Legislative Analyst Report - Independent Living (File No. 012072)
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LEGISLATIVE ANALYSIS
TO: Honorable Members of the Board of Supervisors
FROM: Gabe Cabrera, Legislative Analyst
DATE: April 5, 2002
SUBJECT: INDEPENDENT LIVING (File No. 012072)
SUMMARY OF REQUESTED ACTION
Motion (introduced by Supervisor Daly) requesting the Office of the Legislative Analyst (OLA) to investigate and report on San Francisco"s existing policies and expenditures related to independent living of seniors and persons with disabilities, as well as those policies in other jurisdictions. The motion also requests that the OLA recommend policy approaches to foster independent living in San Francisco for seniors and persons with disabilities.
EXECUTIVE SUMMARY
"Independent living" is an alternative to institutionalized care of the elderly and disabled; independent living services provided by the City and County of San Francisco allow persons to live in their homes and communities, rather than in nursing homes, hospitals and other institutions. The goal of this report is to provide a preliminary look at the services and costs related to independent living in San Francisco, but further research and analysis will need to be done before our estimates can be accepted as precise.
Nevertheless, the principal findings of this report are the following:
There are 106,111 persons age 65 and over in San Francisco. This is approximately 14% of the total population. Of the 16 and over non-institutionalized population, 145,253 persons have a disability, while 77,633 persons have a severe disability.
The City and County of San Francisco spent approximately $173,638,866 on independent living services in FY 00-01.
Of this amount, $55,886,893 was General Fund support. This represents about one-third of the City"s total expenditures on independent living.
San Francisco"s service system may be described as decentralized. Several City departments provide the elderly and disabled with community-based services. No central agency exists.
Advocates of the elderly and disabled contend that the existing system is fragmented, uncoordinated and not consumer-friendly. There is some evidence to support this assertion.
Based on these findings, the Board of Supervisors may: (1) establish a new or using an existing City task force to look more closely at the current system, (2) commission a study to determine whether it costs less to treat an individual with community-based services rather than in an institution and (3) adopt legislation to require departments to organize services from a consumer perspective. The Board of Supervisors may also urge State and Federal agencies on aging to ease restrictive funding and eligibility guidelines in order to meet the priority needs of the elderly and disabled. Of course, this is a policy matter for the Board of Supervisors.
BACKGROUND
Demographic Characteristics
According to 2000 U.S. Census Bureau data, the total population of the City and County of San Francisco is 776,733. There are 106,111 persons age 65 and over in San Francisco. This is approximately 14% of San Francisco"s total population.
The over 65 population in San Francisco is 49.4% White and 50.6% ethnic/racial minorities. The largest minority group of persons age 65 and over is Asian (36.9%), followed by Hispanic or Latino (8.7%), Black/African American (8.1%), Alaskan/Native American (0.2%), Native Hawaiian/Other Pacific (0.2%), other race (2.7%). Additionally, the 65 and over population in San Francisco is composed of 58.2% (61,736) women and 41.8% (44,375) men.
Moreover, the Census Bureau estimates that of San Francisco"s age 16 and over non-institutionalized population, 145,253 persons have a disability, while 77,633 persons have a severe disability. A person is considered to have a disability if he/she has difficulty performing certain activities of daily living. These figures represented 23.8% and 12.7% of the 16 and over non-institutionalized population, respectively.
Description of Existing System
San Francisco"s service system may be generally described as decentralized. Several City departments provide the elderly and disabled with community-based services. According to a 1998 Department of Health report, the existing system has the following deficiencies:1
1. No single point of entry: When individuals begin to use services offered by the various departments, they must undergo numerous intakes and assessments.
2. Lack of integration: Services are not organized from a consumer perspective. For example, consumers must apply and obtain housing, in-home supportive services and home-delivered meals from three separate departments (DPH, DHS, DAAS, respectively).
3. Limited case management: Some services have internal case management programs. Only a few case management programs consider the comprehensive needs of the consumer.
Advocates of the elderly and disabled, such as the Independent Living Resource Center (ILRC) and Planning for Elders in the Central City (PECC), contend that the existing system also has the following deficiencies:2
4. Funding limitations: Large portions of Federal, State and local funds are earmarked for specific services, but have differing and often restrictive eligibility guidelines. Thus, they cannot be directed to meet the priority needs of the consumer.
5. Fragmented data collection: Departments collect data on consumers using disparate terms, categories and methods, making it difficult to use information to better plan and evaluate use of services.
The City"s Response
The City has taken steps to address above-noted deficiencies. Most notably, the Department of Aging and Adult Services (DAAS) was created in July 2000, which merged the Office on the Aging, Public Guardian/Administrator, and the Mental Health Conservator Office. These were formerly three separate departments. DAAS, in turn, made the following improvements to the existing system:
Continued to consolidate services. DAAS absorbed Adult Protective Services in January 2002, which was formerly within DHS, and will do the same with DHS"s In-Home Supportive Services (IHSS) program in January 2003.
Assumed responsibility for implementing improvements to the City"s long-term care service delivery system. This was formerly a function of DPH"s Long-Term Care Pilot Project Task Force, which concluded its work in February 2001.
Established the Living with Dignity Policy Committee. DAAS formed this committee in May 2001 to guide the improvements to the City"s long-term care service delivery system of services. Membership includes City agencies, providers, advocates and consumers.
Developed SFGetCare. This is a web-based system designed to assist consumers to obtain information on available in-home and community-based services, and record track and enroll consumers in DAAS services.
DAAS also intends to make the following improvements to the existing system:
Evaluate how to best organize DAAS"s intake and referral services
Undertake a strategic planning process to improve the City"s long-term care service delivery system
Investigate the optimum way to organize case management services
Sponsor a Living with Dignity Policy Summit (October 2002)
Our office cannot claim to have identified all of DAAS"s efforts to date. Instead, we sought to provide the Board of Supervisors with broad overview of completed and scheduled activities. For specific programmatic information, see the Appendix section of this report.
CURRENT LAW
The Older Americans Act of 1965
The Older Americans Act was passed by Congress in 1965. The Act calls for a range of programs that offer services and opportunities for older Americans, especially those at risk of losing their independence. The Act established the Administration on Aging (AoA), which is part of the U.S. Department of Health and Human Services.
The AoA awards funds under several titles of the Act to State Agencies on Aging nationwide.3 Program funding is allocated to each State Agency on Aging, based on the number of older persons in the State, to plan, develop and coordinate systems of supportive in-home and community-based services. Most States, including California, are divided into Planning and Service Areas (PSAs) so that programs can be effectively developed and targeted to meet the unique needs of the elderly residing in the area. Area Agencies on Aging (AAA) receive funds from their respective State Agencies on Aging to plan, develop, coordinate and arrange for services in each PSA. AAAs contract with public or private groups to provide services. In some cases, the AAA may act as the service provider, if no local contractor is available.
The Olmstead Decision of 1999
On June 22, 1999, the U.S. Supreme Court ruled in the case Olmstead v. L.C. and E.W. that the "integration mandate" of the Americans with Disabilities Act (ADA) requires public agencies (i.e., Federal, state and local governments) to provide services "in the most integrated setting appropriate to the needs of qualified individuals with disabilities" unless doing so would "fundamentally alter" the nature of such services. Disabled people segregated in institutions have used this ruling to require states to provide state services in the community. Olmstead v. L.C. and E.W. reached the Supreme Court when the Georgia Department of Human Resources appealed a decision by the 11th Circuit that it had violated the ADA"s "integration mandate" by segregating two women with mental disabilities in a state psychiatric hospital after the agency"s treatment professionals had recommended their transfer to state provided community care.
ISSUES AND OPTIONS
The Cost of Independent Living
Determining the cost of independent living services to the City is not as simple as opening the City and County budget and pointing to a line item for "independent living." As discussed below, several City departments offer independent living services. Further complicating the analysis is the fact that departments derive funding for their independent living programs from a combination of Federal, State and local sources. Noting these complications, the Legislative Analyst estimates that in fiscal year 2000-2001, the City and County of San Francisco spent approximately $173,638,866 on independent living programs and services. Of this amount, $55,415,601 were General Fund dollars.
The Office on the Aging (OOA)
The Office on the Aging is San Francisco"s designated Area Agency on Aging (AAA). The OOA is one of three divisions of the recently consolidated Department of Aging and Adult Services. It contracts with 43 community-based nonprofit and two public agencies to provide services to San Franciscans age 60 and over. The majority of OOA funding dollars for direct services support nutrition programs (congregate and home-delivered meals) and senior center activities (community services). The Senior Information and Referral Program also operates within the OOA.
Total OOA expenditures on Independent Living services equal $11,711,108 in FY 2000-2001, of which $8,080,665 were General Fund dollars.
Public Administrator/Public Guardian/County Veterans Service Office
The Public Guardian is also one of the three divisions of the recently consolidated Department of Aging and Adult Services. The Public Guardian serves as probate conservator of person and/or estate for elderly and developmentally disabled adult residents in San Francisco. The Public Guardian Representative Payee Program serves mentally ill residents in locked psychiatric facilities and community resident adults who have mental health case managers.
Total Public Guardian expenditures on Independent Living services equal $2,836,062 in FY 2001-2002, of which $2,336,062 were General Fund dollars and Fees for Services.
Adult Protective Services (APS)
In January 2002, DAAS absorbed Adult Protective Services, which was formerly a part of the Department of Human Services. APS investigates possible abuse or neglect of seniors and disabled/dependent adults. The abuse may be physical, emotional or financial, neglect by others or self-neglect. If abuse is suspected, social workers provide short-term counseling, case management and referral services.
Total APS expenditures on Independent Living services equal $5,155,375 in FY 2000-2001, of which $227,282 were General Fund dollars.
Department of Human Services (DHS)
The Adult Services Program, within DHS administers the In-Home Supportive Services (IHSS) program. In addition to independent providers hired by the client, DHS contracts with a coalition of community-based non-profit organizations (IHSS Consortium) to provide in-home supportive services to seniors and people with disabilities. These services include case management, homemaker/chore and personal care services (meal preparation, cleaning, and personal grooming). The San Francisco IHSS Public Authority, a public agency that is managed by its own governing body, oversees the independent provider service delivery system within the IHSS program.
Total DHS expenditures on Independent Living services equal $119,000,000 in FY 2000-2001, of which $30,040,000 were General Fund dollars.
Municipal Railway (MUNI)
MUNI"s Accessible Services Program oversees fixed-route and paratransit services for San Francisco. Paratransit services are available for persons unable to access fixed route services. Paratransit services include lift-van for individual trips by wheelchair users, group van for ten or more persons transported to a common site, taxi scrips for ambulatory individuals and ramped taxi service. These services are available to ADA eligible persons of all ages citywide. The OOA funds group van services to senior meal sites, shopping trips and recreation and individual trips for seniors who are not eligible for services under ADA guidelines.
Total MUNI expenditures on Independent Living services equal $16,930,511 in FY 2001-2002, of which $2,377,130 were General Fund dollars.
Mayor"s Office on Housing (MOH)
MOH provides funds for nonprofit housing development corporations to develop senior housing projects. Funds are derived from a combination of revenue streams including General Obligation bonds, federal grants and San Francisco Redevelopment Agency tax-increment monies. MOH also provides loans for housing code upgrades to low-income senior and disabled homeowners in target areas and citywide.
Total MOH expenditures on Independent Living services equal $2,645,035 in FY 2000-2001, of which none were General Fund dollars.
Department of Public Health (DPH)
DPH provides health and health-related services to seniors and people with disabilities living in the community. The Department offers these services within its two divisions: the Community Health Network (CHN) and Public Health (PH). Specifically, CHN offers (1) housing and support services for clients and patients of the DPH System of Care and (2) home health care services for patients discharged from the hospital requiring nursing care that would otherwise require institutionalized care. PH provides Adult Day Health Care for elderly or disabled adults in the community and those who have been recently discharged from the hospital or skilled nursing facility that might otherwise require institutionalized care.
Total DPH expenditures on Independent Living services equal $15,360,775 in FY 2000-2001, of which $12,825,754 were General Fund dollars.
Community-Based Services v. Institutionalized Care
Little detailed research has been done to compare the costs of community-based services to the cost of institutionalized care for the elderly and disabled in San Francisco. Whether or not community-based services are more or less costly than institutionalized care remains an open question. Advocates of independent living assert that it costs less to treat an individual with community-based services rather than in a nursing home, hospital or other institution, but often only by comparing the cost of community-based services to all of the costs related to institutions. This approach will almost always reveal a huge difference in costs, which favors the use of community-based services. However, in the Olmstead decision, the Court noted that "a comparison so simple overlooks the costs the State cannot avoid, most notably, a `State...may experience increased overall expenses by funding community placements without being able to take advantage of the savings associated with the closure of institutions." As already observed,...the ADA is not reasonably read to impel States to phase out institutions." Other advocates contend that more clients are served with the same State Medicaid dollars in community-based programs than in institutions, but only by using a comparison formula which contrasts certain cost-effective programs to less economical institutions.
Thus, neither of these approaches provides little accurate analysis of how much it costs to offer community-based services versus institutionalized care, and more importantly, little guidance in terms of what methodology should be implemented to assess and compare costs. We believe that further research and analysis should be done in this area before any conclusions may be drawn.
OTHER JURISDICTIONS
Alameda County, California
Alameda County maintains a "coordinated decentralized" service system. Like San Francisco, several departments in Alameda County provide services to the elderly and disabled. However, most of these services are coordinated through the Adult and Aging Services (AAS) department located within the Alameda County Social Services Agency.
The Alameda County Area Agency on Aging (AAA) is one of eight divisions within Adult and Aging Services. AAA is Alameda"s designated Area Agency on Aging, which provides subcontracted services to persons age 60 and over through grants from Federal Administration on Aging, the State of California and the County of Alameda. Other divisions include Adult Protective Services, In-Home Supportive Services (IHSS) (which provides in-home care to seniors and persons with disabilities), the Public Authority for IHSS, and the Public Guardian/Probate Conservatorship. According to the AAA, divisions within the Aging and Adult Services are fairly well connected. Thus, duplication of services is minimized. However, no single point of entry exists, as is the case in San Francisco. The AAA performs needs assessment activities for Alameda"s PSA that are sometimes based on census data, surveys and focus groups organized in conjunction with community-based groups.
In FY 01-02, Alameda County spent a total of $126,838,530 on independent living services, including $114,021,305 for IHSS and $12,817,225 for Aging and Adult Services. The County derived funds from a combination of revenue streams including Federal, State and local sources.
The City of Seattle, Washington (King County)
Seattle"s service system may be described as centralized. Aging and Disability Services (ADS) is the assigned Area Agency on Aging for the Seattle-King County region. The City of Seattle Human Services Department acts as the legal contracting authority. Under a regional agreement, the City of Seattle, King County and the United Way serve as the sponsors and policy-setting board for ADS.
ADS funds eighteen (18) services to seniors and persons with disabilities who live in King County. Services related to independent living include: adult day services, case management, client specific funding program, COPES/Chore Personal Care/Personal Care, disability access services, elder abuse prevention, employment (job placement assistance), home health and health maintenance, homesharing, nutrition, respite care, transportation. In addition, general services for the elderly and disabled include: the Alzheimer program, disease prevention/health promotion, information and assistance, legal services, mental health, nurse consultation, outreach advocacy, senior centers, Seniors in Service to Seattle, technology support, utility discount program.
Because ADS administers all Federal, State and local funds for these services, it is able to recognize gaps in services and minimize duplication of services. According to ADS, its Senior Information and Assistance Center is essentially a central intake and referral system. Moreover, ADS performs needs assessments, typically in collaboration with community-based organizations. ADS"s 2000 budget totals $32,564,226. Most of this funding (about $23 million) is "non-discretionary" or earmarked for specific services. Discretionary funding (about $7 million) is more flexible in nature and can be directed to meet the priority needs of King County.
RECOMMENDATIONS
Based on our preliminary research and analysis, the Legislative Analyst offers the following recommendations for your consideration:
1. Create a new or use an existing City task force to look more closely at the current system. The Living with Dignity Policy Committee is the obvious candidate for this task. However, it is an advisory group to DAAS, not the Board of Supervisors. The Board of Supervisors would need to establish either a link to this group or a line of communication to it through DAAS.
2. Commission a study to determine whether it costs less to treat an individual with community-based services rather than in a nursing home, hospital or other institution. We would like to note that whether or not independent living saves the City money might not be the most appropriate guideline for determining whether community-based services should be increased. Independent living undoubtedly provides benefits to the elderly and disabled, whose value a cost analysis may not attempt to assess.
3. Adopt legislation that addresses the deficiencies of the existing system as identified in this report. Specifically, the Board of Supervisors may continue to consolidate departments and require departments to organize services from a consumer perspective. The Board of Supervisors may also urge State and Federal agencies on aging to ease restrictive funding and eligibility guidelines in order to meet the priority needs of the consumer.
City Department | Program Description | Eligibility | No. of persons served | Program Costs and Revenue Sources (FY 00-01) |
|---|---|---|---|---|
Department of Human Services (DHS), Adult Services Program | In-Home Support Services (IHSS) The Adult Services Program, within DHS administers IHSS. IHSS assists elderly, blind, and disabled people to remain in their homes when they are no longer able to fully care for themselves or handle routine household tasks. IHSS pays for a wide variety of services - household chore and personal care - enabling the individual to live safely in his/her own home, while encouraging independence and rehabilitation where possible. IHSS is an alternative to out-of-home care/institutional placement. | Any person who is age 65 or older, or a person who is blind or disabled (of any age), who is unable to remain safely at home without such services, and who receives, or is eligible to receive, a cash grant through the Supplemental Security Income/State Supplemental Payment (SSI/SSP) Program, or who meets the eligibility criteria for SSI/SSP but has too much income to get a cash grant. | 11,239 (active cases in Sept. 2001) | $109,000,000 for IHSS services (45% Federal, 29% State, 26% General Fund) $10,000,000 for IHSS administration (49% Federal, 34% State, 17% General Fund) |
| Â | Adult Protective Services (APS): APS investigates possible abuse or neglect of elders and disabled/dependent adults. The abuse may be physical, emotional, financial, neglect by others, or self-neglect. If abuse is suspected, social workers provide short-term counseling, case management and referral services. | These services are available to all San Franciscan residents 65 and over, or disabled/dependent younger adults, 18-64. | 220-250 (active case per month) | $5,155,375 ($2,503,179 Federal, $2,424,914 State, $227,282 General Fund) |
Department of Aging and Adult Services (DAAS), Office on the Aging (OOA) | In-Home Services: The OOA funds an agency to provide emergency in-home services to elders who need immediate, temporary in-home services. In-Home Services consist of three components: Personal Care, Homemaker and Chore. | Provides services to individuals 60 years and older per the 1965 Older Americans Act and younger individuals with disabilities. | 42,782 | $238,751 (21% Federal, 10% State, 69% General Fund and local off-street parking fees) |
| Â | Home-Delivered Meals: Nine different providers provide-home-delivered meals in all neighborhoods. Meals on Wheels is largest provider. | See above. | Â | $4,353,482 (21% Federal, 10% State, 69% General Fund and local off-street parking fees) |
| Â | Adult Day Care/Health Services: The OOA funds the San Francisco Adult Services Network to provide adult day health service subsidies to low-income elders who are not eligible for Medi-Cal and cannot pay the sliding fee schedule. The OOA also funds two agencies to provide adult day support. | See above. | Â | $568,163 (21% Federal, 10% State, 69% General Fund and local off-street parking fees) |
| Â | Case Management: The OOA funds ten different Case Management programs. Providers target this service in specific neighborhoods. | See above. | Â | $846,323 (21% Federal, 10% State, 69% General Fund and local off-street parking fees) |
| Â | Transportation: The OOA funds the Municipal Transportation Agency Muni Accessible Services Program, which is described below. | See above. | Â | $683,031 (21% Federal, 10% State, 69% General Fund and local off-street parking fees) |
| Â | Legal Services: The OOA funds four agencies to provide legal services. In addition, staff from these agencies provide intake, advice and community education sessions to older persons. | See above. | Â | $745,039 (21% Federal, 10% State, 69% General Fund and local off-street parking fees) |
| Â | Other Services: Community services including activity scheduling, translation, and social services. 10 Senior Centrals located around the City provide one-stop neighborhood access to an expanded range of information and services called for by seniors. Other services also include health screenings. | See above. | Â | $4,276,319 (21% Federal, 10% State, 69% General Fund and local off-street parking fees) |
San Francisco Municipal Railway (MUNI) | Accessible Services Program: Paratransit services through the Municipal Transportation Agency Muni Accessible Services Program serve all neighborhoods and provide wheelchair lift-van and group van transportation to ADA eligible persons of all ages citywide. | These services are available to ADA eligible persons of all ages citywide. | Not available as of the writing of this report. | $16,930,511 ($3,280,000 Federal, $568,819 State, $2,377,130 MTA General Fund, $9,661,456 SF Transportation Authority and $1,043,106 BART; The OOA"s contribution to this program is listed above)4 |
| Â | Public Guardian (Probate Conservatorship): The Public Guardian serves as probate conservator of person and/or estate for geriatric and developmentally disabled adult San Franciscans. | Priority is given to seniors in the community at risk of financial or physical abuse. | 425 elderly clients and developmentally disabled clients. | $2,836,062 (approximately $2,336,062 General Fund, $500,000 Fee for Services)5 |
| Â | Representative Payee Program: The Public Guardian Representative Payee Program serves mentally ill residents in locked psychiatric facilities and community resident adults who have mental health case managers. | Priority is given to mentally ill clients. | 1,200 mentally-ill and elderly clients | See above. |
Department of Public Health (DPH) | Community Health - Housing and Support Services: Housing and support services for clients and patients of the DPH System of Care. Specialty case management services are provided to mental health client discharges from the hospital and psychiatric skilled nursing facilities, persons with HIV/AIDS, disabled patients who lack a support network, and the frail and elderly who would otherwise require institutionalized care. | Not available as of the writing of this report. | Not available as of the writing of this report. | $9,273,123 ($392,350 Federal and State, $8,880,773 General Fund) |
| Â | Community Health Network - Health at Home: Home health services for patients discharged from the hospital requiring nursing care that would otherwise require institutionalized care. | See above. | Â | $4,993,787 ($1,388,515 Federal and State, $3,605,272 General Fund) |
| Â | Laguna Honda Hospital - Community Support: Adult Day Health (like daycare) for adults, many who are elderly or disabled, from the community or that have recently been discharged from the hospital or skilled nursing facility that might otherwise require institutionalized care. | See above. | Â | $1,093,865 ($754,156 Federal and State, $339,709 General Fund) |
Mayor"s Office on Housing (MOH) | Affordable Rental Housing Units: The MOH provides funds for nonprofit housing development corporations to develop senior housing projects, and loans to rehabilitate existing homes of the elderly and disabled. | Low-income elders (age 62 or older) and developmentally disabled individuals who live independently. | 180 | $2,645,035 (Funds are derived from a combination of revenue streams including General Obligation bonds, federal grants and SF Redevelopment tax- increment monies. |
1 DPH"s Long-Term Care Integration Pilot Project, Main Report, Page 13.
2 The Legislative Analyst could not corroborate these assertions in prior studies of the existing system. However, two advocates interviewed for this report mentioned them during separate interviews.
3 Title III, for instance, supports a range of services including nutrition, transportation, senior center, health promotion and homemaker services. Title VII places emphasis on elder rights programs including the nursing home ombudsman program, legal services, outreach, public benefit and insurance counseling, and elder abuse and prevention efforts.
4 This budget is for FY 2001-2002.
5 This budget is also for FY 2001-2002 and funds both Probate Conservatorship and the Representative Payee Program.