The state and local agencies are  responsible for the planning, development, and coordination of an array of  home- and community-based services within each state, though states also  provide services to older adults through other funding, such as Medicaid,  and through separate programs and departments. Funding for the program generally increased in small  increments over the past 5 years, while the number of people age 60 and  over increased from 48.9 million in 2004 to 55.4 million in 2009. Estimates Show That Many Older Adults Likely Needed but Did Not Receive Meals and Home-Based Care

		Many Older Adults with Low Incomes Who Were Likely to Need Meals Programs Did Not Receive Them

The meals services provided in 2008 did not serve most of the low-income  older adults likely to need them. Many People Age 60 and Older Who Had Difficulties with Daily Activities Received Limited or No Home-Based Care

While most older adults who had difficulties with daily activities such as  walking or bathing received at least some help completing such tasks,  many received limited help and some did not receive any help. Likely Need for Transportation Services Is Significant

Many older adults were likely to need transportation services like those  provided by Title III programs due to circumstances such as being unable  to drive or not having access to a vehicle. Agencies Transfer Funds among Programs and Use Funds from Multiple Sources to Provide Services

		Agencies Transfer Funds among Title III Programs to Meet Needs, but Some Want Additional Flexibility

Most state and some local agencies utilize the flexibility provided by the  OAA to transfer funds among Title III programs. According to AoA data, 45  state agencies transferred funds among congregate meal programs, home- delivered meal programs, and support services in fiscal year 2008, and,  according to our survey results, an estimated 45 percent of local agencies  did so in fiscal year 2009. Agencies most commonly transferred funds  from congregate meals to home-delivered meals or support services. In addition to receiving funds from governments and private sources,  clients can also contribute to the cost of services. While the OAA allows for cost sharing for some OAA services wherein  clients are asked to pay a portion of the cost of services based on their  income, 5 of the 14 states we spoke with actually permit cost sharing. In fact, according to our survey, an estimated 47 percent of local  agencies experienced reductions to their budgets in fiscal year 2010. Alternatively, in response to these funding cuts, many local agencies said  they took steps to reduce administrative and operations costs. Of the 10 state agencies we spoke  with in early fall 2010, 5 told us that they will have to cut back services, 2  told us that they reserved funds from other sources to compensate for  some of the lost Recovery Act funds, 2 states had not decided how to  make up for the lost Recovery Act funds, and 1 state will maintain  services. Lack of Federal Guidance and Data Make It Difficult for States to Fully Estimate Need and Unmet Need

		States Lack Specific Guidance on How to Evaluate Need and Unmet Need

The OAA requires AoA to design and implement uniform data collection  procedures that include procedures for states to assess the receipt, need,  and unmet need for Title III services. State Agencies Assess Need and Some Assess Unmet Need, but None Fully Estimate the Number of Older Adults Likely in Need of Services

Without standardized definitions and measurement procedures, states use  a variety of approaches to measure need and measure unmet need to  varying extents. Overall, AoA and state agency officials noted that there are various  challenges to fully estimating need and unmet need. As the number of older adults grows, demand for services will also grow. To help ensure that agencies have adequate and consistent information  about older adults’ needs and the extent to which they are met, we  recommend that the Secretary of Health and Human Services partner with  other government agencies that provide services to Older Americans and,  as appropriate, convene a panel or work group of researchers, agency  officials, and others to develop consistent definitions of need and unmet  need and to propose interim and long-term uniform data collection  procedures for obtaining information on older adults with unmet needs for  services provided from sources like Title III. Appendix I: Objectives, Scope, and Methodology

Our objectives were to identify: (1) what is known about the need for  home- and community-based services like those funded by the Older  Americans Act (OAA) and the potential unmet need for these services; (2)  how have agencies used their funds, including Recovery Act funds, to meet  program objectives; and (3) how have government and local agencies  measured need and unmet need. By this definition, an estimated 21 percent of older  adults age 65 and over were likely to need transportation services.
Why GAO Did This Study

The Older Americans Act (OAA) was enacted to help older adults remain in their homes and communities. In fiscal year 2008, about 5 percent of the nation's adults 60 and over received key aging services through Title III of the OAA, including meals and home-based care. In fiscal year 2010, states received $1.4 billion to fund Title III programs. Studies project large increases in the number of adults who will be eligible for services in the future and likely government budget constraints. In advance of program reauthorization scheduled for 2011, GAO was asked to determine: (1) what is known about the need for home- and community-based services like those funded by OAA and the potential unmet need for these services; (2) how have agencies used their funds, including Recovery Act funds, to meet program objectives, and (3) how government and local agencies measured need and unmet need. To do this, GAO analyzed national self-reported data; surveyed a random sample of 125 local agencies; reviewed agency documents; and spoke with officials from the Administration on Aging (AoA) and state and local agencies.

What GAO Found

National data show many older adults likely needed meals or home-based care in 2008, but they did not all receive assistance from Title III programs or other sources, like Medicaid. For instance, while about 9 percent of low-income older adults received meals services, many more were likely to need them due to financial or other difficulties obtaining food. Also, while most older adults who were likely to need home-based care because of difficulties with activities such as walking or bathing received at least some help completing such tasks, many received limited help and some did not receive any. Finally, an estimated 21 percent of people age 65 and older were likely to need transportation services due to their inability to drive or lack of access to a vehicle. Some aspects of need and receipt could not be captured with existing data. For example, GAO could not identify whether the meals and home-based care older adults received was adequate or estimate the number of individuals with transportation needs who did and did not receive such services. Many agencies utilize the flexibility afforded by the OAA to transfer funds among programs and use funds from multiple sources to provide services in their communities. State agencies annually transferred an average of $67 million from congregate meals to home-delivered meals and support services over the past 9 years. Agencies also use funds from other sources, such as Medicaid, state and local governments, and client contributions, to fund Title III services for clients. While client donations are common, formal arrangements with clients to pay a portion of the cost of services are limited. These payments by individuals with higher incomes could help defray the costs of serving others, as the demand for services increases in the future. The recent economic downturn affected agency resources and funding, with about 47 percent of local agencies reporting budget reductions in fiscal year 2010. To cope, many agencies cut administrative and operational costs and some reduced services. The Recovery Act temporarily replaced some lost funding by providing $97 million for meals, but ended in 2010. GAO spoke to 10 state agencies about how they will adjust to lost Recovery Act dollars and found 5 plan to cut services, 2 reserved funds from other sources, 2 are not sure how they will adjust, and 1 will maintain services. The OAA requires AoA to design and implement uniform data collection procedures for states to assess the receipt, need, and unmet need for Title III services. While AoA provides uniform procedures for measuring receipt of services, it does not provide standardized definitions or measurement procedures for need and unmet need that all states are required to use. Within this context, states use a variety of approaches to measure need and measure unmet need to varying extents. No agencies that GAO spoke with fully estimate the number of older adults with need and unmet need. AoA and state agency officials noted that there are various challenges to collecting more information, such as cost and complexity. However, as a result of limited and inconsistent information, AoA is unable assess the full extent of need and unmet need nationally, and within each state.

What GAO Recommends

GAO recommends that the Department of Health and Human Services study the effectiveness of cost-sharing and definitions and measurement procedures for need and unmet need. The agency said they would explore options for implementing the recommendations.