Housing Policy Academy

Housing Policy Academy Creating Inclusive Accessible Communities for All Rita M. Landgraf Cabinet Secretary Department of Health and Social Services Wednesday, February 16, 2011

DHSS Services Must facilitate and empower individuals and communities to gain healthy outcomes, both in physical wellness and emotional well being; to gain economic self sufficiency, which will eliminate or limit long term reliance on government, and to protect and support those citizens most vulnerable due to advanced age, disabilities, and produce positive outcomes for the individuals we serve

The Aging Demographics “Senior Americans, whether rich, poor, or somewhere in the middle, face many barriers to an old age in which very basic human desires for physical safety, appropriate health care, and maximal independence are met. For some, crucial family supports will disappear as they outlive spouses or children move to distant places. For others, limited resources will prevent them from identifying and purchasing needed services. Many will lose their homes—long a symbol of their independence—due to rising property taxes and maintenance costs. Living alone, isolated from services and perhaps coping with disabilities that prevent social interactions, a large and growing number of seniors will face triple jeopardy: inadequate income, declining health and mobility, and growing isolation.” -Executive Summary, A Quiet Crisis in America A Report to Congress by the Commission on Affordable Housing and Health Facility Needs for Seniors in the 21st Century

Demographic Makeup of Delaware • Delaware’s population of those age 65 and over will increase by almost 106% between 2005 – 2030… an increase of 123,000 people • 87,000 one-person households in Delaware, most of them older citizens • Majority of individuals report a strong preference to receive care in home or community as opposed to in facility-based care • Greater community capacity to deal with cardiac, oncology, rehabilitation, and geriatric treatment

Individuals with Disabilities June 1999 U.S. Supreme Court rendered historic decision in Olmstead v. L.C., 527 U.S. 581 –encouraging States to develop plans to ensure promotion of community integration for individuals with disabilities rather than unnecessary institutionalization

Market Driven • An AARP study found that over 80% of seniors would prefer to stay in their current dwelling and never leave to receive care. 1/3 of people 75+ live alone, with no one to help with daily activities. These people are most likely to need an institution to facilitate their long term care needs. -The Road Ahead, p. 68 • 74% of people said they’d prefer to receive long term care in their homes compared to 3% who would prefer a nursing home, or 19% in assisted living - The Road Ahead, p. 14 • In the US, 34 million caregivers age 18 and older were providing unpaid care to friends and family at any given time in 2007. • The estimated economic value of the 34 million caregivers was $375 billion in 2007—an amount that exceeds Medicaid LTC spending in all states. -Across the States 2009, p. 5

Small State – High Institutionalized Population • Focus of Center for Medicaid/ Medicare Services • Focus of United States Department of Justice • Over –reliance of facility based services • DHSS Commitment – Assessments of All in Our Direct Care and Diversions • Community Wide Needs Assessment

The Need for Action The rate of growth of older Delawareans will increase at an even greater pace then the general population - Delaware population of those age 65 and over will increase by almost 106% between 2005 – 2030 An increase of 123,000 people -Delaware Facing Forward, p. 8 Delaware not only has to adjust for its current aging population, but there has been an in-migration of senior citizens. Between 1995 and 2000, 2,679 additional seniors 65+ moved to Delaware according to the Census Bureau, which is about 25 new residents for every 1,000 current residents. -Delaware Facing Forward, p. 10

Barriers to Community • Lack of affordable, accessible housing • Access to transportation (Research estimates that a 75 year old woman is likely to experience 10 years of non-driving and a man, six years) • Limited medical infrastructure • Limited opportunities for engagement – usefulness is a major contributor to vibrant health

Housing Considerations • The most significant issues seniors face can be helped by home modification and assistive technology are: getting in and out of the house, walking up and down stairs, and safely using the bathroom. - A Quiet Crisis, p. 68 • “…it is projected that by 2020 there will be 4.3 million seniors with ADL limitations, • One-third of people age 75+ live alone, which means that there is no one in the household to provide assistance if they need help with daily activities. People living alone are more likely to have to move to a care facility if they need long term care. • More than four out of ten people age 65+ have one or more of the following disabilities that affects their ability to accomplish common tasks of everyday living: sensory, physical, mobility, self-care, and cognitive/mental. By 2010 13% of people age 65+ are projected to have Alzheimer’s Disease. - Across the States 2009, p. 4

Housing Considerations Almost half of seniors are likely to have low-income, with about 1/3 paying more than half their income toward housing. - A Quiet Crisis, p. 14 By 2020, more than 80% of senior householders will be homeowners. Almost 44% of senior householders will be 75+. – A Quiet Crisis, p.22 About 12% of seniors claim their home is “not well” or “not well at all” able to meet their physical needs as they grow older. - Beyond 50, p. 53 Almost 1/5 of Delawareans surveyed report that they need to make major repairs, modifications, or changes to their homes to stay in them as they age. -The Road Ahead, p. 4

Universal Design– housing features that enable people of all ages to efficiently live in their home. Examples of Universal Design elements in a home include wider door ways, lower counter tops, and grab bars to assist individuals in the bathroom and shower. -Beyond 50, p. 56 The most frequently needed modifications are faucet and cabinet adaptations, stair lifts or elevators, bathroom access, ramps, and curbless or roll-in showers -A Quiet Crisis, p. 68 Approximately 20% of those surveyed by AARP in Delaware, claim to need major modifications to their homes in order to be able to stay there as they age. Of this people 66% claim to need bathroom modifications such as grab bars and handrails, 59% need access to accommodations such as ramps and chairlifts, 43% need a new roof or new plumbing, 38% need better cooling for summer, and 36% need better heating. –The Road Ahead (non-truncated version), p. 10

Health and Wellness Benefits • Research shows that continuing to develop and maintain social ties is associated with better physical and mental health among people of all ages • Enhances self esteem and personal control • Helping others generate positive emotions such as satisfaction and pride • Boosts immune functioning • Social and intellectual stimulation helps fight cognitive decline

Paying for Long Term Care It is estimated that a senior would need a min. of $100,000-$250,000, with an annual 3 percent yield, at age 65 to cover future long term care expenses. In 2000, only 18% of the senior citizens most likely to use nursing home care had sufficient financial resources to cover 2.5 years in a nursing home. Home equity loans and reverse mortgages to fund home remodeling projects or to pay for expenses like medical care, basic needs, and/or taxes- -Delaware Facing Forward, p. 21, 24

Nationally, per capita health care expenditures and spending on nursing home and home health are projected to increase by more than 170% by 2015. According to the U.S. administration on Aging, for Delaware this means an increase from $5.8 billion in 2005 to $7.25 billion in 2030 -Delaware Facing Forward, p. 20

In an AARP survey of Delaware residents 35+, 50% of the participants had little to no confidence in their ability to pay for long term care services for themselves or a family member. About 40% plan to rely on government programs and about 30% plan to use long-term care insurance. While an average year in a nursing home is about $81,000, there is hope for reduced expenses in at-home care. An average of 2 hours of daily home care cost about $15,000 per year. -The Road Ahead, p. 16

In 2003, Medicaid paid for 46% of all nursing home expenditures, with an additional 12% paid for by Medicare. While Medicare is the largest single payer for home care services, more than 1/3 of Medicaid funds now go to finance long-term care, which will reach half of all Medicaid spending by 2015, according to CMS, the federal agency responsible for the Medicaid program. –Unsettling the Scores, p.27

Since not everyone qualifies for Medicaid, many will have to resort to other options when their finances fall short. Some will use home equity to finance improvements, accommodations, or relocations. Because long-term care is so expensive, 56% of nursing home residents eventually “spend down” their resources and qualify for help from Medicaid anyways only perpetuating the problem. -Unsettling the Scores, p. 27

Major Initiatives and Focus • Building a Continuum of LTC Support • Affordable Health Care Act • Focus on Olmstead – CMS & USDOJ • Converting to a Needs Based Budgeting Process and Prioritization • Building a seamless system of supports – across government, within DHSS and with our partners

Advancing Opportunities Together • Development of alternative models resulting in greater use of community networks and services • Meeting the needs of an ever growing population while expanding inclusionary opportunities • Creative utilization of resources to support need and leverage community resources

Inclusive Communities • Affordable, accessible, walkable mixed use community housing • Create commercial opportunities both in health, nutrition, exercise, job development (the average working American family spends nearly 60% of their budget on housing and transportation costs)

Delaware Focused Activities • Governor Markell’s agenda - commitment to community based enhancements • Governor’s Institute on Community Design • Cross Cabinet Collaboration • Affordable Care Act opportunities • Commission Dedicated to Community Based Alternatives • Aging and Disability Resource Centers

Value Engagement • Housing, Social Service Providers and Consumers as Partners • Housing, Social Service Providers and Consumers as Advocates for Systemic Reform • Housing, Social Service Providers and Consumers as Conveners to Bring Leadership, Policymakers, and Stakeholders together to Embrace the Vision and Create Path Forward

Conclusion “This “Big Squeeze” poses a serious challenge to Delaware’s future. Large-scale demographic changes are coming to our state—changes over which we will have little control. For the most part, these changes are to be welcomed. We are living longer, becoming more diverse, and present a more and more appealing lifestyle that is attracting others to Delaware… …that’s why anticipating these challenges and being proactive in dealing with them are so important.” - Delaware Facing Forward, p. 42

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