The American Public Welfare Association recommends the adoption of public policies that will assure the eventual development of a universal system of public social services. We believe these services should be available and accessible to all persons who need them, without regard to economic status, and that they should be available to older persons as a matter of statutory right.

As major steps toward the implementation of a universal system of public social serivces, we recommend: (1) clarification of the scope of social services for older persons that should be developed under Title XX of the Social Security Act; (2) broadening of the universal social services for older people included under Title XX; and (3) an improved federal financing base for the Title XX program. We also propose continued expansion of the Older Americans Act and support the Social Security Administration's efforts to give more attention to the social services needed by beneficiaries of old age, survivors, and disability insurance (OASDI) and supplemental security income (SSI). We specifically recommend the following objectives:

1. A broader and improved base of federal financing for public social services. The ceiling on federal matching expenditures for social services should be gradually raised to permit the progressive development of a universal public social services system serving older people, as well as other adults, families, children, and youth.

2. A federal program of "personal" social services needed by older people. These services, which attempt to enhance or maintain the social functioning of the elderly, must be clearly defined and developed if a basic floor of universal services for older people is to be established in the future.

3. Universal eligibility and entitlement for public social services. Social services for older people should be available to all persons in the elderly population, regardless of their economic status.

4. Improved standards and accountability in public social services for older people. A national board, composed of outstanding professionals in the field of public and voluntary social welfare, older people, and the general public, should be named to advise the federal government on national and state standards for social services provided to older persons. The standards should be designed to assure the effectiveness, efficiency, intended scope, and quality of these services.

5. Continued expansion of various programs of the Older Americans Act related to the planning, development, and provision of social services to older people. Specifically, the provisions of Titles III, V, and VII of the act should be strengthened to: (a) further the development of comprehensive and coordinated state systems of services for older people; (b) encourage the development of multi-purpose senior centers that emphasize the provision of social services; and (c) expand the programs and services of the national nutrition program for the elderly, particularly in regard to providing nutritional services for additional numbers of older persons, including the homebound.

6. Improved coordination of social services for older people. The federal government should work with state and local governments to coordinate social services under the Older Americans Act and Title XX of the Social Security Act and should encourage coordination with other public and private social services programs serving the elderly.

7. Demonstration efforts by the Social Security Administration in the areas of social services for the aging. The Social Security Administration should be encouraged to develop and demonstrate information and referral services and other linking services within its general operations for OASDI and SSI beneficiaries. These efforts should be coordinated with state and local public social services agencies. -Adopted by the APWA Board of Directors on December 9, 1976

PUBLIC WELFARE SPECIAL 1977 37

Report on

Older persons should be offered a selection of services and the oppor

Aging

The recommendations contained in this report by the Committee on Policy for the Aging pertain to national policies on social services for the aging and are based on these philosophies.

1. Older people, regardless of their social or economic status-be it poor, middle class, or affluentshould have access to a comprehensive range of personal social services and other support services, such as transportation and legal services. These services should be designed to help the elderly meet the basic and special needs they experience in maintaining their personal and/or familial identity and well-being, whether they live in the community or in a protected social or institutional environment.

2. The base for development of a range of social services should be a system of universal public social services. This system should be operated under strong federal policy leadership, but should be directly administered by state and local governments. State and local units should also be responsible for the actual delivery of social services. This universal system should be complemented, for some years to come, by a public system solely concerned with the needs of the aging. The role of the latter should be to ensure that comprehensive, coordinated social services are planned and developed throughout the United States and appropriately linked to income maintenance, employment, housing, health care, and other functional programs serving older people.

3. The planning and operation of a universal social services system should be aimed at helping older people obtain needed services quickly and should facilitate access to a range of services, if these are required. It should provide for an assessment of the "need for service" that takes into account the judgments and preferences of both the client and the provider of service.

38 PUBLIC WELFARE SPECIAL 1977

which those services are to be delivered. The public social services system also should adhere to standards of operation that stress accountability of performance and maintenance of the quality of services provided. In keeping with this objective, providers of service should be required to carefully monitor the quality of their services and should follow through to make certain additional services are provided, if these are needed.

4. The services offered through a universal public social services system should clearly be personal social services. APWA, and other national organizations active in the social

Congress has enunciated a national goal for planning and implementing "comprehensive and coordinated service systems"

for older people.

services area, should make strong and continuous efforts to assure that the role of personal social services is distinctly understood and is not confused with or subsumed by medical, health, or employment

services.

What are personal social services? APWA's Committee on Social Services Policy defines them as "services that address social problems or conditions that are significantly affecting people and, if ignored, would result in undesirable consequences for the individual and/or society. "This definition is akin to what Alfred J. Kahn, professor, Columbia University School of Social Work, calls "the general social services." In Kahn's words, social services are one of the normal functions of a modern society. He describes them as "social inventions which seek to meet the needs of man in his interrelationships and roles, much as technical innovation is a response to the requirements of modern living."

Universal Public Social
Services for Older People

What specific services should be included in a universal system of public social services? What should be the objectives of such services? The following represents an initial effort to define the range of social services we believe should eventually be included in a universal social services system for older people:

1. Services designed to help older people utilize various benefits, resources. and entitlements and to deal with the complexities of institutional policy, language barriers, age, and other circumstances. These should include information and referral, legal services. follow-up, case advocacy, planning. and "outreach" services. The latter should be located at sites commonly used by older people.

2. Services to prevent or protect the older person from abuse, neglect, and exploitation. These should include organized protective services-especially the legal right to intervention and protection through the provision of medical care, housing, emergency financial assistance, and social services.

3. Twenty-four hour emergency seroices for older people who may be in extreme jeopardy or without any means of self-support or self-care. These should include emergency homemaker or other in-home services, emergency financial assistance, emergency health care, and emergency housing arrangements.

4. Services that provide appropriate social care arrangements on a temporary or permanent basis for older people who cannot remain or be cared for by others in their own homes. These should include counseling and assistance in

locating and using such arrangements as organized day care, personal care group homes, and residential congregate housing.

5. Services that enable older people to remain in their own homes or to readily return to their own homes following a period of care in a hospital, nursing home, or other institution. These should include homemaker services, home help services, transportation assistance, counseling services, friendly visiting, and other "one-to-one" services, such as telephone reassurance and shopping

assistance.

6. Services to help older persons understand and deal with changes in their interpersonal relationships and crisis situations arising from the loss of a spouse, retirement from work, illness, or other circumstances. Individual and group counseling should be provided, inIcluding specialized preretirement and postretirement counseling programs and specialized casework services for the older widow and widower.

7. Services that provide older people with opportunities for continued participation in social activities and constructive use of free time. Access to community recreation and educational programs should be provided, including participation in the programs and activities of multipurpose senior centers or other specialized facilities primarily designed for use by older people. Participation as a volunteer or paid employee in such programs should be promoted. Background

There have been a number of significant developments in national policies affecting social services for the aging in recent years. First, the Older Americans Act of 1965 has undergone several major expansions. Annual appropriations for the act now total in excess of $400 million. Much of the expansion has been for social services programs-either for a general purpose or special purpose (nutrition)-conducted under Titles III, V, and VII of the act. Second, Title XX of the Social Security Act, which established a separate title for support of social services and an annual federal authorization of $2.5 billion, includes some elements of

universality. For example, three social services have been designated by Title XX as universal services i.e., provided without regard to financial eligibility. These are information and referral, protective services for children, and family planning.

At the same time-with the advent of supplementary security income (SSI), and the subsequent physical separation of many SSI beneficiaries from the state and local agencies providing social servicesit has been generally recognized that a basic range of social services is needed for the SSI population, many of whom are aged.

Still another development has been the recent identification by the Federal Council on Aging of a group among the older population that it calls "the frail elderly." The council recommends that these persons, beset with chronic health and social problems, should be given priority for entitlement to essential social "care" services.

Despite these developments, a basic program of universal social services for the older population

does not now exist in the United States, nor does it appear that one will be implemented in the immediate future. With the exception of a few "universal" services being developed under Title XX, older people still lack any basic entitlement to services. As in past years, the receipt of a given social service largely depends on where one resides, rather than on any other factor.

It is possible that a basic universal social services program for the older population could eventually result from the gradual implementation of the Older Americans Comprehensive Services Amendments of 1973 and 1975. Congress has enunciated (in the Older Americans Act and its amendments) a national goal for planning and implementing "comprehensive and coordinated service systems" for older people. The Area Agencies on Aging, created by the 1973 amendments, are expected to provide much of the actual leadership in working toward this goal at the local level. These area agencies are seen primarily as planning agencies, rather than as direct

PUBLIC WELFARE/SPECIAL 1977 39

providers of social services. They have been called "service brokers" and are charged with building a "network" of social services that is both "comprehensive" and "coordinated."

Currently, there are some five hundred Area Agencies on Aging in operation, and there has been a noticeable increase in social service programs either started or expanded as a result of their activities. At the same time, it does not presently appear that a uniform program of social services is emerging from this effort. Social services developed at the local level generally are not universally available, and there is considerable unevenness in the range of social services provided from community to community and from state to state. To a great extent, the success or failure of the area agency approach depends on whether the agencies can tap into the funding for social services under other programs, most notably Title XX. However, Title XX gives the states great latitude regarding the social services they can choose to provide to older people or to other groups. There is no firm national mandate that requires the Title XX state agency to progressively broaden the scope of services made available to older persons, other adults, or children and families.

The uncertainty of this situation is compounded by the physical separation of income maintenance and social services that accompanied the creation of the federally administered SSI program. In effect, the division of responsibility between the state and local public welfare agencies and the Social Security Administration has literally cast many SSI beneficiaries "adrift"; they no longer have a relationship with an agency that provides the social services they require. The Social Security Administration (SSA) has begun to recognize the need to go beyond income maintenance and give some attention to the social service needs of SSI beneficiaries. However, the problems in communication and coordination that now exist between the SSA and state and local public welfare agencies are real and widespread. They constitute

40 PUBLIC WELFARE SPECIAL 1977

some of the most serious organizational problems faced in the field of public social services today.

Finally, there are implicit issues raised by the Federal Council on Aging's concern with the needs of the "frail elderly." The council's proposal to give priority to basic social care services for this group is carefully developed. If implemented successfully, it could have major implications for the future of long-term care, moving these services away from a medical context and into essentially a social services context.

The Administration on Aging also has identified various sub-popu

There is far greater concern about the need to broaden services to older people than existed just a decade ago.

lations at risk within the older population that require attention. These groups include: (1) persons age sixty and over with incomes below the poverty line; (2) the elderly who reside in hospitals, nursing homes, intermediate care facilities, and domiciliary care facilities; (3) the physically and mentally impaired elderly who do not live in institutions; and (4) persons forty-five to sixty years of age who are faced with various midlife crises and the need to prepare for approaching old age.

Given the scarcity of resources, it seems unlikely that a national policy authorizing universal public social services for any of these special groups-or for the general popu lation-will be enacted in the near future. Many obstacles stand in the way of quick acceptance of this goal by national policymakers, including questions about how such a program would be financed, what its priorities would be, what the role of the federal government would be, and how the program would be organized and staffed at the national, state, and local levels.

Nevertheless, experiences in the implementation of Title XX of the Social Security Act and Titles III and

VII of the Older Americans Act have produced documentation of the tremendous need for social services that exists among the older population. There is far greater concern about the need to broaden services than existed just a decade ago. It is likely that this trend will persist and that older people and the organizations representing and working with them will continue to press for the universal availability of social

services.

Recommendations

The Committee on Policy for the Aging recommends that the APWA Board of Directors support national policies that will ultimately lead to the establishment of universal public social services. This program should be administered jointly by the federal government and the states under legislation that clearly embodies the right of older people, children, families, and other groups to a comprehensive range of personal social services, regardless of their

economic status.

A program of universal social services should operate under federal and state policies that assure (1) consumer participation in the formulation of standards; (2) appropri ate assessments of need and case management procedures that guarantee continuity, uniform availability, and access to the required range of services; and (3) adequate and continuing federal support of basic personal social services-including information and referral, legal services, outreach, and protective services.

Services specifically developed for older persons under the program should include (1) supportive services that enable them to remain in or return to their own homes; (2) opportunities for continued social participation; (3) twenty-four-hour emergency services in times of personal crisis; (4) appropriate social care living arrangements for those requiring an alternate living arrangement; and (5) basic casework and counseling services, including assistance in obtaining various benefits and services and help in adjusting to major changes in personal circumstances.

The American Public Welfare Association is committed to encouraging short- and long-range national health policies that will (1) provide more comprehensive protection in meeting the health care costs of older people and (2) provide for a more rational system of delivering health care and related services to the aging. We support the following objectives: Short-range

1. Action should be taken to broaden the coverage of the existing Medicare and Medicaid programs, as well as that of other basic national health care programs, so that they provide more comprehensive protection for older people. Greater protection is needed, especially against such basic health care costs as essential out-of-hospital prescription drugs; dental, eye, and hearing care; and medically prescribed prosthetic devices and equipment. These health care services contribute not only to the health of the elderly, but also to their social functioning and mobility.

ap

2. Medicare and Medicaid, in particular-and where propriate, other basic federal programs should include provisions for the development of preventive health and social services that will enable the elderly to maintain the best possible physical and mental health. The support for these initiatives should come from the research and development authority of such basic federal programs or legislation as Medicare, Medicaid, the Older Americans Act, and the Research on Aging Act (the act that established the National Institute on Aging). Within the scope of this undertaking, special emphasis should be placed on the development of early and periodic diagnosis and treatment services for older persons, including access to specialized geriatric and primary care clinics.

3. Coordinated systems of home-delivered and congregatedelivered services should be developed through Medicare, Medicaid, and other programs. These systems of services should be designed with a two-fold purpose: to maintain the elderly in their own homes and to reduce the incidence of admission to and the length of stay in acute or long-term institutions. To fulfill these purposes, the scope of benefits under the above-men58 PUBLIC WELFARE/SPECIAL 1977

tioned programs should be broadened to include comprehensive inpatient and in-home geriatric assessment, home health care maintenance, and acute treatment services. In addition, Medicaid benefits should include provisions for payment of day and night hospital care and day care services for the severely mentally and/or physically impaired elderly, in order to provide temporary relief for the in-home caretaker. As a necessary complement to the expansion of benefits, the federal government should undertake strong efforts to further the actual development of communitybased services and resources for older people.

4. Steps should be taken toward the development of specialized care services to help the terminally ill patient through the dying process. These measures should be initiated under the research and development authority of such basic federal programs and legislation as Medicare, Medicaid, the Older Americans Act, and the Research on Aging Act of 1974. Through such services, the terminally ill patient could be assisted by careful management of pain and the maintenance of maximum social support. This could occur within a general hospital or similar institutional setting, or specialized staff of these facilities could go into the community to help the terminally ill patient and his family at home.

5. The existing Title XIX (Medicaid) of the Social Security Act should be continued until a comprehensive national health insurance program-one that finances all of the health care services required by older persons-has been fully implemented. Continuation of Medicaid will be necessary during the period of implementation of a comprehensive national health insurance program to assure that basic health care services are available to persons with low incomes. To ease the financial burden this would impose on the states, the federal government should assume the total Medicaid costs of persons receiving supplemental security income. The states should be mandated to provide Medicaid coverage, with federal guidelines and federal sharing of the costs, for medically needy older persons who do not receive cash surport.