 1, 1999, and expired for taxable years beginning on or after January 1, 2004. On January 16, 2003, the Department of Revenue prepared a memorandum for the Revenue Laws Study Committee on the status of the tax credit for premiums paid on long-term care insurance. The memorandum outlined the Department's review of some of the returns on which the credit was claimed. During this review, auditors found that some taxpayers, who were not eligible for the tax credits, claimed the tax credits; and that some taxpayers claimed long-term care credits greater than the cap of $350. The Department found that, "Of the 2,155 returns reviewed, only 192 contained allowable long-term care credits. Taxpayers were not eligible for the credits claimed on the remaining 1,963 returns in this group. As a group, therefore, over 90% of the returns incorrectly claimed the credit." Because this represented a sample, the Department indicated that they did not know the error rate for all returns claiming the credit. They attributed the high error rate to two possible factors: "One factor is the complicated nature of the credit and the other is confusion of this credit with the repealed child health insurance credit." Additionally, the memorandum indicated that, for tax year 2001, the credit reduced tax revenue by $10,367,883. The 2003 North Carolina Study Commission on Aging recommended repealing the sunset on the long-term care insurance tax credit. In its 2003 report, the Commission expressed agreement with a statement from a Division of Aging's report, Increasing Personal Responsibility for Long Term Care through Private Long Term Care Insurance. The Division's report stated that, "In addition to the public benefit of having a much larger segment of the adult population positioned to pay privately for long-term care in terms of the state's economic health, consumers and families benefit from the ability to pay privately through increased choice and flexibility in terms of the range of services and settings of care available." S.L. 1998-212, Section 29A.6(d) made North Carolina Study Commission on Aging 17 Report to the Governor and the 2004 Session of the 2003 General Assembly the credit for premiums paid on long-term care insurance effective for taxable years beginning on or after January 1, 1999, and sunset the credit effective January 1, 2004. The Commission's bills repealing the sunset were introduced during the 2003 Session, but were not successful and the tax credit was allowed to sunset. As a result, the tax credit is not currently in place for the 2004 tax year. During the February 10, 2004 meeting, the Commission heard a presentation on long-term care insurance from Carla Obiol with the Seniors' Health Insurance Information Program (SHIIP), and presentations on issues related to the tax credit from Department of Revenue employees Karl Knapp, Tax Research Division, and Nancy Pomeranz, Personal Taxes Division Appendix E. Carla Obiol with the Department of Insurance's Seniors' Health Insurance Information Program (SHIIP), gave an overview of long-term care insurance. Her handouts included: A Shopper's Guide to Long-Term Care Insurance and Facts About Long-Term Care Insurance In North Carolina . Karl Knapp from the Tax Research Division, and Nancy Pomeranz from the Personal Taxes Division, of the North Carolina Department of Revenue, made presentations on the tax treatment of long-term care insurance in selected states, and on the number of long-term care tax credits claimed in North Carolina Appendix E. Ms. Pomeranz discussed the error rate experienced on the long-term care tax credit and the Department's efforts to reduce that error rate. The Department indicated that they had made progress in reducing the error rate on the long-term care insurance tax credit. Commission staff also obtained a chart Appendix E from the American Association of Health Plans-Health Insurance Association of America (AAHP-HIAA) depicting those states in the United States that offer tax incentives for the purchase of long-term care insurance. AAHP-HIAA is a national trade association representing the private sector in health care. The chart from AAHP-HIAA shows that 6 states offer tax credits and 16 states offer tax deductions. (Note: The information in the AAHP-HIAA chart does vary from the Department of Revenue's information, which could be the result of different compilation dates.) According to information received by the Commission staff, on June 5, 2003, the Department of Revenue reported that they had audited 2,372 returns for the tax year 2002, and adjusted 650 to disallow the credit, representing a 27% error rate. This error rate was down considerably from the 90% error rate on the 2001 returns reported earlier by the Department. The Department attributed the decrease to: 1) informing tax preparers of the appropriate use of the credit; 2) clarifying instructions about eligibility for the credit; 3) improving the verbiage in software developers' tax packages; and 4) communicating with taxpayers whose credit was disallowed in 2001, to inform them of the eligibility criteria for the tax credit. An additional $279,628 was assessed on the 650 returns adjusted, and returns continue to be audited as resources permit. On November 3, 2003, the Department reported that they had processed 3,574,530 returns: 2,158,850 paper and 1,415,680 efiled. Of the total, there were 35,936 on which a credit for long-term care insurance was claimed for a total of $19,110,623. The North Carolina Study Commission on Aging has supported the long-term care insurance tax credit since its inception and the current Commission continues to support it. The Commission scheduled presentations on this issue at the first meeting this interim, and restoration of the long-term care insurance tax credit was an item mentioned frequently during presentations on March 9, 2004, by organizations representing older adults in North Carolina. The Commission recommends that the General Assembly repeal the sunset on the long-term care insurance tax credit. Recommendation 2 The North Carolina Study Commission on Aging recommends that the General Assembly North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 18 require the Department of Health and Human Services to continue to provide support and training for long-term care providers caring for residents with mental illnesses by conducting a study on expanding the mission of Geriatric Mental Health Specialty Teams; and by standardizing criteria across the Teams and tracking utilization and expenditure data. Background On February 10, 2004, the Commission heard presentations on adult care home rules and caring for the mentally ill from Jim Upchurch, Division of Facility Services, Department of Health and Human Services (DHHS); Dottie Harrison, Board Member, NC National Alliance for the Mentally Ill (NAMI); and Lou Wilson, NC Association Long Term Care Facilities. On March 9, 2004, the Commission heard a presentation on Geriatric Mental Health Specialty Teams from Bonnie Morell, Community Policy Section, Division of Mental Health, Developmental Disabilities and Substance Abuse Services, Department of Health and Human Services (DHHS). Appendix F During her presentation, Ms. Wilson mentioned the use of the Geriatric Mental Health Specialty Teams. She indicated that while the intent of the program was positive, she believed, "The State has provided very little guidance for area mental health programs as to how the teams should be operated, thus the program has floundered in many areas of the state." She also stated that, "Area programs all over the State have developed criteria, protocol, policies and procedures that are unique to their area program. As a result, consumers and providers of services are expected to muddle through a system of inconsistency." According to information provided by DHHS, Geriatric Mental Health Specialty Teams were developed to increase the ability of older adults with mental illness to live successfully in their communities by: 1) assisting with the successful reintegration of older adults into the community when they are discharged from State psychiatric hospitals; and 2) providing holistic support services and technical assistance to nursing homes, adult care homes, and other agencies and caregivers that serve older adults who have mental health treatment needs and who may be at risk of psychiatric hospitalization. Currently, the Teams serve individuals 60+ years of age who are preparing to enter a nursing home or an adult care home, who currently reside in a nursing home or adult care home, and who are living in their own home or with family members. Individuals with geriatric-like needs are also served. Dr. Morell noted that, "This is a fairly new program that is being implemented during a time of change in the public mental health system. Focus will be on identifying ways in which to support the work that is being done by the teams that have been put in place." During her presentation on February 10, 2004, Ms. Wilson shared a recommendation for legislation. Ms. Wilson's recommendations include: 1) renaming the Teams to Long Term Care Facility Specialty Teams; 2) requiring all licensed adult care homes and nursing homes that serve individuals with a mental illness to participate in the program; 3) deleting the age requirement and the restrictions for residents to be at risk of psychiatric hospitalization and making services available for all persons with a mental illness who reside in adult care homes and nursing homes; 4) increasing the number of professionals on each team and/or decreasing the geographic areas that each team covers; 5) developing standardized criteria; 6) fully funding the program to support the individuals and facilities eligible for services; and 7) repealing the current adult care home special unit rule for persons with mental illnesses and create a new licensure law and rules that are more realistic. North Carolina Study Commission on Aging 19 Report to the Governor and the 2004 Session of the 2003 General Assembly According to information provided by staff in the General Assembly's Fiscal Research Division, the Geriatric Mental Health Specialty Teams are a contracted service through the Local Management Entities (LME). There are 20 Teams across North Carolina and each one contracts with one or more LME's. These are funded with Mental Health Trust Fund dollars, and these non-recurring funds are being replaced by recurring funds made available through mental hospital downsizing. As a Team delivers services to a facility, they file for reimbursement with the LME, which in turn seeks reimbursement from DHHS. Currently, DHHS cannot report specific cost data on the Geriatric Mental Health Specialty Teams. Based on the information presented to the Commission, the Commission recommends that the General Assembly require the Department of Health and Human Services to continue to provide support and training for long-term care providers caring for residents with mental illnesses by conducting a study on expanding the mission of Geriatric Mental Health Specialty Teams; and by standardizing criteria across the Teams and tracking utilization and expenditure data. Recommendation 3 The North Carolina Study Commission on Aging recommends that the General Assembly require the Department of Health and Human Services to work with long-term care providers and advocates for the elderly and the mentally ill to study issues related to mentally ill individuals residing in long-term care facilities. Background On February 10, 2004, the Commission heard presentations concerning caring for mentally ill individuals in long-term care facilities. One of the presenters was Dottie Harrison, Board Member, NC National Alliance for the Mentally Ill (NAMI). Ms. Harrison questioned whether adult care homes were appropriate housing options for mentally ill individuals, and she questioned the appropriateness of staffing and training at these facilities. Specifically, Ms. Harrison supported training on the appropriate administration of psychiatric medications, and training on appropriate interaction with residents based on their particular mental illness. Another presenter at the February meeting, Lou Wilson, Executive Director of the North Carolina Association of Long Term Care Facilities, stated that adult care home providers, "simply do not know how to muddle through the complex mental health systems, develop good rapports with mental health providers, provide mental health training for staff and recognize issues when specific residents are having difficulty." Ms. Wilson requested training for adult care home staff that will enable them to recognize symptoms of mental illness and urged the State, advocates, and the industry, to work together to ensure that individuals with mental illnesses receive the services they are entitled to receive. During the March 9, 2004 meeting, Dr. Bonnie Morell shared information with the Commission on the Geriatric Mental Health Specialty Teams Appendix F. One of the purposes of these Teams is to provide support services and technical assistance to nursing homes, adult care homes, and other agencies and caregivers that serve older adults who have mental health treatment needs and who may be at risk of psychiatric hospitalization. Currently, the Teams serve individuals 60+ years of age who are preparing to enter a nursing home or an adult care home, who currently reside in a nursing home or adult care home, and who are living in their own home or with family members. Individuals with geriatric-like needs are also served. In addition to other recommendations, Lou Wilson also requested the creation of a new licensure law and rules that are more realistic. During discussions at the April 13, 2004 meeting, North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 20 Commission members voiced support for examining whether current State statutes and Departmental rules adequately address the populations served by long-term care facilities. They also supported examining adult care home rules to determine whether they are easy to understand, attainable under current staffing patterns, give appropriate guidance to facility operators according to the needs and characteristics of residents served, support resident's freedom of choice, and whether they support the autonomy, dignity and independence philosophy of assisted living. The Commission supports quality care for mentally ill individuals and elderly individuals and recommends that the General Assembly require the Department of Health and Human Services to work with long-term care providers and advocates for the elderly and the mentally ill to study issues related to mentally ill individuals residing in long-term care facilities. Recommendation 4 The North Carolina Study Commission on Aging recommends that the General Assembly establish a pilot program to conduct national criminal history record checks of persons seeking employment to provide direct care in adult care homes or contract agencies of adult care homes. Background State law currently requires criminal history record checks of all applicants for employment with nursing homes, home health care agencies, and adult care homes. If the applicant has been a resident of North Carolina for less than five years, the criminal history record check must include both a national and a State criminal history record check. If the applicant has been a resident of North Carolina for five years or more, only a State criminal history record check is required. However, under federal law, the FBI may release results of national criminal history checks directly to nursing homes and home health care agencies on applicants for positions that involve direct patient care. Otherwise, results of criminal history checks performed by the FBI can only be released to a state agency and cannot be released directly to a provider. This has made it difficult for providers to comply with State law. As a result, a moratorium on national criminal history record checks was instituted in S.L. 2002-126, Sec. 10.10C for applicants for positions in nursing homes and home care agencies other than those involving direct patient care and for applicants for all staff positions in adult care homes, until January 1, 2004. Session Law 2003- 284, Sec. 10.8E extended the moratorium to January 1, 2005. Access to national criminal history record checks was an item mentioned frequently during presentations on March 9, 2004, by organizations representing, or advocating on behalf of, older adults in North Carolina. On March 23, 2004, the Commission heard a presentation from John Aldridge of the North Carolina Attorney General's office on this issue. He reiterated that unless federal law provides otherwise, the results of a national criminal history record check can only be released to a governmental agency. Currently, federal law only permits these results to be released to nursing homes and home care agencies on applicants for positions that involve direct patient care. Therefore, in order to be able to conduct national criminal history record checks on applicants for positions in nursing homes and home care agencies that do not involve patient care and on applicants for positions in adult care homes, current State law would have to be changed to direct that the results be sent to a governmental agency. The Commission recognizes that long-term care advocates and providers have legitimate concerns about the current status of national criminal history record checks. Roger Manus, North Carolina Study Commission on Aging 21 Report to the Governor and the 2004 Session of the 2003 General Assembly President of Friends of Residents in Long Term Care, pointed out during the Commission's meeting on March 23, that people living in long-term care facilities are the vulnerable frail elderly and disabled that cannot defend themselves, and many cannot communicate when they perceive a threat. Worst of all, they spend the night in these facilities when staffing levels decrease even further with greater potential and opportunity for abuse. It is important to ensure the safety of this vulnerable population. On the other hand, the Commission recognizes that employee turnover is high in long-term care facilities. It is important that providers be able to fill positions quickly and not have to wait an inordinate amount of time for a determination to be made by an agency about whether an applicant is disqualified because of the applicant's criminal background. Questions arose during the Commission's deliberations about the State's technological and staffing capacity to be able to turn around a determination of disqualification quickly. The Commission recommends moving this issue forward by establishing a pilot program to conduct national criminal history record checks of workers in adult care homes and contract agencies of adult care homes who provide direct resident care and requiring the Department of Health and Human Services to collect information and meet regularly with providers and others to monitor the progress of the pilot to determine what is needed in order to fully implement the national criminal history record checks as the General Assembly intended. Recommendation 5 The North Carolina Study Commission on Aging recommends that the General Assembly support Senior Center development and outreach, and restore funding to the 2002 level, by appropriating $281,000 for the 2004-2005 fiscal year. Background Senior Centers are resources within communities that typically provide nutrition, recreation, social and educational services, and comprehensive information and referral. The National Institute of Senior Centers defines a senior center as a place where “older adults come together for services and activities that reflect their experience and skills, respond to their diverse needs and interests, enhance their dignity, support their independence, and encourage their involvement in and with the center and the community.” Prior to the 2002 Session, State funds for Senior Centers were $1,365,316. During the 2002 Session, funds were reduced by $381,000. During the 2003 Session, $100,000 was restored, and the local match requirement was increased. Support for and/or restoration of funding for Senior Centers was an item mentioned frequently during presentations on March 9, 2004, by organizations representing, or advocating on behalf of, older adults in North Carolina Appendix G. To fully restore State funding to the prior level, an additional $281,000 would be needed. Therefore, the Commission recommends that the General Assembly support Senior Center development and outreach, and restore funding to the 2002 level, by appropriating $281,000 for the 2004-2005 fiscal year. Recommendation 6 The North Carolina Study Commission on Aging recommends that the General Assembly appropriate $1,000,000 to the Housing Trust Fund for the 2004-2005 fiscal year to be used for independent housing with services. Background North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 22 The Housing Finance Agency mission is to create affordable housing opportunities for North Carolinians whose needs are not met by the market. This mission is accomplished through helping older individuals age in place by improving existing housing, and by working to develop new apartments for older adults. In the March 23, 2004 presentation, Bob Kucab, Executive Director, stated that applications for funding requests currently exceed available capital by 3:1. State funds help bring in outside funding because the Housing Finance Agency is able to leverage $5 in development from every $1 the State invests. According to Mr. Kucab, all State funds that they administer are invested in bricks and mortar; staff costs are paid from their revenue. Mr. Kucab reported that, State appropriations are currently down to $3 million from a high of $9 million. The Commission recognizes the need for new apartments with affordable rent, where older adults can enjoy safe and comfortable living environments, and connections to community services. Therefore, the Commission recommends that the General Assembly appropriate $1,000,000 to the Housing Trust Fund for the 2004-2005 fiscal year to be used for independent housing with services. Recommendation 7 The North Carolina Study Commission on Aging recommends that the General Assembly appropriate $1,000,000 for the Home and Community Care Block Grant for the 2004-2005 fiscal year. Background On March 23, 2004, Dennis Streets, Division of Aging and Adult Services, DHHS, made a presentation to the Commission on the Home and Community Care Block Grant (HCCBG) Appendix H. His presentation gave an overview of the program; eligibility criteria; and information on program utilization, availability, and needs. The HCCBG is established by G.S. 143B-181.1(a)(11). Mr. Streets pointed out that by "consolidating several funding sources (i.e., the Older Americans Act, the Social Services Block Grant in support of respite care, portions of the State In-Home and Adult Day Care funds, and other relevant State appropriations)—some of which traditionally went to separate organizations—the HCCBG represented an important step toward establishing a well coordinated service delivery system to meet the needs of a rapidly growing older population." The HCCBG includes federal funds, State funds, local funds, and a client cost sharing component. The two principal purposes of the HCCBG are to give counties greater discretion, flexibility and authority in determining services, service levels and service providers; and to streamline and simplify the administration of services. The HCCBG focuses on: supporting frail elderly in their preference to be cared for at home; improving and maintaining the physical and mental health of older adults; assisting older adults and their caregivers with accessing services and information; providing relief to family caregivers so that they can continue their caregiving; and allowing older adults to remain actively engaged with their communities. Any person age 60 and older is eligible for services under the HCCBG. The HCCBG program places an emphasis on reaching those most in need of services (the Older Americans Act (OAA) gives priority to serving the "socially and economically needy" -with particular attention to low-income minority elderly and older individuals residing in rural areas). Additionally, the OAA calls for reaching out to older individuals with severe disabilities, limited English-speaking ability, and Alzheimer's disease or related disorders (and caregivers of these individuals). North Carolina Study Commission on Aging 23 Report to the Governor and the 2004 Session of the 2003 General Assembly State appropriations for the HCCBG were $25,128,469 for the 2002-2003 fiscal year. State appropriations were cut by $1,055,690 to $24,072,799 for the 2003-2004 fiscal year. State appropriations are currently slated to be reduced to $24,026,079 for the 2004-2005 fiscal year. An increase in federal Older Americans Act funds has helped to offset the decrease in State funding and overall funding of the program was down from the previous year only $341,603 for 2003-2004. However, the Division anticipates a decrease in federal funding for 2004-2005, which would leave the overall total down another $389,974. Unless the General Assembly increases State appropriations, the total net funding for HCCBG would be down $731,577 for the period from 2002-2003 to 2004-2005. Support for and/or restoration of funding for the HCCBG was an item mentioned frequently during presentations on March 9, 2004, by organizations representing, or advocating on behalf of, older adults in North Carolina Appendix G. The Commission recognizes the vital services that are provided under the HCCBG and recommends that the General Assembly appropriate $1,000,000 for the Home and Community Care Block Grant for the 2004-2005 fiscal year. Recommendation 8 The North Carolina Study Commission on Aging recommends that the General Assembly require the Department of Health and Human Services to study whether the State's Medicaid Program has a bias that favors support for individuals in institutional settings over support for individuals living at home; and to recommend ways to alleviate this bias, if such a bias exists. Background The Final Report by The North Carolina Institute of Medicine Task Force on Long-Term Care reported an institutional bias in Medicaid eligibility rules. The report states that a reason public funding is weighted toward institutional care is that Medicaid and other public program rules make it easier for people to qualify for financial assistance with institutional or residential care than for services provided at home or in the community. Under existing laws, individuals can qualify for either nursing home care or State-County Special Assistance for adult care homes with higher monthly incomes than they can if they want to obtain Medicaid coverage for health services provided in their own home. With these different income eligibility limits, individuals living at home who may have too much income to qualify for Medicaid coverage as long as they remain in their home, may qualify if they move into a more costly institutional or residential setting. In Olmstead v. L.C., the United States Supreme Court concluded that inappropriate institutionalization of a person with a mental disability may be discrimination under ADA. The Commission recognizes that the law favors caring for an individual in the community rather than in an institution, and institutional care may be more costly than residential care. Therefore, the Commission recommends that the General Assembly direct the Department of Health and Human Services to study whether an institutional bias in Medicaid eligibility rules do in fact exist and if they do exist, to determine how to alleviate the bias. Recommendation 9 The North Carolina Study Commission on Aging recommends that the General Assembly establish a Legislative Study Commission to study State guardianship laws. North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 24 Background Guardianship is a legal relationship in which a person or agency (the guardian) is appointed by a court to make decisions and act on behalf of another person (the ward) with respect to the ward’s personal or financial affairs because the ward, due to a specific mental or physical impairment, lacks sufficient capacity to make or communicate important decisions concerning his or her person, family, or property or lacks sufficient capacity to manage his or her personal or financial affairs. Laws regarding guardianship for incapacitated adults attempt to strike a balance between preserving the legal rights, freedom, and autonomy of individuals vs. society’s duty (parens patriae) to protect individuals who are unable to protect or care for themselves. On February 10, 2004, the Commission heard a presentation on "Guardianship Reform in the Twenty-First Century" Appendix D by John Saxon, Professor of Public Law and Government, UNC Chapel Hill. According to his presentation, the last substantive revision to the guardianship law was in 1977, and the last consolidation and clarification was enacted in 1987. Since 1987, there have been efforts to review and revise the statutes, but none resulted in change. Current law consists of an assortment of statutes, some of which date back to the 1800s. As a result, there are a number of issues in the guardianship statutes that need review and updating, including interstate jurisdiction, the definition and standard of incapacity, due process, guardianship alternatives, limited guardianship, the guardian's powers, and the role of human service agencies. Professor Saxon suggested that as an alternative to rewriting current law, North Carolina could adopt the Uniform Guardianship and Protective Proceedings Act (UGPPA). The UGPPA has been enacted in four states. The UGPPA authorizes two types of legal proceedings: guardianship proceedings to appoint guardian (guardian of the person) for a minor or incapacitated person; and protective proceedings regarding the property of a minor or a missing, absent, detained, or incapacitated person, including proceedings seeking the appointment of a conservator (i.e. guardian of the estate). Under the UGPPA, guardianship and conservatorship is viewed as last resort. A guardian or conservator may be appointed only if there are no other lesser restrictive alternatives that will meet the respondent’s needs, and limited guardianship or conservatorship should be used whenever possible. According to Professor Saxon, the UGPPA is advantageous because it is modern, comprehensive, legally adequate, balanced, proven, and could be customized to address any issues that are unique to North Carolina. The North Carolina Study Commission on Aging recognizes that the laws pertaining to guardianship are important for the protection of citizens who are unable to make personal decisions due to impairment or incapacity, and that these laws have not been thoroughly reviewed in 17 years. Therefore, the Commission recommends the General Assembly establish a Legislative Study Commission on State Guardianship Laws. Recommendation 10 The North Carolina Study Commission on Aging recommends that the General Assembly appropriate funds and require the Social Services Commission to adopt a rate increase of no less than five dollars ($5.00) per day for adult day and adult day health services. Background North Carolina General Statute 131D-6 provides that adult day care enables people who would otherwise need full-time care away from their own residences to remain in their residences as long as possible. An adult day care program provides group care and supervision for physically or mentally disabled adults in a place other than their usual place of abode on a less than 24-hour North Carolina Study Commission on Aging 25 Report to the Governor and the 2004 Session of the 2003 General Assembly basis. Adult day services include a social model and a health model. Both models provide a community setting that promotes social interaction, and physical and emotional well-being. Adult day health programs also offer health care services to meet the needs of individual participants. Nutritional meals and snacks are provided and transportation to and from the program may be provided or arranged when needed. Often these programs provide a safe stimulating environment while a primary caregiver is at work. Providers of adult day care must meet North Carolina State Standards for Certification. The Social Services Commission sets these standards and the reimbursement rates paid for adult day and adult day health services. During the March 23, 2004 meeting, the Commission heard from Nancy J. Cox, Director of Partners in Caregiving, Wake Forest University School of Medicine; Suzi Kennedy from the Life Enrichment Center of Cleveland County, Inc.; and Steve Freedman from the Division of Aging and Adult Services, DHHS Appendix I. The Commission received information on the predictors of success for adult day programs from a marketing, financing, and programming perspective; the challenges of operating a successful adult day program, particularly the insufficiency of public reimbursement rates to cover the costs of running a program; and the status of adult day programs across the State. During this meeting, Suzi Kennedy from the Life Enrichment Center of Cleveland County, Inc. spoke about the challenges of operating a successful adult day program and presented her menu for success at the Life Enrichment Center. Ms. Kennedy stated that, "Without financial stability there can be no social good," and she pointed out that public reimbursement rates are often insufficient to cover the costs of running a program. Based on a survey conducted by the North Carolina Adult Day Services Association, in conjunction with the Division of Aging and Adult Services, the average cost to operate an adult day program in North Carolina is $31.00 per day for social models and $44.00 per day for health models. Rates established by the Social Services Commission, effective December 8, 1997, provided the maximum reimbursement rate for the purchase of adult day services at $565 per month ($26.07 per day). Of this amount, $500 per month ($23.07) is for daily care and $65 per month ($3.00 per day) is for round trip transportation. The maximum reimbursement rate for the purchase of adult day health services is $715 per month ($33 per day). Of this amount, $650 per month is for daily care ($30.00 per day) and $65 per month ($3.00 per day) is for round trip transportation. In 1999, the Division of Aging and Adult Services considered approaching the Social Services Commission about a rate increase; however, the Division was advised that there was little chance of a rate increase without an overall increase in the State Adult Day Care fund, since a rate increase without a budget increase would result in a cut to services. S.L. 2003-284, Section 10.58 required the Social Services Commission to consider adopting rules increasing the rates for adult day centers and adult day health centers. However, any rate increase adopted by the Commission for adult day centers and adult day health had to be implemented within existing funds. The Commission supports adult day and adult day health programs and understands the important role they play in our communities. Therefore, the Commission recommends that the General Assembly appropriate funds and require the Social Services Commission to adopt a rate increase of no less than five dollars ($5.00) per day for adult day and adult day health services. North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 26 APPENDICES North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 27 APPENDIX A North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 28 North Carolina Demographics of Aging NC County Range Total population, 2002i 8,323,946 4,170 - 734,403 Projected total population, 2020ii 10,966,139 4,706 - 1,102,003 Population age 60+, 2002iii 1,338,075 858 - 84,420 Population age 85+, 20023 116,922 88 - 7,567 Baby boomers (as % of total population), 20003 27.8% 20.6% - 32.4% Rural population for all ages (as % of total population), 2000iv 39.8% 3.9% - 100% Persons age 65+ without HS diploma (as % of age group), 2000v 41.6% 21.0% - 61.9% Persons age 45-64 without HS diploma ( • ), 20005 19.9% 8.7% - 36.7% Persons age 65+ with graduate school education ( • ), 20005 5.5% 1.1% - 18.7% Persons age 45-64 with graduate school education ( • ), 20005 8.8% 2.4% - 32.4% Persons age 65+ with limited or no English ( • ), 2000vi 0.5% 0% - 3.8% Grandparents raising grandchildren age less than 18, 2000vii 79,810 31 – 5,985 Veterans age 65+ (as % of age group), 2000viii 26.8% 16.2% - 37.7% Distribution by Age1, 2 0-17 18-49 50-64 65-84 85+ Age groups, 2002 24.5% 47.6% 16.0% 10.5% 1.4% Projection for 2020 23.1% 43.0% 18.8% 13.3% 1.7% Growth, 2002-2020 124.3% 119.2% 155.5% 166.8% 162.4% Distribution by Race/ Hispanic Originix White African American Native American Asian Hispanic/ Latino Population age 60+ (as % of age group), 2000 82.0% 16.0% 0.7% 0.5% 0.7% Population age 45-59 ( “ ), 2000 77.2% 18.9% 1.1% 1.2% 1.7% Healthy Aging NC County Range Persons age 65+ in community with 0 disabilities* (as % of age group), 2000x 54.3% 40.2% - 66.8% Persons age 65+ in community with 1 disability* ( • ), 200010 20.6% 14.9% - 26.4% Persons age 65+ in community with 2 or more disabilities* ( • ), 200010 25.1% 17.0% - 34.6% * The US Census Bureau defines disability as “a long-lasting physical, mental, or emotional condition. This condition can make it difficult for persons to do activities such as walking, climbing stairs, dressing, bathing, learning, or remembering.” Medicare beneficiaries immunized for influenza, 2000xi 43.5% 17.2% - 63.5% Persons age 65+ living alone ( • ), 2000xii 28.3% 21.0% - 34.6% Long-Term Care and Aging NC County Range Men age 65+ in nursing homes, 2000xiii 11,207 0 – 674 Women age 65+ in nursing homes, 200013 33,630 0 – 2,445 Persons age 65+ in nursing homes per 1000, 1999xiv 42.2 25.4 – 89.1 Persons age 65+ in adult care homes per 1000, 199914 36.5 0.0 – 67.8 CAP/DA* clients age 18+ per 1000 Medicaid eligibles, 199914 36.0 8.4 – 200.0 PCS** clients age 18+ per 1000 Medicaid eligibles, 199914 57.7 0.0 – 199.1 Adult day care/health clients age 60+ served per 1000, 199914 1.0 0.0 – 5.0 In-home aides clients, age 60+ per 1000, 199914 9.9 2.0 – 51.5 Medicaid-eligible persons age 65+, SFY 2002xv 152,300 131 – 7,198 Total Medicaid expenditures for persons age 65+, SFY 200216 $1,665,538,382 $1,151,121- $79,755,555 The amount Medicaid spent on home-based care (CAP/DA, CAP/MR, home health, and PCS) for every $100 spent in nursing homes for clients age 60+, SFY 2002xvi $41.5 $6.9 - $278.4 Special Assistance (SA) expenditures for persons age 60+ in adult care homes, SFY 200216 $90,695,940 $37,987 - $4,035,646 North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 29 Economic Security NC County Range Median household income for age group 55-64, 1999xvii $42,250 $26,582 - $62,759 Median household income for age group 65-74, 199917 $28,521 $16,335 - $41,540 Median household income for age group 75+, 199917 $19,303 $11,195 - $33,822 Poverty Age 55-64 Age 65-74 Age 75+ Persons below poverty (as % of age group), 1999 (NC) xviii 9.5% 10.5% 16.9% Persons in 100-199% of poverty ( • ), 1999 (NC)18 12.9% 20.4% 27.1% Social Security NC County Range Total Social Security (SS) benefits for beneficiaries age 65+, 2000xix $722 million $0.4 – 50.7 million SS beneficiaries age 65+ (as % of age group), 2000xx 94.8% 73.1% - 100.0% Average monthly SS amount received by beneficiaries age 65+, 200019,20 $786 $620 - $889 Medicare/Medicaid Medicare Part A enrollees age 65+ (as % of all enrollees), 2000xxi 77.0% 65.7% - 86.1% Medicare/Medicaid dually eligible persons age 65+, 2001xxii 140,535 109 – 6,609 Labor Force Persons age 45-59 in labor force* (as % of total labor force), 2000xxiii 27.7% 21.7% - 35.8% Persons age 60-64 in labor force* ( • ), 200023 3.6% 2.5% - 6.9% Persons age 65+ in labor force* ( • ), 200023 3.5% 2.2% - 8.8% Persons age 65+ In labor force* (as % of age group), 200023 14.4% 8.9% - 21.1% Unemployed persons age 65+ (as % of population age 65+ in labor Force*), 200023 8.3% 0.0% - 40.7% *Include both employed and job seekers Senior-Friendly Communities NC County Range Homeowners age 45-64 (as % of age group), 2000xxiv 80.3% 70.9% - 89.6% Homeowners age 65+ ( • ), 200024 82.0% 72.0% - 91.4% Households with persons age 60+ and without complete plumbing, 2000xxv 8,184 Undisclosed – 343 Home-delivered meals served to persons age 60+ per 1000, 199914 18.6 0 – 58.5 Food Stamps Food Stamp clients age 60+, SFY 2001xxvi 66,832 66 – 3,893 Total Food Stamp expenditures for clients age 60+, SFY 200126 $39,628,877 $23,963 - $3,177,499 Monthly Food Stamp expenditure per client age 60+, SFY 200126 $49 $35 - $68 Transportation Householder age 55-64 without car (as % of age group), 2000xxvii 6.0% 1.0% - 15.9% Householder age 65-74 without car ( • ), 200027 9.0% 4.0% - 22.7% Householder age 75+ without car ( • ), 200027 21.3% 7.5% - 33.6% Persons Providing Care Age 18-44 Age 45-64 Age 65+ Persons providing regular care for adults age 60+ (as % of age group), 2000* xxviii 14.5% 23.8% 15.7% *Only statewide information available at present North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 30 Sources of Information 1 North Carolina State Data Center (2003). County/state population estimates; July 1, 2002; age groups-adults. Retrieved in 6/2003 from http://www.demog.state.nc.us/. 1 North Carolina State Data Center (2003). County/state population projections; April 1, 2020 county age groups; age groups-adults. Retrieved in 6/2003 from http://www.demog.state.nc.us/. 1 US Bureau of the Census (2003). PCT12. Sex by age (Summary File 1). Retrieved in 6/2003 from http://www.census.gov/. 1 US Bureau of the Census (2003). P2. Urban and rural (Summary File 1). Retrieved in 6/2003 from http://www.census.gov/. 1 US Bureau of the Census (2003). PCT25. Sex by age by educational attainment for the population 18 years and over (Summary File 3). Retrieved in 6/2003 from http://www.census.gov/. 1 US Bureau of the Census (2003). P19. Age by language spoken at home by ability to speak English for the populations 5 years and over (Summary File 3). Retrieved in 6/2003 from http://www.census.gov/. 1 US Bureau of the Census (2003). PCT9. Household relationship by grandparents living with own grandchildren under 18 years by responsibility for own grandchildren for the population 30 years and over in households (Summary File 3). Retrieved in 6/2003 from http://www.census.gov/. 1 US Bureau of the Census (2003). P39. Sex by age by armed forces status by veteran status for the population 18 years and over (Summary File 3). Retrieved in 6/2003 from http://www.census.gov/. 1 US Bureau of the Census (2003). P12 A, B, C, D, and H. Sex by age (Summary File 1). Retrieved in 6/2003 from http://www.census.gov/. 1 US Bureau of the Census (2003). PCT26. Sex by age by types of disability for the civilian noninstitutionalized population 5 years and over (Summary File 3). Retrieved in 6/2003 from http://www.census.gov/. 1 Medical Review of North Carolina (2003). Influenza immunization data. Retrieved in 2/2003 from http://www.mrnc.org/MCMED/influenza-results.asp. 1 US Bureau of the Census (2003). P11. Household type (including living alone) by relationship for the population 65 years and over (Summary File 3). Retrieved in 6/2003 from http://www.census.gov/. 1 US Bureau of the Census (2003). PCT17. Group quarters population by sex by age by group quarters type (Summary File 1). Retrieved in 6/2003 from http://www.census.gov/. 1 NC Institute of Medicine (2001). A long-term care plan for North Carolina: Final report. Appendix D: Comparisons of availability of services. 1 NC Division of Medical Assistance (2003). Special tabulations provided for NC Division of Aging in 6/2003. 1 NC Division of Aging (2003). Expenditure data by county for Fiscal Year 2002. Retrieved 6/2003 from http://www.dhhs.state.nc.us/aging/exp2002/coexp2002.htm. 1 US Bureau of the Census (2003). P56. Median household income in 1999 (dollars) by age of householder (Summary File 3). Retrieved in 6/2003 from http://www.census.gov/. 1 US Bureau of the Census (2003). PCT50. Age by ratio of income in 1999 to poverty level. (Summary File 3). Retrieved in 6/2003 from http://www.census.gov/. 1 US Social Security Administration (2003). Table 5. Amount of OASDI benefits in current-payment status, by type of benefit, by sex of beneficiaries aged 65 or older, and by state and county, December 2000 (OASDI beneficiaries by state and county, 2000). Retrieved in 6/2003 from http://www.ssa.gov/policy/docs/statcomps/oasdi_sc/2000/nc.html. 1 US Social Security Administration (2003). Table 4. Number of OASDI beneficiaries with benefits in current-payment status, by type of benefit, by sex of beneficiaries aged 65 or older, and by state and county, December 2000 (OASDI beneficiaries by state and county, 2000). Retrieved in 6/2003 from http://www.ssa.gov/policy/docs/statcomps/oasdi_sc/2000/nc.html. 1 Medical Review of North Carolina (2003). Medicare Part A Enrollees. Retrieved from in 6/2003 http://www.mrnc.org/NCMED/beneficiary.asp. 1 Medical Review of North Carolina (2003). Dually eligible beneficiaries, 2000. Retrieved from in 6/2003 http://www.mrnc.org/NCMED/beneficiary_dual2001.asp. 1 US Bureau of the Census (2003). PCT35. Age by sex by employment status for the population 16+ years. (Summary File 3). Retrieved in 6/2003 from http://www.census.gov/. 1 US Bureau of the Census (2003). HCT8. Tenure by age of householder (Summary File 2). Retrieved in 6/2003 from http://www.census.gov/. 1 NC State Library (2003). Special tabulation from the Census 2000 data as requested by the NC Division of Aging in 6/2003. 1 NC Division of Social Services (2002). Special tabulation as requested by the NC Division of Aging in 9/2002. 1 US Bureau of the Census (2003). P45. Tenure by vehicles available by age of householder (Summary File 3). Retrieved in 6/2003 from http://www.census.gov/. 1 NC Center for Health Statistics (2001). BRFSS-2000 survey results. Retrieved in 7/2003 from http://www.schs.state.nc.us/SCHS/healthstats/brfss/2000/caretakr.html. North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 31 APPENDIX B North Carolina Study Commission on Aging Recommendations to the 2003 North Carolina General Assembly, 2003 Regular Session Prepared by Staff for the North Carolina Study Commission on Aging February 9, 2004 North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 33 Recommendation Status Report North Carolina Study Commission on Aging RECOMMENDATIONS BILLS INTRODUCED RESULTS RECOMMENDATION 1 The Commission finds that the Community Alternative Program for Disabled Adults (CAP/DA) is the cornerstone of community-based care for older adults and recommends that the General Assembly fund the program at a level sufficient to preserve the availability of community-based services offered through the program. N/A CAP/DA funds for the 02/03 fiscal year are $255,000,000, funds were increased by approximately $61,000,000 last session. RECOMMENDATION 2 The Commission recommends that the 2002 Session of the 2001 General Assembly direct the Department of Health and Human Services to study ways to establish a group health insurance purchasing arrangement for long-term care staff. H 1559 S 1196 S.L. 2002-180, Sec. 5.2 (SB 98, Sec. 5.2) Group Health Insurance for Long-Term Care Staff Study The Department of Health and Human Services, in consultation with the Department of Insurance, shall study ways to establish a group health insurance purchasing arrangement for staff, including paraprofessionals, in residential and nonresidential long-term care facilities and agencies, as described in Recommendation #22 of the Institute of Medicine's (IOM) Long-Term Care Task Force Final Report of January 2001. The Department shall report its findings and recommendations to the North Carolina Study Commission on Aging on or before January 1, 2003. RECOMMENDATION 3 The Commission recommends that the General Assembly direct the Department of Health and Human Services to study ways the State can coordinate and facilitate public access to public and private free and discount prescription drug programs for senior citizens. H 1560 S 1199 S.L. 2002-180, Sec. 5.1 (SB 98, Sec. 5.1) Prescription Drug Access/Coordination The Department of Health and Human Services shall study ways the State can coordinate and facilitate public access to public and private free and discount prescription drug programs for senior citizens. In undertaking this study, the Department shall consider the coordination and facilitation methods being implemented by other states. On or before January 1, 2003, the Department shall report its findings and recommendations to the North Carolina Study Commission on Aging. The report shall include the following: (1) A description of the various coordination and facilitation methods considered. (2) A description of the coordination and facilitation methods of other states. North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 34 (3) A recommendation as to the best way to coordinate and facilitate access in this State, which shall include the reasons for the recommendation, a fiscal analysis of the cost of the recommendation, and whether any legislation is necessary to implement the recommendation. RECOMMENDATION 4 The Commission recommends the General Assembly establish a Legislative Study Commission on State Guardianship Laws. H 246 S 179 No action taken on this issue. RECOMMENDATION 5 The Commission recommends the General Assembly pursue ways in which national criminal record checks may be obtained and reviewed by long-term care facilities to effectuate State policy and to protect facility residents. H 1561 S 1264 S.L. 2002-180, Sec. 2.1A (SB 98, Sec. 2.1A) Study Issues Related to Criminal History Record Checks of Employees of Long-Term Care Providers The Legislative Research Commission may study how federal law affects the distribution of national criminal history record check information requested for nursing homes, home care agencies, adult care homes, assisted living facilities, and area mental health, developmental disabilities, and substance abuse services authorities, and the problems federal restrictions pose for effective and efficient implementation of State-required criminal record checks. The study may include the following: (1) Ways in which national record checks may be obtained and reviewed for these facilities to effectuate State policies and protections of facility residents, and the advantages, disadvantages, and costs of various approaches to implementation. (2) A review of ways in which national record checks are obtained by the Division of Child Development, Department of Health and Human Services, and other State agencies, and related costs to the State. (3) Solutions adopted by other states to effectively and efficiently implement criminal record check requirements, including costs to the State in implementing these solutions. (4) Other issues relevant to State requirements for criminal history record checks in long-term care facilities. For each of the topics the Legislative Research Commission decides to study, the Commission may report its findings, together with any recommended legislation, to the 2003 General Assembly. Summary of Substantive Legislation Related to Aging North Carolina General Assembly 2003 Session Prepared by Staff for the: North Carolina Study Commission on Aging February 10, 2004 North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 36 Enacted Legislation Continuing Care Retirement/Technical Changes S.L. 2003-193 (HB 253) makes various technical changes to the statutes that regulate continuing care retirement communities (CCRCs). These facilities provide housing and health-related services either for life or for a period in excess of one year. CCRCs provide independent living and also offer nursing home or adult care home level of care. Because CCRCs include contractual requirements where, for certain fees, the facility agrees to provide health care coverage over a given period of time, they are considered an insurance product and are regulated by the Department of Insurance under Article 64 of Chapter 58. The act makes the following changes to the statutes: · Repeals an unused, and likely unusable, provision allowing for a continuing care retirement facility that is accredited under a process approved by the Commissioner to be issued a license based on that accreditation. · Replaces the word "facility" with "provider" to clarify that it is the provider that operates the facility that is responsible for meeting the various statutory requirements. · Clarifies language governing operating reserves for continuing care retirement facilities and providers, including: 1. Changing the wording to reflect the fact that a provider is to calculate and maintain a separate operating reserve for each continuing care facility operated by the provider. 2. Changing the words "annual statement" to "disclosure statement." 3. Changing the words "invested cash" to "cash equivalents." · Makes the following changes governing the rights of residents of continuing care retirement facilities to organize: 4. Changes "registered under this Article" to "operated by a provider licensed under this Article" in G.S. 58-64-40(a). No entity is "registered" under G.S. 58-64. 5. Makes gender neutral corrections. 6. Clarifies that the governing body of a provider must hold semi-annual meetings with the residents of each facility operated by the provider. · Makes various changes governing supervision, rehabilitation and liquidation of continuing care retirement providers including: 7. Replacing the word "projected" with "forecasted". 8. Amending the statute as necessary to accommodate the fact that a provider can own or operate more than one facility. · Amends the provision on receiverships, to reflect the fact that the Commissioner would be appointed as receiver for a provider not a facility. · Replaces the word "agreements" with "contracts" for consistency of wording within Article 64. · Removes unnecessary language to conform with the removal of the "accredited facility" provision. · Amends the provision, governing civil liability, to: 9. Remove the misleading words "facility, or person violating this Article" because the provider is the entity entering into a contract for continuing care, not the facility or other person. 10. Remove the words "or person liable" because the provider is the only entity that is required to deliver a disclosure statement to the contracting party. 11. Remove the words "facility, or person" since payment is made to the provider, and the provider is the entity responsible for the dissemination of the disclosure statement. This act became effective June 12, 2003. (DJ) North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 37 Senior Cares Program Administration S.L. 2003-284, Sec. 10.5 (HB 397, Sec. 10.5) provides that the Department of Health and Human Services may administer the "Senior Cares" prescription drug access program approved by the Health and Wellness Trust Fund Commission and funded from the Health and Wellness Trust Fund. This section became effective July 1, 2003. (TM) Effective Date of Long-Term Care Criminal Record Checks for Employment Positions S.L. 2003-284, Sec. 10.8E (HB 397, Sec. 10.8E) continues the suspension of the requirements of G.S. 131E-265 for nursing homes and G.S. 131D-2 for adult care homes to conduct national criminal history checks for certain employees until January 1, 2005. These requirements were also suspended during the last biennium. This section became effective July 1, 2003. (DJ) Implement a Pilot Project for Long-Term Care Community Service Coordination S.L. 2003-284, Sec. 10.8F (HB 397, Sec. 10.8F) requires the Department of Health and Human Services to implement a communications and coordination initiative to support local coordination of long- term care, and to pilot the establishment of local lead agencies to facilitate the long-term care coordination process at the county or regional level. The initiative must eliminate fragmentation and barriers to information and services; provide a seamless connection among State agencies and local entities, regardless of funding sources; and allow consumers to efficiently and effectively navigate among long-term care services. For those counties that voluntarily participate, the local long-term care coordination initiative must aid in the development of core services, coordinate local services, and streamline access to services. The Department of Health and Human Services must submit an interim report on the pilot project for local long-term care coordination to the North Carolina Study Commission on Aging by October 1, 2004 and a final report by October 1, 2005. The Institute of Medicine Long-Term Care Task Force found that "long-term care services are often fragmented, duplicative, complex, and not consumer-friendly and that many counties lack needed core long-term care services." In response to this finding, and a report presented in accordance with S.L. 2001-491, Part XXII, the North Carolina Study Commission on Aging's 2003 report to the General Assembly and the Governor made a recommendation that the General Assembly fund a pilot project on long-term care local lead agencies. This provision is in response to that recommendation. This section became effective July 1, 2003. (TM) Medicare Enrollment Required S.L. 2003-284, Sec. 10.27 (HB 397, Sec. 10.27) directs the Department of Health and Human Services to require Medicaid recipients who qualify for Medicare to enroll in Medicare in order to pay medical expenses that qualify for payment under Medicare Part B. Medicare is the federally sponsored health insurance program for persons aged 65 or older and for certain disabled persons under age 65. Medicare Part B pays for doctors' services, outpatient hospital care, and some other medical services that Part A does not cover, such as the services of physical and occupational therapists, and some home health care. In order to obtain coverage under Medicare Part B, an eligible person must pay a premium. Requiring eligible persons to enroll in Medicare will shift health care costs from the Medicaid program (which is paid in part with State and local funds) to the Medicare program (which is paid entirely with federal funds). This section became effective July 1, 2003. (DJ) North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 38 Medicaid Assessment Program for Skilled Nursing Facilities S.L. 2003-284, Sec. 10.28 (HB 397, Sec. 10.28) directs the Secretary of Health and Human Services to implement a Medicaid assessment program for skilled nursing facilities effective October 1, 2003. The assessment program applies to skilled nursing facilities licensed under Chapter 131E of the General Statutes and must be imposed in a manner consistent with federal regulations under 42 C.F.R. Part 433, Subpart B. Funds realized from assessments imposed shall: · Be used only to draw down federal Medicaid matching funds for implementing the new reimbursement plan for nursing homes and for increasing nursing facility rates in accordance with the plan, · Be used to pay 100% of the nonfederal share for the new reimbursement plan for nursing homes; and · Not be used to supplant State funds appropriated for nursing facility services. This section became effective July 1, 2003. (TM) Rename North Carolina Heart Disease and Stroke Prevention Task Force S.L. 2003-284, Sec. 10.33B (HB 397, Sec. 10.33B) renames the North Carolina Heart Disease and Stroke Prevention Task Force. The new name is the Justus-Warren Heart Disease and Stroke Prevention Task Force. This section became effective July 1, 2003. (SA) Senior Center Outreach S.L. 2003-284, Sec. 10.42 (HB 397, Sec. 10.42) provides that the funds appropriated to the Department of Health and Human Services, Division of Aging, for the 2003-2005 fiscal biennium, shall be allocated by October 1 of each fiscal year and used by the Division of Aging to enhance senior center programs in the following ways: · To expand the outreach capacity of senior centers to reach unserved or underserved areas; or · To provide start-up funds for new senior centers. However, prior to funds being allocated for start-up funds for a new senior center, the county commissioners of the county in which the new center will be located shall: 12. Formally endorse the need for such a center; 13. Formally agree on the sponsoring agency for the center; and 14. Make a formal commitment to use local funds to support the ongoing operation of the center. Additionally, State funding shall not exceed 75% of reimbursable costs. This section became effective July 1, 2003. (TM) Adult Care Home Model for Community-Based Services S.L. 2003-284, Sec. 10.43 (HB 397, Sec. 10.43) requires the Department of Health and Human Services to develop a model project for delivering community-based mental health, developmental disabilities, and substance abuse housing and services through adult care homes that have excess capacity. The model must be designed for implementation on a pilot basis and address the following: · Services that will be provided by the facility or under contract with the facility, including assistance with daily medication. North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 39 · Access of clients to mental health, developmental disabilities, and substance abuse services provided in the community, including transportation to services outside of the client's residence in the adult care home facility. · Physical plant additions or changes necessary to provide for independent living of residents. · Methods for assuring quality of services, resident safety, and cost-effectiveness. · Consistency with the Department's Olmstead plan, other policies on community-integration, and disability plans adopted by the State. The Department must submit a final report on the development of the model to the Senate Appropriations Committee on Health and Human Services, the House of Representatives Appropriations Subcommittee on Health and Human Services, and the Fiscal Research Division on or before March 1, 2004. The report shall address the following: · Proposed time and location for implementation of the pilot. · Proposed number of residents to be placed and services to be provided directly by the facility or under contract with the facility. · Method for evaluating the pilot, including services provided, on a regular basis. · A description of the living environment for each resident and a comparison of how the living environment compares to that of other residents in the adult care home. · Changes to State law necessary to implement the pilot. · Projected cost to the State for pilot and statewide implementation. This section provides that the development of this model is in response to the State policy to provide appropriate services to clients in the least restrictive and most appropriate environment and with the United States Supreme Court Decision in Olmstead vs. L.C. & E.W. This section became effective July 1, 2003. (TM) Special Assistance In-Home Program S.L. 2003-284, Sec. 10.51 (HB 397, Sec. 10.51) allows the Department of Health and Human Services to use funds from the existing State-County Special Assistance for Adults budget to provide Special Assistance payments to eligible individuals with in-home living arrangements. These payments may be made for up to 800 individuals during the 2003-2004 fiscal year and the 2004-2005 fiscal year. The standard monthly payment to individuals enrolled in the Special Assistance in-home program shall be 50% of the monthly payment the individual would receive, if the individual resided in an adult care home and qualified for Special Assistance, except if a lesser payment amount is appropriate for the individual as determined by the local case manager. For State fiscal year 2003-2004, qualified individuals shall not receive payments at rates less than they would have been eligible to receive in State fiscal year 2002-2003. The Department must implement Special Assistance in-home eligibility policies and procedures to assure that in-home program participants are those individuals who need and, but for the in-home program, would seek placement in an adult care home facility; and shall include the use of a functional assessment. This in-home option must be available to all counties on a voluntary basis; and to the maximum extent possible, the Department shall consider geographic balance in the dispersion of payments to individuals across the State. The Department is required to report on or before January 1, 2004, and on or before January 1, 2005, to the cochairs of the House of Representatives Appropriations Committee, the House of Representatives Appropriations Subcommittee on Health and Human Services, the cochairs of the Senate Appropriations Committee, and the cochairs of the Senate Appropriations Committee on Health and Human Services. This report shall include the following information: · A description of cost savings that result from allowing individuals eligible for State-County Special Assistance the option of remaining in the home. · A complete fiscal analysis of the in-home option to include all federal, State, and local funds expended. · How much case management is needed and which types of individuals are most in need of case management. · The geographic location of individuals receiving payments under this section. North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 40 · A description of the services purchased with these payments. · A description of the income levels of individuals who receive payments under this section and the impact on the Medicaid program. · Findings and recommendations as to the feasibility of continuing or expanding the in-home program. · The level and quantity of services (including personal care services) provided to the demonstration project participants compared to the level and quantity of services for residents in adult care homes. Additionally, the Department shall incorporate data collection tools designed to compare quality of life among institutionalized versus noninstitutionalized populations (i.e., an individual's perception of his or her own health and well-being, years of healthy life, and activity limitations). To the extent national standards are available, the Department shall utilize those standards. These provisions are based on recommendations from the North Carolina Study Commission on Aging. This section became effective July 1, 2003. (TM) State/County Special Assistance Transfer of Assets S.L. 2003-284, Sec. 10.53 (HB 397, Sec. 10.53) codifies the provision adopted in last year's budget providing that Supplemental Security Income (SSI) policy concerning transfer of assets and estate recovery applies to applicants for State-county Special Assistance and repeals current codified law on the issue. The provision also requires the Department of Health and Human Services to continue reviewing whether policy for State-county Special Assistance should be changed to permit an assisted living facility to accept from a family member of a resident who qualifies for State-county Special Assistance payment for the difference in the monthly rate for room, board, and services available. The Department must report its activities on this policy review by March 1, 2004 to the Senate Appropriations Committee on Health and Human Services, the House of Representatives Appropriations Subcommittee on Health and Human Services, and the Fiscal Research Division. This section became effective July 1, 2003. (DJ) Social Services Commission Rules on Rate-Setting For Adult Day Centers and Adult Day Health Centers S.L. 2003-284, Sec. 10.58 (HB 397, Sec. 10.58) provides that the Social Services Commission shall consider adopting rules increasing the rates for adult day centers and adult day health centers and that any rate increase shall be implemented within existing funds. This section became effective July 1, 2003. (TM) Nursing Home/Medication Errors S.L. 2003-393 (SB 1016) requires every nursing home to establish a medication management advisory committee to advise the quality assurance committee on quality of care issues related to pharmaceutical and medication management and use in the nursing home. The Advisory Committee will have the following duties: · Assess the facility's pharmaceutical management system and practices and identify areas at high risk for medication-related errors. · Review the facility's pharmaceutical management goals and ensure these goals are being met. · Review, investigate, and respond to facility incident reports and resident grievances. · Identify goals and recommendations for the implementation of best practices. · Develop recommendations for the establishment of a mandatory, nonpunitive, confidential reporting system. North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 41 · Develop specifications for drug dispensing and administration documentation procedures to ensure compliance with federal and State law, including the NC Nursing Practice Act. · Develop specifications for self-administration of drugs by qualified patients in accordance with law. As part of its requirement to minimize risk of medication-related error, the act requires every nursing home quality assurance committee to undertake the following: · Educate and make the patient and the patient's family members aware of all the medications the patient is using. · Increase prescription legibility. · Minimize confusion in prescription drug labeling and packaging. · Develop a confidential and nonpunitive process for internal reporting of actual and potential medication-related errors. · To the extent practicable, implement proven medication safety practices. · Educate facility staff engaged in medication administration. · Implement a system to accurately identify recipients before any drug is administered. · Implement policies and procedures designed to improve accuracy in medication administration and in documentation. · Implement policies and procedures for the self-administration of medication. · Investigate and analyze the frequency and root causes of general categories and specific types of actual or potential medication-related errors. · Develop recommendations for plans of action to correct identified deficiencies in the facility's pharmaceutical management practices. The act also requires nursing home to provide a minimum of one hour of education and training in the prevention of actual or potential medication-related errors for all nonphysician personnel involved in direct patient care. A new statute enacted in this act requires consultant pharmacists of nursing homes to undertake certain drug regimen reviews, make reports concerning drug irregularities, drug product defects and adverse drug reactions, ensure proper documentation of allergies and adverse effects, and ensure that drugs that are not specifically limited as to duration of use or number of doses are controlled by automatic stop orders. Finally, the act requires the Secretary of Health and Human Services to contract with a public or private entity to develop and implement a Medication Error Quality Initiative. As part of the Initiative, each nursing home must report annually on the nursing home's medication-related errors. The report submitted by each nursing home would not contain information that would identify the patient, individual reporting the error, or other persons involved in the occurrence. The contracting entity would analyze the reports to determine trends in the incidence of medication-related errors in nursing homes. Information released to the contractor would retain its confidentiality and would not be subject to discovery or use in any civil action as provided under the act. This act becomes effective January 1, 2004. (DJ) Audit of CAP/DA Programs by State Auditor S.L. 2003-284, Sec. 10.29B (HB 397, Sec. 10.29B) directs the State Auditor to perform an audit of the Community Alternatives Program for Disabled Adults (CAP/DA), provided that State funds are appropriated for this purpose. The audit shall build upon the results of the study conducted by the North Carolina Institute of Medicine, in accordance with Section 10.16(c) of S.L. 2002-126, and provide information necessary to determine whether CAP/DA is operating within waiver guidelines and program goals. The State Auditor shall report the results of the audit to the North Carolina Study Commission on Aging by January 1, 2004. This section also directs the Department of Health and Human Services to review, on a pilot basis, a selected number of CAP/DA programs to determine compliance with eligibility requirements for the program. Additionally, the Department shall continue to examine aspects of CAP/DA including: the current assessment process; an analysis of per-client costs in CAP/DA to per-client costs in nursing North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 42 homes and adult care homes; per-participant costs for the State-County In-Home Program; an analysis of per-person costs for personal care services through Medicaid; the monitoring of quality of care for CAP/DA clients; the current waiting list procedures. The Department is required to make a report of its findings to the North Carolina Study Commission on Aging by January 1, 2004. This section became effective July 1, 2003. (TM) Staff Contributing to this publication: Sandra Alley (SA), Dianna Jessup (DJ), and Theresa Matula (TM). North Carolina Study Commission on Aging Report to the Governor and the 2003 Session of the 2003 General Assembly 43 Studies and Reports Related to Aging Study/Report Entities Involved Reporting Date Reference Report on the pilot project for local long-term care coordination. DHHS to Aging Study Commission Interim report 10/1/04 Final report 10/1/05 S.L. 2003-284 (HB 397), Sec. 10.8.F.(b) Report on examination of CAP/DA that includes certain cost comparisons DHHS to Aging Study Commission 1/1/04 S.L. 2003-284 (HB 397), Sec. 10.29B. Report on development of the adult care home model for community-based services DHHS to HHS and FRD 3/1/04 S.L. 2003-284 (HB 397), Sec. 10.43.(b) Report on the Special Assistance In-Home Demonstration Program DHHS to HHS 1/1/04 and 1/1/05 S.L. 2003-284 (HB 397), Sec. 10.51(b) DHHS to review whether policy for Special Assistance should be changed to permit an assisted living facility to accept from a family member of a resident who qualifies for the program payment for the difference in the monthly rate. DHHS to HHS and FRD 3/1/04 S.L. 2003-284 (HB 397), Sec. 10.53(c) DHHS to review activities and costs related to the provision of care in adult care homes and determine what costs may be considered to properly maximize allowable reimbursement available through Medicaid and may transfer funds from DSS to DMA to draw down federal Medicaid funds. DHHS to HHS and FRD As funds are transferred and rates are modified Abbreviations: DHHS: the Department of Health & Human Services FRD: Fiscal Research Division HHS: House of Representatives Appropriations Subcommittee on Health and Human Services & Senate Appropriations Committee on Health and Human Services North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 44 APPENDIX C North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 45 Overview of Aging Services & State Aging Plan N.C.G.S. 143B-181.1A prepared by Division of Aging, N.C. Department of Health and Human Services for the Study Commission on Aging NC Division of Aging 2 The Aging of North Carolina— General Organization of Plan ¡ Aging NC ¡ Healthy Aging ¡ Long-Term Care and Aging ¡ Economic Security ¡ Senior-Friendly Communities �� Priorities of Senior Advocates ¡ State Agencies Major Activities and Future Directions NC Division of Aging 3 Actual and Projected Population Age 65 and Older, North Carolina, 1940 t
Object Description
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Title | North Carolina Study Commission on Aging : report to the... General Assembly of North Carolina... session |
Other Title | Report to the Governor and the... regular session of the... General Assembly |
Date | 2004 |
Description | 2004 |
Digital Characteristics-A | 1 MB; 116 p. |
Digital Format |
application/pdf |
Pres Local File Path-M | \Preservation_content\StatePubs\pubs_borndigital\images_master\ |
Full Text | NORTH CAROLINA STUDY COMMISSION ON AGING REPORT TO THE GOVERNOR AND THE 2004 REGULAR SESSION OF THE 2003 GENERAL ASSEMBLY A LIMITED NUMBER OF COPIES OF THIS REPORT IS AVAILABLE FOR DISTRIBUTION THROUGH THE LEGISLATIVE LIBRARY. ROOMS 2126, 2226 STATE LEGISLATIVE BUILDING RALEIGH, NORTH CAROLINA 27611 TELEPHONE: (919) 733-7778 OR ROOM 500 LEGISLATIVE OFFICE BUILDING RALEIGH, NORTH CAROLINA 27603-5925 TELEPHONE: (919) 733-9390 North Carolina Study Commission On Aging April 27, 2004 To: Governor Michael Easley Lieutenant Governor Beverly Perdue, President of the North Carolina Senate Senator Marc Basnight, President Pro Tempore of the North Carolina Senate Representative James Black, Speaker of the North Carolina House of Representatives Representative Richard Morgan, Speaker of the North Carolina House of Representatives Members of the 2003 General Assembly, Regular Session 2004 Attached is a report from the North Carolina Study Commission on Aging submitted to you pursuant to North Carolina General Statute §120-187. The North Carolina Study Commission on Aging presents to you findings and recommendations based on study conducted after the adjournment of the 2003 Regular Session of the 2003 General Assembly. Proposed legislation is contained within this report. Respectfully submitted, ___________________________ ___________________________ Senator A.B. Swindell, IV Representative Debbie A. Clary Co-Chair Co-Chair ___________________________ Representative Edd Nye Co-Chair i North Carolina Study Commission On Aging 2004 Membership List President Pro Tempore's Appointments Speakers' Appointments Senator Albin B. Swindell IV, Co-Chair Representative Debbie A. Clary, Co-Chair Senator Austin M. Allran Representative Edd Nye, Co-Chair Senator Charlie S. Dannelly Representative David R. Lewis Senator Tony P. Moore Representative Jennifer Weiss Senator Joe Sam Queen Representative William Eugene Wilson Mr. Brad Allen Ms. Katherine Fox Price Ms. Jan Elliot Ms. Florence Gray Soltys Mr. Sam Marsh Ms. Linda Howard Ex Officio: Mr. Jackie Sheppard, Assistant Secretary, Long Term Care and Family Services, Department of Health and Human Services Clerk: Jo Bobbitt 919/733-5477 Staff: Theresa Matula Dianna Jessup Research Division 919/733-2578 Susan Morgan Fiscal Research Division 919/733-4910 ii North Carolina Study Commission on Aging 1 Report to the Governor and the 2004 Session of the 2003 General Assembly TABLE OF CONTENTS LETTER OF TRANSMITTAL ................................................................................................. i MEMBERSHIP LIST ................................................................................................................ ii PREFACE ................................................................................................................................. 4 EXECUTIVE SUMMARY......................................................................................................... 5 OLDER ADULTS IN NORTH CAROLINA: A PROFILE .................................................... 7 COMMISSION PROCEEDINGS.............................................................................................. 11 COMMISSION RECOMMENDATIONS................................................................................. 16 APPENDICES APPENDIX A ............................................................................................................................. 27 North Carolina Demographics of Aging APPENDIX B ............................................................................................................................ 31 Commission Recommendations to 2003 General Assembly, 2003 Regular Session Summary of Substantive Legislation Related to Aging, 2003 Session Studies and Reports Related to Aging APPENDIX C ............................................................................................................................ 44 Overview of Aging Services and the State Aging Plan Presentation APPENDIX D ............................................................................................................................ 48 Guardianship Reform in the Twenty-First Century APPENDIX E ............................................................................................................................. 53 Tax Treatment of Long-Term Care Insurance in Selected States Long-Term Care Credits Claimed for TY 2002 AAHP-HIAA State Tax Incentives for Purchase of LTCI APPENDIX F.............................................................................................................................. 58 Mentally Ill Population in Adult Care Homes In NC Geriatric Mental Health Specialty Teams Presentation Geriatric Mental Health Specialty Team Model and Guidelines APPENDIX G............................................................................................................................. 66 Summary of Presentations by Organizations Representing Older Adults North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 2 APPENDIX H............................................................................................................................. 72 Home and Community Care Block Grant Presentation Facts about the Home and Community Care Block Grant Summary of Home and Community Care Block Grant Budgeted Funding APPENDIX I.............................................................................................................................. 85 Adult Day Services in Brief Types of Programs and Geographic Location in North Carolina Staffing Ratios Adult Day Services Program Closings 2001-2003 Adult Day Services Funding Fact Sheet APPENDIX J: LEGISLATIVE PROPOSALS ......................................................................... 95 (SWz-32) AN ACT TO REPEAL THE SUNSET ON THE LONG-TERM CARE INSURANCE TAX CREDIT, AS RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON AGING. (SHz-13) AN ACT TO PROVIDE SUPPORT AND TRAINING FOR LONG-TERM CARE PROVIDERS CARING FOR RESIDENTS WITH MENTAL ILLNESSES, AS RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON AGING. (SHz-16) AN ACT TO DIRECT THE DEPARTMENT OF HEALTH AND HUMAN SERVICES TO STUDY ISSUES RELATED TO MENTALLY ILL RESIDENTS IN LONG-TERM CARE FACILITIES, AS RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON AGING. (SWz-37) AN ACT TO ESTABLISH A PILOT PROGRAM TO CONDUCT NATIONAL CRIMINAL HISTORY RECORD CHECKS OF PERSONS SEEKING EMPLOYMENT TO PROVIDE DIRECT CARE IN ADULT CARE HOMES AND CONTRACT AGENCIES OF ADULT CARE HOMES, AND TO MAKE CONFORMING CHANGES, AS RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON AGING. (SHz-6) AN ACT TO APPROPRIATE FUNDS FOR SENIOR CENTER DEVELOPMENT AND OUTREACH, AS RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON AGING. (SHz-7) AN ACT TO APPROPRIATE FUNDS FOR SENIOR ADULT HOUSING, AS RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON AGING. (SHz-8) AN ACT TO APPROPRIATE FUNDS FOR THE HOME AND COMMUNITY CARE BLOCK GRANT, AS RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON AGING. (SWz-34)AN ACT TO DIRECT THE DEPARTMENT OF HEALTH AND HUMAN SERVICES TO STUDY WHETHER AN INSTITUTIONAL BIAS EXISTS IN THE STATE'S MEDICAID PROGRAM, AS RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON AGING. North Carolina Study Commission on Aging 3 Report to the Governor and the 2004 Session of the 2003 General Assembly (SWz-33) AN ACT TO ESTABLISH THE LEGISLATIVE STUDY COMMISSION ON STATE GUARDIANSHIP LAWS, AS RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON AGING. (SHz-11) AN ACT TO APPROPRIATE FUNDS AND TO REQUIRE THE SOCIAL SERVICES COMMISSION TO ADOPT A RATE INCREASE FOR ADULT DAY SERVICES, AS RECOMMENDED BY THE NORTH CAROLINA STUDY COMMISSION ON AGING. North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 4 PREFACE As outlined in Chapter 120, Article 21 of the North Carolina General Statutes, the North Carolina Study Commission on Aging is charged with studying and evaluating the existing system of delivery of State services to older adults and recommending an improved system of delivery to meet the present and future needs of older adults. The Commission consists of 17 members. Of these members, eight are appointed by the Speaker of the House of Representatives, eight are appointed by the President Pro Tempore of the Senate, and the Secretary of the Department of Health and Human Services or the Secretary’s designee serves as an ex officio, non-voting member. This report represents the work performed by the North Carolina Study Commission on Aging from the conclusion of the 2003 Session of the 2003 General Assembly until the convening of the 2004 Session of the 2003 General Assembly. The Study Commission on Aging met on five occasions to study a variety of topics concerning older adults including: guardianship, a long-term care insurance tax credit, caring for the mentally ill in long-term care facilities, prescription drug assistance, disease management, elder care housing, the long-term care workforce, adult day services, the Home and Community Care Block Grant, and criminal history record checks of long-term care employees. During the course of its study, the Commission also heard presentations by representatives from fourteen (14) organizations advocating on behalf of older adults in North Carolina. North Carolina Study Commission on Aging 5 Report to the Governor and the 2004 Session of the 2003 General Assembly EXECUTIVE SUMMARY North Carolina General Statutes Chapter 143B, Article 3, Parts 14A. and 14B. establish North Carolina's Policy Act for the Aging, and Long-Term Care. The principles of the Policy Act for the Aging are to effectively utilize the resources of the State, to provide a better quality of life for senior citizens, and to assure older adults the right of choosing where and how they want to live. The Long-Term Care policy recognizes that traditional caregivers are increasingly employed outside the home and create a growing demand for improvement and expansion of home and community-based long-term care services to support and complement the services provided by informal caregivers. The long-term care policy provides that the public interest would best be served by a broad array of long-term care services that support persons who need services in the home or in the community whenever practicable, and that promote individual autonomy, dignity and choice. The provision also provides that institutional care will continue to be a critical part of the State's long-term care options and that services should promote individual dignity, autonomy, and a home-like environment. The current size of North Carolina's older adult population, and trends indicating that this segment of the population will increase, indicate the importance of an intense and sustained focus on the support systems and services that North Carolina has in place for older adults. Study efforts undertaken during the 2003-2004 interim by the North Carolina Study Commission on Aging, sought to evaluate the existing system of services to older adults and to recommend improvements. In response to this study, the North Carolina Study Commission on Aging makes the following recommendations to the Governor and the 2004 Session of the 2003 General Assembly: Recommendation 1 The North Carolina Study Commission on Aging recommends that the General Assembly repeal the sunset on the Long-Term Care Insurance Tax Credit. Recommendation 2 The North Carolina Study Commission on Aging recommends that the General Assembly require the Department of Health and Human Services to continue to provide support and training for long-term care providers caring for residents with mental illnesses by conducting a study on expanding the mission of Geriatric Mental Health Specialty Teams; and by standardizing criteria across the Teams and tracking utilization and expenditure data. Recommendation 3 The North Carolina Study Commission on Aging recommends that the General Assembly require the Department of Health and Human Services to work with long-term care providers and advocates for the elderly and the mentally ill to study issues related to mentally ill individuals residing in long-term care facilities. Recommendation 4 The North Carolina Study Commission on Aging recommends that the General Assembly establish a pilot program to conduct national criminal history record checks of persons seeking employment to provide direct care in adult care homes or contract agencies of adult care homes. North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 6 Recommendation 5 The North Carolina Study Commission on Aging recommends that the General Assembly support Senior Center development and outreach, and restore funding to the 2002 level, by appropriating $281,000 for the 2004-2005 fiscal year. Recommendation 6 The North Carolina Study Commission on Aging recommends that the General Assembly appropriate $1,000,000 to the Housing Trust Fund for the 2004-2005 fiscal year to be used for independent housing with services. Recommendation 7 The North Carolina Study Commission on Aging recommends that the General Assembly appropriate $1,000,000 for the Home and Community Care Block Grant for the 2004-2005 fiscal year. Recommendation 8 The North Carolina Study Commission on Aging recommends that the General Assembly require the Department of Health and Human Services to study whether the State's Medicaid Program has a bias that favors support for individuals in institutional settings over support for individuals living at home; and to recommend ways to alleviate this bias, if such a bias exists. Recommendation 9 The North Carolina Study Commission on Aging recommends that the General Assembly establish a Legislative Study Commission to study State guardianship laws. Recommendation 10 The North Carolina Study Commission on Aging recommends that the General Assembly appropriate funds and require the Social Services Commission to adopt a rate increase of no less than five dollars ($5.00) per day for adult day and adult day health services. North Carolina Study Commission on Aging 7 Report to the Governor and the 2004 Session of the 2003 General Assembly OLDER ADULTS IN NORTH CAROLINA: A PROFILE Prepared by the Department of Health and Human Services, Division of Aging and Adult Services Older Population Today North Carolina ranks tenth among states in the number of persons age 65 and older and eleventh in the size of the entire population.i The fast pace of growth of the State’s older population is evident in a recent US Census Bureau’s release in which North Carolina was ranked fourth nationally in the increase of the number of older persons age 65+ (47,198 in NC) between April 2000 to July 2003. Only three other states (California, Texas, and Florida) reported a greater increase among their older populations. Even so, when combined with the equally strong growth in other age groups, the State continues to maintain an overall healthy demographic balance among the generations. Currently, North Carolina ranks thirty-third nationally in the percentage of the population that is 65 years of age and older (65+). § North Carolina population age 65+ in 2004: 1,016,214 (12.1% of total population) § North Carolina population age 85+ in 2004: 118,511 (1.4% of the total population) North Carolina is rich in diversity, but its citizens face challenges because of the disparity that exists among all populations, including older adults. Some important differences among the State's older adults relate to gender, marital status, race/ethnicity, residence, rurality, disability, health status, and veteran status. § Gender: Older women represent 59.8% of the 65+ age group and 74.0% of the 85+ age group.ii The higher rate of poverty among older women remains a primary issue today. For example, women age 75+ are twice as likely to be poor as men the same age.iii § Marital Status: At age 65 and older, women are more than twice as likely to be unmarried as men in their age group.iv Data show that being unmarried (widowed, divorced, separated, or never married) increases a woman’s vulnerability to poverty. According to the Social Security Administration, 50% of unmarried women rely on Social Security for 80% of their income and 25% rely on Social Security as their sole source of income.v Age 65-74 Age 75-84 Age 85+ Unmarried Women in NC 45.4% 65.8% 76.5% Unmarried Men in NC 18.7% 25.2% 39.4% Source: NC Division of Aging and Adult Services (2003). The Aging of North Carolina: The 2003-2007 North Carolina Aging Services Plan § Ethnicity/Race: Altogether 18.1% of persons age 65+ are members of ethnic minority groups in North Carolina.vi Compared to the nation as a whole, North Carolina’s population age 65+ includes a larger proportion who are African American (15.3% in NC to 8.3% nationally) and a smaller proportion of Latinos (0.6% in NC to 4.7% nationally). American Indians, Asian Americans, and other ethnic groups each account for 1% or less of the age group 65+. The statistics for African American and other older adults who are minority group members, in North Carolina as well as nationally, show both a higher poverty rate and a lower life North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 8 expectancy when compared with the white population. 65+ White Minority Total Male Female Male Female Below Poverty 13.2% 6.5% 12.9% 21.7% 30.3% “Near Poor”(101-200% Poverty) 23.2% –* –* –* –* Life Expectancy at Birth (years) 75.6 73.8 79.6 68.0 75.8 Life Expectancy at Age 65 (years) 17.1 15.4 18.9 13.8 17.8 *Information currently not available. Source: NC Division of Public Health (2002). Healthy Life Expectancy in North Carolina, 1996-2000. § Residence: In North Carolina, 23.8% of all homeowners are age 65+, yet among older homeowners, over 61,000 reported incomes for 1999 that were below poverty.vii This figure represented 38% of the homeowners of all ages with income below poverty and exceeded the national average of 32.7%. Among renters age 65+ who provided information, 53%, or almost 48,000, spent more than 30% of their household income on rent. Furthermore, 5,000 North Carolina homeowners and renters age 65+ lacked complete plumbing facilities in their homes.viii Even more disturbing news is found in the statistics of emergency shelters—where the largest increase among the homeless between 2001 and 2002 in North Carolina were among those 55+.ix While the total population of homeless reported by shelters increased by 5% during this period, the elder homeless grew by 71% (totaling 3,494 persons in 2002). § Rurality: Although the United States Census Bureau has not yet released figures specifically for the older population residing in rural areas, it is expected to easily exceed 39.8%, the rate for the total population.x In 2000, North Carolina's rural population (3,199,831) was almost as large as the one in Texas (3,647,539), the state with the largest number of rural residents in the nation. Not only was North Carolina's rural population among the largest in terms of numbers, but the state also reported the highest proportion (39.8%) of rural population among the 20 most populous states in the nation. While 11 other states reported higher proportions of rural population, ranging from 40.7% to 61.8%, all of these states are much smaller in total population than North Carolina. Thus, North Carolina is unique among more populous states in having so large a rural contingent. A 2002 report highlights a long list of challenges rural residents and their communities face—isolation by distance, lagging infrastructure, sparse resources that cannot adequately support education and other public services, and weak economic competitiveness.xi § Disability: In North Carolina, 45.7% of the non-institutionalized civilian population age 65+ reported having one or more disablities•47.5% of women and 43.2% of men, according to the 2000 Census.xii The Census defines disability as “a long-lasting physical, mental, or emotional condition. This condition can make it difficult for a person to do activities such as walking, climbing stairs, dressing, bathing, learning, or remembering. This condition can also impede a person from being able to go outside the home alone or to work at a job or business.” § Health Status: In a statewide survey, over one third of people age 65+ say that their general health status is fair or poor, ranging from 34.1% for white women to 49.3% for minority women.xiii In the same survey, 18.4% (highest) of minority women and 4.4% (lowest) of white men age 65+ said that there was a time they could not see a doctor due to medical cost. North Carolina Study Commission on Aging 9 Report to the Governor and the 2004 Session of the 2003 General Assembly § Veteran Status: Of the 779,393 veterans living in North Carolina, 263,102, or 34%, were age 65 and older in 2000. Another 34% were Vietnam-era veterans (between 43 and 57 years old in 2000). The population of veterans of the Vietnam-era contains proportionally more disabled members than the veterans’ populations of earlier wars.xiv The Veterans Administration cites the aging of the veterans as a major challenge to its health care system in coming years.xv North Carolina’s Demographic Shift Older adults are North Carolina’s fastest growing population. By 2030, our senior population should exceed more than 2.2 million, comprising 17.9% of total population.xvi The median age climbs from 35.3 years in 2000 to 38.4 years in 2030. Projected Growth of Population Age 65+ (2000 – 2030) 969,048 1,183,243 1,652,288 2,221,470 0 500,000 1,000,000 1,500,000 2,000,000 2,500,000 2000 2010 2020 2030 Year Population Age 65+ Why This Demographic Shift A combination of improved life expectancy and lower birth rates contributes to a society’s “aging”. In North Carolina, as anywhere in the nation, the aging of the “Baby Boomers” (born between 1946 and 1964) will greatly accelerate this societal aging in coming years. Another factor in the State’s aging is migration. North Carolina ranked sixth among the states with a net migration rate of 22.1 per 1,000 among persons age 65+, in the five-year period between 1995 and 2000. [Note: A positive net migration indicates that more older adults moved to North Carolina than left during that time.] Along with other Sunbelt states, North Carolina remains a popular destination for people of all ages, including seniors. Other southern states with high positive net migration among older adults include: Florida (56.9); South Carolina (33.6); Georgia (18.1); and Tennessee (15.2). There are other important factors influencing the diverse experiences in demographic shifts among the State’s 100 counties.xvii In 83 counties, the rate of increase among citizens age 65+ (22%) is expected to exceed the growth of the total population (18%). § Rural-to-urban migration of young adults continues to age rural counties. § Large metropolitan counties attract large numbers of persons from outside the State as well as from rural counties. § The large metropolitan counties are experiencing greater growth among younger adults than North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 10 they are among older adults. § A large number of older adults with higher incomes are retiring in some western and coastal counties. What Are the Implications of This Shift? The aging of the population is a national and international trend, and North Carolina, like the rest of the world, must be prepared to reap the benefits and face the challenges of an older population. Government faces decisions about the allocation of public resources from a tax base that may experience slowed growth, especially in many aging rural counties. People must consider living and caregiving arrangements in light of smaller nuclear and extended families. The health, human service, employment, and education systems must adapt to the changing needs and interests of seniors of today and tomorrow. The business, faith communities, and others must identify and respond to the challenges and opportunities of these demographic shifts. In the 2003-2007 State Aging Plan, the North Carolina Division of Aging and Adult Services introduced a new initiative–Senior-Friendly Communities–to raise awareness of the aging of our population and to promote the North Carolina communities becoming senior-friendly through collaboration among citizens, agencies, organizations, and programs, in both the public and private arenas. A senior-friendly community in North Carolina will draw on the talents and resources of active seniors while enhancing services for those are vulnerable because of their health, economic hardships, social isolation, or other conditions. A senior-friendly community will bring together a wide range of issues and concerns (e.g., air quality, housing, long-term care services, employment, enrichment opportunities) that, as a whole, affect the quality of life of seniors and others in the community. Also, a senior-friendly community will assure stewardship of its resources to meet the needs of today’s seniors, while helping baby boomers and younger generations prepare for the future. For additional information on North Carolina aging demographics, please refer to Appendix A. Sources of Information 1 US Census Bureau (2004). Annual Estimates of the Resident Population by Selected Age Groups for the United States and States: July 1, 2003 and April 1, 2000. 1 NC State Data Center (2004). County/State Population Estimates. 1 Institute for Research on Women & Gender (2002). Difficult Dialogues Program Consensus Report: Aging in the Twenty-first Century. 1 US Census Bureau (2002). PCT 7 (Summary File 3). 1 US Social Security Administration (1998). Fast Facts & Figures about Social Security. 1 US Census Bureau (2003). P12 (Summary File 1). 1 US Census Bureau (2002). HCT 8 (Summary File 2). 1 NC State Library (2003). Special tabulation from the Census 2000 data as requested by the NC Division of Aging. 1 NC Office of Economic Opportunity (2002). Comparison of Beneficiary Characteristics: Emergency Shelter Grants Program (FY 2000 and FY 2001). 1 US Census Bureau (2003). P2 (Summary File 1). 1 MDC (2002). State of the South 2002. 1 US Census Bureau (2003). PCT 26 (Summary File 3). 1 NC Department of Health and Human Services (2003). A Health Profile of Older North Carolinians. 1 US Department of Veterans’ Affairs (2002). VA History in Brief. 1 US Department of Veterans’ Affairs (2002). Data on the Socioeconomic Status of Veterans and on VA Program Usage. 1 NC State Data Center (2004). County/State Population Projections. 1 NC Division of Aging and Adult Services (2003). The Aging of North Carolina: The 2003-2007 North Carolina Aging Services Plan. North Carolina Study Commission on Aging 11 Report to the Governor and the 2004 Session of the 2003 General Assembly COMMISSION PROCEEDINGS February 10, 2004 The North Carolina Study Commission on Aging met on Tuesday, February 10, 2004 at 10:00 a.m. in Room 643 of the Legislative Office Building. Representative Edd Nye was the presiding Co-Chair. Following Commission member introductions and approval of the budget, Theresa Matula, Commission staff, provided an overview of the statutory basis for the Commission and its charge. By law, the Commission is required to study and evaluate the existing system of delivery of State services to older adults and to recommend an improved system of delivery to meet the present and future needs of older adults. Mrs. Matula pointed out the specific duties of the Commission as they appear in G.S. 120-181, and the reporting requirements contained in G.S. 120-187. Theresa Matula and Dianna Jessup, Commission staff, reviewed the status of the Commission's recommendations to the 2003 Session of the 2003 General Assembly and presented an overview of other legislation of interest to older adults Appendix B. Karen Gottovi, Director, Division of Aging and Adult Services, Department of Health and Human Services (DHHS), presented an overview of the services available for older adults in North Carolina Appendix C. Mrs. Gottovi also presented The Aging of North Carolina, the 2003-2007 North Carolina Aging Services Plan. The Plan was submitted to the North Carolina General Assembly on March 1, 2003. Mrs. Gottovi pointed out that the 2003-2007 Plan builds upon the achievements of the 1999-2003 Plan as well as three other earlier plans developed in the 1990s (1991, 1993, and 1995) and provides a foundation for new developments. The Aging Services Plan is required by G.S. 143B-181.1A and the federal Older American Act. John Saxon, Professor of Public Law and Government, University of North Carolina at Chapel Hill gave a presentation on guardianship laws. Appendix D. The presentation outlined the legal history of guardianship reform, the current law and issues that may need to be addressed, as well as and overview of the Uniform Guardianship and Protective Proceedings Act (UGPPA). The North Carolina tax credit for long term care insurance expired for taxable years beginning on or after January 1, 2004. As a result, the Commission heard from Carla Obiol with the Department of Insurance's Seniors' Health Insurance Information Program (SHIIP), who gave an overview of long term care insurance. Her handouts included: A Shopper's Guide to Long-Term Care Insurance and Facts About Long-Term Care Insurance In North Carolina . Additionally, Karl Knapp from the Tax Research Division, and Nancy Pomeranz from the Personal Taxes Division, of the North Carolina Department of Revenue, made presentations on the tax treatment of long-term care insurance in selected states, and on the number of long-term care tax credits claimed in North Carolina Appendix E. Ms. Pomeranz discussed the error rate experienced on the long-term care tax credit and the Department's efforts to reduce that error rate. Some of the Department's efforts include informing taxpayers who made errors, and working with software vendors to improve the long-term care tax credit information in their programs. The final item on the agenda concerned adult care home rules and caring for the mentally ill. The Commission heard presentations from Jim Upchurch, Division of Facility Services, Department of Health and Human Services Appendix F; Dottie Harrison, Board Member, NC National Alliance for the Mentally Ill (NAMI); and Lou Wilson, NC Association of Long Term North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 12 Care Facilities. Ms. Harrison addressed the consequences of the lack of appropriate housing for mentally ill individuals and her concerns for adequate staffing and training to care for mentally ill individuals in long-term care facilities. Ms. Wilson mentioned the use of the Geriatric Mental Health Specialty Teams and provided recommendations for improvement. March 9, 2004 The North Carolina Study Commission on Aging met on Tuesday, March 9, 2004 at 10:00 a.m. in Room 643 of the Legislative Office Building. Senator A.B. Swindell was the presiding Co- Chair. Topics of this meeting included brief remarks by organizations advocating on behalf of older adults in North Carolina; disease management; NC Senior Care; the new Medicare prescription drug program; and geriatric mental health specialty teams. The Commission heard from fifteen (15) individuals that represent, or advocate on behalf of, older adults in North Carolina. Each representative was allowed approximately three minutes to make a brief presentation on the issues affecting older adults in North Carolina. Staff presented the Commission members with a Summary of Presentations by Organizations Representing Older Adults Appendix G during the March 23, 2004 meeting. The legislative priorities/issues of concern that were mentioned with the greatest frequency were: Access to National Criminal Record Checks (6 responses); Restoration of the LTC Insurance Tax Credit (4 responses); Support for and/or Restoration of Funding for the home and Community Care Block Grant (HCCBG) (3 responses); Support for/and or Restoration of Funding for Senior Centers (3 responses); and Maintaining the Viability of the Community Alternatives Program for Disabled Adults (CAP/DA) (3 responses) Appendix G. Alan Dobson, Chairman of Cabarrus Community Care; Chairman of Physician Advisory Group; and President/CEO of Cabarrus Family Medicine delivered a presentation on disease management. Community Care of North Carolina focuses on improved quality, utilization and cost effectiveness with thirteen (13) networks with more than 2,000 physicians and 417,000 enrollees. Dr. Dobson indicated that the primary goals of Community Care of North Carolina are to: Improve the care of the Medicaid population while controlling costs; and to Develop community based networks capable of managing populations. He pointed out that these goals are achieved by making sure people get the care when they need it; increasing local provider collaboration; obtaining quality care; implementing best practice guidelines; and managing Medicaid costs. Key program efforts for the aged and disabled include: diabetes, poly-pharmacy in skilled nursing facilities, poly-pharmacy for the disabled, and therapy services. Michael Keough, from the Department of Health and Human Services, gave a presentation on the North Carolina Senior Care program. He first gave an overview of the program, which is designed specifically to provide assistance to North Carolina seniors (age 65 or older), diagnosed with one of three diseases (diabetes mellitus, cardiovascular disease, and chronic obstructive pulmonary disease); have an annual household income at or below 200% of the federal poverty level and no other prescription drug coverage. As of March 2004, there were 32,600 enrollees, representing all 100 counties. Outreach efforts include the distribution of 400,000 enrollment applications and an outreach grant with the General Baptist State Convention. Mr. Keough also presented information on the Medication Assistance Program in which 23 grantees cover 60 sites in 60 counties. The key components of the Medication Assistance Program include: Prescription Assistance (facilitating use of pharmaceutical manufacturers' free and low cost drug programs), and Medication Management including pharmacist evaluation of individual senior's drug North Carolina Study Commission on Aging 13 Report to the Governor and the 2004 Session of the 2003 General Assembly regimens. NC Senior Care is reviewing options to coordinate coverage with the recently enacted changes to the Medicare program. Carla Obiol, Deputy Commissioner, Seniors' Health Insurance Information Program (SHIIP) made a presentation to the Commission on the Medicare Prescription Drug Improvement and Modernization Act of 2003 (Act). Ms. Obiol gave an overview of the timetable of benefits, information on the Medicare Prescription Drug Discount Card and the Transitional Assistance Program, the discount card sponsor qualifications, Medicare Part D: Prescription Drug Plan (PDP), and outreach efforts by SHIIP and the Centers for Medicare & Medicaid Services (CMS). Provisions of the Act include a Medicare-approved Prescription Drug Discount Card, a Transitional Assistance Program, and Medicare Advantage from 2004-2005. It is anticipated that Medicare Part D: Prescription Drug Plan will be in place by 2006. Details are continuing to evolve and Ms. Obiol recommended the following resources: the Medicare Program: http://www.medicare.gov/ or http://www.cms.gov/ or 1-800-MEDICARE; and SHIIP http://www.ncshiip.com./ (see Senior Citizens heading). This meeting concluded with a presentation on Geriatric Mental Health Specialty Teams from Dr. Bonnie Morell, Division of Mental Health, Developmental Disabilities and Substance Abuse Services, Department of Health and Human Services. According to Dr. Morell, the Geriatric Mental Health Specialty Teams were developed to provide expertise and services throughout the State in recognition of the need for greater local capacity to address and serve the needs of older adults with mental illness. According to information presented, "The purpose of these teams is to increase the ability of older adults with mental illness to live successfully in their communities by: 1) assisting with the successful reintegration of older adults into the community when they are discharged from State psychiatric hospitals, and 2) providing holistic support services and technical assistance to nursing homes, adult care homes, and other agencies and caregivers that serve older adults who have mental health treatment needs and who may be at risk of psychiatric hospitalization." Appendix F March 23, 2004 The North Carolina Study Commission on Aging met on Tuesday, March 23, 2004 at 10:00 a.m. in Room 643 of the Legislative Office Building. Representative Debbie Clary was the presiding Co-Chair. Presentation topics for this meeting were elder housing, the long-term care workforce, adult day services, the Home and Community Care Block Grant (HCCBG), a report on CAP/DA, and criminal history record checks. Bob Kucab, Executive Director of the North Carolina Housing Finance Agency, spoke to the Commission about the work of the agency. The purpose of the agency is to finance housing for persons who are not served by the private market. The agency helps seniors by improving their existing housing and by working to develop new apartments where seniors can have affordable rents, good living environments, and connections to community services. While the agency is involved in a number of projects, applications for funding exceed available capital by 3 to 1. Mr. Kucab requested an increase in the $3 million State appropriation for the Housing Trust Fund to aid the agency in its efforts. Susan Harmuth from the Office of Long Term Care and Family Services, Department of Health and Human Services (DHHS), updated the Commission on the Department's long-term care workforce initiatives. She reported that employee turnover has been decreasing since 2000, but it is still high. The Department is working on a variety of projects to combat this turnover. One North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 14 of these projects is The Better Jobs/Better Care Demonstration. Under this demonstration, the State's Better Jobs/Better Care Partner Team is working to develop a uniform (and voluntary) set of expectations and criteria for use across home care, adult care homes and nursing facilities that relate to issues impacting the recruitment and retention of direct care workers. Major domain areas include safe and balanced workloads, training and career advancement opportunities, supportive workplaces, worker empowerment, peer mentoring, orientation, management support, coaching supervision, and reward and recognition. Following Ms. Harmuth's presentation, the Commission heard several presentations concerning adult day and adult day health services. Nancy J. Cox, Director of Partners in Caregiving, Wake Forest University School of Medicine, presented information concerning the predictors of success for adult day programs from a marketing, financing, and programming perspective. Created in 1987 by The Robert Wood Johnson Foundation, Partners in Caregiving is a national adult day services program. The focus of Partners in Caregiving is to teach non-profit adult day centers the principles of business and marketing to be financially self-sufficient and not rely on grants. She presented the results of a recent national study of adult day services that showed the need for adult day service capacity building at the State level in three areas: increased public awareness in underutilized areas, increased availability in areas where the service is not currently an option for caregivers, and increased knowledge at the provider level regarding predictors of success. Suzi Kennedy from the Life Enrichment Center of Cleveland County, Inc. spoke about the challenges of operating a successful adult day program. Ms. Kennedy showed pictures of the facilities in her area and presented the "Menu for Financial Success for the Life Enrichment Center." This Menu included: 1) a strong Board with effective committees; 2) diversified revenue streams (operating and non-operating); 3) a diversified population; 4) unbundling the services (i.e. transportation, personal care services, hair care); and 5) pre-billing for enrollment rather than attendance, for the levels of care, and for ancillary services. Ms. Kennedy stated that, "Without financial stability there can be no social good," and she pointed out that public reimbursement rates are often insufficient to cover the costs of running a program. Steve Freedman from the Division of Aging and Adult Services, DHHS, was the final speaker on the subject of adult day services Appendix I. Mr. Freedman stated that there are currently 113 certified adult day and adult day health programs in the State, a decrease from the peak of 125 programs in 2000. The programs are currently located in 60 counties. The Division of Aging and Adult Services has been working with the North Carolina Adult Day Services Association to develop fiscal training for adult day programs. According to the Division, the aim of this project is to assist adult day programs with budgeting and help increase their understanding of service costs. Mr. Freedman also addressed reimbursement rates. Currently, the maximum reimbursement rate for adult day services is $26.07 per day, and $33.00 per day for adult day health services. According to the North Carolina Adult Day Services Association, the average cost to operate an adult day program is $31.00 per day, and for adult day health programs it is $44.00 per day. In the 2003 budget bill, the General Assembly directed the Social Services Commission to consider adopting rules to increase these rates within existing funds. A rate increase has not occurred. Next, Dennis Streets from the Division of Aging and Adult Services, DHHS presented information concerning the Home and Community Care Block Grant Appendix H. The Home and Community Care Block Grant (HCCBG) was established by the General Assembly in 1992. North Carolina Study Commission on Aging 15 Report to the Governor and the 2004 Session of the 2003 General Assembly By consolidating several funding sources (i.e. the Older Americans Act, the Social Services Block Grant in support of respite care, portions of the State In-Home and Adult Day Care funds, and other relevant State appropriations), the HCCBG helps to coordinate the service delivery system to meet the needs of seniors. The focus of the HCCBG is to support the frail elderly at home, assist with access to services and information, provide family caregiver relief and help seniors remain active. While there have been some increases in federal funds, State support has decreased. According to Mr. Streets, there are more than 6,500 unmet service needs, especially for home-delivered meals and in-home aide services. Gary Fuquay, Division of Medical Assistance, DHHS, presented a report on the Community Alternatives Program for Disabled Adults (CAP/DA), required by S.L. 2003-284, Sec. 10.29B(b) and (c). The section basically required the Department to conduct a cost analysis of CAP/DA and the State/County Special Assistance In-Home program in relation to the per client cost of nursing homes and adult care homes. While the report attempted to provide cost comparisons, Mr. Fuquay warned that it is difficult to draw conclusions from the data because one cannot compare level of care indicators. The Commission next heard from various speakers concerning national criminal history records checks of long-term care workers. John Aldridge from the North Carolina Attorney General's Office gave an overview of current law regarding who can receive the results of national criminal history records checks and for what purposes. Jackie Sheppard from the Office of Long-Term Care and Family Services, DHHS, gave an overview of what the state of Mississippi is doing to address this issue. Roger Manus, representing Friends of Residents in Long-Term Care, urged the Commission to look at Florida's system for conducting background checks. Stacy Flannery, representing the NC Health Care Facilities Association, presented the providers' concerns about this issue. Finally, the meeting concluded with a brief presentation summarizing Appendix G the association presentations from the March 9 meeting. Chief among the issues raised by the associations was the current moratorium on national criminal history records checks of long-term care workers. April 13, 2004 The North Carolina Study Commission on Aging met on Tuesday, April 13, 2004 at 10:00 a.m. in Room 643 of the Legislative Office Building. Senator A.B. Swindell was the presiding Co- Chair. During this meeting, the Commission heard a presentation from Jackie Franklin with the Division of Aging and Adult Services, Department of Health and Human Services, on the State/County Special Assistance In-Home program. The Commission discussed and initially approved recommendations to the Governor and the General Assembly. The Commission also directed the staff to prepare a draft report for review at the final meeting. April 27, 2004 The North Carolina Study Commission on Aging met on Tuesday, April 27, 2004 at 10:00 a.m. in Room 643 of the Legislative Office Building. Members discussed and approved the Commission’s Report to the Governor and to the 2004 Session of the 2003 General Assembly. North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 16 COMMISSION RECOMMENDATIONS The North Carolina Study Commission on Aging makes the recommendations presented in this section to the Governor and the 2004 Session of the 2003 General Assembly. Each recommendation is followed by background information, and corresponding legislative proposals appear in Appendix J of this report. Recommendation 1 The North Carolina Study Commission on Aging recommends that the General Assembly repeal the sunset on the Long-Term Care Insurance Tax Credit. Background In 1997, the North Carolina Study Commission on Aging recommended that the 1997 General Assembly enact a 15% tax credit, up to a maximum of $350, on the premiums paid by the purchaser of long-term care insurance policies. According to the 1997 Commission report, the Office of State Budget and Management estimated that a 15% tax credit up to a maximum of $350 may result in a revenue loss of $17 million. The report further stated that, the average premium was $1,600, thus a 15% credit would be equal to $240. The report acknowledged that it was difficult to estimate the offsetting benefits of the tax credit in terms of reduced Medicaid payments, but that the cost of a year's stay in a North Carolina nursing home was $40,000. The Commission recommended this tax credit again in 1998, and the credit became Section 29A.6 of Session Law 1998-212. The tax credit was effective for taxable years beginning on or after January 1, 1999, and expired for taxable years beginning on or after January 1, 2004. On January 16, 2003, the Department of Revenue prepared a memorandum for the Revenue Laws Study Committee on the status of the tax credit for premiums paid on long-term care insurance. The memorandum outlined the Department's review of some of the returns on which the credit was claimed. During this review, auditors found that some taxpayers, who were not eligible for the tax credits, claimed the tax credits; and that some taxpayers claimed long-term care credits greater than the cap of $350. The Department found that, "Of the 2,155 returns reviewed, only 192 contained allowable long-term care credits. Taxpayers were not eligible for the credits claimed on the remaining 1,963 returns in this group. As a group, therefore, over 90% of the returns incorrectly claimed the credit." Because this represented a sample, the Department indicated that they did not know the error rate for all returns claiming the credit. They attributed the high error rate to two possible factors: "One factor is the complicated nature of the credit and the other is confusion of this credit with the repealed child health insurance credit." Additionally, the memorandum indicated that, for tax year 2001, the credit reduced tax revenue by $10,367,883. The 2003 North Carolina Study Commission on Aging recommended repealing the sunset on the long-term care insurance tax credit. In its 2003 report, the Commission expressed agreement with a statement from a Division of Aging's report, Increasing Personal Responsibility for Long Term Care through Private Long Term Care Insurance. The Division's report stated that, "In addition to the public benefit of having a much larger segment of the adult population positioned to pay privately for long-term care in terms of the state's economic health, consumers and families benefit from the ability to pay privately through increased choice and flexibility in terms of the range of services and settings of care available." S.L. 1998-212, Section 29A.6(d) made North Carolina Study Commission on Aging 17 Report to the Governor and the 2004 Session of the 2003 General Assembly the credit for premiums paid on long-term care insurance effective for taxable years beginning on or after January 1, 1999, and sunset the credit effective January 1, 2004. The Commission's bills repealing the sunset were introduced during the 2003 Session, but were not successful and the tax credit was allowed to sunset. As a result, the tax credit is not currently in place for the 2004 tax year. During the February 10, 2004 meeting, the Commission heard a presentation on long-term care insurance from Carla Obiol with the Seniors' Health Insurance Information Program (SHIIP), and presentations on issues related to the tax credit from Department of Revenue employees Karl Knapp, Tax Research Division, and Nancy Pomeranz, Personal Taxes Division Appendix E. Carla Obiol with the Department of Insurance's Seniors' Health Insurance Information Program (SHIIP), gave an overview of long-term care insurance. Her handouts included: A Shopper's Guide to Long-Term Care Insurance and Facts About Long-Term Care Insurance In North Carolina . Karl Knapp from the Tax Research Division, and Nancy Pomeranz from the Personal Taxes Division, of the North Carolina Department of Revenue, made presentations on the tax treatment of long-term care insurance in selected states, and on the number of long-term care tax credits claimed in North Carolina Appendix E. Ms. Pomeranz discussed the error rate experienced on the long-term care tax credit and the Department's efforts to reduce that error rate. The Department indicated that they had made progress in reducing the error rate on the long-term care insurance tax credit. Commission staff also obtained a chart Appendix E from the American Association of Health Plans-Health Insurance Association of America (AAHP-HIAA) depicting those states in the United States that offer tax incentives for the purchase of long-term care insurance. AAHP-HIAA is a national trade association representing the private sector in health care. The chart from AAHP-HIAA shows that 6 states offer tax credits and 16 states offer tax deductions. (Note: The information in the AAHP-HIAA chart does vary from the Department of Revenue's information, which could be the result of different compilation dates.) According to information received by the Commission staff, on June 5, 2003, the Department of Revenue reported that they had audited 2,372 returns for the tax year 2002, and adjusted 650 to disallow the credit, representing a 27% error rate. This error rate was down considerably from the 90% error rate on the 2001 returns reported earlier by the Department. The Department attributed the decrease to: 1) informing tax preparers of the appropriate use of the credit; 2) clarifying instructions about eligibility for the credit; 3) improving the verbiage in software developers' tax packages; and 4) communicating with taxpayers whose credit was disallowed in 2001, to inform them of the eligibility criteria for the tax credit. An additional $279,628 was assessed on the 650 returns adjusted, and returns continue to be audited as resources permit. On November 3, 2003, the Department reported that they had processed 3,574,530 returns: 2,158,850 paper and 1,415,680 efiled. Of the total, there were 35,936 on which a credit for long-term care insurance was claimed for a total of $19,110,623. The North Carolina Study Commission on Aging has supported the long-term care insurance tax credit since its inception and the current Commission continues to support it. The Commission scheduled presentations on this issue at the first meeting this interim, and restoration of the long-term care insurance tax credit was an item mentioned frequently during presentations on March 9, 2004, by organizations representing older adults in North Carolina. The Commission recommends that the General Assembly repeal the sunset on the long-term care insurance tax credit. Recommendation 2 The North Carolina Study Commission on Aging recommends that the General Assembly North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 18 require the Department of Health and Human Services to continue to provide support and training for long-term care providers caring for residents with mental illnesses by conducting a study on expanding the mission of Geriatric Mental Health Specialty Teams; and by standardizing criteria across the Teams and tracking utilization and expenditure data. Background On February 10, 2004, the Commission heard presentations on adult care home rules and caring for the mentally ill from Jim Upchurch, Division of Facility Services, Department of Health and Human Services (DHHS); Dottie Harrison, Board Member, NC National Alliance for the Mentally Ill (NAMI); and Lou Wilson, NC Association Long Term Care Facilities. On March 9, 2004, the Commission heard a presentation on Geriatric Mental Health Specialty Teams from Bonnie Morell, Community Policy Section, Division of Mental Health, Developmental Disabilities and Substance Abuse Services, Department of Health and Human Services (DHHS). Appendix F During her presentation, Ms. Wilson mentioned the use of the Geriatric Mental Health Specialty Teams. She indicated that while the intent of the program was positive, she believed, "The State has provided very little guidance for area mental health programs as to how the teams should be operated, thus the program has floundered in many areas of the state." She also stated that, "Area programs all over the State have developed criteria, protocol, policies and procedures that are unique to their area program. As a result, consumers and providers of services are expected to muddle through a system of inconsistency." According to information provided by DHHS, Geriatric Mental Health Specialty Teams were developed to increase the ability of older adults with mental illness to live successfully in their communities by: 1) assisting with the successful reintegration of older adults into the community when they are discharged from State psychiatric hospitals; and 2) providing holistic support services and technical assistance to nursing homes, adult care homes, and other agencies and caregivers that serve older adults who have mental health treatment needs and who may be at risk of psychiatric hospitalization. Currently, the Teams serve individuals 60+ years of age who are preparing to enter a nursing home or an adult care home, who currently reside in a nursing home or adult care home, and who are living in their own home or with family members. Individuals with geriatric-like needs are also served. Dr. Morell noted that, "This is a fairly new program that is being implemented during a time of change in the public mental health system. Focus will be on identifying ways in which to support the work that is being done by the teams that have been put in place." During her presentation on February 10, 2004, Ms. Wilson shared a recommendation for legislation. Ms. Wilson's recommendations include: 1) renaming the Teams to Long Term Care Facility Specialty Teams; 2) requiring all licensed adult care homes and nursing homes that serve individuals with a mental illness to participate in the program; 3) deleting the age requirement and the restrictions for residents to be at risk of psychiatric hospitalization and making services available for all persons with a mental illness who reside in adult care homes and nursing homes; 4) increasing the number of professionals on each team and/or decreasing the geographic areas that each team covers; 5) developing standardized criteria; 6) fully funding the program to support the individuals and facilities eligible for services; and 7) repealing the current adult care home special unit rule for persons with mental illnesses and create a new licensure law and rules that are more realistic. North Carolina Study Commission on Aging 19 Report to the Governor and the 2004 Session of the 2003 General Assembly According to information provided by staff in the General Assembly's Fiscal Research Division, the Geriatric Mental Health Specialty Teams are a contracted service through the Local Management Entities (LME). There are 20 Teams across North Carolina and each one contracts with one or more LME's. These are funded with Mental Health Trust Fund dollars, and these non-recurring funds are being replaced by recurring funds made available through mental hospital downsizing. As a Team delivers services to a facility, they file for reimbursement with the LME, which in turn seeks reimbursement from DHHS. Currently, DHHS cannot report specific cost data on the Geriatric Mental Health Specialty Teams. Based on the information presented to the Commission, the Commission recommends that the General Assembly require the Department of Health and Human Services to continue to provide support and training for long-term care providers caring for residents with mental illnesses by conducting a study on expanding the mission of Geriatric Mental Health Specialty Teams; and by standardizing criteria across the Teams and tracking utilization and expenditure data. Recommendation 3 The North Carolina Study Commission on Aging recommends that the General Assembly require the Department of Health and Human Services to work with long-term care providers and advocates for the elderly and the mentally ill to study issues related to mentally ill individuals residing in long-term care facilities. Background On February 10, 2004, the Commission heard presentations concerning caring for mentally ill individuals in long-term care facilities. One of the presenters was Dottie Harrison, Board Member, NC National Alliance for the Mentally Ill (NAMI). Ms. Harrison questioned whether adult care homes were appropriate housing options for mentally ill individuals, and she questioned the appropriateness of staffing and training at these facilities. Specifically, Ms. Harrison supported training on the appropriate administration of psychiatric medications, and training on appropriate interaction with residents based on their particular mental illness. Another presenter at the February meeting, Lou Wilson, Executive Director of the North Carolina Association of Long Term Care Facilities, stated that adult care home providers, "simply do not know how to muddle through the complex mental health systems, develop good rapports with mental health providers, provide mental health training for staff and recognize issues when specific residents are having difficulty." Ms. Wilson requested training for adult care home staff that will enable them to recognize symptoms of mental illness and urged the State, advocates, and the industry, to work together to ensure that individuals with mental illnesses receive the services they are entitled to receive. During the March 9, 2004 meeting, Dr. Bonnie Morell shared information with the Commission on the Geriatric Mental Health Specialty Teams Appendix F. One of the purposes of these Teams is to provide support services and technical assistance to nursing homes, adult care homes, and other agencies and caregivers that serve older adults who have mental health treatment needs and who may be at risk of psychiatric hospitalization. Currently, the Teams serve individuals 60+ years of age who are preparing to enter a nursing home or an adult care home, who currently reside in a nursing home or adult care home, and who are living in their own home or with family members. Individuals with geriatric-like needs are also served. In addition to other recommendations, Lou Wilson also requested the creation of a new licensure law and rules that are more realistic. During discussions at the April 13, 2004 meeting, North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 20 Commission members voiced support for examining whether current State statutes and Departmental rules adequately address the populations served by long-term care facilities. They also supported examining adult care home rules to determine whether they are easy to understand, attainable under current staffing patterns, give appropriate guidance to facility operators according to the needs and characteristics of residents served, support resident's freedom of choice, and whether they support the autonomy, dignity and independence philosophy of assisted living. The Commission supports quality care for mentally ill individuals and elderly individuals and recommends that the General Assembly require the Department of Health and Human Services to work with long-term care providers and advocates for the elderly and the mentally ill to study issues related to mentally ill individuals residing in long-term care facilities. Recommendation 4 The North Carolina Study Commission on Aging recommends that the General Assembly establish a pilot program to conduct national criminal history record checks of persons seeking employment to provide direct care in adult care homes or contract agencies of adult care homes. Background State law currently requires criminal history record checks of all applicants for employment with nursing homes, home health care agencies, and adult care homes. If the applicant has been a resident of North Carolina for less than five years, the criminal history record check must include both a national and a State criminal history record check. If the applicant has been a resident of North Carolina for five years or more, only a State criminal history record check is required. However, under federal law, the FBI may release results of national criminal history checks directly to nursing homes and home health care agencies on applicants for positions that involve direct patient care. Otherwise, results of criminal history checks performed by the FBI can only be released to a state agency and cannot be released directly to a provider. This has made it difficult for providers to comply with State law. As a result, a moratorium on national criminal history record checks was instituted in S.L. 2002-126, Sec. 10.10C for applicants for positions in nursing homes and home care agencies other than those involving direct patient care and for applicants for all staff positions in adult care homes, until January 1, 2004. Session Law 2003- 284, Sec. 10.8E extended the moratorium to January 1, 2005. Access to national criminal history record checks was an item mentioned frequently during presentations on March 9, 2004, by organizations representing, or advocating on behalf of, older adults in North Carolina. On March 23, 2004, the Commission heard a presentation from John Aldridge of the North Carolina Attorney General's office on this issue. He reiterated that unless federal law provides otherwise, the results of a national criminal history record check can only be released to a governmental agency. Currently, federal law only permits these results to be released to nursing homes and home care agencies on applicants for positions that involve direct patient care. Therefore, in order to be able to conduct national criminal history record checks on applicants for positions in nursing homes and home care agencies that do not involve patient care and on applicants for positions in adult care homes, current State law would have to be changed to direct that the results be sent to a governmental agency. The Commission recognizes that long-term care advocates and providers have legitimate concerns about the current status of national criminal history record checks. Roger Manus, North Carolina Study Commission on Aging 21 Report to the Governor and the 2004 Session of the 2003 General Assembly President of Friends of Residents in Long Term Care, pointed out during the Commission's meeting on March 23, that people living in long-term care facilities are the vulnerable frail elderly and disabled that cannot defend themselves, and many cannot communicate when they perceive a threat. Worst of all, they spend the night in these facilities when staffing levels decrease even further with greater potential and opportunity for abuse. It is important to ensure the safety of this vulnerable population. On the other hand, the Commission recognizes that employee turnover is high in long-term care facilities. It is important that providers be able to fill positions quickly and not have to wait an inordinate amount of time for a determination to be made by an agency about whether an applicant is disqualified because of the applicant's criminal background. Questions arose during the Commission's deliberations about the State's technological and staffing capacity to be able to turn around a determination of disqualification quickly. The Commission recommends moving this issue forward by establishing a pilot program to conduct national criminal history record checks of workers in adult care homes and contract agencies of adult care homes who provide direct resident care and requiring the Department of Health and Human Services to collect information and meet regularly with providers and others to monitor the progress of the pilot to determine what is needed in order to fully implement the national criminal history record checks as the General Assembly intended. Recommendation 5 The North Carolina Study Commission on Aging recommends that the General Assembly support Senior Center development and outreach, and restore funding to the 2002 level, by appropriating $281,000 for the 2004-2005 fiscal year. Background Senior Centers are resources within communities that typically provide nutrition, recreation, social and educational services, and comprehensive information and referral. The National Institute of Senior Centers defines a senior center as a place where “older adults come together for services and activities that reflect their experience and skills, respond to their diverse needs and interests, enhance their dignity, support their independence, and encourage their involvement in and with the center and the community.” Prior to the 2002 Session, State funds for Senior Centers were $1,365,316. During the 2002 Session, funds were reduced by $381,000. During the 2003 Session, $100,000 was restored, and the local match requirement was increased. Support for and/or restoration of funding for Senior Centers was an item mentioned frequently during presentations on March 9, 2004, by organizations representing, or advocating on behalf of, older adults in North Carolina Appendix G. To fully restore State funding to the prior level, an additional $281,000 would be needed. Therefore, the Commission recommends that the General Assembly support Senior Center development and outreach, and restore funding to the 2002 level, by appropriating $281,000 for the 2004-2005 fiscal year. Recommendation 6 The North Carolina Study Commission on Aging recommends that the General Assembly appropriate $1,000,000 to the Housing Trust Fund for the 2004-2005 fiscal year to be used for independent housing with services. Background North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 22 The Housing Finance Agency mission is to create affordable housing opportunities for North Carolinians whose needs are not met by the market. This mission is accomplished through helping older individuals age in place by improving existing housing, and by working to develop new apartments for older adults. In the March 23, 2004 presentation, Bob Kucab, Executive Director, stated that applications for funding requests currently exceed available capital by 3:1. State funds help bring in outside funding because the Housing Finance Agency is able to leverage $5 in development from every $1 the State invests. According to Mr. Kucab, all State funds that they administer are invested in bricks and mortar; staff costs are paid from their revenue. Mr. Kucab reported that, State appropriations are currently down to $3 million from a high of $9 million. The Commission recognizes the need for new apartments with affordable rent, where older adults can enjoy safe and comfortable living environments, and connections to community services. Therefore, the Commission recommends that the General Assembly appropriate $1,000,000 to the Housing Trust Fund for the 2004-2005 fiscal year to be used for independent housing with services. Recommendation 7 The North Carolina Study Commission on Aging recommends that the General Assembly appropriate $1,000,000 for the Home and Community Care Block Grant for the 2004-2005 fiscal year. Background On March 23, 2004, Dennis Streets, Division of Aging and Adult Services, DHHS, made a presentation to the Commission on the Home and Community Care Block Grant (HCCBG) Appendix H. His presentation gave an overview of the program; eligibility criteria; and information on program utilization, availability, and needs. The HCCBG is established by G.S. 143B-181.1(a)(11). Mr. Streets pointed out that by "consolidating several funding sources (i.e., the Older Americans Act, the Social Services Block Grant in support of respite care, portions of the State In-Home and Adult Day Care funds, and other relevant State appropriations)—some of which traditionally went to separate organizations—the HCCBG represented an important step toward establishing a well coordinated service delivery system to meet the needs of a rapidly growing older population." The HCCBG includes federal funds, State funds, local funds, and a client cost sharing component. The two principal purposes of the HCCBG are to give counties greater discretion, flexibility and authority in determining services, service levels and service providers; and to streamline and simplify the administration of services. The HCCBG focuses on: supporting frail elderly in their preference to be cared for at home; improving and maintaining the physical and mental health of older adults; assisting older adults and their caregivers with accessing services and information; providing relief to family caregivers so that they can continue their caregiving; and allowing older adults to remain actively engaged with their communities. Any person age 60 and older is eligible for services under the HCCBG. The HCCBG program places an emphasis on reaching those most in need of services (the Older Americans Act (OAA) gives priority to serving the "socially and economically needy" -with particular attention to low-income minority elderly and older individuals residing in rural areas). Additionally, the OAA calls for reaching out to older individuals with severe disabilities, limited English-speaking ability, and Alzheimer's disease or related disorders (and caregivers of these individuals). North Carolina Study Commission on Aging 23 Report to the Governor and the 2004 Session of the 2003 General Assembly State appropriations for the HCCBG were $25,128,469 for the 2002-2003 fiscal year. State appropriations were cut by $1,055,690 to $24,072,799 for the 2003-2004 fiscal year. State appropriations are currently slated to be reduced to $24,026,079 for the 2004-2005 fiscal year. An increase in federal Older Americans Act funds has helped to offset the decrease in State funding and overall funding of the program was down from the previous year only $341,603 for 2003-2004. However, the Division anticipates a decrease in federal funding for 2004-2005, which would leave the overall total down another $389,974. Unless the General Assembly increases State appropriations, the total net funding for HCCBG would be down $731,577 for the period from 2002-2003 to 2004-2005. Support for and/or restoration of funding for the HCCBG was an item mentioned frequently during presentations on March 9, 2004, by organizations representing, or advocating on behalf of, older adults in North Carolina Appendix G. The Commission recognizes the vital services that are provided under the HCCBG and recommends that the General Assembly appropriate $1,000,000 for the Home and Community Care Block Grant for the 2004-2005 fiscal year. Recommendation 8 The North Carolina Study Commission on Aging recommends that the General Assembly require the Department of Health and Human Services to study whether the State's Medicaid Program has a bias that favors support for individuals in institutional settings over support for individuals living at home; and to recommend ways to alleviate this bias, if such a bias exists. Background The Final Report by The North Carolina Institute of Medicine Task Force on Long-Term Care reported an institutional bias in Medicaid eligibility rules. The report states that a reason public funding is weighted toward institutional care is that Medicaid and other public program rules make it easier for people to qualify for financial assistance with institutional or residential care than for services provided at home or in the community. Under existing laws, individuals can qualify for either nursing home care or State-County Special Assistance for adult care homes with higher monthly incomes than they can if they want to obtain Medicaid coverage for health services provided in their own home. With these different income eligibility limits, individuals living at home who may have too much income to qualify for Medicaid coverage as long as they remain in their home, may qualify if they move into a more costly institutional or residential setting. In Olmstead v. L.C., the United States Supreme Court concluded that inappropriate institutionalization of a person with a mental disability may be discrimination under ADA. The Commission recognizes that the law favors caring for an individual in the community rather than in an institution, and institutional care may be more costly than residential care. Therefore, the Commission recommends that the General Assembly direct the Department of Health and Human Services to study whether an institutional bias in Medicaid eligibility rules do in fact exist and if they do exist, to determine how to alleviate the bias. Recommendation 9 The North Carolina Study Commission on Aging recommends that the General Assembly establish a Legislative Study Commission to study State guardianship laws. North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 24 Background Guardianship is a legal relationship in which a person or agency (the guardian) is appointed by a court to make decisions and act on behalf of another person (the ward) with respect to the ward’s personal or financial affairs because the ward, due to a specific mental or physical impairment, lacks sufficient capacity to make or communicate important decisions concerning his or her person, family, or property or lacks sufficient capacity to manage his or her personal or financial affairs. Laws regarding guardianship for incapacitated adults attempt to strike a balance between preserving the legal rights, freedom, and autonomy of individuals vs. society’s duty (parens patriae) to protect individuals who are unable to protect or care for themselves. On February 10, 2004, the Commission heard a presentation on "Guardianship Reform in the Twenty-First Century" Appendix D by John Saxon, Professor of Public Law and Government, UNC Chapel Hill. According to his presentation, the last substantive revision to the guardianship law was in 1977, and the last consolidation and clarification was enacted in 1987. Since 1987, there have been efforts to review and revise the statutes, but none resulted in change. Current law consists of an assortment of statutes, some of which date back to the 1800s. As a result, there are a number of issues in the guardianship statutes that need review and updating, including interstate jurisdiction, the definition and standard of incapacity, due process, guardianship alternatives, limited guardianship, the guardian's powers, and the role of human service agencies. Professor Saxon suggested that as an alternative to rewriting current law, North Carolina could adopt the Uniform Guardianship and Protective Proceedings Act (UGPPA). The UGPPA has been enacted in four states. The UGPPA authorizes two types of legal proceedings: guardianship proceedings to appoint guardian (guardian of the person) for a minor or incapacitated person; and protective proceedings regarding the property of a minor or a missing, absent, detained, or incapacitated person, including proceedings seeking the appointment of a conservator (i.e. guardian of the estate). Under the UGPPA, guardianship and conservatorship is viewed as last resort. A guardian or conservator may be appointed only if there are no other lesser restrictive alternatives that will meet the respondent’s needs, and limited guardianship or conservatorship should be used whenever possible. According to Professor Saxon, the UGPPA is advantageous because it is modern, comprehensive, legally adequate, balanced, proven, and could be customized to address any issues that are unique to North Carolina. The North Carolina Study Commission on Aging recognizes that the laws pertaining to guardianship are important for the protection of citizens who are unable to make personal decisions due to impairment or incapacity, and that these laws have not been thoroughly reviewed in 17 years. Therefore, the Commission recommends the General Assembly establish a Legislative Study Commission on State Guardianship Laws. Recommendation 10 The North Carolina Study Commission on Aging recommends that the General Assembly appropriate funds and require the Social Services Commission to adopt a rate increase of no less than five dollars ($5.00) per day for adult day and adult day health services. Background North Carolina General Statute 131D-6 provides that adult day care enables people who would otherwise need full-time care away from their own residences to remain in their residences as long as possible. An adult day care program provides group care and supervision for physically or mentally disabled adults in a place other than their usual place of abode on a less than 24-hour North Carolina Study Commission on Aging 25 Report to the Governor and the 2004 Session of the 2003 General Assembly basis. Adult day services include a social model and a health model. Both models provide a community setting that promotes social interaction, and physical and emotional well-being. Adult day health programs also offer health care services to meet the needs of individual participants. Nutritional meals and snacks are provided and transportation to and from the program may be provided or arranged when needed. Often these programs provide a safe stimulating environment while a primary caregiver is at work. Providers of adult day care must meet North Carolina State Standards for Certification. The Social Services Commission sets these standards and the reimbursement rates paid for adult day and adult day health services. During the March 23, 2004 meeting, the Commission heard from Nancy J. Cox, Director of Partners in Caregiving, Wake Forest University School of Medicine; Suzi Kennedy from the Life Enrichment Center of Cleveland County, Inc.; and Steve Freedman from the Division of Aging and Adult Services, DHHS Appendix I. The Commission received information on the predictors of success for adult day programs from a marketing, financing, and programming perspective; the challenges of operating a successful adult day program, particularly the insufficiency of public reimbursement rates to cover the costs of running a program; and the status of adult day programs across the State. During this meeting, Suzi Kennedy from the Life Enrichment Center of Cleveland County, Inc. spoke about the challenges of operating a successful adult day program and presented her menu for success at the Life Enrichment Center. Ms. Kennedy stated that, "Without financial stability there can be no social good," and she pointed out that public reimbursement rates are often insufficient to cover the costs of running a program. Based on a survey conducted by the North Carolina Adult Day Services Association, in conjunction with the Division of Aging and Adult Services, the average cost to operate an adult day program in North Carolina is $31.00 per day for social models and $44.00 per day for health models. Rates established by the Social Services Commission, effective December 8, 1997, provided the maximum reimbursement rate for the purchase of adult day services at $565 per month ($26.07 per day). Of this amount, $500 per month ($23.07) is for daily care and $65 per month ($3.00 per day) is for round trip transportation. The maximum reimbursement rate for the purchase of adult day health services is $715 per month ($33 per day). Of this amount, $650 per month is for daily care ($30.00 per day) and $65 per month ($3.00 per day) is for round trip transportation. In 1999, the Division of Aging and Adult Services considered approaching the Social Services Commission about a rate increase; however, the Division was advised that there was little chance of a rate increase without an overall increase in the State Adult Day Care fund, since a rate increase without a budget increase would result in a cut to services. S.L. 2003-284, Section 10.58 required the Social Services Commission to consider adopting rules increasing the rates for adult day centers and adult day health centers. However, any rate increase adopted by the Commission for adult day centers and adult day health had to be implemented within existing funds. The Commission supports adult day and adult day health programs and understands the important role they play in our communities. Therefore, the Commission recommends that the General Assembly appropriate funds and require the Social Services Commission to adopt a rate increase of no less than five dollars ($5.00) per day for adult day and adult day health services. North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 26 APPENDICES North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 27 APPENDIX A North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 28 North Carolina Demographics of Aging NC County Range Total population, 2002i 8,323,946 4,170 - 734,403 Projected total population, 2020ii 10,966,139 4,706 - 1,102,003 Population age 60+, 2002iii 1,338,075 858 - 84,420 Population age 85+, 20023 116,922 88 - 7,567 Baby boomers (as % of total population), 20003 27.8% 20.6% - 32.4% Rural population for all ages (as % of total population), 2000iv 39.8% 3.9% - 100% Persons age 65+ without HS diploma (as % of age group), 2000v 41.6% 21.0% - 61.9% Persons age 45-64 without HS diploma ( • ), 20005 19.9% 8.7% - 36.7% Persons age 65+ with graduate school education ( • ), 20005 5.5% 1.1% - 18.7% Persons age 45-64 with graduate school education ( • ), 20005 8.8% 2.4% - 32.4% Persons age 65+ with limited or no English ( • ), 2000vi 0.5% 0% - 3.8% Grandparents raising grandchildren age less than 18, 2000vii 79,810 31 – 5,985 Veterans age 65+ (as % of age group), 2000viii 26.8% 16.2% - 37.7% Distribution by Age1, 2 0-17 18-49 50-64 65-84 85+ Age groups, 2002 24.5% 47.6% 16.0% 10.5% 1.4% Projection for 2020 23.1% 43.0% 18.8% 13.3% 1.7% Growth, 2002-2020 124.3% 119.2% 155.5% 166.8% 162.4% Distribution by Race/ Hispanic Originix White African American Native American Asian Hispanic/ Latino Population age 60+ (as % of age group), 2000 82.0% 16.0% 0.7% 0.5% 0.7% Population age 45-59 ( “ ), 2000 77.2% 18.9% 1.1% 1.2% 1.7% Healthy Aging NC County Range Persons age 65+ in community with 0 disabilities* (as % of age group), 2000x 54.3% 40.2% - 66.8% Persons age 65+ in community with 1 disability* ( • ), 200010 20.6% 14.9% - 26.4% Persons age 65+ in community with 2 or more disabilities* ( • ), 200010 25.1% 17.0% - 34.6% * The US Census Bureau defines disability as “a long-lasting physical, mental, or emotional condition. This condition can make it difficult for persons to do activities such as walking, climbing stairs, dressing, bathing, learning, or remembering.” Medicare beneficiaries immunized for influenza, 2000xi 43.5% 17.2% - 63.5% Persons age 65+ living alone ( • ), 2000xii 28.3% 21.0% - 34.6% Long-Term Care and Aging NC County Range Men age 65+ in nursing homes, 2000xiii 11,207 0 – 674 Women age 65+ in nursing homes, 200013 33,630 0 – 2,445 Persons age 65+ in nursing homes per 1000, 1999xiv 42.2 25.4 – 89.1 Persons age 65+ in adult care homes per 1000, 199914 36.5 0.0 – 67.8 CAP/DA* clients age 18+ per 1000 Medicaid eligibles, 199914 36.0 8.4 – 200.0 PCS** clients age 18+ per 1000 Medicaid eligibles, 199914 57.7 0.0 – 199.1 Adult day care/health clients age 60+ served per 1000, 199914 1.0 0.0 – 5.0 In-home aides clients, age 60+ per 1000, 199914 9.9 2.0 – 51.5 Medicaid-eligible persons age 65+, SFY 2002xv 152,300 131 – 7,198 Total Medicaid expenditures for persons age 65+, SFY 200216 $1,665,538,382 $1,151,121- $79,755,555 The amount Medicaid spent on home-based care (CAP/DA, CAP/MR, home health, and PCS) for every $100 spent in nursing homes for clients age 60+, SFY 2002xvi $41.5 $6.9 - $278.4 Special Assistance (SA) expenditures for persons age 60+ in adult care homes, SFY 200216 $90,695,940 $37,987 - $4,035,646 North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 29 Economic Security NC County Range Median household income for age group 55-64, 1999xvii $42,250 $26,582 - $62,759 Median household income for age group 65-74, 199917 $28,521 $16,335 - $41,540 Median household income for age group 75+, 199917 $19,303 $11,195 - $33,822 Poverty Age 55-64 Age 65-74 Age 75+ Persons below poverty (as % of age group), 1999 (NC) xviii 9.5% 10.5% 16.9% Persons in 100-199% of poverty ( • ), 1999 (NC)18 12.9% 20.4% 27.1% Social Security NC County Range Total Social Security (SS) benefits for beneficiaries age 65+, 2000xix $722 million $0.4 – 50.7 million SS beneficiaries age 65+ (as % of age group), 2000xx 94.8% 73.1% - 100.0% Average monthly SS amount received by beneficiaries age 65+, 200019,20 $786 $620 - $889 Medicare/Medicaid Medicare Part A enrollees age 65+ (as % of all enrollees), 2000xxi 77.0% 65.7% - 86.1% Medicare/Medicaid dually eligible persons age 65+, 2001xxii 140,535 109 – 6,609 Labor Force Persons age 45-59 in labor force* (as % of total labor force), 2000xxiii 27.7% 21.7% - 35.8% Persons age 60-64 in labor force* ( • ), 200023 3.6% 2.5% - 6.9% Persons age 65+ in labor force* ( • ), 200023 3.5% 2.2% - 8.8% Persons age 65+ In labor force* (as % of age group), 200023 14.4% 8.9% - 21.1% Unemployed persons age 65+ (as % of population age 65+ in labor Force*), 200023 8.3% 0.0% - 40.7% *Include both employed and job seekers Senior-Friendly Communities NC County Range Homeowners age 45-64 (as % of age group), 2000xxiv 80.3% 70.9% - 89.6% Homeowners age 65+ ( • ), 200024 82.0% 72.0% - 91.4% Households with persons age 60+ and without complete plumbing, 2000xxv 8,184 Undisclosed – 343 Home-delivered meals served to persons age 60+ per 1000, 199914 18.6 0 – 58.5 Food Stamps Food Stamp clients age 60+, SFY 2001xxvi 66,832 66 – 3,893 Total Food Stamp expenditures for clients age 60+, SFY 200126 $39,628,877 $23,963 - $3,177,499 Monthly Food Stamp expenditure per client age 60+, SFY 200126 $49 $35 - $68 Transportation Householder age 55-64 without car (as % of age group), 2000xxvii 6.0% 1.0% - 15.9% Householder age 65-74 without car ( • ), 200027 9.0% 4.0% - 22.7% Householder age 75+ without car ( • ), 200027 21.3% 7.5% - 33.6% Persons Providing Care Age 18-44 Age 45-64 Age 65+ Persons providing regular care for adults age 60+ (as % of age group), 2000* xxviii 14.5% 23.8% 15.7% *Only statewide information available at present North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 30 Sources of Information 1 North Carolina State Data Center (2003). County/state population estimates; July 1, 2002; age groups-adults. Retrieved in 6/2003 from http://www.demog.state.nc.us/. 1 North Carolina State Data Center (2003). County/state population projections; April 1, 2020 county age groups; age groups-adults. Retrieved in 6/2003 from http://www.demog.state.nc.us/. 1 US Bureau of the Census (2003). PCT12. Sex by age (Summary File 1). Retrieved in 6/2003 from http://www.census.gov/. 1 US Bureau of the Census (2003). P2. Urban and rural (Summary File 1). Retrieved in 6/2003 from http://www.census.gov/. 1 US Bureau of the Census (2003). PCT25. Sex by age by educational attainment for the population 18 years and over (Summary File 3). Retrieved in 6/2003 from http://www.census.gov/. 1 US Bureau of the Census (2003). P19. Age by language spoken at home by ability to speak English for the populations 5 years and over (Summary File 3). Retrieved in 6/2003 from http://www.census.gov/. 1 US Bureau of the Census (2003). PCT9. Household relationship by grandparents living with own grandchildren under 18 years by responsibility for own grandchildren for the population 30 years and over in households (Summary File 3). Retrieved in 6/2003 from http://www.census.gov/. 1 US Bureau of the Census (2003). P39. Sex by age by armed forces status by veteran status for the population 18 years and over (Summary File 3). Retrieved in 6/2003 from http://www.census.gov/. 1 US Bureau of the Census (2003). P12 A, B, C, D, and H. Sex by age (Summary File 1). Retrieved in 6/2003 from http://www.census.gov/. 1 US Bureau of the Census (2003). PCT26. Sex by age by types of disability for the civilian noninstitutionalized population 5 years and over (Summary File 3). Retrieved in 6/2003 from http://www.census.gov/. 1 Medical Review of North Carolina (2003). Influenza immunization data. Retrieved in 2/2003 from http://www.mrnc.org/MCMED/influenza-results.asp. 1 US Bureau of the Census (2003). P11. Household type (including living alone) by relationship for the population 65 years and over (Summary File 3). Retrieved in 6/2003 from http://www.census.gov/. 1 US Bureau of the Census (2003). PCT17. Group quarters population by sex by age by group quarters type (Summary File 1). Retrieved in 6/2003 from http://www.census.gov/. 1 NC Institute of Medicine (2001). A long-term care plan for North Carolina: Final report. Appendix D: Comparisons of availability of services. 1 NC Division of Medical Assistance (2003). Special tabulations provided for NC Division of Aging in 6/2003. 1 NC Division of Aging (2003). Expenditure data by county for Fiscal Year 2002. Retrieved 6/2003 from http://www.dhhs.state.nc.us/aging/exp2002/coexp2002.htm. 1 US Bureau of the Census (2003). P56. Median household income in 1999 (dollars) by age of householder (Summary File 3). Retrieved in 6/2003 from http://www.census.gov/. 1 US Bureau of the Census (2003). PCT50. Age by ratio of income in 1999 to poverty level. (Summary File 3). Retrieved in 6/2003 from http://www.census.gov/. 1 US Social Security Administration (2003). Table 5. Amount of OASDI benefits in current-payment status, by type of benefit, by sex of beneficiaries aged 65 or older, and by state and county, December 2000 (OASDI beneficiaries by state and county, 2000). Retrieved in 6/2003 from http://www.ssa.gov/policy/docs/statcomps/oasdi_sc/2000/nc.html. 1 US Social Security Administration (2003). Table 4. Number of OASDI beneficiaries with benefits in current-payment status, by type of benefit, by sex of beneficiaries aged 65 or older, and by state and county, December 2000 (OASDI beneficiaries by state and county, 2000). Retrieved in 6/2003 from http://www.ssa.gov/policy/docs/statcomps/oasdi_sc/2000/nc.html. 1 Medical Review of North Carolina (2003). Medicare Part A Enrollees. Retrieved from in 6/2003 http://www.mrnc.org/NCMED/beneficiary.asp. 1 Medical Review of North Carolina (2003). Dually eligible beneficiaries, 2000. Retrieved from in 6/2003 http://www.mrnc.org/NCMED/beneficiary_dual2001.asp. 1 US Bureau of the Census (2003). PCT35. Age by sex by employment status for the population 16+ years. (Summary File 3). Retrieved in 6/2003 from http://www.census.gov/. 1 US Bureau of the Census (2003). HCT8. Tenure by age of householder (Summary File 2). Retrieved in 6/2003 from http://www.census.gov/. 1 NC State Library (2003). Special tabulation from the Census 2000 data as requested by the NC Division of Aging in 6/2003. 1 NC Division of Social Services (2002). Special tabulation as requested by the NC Division of Aging in 9/2002. 1 US Bureau of the Census (2003). P45. Tenure by vehicles available by age of householder (Summary File 3). Retrieved in 6/2003 from http://www.census.gov/. 1 NC Center for Health Statistics (2001). BRFSS-2000 survey results. Retrieved in 7/2003 from http://www.schs.state.nc.us/SCHS/healthstats/brfss/2000/caretakr.html. North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 31 APPENDIX B North Carolina Study Commission on Aging Recommendations to the 2003 North Carolina General Assembly, 2003 Regular Session Prepared by Staff for the North Carolina Study Commission on Aging February 9, 2004 North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 33 Recommendation Status Report North Carolina Study Commission on Aging RECOMMENDATIONS BILLS INTRODUCED RESULTS RECOMMENDATION 1 The Commission finds that the Community Alternative Program for Disabled Adults (CAP/DA) is the cornerstone of community-based care for older adults and recommends that the General Assembly fund the program at a level sufficient to preserve the availability of community-based services offered through the program. N/A CAP/DA funds for the 02/03 fiscal year are $255,000,000, funds were increased by approximately $61,000,000 last session. RECOMMENDATION 2 The Commission recommends that the 2002 Session of the 2001 General Assembly direct the Department of Health and Human Services to study ways to establish a group health insurance purchasing arrangement for long-term care staff. H 1559 S 1196 S.L. 2002-180, Sec. 5.2 (SB 98, Sec. 5.2) Group Health Insurance for Long-Term Care Staff Study The Department of Health and Human Services, in consultation with the Department of Insurance, shall study ways to establish a group health insurance purchasing arrangement for staff, including paraprofessionals, in residential and nonresidential long-term care facilities and agencies, as described in Recommendation #22 of the Institute of Medicine's (IOM) Long-Term Care Task Force Final Report of January 2001. The Department shall report its findings and recommendations to the North Carolina Study Commission on Aging on or before January 1, 2003. RECOMMENDATION 3 The Commission recommends that the General Assembly direct the Department of Health and Human Services to study ways the State can coordinate and facilitate public access to public and private free and discount prescription drug programs for senior citizens. H 1560 S 1199 S.L. 2002-180, Sec. 5.1 (SB 98, Sec. 5.1) Prescription Drug Access/Coordination The Department of Health and Human Services shall study ways the State can coordinate and facilitate public access to public and private free and discount prescription drug programs for senior citizens. In undertaking this study, the Department shall consider the coordination and facilitation methods being implemented by other states. On or before January 1, 2003, the Department shall report its findings and recommendations to the North Carolina Study Commission on Aging. The report shall include the following: (1) A description of the various coordination and facilitation methods considered. (2) A description of the coordination and facilitation methods of other states. North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 34 (3) A recommendation as to the best way to coordinate and facilitate access in this State, which shall include the reasons for the recommendation, a fiscal analysis of the cost of the recommendation, and whether any legislation is necessary to implement the recommendation. RECOMMENDATION 4 The Commission recommends the General Assembly establish a Legislative Study Commission on State Guardianship Laws. H 246 S 179 No action taken on this issue. RECOMMENDATION 5 The Commission recommends the General Assembly pursue ways in which national criminal record checks may be obtained and reviewed by long-term care facilities to effectuate State policy and to protect facility residents. H 1561 S 1264 S.L. 2002-180, Sec. 2.1A (SB 98, Sec. 2.1A) Study Issues Related to Criminal History Record Checks of Employees of Long-Term Care Providers The Legislative Research Commission may study how federal law affects the distribution of national criminal history record check information requested for nursing homes, home care agencies, adult care homes, assisted living facilities, and area mental health, developmental disabilities, and substance abuse services authorities, and the problems federal restrictions pose for effective and efficient implementation of State-required criminal record checks. The study may include the following: (1) Ways in which national record checks may be obtained and reviewed for these facilities to effectuate State policies and protections of facility residents, and the advantages, disadvantages, and costs of various approaches to implementation. (2) A review of ways in which national record checks are obtained by the Division of Child Development, Department of Health and Human Services, and other State agencies, and related costs to the State. (3) Solutions adopted by other states to effectively and efficiently implement criminal record check requirements, including costs to the State in implementing these solutions. (4) Other issues relevant to State requirements for criminal history record checks in long-term care facilities. For each of the topics the Legislative Research Commission decides to study, the Commission may report its findings, together with any recommended legislation, to the 2003 General Assembly. Summary of Substantive Legislation Related to Aging North Carolina General Assembly 2003 Session Prepared by Staff for the: North Carolina Study Commission on Aging February 10, 2004 North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 36 Enacted Legislation Continuing Care Retirement/Technical Changes S.L. 2003-193 (HB 253) makes various technical changes to the statutes that regulate continuing care retirement communities (CCRCs). These facilities provide housing and health-related services either for life or for a period in excess of one year. CCRCs provide independent living and also offer nursing home or adult care home level of care. Because CCRCs include contractual requirements where, for certain fees, the facility agrees to provide health care coverage over a given period of time, they are considered an insurance product and are regulated by the Department of Insurance under Article 64 of Chapter 58. The act makes the following changes to the statutes: · Repeals an unused, and likely unusable, provision allowing for a continuing care retirement facility that is accredited under a process approved by the Commissioner to be issued a license based on that accreditation. · Replaces the word "facility" with "provider" to clarify that it is the provider that operates the facility that is responsible for meeting the various statutory requirements. · Clarifies language governing operating reserves for continuing care retirement facilities and providers, including: 1. Changing the wording to reflect the fact that a provider is to calculate and maintain a separate operating reserve for each continuing care facility operated by the provider. 2. Changing the words "annual statement" to "disclosure statement." 3. Changing the words "invested cash" to "cash equivalents." · Makes the following changes governing the rights of residents of continuing care retirement facilities to organize: 4. Changes "registered under this Article" to "operated by a provider licensed under this Article" in G.S. 58-64-40(a). No entity is "registered" under G.S. 58-64. 5. Makes gender neutral corrections. 6. Clarifies that the governing body of a provider must hold semi-annual meetings with the residents of each facility operated by the provider. · Makes various changes governing supervision, rehabilitation and liquidation of continuing care retirement providers including: 7. Replacing the word "projected" with "forecasted". 8. Amending the statute as necessary to accommodate the fact that a provider can own or operate more than one facility. · Amends the provision on receiverships, to reflect the fact that the Commissioner would be appointed as receiver for a provider not a facility. · Replaces the word "agreements" with "contracts" for consistency of wording within Article 64. · Removes unnecessary language to conform with the removal of the "accredited facility" provision. · Amends the provision, governing civil liability, to: 9. Remove the misleading words "facility, or person violating this Article" because the provider is the entity entering into a contract for continuing care, not the facility or other person. 10. Remove the words "or person liable" because the provider is the only entity that is required to deliver a disclosure statement to the contracting party. 11. Remove the words "facility, or person" since payment is made to the provider, and the provider is the entity responsible for the dissemination of the disclosure statement. This act became effective June 12, 2003. (DJ) North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 37 Senior Cares Program Administration S.L. 2003-284, Sec. 10.5 (HB 397, Sec. 10.5) provides that the Department of Health and Human Services may administer the "Senior Cares" prescription drug access program approved by the Health and Wellness Trust Fund Commission and funded from the Health and Wellness Trust Fund. This section became effective July 1, 2003. (TM) Effective Date of Long-Term Care Criminal Record Checks for Employment Positions S.L. 2003-284, Sec. 10.8E (HB 397, Sec. 10.8E) continues the suspension of the requirements of G.S. 131E-265 for nursing homes and G.S. 131D-2 for adult care homes to conduct national criminal history checks for certain employees until January 1, 2005. These requirements were also suspended during the last biennium. This section became effective July 1, 2003. (DJ) Implement a Pilot Project for Long-Term Care Community Service Coordination S.L. 2003-284, Sec. 10.8F (HB 397, Sec. 10.8F) requires the Department of Health and Human Services to implement a communications and coordination initiative to support local coordination of long- term care, and to pilot the establishment of local lead agencies to facilitate the long-term care coordination process at the county or regional level. The initiative must eliminate fragmentation and barriers to information and services; provide a seamless connection among State agencies and local entities, regardless of funding sources; and allow consumers to efficiently and effectively navigate among long-term care services. For those counties that voluntarily participate, the local long-term care coordination initiative must aid in the development of core services, coordinate local services, and streamline access to services. The Department of Health and Human Services must submit an interim report on the pilot project for local long-term care coordination to the North Carolina Study Commission on Aging by October 1, 2004 and a final report by October 1, 2005. The Institute of Medicine Long-Term Care Task Force found that "long-term care services are often fragmented, duplicative, complex, and not consumer-friendly and that many counties lack needed core long-term care services." In response to this finding, and a report presented in accordance with S.L. 2001-491, Part XXII, the North Carolina Study Commission on Aging's 2003 report to the General Assembly and the Governor made a recommendation that the General Assembly fund a pilot project on long-term care local lead agencies. This provision is in response to that recommendation. This section became effective July 1, 2003. (TM) Medicare Enrollment Required S.L. 2003-284, Sec. 10.27 (HB 397, Sec. 10.27) directs the Department of Health and Human Services to require Medicaid recipients who qualify for Medicare to enroll in Medicare in order to pay medical expenses that qualify for payment under Medicare Part B. Medicare is the federally sponsored health insurance program for persons aged 65 or older and for certain disabled persons under age 65. Medicare Part B pays for doctors' services, outpatient hospital care, and some other medical services that Part A does not cover, such as the services of physical and occupational therapists, and some home health care. In order to obtain coverage under Medicare Part B, an eligible person must pay a premium. Requiring eligible persons to enroll in Medicare will shift health care costs from the Medicaid program (which is paid in part with State and local funds) to the Medicare program (which is paid entirely with federal funds). This section became effective July 1, 2003. (DJ) North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 38 Medicaid Assessment Program for Skilled Nursing Facilities S.L. 2003-284, Sec. 10.28 (HB 397, Sec. 10.28) directs the Secretary of Health and Human Services to implement a Medicaid assessment program for skilled nursing facilities effective October 1, 2003. The assessment program applies to skilled nursing facilities licensed under Chapter 131E of the General Statutes and must be imposed in a manner consistent with federal regulations under 42 C.F.R. Part 433, Subpart B. Funds realized from assessments imposed shall: · Be used only to draw down federal Medicaid matching funds for implementing the new reimbursement plan for nursing homes and for increasing nursing facility rates in accordance with the plan, · Be used to pay 100% of the nonfederal share for the new reimbursement plan for nursing homes; and · Not be used to supplant State funds appropriated for nursing facility services. This section became effective July 1, 2003. (TM) Rename North Carolina Heart Disease and Stroke Prevention Task Force S.L. 2003-284, Sec. 10.33B (HB 397, Sec. 10.33B) renames the North Carolina Heart Disease and Stroke Prevention Task Force. The new name is the Justus-Warren Heart Disease and Stroke Prevention Task Force. This section became effective July 1, 2003. (SA) Senior Center Outreach S.L. 2003-284, Sec. 10.42 (HB 397, Sec. 10.42) provides that the funds appropriated to the Department of Health and Human Services, Division of Aging, for the 2003-2005 fiscal biennium, shall be allocated by October 1 of each fiscal year and used by the Division of Aging to enhance senior center programs in the following ways: · To expand the outreach capacity of senior centers to reach unserved or underserved areas; or · To provide start-up funds for new senior centers. However, prior to funds being allocated for start-up funds for a new senior center, the county commissioners of the county in which the new center will be located shall: 12. Formally endorse the need for such a center; 13. Formally agree on the sponsoring agency for the center; and 14. Make a formal commitment to use local funds to support the ongoing operation of the center. Additionally, State funding shall not exceed 75% of reimbursable costs. This section became effective July 1, 2003. (TM) Adult Care Home Model for Community-Based Services S.L. 2003-284, Sec. 10.43 (HB 397, Sec. 10.43) requires the Department of Health and Human Services to develop a model project for delivering community-based mental health, developmental disabilities, and substance abuse housing and services through adult care homes that have excess capacity. The model must be designed for implementation on a pilot basis and address the following: · Services that will be provided by the facility or under contract with the facility, including assistance with daily medication. North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 39 · Access of clients to mental health, developmental disabilities, and substance abuse services provided in the community, including transportation to services outside of the client's residence in the adult care home facility. · Physical plant additions or changes necessary to provide for independent living of residents. · Methods for assuring quality of services, resident safety, and cost-effectiveness. · Consistency with the Department's Olmstead plan, other policies on community-integration, and disability plans adopted by the State. The Department must submit a final report on the development of the model to the Senate Appropriations Committee on Health and Human Services, the House of Representatives Appropriations Subcommittee on Health and Human Services, and the Fiscal Research Division on or before March 1, 2004. The report shall address the following: · Proposed time and location for implementation of the pilot. · Proposed number of residents to be placed and services to be provided directly by the facility or under contract with the facility. · Method for evaluating the pilot, including services provided, on a regular basis. · A description of the living environment for each resident and a comparison of how the living environment compares to that of other residents in the adult care home. · Changes to State law necessary to implement the pilot. · Projected cost to the State for pilot and statewide implementation. This section provides that the development of this model is in response to the State policy to provide appropriate services to clients in the least restrictive and most appropriate environment and with the United States Supreme Court Decision in Olmstead vs. L.C. & E.W. This section became effective July 1, 2003. (TM) Special Assistance In-Home Program S.L. 2003-284, Sec. 10.51 (HB 397, Sec. 10.51) allows the Department of Health and Human Services to use funds from the existing State-County Special Assistance for Adults budget to provide Special Assistance payments to eligible individuals with in-home living arrangements. These payments may be made for up to 800 individuals during the 2003-2004 fiscal year and the 2004-2005 fiscal year. The standard monthly payment to individuals enrolled in the Special Assistance in-home program shall be 50% of the monthly payment the individual would receive, if the individual resided in an adult care home and qualified for Special Assistance, except if a lesser payment amount is appropriate for the individual as determined by the local case manager. For State fiscal year 2003-2004, qualified individuals shall not receive payments at rates less than they would have been eligible to receive in State fiscal year 2002-2003. The Department must implement Special Assistance in-home eligibility policies and procedures to assure that in-home program participants are those individuals who need and, but for the in-home program, would seek placement in an adult care home facility; and shall include the use of a functional assessment. This in-home option must be available to all counties on a voluntary basis; and to the maximum extent possible, the Department shall consider geographic balance in the dispersion of payments to individuals across the State. The Department is required to report on or before January 1, 2004, and on or before January 1, 2005, to the cochairs of the House of Representatives Appropriations Committee, the House of Representatives Appropriations Subcommittee on Health and Human Services, the cochairs of the Senate Appropriations Committee, and the cochairs of the Senate Appropriations Committee on Health and Human Services. This report shall include the following information: · A description of cost savings that result from allowing individuals eligible for State-County Special Assistance the option of remaining in the home. · A complete fiscal analysis of the in-home option to include all federal, State, and local funds expended. · How much case management is needed and which types of individuals are most in need of case management. · The geographic location of individuals receiving payments under this section. North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 40 · A description of the services purchased with these payments. · A description of the income levels of individuals who receive payments under this section and the impact on the Medicaid program. · Findings and recommendations as to the feasibility of continuing or expanding the in-home program. · The level and quantity of services (including personal care services) provided to the demonstration project participants compared to the level and quantity of services for residents in adult care homes. Additionally, the Department shall incorporate data collection tools designed to compare quality of life among institutionalized versus noninstitutionalized populations (i.e., an individual's perception of his or her own health and well-being, years of healthy life, and activity limitations). To the extent national standards are available, the Department shall utilize those standards. These provisions are based on recommendations from the North Carolina Study Commission on Aging. This section became effective July 1, 2003. (TM) State/County Special Assistance Transfer of Assets S.L. 2003-284, Sec. 10.53 (HB 397, Sec. 10.53) codifies the provision adopted in last year's budget providing that Supplemental Security Income (SSI) policy concerning transfer of assets and estate recovery applies to applicants for State-county Special Assistance and repeals current codified law on the issue. The provision also requires the Department of Health and Human Services to continue reviewing whether policy for State-county Special Assistance should be changed to permit an assisted living facility to accept from a family member of a resident who qualifies for State-county Special Assistance payment for the difference in the monthly rate for room, board, and services available. The Department must report its activities on this policy review by March 1, 2004 to the Senate Appropriations Committee on Health and Human Services, the House of Representatives Appropriations Subcommittee on Health and Human Services, and the Fiscal Research Division. This section became effective July 1, 2003. (DJ) Social Services Commission Rules on Rate-Setting For Adult Day Centers and Adult Day Health Centers S.L. 2003-284, Sec. 10.58 (HB 397, Sec. 10.58) provides that the Social Services Commission shall consider adopting rules increasing the rates for adult day centers and adult day health centers and that any rate increase shall be implemented within existing funds. This section became effective July 1, 2003. (TM) Nursing Home/Medication Errors S.L. 2003-393 (SB 1016) requires every nursing home to establish a medication management advisory committee to advise the quality assurance committee on quality of care issues related to pharmaceutical and medication management and use in the nursing home. The Advisory Committee will have the following duties: · Assess the facility's pharmaceutical management system and practices and identify areas at high risk for medication-related errors. · Review the facility's pharmaceutical management goals and ensure these goals are being met. · Review, investigate, and respond to facility incident reports and resident grievances. · Identify goals and recommendations for the implementation of best practices. · Develop recommendations for the establishment of a mandatory, nonpunitive, confidential reporting system. North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 41 · Develop specifications for drug dispensing and administration documentation procedures to ensure compliance with federal and State law, including the NC Nursing Practice Act. · Develop specifications for self-administration of drugs by qualified patients in accordance with law. As part of its requirement to minimize risk of medication-related error, the act requires every nursing home quality assurance committee to undertake the following: · Educate and make the patient and the patient's family members aware of all the medications the patient is using. · Increase prescription legibility. · Minimize confusion in prescription drug labeling and packaging. · Develop a confidential and nonpunitive process for internal reporting of actual and potential medication-related errors. · To the extent practicable, implement proven medication safety practices. · Educate facility staff engaged in medication administration. · Implement a system to accurately identify recipients before any drug is administered. · Implement policies and procedures designed to improve accuracy in medication administration and in documentation. · Implement policies and procedures for the self-administration of medication. · Investigate and analyze the frequency and root causes of general categories and specific types of actual or potential medication-related errors. · Develop recommendations for plans of action to correct identified deficiencies in the facility's pharmaceutical management practices. The act also requires nursing home to provide a minimum of one hour of education and training in the prevention of actual or potential medication-related errors for all nonphysician personnel involved in direct patient care. A new statute enacted in this act requires consultant pharmacists of nursing homes to undertake certain drug regimen reviews, make reports concerning drug irregularities, drug product defects and adverse drug reactions, ensure proper documentation of allergies and adverse effects, and ensure that drugs that are not specifically limited as to duration of use or number of doses are controlled by automatic stop orders. Finally, the act requires the Secretary of Health and Human Services to contract with a public or private entity to develop and implement a Medication Error Quality Initiative. As part of the Initiative, each nursing home must report annually on the nursing home's medication-related errors. The report submitted by each nursing home would not contain information that would identify the patient, individual reporting the error, or other persons involved in the occurrence. The contracting entity would analyze the reports to determine trends in the incidence of medication-related errors in nursing homes. Information released to the contractor would retain its confidentiality and would not be subject to discovery or use in any civil action as provided under the act. This act becomes effective January 1, 2004. (DJ) Audit of CAP/DA Programs by State Auditor S.L. 2003-284, Sec. 10.29B (HB 397, Sec. 10.29B) directs the State Auditor to perform an audit of the Community Alternatives Program for Disabled Adults (CAP/DA), provided that State funds are appropriated for this purpose. The audit shall build upon the results of the study conducted by the North Carolina Institute of Medicine, in accordance with Section 10.16(c) of S.L. 2002-126, and provide information necessary to determine whether CAP/DA is operating within waiver guidelines and program goals. The State Auditor shall report the results of the audit to the North Carolina Study Commission on Aging by January 1, 2004. This section also directs the Department of Health and Human Services to review, on a pilot basis, a selected number of CAP/DA programs to determine compliance with eligibility requirements for the program. Additionally, the Department shall continue to examine aspects of CAP/DA including: the current assessment process; an analysis of per-client costs in CAP/DA to per-client costs in nursing North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 42 homes and adult care homes; per-participant costs for the State-County In-Home Program; an analysis of per-person costs for personal care services through Medicaid; the monitoring of quality of care for CAP/DA clients; the current waiting list procedures. The Department is required to make a report of its findings to the North Carolina Study Commission on Aging by January 1, 2004. This section became effective July 1, 2003. (TM) Staff Contributing to this publication: Sandra Alley (SA), Dianna Jessup (DJ), and Theresa Matula (TM). North Carolina Study Commission on Aging Report to the Governor and the 2003 Session of the 2003 General Assembly 43 Studies and Reports Related to Aging Study/Report Entities Involved Reporting Date Reference Report on the pilot project for local long-term care coordination. DHHS to Aging Study Commission Interim report 10/1/04 Final report 10/1/05 S.L. 2003-284 (HB 397), Sec. 10.8.F.(b) Report on examination of CAP/DA that includes certain cost comparisons DHHS to Aging Study Commission 1/1/04 S.L. 2003-284 (HB 397), Sec. 10.29B. Report on development of the adult care home model for community-based services DHHS to HHS and FRD 3/1/04 S.L. 2003-284 (HB 397), Sec. 10.43.(b) Report on the Special Assistance In-Home Demonstration Program DHHS to HHS 1/1/04 and 1/1/05 S.L. 2003-284 (HB 397), Sec. 10.51(b) DHHS to review whether policy for Special Assistance should be changed to permit an assisted living facility to accept from a family member of a resident who qualifies for the program payment for the difference in the monthly rate. DHHS to HHS and FRD 3/1/04 S.L. 2003-284 (HB 397), Sec. 10.53(c) DHHS to review activities and costs related to the provision of care in adult care homes and determine what costs may be considered to properly maximize allowable reimbursement available through Medicaid and may transfer funds from DSS to DMA to draw down federal Medicaid funds. DHHS to HHS and FRD As funds are transferred and rates are modified Abbreviations: DHHS: the Department of Health & Human Services FRD: Fiscal Research Division HHS: House of Representatives Appropriations Subcommittee on Health and Human Services & Senate Appropriations Committee on Health and Human Services North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 44 APPENDIX C North Carolina Study Commission on Aging Report to the Governor and the 2004 Session of the 2003 General Assembly 45 Overview of Aging Services & State Aging Plan N.C.G.S. 143B-181.1A prepared by Division of Aging, N.C. Department of Health and Human Services for the Study Commission on Aging NC Division of Aging 2 The Aging of North Carolina— General Organization of Plan ¡ Aging NC ¡ Healthy Aging ¡ Long-Term Care and Aging ¡ Economic Security ¡ Senior-Friendly Communities �� Priorities of Senior Advocates ¡ State Agencies Major Activities and Future Directions NC Division of Aging 3 Actual and Projected Population Age 65 and Older, North Carolina, 1940 t |
OCLC number | 27395158 |