Maine Policy Review Summer/Fall 2015 by University of Maine

Summer/Fall 2015 · Vol. 24, No. 2 · $15

Maine Policy Review

Special Issue on Aging

Margaret Chase Smith Policy Center

Maine Policy Review

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PUBLISHER MARGARET CHASE SMITH POLICY CENTER Laura Lindenfeld, Director

EDITORIAL STAFF

Maine Policy Review (ISSN 1064-2587) publishes

EDITOR

independent, peer-reviewed analyses of public policy issues relevant to Maine.

Ann Acheson Margaret Chase Smith Policy Center

The journal is published two times per year by the Margaret Chase Smith Policy Center at the University of Maine. The material published within does not necessarily reflect the views of the Margaret Chase Smith Policy Center.

MANAGING EDITOR Barbara Harrity Margaret Chase Smith Policy Center

The majority of articles appearing in Maine Policy Review are written by Maine citizens, many of whom are readers of the journal. The journal encourages the submission of manuscripts concerning relevant public policy issues of the day or in response to articles already published in the journal. Prospective authors are urged to contact the journal at the address below for a copy of the guidelines for submission or see the journal’s Website, http://digitalcommons.library .umaine.edu/mpr/.

PRODUCTION Beth Goodnight Goodnight Design

DEVELOPMENT Eva McLaughlin Margaret Chase Smith Policy Center

COVER ILLUSTRATION Robert Shetterly

PRINTING Penmor Lithographics

For permission to quote and/or otherwise reproduce articles, please contact the journal at the address below. Current and back issues of the journal are available at: digitalcommons.library.umaine.edu/mpr/ The editorial staff of Maine Policy Review welcome your views about issues presented in this journal. Please address your letter to the editor to:

Maine Policy Review

5784 York Complex, Bldg. #4 University of Maine Orono, ME 04469-5784

207-581-1567 • fax: 207-581-1266 http://mcspolicycenter.umaine.edu mpr@maine.edu

The University of Maine does not discriminate on the grounds of race, color, religion, sex, sexual orientation, including transgender status and gender expression, national origin, citizenship status, age, disability, genetic information or veteran’s status in employment, education, and all other programs and activities. The following person has been designated to handle inquires regarding nondiscrimination policies: Director, Office of Equal Opportunity, 101 North Stevens Hall, 207-581-1226.

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THANKS TO… Major Sponsors

Margaret Chase Smith Foundation Benefactors

*Maine Community Foundation *Maine Health Access Foundation Donors

*AARP Maine *University of Maine Center on Aging Contributors

*Dirigo-Maine Geriatric Society John and Carol Gregory Merton G. Henry William Knowles

*Maine Gerontological Society *Maine State Housing Authority Samuel A. Ladd III and Nancy E. Ladd

H. Paul McGuire

Hon. Peter Bowman David Hart

Elizabeth Ward Saxl and Michael Saxl

David Vail And anonymous Friends

Peter Mills Mark R. Shibles And anonymous Contributors

Friends

*With special thanks for their targeted support for Volume 24, Number 1, special issue on aging. Volume Twenty-four of Maine Policy Review is funded, in part, by the supporters listed above. Tax-deductible contributions to the journal can be directed to the Margaret Chase Smith Policy Center at: 5784 York Complex, Bldg. 4, University of Maine, Orono, ME 04469-5784. Donations by credit card may be made through our secure website at digitalcommons.library.umaine.edu/mpr and clicking on “Donate.” Information regarding corporate, foundation or individual support is available by contacting the Margaret Chase Smith Policy Center.

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Contents

F E AT U R E S The Demographic Transformation in Maine (and Beyond) Is in Full Swing by Lenard W. Kaye . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

The Economic Implications of Maine’s Changing Age Structure by James Breece, Glenn Mills, and Todd Gabe . . . . . . . . . . 13

TO OUR READERS . . . . . . . . . . . . . . . . . 6

The View from Augusta: Developments Growing Out of the Speaker’s 2013 Round Table Discussions and 2014 Aging Summit

THE MARGARET CHASE SMITH ESSAY Priorities of the U.S. Senate Aging Committee by Susan M. Collins . . . . . . . . . . . . . . . . . .

by Mark Eves and Jessica Maurer . . . . . . . . . . . . . . . . . 23

Technology and Aging: An Emerging Research and Development Sector in Maine

THANKS TO OUR REVIEWERS . . . . . . . . . . . . . . . . 128

by Carol H. Kim, David Neivandt, Lenard W. Kaye, and Jennifer A. Crittenden . . . . . . . . . . . . . . . . . . . . . . 29

A Call to Action: Maine’s Colleges and Universities Respond to an Aging Population by Jeffrey E. Hecker and Marilyn R. Gugliucci . . . . . . . . . . . 36

The Evolution of Elder Housing Design and Development by John Gallagher . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Getting from Here to There: Maine’s Elder Transportation Challenge by Katherine Freund . . . . . . . . . . . . . . . . . . . . . . . . . . 49

The Age-Friendly Community Movement in Maine by Patricia Oh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

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Contents

F E AT U R E S Maine’s Initiatives in Geriatric Medical Care: Commentary from the Front Lines

THE EMERGENCE OF AGEFRIENDLY COMMUNITIES Highlighting the Town of Bucksport by James Bradney . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

The City of Bangor by Benjamin Sprague . . . . . . . . . . . . . . . . . . . . . . . . . 62

The Future Is Now: Legal Planning for Elders

Shaping the Health and LongTerm Services and Supports Infrastructure Serving Older Adults: Historical Trends and Future Directions by Julie Fralich . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

by Jennifer L. Eastman . . . . . . . . . . . . . . . . . . . . . . . . 63

Older Workers at L.L.Bean by Wendy Estabrook . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Immigrant Elders: What Can Maine Learn from Other States?

Keep Them Rocking at Home: Thriving in Place by Becky Hayes Boober . . . . . . . . . . . . . . . . . . . . . . . 111

Home Care in Maine: The Worker’s Experience

by Linda Silka . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

by Sandra S. Butler . . . . . . . . . . . . . . . . . . . . . . . . .

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COMMENTARY:

Aging, Diversity, and Difference in Rural Perspective by Douglas Kimmel . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Creativity and Aging by Kathleen Mundell . . . . . . . . . . . . . . . . . . . . . . . . . . 76

Never Too Old to Lead: Activating Leadership Among Maine’s Older Adults

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THE ROLE OF FOUNDATION GRANTMAKERS IN RESPONDING TO COMMUNITY AGING

Maine Community Foundation by Meredith Jones . . . . . . . . . . . . . . . . . . . . . . . . . . 122

by David C. Wihry . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

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by Lenard W. Kaye, Lucille A. Zeph, and Alan B. Cobo-Lewis . . . . . . . . . . . . . . . . . . . . . . . 115

by Tony Cipollone . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

Organizing Voices in Maine to Support Successful Aging

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The Aging and Developmental/ Physical Disabilities Networks: Can the Silos Be Dismantled?

John T. Gorman Foundation

by Jennifer A. Crittenden and Lelia DeAndrade . . . . . . . . . . 80

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by Cliff Singer and Roger Renfrew . . . . . . . . . . . . . . . . . . 89

Maine Health Access Foundation by Wendy J. Wolf . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

Dear Readers,

s world nothing can be d as having said, “In thi ote qu sly ou fam is n t list of certainties— Benjamin Frankli e can add aging to tha W ” es. tax d an ath de t ep . Maine has the said to be certain, exc ading in that direction he are us of all t bu , elders e, and we have some of us are already in terms of median ag n tio na the in te sta Policy oldest special issue of Maine distinction of being the is Th te. sta er oth y an r capita than sive overview of the more baby boomers pe timely and comprehen a s nt ese pr ing ag of ye, director Review on the topic ift. Guest editor Len Ka sh ic ph gra mo de s thi by ed group of ramifications presented assembled a distinguish s ha , ing Ag on er nt aine Ce al innovaof the University of M e, housing, technologic car h alt he m fro g gin topics ran creativity and aging, contributors who tackle aine’s age’s structure to M of s ion cat pli im c responding to tion, and the economi role of philanthropy in the d an s, itie un mm co ing implications leadership, age-friendly re the policy and plann plo ex rs tho au the t, roughou not only the country’s community aging. Th ext of Maine’s status as nt co the in ic ph gra to be an informative, of the aging demo pe you’ll find this issue ho e W te. sta ral ru st e. oldest but also its mo topic of aging in Main iew of the important erv ov pth de ind an helpful, Best,

), I am extremely licy Center (MCSPC Po ith Sm ase Ch t are ing have built As director of the Marg of Maine Center on Ag ty rsi ive Un the d an Center has resulted pleased that the Policy ing. This partnership ag of me the nt rta po but und the im aine Policy Review, substantive bridges aro this special issue of M of ion cat well s bli wa pu d ue an iss s aging in the development further. Planning for thi ck ba es go ion the rat all bo lla see the context for our co and I am delighted to or in the fall of 2014, ect dir e oached cam pr be ap I ye en Ka hen Len underway wh anding publication. W tst ou s thi in ed on n us itio foc fru teaching efforts come to propose research and to ers oth d an ce” in him en th ell as of exc me about joining wi ognized “emerging are rec e’s ain M of ty rsi is ive area. Th special aging as one of the Un orts to this important eff ’s PC CS M the it comm rtant policy 2014, I was thrilled to cation devoted to impo bli pu e ier em pr r ou , w y Review conversation about ho issue of Maine Polic to a lively, important ute rib nt co to . s ion aim lat pu issues facing Maine, ues around an aging po n in addressing the iss tio na the d lea can te our sta

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Best,

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My Creed . . .

is that public service must be more than doing a job efficiently and honestly. It must be a complete dedication to the people and to the nation with full recognition that every human being is entitled to courtesy and consideration, that constructive criticism is not only to be expected but sought, that smears are not only to be expected but fought, that honor is to be earned but not bought.

Margaret Chase Smith

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The Margaret Chase Smith Essay

Priorities of the U.S. Senate Aging Committee by Susan M. Collins

s a senator representing the state with the oldest median age, I am particularly focused on the well-being of America’s seniors. It has been my privilege to serve on the Senate Aging Committee since my first days in the Senate and an honor to have been elected chairman for the 114th Congress. The committee has three major priorities: investing in biomedical research targeting diseases that disproportionately affect older Americans, such as Alzheimer’s and diabetes; protecting seniors against financial exploitation and scams; and improving retirement security. In my work as chairman of the Congressional Alzheimer’s Caucus, I have learned much about our nation’s most costly disease and the devastating effect it has on more than five million Americans and their families. Although promising research is underway, there currently are no means of prevention, effective treatments, or cure for Alzheimer’s disease. The good news is that the Senate Appropriations Committee, on which I serve, recently approved a 60 percent increase in Alzheimer’s research funding. I am delighted that the Senate is finally recognizing the need for a greater investment in Alzheimer’s research and will work for this funding to be retained in the final version of the appropriations for the National Institutes of Health. A national plan to combat Alzheimer’s and other debilitating conditions must include assistance for the family caregivers on the front lines. The bipartisan RAISE Family Caregivers Act that I have introduced would help us to leverage our resources, promote innovation and promising practices, and MAINE POLICY REVIEW

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provide our nation’s family caregivers with much-needed recognition and support. Investments in biomedical research not only improve the health and longevity of Americans, but also provide ongoing benefits to our economy and the federal budget. For example, nearly one of three Medicare dollars is spent treating people with diabetes, and the incidence and costs of that disease are projected to go up as our population ages. Advancements in the prevention and treatment of diabetes can save lives and help extend the solvency of Medicare. Since I founded the Senate Diabetes Caucus in 1997, funding for diabetes research has more than tripled from $319 million to well over a billion dollars this year. As a consequence, we have seen some encouraging breakthroughs and are on the threshold of a number of new discoveries. The Aging Committee has taken an aggressive approach to fighting fraud and schemes targeting our nation’s seniors. Financial exploitation of older Americans is a growing epidemic that cost seniors an estimated $2.9 billion in 2010. It is very troubling that in as many as 90 percent of these cases, the senior is victimized by someone he or she knows well. Financial abuse of seniors can jeopardize their physical and emotional wellbeing as well as their financial security. Maine is on the cutting edge of helping to combat financial abuse through a program called “Senior$afe,” which is a collaborative effort by Maine, regulators of financial institutions, and legal organizations to help educate bank and credit union employees about how to identify and help stop financial exploitation. Based on that model, I am

exploring possible federal legislation to encourage banks and credit unions to train their employees to spot the signs that a senior may have fallen victim to fraud. In addition, the Aging Committee has established a toll-free fraud hotline at (1-855-303-9470). Increased calls to our hotline this spring enabled us to issue an advisory that warned seniors of phony IRS agents demanding payment for back taxes and penalties that were not owed. As for retirement security, one in four retirees has no source of income beyond Social Security. Nearly six in ten Americans are worried whether they will be able to maintain their standard of living in retirement, and for good reason. There is an estimated $7.7 trillion gap between the savings American households need to maintain their standard of living and what they have actually saved. There are many reasons for the decline in retirement security facing American seniors, including the demise of many defined-benefit pensions in the private sector, the severity of the recent financial crisis, rising health care costs, the need for long-term care, and most of all, the fact that Americans are living far longer than they did in the past. Many Americans reaching retirement age also have more debt than retirees of previous generations. These are all issues that the Aging Committee is exploring in depth. Maine’s demographics present a challenge, but also an opportunity. The role played by America’s small businesses in creating jobs and economic growth is well known, but the role played by America’s seniors may come as a surprise. Individuals between the ages of 55 and 64 make up the largest percentage of 8

THE MARGARET CHASE SMITH ESSAY

new business owners in the United States. In the realm of human capital, these encore entrepreneurs can be a significant asset. Seniors often have advantages that make them excellent entrepreneurs. These include their life experience and real-world education and the networks they have established and maintained throughout their careers. I am committed to helping ensure that our senior entrepreneurs have the resources and support that will help them succeed. Last year, our committee joined with the Small Business and Entrepreneurship Committee to explore this issue. At our hearing, I shared some stories of the many successful encore entrepreneurs in Maine. Whether they turned hobbies into thriving businesses or applied their work experience to new enterprises, they provide financial security for themselves and rewarding jobs for their employees. This June, I invited Maine entrepreneur Susan Nordman to testify at an Aging Committee hearing on work after retirement. She told the committee that the success of her artisan handbag company, Erda, in Dexter, is due in large part to the experience, work ethic, and appreciation for Maine’s manufacturing heritage among her senior employees, who need to work and who also want to stay active, physically and mentally. Since its inception in 1961, the Aging Committee has spurred Congress to action on issues important to older Americans through its hearings, investigations, and reports, and it has a long tradition of bipartisanship. As the baby boom generation becomes a silver tsunami of retirees, this work will be ever more important, and I am grateful to be part of it. -

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Susan M. Collins has represented Maine in the U.S. Senate since 1996. She has earned a national reputation as an effective legislator who works across party lines to seek consensus on important national issues. Sen. Collins chairs the Senate Select Committee on Aging and serves on the Appropriations and Intelligence Committees, as well as the Committee on Health, Education, Labor and Pensions. Known for her Maine work ethic, Sen. Collins has never missed a vote in her years in office—more than 6,000 votes in a row.

DEMOGRAPHIC TRANSFORMATION IN MAINE

The Demographic Transformation in Maine (and Beyond) Is in Full Swing by Lenard W. Kaye

LOOKING BACK OVER 40 YEARS

celebrated my 65th birthday this fall and recently visited the Social Security Administration office in Bangor to enroll in Medicare Part A. These notable firsts in my life were powerful reminders that I have been a gerontological practitioner, educator, and researcher for more than 40 years. Over the past four decades, I have all too often observed varying degrees of negativism, sarcasm, denial, and outright dismissal of the implications of an aging society by professionals and the general public alike. During much of this time, children, youth, and families have proven to be far more attractive points of focus when it came to policy making, program planning, curricular development, and research inquiry. When the phenomenon of growing older and the aging experience was addressed, it was frequently subject to stereotyping, discrimination, and simplistic thinking. Pessimism and a nihilistic mentality clearly predominated. Health and social science researchers (including myself, I’m afraid!) seemed fixated on studying older adults who were either incapacitated or institutionalized, and consequently findings from those studies highlighted vulnerability, illness, decline, loss, and ultimately death. Economists were no different, issuing gloom-and-doom forecasts of governments and communities going bankrupt under the backbreaking burden of needy elders consuming inordinate amounts of health care resources and other costly public benefits. Frequently, the media seemed to fuel the fires of ageism by featuring news stories that showcased growing old as being inevitably accompanied by large measures of unhappiness, failure, and a wide range of other undesirable conditions. Well, I am delighted to report that “the times they are a-changin.” More and more commonly, attention is being directed to a host of positive, successful, and productive aging experiences that affect families, workplaces, and communities for the better. Adults are perceived as carrying with them increasing measures of

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wisdom, expertise, The Numbers Speak and capacity into for Themselves their later years. We are now talking • One million people turn about ways in which 60 years of age every these personal assets month around the world. can be harnessed and • Ten thousand people applied to benefit turn 65 every day in the families, organizaUnited States. tions, and communities. The trend • 50 people celebrate their sixty-fifth birthdays toward early retireevery day in Maine. ment has reversed and older adults are remaining in the workforce longer, no doubt in part out of economic necessity, but also because they are increasingly healthy and active and want to remain engaged in the hustle and bustle of daily life. Labor-force-participation rates of people age 50 and over, which had been declining for much of the twentieth century, since the 1990s have been steadily increasing, and older workers are seen as bringing valuable social and human capital to the employment sector. In forward-thinking companies, elders are serving as role models and teachers for younger employees. THE DEMOGRAPHICS OF LONGEVITY CAN NO LONGER BE PUSHED ASIDE

ne thing is for sure—the aging revolution is in full swing and shows no signs of slowing down. Maine is in the thick of it, well ahead of the demographic curve when compared to virtually every other state and the nation as a whole. We continue to hold the distinction of being the oldest state in the nation based on median age (44.2 years compared to the national median age of 37.7 years) (U.S. Census Bureau 2015) and have the largest proportion of baby boomers (Wright 2010). Our median age is rising faster than any other state, and we have 18 percent more baby boomers per capita than the nation. 10

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We are also the most rural state in the nation (61.3 percent of Maine’s population lives in rural areas having populations less than 2,500), according to an article by Matt Wickenheiser in the Bangor Daily News (March 26, 2012). Rural communities tend to be older ones and those very communities are aging at an accelerated rate primarily due to the out-migration of younger residents, the in-migration of retiring older adults, and the aging in place of long-term adult residents. Maine, having been dealt the highest-ranking rural and age cards in the most recent census, is compelled to address the powerful economic, social, and political consequences of these coexisting realities.

ingly diverse both racially and ethnically, at the same time that they are more educated, mobile, and well informed than their predecessors. You can be sure that their expectations will also be heightened and their voices heard more loudly and clearly than those of their parents and grandparents. They will want to be genuinely engaged in the planning and design of the communities in which they live and the services and programs made available to them. Their heightened engagement needs to be both anticipated and encouraged.

…in general, the baby boomers tend to be in better health and are more educated than the preceding generation.

MAINE’S ELDERS

espite common stereotypes, the large majority of older adults in Maine (76 percent) describe their health to be good, very good, or excellent. These individuals are able to live independently without support from community professionals or caregivers (FIFAS 2012). Older adults today are increasingly mobile, active, and engaged. The numbers of these well elders are increasing as the baby boomer generation ages. Indeed, in general, the baby boomers tend to be in better health and are more educated than the preceding generation. There is additional good news to report. Older adults in rural states such as Maine commonly report higher rates of marriage, more involvement in community activities, more support from local organizations, less fear of crime, less abrupt retirement, and greater feelings of open space. Of course, not all the news is good. Generally, older adults living in rural communities have lower incomes, less education, and high rates of chronic conditions. They are more limited in activity and reside in less adequate housing. They also continue to have less access to a wide range of community and social services including access to long-term care facilities. Transportation continues to be a key obstacle in ensuring that older adults remain mobile, able to get where they need to go, and that service providers are able to reach them. Surprisingly, however, it should not be assumed that older adults in rural states like Maine feel deprived because, in fact, they reflect equal or greater measures of positive affect compared to their urban counterparts. Even though Maine is considered to be one of the least racially diverse states in the nation, it is safe to say that Maine’s older adults of the future will be increas-

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At the same time, there continues to be an urgent call to expand and strengthen the geriatrics health care workforce to serve older residents of the state. The magnitude of inadequate workforce training in serving an aging population and geriatrics personnel shortages in rural states such as Maine, in particular, has grown to enormous proportions. These shortages span a multitude of professions, including medicine, nursing, social work, dentistry, the therapies, the mental health professions, direct care, and more. The Maine Department of Labor projects that these shortages will continue well into the future. Besides skills and training, a well-prepared geriatrics workforce needs to dispense with outdated mentalities about older adults, which are reinforced by negative stereotypes that don’t adequately recognize the abilities and resourcefulness that older adults display even in the face of declining physical and mental health (Kaye 2012). THE CALL FOR THIS SPECIAL ISSUE ON AGING

t has been 12 years since the first special issue on aging of Maine Policy Review was published. Changes in public and private as well as professional and lay perspectives on the aging experience and our response to it in Maine, the nation, and the world compels us to revisit the topics and concerns addressed in 2003. We also need to take stock of where we stand on a number of other critical issues coloring the aging-related policy landscape. 11

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The plot has thickened over the past 12 years, and we are feeling the impacts of the aging of our populace much more broadly and deeply. This special issue consequently needed to cover a more comprehensive set of issues and topics than were addressed in 2003. The discussion must be extended since aging and its implications now reach into all facets of life in the state. One can rather easily argue that no dimension of daily living can escape the ramifications of demographic change— not just the economy, but also education, health, housing, law, transportation, communications, recreation and leisure, community life, and employment, to name just a few. Maine’s story is especially important because the majority of aging-related policy discussion at the national level and elsewhere in the country continues to emphasize the experiences of individuals as they age in metropolitan regions and urban settings. Lost in the shuffle, all too often, are the consequences of population aging in small towns and rural communities. To be sure, aging is on the state’s radar screen. The second annual Maine Summit on Aging was held in Augusta in September 2015 and attracted 500 diverse stakeholders from all corners of the state. Multiple clinical, special-interest, and policy-oriented coalitions and associations dedicated to addressing aging-related issues have been organized in the state in the last five years. Aging research and education across Maine is growing in scope and breadth as are the number of innovative health and human service programs that serve older adults, life-long learning opportunities for older adults, and specialized housing and continuing care retirement communities. Institutions of higher education continue to dedicate increasing attention and resources to addressing the aging phenomenon as well. The University of New England has active research, education, and clinical training programs in geriatrics. The University of Southern Maine’s Muskie School of Public Service provides technical assistance, evaluations, and policy analysis work on topics in aging, long-term care, and disabilities. The University of Maine has launched a major aging initiative fueled by the provost’s announcement that aging research is a designated emerging area of excellence on the campus. Engagement of all University of Maine System campuses in the aging research initiative is now underway. All of these noteworthy events and developments across the state and more are addressed in this issue. The demographic landscape of Maine is destined to continue to evolve in the years ahead. Much discussion MAINE POLICY REVIEW

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and debate will take place in Washington, D.C., as well as in Augusta and cities, towns, and communities throughout the state that consider how best to respond to a rapidly aging population. This special issue was prepared to serve as a much needed comprehensive policy resource to spur informed discussion and decision making as we address the challenges and opportunities of an aging Maine. ACKNOWLEDGMENTS A major debt of thanks is due my good colleague Ann Acheson, research associate and editor of Maine Policy Review, for her unparalleled commitment to quality and attention to detail. Her consummate editorial skills ensured this project was able to remain on schedule and on task. Thanks as well to the many outside expert readers who graciously agreed to review the manuscripts included in this issue.

REFERENCES Federal Interagency Forum on Aging-Related Statistics (FIFAS). 2012. Older Americans 2012: Key Indicators of Well-Being. U.S. Government Printing Office, Washington, DC. Kaye, Lenard W. 2012. “Interviews with Health Workforce Experts: The Boomers Have Arrived: Preparing to Meet the Needs of Our Aging Population.” HWIC Health Workforce News. Health Workforce Information Center, Grand Forks, ND. U.S. Census. 2015. Millennials Outnumber Baby Boomers and Are Far More Diverse. Census Bureau Bureau Reports CB15-113. U.S. Census Bureau, Washington, DC. https://www.census.gov/newsroom/press-releases/2015 /cb15-113.html. Wright, Joshua. 2010. Interactive Map: Maine Has Highest Concentration of Baby Boomers. Economic Modeling Specialists International, Moscow, ID.

Lenard W. Kaye is professor of social work at the University of Maine School of Social Work and founding director of the University of Maine Center on Aging. During the 2014–2015 academic year, he was honored with the University of Maine Trustee Professorship. Prior to coming to UMaine he was a faculty member at Bryn Mawr College’s Graduate School of Social Work & Social Research and assistant director of the Brookdale Institute on Aging & Adult Human Development at Columbia University. 12

ECONOMIC IMPLICATIONS OF MAINE’S CHANGING AGE STRUCTURE

The Economic Implications of Maine’s Changing Age Structure by James Breece, Glenn Mills, and Todd Gabe The authors analyze the major implications of Maine’s aging population on the state’s workforce and economy. They note that there are steps that can be taken to partially mitigate the negative impacts and capitalize on the opportunities associated with an aging population.

INTRODUCTION

aine has the highest median age in the United States, a fact that has drawn the attention of policymakers in Augusta and employers throughout the state. Aging has major implications for the workforce and economy, influencing the supply of workers and demand for goods and services (e.g., health care), but the extent and timing of these impacts are not well understood. The first section of this paper examines the changing age structure of the population and how these changes affect the workforce. The second section focuses on the industries and occupations that will be most affected by aging, as well as the implications for the demand for various types of goods and services. The last section reviews the economic consequences of an aging population projected by other economists, demographers, and social scientists around the world to ascertain common themes, points of consensus, and pertinent policy recommendations that are applicable to Maine. CHANGING AGE STRUCTURE AND WORKFORCE GROWTH

n the United States, life expectancy at birth increased tremendously from an average of 48 years in 1900, to 68 years in 1950, to 79 years today. We often hear that the financial strains on the Social Security and Medicare programs are because people are living far longer in retirement. It is true that longevity has increased, but that is a small part of the increase in life expectancy. Average life expectancy for those who reach age 65 increased from 77 years in 1900, to 79 years in 1950, to 84 years today (NCHS 2014). Between 1900 and 2013,

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rising longevity of elders added just seven of the 31-yeargain in life expectancy at birth. Improvements in the diagnosis and treatment of disease and trauma care, reductions in infant mortality, and other factors played a much larger role in the gains in life expectancy—that is, we have become much better at preventing people from dying before reaching old age. That being the case, it would seem that the median age of the population should be going down, which is what occurred between 1950 and 1970. However, since 1970, the median age in the United States increased faster than any time in our history, rising 9.6 years from 28.1 to 37.7 years between 1970 and 2014.1 This occurred because birth rates plunged after the 1946 to 1964 baby boom to historic lows that prevail today. Baby boomers, who in 2015 range in age from 51 to 69, constitute an unusually high share of the U.S. population. Their advancing age is the major driver of the increase in median age. The Oldest State The median age in Maine was about the same as the nation’s in 1970. Since then, it increased 15.6 years to 44.2 years of age in 2014, which is 6.5 years above the U.S. median. This occurred because the decline in birth rates was much greater in Maine than in the nation as a whole. Compared with the United States as a whole, Maine has a higher proportion of its population in the age groups of 45 and older and a lower proportion in the younger age groups (Figure 1). Nationwide, birth rates are down among all racial groups, but especially among whites who no longer maintain replacement fertility rates. Maine, New Hampshire, Vermont, and West Virginia are the least racially diverse states, 94 or

ECONOMIC IMPLICATIONS OF MAINE’S CHANGING AGE STRUCTURE

Figure 1:

Percentage of Maine and U.S. Population by Age, 2014

2.0

Percentage of Population

1.5

1.0

0.5

U.S. 0

Maine 15

Age

Source: U.S. Census Bureau, Population Estimates, State Characteristics: Vintage 2014. https://www.census.gov/popest/data/state/asrh/2014/index.html

Figure 2:

Maine’s Civilian Labor Force, 1950–2014

750,000

Civilian Labor Force

650,000

550,000

450,000

350,000 1950 1954 1958 1962 1966 1970 1974 1978 1982 1986 1990 1994 1998 2002 2006 2010 2014

Source: Maine Department of Labor, Center for Workforce Research and Information. 2014. Maine Job Outlook 2012–2022. http://www.maine.gov/labor/cwri/outlook.html

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95 percent white; it is no coincidence they are also the four oldest states. Through most of Maine’s history, the workforce grew because the number of young people reaching working age outnumbered those exiting for retirement, disability, or other reasons. The fastest growth on record occurred in the 1970s and 1980s, the period when most baby boomers entered the workforce. 2 Growth slowed in the 1990s, after all the boomers reached their peak years of labor force attachment. Around 2000, baby boomers began to exert downward pressure on the size of the labor force when the oldest of the group began to transition beyond the age of peak labor force participation. (Labor force participation is highest among those 25 to 54 years of age; it is lower for young people and those 55 and over.) The growth of Maine’s labor force continued at a very slow rate until 2006, at which time it essentially stalled. From 2006 to 2013 the workforce was largely unchanged, before beginning to decline in the middle of 2013 (Figure 2). As of 2014, most of Maine’s 370,000 baby boomers were still in the labor force. Two decades from now, the youngest 14

ECONOMIC IMPLICATIONS OF MAINE’S CHANGING AGE STRUCTURE

boomers will be 71 and only a small share will still be working. On the other end of the age spectrum, the population of youths under 19 who will replace them in the workforce totals 259,000. That 111,000 gap is significant in light of the fact that there are fewer than 700,000 in the workforce today. Population Changes According to its most recent forecast, the U.S. Census Bureau estimates that the U.S. population will increase by 38 million people between 2015 and 2030. The number of individuals aged 65 and older is expected to increase by 26 million, which is nearly three times the nine million additional people aged 16 to 64.1 The ratio of working-age people (16 to 64) to seniors is expected to decline from 4.2 in 2015 to 2.8 in 2030. The situation in Maine is far more striking. The Maine Office of Policy and Management (OPM) forecasts the total population will not change significantly through 2025, remaining around 1.3 million people, continuing the flat trend that has prevailed since 2008. After 2025, the OPM expects a slight decline in the total population through 2030.3 Underlying this seeming stability is tremendous change in the age structure. The OPM projects the population aged 65 and older will increase by 101,000 people to a total of 350,000 residents, while the number age 16 to 64 will decline by 98,000 to a total of 755,000 individuals. The workingage-to-senior ratio is expected to decline from an already low 3.4 in 2015 to 2.2 in 2030.

nations of manufactured goods—especially commodity items such as apparel, textiles, and footwear—resulted in declining opportunities in some parts of Maine. The economic development challenge for regions is the constant search for what’s next in light of the changes in technology, trade, purchasing patterns, and demands for amenities. Regions that have not been able to fully replace the previous economic structure with something new are not able to offer the same opportunities to young people as were available to their parents. For large swaths of Maine, this general trend of decline has been taking place over the last several decades. As a result, many young people have responded by moving to areas offering better job opportunities, either in southern Maine or elsewhere. The ratio of working-age people to seniors in Maine is lower than the U.S. average in every county (Table 1). Table 1: Working-Age-to-Senior Ratio*

2015

2030

United States

4.2

2.8

Androscoggin

4.1

2.8

Penobscot

4.0

2.6

Cumberland

3.9

2.4

Kennebec

3.6

2.3

York

3.5

2.0

Maine

3.4

2.2

Differing Population Profiles among Maine’s Regions

Oxford

3.3

2.0

Somerset

3.3

2.0

Historically, population patterns have not been uniform across all regions of the state. Regional economic development has been driven by different factors over time, with subsequent differences in population and labor force patterns. Opportunities in agriculture and forest products industries such as logging and paper mills attracted many people to northern and western Maine in the late 1800s and early 1900s. Around that same time, the rise of apparel and textile mills and shoe shops built many of Maine’s cities, especially in the central region of the state. Like living creatures, industries and companies tend to follow a lifecycle of growth, maturity, and decline. The rise of mechanized harvesting of crops and timber over the last few decades meant that far fewer people were needed per unit of output. Off-shoring of production to lower-wage

Franklin

3.2

2.0

Sagadahoc

3.1

1.8

Waldo

3.1

1.9

Aroostook

2.9

1.9

Hancock

2.8

1.7

Knox

2.7

1.8

Washington

2.6

1.8

Piscataquis

2.4

1.5

Lincoln

2.2

1.3

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*The ratio is derived by dividing population of people age 16 to 64 by that of those 65 and over. Sources: http://www.census.gov/population/projections/data /national/2014.html and http://maine.gov/economist /projections/index.shtml

ECONOMIC IMPLICATIONS OF MAINE’S CHANGING AGE STRUCTURE

Figure 3:

90,000 Population

Employment

60,000

30,000

-30,000

-60,000

forecasts for different age groups with labor force participation rates for those age cohorts (Figure 3). The CWRI expects the rate of participation in the labor force (i.e., the share of the population employed or actively seeking employment) to rise in all age groups, especially those under 35 and over 65 years of age. For younger people, this reflects greater opportunity as the economy strengthens and large numbers of elders retire. For elders, this is influenced by changes in eligi55–64 65+ bility for retirement benefits and an increase in jobs that are not physically demanding, but primarily it reflects the rising share of young seniors in their upper sixties and early seventies. Young seniors have always been more likely to work than those in their upper seventies and beyond. This rise in participation of those aged 65 and older is expected to last for about the next 10 to 15 years, and then turn lower when most baby boomers are in their seventies and eighties. Despite rising participation among all age groups, the overall labor-force-participation rate is expected to continue to decline because of the rising proportion of seniors in the population. The CWRI projects the labor force will decline slightly between 2012 and 2022, though they expect that employment will rise by 15,000 (Table 2). The diverging labor force and employment growth is based on the expectation of declining unemployment from the elevated levels of 2012, when the unemployment rate averaged 7.5 percent and there were more than 52,000 unemployed. At the time of this writing in 2015, the unemployment rate has declined to below 4.5 percent, and there are 22,000 fewer unemployed individuals. Delving deeper into what influenced the recent reduction in unemployment reveals the extent to which aging has already affected Maine’s workforce. About one-third of the reduction in unemployment was due to rising

Maine’s Projected Population and Employment Change by Age Group, 2012 to 2022

16–19

20–24

25–34

35–44

45–54

Source: Maine Department of Labor (2014).

The exodus of young people from northern Maine left behind an older population. All five counties bordering Quebec or New Brunswick, as well as Piscataquis County, have a lower ratio of working-age people than the statewide average. The lone exception in northern Maine is Penobscot County, anchored by Bangor, which has a more diverse economy and is the region’s primary service center. Mid-coast counties from Sagadahoc to Hancock also are among the oldest for a different reason: they attract retirees to some coastal communities. Among the five counties with higher working-ageto-senior ratios than the state as a whole (the younger regions), the common thread is their location along the I-95 corridor and the inclusion in or proximity to a metropolitan area. Forecasts indicate that the workingage-to-senior population ratio will decline in each county as baby boomers advance in age. The OPM projects that the ratio will range from a high of 2.8 in Androscoggin County to a low of 1.3 in Lincoln County by 2030. Future Workforce Growth The Maine Department of Labor’s Center for Workforce Research and Information (CWRI) developed a forecast of the state’s labor force for the period of 2012 to 2022 by combining OPM’s population MAINE POLICY REVIEW

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Table 2:

Age Group

Civilian Noninstitutionalized Population and Labor Force in Maine, 2012 and Projected 2022 Number 2012

Change

2022

Net

Percentage

the demand for health and retirement services and encourage employers to pursue improvements in productivity through automation and more efficient work practices. (See MDOL [2014] for further discussion of workforce trends and projections.) THE SUPPLY-SIDE AND DEMANDSIDE IMPACTS OF AGING

Civilian Noninstitutional Population Total 16+ 1,084,000

1,087,100

3,100

0.3

16-19

73,000

65,400

-7,600

-10

20-24

83,000

82,400

-600

-1

25-34

137,000

144,000

7,000

35-44

162,000

149,000

-13,000

-8

45-54

215,000

165,100

-49,900

-23

55-64

204,000

199,600

-4,400

-2

65+

210,000

281,600

71,600

Civilian Labor Force Total 16+ 16-19

704,000

695,500

-8,500

-1

34,000

34,700

700

20-24

64,000

65,700

1,700

25-34

111,000

122,100

11,100

35-44

137,000

128,200

-8,800

-6

45-54

176,000

137,800

-38,200

-22

55-64

140,000

138,100

-1,900

-1

42,000

68,900

26,900

65+

Employment Total 16+

650,000

665,000

15,000

16-19

26,000

30,300

4,300

20-24

55,000

60,900

5,900

25-34

100,000

117,000

17,000

35-44

130,000

124,000

-6,000

-5

45-54

165,000

133,700

-31,300

-19

55-64

133,000

133,500

500

0.4

40,000

65,600

25,600

65+

Source: Maine Department of Labor (2014).

employment. The other two-thirds of the reduction in unemployment was due to people leaving the labor force, nearly all for retirement. Beyond 2022, employment will be further constrained by Maine’s advancing age structure, which will influence the demand for products and services and the types of jobs that are available. Aging will stimulate MAINE POLICY REVIEW

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aine’s aging population will have significant implications for the economy, with particularly strong impacts not only on the labor market but also on the variety of goods and services purchased. These two types of impacts illustrate the dual roles that people of all ages play in the economy. First, the state’s residents contribute to the demand-side of the market for goods and services, as households make purchases to satisfy needs and desires. And, relevant to the state’s aging population, the goods and services purchased by households change as people grow older. Second, the state’s residents also contribute to the supply-side of the market, as they constitute the workforce employed by businesses. Just as expenditures change as households grow older, the types of jobs held by workers also differ with age. The Impact of Aging on Industry Employment in Maine

The supply-side impacts of an aging population—i.e., how the types of jobs held by workers differ with age—can be observed by looking at the age profile of industry employment in Maine. As shown in Figure 4, there is substantial heterogeneity across industries in terms of the percentages of jobs held by older workers. This fact, combined with the realization that some industries in Maine are expected to grow while others are not, suggests that the impacts of aging will play out in different ways across sectors of the economy. Figure 4 is a bubble chart showing the projected growth of industries in Maine, as well as the shares of workers aged 55 and older. The size of the bubbles indicates the relative number of workers aged 55 and older. For example, the number of older workers is almost seven times higher in manufacturing (15,000 workers) than in the information sector (2,200 workers). Utilities and education/public administration have the highest shares of workers aged 55 and older, about one out of three. At the other end of the age spectrum, only one out of ten workers in the accommodation and food service sector is aged 55 and older. 17

ECONOMIC IMPLICATIONS OF MAINE’S CHANGING AGE STRUCTURE

workers transition into retirement), but the state’s aging population will not increase Education and public administration 35% the demand for goods Utilities Transportation and manufactured here. warehousing This comparison 30% of health care and Manufacturing Healthcare and Professional social assistance services social assistance to 25% the manufacturing Information industry illustrates the point that—even for 20% sectors with similar Finance and insurance Administrative shares of older services 15% workers—there’s no one-size-fits-all impact of aging on 10% Accommodation and food service the Maine workforce. The same thing can 5% be said about the impacts of aging on 0% different occupations -15% -10% -5% 0% 5% 10% 15% (e.g., job titles such as Projected Industry Growth nurses, engineers, or high school teachers) *Bubble size indicates relative number of workers aged 55 and older. within the same Sources: Industry growth figures from MDOL (2014); worker age data from U.S. Census Bureau, industry. Focusing Quarterly Workforce Indicators (http://qwiexplorer.ces.census.gov/). again on health care, we know that this The health care and social assistance sector has the industry has large numbers of workers in two distinct highest projected growth rate between 2012 and 2022, occupational categories: (1) health care practitioners and as well as a large share of workers aged 55 and older. The technician occupations (e.g., dentists, physicians, theraprojected employment growth in this industry is fueled pists, and nurses), and (2) health care support occupain large part by the high demands for health care associtions (e.g., home health aides and nursing assistants). ated with an aging population. Health care and social Employment in both of these occupational groups assistance will also experience a supply-side impact of is expected to increase by about 10 percent between aging as about one out of four workers in the industry 2012 and 2022, consistent with growth projected for is aged 55 and older. In the face of these demand- and the health care and social assistance industry as a whole. supply-side pressures, this sector will require a combinaHealth care practitioners and technician occupations, tion of an influx of new employees and current employees however, have one of the highest shares of older workers, working past traditional retirement age. whereas health care support occupations have a much The situation for manufacturing is very different. younger workforce. This large difference in the share of Although the manufacturing sector also has about one older workers points to different impacts related to an out of four workers aged 55 and older—similar to aging population. Both occupational groups will experihealth care and social assistance—the projected decline ence demand-side pressures due to aging. The high in employment means that this sector will require fewer expected growth combined with an older current worknew workers to replace the current cohort of older force in health care practitioners and technician occupaemployees. In other words, Maine’s manufacturing tions (e.g., dentists and doctors) means that the state sector will experience a supply-side impact (as older will need an influx of new employees, and/or current Figure 4:

Projected Industry Growth in Maine, 2012 to 2022, and Share of Workers Aged 55 and Older*

Share of Industry Workers Aged 55 and Older, 2013

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consumer expenditure data discussed here are for the entire United States and are not specific Compared Compared to Maine, examining this inforAge Age to Age Age to Age mation provides a glimpse of how 55–64 65–74 55–64 75+ 55–64 an aging population might affect Average annual retailers and service providers in expenditures $26,615 $24,609 -$2,006 $21,489 -$5,126 the state. Table 3 shows how per Food at home $2,015 $1,962 -$53 $1,766 -$250 person consumer expenditures Food away from home $1,180 $1,206 $26 $824 -$356 are related to the age of the Alcoholic beverages $221 $211 -$11 $145 -$76 household head. The table focuses on the age cohorts of “65 to 74” Owned dwellings $3,460 $3,196 -$264 $2,646 -$813 and “75 and older,” with comparRented dwellings $922 $760 -$162 $1,433 $510 isons to households headed by someone aged “55 to 64.” For Other lodging $500 $471 -$29 $223 -$277 ease of interpretation, the expenUtilities, fuels, and diture categories with annual per public services $1,969 $2,013 $44 $1,889 -$80 person differences (either higher Household operations $492 $518 $26 $648 $156 or lower) of $200 or more relaHousekeeping supplies $336 $423 $86 $333 -$4 tive to the benchmark age cohort (of households headed by Household furnishings and equipment $862 $852 -$11 $526 -$337 someone aged 55 to 64) are shaded in the table. Apparel and services $744 $643 -$101 $480 -$264 We see that households in the oldest two cohorts have Transportation $4,515 $4,196 -$319 $3,218 -$1,297 substantially higher expenditures Health care $2,085 $2,731 $646 $3,069 $984 on health care than their younger Entertainment $1,262 $1,309 $47 $889 -$374 counterparts. The oldest cohort Personal care prodspends over $3,000 per person on ucts and services $304 $326 $22 $307 $3 health care, which is about 15 Reading $63 $77 $14 $79 $17 percent of annual expenditures. For the cohort of households Education $591 $184 -$407 $175 -$416 headed by someone aged 65 to 74, Tobacco products and per person expenditures on health smoking supplies $209 $136 -$73 $56 -$153 care are over 11 percent of annual Source: U.S. Bureau of Labor Statistics (2015) expenditures. By comparison, and this figure is not shown in the table, households headed by workers will need to remain in their jobs longer. On the individuals under 25 years of age devote about 3 percent other hand, although the state is expected to experience of their annual expenditures to health care. an increase in demand for health care support workers, The consumer expenditure figures also point to a these occupations will be less affected by the retirement change in the living arrangements associated with age. of current workers. The data reveal a sharp decline in expenditures on owned dwellings, corresponding with an increase in The Impact of Aging on Household Purchases expenditures on rentals in the oldest cohort. These Another important trend related to Maine’s aging results are consistent with the behavior of older adults population pertains to changes in the types of goods moving into senior and rental housing communities, or and services demanded by households. Although the to some form of assisted living. This trend will have Table 3:

Per Person Consumer Expenditures of Older U.S. Households, 2013

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important implications for Maine’s housing market— both in terms of the demand for senior-appropriate rentals and the potential increased supply of single-family homes as older households transition into these rentals. Other noteworthy trends in consumer expenditures associated with aging are the reductions in spending by the oldest age cohort on apparel and services, household furnishings and equipment, transportation, education, and even groceries (i.e., food at home). The data provide a clear indication that the oldest households reduce their spending compared to peak expenditure years (i.e., 55 to 64) in a variety of categories. These trends—along with others such as older households changing where they shop or purchasing different goods within the same broad expenditure category—will affect businesses ranging from grocery stores and clothiers to automobile and furniture dealers. THE MACRO VIEW

aine is not alone with a changing age structure. A National Bureau of Economic Research (NBER) report (Bloom, Canning, and Fink 2011) using data and projections from the United Nations, shows that nearly all countries in the world will experience aging of their populations, with drastic effects by 2050.4 Countries such as Japan, Germany, and South Korea have elder populations that are outpacing those in Maine. Economists, demographers, and other social scientists around the world have investigated, modeled, and projected the economic consequences of an aging population. There are common themes and points of consensus that are applicable to Maine, along with pertinent policy recommendations.

Economic Implications The changing age structure experienced to date is mild compared to the looming predictions of the future, making the work of gauging the impending economic and social consequences more difficult. Nevertheless, there are some predictions that many researchers agree upon. Specifically, there will be significant labor and skill shortages; decreases in labor productivity; sectorial shifts driven by changes in supply and demand factors; and falling savings rates and increasing interest rates with corresponding changes in asset prices. When combined, these outcomes will contribute to slower economic growth, as already experienced in Japan and here in Maine. MAINE POLICY REVIEW

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In the United States, public spending for Medicare, Social Security, and Medicaid long-term care is expected to grow from 6.8 percent of GDP in 2000 to over 13 percent in 2050 (Wiener and Tilly 2002). Of course, these percentages depend on underlying growth in health care expenditures and the expansion of the overall economy. Nonetheless, this expected expenditure shift will place pressure on federal and state policymakers to set priorities on government spending and taxation. Maine elders will react to the changing economic conditions they face and in so doing may cause consequences for others. For example, to minimize their financial portfolio risks, elders will be shifting their portfolios from equity to fixed-income annuities as they draw down their savings. This will directly affect stock prices and interest rates in national markets. At the same time, they will be downsizing their homes and moving into apartments that are closer to medical providers. Rural single-family home prices may fall (helping first time homebuyers) while urban apartment rents may rise (hindering young apartment seekers). Behavioral Changes The economic projections and consequences of an aging population may not be as adverse as they first appear, namely, because the projections are static and do not take into account behavioral changes as people adapt to the situation. Several potential behavioral changes may mitigate the consequences of an aging population (Bloom, Canning, and Fink 2011), including the following:

• As people age, if they remain in good health, they may opt to work longer—hence partially offsetting labor shortages. • If people work longer, they will be able to sustain a higher standard of living, contributing to the economy. • Labor force participation of aging women may increase and add to the overall workforce and improve productivity. • An increase in human capital (e.g., formal education and training) either directly or by funding others will further increase productivity. Older adults may opt to go back to school or help others to obtain more education.

ECONOMIC IMPLICATIONS OF MAINE’S CHANGING AGE STRUCTURE

• Businesses, in reaction to labor shortages, may amend their practices and encourage older workers to remain employed by offering a more convenient and supportive work environment. • Firms may respond by using more capital-intensive production practices to increase productivity. • Shifts in migration patterns, both regionally and internationally, may occur to offset labor market gaps in some regions. The combined impact of these behavioral changes can be significant. Maine people and business are likely to change their behavior in response to needs, circumstances, and incentives. Policy Recommendations McKinsey & Company wrote a short report making several recommendations to help Japan face the economic strains caused by their rapidly aging population (Adachi, Ishide, and Oka 2015). Other reports and writings have made additional recommendations, many of which directly apply to Maine’s situation. Below are five reoccurring recommendations that are viable for Maine. First, recognize that not all elders will age in a similar fashion—some will remain healthy and active while others will develop health problems and become less mobile. Healthy elders may be able to continue working beyond the traditional retirement age. This will require adjustments to the labor market and enterprises’ handling of the expectations of older workers. Elders need a supportive and nurturing work environment. For example, elders often have physical limitations, may not want or be able to work full time, and may desire new careers. Second, elders can share their knowledge and experiences with younger workers to enhance human capital and overall labor productivity. This sharing and engagement occurs in the workplace and through volunteer activities. Of course, volunteerism also adds directly to the social wellbeing of society. Avenues for engagement and volunteerism must be established and supported. (Crittenden and DeAndrade [2015] have a discussion of senior leadership and engagement programs currently underway in Maine.) Third, policymakers and businesses should recognize that elders understand elders. Some healthy, active elders may focus their energy towards helping others in need in a thoughtful, understanding, and compassionate way. One example suggested in the article by MAINE POLICY REVIEW

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Adachi, Ishide, and Oka (2015) is to have able-bodied elders provide nursing care for dependent elders. This directly fills a workforce need and contributes to the economy. Active elders could also help develop new products and services desired by other elders. Fourth, to help able-bodied elders work beyond the traditional retirement age, new mechanisms, technology, and networks should be created to widen the flow of information to connect with potential employers and locate jobs that fit the elders’ skills and situations. Current federal, state, and private senior employment services must be enhanced and expanded. Employers and elders must have access to these services and become comfortable using them. Last, engaged elders who want to stay in place and continue working will require support networks that enable them to remain active and productive. They will need assistance in transportation; access to rural health providers and financial advisors; help with home maintenance and shopping for necessities; the establishment of social networks and entertainment (online and in-person); and functional telecommunications designed for the future digital world. (See Boober [2015] for discussion of aging in place in Maine, and Oh [2015] for discussion of the age-friendly community movement in Maine.) Unfortunately, encouraging able-bodied elders to continue working will not fully offset the projected labor market gaps in Maine. Therefore, it is imperative to enhance the labor market in other ways so that more workers are available and equipped with the skills required for Maine’s future economy. Widely articulated recommendations include making higher education more accessible; attracting others (of all ages and residencies) to move to Maine to live and work; creating incentives for higher rates of fertility; and establishing a virtual labor force through technology (as the health care industry does with telemedicine). CONCLUSION

aine is facing serious challenges associated with an aging population. If nothing changes, the working-age-to-senior ratio will fall by one-third and significant labor shortages will develop. The composition of the economy will also change. Collectively, these outcomes could stymie growth, placing financial pressures on state and local budgets. But behavioral change that could mitigate some of these consequences 21

ECONOMIC IMPLICATIONS OF MAINE’S CHANGING AGE STRUCTURE

is possible. With vision, leadership, and determination, new avenues for using elders in the labor market and establishing new products and services may produce positive results. But Maine must also find alternative ways not dependent on elders to expand the labor force and increase labor productivity. ENDNOTES 1. These figures come from the U.S. Census Bureau’s 2014 National Population Projections. (http://www.census. gov/population/projections/data/national/2014.html) and U.S. Bureau of the Census (1973). 2. Much of the information in this section, unless otherwise noted, is based on data and calculations from the Maine Department of Labor, Center for Workforce Research and Information (CWRI). 3. Data are from the Maine Office Policy and Management’s website: http://maine.gov/economist/ projections/index.shtml 4. Projections indicate that nearly two billion people worldwide will be over the age of 60 by 2050, representing 22 percent of the world’s population. This age cohort will grow from 20 percent to 30 percent of the population in developed countries, and from 10 percent to 20 percent of the population in less-developed nations.

REFERENCES Adachi, Misato, Ryo Ishide, and Genki Oka. 2015. “Japan: Lessons from a Hyperaging Society.” McKinsey Quarterly (March). http://www.mckinsey.com/insights /asia-pacific/japan_lessons_from_a_hyperaging_society Bloom, David, David Canning, and Gunther Fink. 2011. Implications of Population Aging for Economic Growth. NBER Working Paper 16705, National Bureau of Economic Research, Cambridge, MA. http://www.nber.org/papers/w16705 Boober, Becky Hayes. 2015. “Keep Them Rocking at Home: Thriving in Place.” Maine Policy Review 24(2): 111–112. Crittenden, Jennifer A., and Lelia DeAndrade. 2015. “Never Too Old to Lead: Activating Leadership among Maine’s Older Adults.” Maine Policy Review 24(2): 80–85. Maine Department of Labor (MDOL). 2014. Maine Workforce Outlook, 2012 to 2022. MDOL, Center for Workforce Research and Information, Augusta. http://www.maine.gov/labor/cwri/publications/pdf /Maine_Workforce_Outlook_2012_to_2022.pdf National Center for Health Statistics (NCHS). 2014. Table 18. Life Expectancy at Birth, at Age 65, and at Age 75, by Sex, Race, and Hispanic Origin: United States, Selected Years 1900–2011. http://www.cdc.gov/nchs/hus/contents2013.htm#018

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Oh, Patricia. 2015. “The Age-Friendly Community Movement in Maine.” Maine Policy Review 24(2): 56–59. U.S. Bureau of the Census. 1973. Census of Population: 1970, Vol. 1, Characteristics of the Population, Part 21, Maine. U.S. Government Printing Office, Washington, DC. http://www2.census.gov/prod2/decennial /documents/1970a_me-01.pdf U.S. Bureau of Labor Statistics. 2015. Consumer Expenditures in 2013. BLS Report 1053. http://www.bls.gov/cex/csxann13.pdf Wiener, Joshua, and Jane Tilly. 2002. “Population Ageing and the United States of America: Implications for Public Programmes.” International Journal of Epidemiology 31(4): 776–781.

James Breece joined the economics faculty at the University of Maine in 1983. His specialties are in macroeconomics, international finance, economic modeling, and forecasting. He monitors and forecasts the Maine economy and is a member of the Maine Revenue Forecasting Committee.

Glenn Mills is the chief economist in the Maine Department of Labor’s Center for Workforce Research, which collects workforce data on employment, unemployment, and wages. He develops workforce forecasts, provides staff support to the Consensus Economic Forecasting Commission, and works with a wide range of customers to provide context to the dynamics of the economy in light of often-contradictory indicators. Todd Gabe is a professor of economics at the University of Maine. He teaches courses related to state and local economic development and conducts research on the knowledge and creative economies.

VIEW FROM AUGUSTA

The View from Augusta: Developments Growing Out of the Speaker’s 2013 Round Table Discussions and 2014 Aging Summit by Mark Eves and Jessica Maurer Mark Eves and Jessica Maurer describe the significant progress made since 2013 in addressing aging-related issues through collaboration between legislative and community-based efforts. The Maine Aging Initiative, formed in 2014 and coordinated through the Maine Council on Aging and the House Speaker’s office, plays a significant role in supporting these efforts.

ver the next few decades, the United States will experience a considerable growth in its older population. The aging of the baby boomers, who began turning 65 in 2011, is largely responsible for this dramatic increase in the population aged 65 and older (Ortman, Velkoff, and Hogan 2014). With the oldest population in the nation, Maine is at the epicenter of this demographic shift. We have the highest concentration of baby boomers per capita. One in four Mainers will be over the age of 65 in the next two decades (Fralich et al. 2012). Adding to the challenge of an aging population, Maine has the nation’s third lowest number of working-age adults (age 20–64) per 100 persons age 65 and above (Fralich et al. 2012). Maine also has a low rate of in-migration. Without a significant infusion of working-age adults, the state’s employment needs are expected to continue to grow. This demographic shift has huge implications for our economy and our state. The aging challenges we face are significant—and will have an impact on all of us. Whether you are among the aging population struggling to stay in your home, a family member balancing work with caring for an aging parent, or an employer with a retiring workforce, you are one of the Mainers who are directly affected by these demographics. Though the policy, economic, and social implications are large, we cannot allow Maine to become paralyzed as we cope with the demographic shift in population and the impact that it will inevitably have on our people and local communities. Mainers must

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work together to address this change head on and proactively. Along with the clear challenges there is great opportunity as science, medicine, and technology allow Mainers to live longer, healthier lives and provide all of us with the opportunity to benefit from the wisdom and experience of our older neighbors. Older Mainers are an asset, not a problem, and keeping them healthy and active in our communities will enrich us all. If we act now, we can ensure that our seniors have an opportunity to age independently and with dignity. We can support employers as they prepare for a retiring workforce. We can prepare local communities for the changes that will inevitably occur as they adapt to meet the needs of older citizens. Success will require coordination of efforts at the legislative level to change statewide policy and at the community level to implement concrete and innovative solutions. The good news is that since we focused our efforts in 2013 we have already had success in sparking significant interest in addressing this important policy imperative, which has led to passing needed legislation at the state level and the expansion of community efforts to support seniors and build more age-friendly communities. In fall of 2013, the Maine Council on Aging and Speaker of the Maine House [and co-author of this article] Mark Eves convened the Speaker’s Round Table on Aging and in January 2014 hosted the first Maine Summit on Aging. The response was overwhelming and underscores that Maine leaders understand we must rise up to face these challenges and embrace the opportunities. These two events brought together more than 500

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leaders from business, higher education, health care, finance, philanthropy, and state and local government to map out a community-based approach to turning the challenges of Maine’s aging population into an opportunity that will benefit all Mainers. Participants learned about our aging demographic, considered its implications, and shared ideas about innovative solutions and potential opportunities on both the local and state level. During the discussions, it became clear that a broad cross-section of individuals—including Maine employers, health and education professionals, and municipal and state leaders—will need to work together to develop and implement innovative ways to attract and retain workers, create housing and transportation options for older adults, and deliver supports and services to keep people healthy and thriving in their homes. The Speaker’s Round Table and the Aging Summit generated a series of community-based and legislative recommendations, which are compiled in the Blueprint for Action on Aging. Following the Summit, the Maine Aging Initiative was formed. The Aging Initiative, coordinated through the Maine Council on Aging and the Speaker’s office, supports the formation and implementation of community based initiatives and the work of the legislature’s Caucus on Aging.

The Speaker’s Round Table and the Aging Summit generated a series of community-based and legislative recommendations, which are compiled in the Blueprint for Action on Aging. COMMUNITY-BASED INITIATIVES

rom the beginning, we knew that local community work would be essential for the success of this initiative. As a result of the round table discussions and the summit, approximately 100 participants and other engaged people started working in one of five workgroups: higher education, workforce and employment, health and wellness, public and private safety,

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and aging-friendly communities. The groups meet monthly to develop and implement community-based solutions targeted to those critical areas. Along with key members of the Maine Council on Aging, workgroup leaders and participants include representatives from local credit unions and banks, the business community, the university and community college systems, and law enforcement. These groups are charged with driving the implementation of innovative strategies and solutions to build aging-friendly communities with a focus on new models of housing; to support older workers and family caregivers in the workforce; to protect older people from abuse and exploitation; to coordinate health and homebased care; and to support efforts to coordinate and expand aging-related research to build new technology to help older adults age safely at home. The broad range of expertise and experience within the workgroups provides opportunity to accurately assess each initiative from multiple perspectives, increasing the likelihood of success for each activity. The workgroups have completed their first full year of work. Each workgroup has used this initial period to gather information about the work that is already happening statewide. It is critical to the overall success of the initiative (1) to ensure that community-level efforts are not being duplicated; (2) to identify best practices that can be replicated in other parts of Maine; and (3) to coordinate to the greatest extent possible the work of various groups throughout the state. As conveners of the workgroups, the Maine Council on Aging, in coordination with the Speaker’s office, is currently compiling a report highlighting the work completed in the first year. This report was made available at the Second Summit on Aging held on September 15, 2015, in Augusta. Here are just a few highlights of work completed by the workgroups over the last year: • The Aging-Friendly Communities Workgroup developed two white papers for towns and local leaders. The first white paper focused on concrete recommendations for towns to improve opportunities to help seniors live independently including changing zoning to promote accessory or “in-law” apartments. The second paper offered local leaders detailed information about the return on investments for communities that formally assess and plan to meet the needs of older adults.

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• The Public and Private Safety Workgroup successfully recruited 20 weekly papers throughout Maine to begin publishing a “tip of the week” to alert older residents to ongoing frauds and scams. • The Higher Education Workgroup has compiled data about research related to aging being conducted in all institutions in Maine and has begun to coordinate these efforts statewide to enhance and expand this work (see Hecker and Gugliucci 2015). Members of the workgroups have unanimously agreed that this effort must continue, and they are all committed to participating for another 12 months. Most of the workgroups have honed their focus, and we expect that they will spend the next year implementing more important and innovative changes on the local level. Perhaps the best gauge of the success of the initiative is the substantial support it has engendered in local communities. Hundreds of people have taken action in their own cities and towns to address the needs of older adults. They have joined aging-friendly community initiatives and talked with their municipal officials about addressing the needs of seniors more directly. Several have initiated increased education and training in work environments on age-related issues. Many communities around Maine have held forums to talk about aging in their towns. LEGISLATIVE ACTIVITY

olicy work is often most effectively and efficiently implemented at the state level. Through our work in the legislature, we quickly discovered that the issue of aging is not a partisan issue and that legislators from both rural and more populated parts of Maine are eager to help their older constituents to lead the best lives possible. Members of the legislature are all either directly affected by this challenge or have constituents who are. People from both sides of the aisle are interested in finding concrete solutions to support seniors and address the changing demographic we face as a state. As the session unfolded, we found that, even in a divided legislature where the Democrats control the House and the Republicans control the Senate, this issue gave us an opportunity to work together to make positive change. In January 2015, immediately upon convening the first session of the 127th legislature, legislators from

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both parties formed the first-in-the-nation Legislative Caucus on Aging led by the Speaker and State Senator David Burns (R-Whiting). The caucus included more than 50 members from both parties, met frequently over the session, and tracked 28 specific aging-related bills as they moved through the legislature. The Caucus on Aging gave legislators from across the spectrum a forum to strategize and chart a course for improving the lives of Maine seniors and for jump-starting a Maine economy that will be called upon to meet the needs of our older neighbors. We heard from members who participated and invested their time in these meetings that they found the work of the caucus valuable and are now better equipped to go back to their home districts and make their local communities more age-friendly.

Through our work in the legislature, we quickly discovered that aging is not a partisan issue…. In addition to the overall success of the caucus, there are some key areas of focus where the legislature was able to make some significant strides in its effort to support seniors. Through his KeepME Home Initiative, the Speaker spearheaded the legislative effort to help older Mainers to age in place. This initiative included legislation to direct state resources to help older Mainers to live independently in their homes and communities by investing in the development of affordable senior housing, increasing property tax relief for seniors, and boosting pay for direct care workers who provide care to seniors in their homes. Each of these efforts is detailed in this article. The KeepME Home Initiative was part of a broader policy agenda in the legislature. In addition to successfully passing components of the KeepME Home Initiative, the legislature passed legislation to fund critical programs such as Alzheimer’s respite care and Meals on Wheels, to protect seniors from financial exploitation, to support family caregivers, and to increase MaineCare reimbursement for assisted-living facilities and nursing homes. We see this as just the beginning of an effort to address one of the most important policy imperatives 25

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for this state. There is still much work to be done, but we are pleased to report that this session the legislature rose to the challenge and passed bipartisan reforms that will begin to address some of the significant challenges facing the future of Maine. Build More Affordable Housing for Seniors

There is a growing need for affordable housing for seniors. Maine’s housing stock is among the oldest in the country and is poorly matched with the needs of seniors. It is often unaffordable, inaccessible, energy inefficient, and too remote from the services and resources older adults need to thrive in their communities. It is expensive to maintain and in some cases even unsafe. A recent report by the independent national research firm Abt Associates estimates that Maine has a shortage of nearly 9,000 affordable rental homes for low-income older Mainers and that this shortfall will grow to more to than 15,000 by 2022 unless we take immediate action to address the fundamental mismatch between our housing supply and housing needs of older Mainers (Henry et al. 2015).

Helping seniors to access personal support services is a wise investment for the state. As part of his KeepME Home initiative, the Speaker proposed a major investment in Maine’s infrastructure through an innovative senior housing bond. This $65 million general obligation bond would be used in combination with a mix of private and public resources to create 1,000 highly energy-efficient homes for Maine’s seniors in locations that will enable them to successfully and affordably age in their home communities. The Speaker worked in partnership with Senator Burns and a broad coalition of stakeholders including Associated General Contractors of Maine and the Maine Affordable Housing Coalition to educate the legislature and the public about the growing need for affordable senior housing. After extensive negotiation, the legislature approved a $15 million bond measure which was approved by voters in November, 2015. This important investment is expected to fund up to 225 housing units MAINE POLICY REVIEW

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of energy-efficient affordable housing for seniors. Preference will be given to projects that are built in or near service centers or downtown areas where health care or other essential goods and services are located. At least four of these projects will be in counties with fewer than 100,000 people, ensuring that seniors in more rural areas will be among those who benefit from this effort. These projects will allow seniors to move out of old homes that they can no longer afford, are too big for their needs, and/or are falling down around them, while still being able to stay in their own communities. They will be able to continue to go to the same coffee shop, to see the same health care provider, and to stay connected to the people they know. We know that this is what older Mainers want and deserve. While 225 units will meet the needs of only a small number of the Maine elders who need appropriate and affordable housing, it is a huge step forward. We made this significant progress because we listened to Maine people, understood and analyzed the problem, and took the time to educate legislative members and the public about the need for this critical investment. We are hopeful that the bond will be passed by the voters and that we will soon see additional suitable and affordable units available for seniors. Strengthen the Direct Care Workforce The Speaker also introduced legislation to boost hourly rates for the direct care workers who care for seniors in their homes as they age. The personal support services provided by these workers are critical to helping Maine seniors maintain independence. Helping seniors to access personal support services is a wise investment for the state. Providing these services in people’s homes helps prevent unnecessary emergency department visits, hospitalizations, and institutionalization in nursing facilities. MaineCare, the state’s Medicaid program, spent an average of $558 per month for each client who received personal care services at home in 2010, compared with $4,150 per month for each nursing home resident during the same year (Fralich 2012). Unfortunately, MaineCare reimbursement for direct care workers has remained stagnant for more than a decade at $15 per hour, with most direct care workers receiving only $9 to $10 per hour for the services that they provide (see Butler 2015 for a further discussion of this issue). Due to low wages and few advancement opportunities, home care agencies are struggling to recruit and maintain a qualified workforce that can meet 26

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the current demand. With demand for services growing by leaps and bounds, agencies currently have long wait lists. For example, in a Portland Press Herald article (May 18, 2015) highlighting the Speaker’s legislation, the executive director of SeniorsPlus, a Lewiston-based agency that coordinates home care statewide, reported she was seeking workers to provide home care services for 471 clients on a wait list. Through efforts by the Speaker, Representative Espling, other legislators, direct care agencies, and advocates, a small increase in reimbursement rates for direct care workers was funded in the biennial budget passed by the legislature this session. The state budget approved by the Appropriations Committee and supported overwhelmingly by over two-thirds of the legislature made an investment of $4 million over two years to increase the reimbursement for direct care workers for the first time in more than a decade. As with the housing bond, we see this investment as a start. We need to do more to raise wages and benefits for direct care workers to ensure that agencies are able to recruit a strong workforce and do not lose potential workers to other low-wage industries like fast food restaurants or Walmart. These workers are the backbone of the home care industry and Maine cannot provide the quantity or quality of home-based care that our seniors deserve unless we can attract and maintain a workforce that is well trained and fairly compensated for the difficult job they are called to do. Unfortunately, we have already received clear indications that this increase was not enough. Shortly after the budget passed in the legislature, an agency in Westbrook that served seniors closed its doors, leaving its clients without services essential to maintain their independence and stay in their homes. Along with increasing wages, we need to expand advancement opportunities for people who enter the health care field as direct care workers. Providing support services for seniors in their homes can be rewarding but grueling work. Many enter the industry because they want to care for and help seniors. However, many are either leaving the field or deterred from entering at all because of low wages and the lack of opportunity for career advancement. There is no structure in place to support direct care workers’ use of their experiences and expertise to upgrade their skills to become registered nurses or nurse practitioners. If young adults leaving high school could see potential for advancement, it is much more likely that people would MAINE POLICY REVIEW

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choose to enter the field, even if it meant that they were not making high wages to start. We were pleased that we were able to provide a small bump in reimbursement rates for direct care agencies, but there is a lot more work to be done to avert a crisis. Agencies are on the edge and public policy needs to support and prioritize the recruitment and retention of direct care workers to ensure that we have the qualified workforce to support seniors to stay in their homes as they age. Unless we take further action to invest in the direct care workforce, there is no doubt the state of Maine will face a caregiving crisis that could jeopardize the quality of life for Maine seniors who need support with daily activities.

Along with increasing wages, we need to expand advancement opportunities for people who enter the health care field as direct care workers. Property Tax Relief The third component of the KeepME Home Initiative proposed improving the property tax fairness credit to better target property tax relief to low- and moderate-income seniors. Seniors on fixed incomes are often unable to afford the high cost of property taxes. All legislators report meeting with seniors in their districts who live on fixed incomes and hearing about their struggles to pay their property taxes. In the new budget this past session, the legislature successfully implemented property tax relief for seniors by doubling the annual homestead exemption from $10,000 to $20,000 for all Maine householders. Unfortunately, the legislature was not successful in passing specific legislation to provide targeted relief for seniors through the Property Tax Fairness Credit. As with other aspects of the KeepME Home Initiative, the work must continue. Future legislatures must seriously consider improving the Property Tax Fairness Program to make it more effective. We know that seniors want to age in their communities and these property tax fairness programs are critical to achieving that goal. 27

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CONCLUSION

ll of these efforts are crucial to the future of Maine. If we are successful in improving Mainers’ ability to live longer and healthier lives, and more independently, we will achieve multigenerational success that will benefit all Mainers. Failure is not an option. The connection between local community response and state public policy has been key to our success. The partnerships that have formed through the Maine Aging Initiative will ensure that this important work will continue. We have had some important early successes, but in many respects, we have just started to lay the groundwork for the future. Thanks to the great work of so many at the community level, in the legislature, and in our media, the public is much more aware of the challenges and the opportunities we face as the oldest state in the nation. We truly are leaders in this effort as we bring together unlikely partners to work on community-based solutions and we break through partisan politics to promote policies that will help seniors to live independently in their homes and their communities. This work will continue, and we look forward to the next stage of this important initiative. -

Mark Eves of North Berwick is serving his second term as Speaker of the Maine House and his fourth term in the legislature. He has dedicated his time in the legislature and his professional career to improving the lives of children, seniors, veterans, and working families. Jessica Maurer is executive director of the Maine Association of Area Agencies on Aging. She serves on the Maine Council on Aging; co-authored the 2012-2016 Maine State Plan on Aging; and is leading the Maine Aging Initiative and the Tri-State Learning Collaborative. A licensed Maine attorney, she worked for nearly 17 years in the Maine Office of the Attorney General.

REFERENCES Butler, Sandra. 2015. “Home Care in Maine: The Worker’s Experience.” Maine Policy Review 24(2): 113–114. Fralich, Julie, Stuart Bratesman, Louise Olsen, Cathy McGuire, Tina Gressani, Jasper Ziller, Karen Mauney, Cynthia Shaw, and Catherine Gunn. 2012. Older Adults and Adults with Disabilities: Population and Service Use Trends in Maine, 2012 Edition. University of Southern Maine, Muskie School of Public Service, Portland, ME. Hecker, Jeffrey E. and Marilyn R. Gugliucci. 2015. “A Call to Action: Maine’s Colleges and Universities Respond to an Aging Population.” Maine Policy Review 24(2): 36–41. Henry, Megan, Carissa Climaco, Rebecca Cohen, and Gabe Schwartz. 2015. A Profile of Maine’s Older Population and Housing Stock. Prepared for Maine Affordable Housing Coalition. Abt Associates, Cambridge, MA. Ortman, Jennifer, Victoria A. Velkoff, and Howard Hogan. 2014. The Aging Nation: The Older Population in the United States. U.S. Census Bureau, Washington DC.

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TECHNOLOGY AND AGING R&D

Technology and Aging: An Emerging Research and Development Sector in Maine by Carol H. Kim, David Neivandt, Lenard W. Kaye, and Jennifer A. Crittenden The authors discuss the importance of research for developing products and services that cater to the needs of a rapidly growing aging population and provide examples of projects underway at the University of Maine. Products designed to improve and protect older adult health and well-being represent a significant opportunity for economic growth in Maine.

t is often assumed that the aging of Maine will have a negative impact on economic and innovation prospects. However, Maine’s older-adult demographic provides a critical opportunity for developing products and services that can cater to the needs of a rapidly growing aging population nationally and globally. Older adults are already incorporating innovative products and devices in their daily lives, making them a prime audience for the next generation of new and emerging technologies. In 2013, 59 percent of adults 65 and older used the Internet and 77 percent used a cell phone to communicate with family, friends, and providers. Older adults are also the fastest-growing age group of users of social networking sites (Pew Research Center 2014). As a state, Maine is no stranger to the use of technology to support older adults and deliver health care services. For example, telehealth is already used extensively throughout the state to serve patients of all ages and provide access to specialty care in rural areas. Other technology trends can be expected to take increasing hold in Maine as broadband (high-speed Internet access) reaches more communities, businesses, and individuals around the state. This includes the use of smarthome technology to provide remote monitoring of loved ones; the increasing use of wearable technology that will allow older adults and caregivers to monitor vital signs, sleep, and physical activity; the use of personal emergency-response systems allowing an individual to reach emergency assistance when needed; and medication-adherence technologies that remind an individual to take medication or that provide medication monitoring for a caregiver. Internet sites and apps are

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also creating opportunities for rural older adults to connect with others elsewhere in the country, whether they are grandparents who want to stay in touch with their grandchildren or individuals looking to interact with others for support across the country.1 In this respect, Maine’s rural nature provides ripe opportunities for using technology to reduce social isolation and deliver the best care and support possible at a reduced cost. AARP has identified nine focal points of health innovation that represent areas poised to experience rapid expansion and tap into the $7.1 trillion longevity economy. Such technologies, encompassing products and services used for and by adults over the age of 50, represent a five-year revenue potential of approximately $30 billion nationally (AARP 2014). These technologies are segmented into the following categories of innovation: • Medication management—Technologies for tracking and managing medication adherence • Aging with vitality—Maintaining health and well-being through preventive interventions that preserve hearing, sight, and cognition. • Vital-sign monitoring—Technologies often including features for tracking, recording, and sharing vital-sign information with designated caregivers and health care providers • Care navigation—Products designed to put older adults and caregivers in the driver’s seat of their care. These technologies include features such as tracking care expenses, appointments, 29

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and connecting with health and social service providers. • Emergency detection and response—Technologies that allow for remote monitoring of a loved one, fall detection, and personal emergency-response devices that allow individuals to quickly connect with emergency support when needed. • Physical fitness—Applications, devices, technologies, and approaches for maintaining and boosting physical fitness. • Social engagement—Technologies that allow users to stay engaged with others as they age including web-connected applications, devices, and websites that provide outlets for connecting and engaging. • Diet and nutrition—Innovations include solutions that allow individuals to track food intake, monitor personal nutrition, learn more about nutrition, and prepare meals. • Behavioral and emotional health—Solutions encompass products and services that boost behavioral and emotional health through support groups, self-help options, and education.

A key ingredient for developing technologies for healthy aging is the cross-fertilization of ideas to address the wants and needs of the 50+ market. The AARP innovations model is an apt framework through which to view new and emerging technologies in aging, as these areas of innovation lend themselves particularly well to interdisciplinary and interprofessional research and discovery through a variety of methodologies. From psychology to computer science, nutrition, engineering, biomedical science, and even the arts and humanities, these nine areas of innovation invite researchers to develop technologies for aging in place that appeal to a wide range of target audiences MAINE POLICY REVIEW

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using unique approaches. For example, an innovation within the behavioral and emotional health area could marry well-established approaches from the field of psychology with platforms readily available within computer science and new media to create interactive apps for boosting emotional health. DEVELOPMENT OF TECHNOLOGIES FOR AGING AT THE UNIVERSITY OF MAINE

he University of Maine (UMaine) recently identified aging as one of its “emerging areas of excellence.” By seizing this opportunity, UMaine is positioning itself for creating cutting-edge research and learning opportunities that can reinvigorate the state’s economy with new industries that feed an expanding 50+ market. UMaine scientists are designing and testing products that maximize quality of life at home and in the community regardless of life stage and that maximize the ability of older adults to stay physically active, engage in satisfying activities, and preserve their safety and well-being. Not only are these products designed to improve and protect the health of older adults, but they also represent a significant opportunity for economic growth in Maine. A key ingredient for developing technologies for healthy aging is the cross-fertilization of ideas to address the wants and needs of the 50+ market. The following sections provide examples of how UMaine is developing innovations that help older adults to age in place, while tapping into an expanding market to create economic opportunities in Maine. Aging with Vitality Within the aging-and-vitality focus area, UMaine is developing technologies to prevent falls by helping individuals compensate for age-related declines to preserve function and avoid injury.

Edge Detection One of the most common challenges that occur with age is a loss of visual contrast sensitivity. This can be extremely dangerous for older adults as it turns commonplace low-contrast features, such as cement stairs, curbs, or benches into falling hazards. Indeed, accidental falls lead to more than 25,000 deaths per year and medical and health care costs of over $30 billion annually.2 Current solutions to the low-contrast falling problem involve using bright, high-contrast markings to 30

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distinguish potential hazards, e.g. the edges of subway platforms. While these techniques are an excellent solution for drawing attention to the hazard and limiting falls for older adults and travelers, it is simply not practical or cost effective to paint high contrast lines on all potentially dangerous edges in the environment. The goal of UMaine’s work in this area is to improve safety and reduce falling via a cost-efficient solution that can be implemented without an expansion of existing infrastructure. To do this, UMaine researchers are exploring the use of computer vision to detect low-contrast edges in the environment and improve their visibility. This is done using an algorithm that analyzes the contrast of a live video feed, and once a relevant edge is detected, superimposes virtual highlighted edges onto the image of the physical environment, using a headmounted display. As camera and display hardware become smaller, the hardware will be mounted on simple glasses and will provide a cost-effective solution to the problem of accidental falls by allowing older adults to easily identify and avoid obstacles that they may otherwise fail to observe. The system can also be used to convey and enhance other environmental cues that may be hard for older adults to access such as the text on signs. Head Protection In 2013, over 2.5 million people over the age of 65 were treated in hospital emergency departments for moderate to severe injuries from falling, including traumatic brain injury (TBI). In fact, adults 65 and older have the highest rate of TBI hospitalizations and death as compared to their younger counterparts. To further compound this issue, every year between 700,000 and one million patients suffer a fall during a hospital stay, with a resultant increase in hospital operational costs in excess of $13,000 per patient and an increase in patient length of stay of 6.3 days per incident.3 In light of the prevalence and severity of fall-related injuries, UMaine is working to develop nonstigmatizing protective gear to reduce the risk of injury for persons at risk of falling. UMaine is working in conjunction with James R. Ferguson of Alba-Technic, LLC, Winthrop Maine, who holds U.S. and European patents on a highly effective impact-resisting material system. Research has focused on the development of protective headgear. Researchers have recently initiated a project to expand the work to developing hip

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protection. The development of the headgear was supported by a National Institutes of Health/National Institute on Aging SBIR Phase I/II award, by the Maine Technology Institute (MTI), and is currently being supported by a National Science Foundation STTR Phase I award under the small batch manufacturing program.

…UMaine is working to develop nonstigmatizing protective gear to reduce the risk of injury for persons at risk of falling. Alba-Technic’s SMARTY® concept offers a headgear option for older adults that is designed to be integrated into fashionable headwear, while providing protection against head injury. Advanced manufacturing techniques create a contoured impact-resistant structure for the headgear, and the shape of the internal impact-resisting system is designed for fit, aesthetic appeal, function, and comfort and then covered with a fabric material that can be selected by the user. It is important that the technology is lightweight and can be incorporated into caps, scarves, and hats, because other commercially available products are bulky and often stigmatizing for the wearer. Additionally, focus groups of health care experts and potential wearers of the product suggest that people would only wear this protection if it looked like everyday headwear such as a ski or baseball cap. In a recent social marketing and consumer preference trial conducted by the University of California-Los Angeles in a senior community in southern California, there was a significant increase in the acceptance of the prototype SMARTY® product as measured by a preand post-attitudes questionnaire based on the theory of planned behavior. Performance of the headgear is tested by an apparatus designed and fabricated at UMaine, which has demonstrated that various versions of SMARTY® significantly reduce the likelihood of head injury and have the potential to reduce a major injury to a comparatively minor one.

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Hip Protection Falls account for a significant number of hip fractures. Hip fracture in the elderly is disabling and may lead to death. With more than one-third of adults 65 and older falling each year, it is imperative that new solutions be developed to address this issue. UMaine’s Hip Project aims to leverage the current research and development in head protection by creation of innovative, wearable hip protection for elders. Current hip protective gear is bulky and unsightly, so people do not use the gear. UMaine is developing, and aims to commercialize, an aesthetically pleasing hip protection system consisting of undergarments and a changeable and fashionable shell for women and men that elders at risk of falling will feel comfortable wearing.

Technologies for monitoring vital signs provide the opportunity for convenient remote monitoring of health indicators, while reducing medical costs and allowing individuals to remain in their homes longer.

Driving Simulator Driving can be one of the most important aspects of an individual’s independence. Unfortunately, it is also one of the most dangerous practices for older adults. According to the Insurance Institute for Highway Safety, the likelihood of experiencing a fatal car crash increases with driver age, and drivers over the age of 85 have higher rates of fatal crashes than any other age group. Older adults are now driving longer and logging more miles, which increases the potential for fatalities on the road.4 To address this growing problem, UMaine is exploring ways to keep drivers in the aging population safer by (1) better characterizing the situations where accidents and other dangerous driving events occur, and (2) developing new compensatory techniques to provide key information to reduce these events. To this end, MAINE POLICY REVIEW

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UMaine has built a driving simulator specifically designed for aging adults. Using a combination of actual vehicle hardware and a head-mounted display, the simulator immerses the driver in a virtual car and driving environment. It has been demonstrated that driver behavior in these simulated, virtual environments closely resembles driver behavior in reality. The simulator provides an excellent means of assessing problems faced by aging drivers in a fast, safe, and affordable manner. In addition the simulator enables researchers to develop and test augmented-reality tools that address the problems that older adults have seeing or identifying road signs and markings. The technology superimposes highlighted and higher-contrast edges on road signs and magnifies them, making it easier for older adults to see them. Researchers are currently determining which specific method of augmentation is most effective. Future work will expand upon the augmented-reality research by helping elder drivers to locate and identify landmarks. Vital Signs Monitoring Technologies for monitoring vital signs provide the opportunity for convenient remote monitoring of health indicators, while reducing medical costs and allowing individuals to remain in their homes longer. Addressing one aspect of this technology area, researchers at UMaine are developing innovations that will allow the monitoring of sleep patterns of older individuals. UMaine is exploring early sleep-related movement (SM) dysregulation as an important marker of emerging cognitive decline in the aging population. Accurate analysis of body movements, changes in heart rate and respiratory patterns, and identifying subtle periods of arousals during sleep reveal important information about brain activities and cognitive changes. UMaine has developed a highly sensitive prototype device to wirelessly record high-frequency, ultra-low-amplitude time-series of these indicators for mild TBI diagnostics. The device is embedded within a mattress cover, so measurements can be made in the home rather than through costly and invasive sleep lab studies. The original work was funded by the U.S. Army with the intent of diagnosing and monitoring veterans and is currently being expanded for use by athletes and older adults. A study currently underway is assessing older adults (60–80 years) with a recent (< 6 months) history of a fall. Data will be collected and analyzed to identify changes in brain activity and cognitive degradation even in the early stages of decline. 32

TECHNOLOGY AND AGING R&D

Physical Fitness

Maintaining physical fitness during the aging process is an important component of preventing illness and increasing longevity. Adaptive solutions can be used to encourage physical fitness and provide opportunities for maintaining social contact and avoiding isolation by providing nonstigmatizing exercise options for older adults. Although durable medical equipment (DME)—such as walkers, crutches, and canes—is available, DME is minimally functional for outdoor exercise and is perceived as stigmatizing and inconvenient. Therefore, many people who would be unsafe without such equipment abandon it, withdrawing from exercise and movement. Created to fill a need for people who, without adequate mobility support, would be less likely, or unable or unwilling, to participate in ambulatory exercise, UMaine has developed an assistive jogger, which is currently in the early phase of commercialization. The assistive jogger is an aesthetically designed, convenient, foldable, actively steered, three-wheeled standing support device that assists with balance and weight-bearing during walking, jogging, and/or running. It is fitted with biofeedback and innovative load-sensing technology, which could be used to help individuals or caregivers to monitor vital signs during physical activity. Emergency Detection and Response When an older adult experiences a fall, a rapid medical response is vital to preserving health and function. UMaine is developing new technologies that integrate wireless detection and vital-sign sensors to accelerate response time and access by first responders after a fall has occurred.

Indoor Navigation and Monitoring Problems related to the loss of sensory, cognitive, and motor function with aging can lead to many safety risks for older adults living independently. These risks are magnified for people who are geographically separated from their support network, as it is difficult for friends or family members to check in on older adults living on their own. This is especially true in Maine, which is sparsely populated and has a widely dispersed population. Current responses to this concern involve installation of expensive and obtrusive video-monitoring technology or an alarm trigger such as LifeAlert that requires the user to be conscious and physically able to activate the device. MAINE POLICY REVIEW

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UMaine is developing a low-cost, nonintrusive system that allows older adults to retain their dignity and a sense of personal privacy, while still giving their support networks a mechanism to check in and monitor their behaviors and important daily activities. To test and refine the system, UMaine researchers have created a typical apartment setting on campus. The monitoring system employs minute and low-cost technologies including radio frequency identification (RFID) tags and Arduino controllers. RFID tags emit no signal and require no power, and they can be readily and unobtrusively embedded into the physical structure of an apartment, for example, under carpets, or behind the paint on walls and ceilings. Typical RFID reading devices used in commercial applications are comparatively large (approximately the size of a hair dryer). UMaine has miniaturized the RFID reader to the point that it can be worn comfortably by an individual. The system tracks the user’s location as she moves about her home and sends an alert if an issue is detected. For example, if the user has been stationary for several hours during the daytime, a text notification could be sent to the caregiver. With the addition of an accelerometer, the system can detect if the user falls and whether or not he gets back up. Critically, this functionality allows alerts to be sent to caregivers even if the user is unconscious or otherwise unable to communicate. Importantly, since the system does not rely on cameras or visual tracking, the user’s privacy and dignity are maintained. Databases may be employed to monitor regular activity and identify potentially dangerous deviations. The next iteration of development is to integrate a hazard-detection and -avoidance component into the system. RFID tags can be affixed to specific objects within the house (e.g., pets, shoes, cords, furniture) and the older user’s spatial position relative to the tagged item tracked; if necessary the user can be alerted to a specific danger. The system holds the potential to reduce in-home falls and improve safety, efficiency, and independence. Sensor Systems for Home Appliances Successful aging in place relies heavily on effective use of a range of appliances within a home, from cooking stoves to washing machines. Improper use of such appliances due to age-related loss of cognition or physical ailments may lead to ineffective or incomplete performance of the associated task or even physical injury. Indeed, cooking accidents are the leading cause of 33

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fire-related injuries for older Americans. Cooking is the leading cause of home fires and fire injuries and most kitchen fires occur because food is left unattended on the stove or in the oven (U.S. Fire Administration 2015). In spring 2014, senior bioengineering students at UMaine completed a capstone project in collaboration with residents of Dirigo Pines Retirement Community in Orono, Maine. The residents volunteered issues that they face in their daily lives that are potentially amenable to solution by engineering principles. One student group designed a safety stove, which incorporated motion sensors and an automated shut-off of the stove in the absence of movement for a certain period of time. In addition, the stove incorporated mass load sensors enabling the detection of rapid weight loss associated with combustion of food, which would lead to an automated shut-off. A second group developed an automated means of removing heavy, wet, and compressed clothing from a washing machine by using a mesh containment bag and a roller system that retrieved the bag. CONCLUSION AND FUTURE DIRECTIONS

s illustrated by the examples in this article, UMaine is serving as fertile ground for innovation with significant economic potential. The recent designation of aging as an emerging area of excellence for UMaine will provide additional pathways for researchers from a variety of disciplines and from across system campuses to collaborate and innovate together. In fact, this is already well underway. The technologies presented in this article just scratch the surface. Not mentioned are a myriad of products, devices, and approaches for healthy aging arising from fields such as communication sciences and disorders, nutrition, communications, psychology, disability studies, and the arts and humanities. What does the future of this field hold? Future technology trends will provide attractive, affordable, and effective solutions for helping individuals to age in place and maximize their independence. To be most effective, these technologies need to be easily integrated into daily life through wearable options and linked with existing appliances and devices in the home. Overall, technology options for older adults will be increasingly shaped by customization to meet individual needs and support the provision of health care as it moves toward home and community rather than institutional settings.

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Furthermore, efforts to develop and improve technologies and products to assist aging individuals need to be responsive to the personal preferences of the aging population. The participation of older adults in consumer focus groups and field testing will ensure that the technologies are sensitive to the evolving needs and wants of this population and the settings in which the products will be used. Consultations with medical specialists in geriatrics will ensure that technology development is informed by the physical/mental health dimensions of the aging experience and clinical geriatrics best practices. New companies will continue to be formed in the state, commercializing products conceived through research and development. Such companies will retain Maine’s best and brightest, contribute to Maine’s economy, and assist Maine’s aging population to live and thrive in place. Tapping into the 50+ market is imperative, not only for the health and well-being of Maine’s older adults and their families, but also for the state’s economy, turning the aging of the population into a ripe opportunity for learning, research, innovation, and business development. ENDNOTES 1. More about this topic is available in this article by Jennifer A. Crittenden on the Bangor Daily News website: http://bangordailynews.com/2015/06/26/next /a-tech-friendly-future-for-seniors-from-smart-homes-to -an-app-that-lets-you-read-to-grandchildren-remotely 2. The statistics in this paragraph came from the following websites: http://www.nsc.org/learn/safety-knowledge /Pages/safety-at-home-falls.aspx and http://www.cdc.gov /homeandrecreationalsafety/falls/adultfalls.html 3. Sources for this paragraph include two pages on the Centers for Disease Control’s website http://www.cdc .gov/homeandrecreationalsafety/falls/adultfalls.html and http://www.cdc.gov/TraumaticBrainInjury/severe.html the Agency for Healthcare Research and Quality http://www.ahrq.gov/professionals/systems/hospital /fallpxtoolkit/fallpxtkover.html and Wong et al. (2011). 4. Information on older drivers may be found here: http://www.iihs.org/iihs/topics/t/older-drivers/fatalityfacts /older-people REFERENCES AARP. 2014. Health Innovation Frontiers. AARP, Washington, DC. Pew Research Center. 2014. Older Adult and Technology Use. Pew Research Center, Wasington, DC. http://www.pewinternet.org/2014/04/03 /older-adults-and-technology-use/

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U.S. Fire Administration. 2015. Topical Fire Report Series: Residential Building Fires 16(1): 1–15. Wong, Catherine, Angela J. Recktenwald, Marilyn L. Jones, Brian M. Waterman, Mara L. Bollini, and Wm. Claiborne Dunagan. 2011. “The Cost of Serious Fall-Related Injuries at Three Midwestern Hospitals.’’ The Joint Commission Journal on Quality and Patient Safety 37(2): 81–87.

Carol H. Kim is the vice president for research and dean of the Graduate School at the University of Maine.

Lenard W. Kaye is professor of social work at the University of Maine and founding director of the University of Maine Center on Aging. During the 2014–2015 academic year, he was honored with the University of Maine Trustee Professorship. Jennifer A. Crittenden is the assistant director at the University of Maine Center on Aging where she oversees aging-related research and evaluation.

David J. Neivandt is the associate vice president for research and graduate studies and director of the Graduate School of Biomedical Science and Engineering at the University of Maine.

The AfariTM was co-invented by University of Maine professors Stephen Gilson, Liz DePoy, and Vince Caccese. The stylized mobility aid enables persons who need or want balance, stability, and/or weight-bearing assistance to participate in outdoor jogging, running, and distance walking in diverse terrain. MAINE POLICY REVIEW

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A CALL TO ACTION

A Call to Action: Maine’s Colleges and Universities Respond to an Aging Population by Jeffrey E. Hecker and Marilyn R. Gugliucci Jeffrey E. Hecker and Marilyn R. Gugliucci report on the findings of the Higher Education Workgroup, which is part of the Maine Aging Initiative. They present summary information on aging-related research, gerontology/geriatrics educational curricula, and educational opportunities for older adults including retooling for employment.

aine is at the center of one of the biggest demographic shifts in its history. It is predicted that one in four Mainers will be 65 years of age or older within the next two decades. The age demographic shifts in the population are a national phenomenon, but Maine, as the oldest state in the nation, is at the forefront of change. Maine’s older adult population (65 years and older) is expected to reach 20.9 percent by 2020 and 26.5 percent by 2030, second only to Florida (Ortman, Velkoff, and Hogan, 2014). Some towns in Maine, Kennebunk, for example, will reach the 25 percent 65-or-older benchmark by 2016 (SMRPC 2012), making the demographic shift of older adults in this town a full 5 percent higher and 14 years ahead of the national prediction of 20.3 percent (http://quickfacts.census .gov/qfd/states/23000.html). To further illustrate this point, currently, Maine’s median age is 44.0 years and Kennebunk’s median age is 56.2 (http://www.city-data .com/city/Kennebunk-Maine.html). Read the mission statement of most colleges and universities in the United States and you will find reference to the tripartite mission of educating students so that they are prepared to lead productive lives (teaching), producing new knowledge (research), and applying knowledge to enhance communities, be they local or global (service). The teaching–research–service mission is particularly emphasized in public universities. For example, The University of Maine advances learning and discovery through excellence and innovation in undergraduate and graduate academic programs while addressing the complex challenges and opportunities of the 21st century through research-based knowledge. At the University of New England, a private university, the mission statement follows suit: The University of New England provides students with a

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highly integrated learning experience that promotes excellence through interdisciplinary collaboration and innovation in education, research, and service. Given their missions, Maine’s higher education institution’s focus on education, research, and service make them well poised to respond to the aging demographic. Last year, Maine Speaker of the House, Mark Eves, convened a working group to explore higher education’s response to Maine’s aging population. The Higher Education Workgroup was one of five groups that constituted the Maine Council on Aging (MCOA) Maine Aging Initiative (the other four were Workforce and Employment, Aging-Friendly Communities, Public and Private Safety, and Health and Well-being of Older Mainers). The members of the Higher Education Workgroup included representatives from Maine’s public and private institutions of higher education and a community member.1 We are greatly indebted to our colleagues on the work group. In this article, we summarize the findings of the Higher Education Workgroup and draw some general conclusions and suggestions for the future. The findings were a result of the workgroup creating three sub-groups: one focused on aging-related research; the second on gerontology/geriatrics educational curricula; and the third on educational opportunities for older adults including retooling for employment. The sub-groups used survey methods and interviews, as well as information gathered from existing data sources. The work was supported by the Maine Council on Aging and Speaker Eves’s office. The resultant MCOA report, Maine’s Colleges and Universities Initiatives on Aging: Research, Education, and Retooling, can be found on the on the MCOA website: http:// www.mainecouncilonaging.org/education.php

A CALL TO ACTION

AGING-RELATED RESEARCH

he fact that a larger percentage of Maine’s population is over the age of 60 than at any prior time in the state’s history presents a myriad of opportunities to advance our understanding of aging. An endless array of research questions beg to be answered. How can individuals and communities best adapt to the physical changes correlated with age? What diseases increase in prevalence as the population ages and why? What can be done to prevent these diseases or moderate their impact? How can we adapt physical environments so that they facilitate independent living for older adults? What policies support healthy aging and what policies exacerbate the challenges faced by the elderly? We found that Maine’s institutions of higher education and research facilities are addressing these and related questions. We surveyed Maine’s colleges and universities, as well as medical centers and other research facilities, to get a snapshot of research activities related to aging that are currently underway in Maine. While the survey is undoubtedly incomplete, it provides an idea of the breadth of scholarship related to aging in Maine. We identified 74 aging-related research projects underway at seven institutions in the state (Table 1).

Table 1:

Institutions Engaged in Agingrelated Research and Number of Projects at Each Number of projects

Academic/Research Center Colby College

Jackson Lab

Maine Medical Center Research Institute

Mount Desert Island Biological Laboratory

University of Maine

University of Maine at Farmington

University of New England

University of Southern Maine

University of Texas: Austin

Total

To get a picture of the types of research being carried out by Maine scientists, we asked respondents to categorize their projects (see Table 2) and to indicate what funding agencies support their work. Researchers MAINE POLICY REVIEW

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identified over 70 sources of funding for aging-related research. Federal granting agencies, which tended to fund relatively larger projects (e.g., National Institute of Aging, National Institute of Health, National Science Foundation), funded 27 projects. The second most common source of funding was private foundations and trusts (16 projects, e.g., Maine Community Foundation, Atlantic Philanthropies) and state agencies (14 projects, e.g., Maine Center for Disease Control, Maine Department of Health and Human Services). Table 2:

Types of Research

Nature of Research Education Other

N* 7

Percentage 7.1

5.1

Basic Science

23.2

Policy

12.1

Applied/Clinical

27.3

Program Evaluation

25.3

Total types

99*

* Sum greater than the total projects shown in Table 1, as some research fits two or more categories.

Maine is home to some well-established institutions whose research missions are focused on aging. For example, at the University of Maine (UMaine), the Center on Aging is a multidisciplinary center with an active research and evaluation division. The Center on Aging provides technical assistance, consultation, and a sponsoring site for faculty and community researchers developing aging research proposals and conducting aging research. The center is also committed to disseminating aging research and best practice innovation through its publication and professional and community presentations. At the University of New England (UNE), much of the research portfolio has implications for optimizing aging or is explicitly focused on health-related quality of life. Fully 26 of the 74 research projects identified in our survey are underway at UNE. Faculty at the UNE College of Osteopathic Medicine’s Department of Geriatric Medicine engage in scholarship focused on translating evidence-based principles and practices of geriatric medicine to improve patient-centered outcomes. The University of Southern Maine’s (USM) Cutler Institute for Health and Social

A CALL TO ACTION

Policy identifies disability and aging as one of its core programs. The institute’s staff conducts program evaluations and performs policy analysis related to aging. Speaker Eves’s formation of the Maine Aging Initiative served as a catalyst for expansion of agingrelated research in Maine. Carol Kim, UMaine’s vice president for research, has launched the Aging Research Initiative—a research collaborative among several units within UMaine as well as researchers from the other six University of Maine System campuses. The theme of the initiative focuses on successful aging. Kim has brought together engineers, social workers, and social scientists and challenged them to think about how their work relates to healthy aging and how they might collaborate to address larger questions related to aging. For example, at the Virtual Environment and Multimodel Interaction Laboratory (VEMI Lab), Nicholas Guidice and his research team are developing electronic interfaces that facilitate navigation of indoor and outdoor spaces for people with diminished vision. Other projects emanating from the Aging Research Initiative include exercise equipment adapted for people with impaired motor functioning and clothing designed to reduce the risk of injuries caused by falls. GERONTOLOGY/GERIATRICS CURRICULA

s Maine and the nation age, there is a growing need for a workforce that understands the special needs of older adults. The need for specialized education in aging is, of course, most obvious in the health professions. Diagnostic protocols and treatment regimens developed from studies of middle-aged patients cannot be assumed to be valid for older adults. But the health care sector is not the only area where knowledge of physical, psychological, and social issues unique to older adults is important. People working in government, at cultural institutions, or in recreation or business sectors will need some understanding of the aging demographic if they are to be successful. Given the importance of the growing population of older adults, it is reasonable to ask what Maine’s colleges and universities are doing to prepare graduates for the new demographic reality. The Higher Education Workgroup set out to address this question by surveying institutions of higher education in Maine. In all, 29 individuals responded, representing 15 different institutions of higher education across the state. One approach to learning about what colleges and universities are doing to prepare

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students to succeed in a world growing older is to look at whether or not the institutions had departments or other units whose primary mission deals with aging. We found that only Maine’s three largest institutions of higher education have units focused solely on aging (Table 3). Table 3:

Maine Higher Education Units Focused Solely on Aging

Institution

Department/Program/Center

University of Southern Maine

Gerontology

University of New England

Department of Geriatric Medicine Maine Geriatrics Education Center

University of Maine

Center on Aging Interprofessional Graduate Certificate in Gerontology Hartford Partnership Program for Aging Education – Certificate in Leadership in Rural Gerontological Practice

Developing a department, unit, or division focused on aging requires a certain scale of operation that is not present at many of Maine’s colleges and universities. We speculated that aging-focused educational experiences exist within many units even though their primary missions did not including aging. This proved to be valid; 14 different programs, housed within nine of the 15 institutions that responded to our survey, offer courses focused on aging. These courses are offered through programs in nursing, psychology, pharmacology, administration, education, mental health, biology, occupational therapy, social work, sociology, geriatric medicine, human development, nutrition, and health care. Narrowing the focus to course offerings over the last two years only, we found that 18 classes on aging or aging-related issues were offered and that 10 of these were medically related courses. While there are no bachelor’s- or master’s-level programs in aging, there are a variety of certificate programs and concentrations within majors focused on aging. Northern Maine Community College offers a noncredit certificate and Washington County Community College offers an associates degree in aging. There are three certificate programs, two at UMaine and one at USM, related to aging, and UMaine offers a doctoral program that can be designed to focus on aging. 38

A CALL TO ACTION

Course offerings and programs related to aging are growing. In response to an open-ended question asking participants to describe what plans their institutions were making for the coming two years in the area of aging and aging-related issues, participants from 10 distinct programs, representing five colleges or universities, indicated plans for adding new curricula or integrating content on aging and aging-related issues into current or future offerings. The plans varied, ranging from intent to incorporate more aging-related content into courses (five comments), to integrating more aging-focused field experiences (three comments), to larger-scale programs or departmental plans to create concentration tracks or new degree programs focused on aging or aging-related issues (four comments). The five colleges or universities developing plans to expand aging-related offerings include the University of Maine at Augusta, St. Joseph’s College, UMaine, UNE, and Husson University. In addition to educating matriculated students, Maine’s institutions of higher education are also involved in the continuing professional education of Maine’s citizens. UNE’s Department of Geriatric Medicine and Maine Geriatrics Education Center, USM, and UMaine’s Center on Aging all offer training and education resources related to aging in the form of gerontological and geriatrics-focused conferences, colloquia, training modules, workshops, publications, reports, and online resources. The Center on Aging, for example, sponsors an annual University of Maine Clinical Geriatrics Colloquium every May (now in its tenth year). UNE’s Geriatric Medicine Department, in partnership with the Maine Gerontological Society, UMaine, USM, and community organizations, offers the annual Maine Geriatrics Conference (now in its 25th year), a two-day event in Bar Harbor each June. The University of New England’s Maine Geriatrics Education Center also offers a series of trainings for health professionals on Alzheimer’s disease and related disorders. EDUCATIONAL OPPORTUNITIES FOR OLDER ADULTS

aine’s changing demographics are challenging the state’s institutions of higher education in a variety of ways. For public universities in particular, the aging of Maine presents significant challenges. The number of students graduating from Maine high schools has been declining every year since 2008, and MAINE POLICY REVIEW

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this downward trend is predicted to continue through at least 2020. Colleges and universities are adapting to the demographic shift by exploring the educational needs of older adults and creating programs to fit those needs. At the same time, there is a complementary need to add older adults to Maine’s workforce. The Maine Development Foundation, for example, has set the goal of adding 12,000 older workers to Maine’s workforce by 2020 (Maine Development Foundation 2014). Clearly there is a need to increase access to higher education for older adults in Maine, and there is a need to understand the workforce competency needs of Maine’s businesses. As a first step toward understanding how Maine’s colleges and universities are meeting the educational needs of older Maine citizens, we gathered baseline information on enrollment. Specifically, we looked at enrollment of students 50 years old or older at UMaine, USM, UNE, and the Maine Community College System. The data sets available for each institution varied so the findings will be presented separately for each. At UMaine, for the decade from 2004 through 2013, just over 4 percent of the total enrollment was made up of students 50 years or older. Given UMaine’s average enrollment over that period, in a typical year approximately 400 to 450 older students were enrolled in classes. For most years, less than 50 percent of these students were enrolled in degree programs. Most were taking courses, but not officially matriculated. For those students enrolled in degree programs, the most popular majors were nursing, educational leadership, literacy education, and social work. Data from USM were available for the five-year period 2010 through 2014. On average, about 600 students 50 or older enrolled in class for at least one semester. This represents about 8 percent of the total head count enrollment for USM during that time period. The top majors for USM students 50 and over who were enrolled in degree programs were nursing, creative writing, counseling, leadership and organizational studies, adult and higher education, and social work. For UNE, data were available for the years 2008 through 2013. During that time period about 3.5 percent of UNE students were 50 years old or older, or about 150 to 200 students per year. At UNE older students tend to choose the certificate of advanced graduate studies, master’s degree in medical educational leadership, and the graduate certificate in program development. 39

A CALL TO ACTION

The enrollment data from Maine’s three largest universities suggest the following general conclusions. Adults over 50 make up a small minority of the enrolled students. Examination of the most popular degree options suggest that the older students who choose to enroll in degree or certificate programs at these institutions are pursuing opportunities that will allow them to advance in their careers or change careers. The programs they choose tend to be in the health, education, or social services sectors.

The opportunities for growth in aging-related research in Maine are tremendous. Clearly there is work to be done to meet the educational needs of a larger portion of Maine’s older adults. Recognizing this need, the University of Maine System developed a plan to target Maine adults who have accumulated credit hours, but have not earned a bachelor’s degree. The Adult Baccalaureate Completion/Distance Education Initiative (ABCDE Initiative) was launched in 2012 to develop a plan to make it easier for adults to complete the bachelor’s degree. The initiative has several components including a “concierge service” available at each of the seven campuses and eight additional outreach centers. The concierge service helps guide adult students through various activities such as applying to the institution, choosing a major, finding financial assistance, and registering for courses. The concierge serves as the single point of contact to support adult students returning to school to pursue their educational goals. UMS has created special scholarships for Maine citizens who want to return to school to complete their degrees as part of the ABCDE Initiative. While not limited to adults age 50 or older, the ABCDE Initiative makes it easier for older Mainers to return to school and complete their bachelor’s degrees. Data from the Maine Community College System were available for every other year from 2003 through 2013. The community college system enrolls approximately 600 to 1,300 students 50 years old or older each year. The Maine Community College System has recognized the importance of retooling older workers for the workforce and is currently conducting a review of best practices for engaging unskilled workers over 50 in training. Following the review (which is scheduled to be MAINE POLICY REVIEW

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completed by fall 2015), the Maine Community College System has committed to defining a plan and implementation schedule to address the needs of older learners beyond what is already being done across the system. Not all education of older Maine citizens involves accredited institutions of higher education. Maine is fortunate to have a vibrant network of “senior colleges.” The Maine Senior College Network (MSCN) is housed at the Wishcamper Campus Center at USM and is a consortium of 17 independent groups in 13 counties around the state. The colleges offer noncredit courses taught by volunteers and charges a modest membership fee and small tuition per course. To learn more about what opportunities Maine’s senior colleges offer older citizens, we surveyed the volunteer presidents and board chairs of the 17 senior colleges. Here’s a summary of what we learned. The student members of Maine’s senior college’s tend to be financially independent individuals. More women than men are enrolled (about 75 percent women). Members tend to be retired with an age range of early 60s to mid-80s. Maine’s senior colleges provide opportunities for lifelong learning and represent a wonderful example of healthy aging in action. CONCLUDING REMARKS

aine is the oldest state in the nation; it is a rural state, and its citizens face unique challenges as a consequence of its geography, culture, and history. At times these characteristics of the state can seem daunting. But they also present incredible opportunities to advance the understanding of, and adaption to, aging. Fortunately, there is already a considerable amount of research related to aging underway at Maine’s colleges, universities, and research institutions—over 70 projects at nine different institutions with funding from 78 sources. The opportunities for growth in aging-related research in Maine are tremendous. Big challenges can be faced and big opportunities can best be taken advantage of by teams of researchers approaching the challenge/ opportunity from different angles through different disciplinary lenses and at different levels of specificity. The time is right to build upon the strong foundation of aging-related research in the state and create new opportunities for researchers to share their findings, interact, and form collaborations. Maine colleges and universities are ramping up course offerings and programs in aging; health professions 40

A CALL TO ACTION

programs are ensuring that content on aging is integrated into existing curricula. These approaches aid in ensuring that graduates are prepared to work in a world where the aging demographic is a primary driver of services, programming, and health care. Maine citizens over the age of 50 are enrolling in academic programs at the state’s public and private colleges and universities in meaningful numbers despite the fact that, until recently, these institutions have not prioritized recruitment and retention of older adults. This picture is beginning to change. The Maine Community College System is completing a review of its programs, policies, and procedures to assure that their offerings match the needs of older Mainers and to make it easy for these students to enroll in and complete programs. The University of Maine System has made baccalaureate completion for older learners one of its strategic priorities. At both public and private institutions, an increasing number of courses and programs are being offered online, thus facilitating enrollment for nontraditional-age students whose family and work commitments require flexible schedules. To ensure that Maine’s colleges and universities meet the needs of older Maine students as well as Maine’s employers, there is more work to be done. What are the highest priority employment areas for older Maine workers looking to retool or return to the workforce? What competencies will they need to develop? What are the most common barriers to obtaining the education they need to compete for jobs in the priority areas? How can businesses and colleges/universities partner to lower those barriers? We have tremendous opportunities in Maine as we have the foundation in aging-related (gerontology/geriatrics) educational programs and research expertise to meet the challenges that lie ahead. Maine is home to nationally recognized researchers and faculty members in gerontology and geriatrics and we have nationally competitive research facilities in some areas of specialization. With Maine’s expanding older adult population, and with those adults living longer, it is prime time for Maine’s colleges and universities to mobilize efforts in research, teaching, and retooling to lead the nation in advancing healthy aging. ENDNOTE 1. Co-conveners of the Maine Aging Initiative’s Higher Education Workgroup were Marilyn R. Gugliucci, Ph.D. (University of New England) and Jeffrey E. Hecker, Ph.D. (University of Maine). Members from the University

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of Maine were Nancy Fishwick, R.N., Ph.D., Lenard W. Kaye, D.S.W., Ph.D., and Carol Kim, Ph.D.; from the University of New England, Cynthia Glidden, M.S. and Judy Metcalfe, M.S.; from the University of Southern Maine, Julie Fralich, M.S.; from Maine Cite, University of Maine–Augusta: Kathryn Adams, O.T.L., A.T.P.; from Maine Senior College, Anne Cardale, M.S.; and from the Maine Community College System, Gary Crocker, M.S.

REFERENCES Maine Development Foundation. 2014. Making Maine Work: Preparing Maine’s Workforce Critical Investments for the Maine Economy. Maine Development Foundation, Augusta. http://www.mdf.org/publications /Making-Maine-Work-Preparing-Maines-Workforce/779/ Ortman, Jennifer M., Victoria A. Velkoff, and Howard Hogan. 2014. An Aging Nation: The Older Population in the United States: Population Estimates and Projections. Current Population Reports. U.S. Census Bureau, Washington, DC. https://www.census.gov/prod/2014pubs/p25-1140.pdf Southern Maine Regional Planning Commission (SMRPC). 2012. Demographic and Income Profile: Kennebunk. SMRPC, Springvale, ME. http://smrpc.org/documents /news/community/demographic/Kennebunk %20Demographic%20and%20Income%20Profile.pdf

Jeffrey E. Hecker is executive vice president of Academic Affairs and provost at the University of Maine. He is professor of psychology and specializes in clinical psychology. His research and teaching interests include anxiety disorders, risk assessment, and professional ethics.

Marilyn R. Gugliucci is the director for geriatrics education and research and a professor within the Department of Geriatric Medicine at the University of New England College of Osteopathic Medicine. She is also a founding board member and executive committee member for the Maine Council on Aging. Gugliucci works nationally on geriatrics and gerontology education competencies in the health professions.

EVOLUTION OF ELDER HOUSING

The Evolution of Elder Housing Design and Development by John Gallagher Maine faces a growing number of elderly households as the baby boomer generation ages, which will have a major impact on housing. John Gallagher discusses the availability of affordable housing for elder adults and what is being done to address the widening gap between the needs and wants of elders with limited financial resources and compares that to what will actually be available to them.

s Maine’s senior population grows, discussions continue among policymakers, housing providers, and advocates on how best to address their needs. Increasingly, state and local governmental agencies, public housing authorities, and service providers are being asked to address the growing number of elderly households, their housing needs, and their quality-of-life expectations. These include proximity to friends and community, stores, health care and other services; accessibility to transportation; availability of adaptive rehabilitative services; and housing affordability, whether a mortgage or rent plus associated living expenses. The available senior housing options come with a price tag, and the question of how these costs will be paid weighs heavily on the people having to make the decisions. Probably the most compelling issue in the coming years will be the widening gap between the needs and wants of elders with limited financial resources and what will actually be available to them. Housing and desired services tend to be centralized in urban areas because demand is greater, units are filled quickly, and costs are kept in check when compared with trying to answer requests for similar accommodations in rural areas. At MaineHousing, we’re hearing more and even louder requests to finance the construction or rehabilitation of additional affordable housing for persons with lower incomes. MaineHousing also is being asked to respond to new and emerging expectations for how senior housing should be designed or rehabilitated, taking into consideration how seniors move safely in their homes, whether health care services can be delivered

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at home or in affordable housing developments, and ways to enhance social interactions. THE EFFECT OF THE BABY BOOMERS

he changing, burgeoning senior housing landscape is being fueled by the baby boomer generation not only in Maine but nationwide, according to the National Historic Geographic Information System (https://nhgis.org/). Only 12 percent of the nation’s population was over 65 in 1980. Now it’s 15.4 percent and will continue to increase through 2030, when the last of the baby boomers turn 65. In Maine it’s slightly higher at 15.9 percent. The Maine Office of Policy and Management projects that by 2032 residents over the Figure 1:

Changing Age Distribution in Maine, 2003–2032

100% 14%

16%

86%

84%

23%

27%

77%

73%

75%

50%

25%

65+ 0– 64

2003

2010

2022

2032

Source: Maine Office of Policy and Management

EVOLUTION OF ELDER HOUSING

age of 65 years will constitute 27 percent of the state’s population, nearly doubling since 2003 (Figure 1). Baby boomers are different from generations before them. They are fiercely independent, technologically inclined, better educated, and consumer oriented. They will live longer and healthier lives thanks to advances in medicine and health care. Their impact on housing trends has been studied and discussed in countless periodicals, conferences, and other forums. One common theme emerges: they will need or demand more of everything including housing units, flexibility, affordability, autonomy, access, and community- and people-centered services. “More” is how baby boomers have lived their lives, shaping trends for decades, and they’ll continue to push others to adapt, provide, and conform. THE EVOLUTION OF PUBLICLY FINANCED HOUSING

eeting the housing needs and demands of baby boomers is the latest of many adaptations in the development of subsidized or affordable housing, which began in the early twentieth century when the United States began transitioning from a predominantly rural farming economy to an urban, industrialized one. Because of the country’s rural nature prior to the 1920s, elderly family members either lived near their children or with them in multigenerational households. Back then, taking care of an elder was a private family matter that was not supported by governmental housing subsidies or health care plans. The less desirable alternative was an almshouse or what later was called an “old folks’ home.” Design enhancements to accommodate aging adults’ needs were not a consideration. Any government involvement in housing at the turn of the century was primarily limited to housing quality and living conditions. Tenement living and substandard housing conditions were the issues when the National Housing Association was created in 1910; its purpose was to improve housing conditions through better regulation and community involvement in urban and suburban areas. Increases in population rates, along with economic upheavals such as the Great Depression and two World Wars—and the recoveries that followed each—put pressures on housing in terms of affordability, living conditions, and availability. Beginning in 1937 and continuing until today, the role of government in providing safe and affordable

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housing has evolved. Over these years, federal and state governments have used financial assistance to achieve a variety of goals: to support housing production, revitalize cities, clear urban blight, support economic development, encourage the development of the mortgage market, and expand housing opportunities for low- and moderate-income home buyers and renters. The Wagner-Steagall Housing Act of 1937 created the foundation for today’s governmental housing agencies by creating a public housing program of constructing and funding affordable rental housing for households with low incomes. In 1943, the first public housing authority was established in Maine. The availability of housing for lower-income households was insufficient to meet the demand as any available housing was being taken by workers coming to South Portland to build Liberty ships for the war effort. The South Portland Housing Authority was created to invest federal funds into housing development to meet the needs of lower-income households.

Meeting the housing needs and demands of baby boomers is the latest of many adaptations in the development of subsidized or affordable housing…. Senior housing became its own specific designation in 1959 when the federal government created the Section 202 Program, which funds private, nonprofit developments that include services such as housekeeping and transportation to help seniors whose income is less than 50 percent of an area median income to live independently. This form of public sector financing (public funds to private developers) is the U.S. Department of Housing and Urban Development’s (HUD) principal deeply subsidized elderly housing program. In the 1960s, Maine’s state housing authority and the majority of the 20 local public housing authorities were created. Against a backdrop of substandard housing conditions that was similar to why public housing financing began in the 1920s, the Maine Legislature created the Maine State Housing Authority 43

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(MaineHousing) in 1969 because “there exists in urban and rural areas in the state unsanitary, unsafe, and overcrowded dwelling accommodations” (Maine Revised Statute, Title 30-A, §4702). In1974, the federal government began to decrease the funding for public housing and its role in property management. This created the Section 8 program, which provides rental assistance for lower-income households (generally up to 30 percent of area median income) to secure housing owned by private sector, primarily for-profit property owners. Section 8 rental assistance is delivered on a project-based approach (the rental assistance is tied to the unit) and a tenant-based approach (portable with the recipient household). Construction of project-based, Section-8-assisted projects was at the forefront of affordable housing development in the 1970s and early 1980s, and the units were almost exclusively for elderly tenants. When these construction projects ended in the mid-1980s, the federal government shifted to a tax-credit model to create incentives for the construction and management of rental housing for households with low incomes that are up to 60 percent of an area median income. The Low Income Housing Tax Credit Program (LIHTC) gives tax credits in exchange for private investment and is Maine’s primary driver of affordable rental housing development. Today, the role of publicly supported housing is extensive. There is an infrastructure of public housing agencies, a cadre of developers of housing for the elderly—both publicly and privately financed—and a host of management companies with responsibility for maintaining these properties. So what will be the role of the housing sector going forward? Generalizations about the baby boom generation can mask important disparities in the economic well-being and health of this aging population, a group that will need greater housing and health services compared to previous generations simply because there are more people. It is highly certain that the contribution and participation of family in meeting elder housing needs will continue to play a significant role. It is also certain that the affordability gap will worsen as the population ages and, as a result, demand continues to outpace supply. AFFORDABILITY OF STAYING INDEPENDENT

hen adults think about getting older, their first choice is to live independently at home.

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According to a recent AARP survey, four out of five Mainers over age 50 said they feel it is extremely or very important for them to stay in their homes as they age, more so for those earning less than $20,000 annually (Bridges 2014). But can older adults afford to remain in their homes? For some there are financial concerns, but those are not as worrisome to them as they are to their influencers, a term used in the 2015 United States of Aging Survey (USAS) to denote family members, financial advisers, health care professionals, and others who may be asked for advice. Almost 65 percent of elders surveyed are worried they won’t have enough money to last the rest of their lives, but for influencers, the uneasiness is 93 percent. Increasing costs of living or unexpected medical expenses carry the greatest uncertainty (National Council on Aging 2015). According to USAS, 58 percent of older adults have not changed residences in more than 20 years, and 75 percent say they intend to live in their current home for the rest of their lives. Many older adults have been proactive in making home modifications including bathroom upgrades and improved lighting systems, and they along with their influencers would like to see more services available to help older Americans to adapt their homes to their changing needs (National Council on Aging 2015). In Maine, a state with an older housing stock, 78 percent of elders own their own home, and 13.7 percent of these households have incomes at or below 30 percent of area median income. Lower fixed incomes combined with an asset that may not be adequately maintained can make it unsafe and unaffordable to remain in the home. MaineHousing’s limited-funded weatherization and home-repair programs help lower-income households with basic modifications, but many households are not eligible because their houses require more work than the programs allow. For older adults wanting to rent an apartment, affordability can be a major challenge. A recent MaineHousing analysis finds that only a third of all rental units (subsidized and market rate) are affordable to older adults with a fixed income. Of seniors who are currently renting, 37.4 percent over the age 65 earn less than 30 percent of area median income (Table 1). Compared to all households in Maine, a higher percentage of elder households are extremely low income.

EVOLUTION OF ELDER HOUSING

Table 1:

Percentage of Households in Maine Earning 30 Percent or Less of Area Median Income

65+

Owners

Renters

Total

13.7%

37.4%

18.4%

8.4%

26.2%

13.5%

All Households Source: MaineHousing

Urban counties, namely York, Cumberland, and Androscoggin, have the highest percentages of elder households with extremely low incomes. The statewide median household income for people over 65 years of age is estimated to be $33,062. A household earning the median can only afford to pay $826 per month in housing costs or they are cost burdened, which means they are paying more than 30 percent of their income towards housing (Table 2). In Maine, nearly half the population of renters and a third of owners over the age of 65 are cost burdened (U.S. Census, American Community Survey). Table 2:

Share of Income Spent on Housing Costs in Maine Owners

Renters

65+ Households

108,061

29,869

137,930

>30% of Income

31,500

14,385

45,885

29.2

48.2

33.3

Percentage

Total

Source: U.S. Census, 2008–2013, American Community Survey, Five-Year Survey, Table S0103

At the Maine Summit on Aging, sponsored by the Maine Council on Aging in September 2014, a report by the Carsey School of Public Policy at the University of New Hampshire offered more insight on incomes of older adults. One in ten Maine older adults was below the poverty line in the 2009–2013 period, and 51 percent would be considered poor if they did not receive Social Security benefits. Without medical expenses, poverty among older adults would be cut roughly in half, from 10.2 percent to 5.2 percent (Schaefer and Mattingly 2015). According to Stephen M. Golant (2015) in his book Aging in the Right Place, dwelling expenses are the single largest spending category for older adults “who are exposed to regular cost increases and who have generally MAINE POLICY REVIEW

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lower incomes,” thus putting them at the greatest risk of feeling financially vulnerable. He cites 2010 Bureau of Labor Statistics data that show the average home-related expenses of people age 65 and older are about 35 percent of their total household spending and represented 43 percent of the total household expenditures for those whose annual income is under $16,208. “In comparison, food, out-of-pocket health care, and transportation costs average, respectively, 12 percent, 13 percent, and 14 percent of their total expenditures” (Golant 2015: 71). SUPPLY AND DEMAND OF AFFORDABLE HOUSING

here is also the challenge of finding an available unit. While Maine’s elder population has grown to 15.9 percent today, senior affordable-housing rentals have remained at 44 percent since the early 1990s, even though the construction of multifamily units in Maine has been far outpaced by the construction of single-family units. More of the units are located in more urban areas than in rural towns where older adults may want to live, and long, multiyear waiting lists are the norm. While the good news is that the supply of affordable housing has remained steady as a percentage of need, the question is whether affordable housing developers will be able to meet the growing demand. A recent assessment of Maine’s housing needs for people ages 55 and older by Abt Associates said that Maine will need more than 15,000 additional senior-housing units by 2022. Maine will need to add more than 6,000 more housing units in the next seven years to meet this demand at a 44 percent rate (Abt Associates 2015). DEVELOPMENT TRENDS AND OPTIONS

hile many Maine older adults may choose to stay at home, others will be looking at other housing options. And there is an expanding smorgasbord of choices. Retirement living centers featured in advertisements give the appearance of luxurious resorts awaiting seniors when they reach the magic age of 65 years (or even younger). They are, however, financially unavailable to elderly households with low incomes. Generally privately owned and developed with commercial credit or investment, continuing-care retirement centers and assisted-living centers combine a sense 45

EVOLUTION OF ELDER HOUSING

of community with residents’ evolving health care needs as well as their desire to remain relatively independent and mobile. These communities can be a mix of marketrate apartments, condos, or small houses, and offer an array of services such as meals and light housekeeping for a fee, plus many options for recreation and socialization. Just as for older adults who live in their own house, home-based care programs expand the viability and attractiveness of independent-living retirement centers. Services may include Medicare-certified home health services, meal delivery, transportation, or a private-duty nurse or personal care assistant. This includes social and community engagements, access to health care services, and amenities including fitness rooms, salons, pools, patios, trails and walkways, or private gathering rooms to invite family and guests for special occasions.

With an eye on the future, developers of affordable housing will be challenged by the expectations and preferences of baby boomers, and many of their residents will want what’s offered in private retirement communities. The hurdle we face is whether these services can be offered while keeping rents affordable.

In publicly supported housing, a housing model focused on attracting residents with common interests is emerging. In Burbank, California, for example, a group called EngAGE spurred the development of an arts-focused subsidized housing project, a first-of-its-kind 141-unit senior apartment community that offers art and creativity as the core physical and intellectual unifying amenity (http://www.engagedaging.org/). The community features a theater group, independent film company, fine arts collective, music program, and an intergenerational arts program with the school district. Its art displays and performances have become a significant neighborhood attraction. Maine is not at that point—yet. Developers of affordable housing seeking financing through the competitive LIHTC program are scored higher if their projects include, in addition to affordable rents, access to community services and public transportation, accessibility for people with mobility concerns or disabilities, energy efficiency, and proximity to medical offices, grocery stores, and community services. Maine does have a strong history of historic preservation and reuse of buildings in the community center. In Hallowell, the rehabilitation of the Cotton Mill Apartments in the downtown area affords residents easy access to shopping, restaurants, galleries, the library and post office. In Augusta, a recent housing development for seniors, the Cony Flatiron Building, maintains many of the elements of its former use as the community high school, such as the auditorium with a stage, yet incorporates many design features now in demand such as wider corridors, and common areas for social interaction.

WHERE YOU LIVE MATTERS

INTEGRATING HEALTH CARE

… the integration of housing and health care services will continue to dominate affordable housing discussions.

ccording to the AARP Livability Index’s neighborhoods category, where people live—their neighborhood—is important. “Two important qualities are access and convenience,” according to the index. “Compact neighborhoods make it easier for residents to reach the things they need most, from jobs to grocery stores to libraries. Nearby parks and places to buy healthy food help people make smart choices, and diverse, walkable neighborhoods with shops, restaurants, and movie theatres make local life interesting. Additionally, neighborhoods served by good access to more distant destinations via transit or automobile help residents connect to jobs, health care, and services throughout the greater community” (http://livabilityindex.aarp.org/). MAINE POLICY REVIEW

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ince housing is a social determinant of health, the integration of housing and health care services will continue to dominate affordable housing development discussions as MaineHousing and its partners look for ways to address the needs of an aging population. Increasingly, publicly funded housing is recognizing the relationship between health care and proximity to services for their roles in quality of life. Several public housing authorities in Maine operate health centers or clinics within their public housing properties in partnership with local health care organizations and nursing schools. If older adults live in rural Maine, however, the services they may need may not be nearby, and transportation can be problematic. In Fort Fairfield, that became 46

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clear. To address the need for affordable senior housing near health care services, the town and Fort Fairfield Housing Authority collaborated to build the Meadows, a 25-unit housing project for people 62 years and older near a clinic operated by Aroostook Medical Center. There is a growing realization that technological advances will be an integral element of design in the merger of housing and health care. Through access to broadband Internet connections, residents can sit at their computers or in a specifically designated private room and discuss health concerns with physicians and other medical staff who are at off-site clinics or hospitals. Also, advances in sensor technologies could aid in home safety and connect people to emergency services, health care professionals, and friends and family. (See article in this issue by Kim et al. [2015] for fuller discussion of the issue of emerging technologies.)

Energy efficiency also is important to keep units affordable. A number of development projects presented to MaineHousing have included features such as thicker insulation and specialized double-paned windows, or alternative energy sources such as solar panels, which typically are financed through other sources. In Farmington, energy efficiency was a must for Brookside Village Apartments, a 44-unit senior and disabled housing project that opened in 2014. While the apartments are hooked up to the utility company, the complex is a net-zero energy-use facility because solar panels and heat pumps use the constant temperature of earth to heat and cool the building.

For many Maine older adults, the reality of where they will live as they age could be different from what they had hoped or expected.

STANDARD DESIGN FEATURES

t is through state and federal regulations, and more importantly through productive discussions among MaineHousing and its development partners, that the construction of new affordable-housing projects for older adults incorporates many key features to support baby boomers’ demands to live independently in a community setting. Standard design features include accessibility and safety, technology, energy efficiency, and amenities. In recent years, public funding at the federal and state levels has targeted efforts to expand the viability of independent living by incorporating features that reduce barriers. Accessible units include features individuals with physical limitations might need to function and be safe in their homes including wheelchair accessibility, while adaptable units can be easily be adjusted to facilitate the needs of those with limited mobility. Items such as grab bars, tub seats, nonslip or roll-in showers, and ramps are installed in each development. Other universal-design features are standard including one-story living, wider doorways and hallways, level door handles, slow-closing storm doors, and automatic-opening building doors. Required features such as smoke and carbon monoxide detectors, sprinkler systems, increased lighting, and security systems ease worries for seniors who want to feel secure in their living environment. Even the thickness of drywall to lessen the noise coming from a neighbors’ apartment is factored into construction.

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HAPPILY EVER AFTER?

or many Maine older adults, the reality of where they will live as they age could be different from what they had hoped or expected. While most older adults prefer to age at home, without societal connections and meaningful relationships, or money to pay for the community-building amenities that may come from residential care or similar living facilities, loneliness can set in, causing serious health problems such as diabetes, depression, decreased dexterity and function, and early death (Kim 2012). People aged 60 and older who reported feeling lonely saw a 45 percent increase in their risk of death, and isolated seniors had a 59 percent greater risk of mental and physical decline than their more social counterparts (Kim 2012). In Maine, older adults who live alone constitute 5 percent of the state’s total population, or 29 percent of the total elder population. Forty-six percent of elder households consist of a person who lives alone. Loneliness and living alone, however, are not connected. The biggest surprise to researchers was that two-thirds of older adults who said they were lonely were either married or living with a partner of some kind (Kim 2015). “It’s so easy to combat loneliness in the elderly,” said Bobby Smith, a professional caregiver with more than 47

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six decades of elderly care experience, in “The Elder Loneliness Epidemic,” an article on AgingCare.com. “But caregivers have to be willing to get up and make that happen.” Emotional experiences are integral to a person’s sense of well-being. “By ascertaining the emotional experiences of older people, we can assess the appropriateness or individual-environment fit of a wide range of settings, whether ordinary homes or planned senior housing, residential care settings, or even nursing homes” (Golant 2015: 24). In the affordable senior-housing sector, that responsibility will rest in greater part on property management companies and will require partnerships with health care providers, social service providers, and community-based programs. WHAT’S NEXT?

or those involved in the development of affordable housing, the questions of when elders plan to move and where they’ll choose to live their last years—if they choose to move at all—are uncertain. For elders on fixed or reduced incomes, waiting too long can narrow their choices. Three of the four senior housing communities mentioned in this article—Cotton Mill, Fort Fairfield, and Brookside Village—were at capacity within a year’s time of opening. Cony Flatiron is nearing full occupancy after a few months. Having an adequate amount of funding to maintain, increase, and administer affordable-housing development, rental assistance, and weatherization and home-repair programs will continue to be a challenge for affordable-housing providers. The rate of growth in public investment that occurred in the last 100 years may not continue and indeed may not even be sustained at today’s level. While “doing more with less” is a common phrase among financing agencies, for those housing agencies on the front lines, telling low-income households that there is a multiyear waiting list for housing is much more often the reality. While there is uncertainty about the future, one thing is certain: the housing choices that baby boomers make as they reach retirement and how the housing sector responds to these choices will likely make the history books. One hundred years from now, the transformative effect will likely be comparable to the effect of change over the last century. -

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ACKNOWLEDGMENTS MaineHousing employees who contributed to this article include Richard Taylor, research manager; Deborah Turcotte, public information manager; Bill Olsen, senior supportive housing loan officer; and Chauncey Devin, research intern and Amherst University senior, from Damariscotta.

REFERENCES Abt Associates. January 2015. A Profile of Maine’s Older Population and Housing Stock. Abt Associates, Cambridge, MA. Bridges, Katherine, 2014. “Issues and Concerns of the 50+ in Maine: 2014 AARP Survey of Maine Registered Voters Age 50 and Older.” AARP Research: 4. Golant, Stephen M. 2015. Aging in the Right Place. Health Professions Press, Inc., Baltimore, MD. National Association of Area Agencies on Aging (n4A), National Council on Aging (NCOA) and UnitedHealthcare. 2015. The 2015 United States of Aging Survey: Full Research Findings. NCOA, Arlington, VA. https://www.ncoa.org/wp-content/uploads /USA15-National-Fact-Sheet-Final.pdf Schaefer, Andrew, and Marybeth J. Mattingly. 2015. Official Poverty Statistics Mask the Economic Vulnerability of Seniors: A Comparison of Maine to the Nation. Carsey Research National Issue Brief #89. Carsey School of Public Policy, University of New Hampshire, Durham. Kim, Carol, David Neivandt, Lenard W. Kaye, and Jennifer A. Crittenden. 2015. “The Emergence of a Technology and Aging Research and Development Sector in Maine.” Maine Policy Review 15(2): 29–35. Kim, Leland. 2012. Loneliness Linked to Serious Health Problems and Death Among Elderly. University of California at San Francisco News Center. http://www .ucsf.edu/news/2012/06/12184/loneliness-linked -serious-health-problems-and-death-among-elderly

John Gallagher was appointed as director of the Maine State Housing Authority by Governor Paul LePage in 2012. He has served as served as executive director of Westbrook Housing Authority and president of Westbrook Development Corporation, and as Development Department program manager at MaineHousing. He has more than 20 years experience in residential real estate and is a member of the Federal Home Loan Bank of Boston’s Advisory Council.

MAINE’S ELDER TRANSPORTATION CHALLENGE

Getting from Here to There: Maine’s Elder Transportation Challenge by Katherine Freund Surveys and studies have repeatedly pointed out the problem of transportation for elders in Maine. Katherine Freund reviews Maine transportation studies and policy and suggests that the solution lies in developing private transportation alternatives that are supported by appropriate public policies.

INTRODUCTION

e live in revolutionary times. Not since the Industrial Revolution brought us manufactured goods, division of labor, big cities, and man-made air pollution have the economy and society undergone such profound changes. We are now in the midst of the information revolution, which has brought us the Internet, the sharing economy, and social media. In the marketplace, Craigslist has replaced newspaper classified advertising; eBay has created a giant flea market in the cloud; Amazon has overtaken Walmart as the world’s largest retailer; and Google has replaced the Encyclopedia Britannica. Refrigerators and stoves have computers; thermostats can be programmed by cell phone from thousands of miles away; washing machines weigh their loads before “deciding” how much water to use; and cars stay in lane, avoid collisions, and navigate themselves. It is the world of automated vehicle technology, the Internet of Things, and it holds enormous promise for transportation in the next few years. What can it do for Maine, and what do planners and policymakers need to do to harness this potential? HOW DO OLDER MAINE RESIDENTS TRAVEL?

aine is not only the nation’s most rural state, with 61.3 percent of the population living in a rural area, it is also the oldest state, with a median age of 42.7.1 This population pattern presents serious safety and mobility problems for Maine’s older drivers: Maine ranks fourth in the country in traffic crashes involving drivers age 65 and older (TRIP 2012).

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The private automobile is the overwhelming transportation preference for Maine citizens, of any age. The Maine Strategic Transit Plan for 2025 found in a telephone survey that 97 percent of citizens hold a driver’s license, 93 percent own a vehicle, and the average household has 2.2 vehicles. The same survey found the number of Mainers who use public transit is so small it cannot be reliably reported, and 68 percent of survey respondents said that increases in the service they admittedly do not use should be funded with lottery proceeds and user fees in preference to taxpayer dollars (MDOT 2015). At the same time, older people who stop driving become dependent on friends and family for their transportation needs. Nationally, women outlive their decision to stop driving by about 10 years, while men outlive their decision to stop by about six years (Foley et al. 2002). How then do planners and policymakers provide responsibly for an aging rural population where everyone drives, older drivers crash, and few wish to use or pay for public transportation? A FRAMEWORK FOR UNDERSTANDING TRANSPORTATION

ne way to penetrate this complex policy problem is to break it down into its essential elements and to look at Maine’s senior transportation through this heuristic device. The “Basic Components of Transportation” (Figure 1) shows how transportation can be understood through resources, logistics, technology, and policy. The arrows among the circles indicate a dynamic relationship between the components, so a change in one creates a corresponding change in the others.

MAINE’S ELDER TRANSPORTATION CHALLENGE

Figure 1:

Basic Components of Transportation

Primary Elements

Consumer Choice Resources • Public • Private

Logistics • Mass • Personal

Source: Freund (2004)

Resources Resources are either public or private. All resources are scarce, but public resources, extracted from citizens through taxes, are especially scarce. Although the majority of survey respondents for the Maine Strategic Plan thought that public transportation should be available to the public the same way fire and emergency services are provided, they preferred to pay for any increase in transit services with voluntary fees. Private resources for transportation are expended as free consumer choices, and with the average Maine household owning more than two vehicles, private expenditures in Maine are both a clear consumer choice and a serious investment. According to Rachel Botsman, named by Fast Company as one of the “most creative people in business” for her leadership on collaboration and sharing through digital technologies, the average automobile sits idle 23 hours a day (Botsman 2015). The question for planners and policymakers can be, “How do we access this vast pool of private resources to meet the mobility needs of Maine’s aging population?”

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Logistics There was a time when the only way to create effiPrimary Forces ciency in transit was to use high-occupancy vehicles, bring the passengers to the vehicle, and move the vehicles Technology on predetermined routes. This • Mechanical is traditional mass transit, • Energy which gives us bus routes, • Information train stations, and airports. It may also be described as a linear or analogue system, and it works in high-density areas such as cities. It is frequently funded with public dollars. It does not work well in a rural Policy state such as Maine, where • Do nothing distances are long, trip costs • Regulate are necessarily higher, and the • Public funding resources to pay for those • Incentives for private costs are lower. Rural commusolutions nities need a more networked, more modern solution, where small vehicles pick people up at their doors and take them where they need to go. Automobiles work well in rural areas. Fortunately, there are many privately owned vehicles available. How can private vehicles be accessed for shared mobility? Technology Technology creates efficiency and produces mode— boats, planes, cars, sleds, bicycles, horse-drawn power, Segways. Energy technology translates to fuel—wind, hay, gasoline, electricity, human power. Until fairly recently, communication or information technology was limited to scheduling existing mechanical solutions. Reading the printed bus schedule, selecting an airline flight on the Internet, or using Google to choose a ground transportation option are all examples. Recent changes in computational speed, handheld computers (e.g., smart phones), the Internet, and global positioning satellites to triangulate ground position have catapulted information technology into a whole new realm, creating modes called transportation networks and offering cars that can drive themselves. The new vehicles are called driverless cars in the same way the

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earliest automobiles were called horseless carriages. The earliest cars were not carriages, and the recent vehicles are not driverless cars, but the beginning of something quite different. According to an article by Mike Ramsey in the Wall Street Journal (October 25, 2015), they hold enormous promise for the transportation future. How do policymakers protect the public, regulate an emerging industry, and welcome the future? Policy The four classic policy paths are (1) do nothing, (2) regulate, (3) publicly fund the solution, and (4) create incentives or remove barriers to private solutions. Maine has pursued each of these paths to some extent. Today, however, the greatest opportunities within this transportation framework pertain to private resources, information technology, and the removal of barriers. Each of these is described in the sections that follow. TRANSPORTATION PLANNING AND POLICY FOR MAINE’S AGING POPULATION

Key Legislative Actions

n 1961, the Maine Legislature began to regulate the older-driver-safety issue by passing An Act Requiring Persons Seventy-Five Years of Age to Take Examination for Motor Vehicle Driver’s License (Maine Public Law 1961, Chapter 348, Section 1 RS Chapter 22, § 60), but in 1983, the legislature repealed the same law (Maine Public Law 1983, Chapter 29, Section 545. Repealed). Ten years later, in 1993, the Maine Legislature created the Task Force to Study the Safe Mobility of Maine’s Aging Population (Public Law 1993, Chapter 297, Section C-6). Charged to evaluate (1) transportation alternatives for an aging population, (2) licensing provisions for a driving population, and (3) educational programs to improve driving performance and highway travel considerations for an aging population, the task force met for more than a year, conducted public hearings across the state in conjunction with the White House Conference on Aging, and published a final report in 1995. The task force’s work resulted in minor regulatory changes to the Bureau of Motor Vehicles vision requirements for older drivers. There was also an agreement to provide Maine Department of Transportation (MDOT) staff support for a grant from the National Academies of Science for the Southern Maine Area Agency on Aging to conduct the research

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and development for the Independent Transportation Network (ITN) in the greater Portland area (Freund and McNight 1997). At about the same time, but working independently, task force member John Clark helped pass PL1995, Chapter 132, Section 1, a law to protect volunteer drivers. Clark, executive vice president of the Independent Insurance Agents of Maine, was also a former Maine state police officer. John’s parents lived in a rural community and needed transportation, but it was his experience with fatalities involving older drivers, as a state police officer that motivated him to support a law that protects volunteer drivers. This simple law protecting Maine volunteers is an excellent example of a policy that removes a barrier to the use of private resources for community mobility and public safety. It relieves volunteer drivers of the worry that their insurance premiums will increase if they help others with rides, but at the same time, it allows insurance companies to terminate policies or increase premiums for valid business reasons. It states: An insurer may not refuse to issue motor vehicle liability insurance to an applicant solely because the applicant is a volunteer driver. An insurer may not impose a surcharge or otherwise increase the rate for a motor vehicle policy solely on the basis that the named insured, a member of the insured’s household or a person who customarily operates the insured’s vehicle is a volunteer driver…. This section does not prohibit an insurer from refusing to renew, imposing a surcharge or otherwise raising the rate for a motor vehicle liability insurance policy based upon factors other than the volunteer status of the insured driver. Another Maine law that removes a barrier to the use of private resources to support senior transportation passed in 2005 as an amendment to car dealership laws (PL 2005, Chapter 437, Section 24). This policy change is similar to an exemption from car dealership laws for nonprofit organizations that improve mobility and encourage economic development by repairing used vehicles and reselling them to low-income people. The policy change for senior transportation became necessary when ITN developed an innovative payment program for older people that allowed them to trade vehicles they no longer used to pay for their rides with the transportation service. The CarTrade program was 51

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so successful that the nonprofit was at risk of being classified as a used car dealer. The policy revision removes this regulatory barrier so older people may use their own resources to fund their own transportation needs. The bill states: Any public or nonprofit organization whose sole or primary purpose is to provide transportation for persons 65 years of age or older that accepts donated vehicles for the purpose of providing that transportation or accepts in trade for transportation services the vehicles belonging to persons 65 years of age or older who use those transportation services is exempt from the requirements of this section. More recent legislation has attempted to extend innovative efforts. Senator Sharon Treat, canvassing door-to-door for re-election in 2012, learned from her older constituents that transportation was an enormous unmet need. Her grasp of the problem produced LD 1365, An Act to Promote New Models of Mobility and Access to Transportation. The bill amends MDOT’s operations plan for transit to promote new models for mobility and service, and it eliminates the Transportation Coordinating Committee, replacing it with a larger, more comprehensive Maine Public Transit Advisory Council. LD1365 was amended in committee, then vetoed by Governor Paul LePage. In the 127th legislative session, Transportation Committee Chair Andrew McClain of Gorham introduced a similar bill, LD 844, An Act to Improve Transit Services Statewide. This effort was also amended in committee and vetoed by the governor, but the veto was overridden, and it became PL2015, Chapter 182. There was no financial impact to the state budget for LD 1365 or its successor, PL2015, Chapter 182, and since neither legislative effort looked beyond public support for transportation, the policy change was an effort to do a better job with existing resources, “to think more broadly about transportation needs and planning, and to correct the fragmented system we have to create the system we need” (Sharon Treat personal communication). Representative McClain also acknowledged that the new law “only addresses part of the problem,” but that it is a start (personal communication). In terms of the transportation framework and a policy approach, both Representative Treat’s and Representative McClain’s efforts attempt to make the use of public resources more efficient and effective; they do not fundamentally MAINE POLICY REVIEW

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change the current senior transportation-delivery system that uses public resources to meet the safety and mobility needs of the aging population. Another bill that passed by overriding the governor’s veto was LD1379, An Act to Establish Transportation Network Company Insurance. Sponsored by Representative Henry Beck of Waterville, chair of the Joint Standing Committee on Insurance and Financial Affairs, the bill became law on June 30, 2015, as PL 2015, Chapter 279. The law is an entirely different approach to public policy because it removes a barrier to the use of private resources. When asked why he sponsored the bill, Representative Beck replied that as committee chair, he was asked to be the sponsor by a representative of a transportation network company (TNC). He saw the bill as useful and noncontroversial (Beck personal communication). When told that TNCs use private resources to create shared community mobility, he modestly declined to take credit for such forward thinking. Public Law 2015, Chapter 279, however, belongs with policies enacted 20 years earlier, PL1995, Chapter 132, Section 1, a law to protect volunteer drivers and PL 2005, Chapter 436, Section 24, the law that allows people to trade their cars to pay for their rides. The primary difference between the laws is that the latter two apply only to nonprofit organizations. All three policies, however, increase the availability of community-based transportation services without using taxpayer dollars, and they foster free consumer choice for people who do not drive. In a rural state such as Maine, such policies hold great promise for the future (Maine DOT 2015). Transportation Planning Maine planning efforts have explored the transportation problem for quite some time. With funding from the Maine Health Access Foundation, the University of Maine Center on Aging (CoA) in collaboration with members of the Eastern Maine Transportation Collaborative conducted a 12-month needs assessment in 2004–2005, focusing on the challenges and barriers that older adults face in accessing chronic-care medical services such as diabetes care, cancer care, dialysis, cardiac rehabilitation, and physical therapy in Hancock, Washington, and Penobscot counties (EMTC 2005). The report described the unmet need for transportation to access health care, but the resources and technology to address the needs were not forthcoming. 52

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A decade later, the Eastern Maine Development Corporation (EMDC) tried again, this time with funding from the U.S. Department of Transportation (USDOT) and the Federal Transit Administration (FTA). Titled “Linking the Rural Regions of Four Counties in Maine to Enhance Transportation Opportunities and Improve Quality of Life,” this planning effort moves beyond publicly funded transportation solutions to community-based efforts and recognizes the importance of transportation networks and Internet communication. It acknowledges the public’s frustration with previous planning efforts, distrust of government solutions, and the need for coordinated management of communication and service (EMDC 2012). “The principal recommendation that arose from this project is that a Rural Transportation Management Association (TMA) should be created to increase mobility options for people in Eastern Maine with limited ability or desire to drive by themselves” (EMDC 2012: Executive Summary). In 2015, three years after publication of this final report, the TMA remains a program at EMDC, staffed by Americorps volunteers and striving mightily to fulfill its innovative, grassroots vision for community mobility. Like ITNEverywhere, discussed below, the implementation of which also remains unfunded, the EMDC effort leans toward a future solution that uses communication technology to access private resources, but that is beyond its grasp. The Maine Strategic Transit Plan for 2025 (Maine DOT 2015) realistically attempts to cope with the awareness that taxpayer dollars to support public transit are and will continue to be scarce in Maine. The steering committee for the 10-Year Strategic Plan for Maine, therefore, set three goals: Goal 1 — M anage the Existing System. Effectively manage Maine’s existing transportation system for safety and effectiveness within reliable funding levels. Goal 2 — Support Economic Opportunity. Wisely invest available resources to support economic opportunity for our customers. Goal 3—Build Trust. Demonstrate our core values of integrity, competence, and service, both individually and organizationally. Within these goals, the recommendations for Goal 2 are especially noteworthy because they include

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recommendations to “encourage volunteer networks and alternatives to traditional transit services” and to “provide incentives for local communities and transit providers to leverage new sources of private funding for transit services” (Maine DOT 2015: xx). While the strategic plan unnecessarily limits volunteer networks to rural areas and reserves higher-density areas for more traditional transit services, it is a step in the right direction. Public transit planners and funders are accustomed to holding the purse strings, living by the golden rule: the one who has the gold makes the rules. This holds true at all levels of government, from the Federal Transit Administration and the Federal Highway Administration of the USDOT, to the Maine DOT and local governments. To a certain extent, this is a necessary characteristic of all public funding. Public dollars are scarce, so policymakers must decide who pays and who benefits. There will never be sufficient taxpayer dollars to meet the mobility needs of the aging population. Private dollars, on the other hand, are always spent as a free consumer choice, whether those dollars are corporate or personal, and whether they are charitable or expended on goods and services for the consumer. USE OF PRIVATE RESOURCES: THE INDEPENDENT TRANSPORTATION NETWORK

he Independent Transportation Network (ITN) is a community-based nonprofit transportation service for older people and people with visual impairments. It uses private automobiles and a combination of paid and volunteer drivers to create an economically sustainable transportation service that delivers rides 24 hours a day, seven days a week, through user fees and voluntary local community support rather than taxpayer dollars. In Maine, ITNPortland was made possible by several pieces of legislation, previously discussed, which protect volunteer drivers and remove barriers to older adults trading their own cars to fund their transportation needs. During the late 1990s and early 2000s, ITN explored the efficiencies possible with information technology. With support from the Transportation Research Board’s Transit IDEA program, ITN conducted research into innovative payment plans that integrated revenue from membership dues, ride payments from health care providers and merchants, computerized routing, ridesharing, and transportation credits for volunteer driving (Freund 2002). This led to a decision to build ITNRides, 53

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enterprise software to support a community-based volunteer-transportation service for the greater Portland area. The Federal Transit Administration subsequently funded a three-year deployment grant to develop ITN as a model suitable for replication across the country. By 2003, the FTA provided a planning grant for ITNAmerica, a national organization to support replication of the ITN model, and in 2006 the Atlantic Philanthropies funded the national rollout. Many Maine communities asked to start an ITN affiliate, but like so many transportation services, the ITN model needed a population base at least as large as the greater Portland area. To address the needs of rural and small communities, ITNAmerica began the research for ITNEverywhere. A comprehensive approach to shared mobility that brings together into one integrated information system rideshare, carshare, volunteer transport, ITN, and community transport, ITNEverywhere research and development was conducted in Maine in Boothbay Harbor and Brunswick, and in Massachusetts, New York, Florida, and Pennsylvania between 2008 and 2014. The core business innovations of ITN, transportation service for seniors and people with visual impairment, are the Personal Transportation Account and a flexible approach to resources. The Personal Transportation Account is a mobility portfolio that holds transportation assets in various forms—cash, credits from trading a car or volunteering to drive, and co-payments from health care providers, pharmaceutical companies, merchants, or family members. ITNEverywhere takes this business model and offers it to the entire population, so anyone can have the Personal Transportation Account. For example, people who wish to share rides to work, together with those who wish to volunteer to drive others, and those who wish to ride may all have Personal Transportation Accounts and participate in shared community mobility. ITNEverywhere is managed through one information system; it not only connects people across communities, it connects them across the state and across the country. A person who lives in Calais and needs a ride for health care may pay for her ride with credits earned by her son or daughter who is sharing a trip to work each day in Orono, Maine, or Orlando, Florida. A nonprofit virtual marketplace for the exchange of community mobility, ITNEverywhere is an example of a new kind of shared community transportation possible through the innovative use of information technology. MAINE POLICY REVIEW

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THE FUTURE: HARNESSING THE POWER OF INFORMATION TECHNOLOGY AND PRIVATE RESOURCES

ictor Hugo once said, “Greater than the tread of mighty armies is an idea whose time has come.” Automated vehicles are here. What may have seemed like science fiction even a few years ago is now predicted as soon as 2019 and 2020. The marketplace will make it happen because so many global corporations are investing in the race for market share. Among those investing are Apple, Google, Intel, Uber, Amazon, Ford, and General Motors, and the reason is the profit to be made. Traffic crashes are predicted to decline by 25 percent. According to a Wonkblog by Brad Plumer on the Washington Post’s website (March 30, 2013), fuel will be economized, wear and tear on the country’s highways will be reduced, the insurance industry will save money, and the automobile industry will sell new cars. If so-called driverless vehicles become a widespread reality, the transit industry would no longer need to hire and train drivers, and older people would be able to travel more freely than they have in years. In this race for the marketplace, the federal government needs to set standards, and states need to think ahead to the policies that will create an environment where this and other transit technologies are welcome, in both the public and private sectors. Representative Beck’s transportation network company bill is one small step. Does Maine need to look at livery laws, traffic laws, and insurance laws? How can transportation organizations in Maine connect through one information system, and how will that system connect to other states? How can we think beyond public transit to community mobility, and how will private resources and public resources come together for the common good and a better economy? What does the Internet of Things mean for transportation and community mobility, and what should policymakers consider as they plan for the changes of the information revolution? ENDNOTES

1. http://www.census.gov/newsroom/releases/archives /2010_census/cb12-50.html; https://www.census.gov/newsroom/releases/archives /2010_census/cb11-cn147.html

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REFERENCES Botsman, Rachel. 2015. “The End of Ownership?” Connected Worlds (Oct./Nov.): 108–113. Eastern Maine Development Corporation (EMDC). 2014. Linking the Rural Regions of Four Counties in Maine to Enhance Transportation Opportunities and Improve Quality of Life. Tiger2 Planning Grant, Final Report. EMDC, Bangor. http://www.emdc.org/image_upload/Final%20EMDC %20TIGER2%20corrected%208%2027%2014.pdf Eastern Maine Transportation Collaborative (EMTC). 2005. The Eastern Maine Transportation Collaborative’s Health Services Initiative Needs Assessment Research Final Report. http://umcoa.siteturbine.com /uploaded_files/mainecenteronaging.umaine.edu /files/FinalTransReport_001.pdf

Katherine Freund is the founder and president of Independent Transportation Network of America. She was featured in the Wall Street Journal as one of the “12 People Who Are Changing Your Retirement,” and on CNN’s “Breakthrough Women” series. Freund has received awards from numerous organizations and has participated in more than 150 national and international panels and conference sessions on alternative transportation for older people.

Foley, Daniel J., Harley K. Heimovitz, Jack M. Guralnik, and Dwight B. Brock. 2002. “Driving Life Expectancy of Persons Aged 70 Years and Older in the United States.” American Journal of Public Health 92(8): 1284–1289. Freund, Katherine. 2002. Pilot Testing Innovative Payment Operations for Independent Transportation for the Elderly. Final Report for Transit IDEA Project 18. Transportation Research Board of the National Academies. http://onlinepubs.trb.org/onlinepubs /archive/studies/idea/finalreports/transit/Transit18 _Final_Report.pdf Freund, Katherine. 2004. “Surviving Without Driving: Policy Options for Safe and Sustainable Senior Mobility.” Transportation in an Aging Society: A Decade of Experience. Transportation Research Board of the National Academies, Special Report 218:114–121. Freund, Katherine, and James MacNight. 1997. Independent Transportation Network: Alternative Transportation for the Elderly. Final Report for Transit IDEA Project 9, Transportation Research Board, the National Academies, Washington, DC. http://onlinepubs.trb.org/onlinepubs /archive/studies/idea/finalreports/transit/Transit9_Final _Report.pdf Maine Department of Transportation (MDOT). 2015. Maine Strategic Transit Plan 2025: Transforming Public Transit Meeting Future Needs, Maine DOT, Augusta. http:// www.maine.gov/mdot/planningstudies/mstp/documents /2015/MEFinalAprilStrategicPlan04-19-2015.pdf TRIP. 2012. Keeping Baby Boomers Mobile: Preserving the Mobility and Safety of Older Americans. TRIP, Washington, DC. http://www.tripnet.org/docs /Older_Drivers_TRIP_Report_Feb_2012.pdf

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AGE-FRIENDLY COMMUNITY MOVEMENT IN MAINE

The Age-Friendly Community Movement in Maine by Patricia Oh Patricia Oh describes how age-friendly communities can provide residents of all ages what they need and want from their communities. She presents the broad guidelines for the integrated community planning necessary to create environments that support optimal aging and gives examples from places in Maine that are adopting the age-friendly community approach.

owns and cities in Maine are grappling with the need to include an aging population in their plans for economic and community development. Maine, with a median age of 44.2, is the oldest state in the United States. Between 2010 and 2014, the population younger than age 60 fell by 3.5 percent while the population over 60 grew by 12.9 percent. In about 100 Maine communities, more than half the population is over age 50.1 Mainers want to age in place, to grow older in their own home in the community where they have meaningful social, cultural, and familial connections. The growing number of older residents in Maine cities and towns is not a blip on the demographic radar but a trend that will continue for several decades. The aging population presents both challenges and opportunities for municipalities that want to foster vital community and economic development. Inadequate transportation and the lack of accessible affordable housing are frequently discussed as key barriers to aging in Maine. Although there are challenges, the shifting demographic also brings opportunities for community and economic development. On average, about 25.6 percent of residents in Maine’s communities are aged 60 or older. Older residents often prefer to shop locally rather than to travel for goods and services, which boosts the local economy. Many municipalities enjoy the benefits of a high rate of civic engagement by their older residents. Maine’s older population makes a significant contribution to the economic vitality of the places where they live and are actively engaged in making their communities better places for all ages. One way for municipalities to maximize the contribution of an aging population to community and

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economic development is to adopt an age-friendly-community approach. Age-friendly communities (1) provide health, recreational, and socialization opportunities; (2) encourage civic engagement; (3) improve accessibility of the built environment; and (4) increase access to services that help older residents to meet basic needs (WHO 2007). Towns and cities lose when they do not have the infrastructure necessary for people of all ages and abilities to volunteer, participate in local decision making, and contribute to the local economy. Traditional city planning has focused on the built environment and not on social inclusion, civic engagement, social participation, support services, and access to information and communication technology—all of which are essential for people to thrive in their community (Peter Morelli personal communication). The movement to create age-friendly communities engages policymakers, service providers, and local organizations in planning that will provide what residents of all ages and abilities need and want in their communities. BACKGROUND: FORMAL AGE-FRIENDLY COMMUNITY NETWORKS

n 2010, the World Health Organization (WHO) launched the WHO-Global Network of Age-Friendly Cities and Communities (WHO-GNAFCC). The initiative encourages municipalities to make changes in the built and social environments that affect the health and well-being of community-dwelling older adults (WHO 2007). Beside recognition for cities and towns that commit to making age-friendly changes, WHO-GNAFCC provides an Internet-based platform 56

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for municipalities around the world to share ideas. In 2012, AARP joined the WHO-GNAFCC as a country affiliate and launched the AARP-Network of Age-Friendly Communities (AARP-NAFC) (Whitman 2013). AARP provides networking opportunities with other municipalities in the United States that have made a similar commitment to becoming more age-friendly, technical support, and information about resources and funding opportunities (Whitman 2013). Municipalities that join the AARP-NAFC are automatically eligible to join the WHO-GNAFCC. However, it is not required that communities join both networks. In 2013, Lori Parham, executive director of AARP Maine, began talking with cities and towns about joining the AARP-NAFC. Funding from the John T. Gorman foundation allowed AARP to offer technical and financial support to municipalities. Joining the WHO-GNAFCC or the AARP-NAFC is simple and free. All that is initially required is a short application and a letter of support for the application from the mayor or chair of the select board. Within the first 24 months, new members complete a needs assessment to identify the strengths and weaknesses of the community for aging in place. An advisory board is formed that works with the municipality to create an action plan reflecting local priorities and community capacity. The advisory board often includes local service providers, advocates, older residents, and representatives of municipal government. As changes are implemented, members of the AARP and WHO networks agree to a continuous cycle of evaluation to ensure that emerging priorities and preferences are addressed by the municipality. Bowdoinham, in June 2014, became the first community in Maine to join the WHO-GNAFCC. Portland, in August 2014, was the first to join the AARP-NAFC. Since then four cities and towns—Bethel, Ellsworth, Kennebunk, and Paris—have joined the AARP-NAFC. The WHO and AARP networks recognize that each community is unique and depends on local officials and residents to create an action plan that is grounded in community goals and a realistic assessment of available financial and human resources. The city of Portland faces different challenges and has different assets to meet its age-friendly goals than does the town of Bethel, with 2,603 residents. Joining the WHO or AARP network provides a jurisdiction with national and international recognition for its commitment to making age-friendly changes. Members have access to evidence-based guidelines to MAINE POLICY REVIEW

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assess the age-friendliness of the community, to inform how identified changes can be implemented, and to develop measures of success. Members do not get a list of features that must be found in a place for it to be age-friendly because WHO and AARP know that, for an age-friendly initiative to be sustainable, it must be based on the character of the local community, build on the success of existing programs, and include a realistic appraisal of the human and economic resources available to make programs and policies successful. PLANNING FOR ALL AGES AND STAGES

lanning for an aging population is complicated because not all older adults are alike—they do not have the same physical abilities or access to social and economic resources (Kaye and Harvey 2014). Age-friendly communities provide social, economic, and recreational resources for healthy, affluent recent retirees as well as for frail adults and those with fewer resources. Changes that make it easier for older adults to age in the community are good for people of all ages. The same wide path that accommodates a wheelchair or walker encourages a young parent to visit the park with a stroller. An intergenerational community gardening project is as attractive to young families as it is to older residents. Parham (personal communication) explains the emphasis on developing communities for all ages: “An intergenerational community is not just one where many generations live. It is a community where individuals of all ages are an integral and valued part of the community.” EIGHT DOMAINS: BUILDING ON COMMUNITY STRENGTHS

he room is packed when the Maine Council on Aging convenes the annual Maine Aging Summit, which brings representatives of age-friendly initiatives from around the state to meet with advocates, politicians, and community members interested in making age-friendly changes. Maine has an impressive number of community-based and regional programs to support aging in place. Age-friendly community planning does not replace existing programs. WHO developed a list of eight broad domains that provide a structure for city planners to work with advocates, service providers, and local residents to create an action plan that not only addresses the most talked-about problems, programs, and policies that are already in place, but expands 57

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planning to include areas that may not have been considered. The eight domains are 1. Outdoor spaces and buildings. Are public spaces safe and accessible to residents of all ages and abilities? 2. Transportation. Are there transportation alternatives for people who no longer choose to drive or who are no longer able to drive? 3. Housing. Does your community have housing options for people who are down-sizing or who need a more supportive environment? Do residents have access to home modification programs? 4. Social participation. Do older residents have access to social and recreational opportunities? Are there opportunities for older residents to visit cultural facilities and participate in cultural events? 5. Respect and social inclusion. Do older people feel respected and socially included in the life of the community? 6. Civic participation and employment. Are older adults who want or need to work for money able to find local jobs? What proportion of older adults regularly volunteer in the community? Do older residents participate in local decision making? 7. Communication and information. Are local sources of information available that address health concerns and service needs? Is information available in print and electronically? 8. Community support and health services. Are formal (public or private) home care services available? Are wellness programs available to promote optimal aging? Some communities add disaster planning and/or food security as additional domains. The eight domains provide broad guidelines for municipal officials to implement the integrated community planning necessary to create environments that support optimal aging. Because the domains cover diverse aspects of the social and built environments, the approach emphasizes collaboration. Departments within

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a jurisdiction must work together to write building and zoning codes that support aging in place and provide social and recreational opportunities for older residents of all abilities. Collaboration builds on successful programs and implements new services that will improve the age friendliness of the community. It also facilitates the exchange of information between stakeholders, establishes shared goals, and builds community support for the initiative. Several municipalities in Maine—not only members of the WHO-GNAFCC or AARP-NAFC—have addressed the eight domains of livability. Bath Housing Authority partnered with Habitat for Humanity 7 Rivers to create the Community Aging in Place initiative, which provides basic home modifications and simple home repairs that allow lower-income older residents to lengthen the time they can remain safely in their own homes.2 Bangor made changes in its outdoor spaces (e.g., adding sidewalk benches in areas frequented by older residents; increasing the length of pedestrian cross signals) that encourage older residents to remain active in the community (Sprague 2015). The Bucksport Bay Thriving in Place Partnership added a transportation program, fitness center, and lifelong learning opportunities to the programs and services available through the Bucksport Area Senior Citizen Center (Bradney 2015). The additions, building on the services and programs already in place in Bucksport, increase the health and well-being of older residents. Using the eight domains of livability to guide age-friendly community planning by municipalities within and outside the WHO or AARP network ensures that municipalities will address a wide spectrum of factors in the built and social environment that affect older residents. JOINING A NETWORK: SIZE AND FINANCIAL COST

oining a network is not limited to large municipalities. Age-friendly approaches are easily adaptable to communities of all sizes and all budgets. While a small town may not have the resources to build supportive housing, it may develop a handyperson network of volunteers willing to do simple home-maintenance chores and provide information about home modification and simple devices that can make everyday chores easier. Residents in a large metropolitan area may identify the need for longer pedestrian cross walk times to

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allow frail residents to cross busy streets safely, while residents in a suburb may identify the need for more designated accessible parking in the downtown shopping area. Changes in zoning to allow accessory dwelling units can benefit older residents in jurisdictions of all sizes. Age-friendly changes do not have to be expensive to improve the health and well-being of older residents. Since joining the WHO-GNAFCC, Bowdoinham has addressed the eight domains of livability without receiving money from the town. Bowdoinham’s Advisory Committee on Aging (ACOA) worked with other local institutions and volunteers to add social, recreational, and lifelong-learning programs, start a senior center, establish an annual aging well(ness) fair, organize a handyperson brigade to help older residents with simple home repairs, and create a display of simple devices that can make everyday life in the home and automobile easier for people living with arthritis, a mobility limitation, or with a sight or hearing impairment. ACOA also worked with the town to increase accessibility to public buildings and town-wide events. In 2014, Bowdoinham was one of 15 jurisdictions worldwide to receive a $5,000 grant from WHO to pilot Measuring the Age-friendliness of Cities: A Guide to Using Core Indicators. Money not used for the pilot became ACOA’s first operating budget. In 2015, ACOA received a small grant from AARP to work with the Bowdoinham Public Library to increase its age-friendliness. Communities do not need to be wealthy or large to benefit from joining the WHO or AARP network. In an era of tight municipal budgets, it is important to recognize the power of low-cost and no-cost approaches to age-friendly community development. CONCLUSION

eveloping cities and towns that are appealing to all generations is an important goal for community and economic development. Municipalities that want to be known as good places for people to grow up will also need to create optimum built and social environments that make the community a good place to grow old. Joining the AARP-NAFC and/or WHO-GNAFCC is one way for communities of all sizes and with different access to human and financial resources to structure planning for an aging population that is based on the preferences and needs of older residents, reflects the character of the community, and builds on existing programs and policies. -

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ENDNOTES 1. Population statistics are available from the U.S. Census Bureau’s American FactFinder website: http://factfinder .census.gov/faces/nav/jsf/pages/index.xhtml. Annual Estimates of the Resident Population for Selected Age Groups by Sex for the United States, States, Counties, and Puerto Rico and Municipios: April 1, 2010 to July 1, 2014, 2014 Population Estimates, Table PEPAGE SEX, Maine. 2. More information is available on the Bath Housing Authority website: http://www.bathhousing.org /programs/community-aging-in-place-cap/

REFERENCES Bradney, James. 2015. “The Emergence of Age-Friendly Communities: Highlighting the Town of Bucksport.” Maine Policy Review 24(2): 60–61. Kaye, Lenard, and Sarah Harvey. 2014. “Planning Services for Well Older Adults in Rural Areas.” In Aging in Rural Places: Programs, Policies and Professional Practice, 135–159. Springer Publishing Company, New York. Sprague, Benjamin. 2015. “The Emergence of Age-Friendly Communities: The City of Bangor.” Maine Policy Review 24(2): 62. Whitman, Deborah. 2013. “Age-Friendly Communities.” AARP International: The Journal 14-17. http://journal .aarpinternational.org/a/b/2013/02/Age-Friendly -Communities World Health Organization (WHO). 2007. Global Age-Friendly Cities: A Guide. WHO, Geneva. http://www.who.int/ageing/publications/Global_age _friendly_cities_Guide_English.pdf

Patricia Oh is the coordinator of older adult services in Bowdoinham, Maine, and a Ph.D. candidate at the University of Massachusetts Boston McCormack Graduate School of Policy and Global Studies in the Department of Gerontology. Her research focuses on the development of age-friendly communities in rural places.

AGE-FRIENDLY COMMUNITIES: BUCKSPORT

The Emergence of Age-Friendly Communities: Highlighting the Town of Bucksport by James Bradney

few miles up from the mouth of the Penobscot River sits the town of Bucksport. It is a town of roughly 5,000 stalwart individuals, many of whom have spent the better parts of their lives working for, or connected to, the recently closed paper mill. Bucksport is a hardworking community, closely knit together through its schools, churches, local businesses, social service agencies, and town government. The Bucksport Bay area is rich in history and scenic beauty. While warmly receptive of visitors from across the country who come to experience this history and beauty firsthand, Bucksport is more than anything a community that takes care of its local residents. Now more than ever, Bucksport’s ability to meet the needs of its older adult population is paramount. Although Buckport’s median age is in line with the Maine average of 44, there are more families in Bucksport living in poverty, more people without health insurance, and more people living with a disability per capita than

throughout the state (U.S. Census 2010; American Consumer Survey 2008–2012). To create healthy communities and citizens, we must all do our part to demonstrate a strong commitment to taking care of our own personal health as well as helping our family members and neighbors. This is the mission of the Bucksport Bay Healthy Communities Coalition, a nonprofit, grassroots community health organization with a particular focus on designing programs and services for pockets of the population who are traditionally underserved and underinsured. Through grant funding and municipal allocations, and with the help of many highly committed local organizations, the coalition has helped create a true age-friendly community. The most recent example of this is the Bucksport Bay Thriving in Place Partnership, which was made possible through grant funding from the Maine Health Access Foundation (MeHAF). MeHAF made it possible for our community to design

Town of Bucksport, Maine, viewed across the Penobscot River from Fort Knox.

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AGE-FRIENDLY COMMUNITIES: BUCKSPORT

a local program tailored to the needs of our older residents. We listened to what seniors were saying—to the things that were important to them in order to stay healthy, safe, and happy as they age in their homes. Out of that process, the Bucksport Bay Thriving in Place Partnership was born. Thriving in Place is an organized response that includes local health care and service providers, municipal departments, Bucksport Regional Health Center, the senior center, church-based volunteer organizations, Hancock County Home Care and Hospice, Eastern Area Agency on Aging, Gardner Commons (a 26 bed Housing and Urban Development-subsidized housing complex), a community care team, Regional School Unit 25, and Maine Long-Term Care Ombudsman’s Program. Together we created a continuum-of-care partnership program in which older adults enroll as participants entitled to a wide array of supportive services, at no cost to them other than a nominal suggested donation. For adults who no longer drive, opportunities abound to access a variety of low- to no-cost transportation options. A volunteer driver program provides transportation to local medical appointments at no charge. A $1 subsidized round-trip taxi service, a $1 weekly shuttle bus, and a monthly $3 roundtrip bus to Bangor are all running and well used. The town operates a lively senior center that hosts a low-cost adult meals program, which is provided by the school district’s food services department. The senior fitness program, “Growing Stronger” has been growing larger by the day, with an increased membership that prompted the recent training of new facilitators and more classes,

and a state-of-the-art fitness center is available for anyone in the community to use for $10 a month. A variety of educational trainings and workshops help older adults to prepare for future challenges. In partnership with the Eastern Area Agency on Aging, the Matter of Balance program helps prevent falls, while Living Well classes help individuals to maintain health and wellness. The United Way of Eastern Maine funds a program for older adults called Healthy Living, facilitated by the Bucksport Bay Healthy Communities Coalition in cooperation with the senior center. Guest speakers help older adults by assisting with legal documentation, powers of attorney, navigating Medicare, end-of-life choices, and a range of other useful topics. Whatever the need, organizations and people committed to working together towards a common cause can make great things possible. We’ve certainly seen that in Bucksport. Our older adult residents love living here and want to remain in their homes for as long as possible. James Bradney is the health planning director for the Bucksport Bay Healthy Communities Coalition, a nonprofit, volunteer-powered, community health organization serving Bucksport, Orland, Verona Island and Prospect. Through his work at the coalition, he has seen the power of organized volunteerism create positive social change and improved health and wellness among its community members.

Matter of Balance class participants learn how to reduce fear of falling and increase activity. MAINE POLICY REVIEW

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AGE-FRIENDLY COMMUNITIES: BANGOR

The Emergence of Age-Friendly Communities: The City of Bangor by Benjamin Sprague

ommentators and observers around the state seem to agree on one thing: Bangor is on the move! With the development of the Bangor Waterfront into an entertainment and cultural destination, the opening of the Cross Insurance Center, and continued growth in the city’s historic downtown area, Bangor is attracting interest and accolades from near and far. Bangor now has the youngest median age of any city in Maine. With all of the excitement, it would be easy for civic leaders to focus entirely on the younger generation when formulating public policy, but this has not been the case. In fact, a pointed effort has been made to highlight that many of the same things that younger people desire when determining where to live, such as recreational opportunities, cultural stimulation, affordable housing, and clean air and water, are the same things that older Americans want. For all the doom-and-gloom talk about Maine’s demographic challenges, what the city of Bangor has realized is that older Americans have a lot to offer in terms of raw economic output, mentorship, and life perspective. Bangor has been ranked one of the top places to retire in the country by Forbes Magazine and one of the best places to retire on less than $30,000 per year by AARP. How has this been done? One thing that has helped is that Bangor City Council has been extraordinarily balanced. During 2013–2014, the nine members of the city council represented every birth decade from the 1930s to the 1990s. This has brought diversity of perspective and the benefits of intergenerational relationships. Beyond this, the city has made extra efforts to engage with its older residents through a variety of channels. With more government information and municipal services online, older residents are potentially missing out on opportunities. The city now records all of its meetings and broadcasts them on the local public access television station. City leaders, including city councilors and representatives from the police and fire departments, have held quarterly workshops at elder living facilities and senior citizen social spots in Bangor.

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The city hosted an “Aging in Bangor” workshop and has surveyed local elders with the help of Eastern Area Agency on Aging. Bangor has implemented a number of ideas from these outreach efforts, such as longer pedestrian signals, improved brickwork, better snow removal, and extra benches on sidewalks where senior citizens frequently travel. More work needs to be done. For example, housing remains a persistent concern. With property taxes rising and many older adults on fixed incomes, municipalities need to partner with other organizations to ensure that elders can stay in their homes if they want to, downsize, or find a safe, stable, healthy, and affordable housing option that fits their needs and interests. Transportation is another concern. The city of Bangor manages a regional bus system, but costs far outpace revenues. The hours of the bus lines should be extended, the fleet of buses needs upgrades, and new routes should be added, but resources are tight. The challenges for Bangor, as for all municipalities in Maine right now, are declining resources and rising costs. Bangor has cut services yet has still seen property taxes increase in recent years. The shifting of unfunded state and federal mandates along with major cuts to the revenue-sharing program are taking their toll. Yet what has started to change in Bangor is the collective attitude about an aging population. We have a long way to go to be a truly age-friendly community, but Bangor has started to understand that an aging population can be an asset and one that we should build around in supportive and cooperative ways. Benjamin Sprague was born and raised in Bangor, where he now serves on the Bangor City Council and works for The First Bancorp. Ben graduated from Harvard University and worked for the Boston Red Sox for four years before returning to Maine in 2011. 62

LEGAL PLANNING FOR ELDERS

The Future Is Now: Legal Planning for Elders by Jennifer L. Eastman Legal planning for elders focuses on protecting retirement income and finding ways to pay for long-term health care. Jennifer Eastman discusses estate and tax planning and planning for retirement income, Social Security issues, and asset preservation. She notes that protecting elder adults requires planning and advocating for (or against) policy changes that could adversely affect elders.

egal planning for elders has changed dramatically in recent years. As estate-tax exemptions rise, along with the cost of and need for long-term care, legal services for elderly individuals have shifted focus from estate and tax planning to planning for adequate retirement income and savings and anticipating costs of long-term care needs in this era of increased longevity. Such planning is amorphous at best, as the rules and regulations surrounding these priorities for elders are in constant flux. While Benjamin Franklin said that nothing is certain except death and taxes, the better mantra of legal planners today emulates John Allen Paulos’s statement that “uncertainty is the only certainty there is, and knowing how to live with insecurity is the only security” (2003: Introduction). Rarely can planners ensure that an elder will have enough income, assets, and protection to provide for a comfortable retirement and a quality end of life. Often planners face families in crisis seeking legal assistance for an elder relative, faced with an unanticipated income, tax, or health care event that threatens to upend the precarious balance of financial security and quality of life. This article describes how the continuing development of retirement income protection and long-term health care present challenges to legal planners in advising the elderly and their families. Income protection includes not only estate and estate-tax planning, but also planning for retirement income, Social Security issues, and asset preservation. Health care issues generally revolve around paying for long-term care, but also include health care decision making. Protecting elder adults requires not only application of the current rule of law, but planning and advocating for (or against)

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those changes in policy that could dramatically affect the lives of elders today, and our lives tomorrow. SOCIAL SECURITY RETIREMENT1

he traditional metaphor of retirement funding as a three-legged stool, built on Social Security, pension income, and private investments, finds itself on three shaky legs in the current fiscal environment. Americans do not have enough savings, are outliving the savings they have amassed, and face a continued threat of reduced Social Security benefits. The Social Security system was designed to provide a minimum level of income for retired workers. Created by President Roosevelt in a post-Depression era, Social Security aimed to provide income for workers who had suffered through the Great Depression and had been unable to accumulate enough savings to fund retirement. Social Security was not intended to be the sole source of income for retirees; however, that is the case for many elders today. Twenty-nine percent of American households with members age 55 or older have no retirement savings or traditional pension benefits (U.S. GAO 2015). The GAO analysis of nine different studies conducted over the course of nine years concluded that up to two-thirds of workers may fall short of retirement saving targets. Current workers tend to overestimate their future retirement income and savings. They intend to work longer and save more in the final chapters of their careers, but those plans do not always come to fruition. People retire earlier than expected, most often because of unanticipated health issues, changes in the workforce, or 63

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health issues of a spouse or family member (VanDerhei 2012). These unexpected developments and shortfalls lead to crises in legal planning for seniors attempting to maintain their independence and a satisfactory quality of life in retirement. For those retirees who are fortunate enough to maintain the additional legs on their financial stools, Social Security funds roughly 39 percent of a retiree’s income. Social Security is estimated to keep over 35 percent of Americans above the poverty level (Shelton 2014). Social Security has become a necessity to maintain a minimum standard of living for many elders.

…threats to Social Security income cause legal planners to look for other ways to supplement and protect the income of their elder clients. Because of the security and protection afforded by Social Security, the retirement income system has been untouchable in the political forum. Attempts at reform within the system are viewed as an attack on the elderly, challenging the one thus-far stable expectation of retirement. But the system cannot last in its current form. The Social Security Administration indicates the surplus trust fund, currently covering the shortage between funds paid out and funds paid in, will be eliminated in 2034. With more baby boomers slated for retirement in the next 20 years, there are not enough workers paying into the Social Security system to balance the draw from benefits paid. Legislative attempts to reduce the Social Security benefit could have dire effects on the retirement income and quality of life of the retired workers who depend on this income. Social Security is underfunded, and Congress is regularly reviewing ways to reduce benefits, particularly looking to curb aggressive claiming strategies that can maximize benefits through manipulating the timing of collection for some upper-income recipients. Considerations for reform include chaining the annual cost-of-living adjustment to the consumer price index, which could have disastrous effects on those elders who rely on their social security to pay for prescriptions and health care. Other proposals include MAINE POLICY REVIEW

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raising Medicare premiums, which would reduce the net benefit paid to Social Security recipients. These potential reforms to protect the Social Security system would have substantial effects on middle- and lower-income retirees who must seek to maximize their Social Security benefits, often with no other source of income and looming health care expenses. These threats to Social Security income cause legal planners to look for other ways to supplement and protect the income of their elder clients. As IRAs and qualified retirement plans become primary retirement savings vehicles for the soon-to-be and newly retired, those funds can be used to supplement any potential losses from Social Security. However, increasing the taxable-income distributions from these plans can raise tax rates for retirees, increasing the amount of Social Security subject to tax, and offsetting any income benefit from the increased withdrawal. While qualified retirement plans are an efficient tax and savings vehicle, such plans can lead to negative tax consequences when they must be liquidated to pay for long-term care. Relying on the remaining legs of pension and private resources to support a weakening Social Security leg will not stabilize the stool of retirement security. Effects on any aspect of retirement income planning have necessary repercussions on the remaining pieces of the retirement puzzle, including tax and health care payment consequences. LONG-TERM CARE PLANNING

s the baby boomer generation increases the draw from the Social Security system, so too do aging boomers increase the demand on an already stressed Medicaid system. Medicare does not cover the expenses of long-term care, including assisted living or skilled nursing care. The average cost of private nursing home care in the state of Maine is estimated at over $100,000 per year. There are three primary sources of payment for such care: personal funds, long-term care insurance, and Medicaid. With the high cost of care and the large number of underfunded retirees, personal funds are easily exhausted, leaving elders in need of care that they have no way to fund. The federal Deficit Reduction Act of 2005 considerably reduced the availability of asset-preservation techniques employed by legal planners in qualifying elder clients for Medicaid benefits to pay for long-term care. An unmarried individual can retain only $2,000 in 64

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countable assets in order to qualify for Medicaid benefits. Retirement assets held in qualified retirement plans are considered countable assets. Withdrawing tax deferred retirement funds in lump sums, to privately pay for long-term care, or to spend down for Medicaid eligibility, will incur a substantial income-tax liability. Elders in need of expensive long-term care find themselves with an increased tax liability caused by the use of these funds to pay for their care, essentially wasting funds on income tax which would otherwise be available for their care. Elder law planners support modification of Medicaid regulations to exempt pretax retirement accounts including 401(k) accounts, 403(b) accounts, IRAs, and other retirement savings from consideration as countable assets for public benefit eligibility purposes. Modification could include a slow spend down of the funds through required minimum distributions, without disqualifying individuals for benefits, or creation of tax deductions to offset the increase in liability where the funds are spent on long-term care. Often elders will be eligible for a medical expense deduction from the high cost of their care, but such a deduction typically does not serve to offset the increase in tax on a dollar-fordollar basis. Qualified retirement plans grew in popularity because of the tax-deferred benefit. Loss of that tax-deferred benefit to pay the high cost of long-term care reduces the funds available to pay privately for the care and hastens eligibility for government benefits, but does not address the long-term care crisis by forcing individuals to spend those funds on income tax rather than for private care. Long-term care insurance can be the port in a storm for elders and their families in health care and financial crises. Long-term care insurance can provide coverage during the five-year look back for Medicaid eligibility, offsetting the cost of care during the interim period between transfer of assets for preservation from spend down and application for Medicaid. (Per federal regulation, upon application for Medicaid long-term care benefits, the previous five years of all financial records must be disclosed for review. Any significant transfer of assets, over $100 in Maine, may subject the applicant to a penalty period of time during which the applicant will be ineligible for benefits. The penalty begins when the applicant is otherwise eligible for benefits, i.e., medically and financially in need of Medicaid for long-term care.) The increasing restrictions on Medicaid eligibility, including an increase in the look-back period for transfers of assets, increased penalty periods for such transfers, MAINE POLICY REVIEW

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and increased estate recovery from the estates of decedents who received Medicaid benefits have all contributed to the attractiveness of long-term care insurance. Historically, long-term care insurance carried expensive premiums, little inflation protection, and often inadequate coverage. Current policies are vastly improved, as the insurance industry better understands its product and the needs of its clientele. Long-term care policies may still be a significant investment, but new policies make the insurance a wise decision. The Maine Partnership Program for Long-term Care provides the policy holders with an asset disregard benefit previously unavailable. The federal Deficit Reduction Act of 2005, which made it more difficult to qualify for Medicaid, also expanded the Partnership Program. “A Partnership Program is a collaboration or ‘partnership’ among a state government, the private insurance companies selling long-term care insurance in that state, and state residents who buy long-term care Partnership policies.”2 Qualified policies provide additional benefits when the policy benefits are exhausted and application is made for Medicaid. Under the Partnership Program, assets in addition to the $2,000 limit may be kept and the individual may still be qualified for Medicaid benefits. The amount of the disregard is calculated by the amount of benefits actually received under the long-term care policy. Policies with inflation protection can provide savings over the amount of the insurance originally purchased. In addition, these disregarded assets are not subject to estate recovery.

Long-term care insurance can be the port in a storm for elders and their families in health care and financial crises. The Partnership Program policy serves as strong motivation for individuals to invest in their own longterm care and sends a message that Maine and other participating states are willing to provide incentives for those willing to do so. It is clear that the United States has failed to create any effective policy on long-term care and instead has been closing loopholes and opportunities for any preservation of assets. Although Medicaid pays for long-term 65

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care, coverage is primarily in skilled nursing facilities, with few benefits (and much stricter eligibility limitations) available for in-home care. Because most people would prefer remain in their homes and receive in-home care, we must support policies that provide cost savings, protect autonomy, and allow for preservation of assets for family and in-home care. We are facing a looming crisis. As the need for long-term care grows with the aging of the baby boomer population, who are faced with reductions in Social Security benefits and already-inadequate retirement savings, the Medicaid system will only become more burdened, pushing costs back on to the people who do not have the assets to bear them. Continued development of policies and programs to support the needs of the elder generation and provide some relief from further reductions in retirement income will help ensure the quality of life and care of our elders and forge the path for continued change to craft a new plan for retirement and health care security for future generations. -

Jennifer L. Eastman is a partner at the law firm of Rudman Winchell, in Bangor, Maine, where she focuses her practice on estate planning and elder law. She serves as chair of the Maine State Bar Association Elder Law Section and is a member of the National Academy of Elder Law Attorneys.

ENDNOTES 1. Much information in this section is from the Social Security Basic Facts website. https://www.ssa.gov /news/press/basicfact.html. 2. Partnership for Long-Term Care website: http://www .partnershipforlongtermcare.com/maine-partnership /index.html.

REFERENCES Paulos, John A. 2003. A Mathematician Plays the Stock Market. Basic Books, New York. Shelton, Alison. 2014. Social Security: A Key Retirement Resource for Women. AARP Public Policy Institute. http://www.aarp.org/content/dam/aarp/research /public_policy_institute/econ_sec/2014/social-security -key-resource-for-women-AARP-ppi-econ-sec.pdf U.S. Government Accountability Office. 2015. Retirement Security: Most Households Approaching Retirement Have Low Savings. GAO-15-419. U.S. Government Accountability Office, Washington DC. VanDerhei, Jack. 2012. “Retirement Income Adequacy for Boomers and Gen Xers: Evidence from the 2012 EBRI Retirement Security Projection Model.” Employee Benefit Research Institute 33(5): 2–14.

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OLDER WORKERS AT L.L.BEAN

Older Workers at L.L.Bean by Wendy Estabrook Wendy Estabrook reviews L.L.Bean’s policies and practices that support older workers, and employees of all ages, through flexible schedules, generous leave policies, its Employee Assistance Program (EAP), and specific educational offerings for retirement planning.

ike most employers, certainly those in Maine, L.L.Bean has an aging workforce—or more accurately—a multigenerational workforce. Currently, we have employees ranging in age from 16 to 91, with an average age of 49. We don’t see this as a problem, but rather as a benefit in many ways. We benefit from having people at all stages of life and career and from engaging and supporting them throughout their careers. Our approach is to be an employer with “ageless appeal.” Most of our benefits, policies, and programs appeal to employees at all stages of life. We have actually found that typically what is good for the 25-year-old is also good for the 55-year-old employee although that may be for different reasons. For instance, flexibility in the workplace is valued by employees at all stages of life and career. As a fairly large employer, we are able to offer many kinds of jobs and schedules. We have full- and part-time jobs with various shifts and flexible hours, as well as a variety of statuses: full-time, and three levels of part-time (on-call, seasonal, and active retiree). Hours associated with the different statuses vary dramatically. Some jobs offer the opportunity to work from home either occasionally or on a regular basis, a situation made possible by today’s technology. Our Customer Satisfaction Department provides many employees the opportunity to work as home agents, taking calls from the comfort of their home offices. To meet the changing needs of employees’ lives, many areas of the company allow employees to easily give away and pick up shifts as needed. We also provide a number of benefits that appeal to all ages. We offer generous leave-of-absence policies so people can take time away to care for themselves or others. In addition to offering required types of leave, we offer L.L.Bean Family Medical Leave. This is available for care of a family member with a serious medical issue that is not covered under FMLA, and employees

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are able to take up to six months in a 12-month period away from work. We focus on health and fitness by providing onsite fitness rooms and classes for employees and retirees. Our goal is to help employees to stay healthy and fit so they can enjoy life to the fullest, including working in a safe and healthy way. We also offer flexible spending accounts, so employees can use pre-tax dollars to pay for health expenses or dependent care for children or for aging parents. With an average employee age of 49, it stands to reason that many of our employees are experiencing issues with aging parents. We see this through the number of leaves of absence taken by employees, as well as through feedback from our Employee Assistance Program (EAP) provider. For each of the past two years, we’ve had a significant and increasing number of employees take a full or intermittent leave of absence to take care of an aging parent. Fortunately, because we offer intermittent leaves, most employees have been able to flex their schedules to care for parents as needed while continuing to work. Approximately 15 percent of the employees who have sought out support through our EAP this year have had a significant issue related to an aging parent: • Looking for emotional support/want to process with a provider • Dealing with role reversal • Dealing with illness and death • Finding themselves addressing sibling issues/ family dynamics • Problem solving/needing to find resources • Experiencing financial issues related to supporting the parent

OLDER WORKERS AT L.L.BEAN

• Requiring legal advice on issues related to powers of attorney. In addition to offering one-on-one counseling on these issues, our EAP partner, Bridgetree Counseling, provides an Eldercare Seminar each year called “Taking Care of Mom and Dad and...Me.” This seminar is made up of four sessions focusing on legal issues, Medicare, living with dementia, and how to find and access community resources. Through the sessions, we bring in different partners including Southern Maine Agencies on Aging, Legal Services for the Elderly, Spectrum Generations, and the Alzheimer’s Association. Because we have many employees nearing retirement, we are also investing heavily in retirement education. Many, maybe even most, people acknowledge that they don’t have a plan for their retirement. They haven’t formed their thoughts about what their retirement life will look like, what the expenses will be, or how they will meet those expenses. In-house, we have developed and are offering quarterly pre-retirement information sessions. These sessions are positioned to be most helpful to employees who are thinking about retiring within the next two years, but often draw a younger crowd. The sessions focus on understanding pension benefits, options within 401(k) accounts, understanding health care options in retirement, company retiree benefits, and what decisions a person needs to make (and when) to make a smooth transition into retirement. In addition to our in-house programs, we’ve also reached out and partnered with many other retirement resources. For instance, we offer a four-part series called “Retirewise” with external provider MetLife, coupled with the opportunity for the employee and a guest to meet one on one with a retirement planner. Our 401(k) administrator provides annual sessions on “Designing a Financial Roadmap and Building a Portfolio for Any Weather” along with one-on-one consultation appointments. We’ve also invested in an online retirement planning system, which allows employees to project sources of income in retirement (pension, 401[k], social security, and other savings) as well as project anticipated financial needs to determine retirement readiness. In 2014, approximately 700 employees attended at least one of our retirement education sessions. For people wishing to phase into retirement, L.L.Bean allows employees to remain working and begin to collect their pension at age 65, which can help MAINE POLICY REVIEW

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them afford to work fewer hours if they are looking for more flexibility in their lives. L.L.Bean also has an active retiree status, so that retirees who leave the company can return to work for us at a future date, typically in a reduced-hour or seasonal situation. Meeting the needs of an ever-changing workforce is an ongoing process. Current indicators, such as feedback through our EAP program and our annual employee engagement survey, tell us that we are on the right track, but we continue to listen and work to provide a great place to work for employees at all stages of life and career. Wendy Estabrook is a director of human resources at L.L.Bean. In her role, she oversees a number of departments in HR to support the company and its employees. She is currently the co-convener of the Maine Workforce and Employment Workgroup, sponsored by the Maine Council on Aging and the state of Maine’s Aging Initiative.

IMMIGRANT ELDERS AND MAINE

Immigrant Elders: What Can Maine Learn from Other States? by Linda Silka Maine is not yet home to large numbers of immigrants, but that may soon change. Linda Silka presents lessons from elsewhere about elder immigrants and considers their implications for Maine. She suggests that attention to the topic of immigrant elders will help Maine to create policy and opportunity for all elders.

he United States is changing demographically. Many more immigrants1 now live in the United States than in the recent past, and immigrants are a major source of population growth and cultural change. From 1960 to 2005, immigrants and their descendants accounted for 51 percent of the increase in U.S. population; from 2005 to 2050, immigrants are projected to contribute 82 percent of the total increase of U.S. population (Passel and Cohn 2008). Maine remains among the least ethnically diverse states in the country and is not yet home to significant numbers of immigrants. In Maine, only 3.4 percent of the population in 2013 was foreign born, compared to 13.1 percent nationally (Table 1). According to 2010 census figures, Cumberland County has the largest proportion of foreign-born residents (5.5 percent); Portland and the surrounding area are home to many

immigrants (Mattingly and Schaeffer 2012). The top country of origin for the foreign-born in the state overall is still Canada. However, the African-born population in Maine has been increasing, now making up 11.2 percent of the foreign-born population in the state, compared to 4.0 percent for the United States as a whole (Gambino, Trevelyan, and Fitzwater 2014). In spite of relatively low absolute numbers, the foreign-born population in Maine is growing at a faster rate than the U.S.-born population, as is the case in the rest of the country. From 2000 to 2013, the foreignborn population in Maine grew by 21.8 percent compared with 3.7 percent for the U.S.-born population. Although immigrant population has increased, Maine has not yet had a major overall increase in immigrant numbers. This allows us time to plan for a future that will be more diverse than the past.

Table 1: Foreign-born Population in Maine and United States, 2000 and 2013

MAINE

UNITED STATES

2013

Number Percentage Percentage change: 2000–2013

2000

2013

2000

Foreign Born

U.S. Born

Foreign Born

U.S. Born

Foreign Born

U.S. Born

Foreign Born

U.S. Born

44,687

1,283,615

36,691

1,238,232

41,348,066

274,780,773

31,107,890

250,314,016

3.4

96.6

2.9

97.1

13.1

86.9

11.1

88.9

21.8

3.7

32.9

9.8

Foreign born refers to people residing in the United States at the time of the population survey who were not U.S. citizens at birth. The foreignborn population includes naturalized U.S. citizens, lawful permanent immigrants (or green-card holders), refugees and asylees, certain legal nonimmigrants (including those on student, work, or some other temporary visas), and persons residing in the country without authorization. Source: U.S. Bureau of the Census’ American Community Survey (ACS) and Decennial Census. 2013 data are from the one-year ACS file

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IMMIGRANT ELDERS AND MAINE

Concerns are often raised about Maine’s stagnating population: declining birth rates, out-migration, and lack of in-migration. Some Maine leaders have been encouraging the state to consider how Maine’s economy might benefit from an increase in immigrants. The sense of urgency about Maine’s future stems from the fact that older people make up an ever larger proportion of Maine’s population. What will happen if there are fewer people to hold jobs, build businesses, and create families? Into this fraught conversation comes the immigrant question: What would it mean if the aging population included many more immigrants? What would be the opportunities and challenges?

Until recently, most services for elders were based on largely unexamined assumptions about culture. What insights can we gain from examining the experiences that communities in other states have found to be successful? In this article I review lessons from elsewhere and consider their implications for Maine’s future, using examples from Lowell, Massachusetts. Lowell has confronted many of the struggles faced by other New England communities: a declining economy and population loss. This has changed in recent years as the city has become diverse in its immigrant population, with residents from Africa, Central and South America, and Southeast Asia. What Lowell reflects is a commitment to innovative problem solving. Here, there has been an effort to use the challenges to enlarge understanding of how to support immigrant elders as a part of creating a lifetime community for all. AGING AND IMMIGRATION: INTERTWINED THEMES, INTERTWINED CONCERNS

he many ways in which issues of aging and immigration are intertwined in the public eye is readily apparent in popular discussions. Immigration is seen as figuring in the future prosperity of the country; immigration is seen as an answer to demographic age shift; and immigrants themselves face challenges in aging in the

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unfamiliar culture of the United States. These different themes speak to the complexity of the immigrant issue. Some factors suggest that elder immigrant populations are likely to be vulnerable. Foreign-born elders often have less personal income than do their U.S.-born counterparts, and immigrants are more likely to live below the poverty line (PRB 2013). Immigrants often have limited English proficiency, little or no U.S. work experience, low educational levels, and weak ties to mainstream social institutions (PRB 2013). On the other hand, many aspects of the lives of immigrant elders could be sources of strength. Their social capital is often high. They often live in multigenerational households rather than alone and in communities surrounded by others from similar backgrounds. They also often have strong ties to ethnic organizations, and churches, temples, or synagogues that bring them into regular contact with their culture and community. Their lives may be organized around a series of daily features that add meaning, value, and structure. INNOVATION AND PROBLEM SOLVING: ILLUSTRATING THE ISSUES

ntil recently, most services for elders were based on largely unexamined assumptions about culture. Given the increasing diversity of the elder population, many communities are finding that they can no longer assume that practices that worked well in the past will succeed in the future. By examining how other communities have responded to the changing face of their elderly population, we can begin to envision how Maine communities can become places that support diverse elder populations. Health Beliefs Cultural beliefs about health may be a source of dissonance between some immigrants and some health care providers. As an example, diabetes is one of the major chronic illnesses to which many health care dollars for elders are devoted. In Lowell, it was assumed that everyone would agree that diabetes is a problem and that individuals should take preventative steps to reduce their likelihood of becoming diabetic. Immigrants, however, helped providers to see the complexities. Diabetes is associated with being overweight, and in countries with high rates of poverty, only the rare individual with plentiful access to food had the luxury of becoming overweight. 70

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Culture

Policymakers sometimes forget in pursuit of the goal of providing health care recommendations to all that it is important to understand individuals’ past experiences. U.S. dietary guidelines emphasize reducing fat and meat intake and eating nutrient-rich whole grains such as brown rice rather than white rice. Providers in Lowell shared these guidelines with immigrants with seemingly little impact, and new immigrants were consuming a diet that was much heavier in meat and fat than the diet they ate in their home countries. It was only through working together at the community level that the cultural factors at work became clear. A high-fat, high-meat diet was in many ways an aspirational diet, one that was not possible to achieve in the poor country from which they came. The advice to change from white rice to brown, from the perspective of many immigrants, was as if they were being told to eat dirty food. In Lowell, the question then became one of how to draw on elder knowledge to create healthier, but still culturally appropriate, recipes. Food Scarcity Immigrants from poor countries have sometimes gone through periods of intense and recurrent food insecurity. In Lowell, many of the new immigrants had experienced extreme periods of food scarcity. Indeed, many Cambodians had lived under near starvation conditions during the difficult Khmer Rouge years. Research has suggested that that the impacts of extreme food deprivation last well beyond the period of actual food scarcity, with persons who faced starvation diets as young people likely to continue showing effects for decades. This knowledge has led to concerted efforts in Lowell to change the approaches of nutrition practitioners to focus on people’s extended histories with food scarcity. Prevention Practices In many immigrant homes, elders live with their adult children and grandchildren. These elders often have high status, which makes it culturally inappropriate for younger members of the family to determine what behaviors are allowable in the home. For example, although research has demonstrated the problems of second-hand smoke, in some cultures it is not appropriate for younger people to insist that their elders go outside to smoke. Providers in Lowell worked with the community to devise ways to combine the old and the new. Using widely attended classes in English as a MAINE POLICY REVIEW

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second language, the providers created a miniature model house to illustrate the healthy practices many immigrant families already followed, such as leaving shoes outside to avoid bringing in contaminants. The presentations were then developed to suggest that not smoking in the house was a similar practice. Aging and Post-Traumatic Stress Disorder

Providers are often faced with people with long-ago pasts that are unfamiliar to the providers. How can they prepare to meet those needs? To some extent this conundrum is true with regard to all elders, but it can be especially true for the immigrant elder. In Lowell, a puzzling problem started to appear among immigrants who had held jobs and been a part of the community for decades. Cambodian elders started showing symptoms of post-traumatic stress disorder after years of exhibiting no symptoms. In some cases, they were no longer able to hold down a job or function in their community. Social workers began revising their practices to meet the needs of these immigrant elders.

Immigrants are far from alone in experiencing elder-onset problems such as post-traumatic stress. Immigrants are far from alone in experiencing elder-onset problems such as post-traumatic stress. The apparent reemergence of post-traumatic stress in older Americans who served in the military is of increasing concern. And it is not just the military. In advanced age, survivors of long-ago disasters may show post-traumatic stress. Examining these different traumatic experiences may help in the development of approaches to building resilience. Well-Being, Exercise, and Walkability Some things are viewed as noncultural. Exercise is often framed as noncultural, as simply something everyone should do. For elders, it can be important for maintaining balance and physical strength, and exercise can be a way to increase one’s social interactions with others. In Lowell, immigrant elders help us to see a much more complicated picture of exercise. As a part of a larger program to look at the best practices immigrants 71

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bring from their home countries, focus groups were held in which immigrants were asked about how community characteristics (such as housing, businesses, and transportation) were organized in their home country. Immigrants repeatedly described that things were located closer together. The home was within walking distance of where one obtained food, shopped, or carried out other daily functions. People expressed surprise at resources being so segregated in American towns and surprise that one mostly had to drive to reach anything. In effect, they described a pattern of livability that is now being touted as new urbanism among community planners, a style of planning that puts an emphasis on increasing the walkability of communities. Immigrants in Lowell missed the experience of walking to do their tasks; elders who were unable to drive expressed concern about their dependence on adult children to get around. Although the arrangement of houses and stores canâ&#x20AC;&#x2122;t be changed without great cost, providers in Lowell began to look for other ways to build in exercise that is consistent with cultural practices. For example, since religion is central to many immigrant elders, Buddhist elders in Lowell began a program of walking meditation, connecting walking to an important faith practice. The emphasis was placed on exercise not as an isolated activity, but as linked to practices that reinforce cultural traditions. Housing Housing issues loom large in elder considerations. What kind of housing will people need as their health fails or they are no longer able to drive? What would congregate housing need to be like to meet the needs of diverse elders? The immigrant experience brings different perspectives to these questions. Immigrants live with family in intergenerational arrangements more often than nonimmigrants do. Within many immigrant communities, families whose elders resort to congregate housing face stigma. And while isolation among homebound elders is a central concern, the various forms of isolation and possible solutions can take different directions in immigrant communities. Immigrant communities are trying to innovate around these issues. For example, members of a Laotian Buddhist temple near Lowell were increasingly concerned that some of their elders were isolated and lonely. Temple members began to envision developing housing near the temple for elders. The temple brought in faculty from the nearby university to help them to MAINE POLICY REVIEW

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design a process that integrated American planning approaches with Buddhist values to create housing that would link elders back to the younger generations. They drew on models from Copenhagen, Denmark, and other places that have found ways to build elder housing adjacent to day care centers as a way to strengthen connections across generations. DISCUSSION

n considering the challenges and opportunities posed by aging in the immigrant population, policymakers need to consider multiple lenses through which issues may be viewed. Culture infuses every part of daily life and longterm hopes and expectations. We can ask what cultural differences might be especially important to understand as we try to create practices that are effective across a range of cultures. Elder issues are deeply linked to family structures and dynamics. As policymakers consider the impact of families, it will be important to understand what family means in different cultures. What is the role of the elder? What are the expectations for family life? What can we learn when intergenerational relationships are especially valued or take unfamiliar forms? Such questions can serve as a beginning point in envisioning new policies. Health is central to much thinking about aging, but the immigrant aging experience brings new issues to the forefront. How do we think about things such as exercise when cultural views of the acceptability of exercise vary widely? With an eye to immigrant experiences, how do we understand aging and mental health issues? What would it mean to take into account health problems in which aging could be linked to a reemergence of past trauma? Food both divides and brings cultures together. Seeking to understand the elder immigrant experience through the lens of food will be instructive. Lowell policymakers saw repeatedly that the food available through food pantries and food-support systems often was not familiar to immigrant families. The food was sometimes inappropriate, for example, heavily emphasizing dairy products for populations with high rates of lactose intolerance. In addition, many immigrants were unfamiliar with programs such as Meals on Wheels. Family traditions might be at odds with U.S. practices of when and what to eat and who decides all this. Gender, family, and income issues all come into play with the issue of food. 72

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For policymakers struggling with the many dilemmas of aging in place, the perspectives and experiences of immigrants can give new examples. Immigrants can help us to think in expanded ways about nursing homes, assisted living, intergenerational living, support structures, community supports, and the role of faith organizations. What form might aging in place take in various immigrant communities? What customs, strategies, and ideas have people adopted and which of these could these be adapted to Maine? Issues of poverty underlie many of the examples mentioned here. Immigrants are more likely to live in poverty, particularly immigrant elders. Does poverty look different or take different forms when one has extended family networks or lives in communities that are enclaves of people of the same cultural background? What new approaches to poverty could be envisioned by understanding these experiences? CONCLUSION

t the outset of this article, I noted that there is limited work about elder immigrants in Maine. Attention to this topic, however, is important; it will help Maine to create policy and opportunity not just for immigrants but for all elders. At present, we often assume that certain approaches to elder issues will work for everyone. Immigrant elders are a reminder of the diverse histories and cultures that characterize the elder experience. Maine is sometimes negatively described as a state with an illustrious past but not much of a future. It is sometimes seen as emptying out—as losing its population, its strategies for growth, and its way forward. Lowell likewise was described in this way: as having an eminent past as a birthplace of America’s industrial revolution, but as having become an emptying, dying place. Multiple intertwined approaches led to the changes in Lowell—approaches Maine needs to consider also as we face an aging and increasingly diverse population. Maine has the potential to be a leader in devising effective, innovative approaches to immigrant elder issues. Many other states have been so inundated that they are forced into a catch-up role. Maine has the luxury of learning from their experiences to set the groundwork for approaches based on Maine experiences, ethos, and resources, and that take into account our weather, economy, and dispersed populations. Maine has a long tradition of welcoming newcomers. Although past newcomers came from different parts of

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the world from where people now are coming, immigration remains an important part of our tradition and part of what has made Maine what it is today. Though others might see a large percentage of elders as a problem, we need to look for the opportunities in the years of knowledge elders carry, and the diversity of that knowledge when the elder population is diverse in its experience, outlook, skills, and traditions. ENDNOTE 1. As is common in much of the literature, the overarching term immigrants will be used here to include both refugees and immigrants.

REFERENCES Gambino, Christine P., Edward N. Trevelyan, and John Thomas Fitzwater. 2014. The Foreign-Born Population From Africa: 2008–2012. American Community Survey Briefs, ACSBR/12-16. U.S. Census Bureau. https://www.census.gov/content/dam/Census/library /publications/2014/acs/acsbr12-16.pdf Mattingly, Marybeth, and Andrew Schaeffer. 2012. Report 1: A Demographic Profile of Maine, Highlighting the Distribution of Vulnerable Populations. Final Report to the John T. Gorman Foundation. Carsey Institute at the University of New Hampshire, Durham. Passel, Jeffrey S., and D’Vera Cohn. 2008. U.S. Population Projections: 2005–2050. Pew Research Center. http://www.pewhispanic.org/2008/02/11 /us-population-projections-2005-2050/ Population Reference Bureau (PRB). 2013. “Elderly Immigrants in the U.S.” Today’s Research on Aging 29(October).

Linda Silka is a social and community psychologist by training, with much of her work focusing on building community-university research partnerships. Silka was formerly director of the University of Maine’s Margaret Chase Smith Policy Center and is now a senior fellow at the George Mitchell Center for Sustainability Solutions. Before coming to UMaine, she was a faculty member at the University of Massachusetts Lowell.

AGING, DIVERSITY, AND DIFFERENCE IN RURAL PERSPECTIVE

C O M M E N T A R Y

Aging, Diversity, and Difference in Rural Perspective by Douglas Kimmel

nowing that someone is age 70, 80, or 90 actually gives little information about the individual person. In our ageist society, chronological age operates as a master status that overwhelms other aspects of human diversity, unless we look closely at the individual. In rural Maine, in fact, it is almost impossible to guess the chronological age of our neighbors, and frequently I am surprised when the person reveals it. We all know of two 65-year-olds who are contrasts of health status, but we seldom are aware of the multiple other aspects of diversity that are important in understanding the individual aging experience. This brief commentary will focus on several aspects of diversity, calling attention to one of the less frequently recognized dimensions: sexual orientation and gender identity. In rural Maine, we frequently think that the aging population is not diverse, that it is overwhelmingly white, and that the important dimensions of diversity are visible, such as race or ethnicity. All white people are not alike, however. We have learned that America is a melting pot that reduces white immigrants into a uniform American. Nonetheless, looking simply at the example of Maine political leaders, we find Franco-Americans such as Mike Michaud and Paul LePage, Arab-American such as George Mitchell, Italian-Americans such as John Baldacci and Louie Luchini, mixed English and French such as Margaret Chase Smith, mixed Irish and English such as Susan Collins, mixed Protestant Irish and

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Russian Jewish such as William Cohen. Each of these cultural heritages bring diversity to the white melting pot of America; not everyone aging in Maine is a descendent of the Pilgrims. In addition to the immigrants from other countries (discussed elsewhere), rural Maine has four tribes of Native Americans: Aroostook Band of Micmac, Houlton Band of Maliseet Indians of Maine, Passamaquoddy Tribe of Maine, and the Penobscot Nation. African American families have lived in Maine since Reconstruction, many returning from Canada after the Civil War ended the Fugitive Slave Act that made Maine an unsafe residence at the end of the Underground Railroad. The Talbot family, for example has lived in Maine for six generations, and Gerald Talbot was Maine’s first AfricanAmerican legislator. Less visible dimensions of diversity in aging individuals in rural Maine are place of birth (born in Maine vs from away); social-economic status, reflecting educational level, work history, housing condition, and retirement income; disabilities such as hearing, vision, mobility, developmental disorders, and mental illness; and sexual orientation or gender identity (SOGI). Few gerontologists considered SOGI as a dimension of diversity until gay and lesbian organizations began to become visible. Prior to the late-twentieth century, gender (e.g., male or female) was regarded as the sole relevant variable of interest. Sexual orientation

was linked with sexuality, which was assumed to no longer be important for old people. Little popular information was available about transgender individuals, aside from Christine Jorgensen who had a sex change operation in the 1950s and drag performers who lip-synched to recorded music at local venues. Often gerontologists responded to my research of gay male aging with surprise: “I never thought homosexuals grew old!” In 2012 SAGE Maine, an affiliate of Services & Advocacy for Gay, Lesbian, Bisexual, and Transgender (GLBT) Elders, conducted a statewide needs assessment to determine the focus this organization was to have as a new affiliate. We found several issues of concern. Two out of three respondents had experienced verbal harassment almost always motivated by homophobia; one out of five had been physically assaulted and one out of seven felt they were assaulted because of homophobia; nearly 30 percent experienced property damage, and one out of six felt this was due to homophobia. Twenty-two percent felt they had been discouraged from participation in faithbased activities or discriminated against in their faith-based community because of their GLBT identity. The respondents want providers who understand their special needs. One in five reported they had been the victim of discrimination while being treated by a health care provider, and 22 percent worried that their health care providers would treat them differently if they disclosed their GLBT identity. There was also a need for appropriate legal assistance: although over half of the respondents had some legal arrangements, 28 percent had none. Moreover, an overwhelming 86 percent said they would be more likely to choose a social service provider who is trained or knowledgeable in GLBT issues.

AGING, DIVERSITY, AND DIFFERENCE IN RURAL PERSPECTIVE

C O M M E N T A R Y The need for social activities was important. While most of the respondents did not feel isolated, 16 percent reported being isolated because of lack of friends and 17 percent because they lived in a rural area. Two out of three reported being depressed for several days or longer in the past two years, and 88 percent said they would participate in GLBT community activities if they were offered in their area. The most serious worries of the respondents were about long-term care facilities and life planning. Sixty-three percent were concerned about the facility honoring their will or their partner’s wishes; 58 percent were concerned about visitation due to staff; and 53 percent were concerned about visitation due to facility regulation. Over two-thirds were concerned about receiving Social Security or other benefits after their partner died. Over half were worried about having their sexual identity honored, and 44 percent were concerned about housing after their partner passed away. There is an important role for affirmative support and education concerning diversity issues in Maine. At least four goals are suggested by these data: 1. Provide support and assistance if harassment or assault is experienced and broader education regarding Maine legal protections for GLBT individuals.

GLBT-affirmative providers of mental health services. 4. Train staff and management of long-term care facilities to provide a referral network of GLBT-affirmative facilities. SAGE Maine has begun work to meet those goals; it can be contacted at www.sagemaine.org. We are fortunate to be growing older in Maine, where legal civil and human rights protections prevent discrimination on the basis of sexual orientation and gender identity in all public accommodations, including nursing homes, assisted living places, and hospitals—for the staff as well as for those being served. Maine is also becoming more ethnically diverse as we find that the skills and youth of immigrants from abroad are essential for economic growth and for meeting the needs of our aging population since it is the oldest state in the country. Our challenge, of course, is to maximize the benefits of diversity and to minimize any aversion to those who are different from us. In truth, the older we get, the more unique we become, each of us adding daily to the diversity of our communities. -

Douglas Kimmel is professor emeritus of the City College of City University of New York, where he taught psychology and aging. He is a co-founder of Services & Advocacy for GLBT Elders (SAGE) and currently is the executive director of SAGE Maine. A retired psychologist, he lives in Hancock, Maine, with his husband whom he married in 2013, 44 years after their church (but not legal) wedding in 1969. -

2. Create a network of health care providers and other professionals who are knowledgeable and affirmative regarding GLBT aging issues. 3. Create opportunities for social support and activities to reduce isolation and depression as well as appropriate referrals to MAINE POLICY REVIEW

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CREATIVITY AND AGING

Creativity and Aging by Kathleen Mundell Kathleen Mundell discusses the importance of creativity and creative engagement for older adults and their communities. She describes several projects sponsored by the Creative Aging Program of the Maine Arts Commission, which is one of 14 state arts agencies invited to participate in a national pilot program as part of the National Center for Creative Aging’s Engage Initiative.

Gene Cohen, director, George Washington University’s Center on Aging, Health & Humanities

etting older doesn’t have to be all bad news. Today, people are living longer than previous generations did, and for many, later life holds exciting opportunities for personal development and exploration. By shifting our focus from physical and mental decline to vitality and an expanded sense of self as we age, we open ourselves to the possibility of future years filled with growth, learning, and fulfillment. Central to this viewpoint is recognition of how creativity affects the aging brain. More than two decades ago, Dr. Gene Cohen, renowned geriatric psychiatrist and director of the Institute on Health, Humanities and Aging at George Washington University, suggested that creativity was like chocolate for the brain. His landmark research pointed to the positive impact of creativity on older adults’ physical, mental, and emotional health. He coined the term creative aging to describe how creativity, in all its multifaceted forms, can not only sharpen cognitive skills but further the aging brain’s ability to grow, change, and form new connections. (Cohen 2000). But creative aging is not just about cultivating creativity. It’s also about engagement. The term creative engagement refers to the benefits of participating in creative endeavors with others at both individual and

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community levels. Such opportunities enable older adults to forge new connections and expand and strengthen their social networks while gaining a sense of personal value and meaning, all of which are keys to brain health (Dahlberg 2002). Anne Basting is founder and director of the University of Wisconsin-Milwaukee Center Center on Age & Community and director of TimeSlips, a nationwide program that uses improvisational storytelling as an invention for people with dementia and other cognitive disabilities. She describes the benefits: “Creative Engagement opens a path to a stronger sense of self in community. It develops a sense of purpose, of legacy. It creates a sense of belongingness” (http://www.utimes.pitt.edu/?p=21699). In 2014, as part of the National Center for Creative Aging’s Engage Initiative, the Maine Arts Commission became one of 14 state arts agencies invited to participate

Photo by Sam James Levine

Creativity is hardly the exclusive province of youth. It can blossom at any age—and in fact it can bloom with more depth and richness in older adults because it is informed by their vast stores of knowledge and experience.

As part of the Beehive Collective’s project, Norma Haynie, Whitneyville, is photographed holding an image of her first boyfriend.

CREATIVITY AND AGING

in a national pilot program aimed at increasing the capacity of state and local arts organizations to improve the lives of older adults. As a result, the commission developed the Creative Aging Program. Aimed at fostering creative engagement, the program supports local projects that enhance older adults’ quality of life and honors the vital role that elders can play in community life. In designing the program, we looked to the research into how older adults learn. Particularly influential was the work of Malcolm Knowles, who contrasted the needs of adult learners with those of younger students. He found that older learners are more self-directed than their younger counterparts and are drawn to challenges that call for problem solving and hands-on engagement—a learning style that Knowles dubbed andragogy. Elders, he found, learn best in collaborative, process-oriented settings, as opposed to more traditional, didactic approaches centered on merely conveying content. They are especially motivated by topics and activities that are relevant to their life experiences (Knowles 1984). In addition, the Creative Aging project is anchored in a set of principles put forth by Gay Hanna and Susan Perlstein (2008) of the National Center for Creative Aging. Following Hanna and Perlstein’s precepts, the Commission sought to • Follow adult learning principles by incorporating students’ expertise and life stories. • Develop programs sequentially with measurable outcomes, both to support evaluation and to increase learners’ sense of meaning and purpose. • Emphasize mastery and skill-building.

in community settings from libraries to senior centers, the roster covers a range of artistic disciplines, including dance, visual arts, theater, and poetry. Participating artists receive training from the commission in best practices in creative aging, program design and implementation, and the development of effective teaching plans. To date, the commission has provided free training for teaching artists by nationally known programs including TimeSlips and Lifetime Arts. Both of these opportunities were positively regarded by participants and have laid an excellent foundation for a strong program in Maine. • Community Partnership Program—a fund for nonprofit organizations seeking to develop participatory programs involving artists from the Teaching Artist Roster. Successful projects incorporate creative-aging principles of social engagement and creativity, as well as a public component that promotes intergenerational exchange while honoring older community members. Throughout the Creative Aging Program’s first year, these resources helped foster a variety of local programs in which painters, dancers, storytellers, and bookmakers teach six- to eight-week workshops at local libraries, senior centers, and assisted living centers. Following are several success stories from year one. Imagine how much stronger communities will be when they choose to benefit from the time and talents of their most experienced citizens. Stacey Easterling, Program Executive for Aging, Atlantic Philanthropies

• Engage professional artists to lead program development and implementation. • Build sustainable partnerships across sectors and agencies to promote public awareness. Thus informed, the commission developed resources aimed at promoting the development of creative-aging programs at the local level. Among the most successful of these resources are the Creative Aging Teacher Artist Roster and the Community Partnership Program. • Teaching Artist Roster—a free, online resource for nonprofit organizations interested in developing creative-aging programs. Featuring teacher artists interested in working with older adults

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THE BEEHIVE DESIGN COLLECTIVE: STORY GATHERING

s part of the pilot for the Creative Aging Program, the Beehive Design Collective, an all-volunteer, art-activists collective based in Machias, Maine, spent the summer of 2014 interviewing town elders and recording their stories. The project coincided with the collective’s restoration of several downtown historic buildings. As project director Hillary Savage explained: We took a moment to gather stories about the buildings’ previous lives and what they meant

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The story-gathering project exceeded expectations. By highlighting and preserving elders’ stories, it not only yielded memories that will be used to inform decisions as to the future of the town’s historic structures, but also sparked connections between generations, heightened townspeople’s sense of place, and served as an overt acknowledgment of the importance of elders as keepers of local culture. As Savage commented, “This process was a way to gain insight into and honor the past as well as use that memory to inform decisions about the next stage of the buildings’ life. The project grew beyond what we initially anticipated and we are now looking to see how we can further honor these stories and share them with generations to come.” TRADITIONAL ARTS APPRENTICESHIP PROGRAM

s we age, sharing our stories helps us to affirm who we are and achieve personal integration, an essential step in the passing on of one’s legacy (Haight and Haight 2007). Being cast in this generative role is one of the gifts of growing older. It allows us to contribute the wisdom we’ve gained through experience and at the same time asks us to step into the role of teacher—a process that often gives our lives a renewed sense of purpose (McAdams and de St. Aubin 1992). The Maine Arts Commission’s Traditional Arts Apprenticeship Program, funded by the National Endowment for the Arts and now in its 25th year, demonstrates one way to put community elders’ cultural knowledge to good use. In this initiative, elder masters of traditional arts teach their skills one-on-one to younger apprentices and, in the process, affirm their

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central role as sources of wisdom and cultural knowledge within their communities. As master Passamaquoddy basket maker Molly Neptune Parker describes it: Basket making to me is about our respect for using the bounty of nature and the talent of generations in making something of value, beauty, and function. The art of Passamaquoddy basket making has been woven throughout all aspects of my life. I have used it to teach myself, my children, my grandchildren, and others about Passamaquoddy traditions, history, values and language. Also involved in the apprenticeship program is master woodcarver Tom Cote. Cote comes from a long line of talented woodcarvers, stretching as far back as his great-great-grandfather Jean Baptiste Cote of Quebec, a carver of church altars. Tom said carving reminds him of growing up in Maine’s St. John Valley, surrounded by a vibrant Franco population that traces its roots to Acadia and Quebec. Now teaching a new generation of woodcarvers, including his granddaughter, Cote reflected on the lessons he offers in his studio in Limestone, Maine: I want to teach my apprentices that carvers have a tradition of dealing with the shaping of dull, common, and ordinary things into objects of interest and value, using local raw materials to enrich the lives of family and friends. This is an important part of the Acadian tradition.

Photo by Peter Dembski

to the town. The relationship of the buildings is important, not only in proximity (as they stood right across the street from each other) but also in memory, as the 5&10 was where most people hung out and bought candy before going over to the theater to watch the show. Many of the folks we interviewed either worked there, or their family members did, and all had very vivid memories to share about the spaces. We heard many different versions of a similar story: what downtown Machias used to be, how it has changed, and hopes for the future.

Master Passamaquoddy basketmaker Molly Neptune Parker with her grandson, George Neptune.

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elders. An emphasis on creative endeavor—on helping people reach within themselves to find meaning and connection—will remain central as we move toward an inspired, and inspiring, future for all Maine people as they adapt to the challenges of later life. -

Photo by Peter Dembski

ACKNOWLEDGMENTS

Master Acadian woodcarver Tom Cote with his two apprentices, Ellyzabeth Bencivenga (middle) and Jessica Stackhouse (right). LIVING ART-LIVING WELL STUDIO

everal of the master artists involved in the apprenticeship program also feature prominently in the work of the Living Art-Living Well Studio of the University of New England Geriatric Education Program. The organization offers professional-development seminars for health care professionals in hospitals and assisted living centers, in which master traditional artists are presented as role models of healthy aging. The goal is to show health care providers how overall wellbeing improves when caregivers take a person-centered approach, getting to know their patients, not just as bundles of symptoms or diagnoses, but as whole human beings with unique abilities and experiences.

The greatest thing about getting older is getting to walk into the deeper part of the pool. Ethan Hawke, actor

LOOKING AHEAD: THE FUTURE OF CREATIVE AGING IN MAINE

etween the aging of longstanding residents and a boom in retirees attracted to Maine’s vaunted quality of life and arts-rich environment, the state now has one of the oldest populations in the nation. While innovative initiatives such as the Creative Aging Program have made impressive strides, there remains much to be done to address the needs of the state’s

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The author would like to thank Devon Gale Smith, Julie Richard, and Hillary Savage for their help in writing this article.

REFERENCES Cohen, Gene D. 2000. The Creative Age: Awakening Human Potential in the Second Half of Life. Harper Collins, New York. Dahlberg, Steven T. 2002. Think and Be Heard: Creativity, Aging, and Community Engagement. National Arts Forum Series. http://appliedimagination.org /artsaging_afta_dahlberg.pdf Erikson, E. H. 1982. The Life Cycle Completed. W.W. Norton & Company, Inc. Haight, Barbara K., and Barret S. Haight. 2007. The Handbook of Structured Life Review. Health Professions Press, Baltimore, MD. Hanna, Gay, and Susan Perlstein. 2008. “Creativity Matters: Arts and Aging in America.” Monograph (September). Knowles, Malcolm S. 1984. The Adult Learner: A Neglected Species. Gulf Publishing, Houston, TX. McAdams, Dan P., and Ed de St. Aubin. 1992. “A Theory of Generativity and Its Assessment through SelfReport, Behavioral Acts, and Narrative Themes in Autobiography.” Journal of Personality and Social Psychology 62(6): 1003–1015.

Kathleen Mundell is the director of the Creative Aging and Traditional Arts Programs at the Maine Arts Commission. Since 2010, she has worked with University of New England’s Geriatric Education Center’s training program for health care professionals on presenting master elder artists from the Maine Arts Commission’s Traditional Arts Apprenticeship program as role models for healthy aging.

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Never Too Old to Lead: Activating Leadership Among Maine’s Older Adults by Jennifer A. Crittenden and Lelia DeAndrade Jennifer A. Crittenden and Lelia DeAndrade review strategies for developing and engaging leadership among older adults. They use an example from a Maine-based program to illustrate how programming can effectively foster leadership and community engagement in this population.

lthough the field of leadership development is growing, there is a dearth of programming that focuses on the development of leadership among older adults. This is especially surprising given that older adults are among the fastest-growing age segments of our population. Moreover, baby boomers have not only continued to challenge the idea that aging necessitates the end of work and community engagement, but they have also helped call attention to opportunities for tapping the strengths of this population. In this article, we review strategies for developing and engaging leadership among older adults using an example from a Maine-based program to illustrate how leadership programming can effectively support older adults while fostering leadership and community engagement. As the current population of baby boomers pushes the definitions and boundaries of the time once considered to be retirement, new possibilities emerge for tapping the strengths of this population. AN AGING MAINE

aine, like other states in the country, is experiencing a rapid growth in its older adult population. Maine currently has the largest baby boomer population in country, surpassing Vermont and New Hampshire, with nearly a third of its population comprised of baby boomers (Rector 2013). In addition, 18 percent of Maine’s population is age 65 or older, as compared to 14 percent nationally (http://quickfacts.census.gov /qfd/states/23000.html). Maine’s aging population has been positioned as a crisis rather than an opportunity to harness the collective power of older adults to solve pressing economic and community issues. The ability

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of Maine as a state to leverage this potential lies in its ability to create access to leadership-development opportunities and pathways for older adults. Maine is poised to strengthen leadership opportunities for older adults given its established network of formal leadership-development programs and its growing cohort of baby boomers and older adults. LEADERSHIP AND LEADERSHIP DEVELOPMENT

hile they may vary somewhat, definitions of leadership usually refer to an ability to influence others to achieve a given goal. For our work, we expand the definition to include influencing and/or mobilizing people and resources to achieve a positive effect. Defined in this way, leadership is the capacity to put community assets to work. As such, leadership is absolutely critical to developing thriving and sustainable communities; without it, the value of other community assets can’t be fully actualized or realized. To be clear, we are not referring here to leaders, those formal roles or positions of authority within a community. Obviously, the value of roles can be quite variable within a community, and thus their importance as a community asset must vary as well. Leadership, although it is a concept that is frequently confounded with leaders, has a distinct meaning and value to community development. Opportunities for leadership development emerge throughout the lifespan and are often tied to context and life milestones. For example, young adult and midlife leadership opportunities often present themselves through work, social avenues, or school-based volunteering connected with children in the household.

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In later life, leadership-development opportunities traditionally exist within work settings, associations or civic groups, community service, and participation in local and state politics (Work Group for Community Health and Development 2014). Formal opportunities for leadership development offered through organizational or programmatic contexts, specifically through community-based, not-for-profit programs, have grown tremendously in their popularity since the 1990s and have been the subject of considerable research. The goal of community leadership programs often is to foster critical thinking in the public domain and develop new and effective approaches to civic challenges (Reed 1996). Such programs have a consistently positive impact on participants and are generally effective in improving leaders’ skills, understanding, and selfimage and also increase civic engagement and networking among community leaders. For example, research has found that program alumni tend to stay active in their communities, often become mentors to others and help those individuals to become more involved and take on leadership roles (Bass and Bass 2008). Core Leadership Competencies Arguably the most important of all skills or competencies developed through these programs is an understanding of leadership as a dynamic set of capacities not tied to a specific position. In other words, programs should emphasize that leadership is a constantly evolving collection of interrelated capacities or skills that are employed or engaged by the actor despite the specific expectations of his or her role. Among the other most common core competencies or characteristics that leadership programs should develop are

• Critical-thinking skills including the ability to assemble and integrate multiple concepts and the ability to understand and recognize value positions and varying perspectives and their influence on perceptions of reality • Communication skills such as active listening, negotiation, and conflict resolution, as well as the ability to recognize the need for, and to adopt, varying communication styles according to social settings (Barsh, Cranston, and Craske, 2008) • Self-awareness, which refers to the ability to assess one’s own positions, skills, and perspectives

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• Adaptability or responsiveness to changing contexts including the ability to view goals as aspirational and not fixed or definitive (Gurdjian, Halbeisen, and Lane, 2014) • Understanding of various leadership styles Core Program Structures At the core of recommendations about program-delivery methods and structures is the notion that leadership-development programs should be focused on developing social and critical-thinking skills. In other words, leadership-development programs should focus on supporting the growth of a base of adaptive skills or capacities. Effective programs also include an emphasis on developing cohesive networks. Programs should engage groups of participants who cross demographic, sector, and geographic boundaries and should include activities and supports that help participants to build active and reciprocal relationships based on a high degree of trust. Supportive relationships offer opportunities to practice taking risks and sharing vulnerability. This by extension builds trust and cohesion and provides a foundation for effective networks. Such networks increase leaders’ sense of belonging, shape their thinking, and provide access to varied resources during and after the program (Bass and Bass 2008; Barsh, Cranston, and Craske 2008). Finally, leadership development programs should use a blend of traditional classroom instruction, coaching, and experiential learning. Real-life practice or experiential learning emphasizes learning through application and practice. Learners gather information through their experiences, reflect, test ideas, and assimilate information. This learn-by-doing approach helps the participants to more fully understand and adopt knowledge and skills. Programs support an experiential-learning approach to leadership development by helping participants to identify strengths and then putting them to work to inspire others for a particular cause. They may also require participants to work on real community or organizational challenges and recommend solutions (Gurdjian, Halbeisen, and Lane 2014). Leadership Development among Older Adults

Traditional approaches to community-engagement and leadership-development programming for older adults rely on lifelong-learning models or agency-driven volunteer work. These programs are not designed to

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develop leadership skills among older adults or engage them in leadership at the community level. More formal models have been developed through the National Council on Aging such as the RespectAbility initiative and the Wisdom Works Teams model, which seek to help business, nonprofits, and programs to create the infrastructure necessary to engage older adults as leaders and change agents. Such initiatives have traditionally focused on building institutional, rather than individual, leadership capacity among older adults.

Leadership in the context of volunteer work allows older adults the opportunity for personal growth and leads to overall health. To address this gap, models of leadership-based programming and initiatives for older adults are cropping up across the country. These programs use volunteerism as a context for leadership development, an approach that aligns with the myriad of theories that emphasize engagement and activity as a facilitator of productive aging. Using this paradigm, volunteerism allows older adults to remain healthy by maintaining their social connections and increasing levels of well-being and life satisfaction overall. Leadership in the context of volunteer work allows older adults the opportunity for personal growth and leads to overall health. An example of such programming can be found within the Third Age initiative developed in Hartford, Connecticut, that engages older adults in action-learning leadership training. Cohorts of older adults receive training and support that they then apply to teamdriven projects such as improving neighborhood quality, providing voter education, and offering juvenile offender rehabilitation. Program participants report improved leadership effectiveness, and nearly all participants who complete the training sequence have launched into new leadership activities as a result of their involvement in Third Age (Hentschel and Eisen 2002). ENCorps Model An innovative Maine-based program for older adult leadership, Encore Leadership Corps (ENCorps), was MAINE POLICY REVIEW

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developed in 2009 by the University of Maine Center on Aging in collaboration with the Maine Community Foundation and through funding from the U.S. Environmental Protection Agency and the Atlantic Philanthropies. The goal of the program is to engage Mainers 50 and older in community-based leadership through volunteer projects. ENCorps members undertake self-driven projects in their communities that are often carried out outside of the confines of an umbrella organization. Volunteer roles vary widely, but include general themes such as serving on local committees, boards, and town councils; revitalizing and developing downtowns; preserving, protecting, and improving public and outdoor areas; working on food security with food pantries and community gardens; and educating community members about important health and environmental issues. The program focuses less on matching individuals to volunteer opportunities (a service offered by a variety of existing programs) and more on leadership training and support to older adults already inclined to volunteer. The program model consists of regular workshops, trainings, and networking sessions that bring older adults from throughout Maine together to learn from expert trainers and from each other. Trainings and supports are uniquely focused on supporting older adults within a community-based, rather than an employment-based, leadership context. The growing ranks of ENCorps volunteers, currently over 250 from across Maine, indicates that older Mainers desire the opportunity for leadership development and enjoy expressing their own leadership through self-driven projects. Interviews and surveys conducted with ENCorps members reveal the reasons why older Mainers are drawn to leadership opportunities, along with the barriers to pursuing further leadership development. When asked what draws them to their civic duties and leadership roles, ENCorps participants note internal factors such as commitment to community, interest in learning new skills and pursuing personal development, desire to share their experiences and expertise with others, and drive to be a part of something meaningful. The external factors that activate leadership for ENCorps members include being offered the opportunity to serve in a leadership capacity, having personal capacity for volunteer work, and generating enthusiasm and motivation in those around them (Wihry et al. 2013). How do older adults view their leadership? Based on information gathered from ENCorps participants, 82

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older adults see themselves as providing leadership when they take initiative, listen, and facilitate interactions with others. What keeps older adults from volunteering their time largely stems from a lack of comfort with leadership roles (see sidebar for more information). Programs offered to older adults, whether they are currently volunteering or not, can provide valuable assistance in increasing comfort with volunteer roles. Interestingly, a lack of time was also noted as a barrier to leadership, an important reminder that older adults are increasingly filling their time with work, family, and community obligations. Leadership activation must take into account the time and energy available for community-based volunteering and create personal benefits that bleed across familial, work, and community roles. Collectively, ENCorps members have added an estimated $3.7 million of value back to Maine communities through their volunteer work. Their projects have resulted in tens of thousands of additional dollars raised directly for nonprofits and initiatives that benefit the community, Older Adults’ Perceptions of Leadership ENCorps members define the characteristics that make them community leaders or not. Characteristics of a leader: • Takes action, initiates contact • Attracts followers • Genuine passion for the cause • Listens to others • Searches out information • Willingness to work with different personalities • Leads by example • Sees the big picture Barriers to being a leader: • Lack of time • Can’t bring self to take the first step • Don’t want to be the one to speak up • Preference for serving as a helper (Source: Wihry et al. 2013)

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increased educational resources that are developed through their efforts, and increased knowledge and capacity of community members who have been trained or supported by ENCorps members. On a personal level, ENCorps participants have reported growth in social connections, emotional and physical well-being, and an increased sense of confidence in their leadership abilities (University of Maine Center on Aging 2013). All of these findings are consistent with the productive aging perspective that leadership-based volunteerism results in community and personal dividends. Some examples of how ENCorps develops leadership among older adults include the following core principles: • Leadership as a dynamic set of competencies— Training is transferable across settings and issues of interest. Environmental volunteers learn alongside older adults interested in health-related volunteerism and downtown revitalization. Participants learn the same skills, but are supported in translating those skills to different contexts. Training is designed to plant seeds rather than be prescriptive in its approach. • Critical-thinking skills—At the core of the annual summit gathering for ENCorps participants is content that provides an overview of Maine’s pressing economic, community, and health-related issues. Local and national experts provide food for thought to help participants to connect and shape their on-the-ground-work to a bigger picture. Small-group work helps participants to formulate their own local solutions and approaches to addressing Maine’s challenges. • Core communications and relationship-building competencies—ENCorps workshops have included sessions on how to collaborate with others, active listening, conflict management, group facilitation, problem solving, critical thinking, and communications strategies. These sessions provide time to practice and reflect on these skills as they are developed. • Self-awareness—Training sessions were held to help ENCorps members to identify strengths, interests, and areas for personal growth. For example, a workshop and one-on-one follow-up with a consultant was offered to help participants to identify their personal passions and use that 83

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assessment as a basis for prioritizing their leadership and self-development work. Participants have also engaged in workshops that help them to identify their learning and communications styles and foster a sense of awareness of how those styles may differ from those of their community partners. • Adaptability or responsiveness to changing contexts—In recent years, ENCorps programming has been offered to help members to learn about new contexts and relevant issues to Maine and develop timely skills. For example, ENCorps recently completed a special initiative on food security, which aimed to educate and mobilize members around the pressing issue of hunger and food access. All participants were encouraged to integrate what they learned about food insecurity into their local work, regardless of its current focus. An additional initiative focused on helping members to learn new media techniques for sharing their volunteer work. Additional tenets threaded throughout ENCorps programming: • Building strong networks—engaging participants from a range of interests and personal backgrounds. • Providing opportunities for deep sharing and peer learning—using formal classroom-style learning mixed with structured interactions, support from a staff coordinator, and a peer network. • Use of leadership in context—learning activities centered around leadership to achieve a particular end focused on project, community challenges, and statewide issues of importance. • Fostering individual development—exercising skills and capacities independent of formal positions participants may hold, not limited by positions as volunteers. • An emphasis on deep, participant-driven learning—identifying skills/capacities needed; learning based on self-identified needs.

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SUMMARY

eadership capacity is a critical need within Maine communities, but little attention has been given to how to effectively develop leadership programs for older adults who have the interest, skills, and commitment for effective leadership. Leadership development in the context of volunteer work offers a promising model for developing leadership skills among older adults in Maine where we have an abundance both of older adults and community issues to be addressed. The ENCorps program provides an example of how traditional leadership competencies and approaches can be tailored to older adults in a volunteer context. Programs that seek to effectively engage this population should focus on blending best practices in leadership and approaches that engage older adults in meaningful and effective ways by focusing on current issues that are community based and of personal interest. REFERENCES Barsh, Joanna, Susie Cranston, and Rebecca Craske. 2008. “Centered Leadership: How Talented Women Thrive.” McKinsey Quarterly (September). Bass, Bernard M., and Ruth Bass. 2008. The Bass Handbook of Leadership. Free Press, New York. Gurdjian, Pierre, Thomas Halbeisen, and Kevin Lane. 2014. “Why Leadership Development Programs Fail.” McKinsey Quarterly (January). Hentschel, Doe, and Mary-Jane Eisen. 2002. “Developing Older Adults as Community Leaders.” Adult Learning 13(4): 12–14. Rector, Amanda. 2013. Maine Population Outlook to 2030. Governor’s Office of Policy and Management, Augusta, ME. http://www.maine.gov/economist/projections/pub /Population%20Outlook%20to%202030.pdf Reed, Trudie K. 1996. “A New Understanding of Followers as Leaders: Emerging Theory of Civic Leadership.” Journal of Leadership Studies 3:95–104. University of Maine Center on Aging. 2013. Encore Leadership Corps Evaluation Report. University of Maine, Orono. http://www.encoreleaders.org /wp-content/uploads/2013/12 /ENCorpsEvaluationReportFINAL.pdf Wihry, David, Jennifer A. Crittenden, Lenard W. Kaye, and Mia Noyes. 2013. “An Analysis of Pathways to Rural Citizen Leadership Among a Sample of Older Adult Volunteers.” Poster presented at the 2013 Annual Scientific Meeting of the Gerontological Society of America, New Orleans, LA, November 21, 2013.

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Jennifer A. Crittenden is the

Work Group for Community Health and Development. 2014. “Section 7: Encouraging Leadership Development across the Life Span.” Community Toolbox: Encouraging Leadership Development Across the Lifespan. University of Kansas, Lawrence. http://ctb.ku.edu/en /table-of-contents/leadership/leadership-ideas /leadership-development/main [Accessed June 11.]

Photo by Adam Kuykendall

assistant director at the University of Maine Center on Aging where she serves as program manager for Encore Leadership Corps in collaboration with the Maine Community Foundation.

Lelia DeAndrade is the director of grantmaking services at the Maine Community Foundation. She was the staff lead for the Encore Leadership Program, in collaboration with the University of Maine’s Center on Aging. Most recently she has led the development of MaineCF’s strategic focus on leadership development.

Photo by Heather Corey

ENCorps volunteer Lynn DeGrenier with Orono Bog Boardwalk director Jim Bird. Lynn has helped raise thousands of dollars in funds for the boardwalk by supporting their annual yard sale event.

ENCorps group photo. MAINE POLICY REVIEW

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ORGANIZING VOICES TO SUPPORT SUCCESSFUL AGING

Organizing Voices in Maine to Support Successful Aging by David C. Wihry David Wihry discusses the efforts of four associations in Maine that are supporting successful aging by organizing the voluntary, private, and public sectors; embracing a multidisciplinary perspective; and bringing together partners from across the state to make a larger impact on policy, attitudes about aging, and the well-being of older adults.

here is an increasing recognition that the challenges for supporting a thriving old age for Maine’s citizens can no longer be addressed in the same ways they have been in the past. Siloed activities by organizations and actors that are bound by the norms of a single discipline, economic sector, or geographic area are no longer suitable for supporting productive aging. This article will discuss the efforts of four associations in Maine that are working to support successful aging for Mainers in a new way—one that organizes the voices of the voluntary, private, and public sectors; embraces the perspectives of multiple disciplines; and brings together partners from across the state in an effort to make a larger impact on public policy, cultural attitudes on aging, and the well-being of older adults. Although four associations are highlighted in this article, they are by no means the only ones working in aging issues in the state, as many professional associations and other entities have aging focus areas. PROFESSIONAL COLLABORATION TO FURTHER PRACTICE, RESEARCH, AND POLICY

t its core, the field of gerontology is defined by its multidisciplinary approach to understanding aging, which brings together perspectives from social sciences, natural sciences, and applied disciplines. In Maine, the group organizing the voices of gerontology in the state is the Maine Gerontological Society (MGS). With a mission of “advancing the field of aging and the care of older adults as well as their caregivers through service, training, advocacy, and research,” the society brings together a diverse group of individuals and organizations

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with an interest in furthering research, practice, and policy related to aging. A prime focus of MGS is supporting the training needs of Maine’s gerontologists and disseminating knowledge of developments in the aging field. MGS distributes a regular electronic newsletter, Gray Matters, which has highlighted pressing issues facing older adults, from care transitions to ageism, while also informing members of legislative activity related to aging and showcasing new resources to support aging research and practice. In further support of gerontology education, MGS is a sponsor of the Maine Geriatrics Conference, which has convened Maine geriatricians yearly for 25 years to build competencies in geriatrics research, practice, and policy. As part of its mission to recognize the best in the field of gerontology, MGS also maintains a fellowship program. A key emphasis of the MGS is playing an active role in shaping public policy. MGS developed a primer for policymakers on unmet needs for Maine’s aging population that provides accessible and evidence-supported overviews and concrete policy recommendations related to food insecurity, support for family caregivers, senior housing, early onset dementia, developmental disabilities, and elder abuse. The Dirigo-Maine Geriatrics Society is another organization in Maine, which brings together health care providers from across the state with an interest in improving health care for older adults. Recently established, the society is Maine’s chapter of the American Geriatrics Society, which takes an approach similar to MGS in improving quality of life for older adults by supporting education, research, and practice.

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RAISING UP THE VOICE OF MAINE’S GLBT COMMUNITY

he aging population in Maine is not a monolithic group. Though there are certain cross-cutting issues that face the aging population, individual needs and challenges facing the sub-groups of the aging population can differ. The Services and Advocacy for GLBT Elders (SAGE) Maine, is a recently established group focused on organizing the voices of gay, lesbian, bisexual, and transgender (GLBT) elders to ensure the quality of life of these individuals. SAGE Maine is an affiliate of SAGENet, which is the network of local SAGE groups around the nation. These groups grew out of the experiences of the original SAGE organization in New York City, which sought to alleviate the health care and financial inequalities experienced by GLBT elders. Founded in 2013, SAGE Maine has been engaged in a number of activities in line with the advocacy, educational, and social support mission of SAGE including social media outreach to connect members of the elder GLBT community throughout Maine and conducting a needs assessment of older adult GLBT Mainers. SAGE Maine has also been heavily engaged in educating and building cultural competency of providers on the unique needs and concerns of the GLBT population in Maine through activities such as integration of an education component on GLBT older adults for Maine long-term care ombudsmen who are working to protect the rights of older adults in Maine long-term care facilities. (See article by Kimmel [2015], this issue, for more details about SAGE Maine.) MOVING AGING POLICY AGENDA FORWARD

common theme in the effort to organize the voices supporting aging in the state of Maine is that engagement in the policy arena is crucial to magnifying the impact individual organizations are making to support the quality of life of older Mainers and to ensure that public policy at the state and local level is informed by the expertise gained through rigorous research and on-the-ground practice. Founded in 2012, the Maine Council on Aging (MCOA) is an association of more than 50 organizations in the state, with the expressed concern “to address broad public policy concerns facing older adults in Maine.” The council has a diverse membership from the perspective of geography and professional and economic

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sectors. Organizations serving York County to Aroostook County are present on the council, and though there is a strong presence from human services organizations, the council also has representation from many other types of institutions and organizations. MCOA can also be seen as almost a superstructure for the policy efforts of professional and other associations working to improve quality of life in Maine for older adults.

…engagement in the policy arena is crucial to magnifying the impact individual organizations are making to support the quality of life of older Mainers…. A focal area in the early life of MCOA has been the Maine Aging Initiative, an organized effort spearheaded by MCOA and Speaker of the House Mark Eves to address challenges faced by Mainers in supporting their ability to age successfully in whatever setting they choose. Early work of the Maine Aging Initiative focused on roundtable-style discussions with stakeholders from across economic sectors to uncover key challenges facing older adults in the coming years, as well as the economic implications that will result from Maine’s increasingly aging population. The fact-finding phase of the Maine Aging Initiative culminated in a 2014 Summit where more than 400 stakeholders from across the state worked to develop potential solutions. The resulting Blueprint for Action on Aging generated a list of community-based and legislative solutions for building aging-friendly communities, supporting aging through the work of higher educational institutions, addressing workforce and employment challenges, public and private safety, and health and well-being. To make concrete progress on these policy areas, small workgroups have been formed to move forward the initiative’s policy agenda. Other efforts have resulted in the development of a Legislative Aging Caucus with Democratic and Republican membership to move forward aging policy priorities. (Eves and Maurer [2015], this issue, have further discussion of developments from the 2013 round table discussions and 2014 Aging Summit.) 87

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address these needs. Whether it is MGS’s efforts to support evidence-informed policy, or the MCOA’s agenda setting for aging in Maine, organizations are not afraid to enter the policy arena.

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lthough these groups differ in their focus areas and methods to various extents, there are commonalities that define these burgeoning efforts to improve the quality of life for older Mainers. 1. A multidisciplinary and cross-sector focus— Across these initiatives, there has been a willingness to include a diversity of perspectives for supporting older Mainers. This has involved raising up the voices of marginalized groups, such as the efforts of SAGE Maine, as well as a willingness to go beyond traditional silos of profession or economic sector. The value of this broad focus is evident in the large and diverse membership of the MCOA, which spans the public, nonprofit, and private sectors, as well as the coming together of multiple disciplines and medical specialties that is a hallmark of DirigoMaine Geriatrics Society and MGS. 2. A comprehensive agenda that recognizes the importance of advocacy, research and education, policy, and practice—Across the four initiatives examined in this article, there is a holistic approach to change that recognizes that moving forward on issues facing older Mainers can only happen through multiple means, including supporting smart public policy, advocacy for older adults, research and education efforts, and the practitioners who are working on the ground to improve the quality of life of older Mainers. Examples include the MCOA’s Blueprint, which outlines both legislative and community-based priorities for better addressing the challenges of an aging state; MGS’s focus on building the skills of community practitioners, while informing policy at the state levels; and SAGE Maine’s efforts to better connect GLBT adults while also supporting cultural competency in medical providers. 3. A willingness to step into the policy arena to make a bigger impact—A third common element of these initiatives is a willingness to engage with policymakers to advance legislative priorities that are informed by research and on-the-ground experience with the needs of Maine’s older adults and promising ways to

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EVALUATING THE PROMISE OF ORGANIZED VOICES IN AGING

he associations described here are still relatively young and the full impact of these initiatives and the viability or their approaches is still to be determined. However, there is reason to be optimistic. During the first regular session of the 127th Legislature, nine of thirteen bills in the Council on Aging’s legislative package met with success. The bills dealt with issues ranging from increased funding for direct care workers to funding for assistance with money management. Regardless of the outcomes of the specific bills, the creation of a legislative caucus on aging is a feat in itself that will support future efforts to move legislation forward. As these fledgling associations continue to grow, Maine will begin to see whether the promise of interdisciplinary and cross-sector partnerships will be successful in raising the voices of Maine’s older adults and the researchers and professionals serving older adults, and Maine lawmakers with an interest in successful aging. Key challenges for these associations will be to skillfully navigate Maine’s challenging fiscal and legislative climate, integrate the insights and priorities of multiple disciplines in a holistic way, and translate insights from geronotological research in ways that are accessible and informative to policymakers. REFERENCES Eves, Mark, and Jessica Maurer. 2015. “Developments Growing Out of the Speaker’s 2013 Round Table Discussions and 2014 Aging Summit.” Maine Policy Review 24(2): 23–28. Kimmel, Douglas. 2015. “Commentary: Aging, Diversity, and Difference in Rural Perspectiv.” Maine Policy Review 24(2): 74–75.

David C. Wihry is project manager with the University of Maine Center on Aging where he coordinates a variety of research projects, needs assessments, and evaluations of programs and initiatives focused on older adults.

MAINE’S INITIATIVES IN GERIATRIC MEDICAL CARE

Maine’s Initiatives in Geriatric Medical Care: Commentary from the Front Lines by Cliff Singer and Roger Renfrew Cliff Singer and Roger Renfrew write from their perspectives as medical practitioners and leaders in geriatric medicine to examine issues affecting health care and outcomes for older adults in Maine. Focusing on the acute and primary care systems, they highlight issues and policy recommendations they think are most urgent or helpful.

his is a time of creative innovation in the health care of older adults. In this article, we offer commentary on some of the many health care initiatives at the national and state level. We are not policy experts. We are two people with decades of experience in the medical care of older adults. We write with a deep and intimate knowledge of how policy affects the patients and families we serve. We write also from the perspective of our leadership roles in elder care both within our medical centers and within the Dirigo-Maine Geriatric Society, our state chapter of the American Geriatric Society, the primary medical organization with a singular focus on improving the health care of older adults. Our aim is to highlight critical issues affecting health outcomes of older adults in Maine’s hospitals and clinics as we perceive them from the bedside and not the boardroom. Our focus will be on the acute and primary care systems, since long-term care is covered elsewhere in this issue. At the end of the article, we highlight the issues and policy recommendations we think are most urgent or helpful. CURRENT STATUS OF HEALTH CARE OF OLDER ADULTS IN MAINE

n many ways, we are doing a good job. National surveys indicate that residents of Maine enjoy good health relative to citizens in other states. This is likely as much due to our demography, active lifestyles, and natural environment as anything else, but access to good medical care plays a role. We are blessed with excellent hospitals. Maine’s hospitals consistently achieve high marks for safety and quality (http://www.themha.org/). We have integrated health care networks that are newly dedicated to primary care, emphasizing better health,

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disease prevention. and integrated, multidisciplinary care of older adults with complex chronic conditions. We also have a high proportion of health care providers who have deep roots in their communities and intimate knowledge of the people they serve. But we are also a state with special challenges. Our population is older than most and older adults need more medical care. Nationally, 23 percent of people over 75 years of age had 10 or more physician office visits in the last 12 months, compared to 14 percent of people aged 45 to 64 (Blackwell, Lucas, and Clarke 2014; Schiller et al. 2014). Seventy-one percent of older adults have hypertension (high blood pressure), 49 percent have been diagnosed with arthritis, 31 percent heart disease, 25 percent cancer, and 21 percent diabetes. Eighty percent of Mainers over 65 years of age take at least one medication prescribed for chronic health problems (MDHHS 2012). As in much of rural America, Maine’s health care infrastructure is comprised of a network of small hospitals, primary care clinics, and nursing homes. Maine hospitals receive high ratings for quality compared to national standards, but struggle financially because of high levels of uncompensated care and below-cost reimbursement for higher than average proportions of MaineCare (Medicaid) and Medicare patients. Maine hospitals lost money in 2014, with an aggregate operating margin of -0.3 percent (loss). According to the Maine Hospital Association, this operating loss was due to lower inpatient-bed use (good), higher taxes, and reduction in Medicaid and Medicare reimbursement rates. Medicaid reimbursement for inpatient care is 28 percent below cost (MHA 2014). Maine’s hospitals face extreme financial pressure from non-Medicare-reimbursed care. Maine’s

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uninsured and MaineCare populations are greater than national averages, and the uncompensated care provided by the state’s hospitals doubled from 2006 to 2013 (MHA 2014). Financial survival is especially challenging for small rural hospitals, which have even higher percentages of MaineCare and Medicare patients and fewer options for highly reimbursed surgeries and subspecialty procedures. These low margins mean our smaller hospitals will fall behind in investment in new technologies, facilities, staff recruitment, and training to meet the needs of our growing geriatric population. Hospital, clinic, and nursing home closures in rural Maine are a special threat to seniors and their family caregivers (Bailey 2009). Increasingly, Maine’s small local facilities are joining the major hospital networks, resulting in improved access to specialists and integrated care, but a loss of autonomy and local control.

Maine’s rural demographic makes access to necessary medical, mental health, or dental care challenging for older adults living outside of the few urban centers.

Overuse of benzodiazepines for anxiety and sleep and opioids for chronic pain continue to contribute to injuries from falls and confusion (MDHHS 2012). Diagnosis and treatment of neurological, cognitive, mental health, and substance-use disorders in old age is especially difficult in Maine given the scarcity of specialists. This means that primary care providers are often left treating these conditions to the best of their abilities. Maine’s rural demographic makes access to necessary medical, mental health, or dental care challenging for older adults living outside of the few urban centers. Driving to specialty care in remote towns is expensive at any time and often hazardous in winter. Military veterans may have even greater distances to drive to get to one of the VA outpatient or hospital facilities. Many of Maine’s older adults live on limited, fixed incomes, making medical co-pays, mental health care, medications, dental care, eye care, or hearing aids out of reach. According to the federal Administration on Aging website (http://www.aoa.gov/), older adults averaged out-of-pocket health care expenditures of $5,069 in 2013, an increase of 35 percent since 2003. Older Americans spent 12.2 percent of their total expenditures on health care, as compared with 7.1 percent among all consumers. These data suggest that the economics of health care hits Maine hard because of the state’s olderthan-average demographic. CHALLENGES TO HIGH-QUALITY CARE

Alzheimer’s disease is the leading cause of progressive cognitive decline to dementia in older adults. It affects 13 percent of seniors (> 65 years of age) and 37,000 people in Maine have the disease, a number that is rapidly increasing and beginning to overwhelm our hospitals and long term care systems (MDHHS 2013). Depression and other mental health disorders are also common in older adults, with major depression affecting from 5 percent to 10 percent of seniors at any given time (Taylor 2014). People with health conditions affecting daily function are at even higher risk of depression. Patients with depression have 50 percent higher health care costs than nondepressed people with comparable levels of medical illness (Unutzer et al. 1997), yet depression is undertreated in seniors (Unutzer et al. 2000). Maine’s rate of alcohol abuse in older adults is higher than national averages, 5.1 percent versus 3.1 percent for those over 65, although these are self-reports. MAINE POLICY REVIEW

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Evidence-based Quality Metrics he National Academy of Science’s Institute of Medicine has challenged us to pursue care that is safe and effective. This has led to the development of evidence-based guidelines for many aspects of care issued by specialty societies of physicians, nurses, and other health care providers. These guidelines provide clinical pathways rated by the soundness of the research evidence base and where good evidence is not available, complemented by expert opinion. They have become the standards of practice and increasingly, reimbursement.1 For providers caring for older adults, there are challenges with many guidelines. Older adults with multiple co-morbidities are often excluded from the studies from which the evidence is derived. This reflects the difficulty of studying a population with high risks of complications and mortality from their underlying conditions. Unfortunately, one cannot assume that research done on

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relatively younger patients with a single disease can be translated to this population. In the cases of diabetes and hypertension, applying guidelines for younger adults may lead to increased mortality in older adults. Yet, once guidelines are developed by specialty societies, they may become national measures upon which reimbursement decisions are made by the Center for Medicare and Medicaid Services (CMS) through programs such as Meaningful Use of the Electronic Health Record, Physician Quality Reporting System (PQRS), and Value Based Purchasing. There has been slow progress at including geriatric-specific indicators into these sets. Of 254 PQRS indicators, 28 may be considered geriatrics-focused. Most of these are specific to a disease or condition, and none address the patient with multiple co-morbid conditions. This is a gap that needs to be addressed, as more than 50 percent of Medicare patients have three or more chronic conditions. At the local system level, there is an advocacy process that is needed to direct limited resources to implementation of these initiatives. There are initiatives that state and federal regulations either require or create incentives for, but there are also, within local institutions, proposals based on recognized local needs and enthusiasms of providers for specific quality initiatives. Pursuing these initiatives often requires buy-in from colleagues to overcome institutional pressure to align initiatives with broader system-level goals that may not always meet the needs of older patients in that community. Even when initiatives are established, embedding best geriatric practices into primary care is a major challenge. This reflects a payment system that is built on acute visits as opposed to management of complex chronic illnesses and that rewards providers for volume of visits. Many of Maine’s primary care practices are small enterprises, without the resources to easily comply with new regulations or meet evolving standards in the care of frail older adults with complex psychosocial and medical needs. Quality metrics may improve the consistency of care provided to patients, but they create an immense strain on practices. For example, the comprehensive provision of preventive services to an average primary care specialist’s practice panel is estimated to require 7.4 hours per day (Yarnall et al. 2003). Individual practices and health systems attempt to meet constantly changing standards. Patient-centered medical homes must meet external standards that can be difficult to implement. This creates a competition for MAINE POLICY REVIEW

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time and resources between various initiatives. A similar process is occurring in public education and has been labeled initiative fatigue, a term that certainly applies here. “The Law of Initiative Fatigue” states that “when the number of initiatives increases while time, resources, and emotional energy are constant, then each new initiative—no matter how well conceived or well intentioned—will receive fewer minutes, dollars, and ounces of emotional energy than its predecessors” (Reeves 2010).

…embedding best geriatric practices into primary care is a major challenge. This becomes a practical matter in implementation of geriatrics-specific programs. A recent report demonstrated good implementation of screening and evaluation for falls in primary care, but poor implementation of a plan and no notable impact on falls overall in the study population. Because of the complexity of the task and the apparent low yield, the program was discontinued to focus on another initiative instead of working to improve performance (Landis and Gavin 2014). Within health systems and practices, there is a political competition for the time and energy needed to implement initiatives that are otherwise seen as important by the providers. Policies that reward persistence in overcoming the challenges of implementing proactive prevention in eldercare are needed. Acute Care of Older Adults: “Geriatric-Capable” Hospitals

A visit to an emergency room or hospital by an older adult can be an early sign of pending decline. The care can be highly challenging if the person is frail or has multiple co-morbid conditions. In fact, some older patients are at risk of harm in health care facilities as well as at transitions of care from one setting to another. Thirty to 60 percent of hospitalized elders are discharged with new or increased disability (Hoogerduijn et al. 2007). Many of them either die or have not recovered function, even 12 months after discharge (Boyd et al. 2008). In all health care environments there is a need for proactive care, which requires providers to think not 91

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only about the acute issues in front of them, but the impact of those problems on other physical, psychological, and social systems. Common concerns in these environments include cognitive function and risk of falls as well as the need to evaluate social support. In the emergency room, both the physical design and culture of care are focused on rapid assessment and stabilization of a presenting symptom and not on the multiple other problems that might lead to rapid failure once sent home. It is not uncommon, for example, for a person with dementia to be discharged from an emergency room with a new medication or care instructions that he is incapable of following.

In the hospital setting, a number of intervention strategies have been tried to improve outcomes and decrease risk of adverse events…. Four national organizations have worked together to develop guidelines to help define a geriatric emergency department concept (ACEP 2013). These guidelines address staffing and environment, follow up and transitions of care, education, quality improvement, equipment and supplies, policies, procedures, and protocols. The opportunity is that “the expertise which an ED [emergency department] staff can bring to an encounter with a geriatric patient can meaningfully impact not only a patient’s condition, but can also impact the decision to utilize relatively expensive inpatient admissions, or less expensive outpatient treatments” (ACEP 2013: 2). Furthermore, as the initial site of care for both inpatient and outpatient events, the care provided in the ED has the opportunity to “set the stage” for subsequent care provided. It is clear though, that this binary approach (inpatient versus outpatient) is driven by rigid reimbursement models and not patient needs. Those needs often demand a range of support and treatment options requiring new reimbursement models for alternatives that are less expensive than hospital admission, but capable of providing professional caregiver support and 24-hour nursing oversight of care. Policies are MAINE POLICY REVIEW

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needed that encourage health care systems to implement a flexible array of services that are not just hospital or home based. In the hospital setting, a number of intervention strategies have been tried to improve outcomes and decrease risk of adverse events such as falls and confusion. Multidisciplinary team care, which incorporates geriatrics expertise, can reduce delirium and result in shorter lengths of stay. Specific units designed for older adults (ACE: acute care for elderly) can improve functional status and increase discharges back to home, versus to nursing home, while decreasing mortality (Counsell et al. 2000). Use of standardized protocols leads to more appropriate prescribing, less functional decline, more discharges to home, and recognition of acute confusional states (delirium). These units may have minimal or no effect on length of stay, readmission rate, or mortality, but these may not be the best metrics of quality for frail patients for whom comfort and quality of life are the defining factors for care. Perhaps the most interesting work in this arena is in the Canadian province of Ontario, which has developed a provincial initiative on senior-friendly hospitals. The elements of this program include the physical environment, implementing evidenced-based processes of care, the emotional and behavioral environment, review of ethics in clinical care and research and organizational support for high-quality geriatric care. At present we have pieces in Maine’s hospitals that work quite well, but there remains a lot to learn about what works best and how to implement this work into day-to-day care. According to the Institute of Medicine’s Principles of Care (IOM 2008: 76): • The health needs of the older population need to be addressed comprehensively. • Services need to be provided efficiently. • Older persons need to be active partners in their own care. In an extensive review of published results from 15 models, Boult and colleagues found that care models based on IOM principles can improve outcomes of interdisciplinary primary care, transitions of care between health care settings or home, providing acute care in patients’ homes, nurse-physician teams for residents of nursing homes, and geriatric care in hospitals (Boult et

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al. 2009). They conclude that “policy makers and healthcare leaders should consider including these 15 models of health care in plans to reform the U.S. healthcare system. The Centers for Medicare and Medicaid Services would need new statutory flexibility to pay for care by the nurses, social workers, pharmacists, and physicians who staff these promising models” (Boult et al. 2009). We agree. It is often said that “geriatrics is a team sport” and reimbursement models are needed to provide maximum flexibility in both the care setting and in multidisciplinary care delivery. Medicare’s new chronic care management (CCM) payment program is certainly a step in the right direction. Under the new program, Medicare could reimburse primary care practices about $40 per month per person for such things as medication management and care coordination for patients who have two or more chronic medical conditions. Dementia in Primary Care Cognitive decline to dementia shows increasing prevalence that doubles every decade after the age of 65, achieving 59 percent in people 80 to 89 years old (Plassman et al. 2007). Alzheimer’s disease is the most common cause of dementia in older adults. It is a terminal illness with a long debilitating course. Its impact on the management of other chronic illnesses is significant. As such, it serves as a model for the challenges we face in providing care to an aging population. Nationwide, and in Maine, there is a shortage of specialty care for persons with dementia. Over 80 percent of the care of older adults occurs in primary care practices. This is quite likely higher in rural states such as Maine. Nationally, one-half of persons with dementia in primary care practices are unrecognized. When they are diagnosed, more than one-half have moderate or late-stage disease. This pattern is true for other geriatrics syndromes such as falls and incontinence. This reflects the difficulty of caring for patients with multiple chronic illnesses and in complex social situations, and the need to address preventive services in a model developed around acute care needs. There is no simple solution to this problem. Minnesota and Ontario have taken on the challenge at a state and province level. Large health systems such as the VA have attempted to support primary care in the care of these patients. Academic institutions have had success in controlled circumstances, but less success when attempting to spread their work into community-based MAINE POLICY REVIEW

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practice. The effectiveness of these models is based on indicators of care that should be accomplished. In reality, these are aspirational even in academic geriatrics practices. Models vary from a single practitioner accomplishing the necessary work over several visits to use of a team-based approach. Team-based approaches vary significantly. One model is to embed a nurse practitioner into a practice with specific responsibility for dementia care for clinic patients. Another model is to use care managers to aid with the coordination of care. More extensive models involve outreach programs that support primary care in the home. Ontario has developed specific training and support for primary care clinics with a primary care specialist within the practice running a memory clinic. In general, these approaches lead to improved quality and to reduced behavioral symptoms and caregiver distress. There is not yet clear indication of decreases in cost for care with these approaches; thus, sustainability is a major challenge (Callahan et al. 2006; The Lancet Neurology 2013).

Nationwide, and in Maine, there is a shortage of specialty care for persons with dementia. Dementia-related psychiatric symptoms often lead to crisis situations in which patients are left sitting in emergency departments because of a lack of safe discharge options. Family caregivers or nursing home staff may no longer be able to provide care to a paranoid, aggressive, or wandering person. There is a severe shortage of psychiatric beds and psychiatric units may consider these patients medical and beyond their expertise or abilities. Hospital medical units consider them psychiatric and unless an acute medical problem is identified (e.g., pneumonia, stroke, or urinary tract infection), Medicare reimbursement for the admission will be denied. Beyond that, acute medical inpatient services are not safe places for people with dementia who may be ambulatory, disoriented, and intermittently aggressive. Therapeutic crisis respite beds are urgently needed for such situations, where people with dementia can be safely supervised and treated until they are safe to either 93

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return home or go to an appropriate memory care facility. Successful efforts to shorten or delete the “3 overnight” requirement for discharge to a skilled facility, and recognition of crisis dementia care as a skilled care need would improve care and possibly reduce costs. Many critical aspects of dementia care, including direct patient assessment in the home setting and caregiver support and education, can be performed via telemedicine. Transporting a person with dementia to a clinic appointment, often to a specialist in a distant town, can be challenging and expensive. The vagaries of Maine’s winter weather adds a burden on family caregivers who are already barely coping. Videoconferencing and office visits via telemedicine provide effective, safe, and cost-effective (especially for the patient) alternatives, yet are not reimbursed by Medicare in two Maine counties considered urban by the Centers of Medicare and Medicaid (Cumberland and Penobscot). Transportation, even within a town, can be trying for our patients, and we look forward to the day when this regulatory policy is changed.

Health care institutions are already finding it difficult to fill vacancies from retiring nurses, physicians, and other health care workers with special skills and decades of knowledge and experience. Geriatric Care Workforce According to the Administration on Aging, the U.S. population aged 65 and over will exceed 70 million by 2030, twice as many as in 2000. In 2030, one in four Mainers will be over 65. Maine’s population of the oldest old (i.e., >85) grew by 58 percent during the 10-year period of 1999 to 2009. This strong trend is continuing, placing special burdens on our systems of care. When older Mainers become patients, as they routinely do, they deserve the best care from a health care workforce that is well trained in geriatric medicine. Maine’s seniors with complex, age-related diseases and functional limitations may be challenged to find medical providers and institutions with the type of specialized knowledge, skills, and facilities that meet MAINE POLICY REVIEW

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current standards for state-of-the-art geriatric medicine. Without recruiting from out of state and out of country, we will be hard-pressed to meet the need. Health care institutions are already finding it difficult to fill vacancies from retiring nurses, physicians, and other health care workers with special skills and decades of knowledge and experience. Workforce policy experts estimate the United States will need 13,522,000 health care providers by 2030, versus the 9,994,000 workers we had in 2005 (Mather 2007). This is occurring at a time when many providers have been reaching retirement age and many Americans have been reaching an age at which they need more medical and nursing care. According to data in the IOM report, less than 1 percent of registered nurses, 4 percent of social workers, and 1 percent of physician assistants identify as specialists in the care of older adults (IOM 2008). There is a particularly acute shortage of primary care geriatricians (internal medicine or family medicine physicians with extra training in geriatric medicine). By 2030, it is estimated that there will only be 7,750 primary care geriatricians, far short of the estimated need of 36,000 (IOM 2008). Geriatric psychiatry faces a more dire shortage. There are only about 1,600 psychiatrists certified in geriatrics in the United States, one for every 11,372 older Americans. The shortfall will only be made up if we improve the training of generalists in geriatric medicine, including not just general internists and family medicine specialists, but general psychiatrists, family nurse practitioners, psychiatric mental health nurse practitioners, and primary care physician assistants. The Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services recently awarded $35.7 million dollars to 44 organizations in 29 states to support geriatric education for health care providers (up to $850K per awardee). The University of New England and the University of Maine each led efforts to submit ambitious grant proposals. Unfortunately, neither proposal was funded this round. Maine is competing with many other states to recruit needed health care professionals. Neither the outstanding quality of life in Maine, nor its natural beauty, has historically been enough to win recruitment competitions. Our best success in meeting our needs for an expanded geriatric-capable health care workforce will come through establishing excellent training programs, providing competitive salaries and incentives for repaying student loans, and above all, supporting all 94

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health care workers to do work they can take pride in. High morale is the best recruiting tool of all. INITIATIVES IN MAINE TO IMPROVE CARE

o paraphrase our opening sentence, these are exciting times in geriatric health care. Many promising initiatives are underway at both the national and local levels to address some of the issues that we’ve covered in the previous sections.

Maine’s State Plan for Aging In 2012, Maine’s Department of Health and Human Services’ (MDHHS) Office of Aging and Disability Services (OADS), in accordance with the federal Older Americans Act of 1965, published a plan outlining goals, objectives, strategies, and performance measures to guide state-coordinated activities for the well-being of Maine’s seniors. The plan was meant as a guide for the development and coordination of statewide projects for health, housing, social, and nutritional services, as developed by each of the five regional Area Agencies on Aging in Maine. The plan will be revised in 2016 and will continue to serve as a road map for improving the wellbeing and independence of Maine’s seniors. State Plan for Alzheimer’s Disease and Related Dementias in Maine

In 2012, another collaborative effort, this time the state chapter of the Alzheimer’s Association and MDHHS, issued a road map to improve the diagnosis and treatment of people with dementia and their families. A HRSA-funded grant to MDHHS in 2013 is helping efforts to meet some of the goals laid out in the state plan to improve the diagnosis and community care of persons with cognitive impairment and dementia in Maine. Maine Council on Aging In 2011, a coalition of organizations providing a wide range of services to older adults formed the Maine Council on Aging (MCOA) to advocate for improved social services and health care for Maine’s seniors. MCOA promotes an ambitious legislative agenda that seeks to improve community-based care and support direct caregivers. MCOA has organized a workgroup that focuses on issues of health and wellbeing and advocates for state and national policies to support evidencebased health care reform. The Health and Wellness MAINE POLICY REVIEW

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Workgroup has proposed seven initiatives for priority action and 16 long-term goals to address policy issues, improve integrated geriatric primary care, and direct workforce education. (MCOA 2015). State Innovation Model The State Innovation Model (SIM) grant ($33 million) provides resources to primary care practices for the integration of physical and behavioral health care through the development of integrated teams.2 The SIM grant acknowledges the critical importance of mental health in the overall health of communities and the need to integrate what have been two systems of care. The behavioral health home and the integration of mental health professionals in the primary care office are two results. Another important part of the project is the training of health care providers in diabetes prevention, care of persons with developmental disabilities, and improving long-term care and transitions of care between levels of service. Maine Health Access Foundation The Maine Health Access Foundation (MeHAF) is a private, nonprofit foundation that promotes access to health care for the underserved and improvements in quality of care for everyone by supporting innovative projects. They have supported several major projects through grant programs: Thriving in Place (brings health care providers and community service providers together to keep people with complex physical and behavioral health care needs at home rather than in institutions), integrated care (behavioral health homes, integrating physical and mental health care), promoting projects in payment reform for improving quality of outcomes, and health information technology (Maine’s HealthInfoNet system) to improve coordination of care among providers. (See Boober [2015] and Bradney [2015], this issue, for discussion of Thriving in Place.) Maine Quality Counts Maine Quality Counts (MQC) is a private, nonprofit agency managing large grants and contracts that aim to transform health and health care in Maine by facilitating collaborative projects that meet pressing needs. By working with all players in health care, MQC is engaged in many of the major efforts in Maine to improve chronic care through innovative, interdisciplinary, comprehensive care models. 95

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Federal Health Care Reform

Current efforts at health care reform are ultimately going to be judged on whether they improved access to care, improved quality, and lowered costs. An accountable care organization (ACO) accepts responsibility for providing care to a community or population for a fixed cost, sharing risk with the payer, in this case, either Medicare or MaineCare. The Affordable Care Act (ACA) has cut Medicare reimbursement of hospitals to help pay for Medicaid expansion, which Maine has not done. The financial squeeze affects our hospitals’ abilities to provide for the growing needs of seniors with acute medical, surgical, and psychiatric needs. On the flip side, the ACA has provided competitive grants for creative pilot programs to test new models of care, some of which are being piloted in Maine: 1. Patient-centered Medical Home (PCMH)— A team of health professionals, consisting of primary care providers, case managers, and mental health providers, working together to meet patient-focused outcomes of improved health. 2. Population-based Care—Communities of people defined in advance who undergo screening and health assessments to prevent and treat chronic health conditions. Treatment and tracking of outcomes is performed by the care teams using measurable outcomes and evidencebased algorithms of care. 3. Accountable Care Organizations—Developed as a way to improve the coordination of care between hospitals, primary care, and community services; health care systems relying on population-based care to reduce costs and improve quality, sharing risks of expenses with payer (Medicare). 4. Community Care Transitions Program — Provides resources for community agencies to coordinate transitions of care (home to hospital, hospital to nursing home, nursing home to home) to reduce errors and help maintain continuity of care. 5. Bundled Payment for Care Improvement Model 2—Links payment for multiple services during an episode of illness with certain key performance measures for quality.

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6. Medicare Care Choices Model—Provides for the integration of palliative care services and primary care practices. There were federal programs to model and provide interdisciplinary, comprehensive, proactive care for frail elders with complex physical, mental, and social needs before the ACA. Program for All-Inclusive Care for the Elderly (PACE) programs provide comprehensive medical and social care to frail older adults, most of whom are dually eligible for Medicaid (MaineCare) and Medicare. By combining revenue streams from Medicare and Medicaid with a high level of flexibility, PACE programs are able to support people at home for longer periods of time. Maine’s effort to develop a PACE program is currently on hold. We need to overcome challenges in developing PACE programs in rural areas and small cities, but we are hopeful PACE programs will be part of our mix of services in the future. SUMMARY

his article has described a few of the most challenging issues we confront on a daily basis as we care for older patients. Some of these problems call for action on a federal level. Some are actually the results of well-intentioned reform efforts, whereas others may be addressed by on-going initiatives. Policy initiatives at the national level to reform health care have led to many promising efforts at the state level, and we are fortunate to have many people engaged in creative efforts to improve proactive, preventive, and comprehensive care. We strongly endorse these efforts and the policy priorities put forward by MCOA in the “Health and Wellbeing” section of their annual report (2015). There are many competing priorities in health care for seniors, but we close by creating our own “wish list” of both federal and state-level policy reforms: Federal

• Policies should reward persistence in overcoming the challenges of implementing proactive eldercare. Culture change takes time. • Policies are needed that encourage health care systems to implement a flexible array of services that are not just hospital or home-based. • Reimbursement models are needed to provide maximum flexibility in both the care setting 96

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and professional discipline of care delivery. Interdisciplinary care can be cost effective with better outcomes.

Blackwell, D.L., J.W. Lucas, and T.C. Clarke. 2014. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2012. National Center for Health Statistics. Vital Health Stat 10.

• Therapeutic crisis respite beds are urgently needed where people with dementia can be safely supervised and treated until they are safe to either return home or go to an appropriate memory care facility.

Boober, Becky Hayes. 2015. “Keep Them Rocking at Home: Thriving in Place.” Maine Policy Review 24(2): 111–114.

• Shorten or delete the “3 overnight” requirement for discharge to a skilled facility, and recognize crisis dementia care as a skilled care need. This would improve care and possibly reduce costs. • Reimburse videoconferencing and office visits via telemedicine in Cumberland and Penobscot counties. Federal and State

• Support excellent training programs, provide competitive salaries and incentives for student loan repayment, and above all, support health care workers to do work they can take pride in. State

• Improve access to high-quality dementia care day programs and assisted living. ENDNOTES 1. More information about the guidelines is available at http://www.iom.edu/Reports/2011/Clinical-Practice -Guidelines-We-Can-Trust 2. More information about the SIM program is available at http://www.maine.gov/dhhs/sim/index.shtml

REFERENCES Bailey, Jon M. 2009. “The Top 10 Rural Issues for Health Care Reform.” Rx (2). http://files.cfra.org/pdf/Ten-Rural -Issues-for-Health-Care-Reform.pdf American College of Emergency Physicians, The American Geriatrics Society, Emergency Nurses Association, and the Society for Academic Emergency Medicine (ACEP). 2013. Geriatric Emergency Department Guidelines. http://www.acep.org/geriEDguidelines/

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Boult, Chad, Ariel Frank Green, Lisa B. Boult, James T. Pacala, Claire Snyder, and Bruce Leff. 2009. “Successful Models of Comprehensive Care for Older Adults with Chronic Conditions: Evidence for the Institute of Medicine’s ‘Retooling for an Aging America’ Report.” Journal of the American Geriatrics Society 57(12): 2328–2337. Boyd, Cynthia M., C. Seth Landefeld, Steven R. Counsell, Robert M. Palmer, Richard H. Fortinsky, Denise Kresevic, Christopher Burant, and Kenneth E. Covinsky. 2008. “Recovery of Activities of Daily Living in Older Adults After Hospitalization for Acute Medical Illness.” Journal of the American Geriatrics Society 56(12): 2171–2179. Bradney, James. 2015. “The Emergence of Age Friendly Communities: Highlighting the Town of Bucksport.” Maine Policy Review 24(2): 60–61. Callahan, Christopher M., Malaz A. Boustani, Frederick W. Unverzagt, Mary G. Austrom, Teresa M. Damush, Anthony J. Perkins, Bridget A. Fultz, Siu L. Hui, Steven R. Counsell, and Hugh C. Hendrie. 2006. “Effectiveness of Collaborative Care for Older Adults with Alzheimer Disease in Primary Care: A Randomized Controlled Trial. Jornal of the American Medical Association 295(18): 2148–2157. Counsell, Steven R., Carolyn M. Holder, Laura L. Liebenauer, Robert M. Palmer, Richard H. Fortinsky, Denise M. Kresevic, Linda M. Quinn, Kyle R. Allen, Kenneth E. Covinsky, and C. Seth Landefeld. 2000. “Effects of a Multicomponent Intervention on Functional Outcomes and Process of Care in Hospitalized Older Patients: A Randomized Controlled Trial of Acute Care for Elders (ACE) in a Community Hospital.” Journal of the American Geriatrics Society 48(12): 1572–1581. Hoogerduijn, Jita G., Marieke J. Schuurmans, Mia S.H. Duijnstee, Sophia E. De Rooij, and Mieke F.H. Grypdonck. 2007. “A Systematic Review of Predictors and Screening Instruments to Identify Older Hospitalized Patients at Risk for Functional Decline.” Journal of Clinical Nursing 16(1): 46–57. Institute of Medicine (IOM) 2008. Retooling for an Aging America: Building the Health Care Workforce. The National Academies Press, Washington, DC. The Lancet Neurology. 2013. “The Road Map to Integrated Dementia Prevention and Care.” The Lancet/Neurology 12(9): 839.

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Landis, Suzanne E., and Shelley L. Gavin. 2014. “Implementation and Assessment of a Fall Screening Program in Primary Care Practices.” Journal of the American Geriatrics Society 62:2408–2414.

Yarnall, K.S., K.I. Pollak, T. Østbye, K.M. Krause, and J.L. Michener. 2003. “Primary Care: Is There Enough Time for Prevention?” American Journal of Public Health 93:635–641.

Maine Council on Aging (MCOA). 2015. Maine Aging Initiative Workgroup Annual Report: Health and Wellness and Aging. MCOA, Lewiston. http://www.mainecouncilonaging.org/assets/files /Annual-report-July-2015-health-wellbeing.pdf

Cliff Singer is chief of Geriatric Mental Health and Neuropsychiatry at Acadia Hospital and Eastern Maine Medical Center in Bangor and an adjunct professor at the University of Maine. He served on the faculty at Oregon Health and Science University in Portland from 1986 to 2005 and at the University of Vermont College of Medicine in Burlington from 2005 to 2009 before moving to Maine to start the geriatric program at Acadia Hospital in 2010.

Maine Department of Health and Human Services (MDHHS). 2012. State Plan on Aging 2012–2016. Office of Aging and Disability Services, MDHHS, Augusta. Maine Department of Health and Human Services (MDHHS). 2013. State Plan for Alzheimer’s Disease and Related Dementias in Maine. Office of Aging and Disability Services, MDHHS, Augusta. Maine Hospital Association (MHA). 2014. Hospital Issues for State Office Candidates 2014. MHA, Augusta. Mather, M. 2007. State Profiles of the U.S. Health Care Workforce. Paper commissioned by the Committee on the Future Health Care Workforce for Older Americans. Plassman B.L., K.M. Langa, G.C. Fisher, S.G. Heeringa, D.R. Weir, M.B. Ofstedal, J.R. Burke, M.D. Hurd, G.G. Potter, W.L. Rodgers,· D.C. Steffens, R.J. Willis, and R.B. Wallace. 2007. “Prevalence of Dementia in the United States: The Aging, Demographics, and Memory Study.” Neuroepidemiology 29:125–132. Reeves, Douglas. 2010. Transforming Professional Development into Student Results. Association for Supervision and Curriculum Development, Alexandria, VA. http://www.ascd.org/publications/books/109050 /chapters/The-Law-of-Initiative-Fatigue.aspx

Roger Renfrew is the facilitator of clinical geriatrics for MaineGeneral Health. He is an internist and geriatrician with more than three decades experience as a clinician, physician leader, and community health advocate. He was formerly medical director at Redington Medical Primary Care in Skowhegan, and is a founding member of the board of directors of the Daniel Hanley Center for Health Leadership.

Schiller, Jeannine S., Brian W. Ward, Gulnur Freeman, and Tainya C. Clarke. 2014. National Center for Health Statistics, National Health Interview Survey, Early Release of Selected Estimates Based on Data from the January-June 2014 U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Washington DC. Taylor, Warren D. 2014. “Depression in the Elderly.” New England Journal of Medicine 37(1): 1228–1236. Unutzer, Jürgen, Donald L. Patrick, Greg Simon, David Grembowski, Edward Walker, Carolyn Rutter, and Wayne Katon. 1997. “Depressive Symptoms and the Cost of Health Services in HMO Patients Aged 65 Years and Older,” Journal of the American Medical Association 277(20): 1618–1623. Unutzer, J. G. Simon, T.R. Belin, M. Datt, W. Katon, and D. Patrick. 2000. “Care for Depression in HMO Patients Aged 65 and Older.” Journal of the American Geriatric Society 48(8): 871–878.

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HEALTH AND LONG-TERM SERVICES AND SUPPORTS INFRASTRUCTURE

Shaping the Health and Long-Term Services and Supports Infrastructure Serving Older Adults: Historical Trends and Future Directions by Julie Fralich Julie Fralich provides a detailed overview of the confluence of demographic and policy changes shaping the future of Maine’s long-term care services and supports (LTSS) system. She notes how policies are driving a shift from nursing facility-based services toward home- and community-based services and describes the challenges Maine faces as it tries to make living at home a viable option for more older adults.

ver the last few decades, federal and state policies have been driving a shift away from nursing facility-based long-term services and supports (LTSS) toward home- and community-based services (HCBS). This process was accelerated by Olmstead v. L.C., a landmark civil rights decision handed down by the Supreme Court in 1999, requiring that individuals with a disability receive public services in the most integrated settings appropriate for their needs. In the coming decades, as Maine’s aging demographics generate increasing demand for LTSS, Maine faces a number of significant challenges as it tries to make living at home longer a viable option for more and more older adults who need assistance to do so. This article reviews the confluence of demographic and policy shifts that will shape the future of Maine’s LTSS system. BACKGROUND

ong-term services and supports is a term that generally refers to services provided in institutions, such as nursing homes and facilities for people with intellectual disabilities, and in other settings, such as group homes, assisted living facilities, adult family homes, adult daycare settings, and in one’s own home. (See glossary for definitions of terms used in the article.) LTSS are financed primarily with public dollars through the Medicare and Medicaid programs. Private funding

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for LTSS is not a sustainable option for most Maine people. The median annual private-pay costs for nursing home services totals 303 percent of median household income for persons aged 65 and older, while the median annual private-pay costs for home care totals 96 percent of median household income for the same age group (Reinhard et al. 2014). Unpaid family caregivers provide the greatest share of LTSS. In 2013, national spending on LTSS was $310 billion, with Medicaid paying for 51 percent of total expenditures; other public payers (such as Medicare) paying for 21 percent of care; private insurance covering 8 percent; and out-of-pocket expenditures representing 19 percent of total payments (Reaves and Musumeci 2015). Medicaid, the primary payer of institutional and community-based LTSS had outlays totaling over $123 billion, or 28 percent of total Medicaid expenditures in 2013. In Maine, Medicare and Medicaid (MaineCare) expenditures for older adults and adults with disabilities totaled over $629.5 million in 2010. This included all hospital, medical, behavioral health, long-term services, and MaineCare pharmacy costs. Of this, approximately $447.7 million or 70 percent was paid by MaineCare and 30 percent by Medicare. Nursing facility costs represent the greatest share of spending at $272.3 million, followed by costs in residential care settings of $96 million, and acute care hospital costs of 99

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Glossary Activities of daily living (ADL) and instrumental activities of daily living (IADL). ADLs are activities related to personal care and include bathing or showering, dressing, getting into or out of bed or a chair, using the toilet, and eating. IADLs are activities related to independent living and include preparing meals, managing money, shopping for groceries or personal items, performing light or heavy housework, and using a telephone. Adult day health services. Adult day health services are health and social services provided to promote optimal functioning, provided in a community-based setting. Adult day health services are sometimes referred to as “adult day care.” Adult family care home. Adult family care homes are residential care services provided in a residential style home for eight or fewer residents. Residents may receive personal assistance, personal supervision, care management, and nursing services when medically necessary. Adult foster home. Adult foster homes are residential care services provided in group settings of up to six residents. Rooms may be semi-private bedrooms, with a common living and dining area shared with the provider’s family. Residents receive care coordination, transportation, and nursing services when medically necessary. Assisted living. Residents live in private apartments with access to common dining and may receive personal assistance, care management, medication administration, and nursing services. Capitated payment. A capitated payment is a fixed amount of money paid in advance to a managed care

$75 million. Other MaineCare and Medicare home and community-based costs totaled $37.9 million (McGuire et al. 2012). Older adults and younger adults with disabilities are most likely to be covered by both Medicare and Medicaid. In 2010, 83 percent of the 14,855 MaineCare members who were 65 and older, or younger with a disability, were eligible for both Medicare and Medicaid services. People with dementia and/or impaired decision making are more likely to use long-term services and supports than

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organization per individual (e.g., a per member per month payment rate) to cover a defined set of services that an individual may use over a defined period of time. The managed care company is at risk for any service costs that exceed the capitated payment. Federal medical assistance percentage (FMAP). FMAP is the federal government’s share of expenditures for Medicaid services; it varies by state based on a state’s per capita income as a percentage of national per capita income. Home and community-based waiver. An HCBS waiver is a waiver of certain federal Medicaid requirements, granted by the Centers for Medicare and Medicaid Services (CMS) under §1915(c) of the Social Security Act, that allows states to provide home- and community-based services as an alternative to institutional services (e.g., nursing facility services), for individuals requiring an institutional level of care. MaineCare. MaineCare is the name for Maine’s Medicaid program, a public health insurance program administered as a state and federal partnership, through the Maine Department of Health and Human Services. Residential care. As used in this article, residential care refers to services provided in facilities reimbursed as private nonmedical institutions under Section 97 of the MaineCare Benefits Manual (10-144 CMR Chapter 101, MaineCare Benefits Manual) that are case mix reimbursed and primarily serve older adults. Case mix reimbursement indexes payment based on a resident classification system that reflects residents’ assessed conditions and the resources required to care for them.

those without dementia, particularly residential and nursing facility services. In 2010, approximately 57 percent of all MaineCare LTSS users had some form of dementia or impaired decision-making skills. The proportion of people with dementia increases with each higher level of care. In MaineCare-funded residential care facilities, almost half of the residents had dementia, and in nursing facilities, nearly two-thirds of the residents had dementia (Fralich et al. 2013).

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EMERGING TRENDS Consumer Preference for Services in the Home

Increasing Use of Assisted Living and Residential Care Services

The use of residential/assisted living services has t is well known that older adults prefer, if posbeen increasing dramatically in Maine and nationally. In sible, to receive long-term services and supports in the last 20 years, assisted living facilities have emerged as their homes. Furthermore, more people with disabilities an important option for housing and services for older are living in the community, even those with higher adults. The model of housing and service options in levels of disability (Redfoot and Houser 2010). assisted living varies widely across the country. The A survey by the AARP Maine of registered Maine Assisted Living Quality Coalition was formed, in part, voters over 50 found that most respondents indicated to provide some consistency within the industry and that it was extremely or very important to remain in developed the following definition of assisted living as “a their home as they age. Eighty-four percent of voters congregate residential setting that provides or coordiage 50 and older in households earning less than nates personal care services, 24-hour supervision and $20,000 say it is extremely or very important to them to assistance, activities and health related activities” be able to remain in their homes as they age. Recent Stevenson and Grabowski 2010: 42). Growth in this studies have also shown that the preference to remain at sector has been driven largely by consumer preference home depends on the level of functioning and health and has occurred with little or no government financing status of individuals. People with low levels of funcor regulation. As a result, assisted living facilities are tional impairment have a greater preference for care at located disproportionately in areas with higher educahome; that preference weakens as the level of disability tional attainment, income, and housing wealth increases and for people with more severe dementia (Stevenson and Grabowski 2010). (Guo et al. 2015). States have been cautious in expanding Medicaid Although Maine has a comprehensive array of coverage for services in assisted living facilities. Unlike MaineCare- and state-funded home care services, the care in nursing homes, Medicaid cannot pay for room number of people using any one of those services on and board expenses in assisted living facilities. States pay average in a month remained relatively constant from for assisted living costs (other than room and board) 2000 to 2010, with great variations among the different types of services. The largest increase in Figure 1: Monthly Average Number of Residents in Residential home care services occurred with Care Facilities Receiving MaineCare the use of private duty nursing/ personal care services, where the 5000 Under 65 Age 65–74 Age 75–84 Age 85+ number of people using personal care services increased from 735 in 4,075 4,005 3,958 4000 3,820 415 2000 to 1,272 in 2010. From 403 470 466 2006 to 2010, use of state-funded 484 514 511 3,087 home care services (for low-in521 3000 392 come people who do not meet the 1,253 442 1,262 Medicaid income threshold) 1,292 1,258 declined approximately 23 percent, 2000 985 but the use of homemaker services increased by 95 percent (Fralich et 1,925 1,826 al. 2012). This program is driven 1000 1,685 1,574 1,267 by the availability of state funds and often has wait lists that will influence access to these services, SFY 2000 SFY 2004 SFY 2006 SFY 2008 SFY 2010 and thus their use. Number of Persons

Bold numbers = Total number of residents for whom age is known Source: Fralich et al. (2012)

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Figure 2: Change in Percentage of Maine Population Residing

in Nursing Facilities, by Age Groups

Percentage of Population Residing in Nursing Facilities

20% Age 85+

16.5%

15%

Age 75–84

Age 65–74

13.6% 12.7% 11.5%

11.5%

10%

people age 75 and over fell by 19.9 percent (Weiner, Anderson, and Brown 2009). In Maine, the number of nursing home residents declined 15 percent from 2000 to 2010, even when the population age 65 and over increased 15 percent (Figure 2). For the oldest old, i.e., persons age 85 or above, Maine nursing home use rates fell from 16.5 percent in 2000 to 11.5 percent in 2010 (Fralich et al. 2012). Decreasing Rates of Functional Disability

4.4%

1.1% 0%

2000

2001

2002

2003

4.1%

3.8%

3.6%

1.0%

0.8%

2004

2005

2006

2007

2008

2009

2010

State Fiscal Year

Source: Fralich et al. (2012)

There have also been dramatic improvements in the overall health and physical functioning of older adults in the last 20 to 25 years. Between 1992 and 2010, a survey of national Medicare beneficiaries, found that the percentage of people over age 85 with either an instrumental activity of daily living (IADL) or activity of daily living (ADL) need fell from 80 percent to 70 percent (Figure 3). Similar trends

Decreasing Use of Nursing Facilities

At the same time that the use of assisted living and residential care facilities has grown, the use of nursing homes has declined, largely because Maine has tightened the medical eligibility criteria for accessing nursing facility services. The number of nursing home residents per 1,000 people aged 75 over has decreased substantially nationally and in Maine. Between 1997 and 2007, the nationwide number of nursing home residents per 1,000 MAINE POLICY REVIEW

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Percentage of Federal Poverty Level

under a Medicaid waiver or under the Medicaid state plan. Maine also uses state dollars to reimburse for services at assisted living facilities. To the extent Figure 3: Percentage of Medicare Beneficiaries in there is oversight of the quality of services provided, United States with IADL or ADL Need, it remains largely within state purview. 1992 and 2010 In Maine, use of MaineCare-funded residen100% tial care facilities increased significantly in the 10 1992 2010 years from 2000 to 2010. As shown in Figure 1, the number of people over age 85 who lived in a 80% 77% 80% 73% MaineCare-funded residential care facility 70% increased 44 percent, from 1,267 people in 2000 to 1,826 older adults in 2010. 60% 53% 44% 40%

33% 27%

20%

Disabled under 65

65 to 74 years

75 to 84 years

85 years and over

Source: NCHS (2014): Table 129

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Figure 4: Disability Rate in Maine

Figure 5:

by Income as Percentage of Federal Poverty Level

40%

50,000

34%

Projected Growth in Maine’s Alzheimer’s Population, 2010 to 2030

75–84 65–74 25%

Under 65

20%

13,863

37,500 13%

10%

49,578

85+

31%

30%

Below Federal Poverty Level (FPL)

100% to 149% of FPL

150% to 199% of FPL

200% of FPL or Above

Source: American Community Survey 2013 (http://www.socialexplorer.com/data/ACS2013 /metadata/?ds=American+Community+Survey +2013&table=B18131)

were seen in the younger age groups as well (NCHS 2014). The literature suggests that these declines may be primarily a result of social and housing innovations as well as the expanded availability of assistive devices. Other contributing factors include investments in biomedical research, innovative and more effective therapeutic and preventive care, increasing levels of education, better nutrition, more emphasis on exercise later in life, and changes in smoking rates and alcohol use (Manton, Gu, and Lamb 2006). Increased Rates of Disability with Lower Income

The relationship between poverty and disability is another factor to consider in a state such as Maine. According to the American Community Survey, a higher proportion of poor adults are disabled compared to adults with incomes at least 200 percent of the federal poverty level. In Maine, 34 percent of adults 18 and over with incomes below the FPL reported having a disability while 13 percent of those with income at least 200 percent of the FPL reported having a disability (Figure 4). Increasing Rates of Dementia with Older Population

Caring for people with dementia will continue to be a challenge in an aging state. As the number of people over age 65 continues to grow, the number with dementia MAINE POLICY REVIEW

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32,300 Number of Persons

Percentage of Federal Poverty Level

26,012 25,000

10,397 26,351

9,401

14,839

12,500 12,192

7,381 0

3,378 * 2010

5,772 * 2020

1,983 2030

*Under 65: 2010=1,041, 2020=1,292

Source: Fralich et al. (2013)

will increase significantly. It is estimated that 18 percent of people between the ages of 75 to 84 have dementia and 32 percent of people over 85. Overall, approximately 12 percent of people over 65 and 4 percent of people under 65 have dementia (Hebert et al. 2013). The number of people in Maine with Alzheimer’s, the most common type of dementia, is expected to almost double between 2010 and 2030 (Fralich et al. 2013). (See Figure 5.) MAINE’S LONG-TERM SERVICES AND SUPPORTS SYSTEM

he greatest share of LTSS is provided by unpaid family caregivers. For the United States as a whole, the economic value of family caregiving was estimated at $450 billion in 2009, greater than both the federal and state share of all Medicaid spending that year ($361 billion) (Feinberg et al. 2011). For many older adults, the family caregiver has the most important role in 103

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of 33 percent over the 10 years between 2000 and 2010. Figure 6 shows the share of LTSS expenditures for each major sector. In 2010 nursing facility expenditures constituted 67 percent of MaineCare LTSS expenditures compared to about 20 percent for residential care and approximately 13 percent for home care services (Figure 6). Not surprisingly, the difference in expenditures is largely driven by differences in the average costs of these services. Since nursing facility care includes room and board as well as nursing services, the average Medicaid cost for a person for a month in a nursing home is higher than in the other settings. In 2010, the average monthly Medicaid cost for a nursing home stay was $4,150; care for personal care and other services in residential care facilities was $1,811; and care for people on the elder/ adult waiver (for people who have needs similar to those in nursing facilities), was $1,940 a month. The distribution of people using nursing facility, residential care, and home care services looks different from the distribution of expenditures. In 2010, 39 percent of all long-term service users were in nursing Figure 6:

Annual MaineCare LTSS Expenditures* by Setting, SFY 2000, 2008, and 2010

Percentage Share of Annual Expenditures

making it possible to continue to live at home. Unpaid caregivers assist with household tasks and personal care, handle bills, provide transportation, arrange for and coordinate services, and provide a host of other needed supports. While the contribution of family caregivers is great, the toll on the family caregiver is also great; family caregiving is now viewed as a public health concern (Feinberg et al. 2011). Older adults who need assistance to live at home also depend on other important components of community infrastructure not typically thought of as LTSS: affordable and accessible housing and transportation services. In Maine, a largely rural state, public transportation is in short supply and the aging housing stock typically is not designed to support aging in place. Maine’s aging network (comprising five area agencies on aging dispersed across the state) also plays an important role by providing a range of other low-level interventions aimed at helping people to maintain their independence at home longer. These services, funded under the Older Americans Act, include transportation services, adult day care, caregiver supports, nutrition services, and other supportive services. Maine also has a long history of providing an array of institutional, residential, and noninstitutional LTSS funded as part of the Medicaid State Plan or as an HCBS waiver benefit. The Medicaid state plan services include nursing facility, personal care, private-duty nursing, and adult day services. Personal care and nursing services are provided to individuals who live in a variety of settings, ranging from in-home to residential care and adult family care homes. Individuals who require a nursing facility level of care may also receive LTSS through Maine’s HCBS elder/adult waiver program. An HCBS waiver program typically provides a wider array of services to individuals living in the community than those that can be provided under the Medicaid state plan. Maine’s elder/adult waiver program provides home health services, personal care services, or self-directed personal attendant services, in addition to adult day health services, assistive technology, environmental modification, respite, service coordination and other services. Maine also spends over $10 million per year on state-funded home care and homemaker services. Other state-funded services include adult day services, respite, and independent housing with services. In 2010, annual MaineCare expenditures for LTSS services was approximately $354.4 million; an increase

100% 80%

60%

70%

66%

67%

12%

21%

19%

18%

1% 12%

1% 13%

SFY 2008 $364.1 mil.

SFY 2010 $354.4 mil.

40%

20%

SFY 2000 $266.5 mil.

Nursing Facility Case Mix Residential Care Other Residential Care* Home Care

*Includes MaineCare LTSS expenditures for older and younger adults. Source: Fralich et al. (2012).

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facilities; 27 percent were in some form of residential care; and 35 percent were receiving MaineCare-funded services at home (Figure 7). This represents a shift over the 10 years from 2000 to 2010. In addition to services funded by MaineCare, Maine also uses state funds to provide home-based care and homemaker services for people whose income is too high to be eligible for MaineCare, but who have limited resources. Underpinning Maine’s formal or paid LTSS system is the direct service worker. Needed in all LTSS settings, the direct service worker in Maine’s elder/adult programs provides assistance with activities of daily living or instrumental activities of daily living. Direct services workers typically are paid at an hourly rate and often do not have access to benefits such as health insurance or vacation and sick time through their employer. In a 2012 survey of Maine provider agencies employing direct service workers (across older adults and adult disability programs), the average hourly wage for a direct service worker was $10.88. Among the provider agencies surveyed, 76 percent reported finding qualified workers as a significant workforce challenge; workforce turnover (58 percent) and employee motivation and worker Figure 7:

Average Monthly MaineCare LTC Users by Setting, SFY 2000 to SFY 2010

100%

Percentage by Setting

80%

45%

40%

39%

25%

26%

33%

35%

60%

40%

20%

17%

38%

35%

SFY 2000

(N = 11,941)

SFY 2006

SFY 2008

(N = 11,839)

(N = 12,190)

SFY 2010

(N = 12,329)

Nursing Facility (N=4,749) Case Mix Residential Care (N=3,156) Other Residential Care (N=133) Home Care (N=4,291)

Source: Fralich et al. (2012).

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competence (both at 38 percent) were other top challenges identified (Westcott, Griffin, and Fralich 2012). FEDERAL AND STATE POLICY

ecause Medicaid is the primary funder of LTSS, to a large degree state Medicaid agencies, in collaboration with the state agencies responsible for administering programs for older adults and adults with disabilities, have a major role in establishing LTSS policy at the state level. State-level LTSS policy, however, is often responding to federal policy drivers, whether in the form of a regulatory requirement or financial incentives. I present here some of the federal and state initiatives underway in Maine and nationally to increase the use of home care services and improve the coordination of those services between the medical and long-term service sectors. I also discuss some of the other policy initiatives that are likely to shape the structure of LTSS in Maine and nationally.

The Affordable Care Act The Affordable Care Act included a number of provisions aimed at improving the availability of Medicaidfunded LTSS. These included demonstrations, enhanced Medicaid matching payments, and new Medicaid state plan options. Generally, states can decide whether and to what extent to participate in these demonstration opportunities and whether to adopt some of the new Medicaid policy options. A number of these initiatives have prerequisites for participation and/or have other requirements that must be weighed by states considering such policy changes. They include the following:

Balancing Incentive Payment (BIP) Program The Balancing Incentive Payment (BIP) program provides enhanced federal matching funds to states that “make structural reforms to increase nursing home diversions and access to non-institutional LTSS. Enhanced matching payments are tied to the percentage of a state’s home and community based spending, with lower Federal Medical Assistance Percentage [FMAP] increases going to states that need to make fewer reforms” (http:// medicaid.gov/). To participate in the BIP, a state must have spent less than 50 percent of total Medicaid expenditures on noninstitutionally based LTSS in FY 2009. Currently 21 states are approved to participate in the program, including Maine.

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To participate in the BIP, state agencies must agree to certain structural changes including a no-wrongdoor single-entry-point system; conflict-free case management; and a core standardized assessment instrument (CMS 2011). According to the Maine Department of Health and Human Services (MDHHS) website, Maine submitted a BIP application in May 2012, and its application was awarded July 2012. Under the BIP program, Maine is developing a no-wrong-door website and a toll-free number where individuals can receive information about LTSS options in the state and schedule appointments with local agencies for assessments of need. Because the adult mental health system operates differently from the older adult system, the state is working to develop a common understanding of the flow of people using the no-wrongdoor framework for all people using LTSS in Maine. The state is also working to establish protocols for removing conflicts of interest by care managers, to develop data for quality reporting, and to standardize the process to determine eligibility. Money Follows the Person The Money Follows the Person demonstration is designed to help eligible individuals to move from institutional to community settings. In Maine, the program is called Homeward Bound, and it provides assistance with transition from a nursing home to home for people who have been in a nursing home or hospital for at least three months and are receiving Medicaid benefits. A transition coordinator works with interested people to understand their needs, develop a plan, and provide help during the transition process. Certain services are available for people moving home including independent living assistance, household start-up, enhanced care coordination, technology services, and peer support. As of December 31, 2014, Maine had transitioned 40 people from nursing homes, 10 of whom were older adults and 19 were individuals with physical disabilities. Health Homes The Affordable Care Act also provided opportunities for states to develop a health home model of service delivery that would enhance the integration and coordination of primary, acute, behavioral health, and LTSS services. Medicaid-eligible individuals must have two or more chronic conditions, have one condition and be at risk of developing another, or have at least one serious and persistent mental health condition. Health home MAINE POLICY REVIEW

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services must include comprehensive care management, care coordination, health promotion, transitional care from inpatient to other settings, individual and family support, and referral to community and social support services (CMS 2010). Maine has implemented health homes for people with chronic conditions and people with mental health conditions. Other Options through Coordinated Care For many years, states have recognized the need to better manage the services provided to older adults and adults with disabilities and to improve quality and outcomes of care through better coordination and integration of Medicare and Medicaid services. Historically, states have relied on HCBS waivers to expand services and provide care management for people with higher levels of need (e.g., those who are eligible for nursing facility [NF] level of care). Maine has had a number of such waivers that provide an expanded set of services for older adults, adults with physical disabilities, and most recently adults with brain injury. People who meet the NF-level-of-care criteria are eligible for these services. These waivers are limited, however, in the people served and the services for which a care coordinator is responsible. Under a number of different federal authorities, states have increasingly moved to the implementation of managed LTSS programs for Medicaid-only services, and more recently to cover the integration of both Medicare and Medicaid services. In addition to providing a vehicle for enhanced care coordination, states are also using managed care to increase access to LTSS services, to expand financial eligibility for services, and to provide quality incentives to providers. Under a managed care program, the state contracts with a managed care organization using a capitated payment to provide a full array of LTSS, including care coordination services, to those needing LTSS. Managed LTSS may include institutionally based services and community-based services (Musumeci 2014). As of June 2015, 26 states had some form of a managed LTSS system and 12 states had signed memoranda of understanding (MOUs) to implement managed LTSS programs for people dually eligible for Medicaid and Medicare. Other Changes in Policy States have also been active in responding to several significant federal policy directives affecting home- and community-based services. Unlike some of the initiatives described earlier in this article, these are regulatory 106

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mandates that are required for states to be in compliance with federal law. These will require changes to some aspects of the service delivery systems that states currently have in place. New HCBS Requirements Effective March 17, 2014, the Centers for Medicare & Medicaid Services (CMS) issued new rules that apply to certain Medicaid HCBS programs, including waiver programs.1 These rules set standards for person-centered planning, conflict-free case management, and the nature of the settings in which HCBS may be provided.2 The underlying intent of the rules is to ensure that home- and community-based services are not provided in settings that have institutional qualities or that isolate service recipients from the larger community. The standards address a range of issues including access to community activities, individual rights and autonomy, and choice of providers. To comply with the new HCBS standards, states were required to file a transition plan with CMS on or before March 17, 2015, with a proposed work plan and timeframes for coming into compliance with the new rules. With CMS approval, states have up to five years from the effective date of the rules to make any necessary changes. Maine’s transition plan may be viewed on the MDHHS website of the Office of Aging and Disability Services.

federal court has delayed implementation. However, the U.S. Court of Appeals (D.C. Circuit) issued a unanimous opinion affirming the validity of the DOL rule; it will become effective 52 days after the August 21, 2015, opinion was issued. DOL had advised states that it will not grant additional time for coming into compliance once the litigation was resolved and that states are responsible for actively continuing planning activities, including securing additional funding, to come into compliance with these new requirements. Nationally, the DOL estimates these new regulations will affect millions of homecare workers in the United States. They are also expected to significantly affect home care agency providers and shared living and participant-directed programs. Now that these rules have been affirmed, these changes are potentially of great significance to states in terms of cost and systems implementation.

As Maine’s demographics and state and federal policy converge, Maine’s LTSS system faces an extraordinary amount of pressure.

New Department of Labor (DOL) Requirements

The U.S. Department of Labor (DOL) recently finalized rules making changes to wage and hour provisions that have significant implications for Medicaid personal care and delivery of other LTSS. Under federal law, many workers providing personal care services were exempt from minimum wage and overtime requirements because those services fell within what was considered companionship services. The new DOL rules significantly limit what can be considered companionship services and also limit who can claim such an exemption if it exists. These rules are expected to affect shared living and participant-directed programs because states may be considered joint employers for purposes of the minimum wage and overtime payment. These changes will also affect workers employed by home care agencies except for states such as Maine, where these workers are already covered by state labor laws. These rules went into effect January 1, 2015, with a phased-in period for enforcement, but litigation in MAINE POLICY REVIEW

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IMPLICATIONS

s Maine’s demographics and state and federal policy converge, Maine’s LTSS system faces an extraordinary amount of pressure. How can Maine meet these challenges?

Family and Community Supports As the primary source of LTSS, strengthening and supporting the role of the family caregiver will be critical to supporting older adults at home. Recognizing and addressing the needs of the family caregiver as part of planning for care of older adults can help sustain the caregiver’s ability to provide and prevent or delay nursing facility care. Access to respite services, including adult day health services, can help a caregiver balance caregiving with other family commitments and work. Strengthening the community supports surrounding the individual is also critical. The AARP’s Livable Communities initiative provides a template for creating communities that support livability at all ages, by 107

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addressing walkability, transportation, housing, promotion of social engagement, and other strategies. Maine’s AARP is bringing this concept to Maine through its network of age-friendly communities. Maine’s aging network and the community-based supports it provides serve as another important strategy for policymakers to consider. The services provided by the local area agencies play a role in preventing or delaying use of nursing facilities. Research has shown, for example, that increased spending on home-delivered meals (e.g., Meals on Wheels) is associated with fewer residents in nursing facilities who have low care needs (Thomas and Mor 2013). Technology Advances in technology hold both promise and challenges for the aging population. While technological advances are fast emerging, developing mainstream products that meet consumer preferences is still a challenge. A mix of technological, individual, and social factors come into play with the adoption of new technologies. Adoption depends not only on a technology’s potential usefulness, but also its usability, affordability, and accessibility, and the level of confidence, reliability, and trust it earns. Involving the end user in the testing and development of technological innovations is critical for its success. Technology is being used to inform the use of space in urban design and living arrangements; to monitor physical activity and movement for people with dementia; to remotely monitor medication compliance and other health status; and to develop driver assisted technologies (Hudson 2014). (See sidebar for examples and Kim et. al [2015], for further discussion on research and development of technological innovations in Maine.) Home- and Community-Based Services There is no question that states will continue to expand access to and financing of home- and community based services as alternatives to institutional services. For some, it is a question of costs. Although studies of cost effectiveness of HCBS have been conducted with mixed and somewhat inconclusive results (Konetzka 2014), many argue that services at home are less expensive than services in a nursing facility. For others, the benefit of expanding home care services and the desire for such services by the consumer is enough to warrant expansion of access to such services and investment in the infrastructure, workforce, and pay scales necessary to support these services. Regardless, the mandate of MAINE POLICY REVIEW

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Examples of Technological Innovations Existing and on the Horizon eHealth—online access to personal health records, online health self-management tools, health websites. mHealth—mobile devices for collecting health data to send to clinicians or caregivers. Remote Monitoring—for monitoring safety (e.g., detecting falls), movement (e.g., sleep behaviors or medication adherence), or vital signs and other health indicators. Smart Homes Systems—integrates appliances, lighting, and security systems with other technologies to control conditions within a home, or monitor environmental conditions and daily activity. Cognitive Coaching and Robotics—virtual coaches to help people with memory loss by detecting when assistance is needed and providing that assistance (e.g., providing instructions on how to use a medical device or comply with a complicated medical regime). Robots may also be used to help with chores, or augment a user’s capacity. Source: Czaja (2015)

Olmstead has clearly put states on the path of supporting people in the least restrictive, most integrated settings possible. With the demand for HCBS likely to grow with Maine’s aging baby boom generation, it seems that the question should not be whether such services should be available, but how to make such services available in a way that assures appropriate oversight and monitoring of quality, differentiation in services for people with varying needs, and support for an adequately trained and compensated workforce. To be successful, Maine needs to continue to build on the efforts described in this article, including timely and appropriate access to HCBS, systems that support transitions from institutional to community settings, promotion of workforce initiatives, and the development of a greater and deeper array of community options. An increase in services provided at home will also need to be accompanied by improved coordination of medical and long-term services, improvements in 108

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technology, and strong oversight of quality. These issues are complex and the challenges are daunting. For this reason, Maine must focus on providing strong leadership to ensure an efficient and effective management infrastructure that supports the development of policy, programs, partnerships, collaborations, and innovations that are critical to the success of its LTSS system. The LTSS Infrastructure Technology is not going to eliminate the need for a high-quality direct service workforce. Policymakers will need to address the shortage of qualified direct care workers needed to meet the increasingly complex needs of people now residing in community settings. People with dementia or cognitive issues, frail older adults who live alone or have no support system, and aging people with developmental disabilities will need low-cost options for a combination of housing with supervision and services. Although the institutional and skilled rehabilitative services will remain an important component of the LTSS system, converting some of the older bricks and mortar of aging institutions into more modern facilities will be challenging. CONCLUSION

hile federal policy will play an important role in shaping the future of Maine’s LTSS system, efforts at the state and local level will define the extent to which Maine will be able to successfully support older adults living at home. The constraints of the state budget are likely to limit Maine’s options. However, investing in low-cost interventions that can reduce or delay the use of high-cost institutional services may be an important short-term strategy for policymakers, as they come to terms with the larger questions about how to finance the institutional- and home-based services that will be needed in the future. ENDNOTES

1. These rules apply to Medicaid-funded HCBS authorized under §1915(c), §1915(i) and §1915(k) of the Social Security Act. 2. Final Rule — CMS 2249-F – 1915(i) State Plan Home and Community-Based Services, 5-Year Period for Waivers, Provider Payment Reassignment, Setting Requirements for Community First Choice, and CMS 2296-F 1915(c) Home and Community-Based Services Waivers.

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REFERENCES Bridges, Katherine. 2014. Issues and Concerns of the 50+ in Maine: 2014 AARP Survey of Maine Registered Voters Age 50 and Older. AARP Research, Washington, DC. Centers for Medicare and Medicaid Services (CMMS). 2010. State Medicaid Director’s Letter, Health Homes for Enrollees with Chronic Conditions. U.S. Department of Health and Human Services, Baltimore, MD. Centers for Medicare and Medicaid Services (CMS). 2011. State Medicaid Director Letter 11-010 on the Balancing Incentive Program. U.S. Department of Health and Human Services, Baltimore, MD. Czaja, Sara J. 2015. “Can Technology Empower Older Adults to Manage Their Health?” Generations: Journal of the American Society on Aging 39(1): 46–51. Feinberg, Lynn, Susan C. Reinhard, Ari Houser, and Rita Choula. 2011. Valuing the Invaluable: 2011 Update: The Growing Contributions and Costs of Family Caregiving. AARP Public Policy Insitute, Washington, DC. Fralich, Julie, Stuart Bratesman, Cathy McGuire, Louise Olsen, Jasper Ziller, Karen Mauney, Cynthia Shaw, Tina Gressani, and Catherine Gunn. 2012. Older Adults and Adults with Disabilities: Population and Service Use Trends in Maine, 2012 edition. University of Southern Maine, Muskie School of Public Service, Portland. Fralich, Julie, Stuart Bratesman, Louise Olsen, Catherine McGuire, Tina Gressani, Karen Mauney, Cynthia Shaw, Catherine Gunn, and Romaine Turyn. 2013. Dementia in Maine: Characteristics, Care, and Cost Across Settings. University of Southern Maine, Muskie School of Public Service, Portland. Guo, Jing, R. Tamara Konetzka, Elizabeth Magett, and William Dale. 2015. “Quantifying Long-term Care Preferences.” Medical Decision Making 35(1): 106–113. Hebert, Liesi E., Jennifer Weuve, Paul A. Scherr, and Denis A. Evans. 2013. “Alzheimer Disease in the United States (2010–2050) Estimated Using the 2010 Census.” Neurology 80(19): 1778–1783. Hudson, Robert B. 2014. “Aging and Technology: The Promise and the Paradox.” Public Policy & Aging Report 24(1): 3–5. Kim, Carol H., David Neivandt, Lenard W. Kaye, and Jennifer A. Crittenden. 2015. “The Emergence of a Technology-and-Aging Research and Development Sector in Maine.” Maine Policy Review 24(2): 29–35. Konetzka, R. Tamara. 2014. “The Hidden Costs of Rebalancing Long-Term Care.” Health Services Research 49(3): 771–777.

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Manton, Kenneth G., XiLiang Gu, and Vicki L. Lamb. 2006. “Change in Chronic Disability from 1982 to 2004/2005 as Measured by Long-term Changes in Function and Health in the U.S. Elderly Population.” Proceedings of the National Academy of Sciences 103(48): 18374–18379. McGuire, Catherine, Stuart Bratesman, Tina Gressani, Julie Fralich, and Eileen Griffin. 2012. Children and Adults with Long Term Services and Support Beeds: MaineCare and Medicare Expenditures and Utilization, State Fiscal Year 2010. University of Southern Maine, Muskie School of Public Service, Portland. Musumeci, MaryBeth. 2014. Key Themes in Capitated Managed Long Term Services and Supports Waivers. Kaiser Commission on Medicaid and the Uninsured, Menlo Park, CA.

Julie Fralich directed the Program on Disability and Aging within the Cutler Institute of the Muskie School, University of Southern Maine, until her retirement in June 2015. She has extensive knowledge of state and federal aging and disability policy, with a particular focus on Medicaid and Medicare payment and quality. She continues to work as a senior research associate on a subcontract with the Research Triangle Institute to evaluate the implementation of the national dual eligible financial alignment initiative.

National Center for Health Statistics (NCHS). 2014. Health, United States, 2013: With Special Feature on Prescription Drugs. NCHS, Hyattsville, MD. http://www.cdc.gov/nchs/data/hus/hus13.pdf Reaves, Erica, and MaryBeth Musumeci. 2015. Medicaid and Long-Term Services and Supports: A Primer. Kaiser Commission on Medicaid and the Uninsured, Menlo Park, CA. Redfoot, Donald, and Ari Houser. 2010. More Older People with Disabilities Living in the Community; Trends from the National Long-Term Care Survey, 1984–2004. AARP Public Policy Institute, Washington, DC. Reinhard, Susan C., Enid Kassner, Ari Houser, Kathleen Ujvari, Robert Mollica, and Leslie Hendrickson. 2014. Raising Expectations 2014: A State Scorecard on LongTerm Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers. AARP Public Policy Institute, Washington, DC. Stevenson, D. G., and D. C. Grabowski. 2010. “Sizing Up the Market for Assisted Living.” Health Affairs 29(1): 35–43. Thomas, Kali S. and Vincent Mor. 2013. “The Relationship between Older Americans Act Title III State Expenditures and Prevalence of Low-Care Nursinig Home Residents.” Health Services Research 48(3): 1215–1226. Weiner, Joshua M., Wayne L. Anderson, and David Brown. 2009. Why Are Nursing Home Utilization Rates Declining? RTI International, Baltimore, MD. Westcott, Danny, Eileen Griffin, and Julie Fralich. 2012. Maine’s Direct Service Workforce Survey Results. University of Southern Maine, Muskie School of Public Service, Portland, ME.

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Keep Them Rocking at Home: Thriving in Place by Becky Hayes Boober The Thriving in Place Initiative (TiP) described by Becky Hayes Boober aims to help people with chronic health conditions remain safely in their communities instead of being hospitalized or placed in residential care facilities. Funded by grants to communities from the Maine Health Access Foundation, TiP builds on and coordinates health care and supports already in a community.

’m glad I have nosey neighbors. I didn’t always feel this way, but since working with communities that support people with chronic health conditions to thrive in place, I have realized nosey neighbors are an important part of an essential social support network. Tapping community resources, including the engaged neighbor, is foundational to the Thriving in Place (TiP) initiative, launched in 2013 by the Maine Health Access Foundation with eight planning grants, four of which have moved to implementation. In 2015, two new planning grants were awarded and three additional implementation grants. TiP helps people with chronic health conditions (including the elderly and persons with disabilities) remain safely in their communities instead of being hospitalized or placed in nursing homes or other residential care facilities. Instead of creating new programs or services, TiP builds on and coordinates health care and supports already in a community. TiP recognizes we cannot afford to expand our current system of services to meet the growing needs of the aging population in Maine, which saw a 58 percent increase in persons age 85 and older between 1990 and 2009, even before the bulk of baby boomers began reaching that age (Office of Aging 2012). Even though 90 percent of older Mainers want to stay in their own homes, the current system relies on costly hospital and long-term residential care. Almost half of health care costs for persons dually eligible for MaineCare and Medicare is spent on nursing homes, other residential-level care, or acute hospital stays (McGuire et al. 2012).

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Since we cannot afford the current system of care for an expanding older population, new strategies are needed to keep people healthy and home. Through community partnerships, TiP links health care systems with community supports such as housing, transportation, home services, caregiving supports, volunteer networks, and social connections. TiP requires four partners: health care providers, home/community-based service providers, community supports, and consumers/ caregivers. Current TiP communities partner with as many as 43 organizations. During the planning period, grantees conduct a community assessment; solicit community input and engage consumers; develop a comprehensive TiP plan to help people to thrive in place by integrating health care, social services and supports, in-home supports, and volunteers; and clearly identify partners’ roles and responsibilities. Community-specific ideas are tried, such as having the homebound call the police or a volunteer each morning to check in. Some Maine hospitals contract with the local Area Agency on Aging to provide Meals on Wheels for two weeks after discharge for a patient and caregiver, reducing readmissions. LESSONS LEARNED

hrough community input, TiP grantees discovered insights on what keeps people safe and healthy in their homes. We anticipated hearing that people were at risk of being placed in long-term residential care because of lack of access to or affordability of health care and pharmaceuticals. Instead, we discovered the following:

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1. Needs were often low barrier, but people lacked resources (snow shoveling, home repairs, heat, transportation, social isolation, caregiver support). 2. People rated their health as good, even when they had four or more chronic health conditions, demonstrating resilience. 3. Maintaining older people’s dignity and sense of purpose is essential. People want to continue contributing to their community. Therefore, TiP networks keep them engaged, often through membership models that ask every member’s help in some way. For example, someone who is homebound can call other people each day to check on them. By helping others, individuals become more comfortable accepting services. 4. Health care providers need to respect and listen to older patients. Those surveyed liked their primary care providers, but did not feel listened to by specialty care providers. 5. Social isolation is a big concern and can affect behavioral health, especially after people can no longer drive. Some primary care providers write prescriptions or letters to patients, recommending them as members of TiP, so they get needed services while staying connected in the community. 6. The aging population is an opportunity for Maine, not a burden. Older Americans are a tremendous community resource with their wisdom, professional and other life experiences, and time. 7. Relationships are fundamental to TiP success. This includes relationships among the partnering organizations and among community members.

winter of 2015, an older Maine man was discovered dead in a home with no heat. Another man who was a caregiver was found dead after a heart attack. Because he was discovered two weeks after his death, his disabled wife had died as well due to lack of care. Maine can and must do better than this. Neighbors need to support each other and to develop systems of coordinated care and support. These tragic incidents are reminders of the importance of creating a community network of professional and volunteer supports that keep all community members safe, healthy and thriving in place. REFERENCES Office of Aging and Disability Services. 2012. State Plan on Aging: October 1, 2012 – September 30, 2016. Maine Department of Health and Human Services, Augusta. http://www.maine.gov/tools/whatsnew/attach .php?id=427427&an=1 McGuire, Catherine, Tina Gressani, Stuart Bratesman, Julie Fralich, and Eileen Griffin. 2012. Analysis of Members Dually Eligible for MaineCare and Medicare: MaineCare and Medicare Expenditures and Utilization State Fiscal Year 2010. University of Southern Maine, Muskie School of Public Service, Portland. http://muskie.usm.maine .edu/Publications/DA/DualEligible-Chartbook-SFY2010 .pdf

Becky Hayes Boober, senior program officer at Maine Health Access Foundation, leads initiatives to integrate behavioral health and primary care and the Thriving in Place initiative to keep persons with chronic health conditions, including older persons, in their homes. She also oversees Access to Quality Care grants. Previously, she worked for more than 20 years in the commissioners’ offices of three state of Maine departments.

8. Collaboration takes time, intense effort, and champions/leaders to sustain. 9. Change in systems is slow, so patience is required. These lessons can help other communities interested in becoming TiP neighborhoods. The neighbors-helping-neighbors aspect of TiP is needed in most Maine communities. In the unrelenting

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HOME CARE IN MAINE

Home Care in Maine: The Worker’s Experience by Sandra S. Butler Sandra Butler presents findings from her study of home care aides, which was aimed at understanding the high rate worker of turnover. The study found that low wages, lack of mileage reimbursement and job benefits, and inconsistent and unreliable hours were key factors in workers’ decisions to leave the field.

ost elders needing assistance to live independently receive that help from family members and friends, sometimes referred to as “informal caregivers.” But for a variety of reasons—including smaller families, higher divorce rates, and increasing numbers of women in the workforce—these informal caregivers are less available than in the past and may not be able to supply all the assistance needed to allow elders to remain at home for as long as possible. This is a particular problem in Maine since children often leave the state in search of better employment opportunities. Not only are informal caregivers in ever shorter supply, but home care workers, sometimes called “formal caregivers,” are not always adequately available either, in part due to high rates of turnover resulting from poor compensation. Addressing this care gap as baby boomers move into their elder years will be a crucial factor in whether current efforts to promote aging-in-place succeed. In Maine, the title for home care aides is “personal support specialist” (PSS). In 2008, I began a longitudinal study examining the experiences of PSS workers in Maine and the factors that contribute to job turnover. For 18 months, our research team followed a sample of 261 PSS workers caring for elders and people with disabilities in communities located in every county in the state. Just over one-third (n = 90) of these workers terminated their employment over that year-and-a-half period. Through mail surveys and telephone interviews we learned that low wages (with an average wage of $9.05 per hour in 2009), lack of mileage reimbursement and job benefits, and inconsistent and unreliable hours were key factors in workers’ decisions to leave the field. We also learned that many were sorry to abandon the work they loved and the clients to whom they felt

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devoted and that younger workers were more likely to terminate than older ones. The life situation and job experiences of one of the older workers in our study, Eleanor (not her real name) who was 65 in 2008, illustrate many of the common elements of home care workers throughout Maine. Eleanor, a high school graduate, lived in Androscoggin County. She was married and had raised four children. She began working in the woolen mills in her early 30s, but decided to return to school in her mid-40s to become a certified nursing assistant. For 10 years, she worked in a residential home for disabled children before she moved into home care work, which she had been doing for 10 years at the time our study began. She often struggled to get enough hours, and sometimes worked for more than one agency in order to have more clients. When asked what appealed to her about being a PSS, Eleanor said, “I always believed in the ‘Golden Rule,’ that some day I may be in their shoes, and I would want somebody like myself to take care of me.” She said the satisfaction and appreciation she received from her clients, “the smiles on their faces,” made her want to stay in this line of work. Although Eleanor received Social Security, she relied on her wages from home care “as like a back-up to help pay bills.” In addition to caring for clients, Eleanor had spent many years caring for her husband at home until his needs became too severe and he needed to be moved to a nursing facility. She visited him as often as possible. To make ends meet, Eleanor shared her small home with her daughter, son-in-law, and brother-in-law. Even so, she reported, it was hard to make the rent payment each month, and she noted that the cost of groceries had

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been increasing while her Social Security and wages remained stagnant. Eleanor wished she received more pay, mileage reimbursement, and recognition for her home care work. She knew she went above and beyond for her clients and would have liked to receive credit for that: “whether it be a certificate for $5 or $10 for gas, or a place to go out to eat. Something!” But compared to younger workers, Eleanor was less reliant on the insecure hours and low wages of home care work, given her monthly Social Security check—low as it was—and thus could remain in the field, ever hopeful of being assigned enough clients who did not live too far from her, given that mileage was not reimbursed. Low compensation has consequences. Nationwide, nearly three out of five home care workers live in households that receive public assistance (PHI 2015). Raising wages for home care aides would reduce expenditures on public support programs. In Maine, increasing the wages of direct care workers is one part of the KeepMEHome initiative introduced by House Speaker Mark Eves. In this country, we undervalue caring work, a shortsighted approach with consequences. It means dedicated workers such as Eleanor can barely pay their bills, and it leaves frail elders in our communities with less consistent care as workers are forced to leave the work they love for jobs with higher pay. -

Sandra S. Butler is a professor and the coordinator of the master’s degree program in social work at the University of Maine. Her research has focused primarily on women’s financial security across the lifespan and successful aging, particularly in rural environments. She is the author of Middle-aged Female and Homeless (1994), and coeditor of Gerontological Social Work in Small Towns and Rural Communities (2003) and Shut-Out: Low Income Mothers and Higher Education (2004) and more than 50 articles and book chapters.

REFERENCES Paraprofessional Healthcare Institute (PHI). 2015. “Paying the Price: How Poverty Wages Undermine Home Care in America.” PHI, Bronx, NY. http://phinational.org /sites/phinational.org/files/research-report/paying-the -price.pdf

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THE AGING AND DEVELOPMENTAL/PHYSICAL DISABILITIES NETWORKS

C O M M E N T A R Y

The Aging and Developmental/ Physical Disabilities Networks: Can the Silos Be Dismantled? by Lenard W. Kaye, Lucille A. Zeph, and Alan B. Cobo-Lewis

he service networks for aging, on the one hand, and developmental and physical disabilities, on the other hand, traditionally have functioned in distinctly separate camps. There are a variety of reasons for this including the historical emphasis of disability services and policies on addressing issues of a consumer population that has been primarily comprised of children, youth, and younger and middle-aged adults, while aging services and policies have focused on individuals in their sixties and beyond regardless of the presence of a disability. The traditional focal points of the two service networks on different age groups has influenced, in large part, their priorities, programs, and educational and research foci. The fact is that, in the past, the disability services community rarely needed to address how someone would manage their developmental or physical disability in old age because such individuals rarely survived beyond middle age. And because they rarely survived beyond middle age, the service system for older adults was also not originally conceived as needing to be particularly responsive to individuals with long-term developmental or physical disabilities. The conceptualization of nonoverlapping populations has resulted in separate public policies and in varying degrees of isolation, territorialism, and specialization across the two service networks (Putnam 2007).

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Historically, the aging and disabilities networks have developed and worked independently of one another. In fact, this independent planning and programming was presumed to be the preferred and most effective approach given what were perceived to be population groups with different, if not unique, needs, interests, and challenges. However, medical advances, lifestyle improvements, and increasingly inclusive philosophies of community life and well-being have, in recent years, compelled us to question and rethink the traditional paradigm. Change is in the air—presumably as much for reasons of economy and effectiveness as for increased philosophical alignment. At the federal level, the Administration for Community Living (ACL) was established in April 2012 to address the needs of people with disabilities and older adults. Under the ACL roof are both the Administration on Aging and the Administration on Intellectual and Developmental Disabilities as well as the Health and Human Services (HHS) Office on Disability (among other units). The mission of the ACL is to maximize the independence, well-being, and health of older adults, people with disabilities across the lifespan, and their families and caregivers. As the name suggests, the emphasis is on increasing access to community supports for all Americans so that they can fully participate in all aspects of their communities. At the

state level, similar administrative restruc turing has occurred. Maine’s Office of Elder Services has been combined with the Office of Adults with Cognitive and Physical Disabilities to form the Office of Aging and Disability Services (OADS). Consistent with the integration of direct community services offered to Maine’s older adults by the Aging and Disability Resource Centers, this merger was intended to improve coordination and integration, create more effective access, reduce duplication of effort, and improve individual outcomes. Are there compelling reasons to encourage aging and disabilities network crossover outside of federal and state government? Are there factors that would discourage integration? Should we be wary about such philosophical and organizational changes? THE CASE FOR NETWORK CROSSOVER The Power of Coalitions ligning one’s interests with those of another group has undeniable political and strategic advantages. In an age of scarce resources, a single voice advocating for the universal needs of individuals who are both aging and disabled can’t help but to create greater leverage when negotiating with decision makers. There is undeniable strength in numbers, and the rapidly increasing number of older adults, when combined with the total number of individuals with disabilities, has the potential to be a strong force for change.

The Appeal of Inclusiveness

History has documented that segregation runs the risk of promoting fear and suspicion among individuals and groups. It can encourage an “us versus them” mentality. Policies and programs

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C O M M E N T A R Y that are premised on inclusiveness tend to promote diversity and equity while minimizing discrimination and bias. Inclusive policies and programs aim to avoid excluding or marginalizing anyone from the benefits, opportunities, and resources to be derived from particular initiatives (BBI 2012). Such policies are more likely to be welcoming to all individuals and embrace diversity more broadly. The combined efforts of the aging and disability networks will enhance all efforts towards creating inclusive communities. Common Human Needs Access to needed health and medical services, housing that enables individuals to live safely and securely and remain in their communities, transportation that is accessible and affordable, and opportunities for community and social engagement are both desired and needed by all citizens whether or not they are living with a disability and regardless of age. These are universal human needs and, when available and accessible, result in vastly improved quality of life and well-being. Long-Term Care and Working with Caregivers to Cross Lines

In the quest for common ground, one of the more compelling arguments for crossing aging and disability network lines is to promote services and supports in the long-term care arena. The National Council on Aging (NCOA), for example, has successfully led a coalition of some 35 national aging and disability organizations—including AARP, the American Association of People with Disabilities, and the Association of University Centers on Disabilities—to advance long-term care services for older adults and individuals with disabilities. The Disability and Aging Collaborative,

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formed during health reform, represents one of the first large-scale efforts to bring the aging and disability communities together. It aims to show that advocacy efforts across the two networks can be coordinated and address improving access to home- and community-based services (HCBS) at the same time that consumer engagement, protections, and quality are enhanced. Aging adults and people with developmental disabilities commonly rely on informal caregivers. For aging parents, these informal caregivers are frequently their adult children. For adults with physical or developmental disabilities, these informal caregivers are frequently their parents—who become less able to provide informal care as they grow older. In both the aging and disability arenas, informal caregivers need support, and informal caregivers of adults with developmental disabilities may need additional support as they, themselves, age. Universal Access and the Age-Friendly Community Movement

There is considerable discussion in the United States and across the globe advocating for the establishment of age-friendly communities. The World Health Organization (WHO) has been a strong advocate of the movement aimed at encouraging cities and communities to actively engage in the steps required to ensure that people of all ages are able to participate in community activities. An age-friendly community is a city or community that makes it easy for older adults to stay connected to those they care about, remain healthy and active, and receive the support they need. An age-friendly community makes deliberate decisions and commitments to ensure that the physical environment and the organizational infrastructure

and available services are responsive to older adults. Age-friendly communities promote health by being accessible, equitable, inclusive, safe, and supportive (WHO 2007). It stands to reason that the characteristics of a community that is responsive to older adults will be responsive to the needs of disabled persons as well, given the universality of the principles that define a community as being age-friendly. For that matter, age-friendly communities are likely to be responsive to the needs of individuals (and families) of all ages whether or not they are older or disabled. It is worth noting that communities specifically tailored to be age-friendly could conceivably be seen by some as not being welcoming or friendly to people with developmental disabilities and other age groups. The argument could therefore be made that the establishment of inclusive communities that are not deliberately focused on the needs and wants of older adults, but are inclusive of and friendly to older adults and all other community groups, may send an even more powerful message that runs little risk of being misinterpreted. Risk of Dementia Depending on a number of aggravating and mitigating factors, aging adults may be at risk of developing some form of dementia, including Alzheimer’s disease. Estimates of the risk of dementia in individuals with developmental disabilities diverge, but it may be comparable to or higher than the risk among people without developmental disabilities (Strydom et al. 2010). Specific subgroups can have a different profile. In particular, persons with Down syndrome are at substantial risk of developing Alzheimer’s at a comparatively early age (Coppus et al. 2006; Tyrrell et al. 2001). Awareness of issues such as the

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C O M M E N T A R Y importance of screening for dementia is thus important in the arenas of aging and developmental disabilities—but the issues can be subtle. For this reason, it is an area in need of further research and information sharing to foster the use (NTG 2013) and further development (Zeilinger, Stiehl, and Weber 2013) of screening tools for dementia that are tailored to individuals with developmental disabilities. A CAUTIONARY NOTE Disability: A Matter of Degree and Functional Impact

ew individuals can claim not to have some physical or developmental condition that has an impact on their life. More significant perhaps is the extent to which such conditions actually limit one’s functional capacity to perform a variety of activities of daily living. One in five persons (19 percent) reports a disability according to the 2012 news release by the U.S. Census Bureau. However, between the ages of 65 and 75 years, only 3.3 percent of the noninstitutionalized population needs help with personal care. This rises to 10.5 percent for those individuals 75 years and older. On the other hand, 61.1 percent of persons 65 years and older report having difficulty with at least one basic action or are limited in terms of performing one complex activity. According to the Centers for Disease Control and Prevention (CDC), that’s approximately 26 million people in the United States. People in the oldest age group—80 and older—are almost nine times more likely to have a disability than those in the youngest group (younger than 15) (71 percent compared with 8 percent). While the probability of having a severe disability is only one in 20 for those 15 to 24 years of age, it increases to one in four for those 65 to 69 years old.1

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It is clear that a large majority of older adults live without significant disability. Most lead active and independent lives. Likewise, individuals with intellectual and developmental disabilities, regardless of age, also seek to live independently, but are often limited by environmental and attitudinal barriers. But, herein lies the rub. Simply put, not all disabled individuals are old—and not all older adults are disabled. Nor do all older adults generally, or older adults living with a disability in particular, need additional levels of assistance and support. Complicating the discussion about network crossover are trends confirming that most gains in life expectancy have been accompanied by declining rates of mortality and the compression of morbidity (shortened time periods that adults live with chronic conditions). Disability incidence rates among older adults have declined, resulting in decreases in older adults with functional impairment caused by a chronic disease or physical condition (Putnam and Stark 2010). Increases in life expectancy—and increases in disability-free life expectancy—have been linked both to delays in the onset of disability and to increments in the rate of recovery from disability (He and Larsen 2014). Current trends that reflect the compression of morbidity—and continued emphasis on healthy, active, and productive aging— may serve to slow or temper the aging and disability crossover process. The current public discourse has emphasized vital aging and the impressive later-life capacities of most of the baby boomer generation. As the boomers redefine the aging experience, it may result in a tendency to distance, or at least separate in some respects, growing older from the experience of living with a disability or impairment. Nevertheless, the rapid

expansion in the number of older adults is expected to result in increases in the absolute number of older adults living with disabilities. Endorsing a Collaborative Perspective

In the final analysis, we can’t help but endorse increased alignment of the aging and disability networks in all arenas, including policy making, program development, education, and research. Undeniable population trends including the survival of individuals with developmental and physical disabilities into later life, the reality of common and universal human needs, the desirability of inclusive thinking, and the strategic advantage to be realized when special interest populations ally themselves all make for a powerful argument in favor of increasing network crossover activities. Because Maine has the oldest population in the nation and one of the highest prevalence rates for physical disability, the state should be in the forefront of initiatives that advance a philosophy of network crossover. While not without its challenges, strong recognition of, and respect for, significant diversity in the aging and disability populations will guard against overly simplistic blanket solutions when it comes to developing policies and programs that meet the needs and wants of both population groups. The University of Maine is well positioned to test the waters associated with strategic integration of the aging and disability networks. We anticipate that the presence of two well-established interdisciplinary research centers at the University of Maine—the Center on Aging and the Center for Community Inclusion and Disability Studies (Maine’s federally designated University Center for Excellence in Developmental

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C O M M E N T A R Y Disabilities)—will serve as excellent venues and programmatic test beds for increased collaboration and the discovery of common ground in the arenas of aging and disabilities education, research, and service in the years ahead. A coordinated effort between these two centers could help break down the barriers within the aging and disability communities and create services and supports that are universally accessible and that contribute to enhancing the quality of life for all Maine citizens. ENDNOTES

World Health Organization (WHO). 2007. Global Age-Friendly Cities: A Guide. World Health Organization, France.

REFERENCES

Zeilinger, Elisabeth L., Katharina A.M. Stiehl, and Germain Weber. 2013. “A Systematic Review on Assessment Instruments for Dementia in Persons with Intellectual Disabilities.” Research in Developmental Disabilities 34:3962– 3977.

Burton Blatt Institute (BBI). 2012. Inclusive Policies & Practices: What Do We Know? BBI at Syracuse University, Syracuse, NY. http://bbi.syr.edu /projects/Demand_Side_Models/docs /b_inclusive_policies.htm Coppus, A., H. Evenhuis, G.-J. Verberne, F. Visser, P. Van Gool, P. Eikelenboom, and C. Van Duijin 2006. “Dementia and Mortality in Persons with Down’s Syndrome.” Journal of Intellectual Disability Research 50:768–777.

Lenard W. Kaye

National Task Group Section on Early Detection and Screening (NTG). 2013. National Task Group Early Detection Screen for Dementia: Manual. http://aadmd.org/ntg/screening He, Wan, and Luke J. Larsen, December 2014. Older Americans with a Disability: 2008–2012. U.S. Department of Health and Human Services, Washington, DC. Putnam, Michelle (ed.). 2007. Aging and Disability: Crossing Network Lines. Springer Publishing Company, New York.

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Strydom, Andre, Shahin Shooshtari, Lynette Lee, Veena Raykar, Jenny Torr, John Tsiouris, Nancy Jokinen, Ken Courtenay, Nick Bass, Margje Sinnema, and Marian Maaskant. 2010. “Dementia in Older Adults with Intellectual Disabilities: Epidemiology, Presentation, and Diagnosis.” Journal of Policy and Practice in Intellectual Disabilities 7:96–110. Tyrrell, Janette, Mary Cosgrave, Mary McCarron, Janet McPherson, Johnston Calvert, Alan Kelly, Martin McLaughlin, Michael Gill, and Brian Lawlor. 2001. “Dementia in People with Down’s Syndrome.” International Journal of Geriatric Psychiatry 16:1168–1174.

1. The U.S. Census Burea news release is available at https://www.census .gov/newsroom/releases/archives /miscellaneous/cb12-134.html and the statistics from the CDC are available at http://www.cdc.gov/nchs/fastats /disability.htm

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Putnam, Michelle, and Susan Stark. 2010. “Aging and Functional Disability.” Handbook of Social Work in Health and Aging, ed. Barbara Berkman and Sarah D’Ambruoso. Oxford University Press, London.

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is professor of social work at the University of Maine School of Social Work and founding director of the University of Maine Center on Aging. During the 2014–2015 academic year, he was honored with the University of Maine Trustee Professorship. Prior to coming to UMaine he was a faculty member at Bryn Mawr College’s Graduate School of Social Work & Social Research.

Lucille A. Zeph is associate professor emerita of education and disability studies at UMaine. From 1992 to 2015, she served as founding director of the University of Maine’s Center for Community Inclusion and Disability Studies. Zeph has been honored for her lifetime contribution to advocacy, public policy, and systems change, resulting in opportunities for all, including people with disabilities.

Alan B. CoboLewis is director of the University of the Maine Center for Community Inclusion and Disability Studies and associate professor of psychology. He is the parent of two children, one of whom has a developmental disability. In addition to having research interests in early childhood and disability issues, he has been active in promoting rational, respectful, and evidence-based practice in health and education, especially regarding persons with developmental disabilities.

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The Role of Foundation Grantmakers in Responding to Community Aging: John T. Gorman Foundation by Tony Cipollone

Foundations respond to a variety of compelling needs. How do you reconcile the responsibility of addressing the needs of Maine’s aging citizens in light of other competing issues? Using data as a decision-making tool is a core value of our foundation. A few years back as we were developing our current strategic plan, we used demographic information to help us to understand the challenges associated with particular populations in Maine. While we didn’t anticipate making seniors one of our foundation’s priority investment areas, it was hard to ignore the compelling picture painted by current and future demographic trends. By far, seniors represent the largest percentage of our state’s population, and unfortunately many face some significant challenges. Almost one in ten are living at or below the federal poverty rate, and seniors 85 and older are about 50 percent more likely to be poor. About a third of seniors live only on Social Security. One in nine has been a victim of elder abuse, and 15 percent of these victims have suffered from financial exploitation (usually at the hand of a family member). Almost 40 percent live alone, and far too many experience significant isolation. Given these statistics and our foundation’s mission, we were hard pressed not to devote some of our resources annually to helping more seniors to age safely and comfortably in their homes and communities, which according to local and national surveys is the overwhelming desire of seniors in our state. However, seniors are also not the only population we focus on at the John T. Gorman Foundation. The challenge for us is to ensure that we make the strongest and most strategic investments we can to advance the supports and opportunities that seniors need and work to leverage more attention and resources to this issue from other philanthropies and public systems.

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Is there a special role that you see philanthropy playing in promoting the experience of positive aging in Maine communities? If yes, what is it? If no, why not? On the whole, foundations have greater flexibility in their ability to devote and deploy resources to promote positive aging in Maine communities. Given this, philanthropy can play a role on a number of fronts that involve varying degrees of risk. These include • Raising awareness about the issues facing seniors in Maine by making investments in data and policy analysis that provide critical information about how well seniors in different parts of the state are faring, the particular contextual challenges they face, and what might be done—based on research and best practices about program and policy interventions statewide and nationally—to address such challenges successfully. • Creating incentives and partnerships with state government and local municipalities to invest creatively in addressing the needs of seniors. • Investing in efforts that help meet seniors’ critical basic needs (food, home safety, heating assistance) that for this population serve as preventive supports that can keep seniors out of more expensive and sometimes unnecessary institutional care. • Where appropriate, use their resources to become investors in critical infrastructure and redevelopment efforts (housing, transportation, new community centers) through vehicles such as low-interest/no-interest loans and loan guarantees. • Participating in regional solutions that are more likely to influence policy and garner support at the federal level (a strategy that a number of

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philanthropies from Maine, New Hampshire, and Vermont are already pursuing). While these are but some of the things that philanthropy might consider doing, what is absolutely critical to keep in mind is what this sector cannot and should not do: act alone. The fact is philanthropic resources represent a small fraction of the investments that are actually needed to help our seniors to thrive. They can supplement, but absolutely cannot supplant, the investments that need to be made by government and the private sector if we are to get ahead of this critical challenge. What strategies, broadly speaking, do you think are likely to be most successful in promoting the wellbeing of older adults in Maine, the oldest and most rural state in the nation? As a rule, we believe that given the complexities of the challenges facing many of our seniors (as well as other disadvantaged Mainers), the smartest and potentially the most successful strategies will likely be those that are comprehensive in scope and grounded in both best practice and the particular realities of different geographic regions. The fact is that seniors are not homogeneous and may need different supports and opportunities at different times in their lives. The basic question should always be: what does this particular senior require to successfully age in the place of her choosing. For some, it may be as basic as having a trusted and compassionate neighbor they can call on in a pinch; for others, it may be a connection to needed basic resources such as food, heating assistance, or health care for a chronic, debilitating condition. Other seniors may face more challenging issues such as unsafe housing or the fear of losing precious financial resources to a predatory relative. For us, this implies that the most effective strategies will likely be those that are rooted in communities; reflect the regional/local needs of senior residents; and knit together so that they can be delivered in an integrated way—i.e., they represent a system of supports that can be tapped into by seniors and caregivers over time, depending on need and desire. Finally, we believe that the most effective strategies will be those that attend to the reality that seniors (like everyone else) are likely to need a connection to someone they trust who can both assuage their apprehension about taking advantage of a

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particular opportunity or support and help them to navigate whatever process is required to do so. Does philanthropy have the power to create agefriendly communities? First, the word “power” is an odd one to use in the context of philanthropy. Foundations really don’t have the power to change or create something. What we do have, however, is the ability and opportunity—if we choose to take advantage of it—to inform and influence how people and sectors think about issues and challenges and to support promising and proven solutions to address them. The power of a foundation lies in the capacity and willingness of the people, organizations, and communities it funds to make a measurable difference. Second, as noted earlier, foundations do not—even when all philanthropic dollars are pooled—have the ability to support, let alone create, something like age-friendly communities at a scale that may be needed in Maine. Can philanthropy play a role? Absolutely, but it needs to be part of a broader effort that includes public and private participation and resources. That said, foundations can and should do what they can to stimulate and create incentives for thinking and action that enable communities to help seniors maintain their safety, their dignity, and their independence. To paraphrase an African proverb, supportive communities are not only critical for raising healthy, successful children—they’re significant for seniors as well. If an anonymous benefactor wrote your foundation a blank check to address the challenges of aging in Maine, what would you consider doing? If money were no object, I think you’d have to consider the tough issues that make life particularly hard for many Maine seniors. They include the following: • Investing in transportation. It’s virtually impossible to have a conversation about seniors in any community without the challenge of transportation quickly emerging. Given this, we’d suggest creating a fund that enables less populated communities to develop innovative approaches to the issue and helping more densely populated areas consider more options for public transportation. • Investing in technology. Around the country (and here in Maine) there are new ideas for using

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technology to better meet the needs of seniors. They range from using technology to monitor and meet senior needs in a nonintrusive way to driverless transportation. Capturing the power of technology for the benefit of seniors at a level that is commensurate with the scale of our population seems to be an area that is ripe for investments. • Investing in new housing and alternative housing models. Even with the state’s encouraging conversations about the need to expand senior housing, the fact remains that we are scratching the surface of existing need. There is a need for investments that can help seniors in older homes to make needed repairs and adjustments, as well as for new housing that can better meet their needs and ensure a connection to communities. -

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Tony Cipollone is president and CEO of the John T. Gorman Foundation, a Portland-based private foundation dedicated to improving the lives of disadvantaged people in Maine. Since joining the foundation in 2011, he has helped advance a range of new investment strategies aimed at improving results for children, youth, and families. Formerly, he worked in senior leadership at the Annie E. Casey Foundation for over 20 years and helped develop and lead numerous initiatives related to education, community redevelopment, and policy advocacy, including Casey’s national KIDS COUNT project.

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The Role of Foundation Grantmakers in Responding to Community Aging: Maine Community Foundation by Meredith Jones

he issue of aging is near and dear to my heart. In an earlier life I worked for the Maine Health Care Association, the trade association for long-term care facilities in Maine. Through this work I got to know many of the people who run nursing homes and assisted living facilities and the staff who provide direct care for their residents. I’m also a few years shy of my seventh decade, so I know I should be thinking about the issue as it relates to my own future needs. In addition, my mother moved to my home community of Belfast from Eastport at the age of 91 to be closer to family, and as a primary caregiver (along with a couple of siblings), I learned first-hand about the needs of at least one nonagenarian. She hated the move. She hated leaving her beloved home in Eastport and always referred to her charming apartment on the shores of Penobscot Bay as a prison. But she was no longer a safe driver, and she needed access to medical professionals for the pulmonary and ophthalmologic care her aging body required. While I don’t dwell on the issue of aging in my day job, the facts and figures about Maine’s aging population along with our work here at Maine Community Foundation to support older adults suggest this issue, along with many others, will shape the future of Maine communities. Although aging is not one of the Maine Community Foundation’s specific areas of focus, it is fair to say that through our donors and competitive grant programs we provide support to an array of organizations focused on the issue. For example, the foundation’s Hospice Fund supports end-of-life and volunteer bereavement services frequently associated with aging. Our community-building grant program has funded senior centers, community action programs, and other social service agencies that provide support to seniors. We have funded Maine’s Senior College Network, which is hosted by the University of Southern Maine and includes chapters from one end of the state to the other.

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Unlike most foundations that were created by an individual, the Maine Community Foundation boasts hundreds of funds and an even greater number of donors. We administer more than 300 donor-advised funds, each of which has its own interests and focus. Less than 2 percent of the foundation’s $400+ million in assets is available for discretionary grantmaking. We administer 18 distinct competitive grant programs and respond to a variety of compelling issues, approaches, and geography. Most of our competitive grantmaking programs embrace an assets-based perspective. We care less about the particular issue being addressed and more about the process and inclusiveness of the work being undertaken. Rather than soliciting proposals for projects that solve problems, we look for activities that will enhance or strengthen a community; use the skills, services, materials, and/or time that people and organizations in the community can and will provide; make the community stronger by helping it address current or future challenges; and continue to affect the community after funding is gone. We also have a particular interest in projects that focus on the community foundation’s own goal areas of increasing higher education attainment, expanding leadership talent, and encouraging downtown revitalization. Foundations respond to a variety of compelling needs. How do you reconcile the responsibility of addressing the needs of Maine’s aging citizens in light of other compelling issues? The Maine Community Foundation’s mission is centered on Maine communities. We are, after all, a community foundation. Our hope for Maine communities—large and small, rural and urban, east and west, north and south—is that they will be vital and confident about their future, and that their residents enjoy a high quality of life.

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Communities need a thriving economy to remain vital. A thriving economy requires people with skills and knowledge to take and create tomorrow’s jobs. To remain vital, communities need to welcome new residents of all ages, embrace change and diversity, and support local amenities (such as restaurants, walkable downtowns, hiking and walking trails) that attract new people and retain others. Communities also need to ensure that Maine’s unique natural resource assets are conserved for generations to come. The needs of Maine’s aging citizens are no different in many ways from the needs of all Mainers. No foundation can solve all of the challenges the state faces. According to the most recent Giving in Maine report issued by the Maine Philanthropy Center, Maine foundations “give a fraction of the money spent each year by state government. For instance, the Maine Department of Education expenditures for 2012 were $2.1 billion. Total Maine grants equal 8% of that budget—enough to operate the DOE for less than 30 days” (Maine Philanthropy Center 2015: 1). Three years ago the Maine Community Foundation developed a 10-year framework to help focus our work. A board and staff team began the planning process by identifying long-term trends that will shape the future of Maine communities; assessing the needs, gaps, and opportunities where philanthropy can make a difference; and determining the most important role the foundation could play in the next decade to shape the future success of Maine communities to ensure a high quality of life for their residents. The outcome of the planning work was compelling and clear and resulted in three primary areas of focus: 1. Help more Maine people to pursue education and training beyond high school since the majority of the jobs of the future will require post-secondary-education credentials. 2. Increase the depth and capacity of current and emerging community and policy leaders since we know from experience and example that one person can make a difference. 3. Help create and support community centers that bring social and economic benefits to towns and cities throughout the state since we know that the strength of our communities will dictate the strength of the state.

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And while our three areas of focus do not specifically include aging, there is no question that the issue of aging is important to all of Maine, and the issues of aging Mainers are not unique to them. They want safe and affordable housing, walkable town centers, places to shop, and public transportation. Maine has the highest concentration of mature and elderly people in the nation and ranks among the top three states, along with our northern New England neighbors, in having one of the lowest birth rates in the country (Weil 2013). Maine also has more second homes than any other state. In 2000, Maine had 650,000 housing units. More than 15 percent of them (100,000) were for seasonal, recreational, or occasional use. The national rate is 3.1 percent. This suggests an opportunity to tap part-time and/or financially secure older adults to become more engaged in their communities. Maine is known for its relatively high levels of civic engagement. Our voting rates are above the national average, and AARP surveys show that Maine people are more likely to write a letter to or call a legislator than the national average. With a fairly homogenous population of 1.3 million people and with average wages always hovering at 85 percent of the U.S. average, Mainers long ago learned to work well with one another and to do more with less. A number of years ago, the Maine Community Foundation participated in a national social capital community benchmark survey. The John F. Kennedy School of Government at Harvard University sponsored the survey in partnership with a consortium of 36 community foundations and a few private foundations. Some key findings from our survey of the LewistonAuburn area include a significant positive relationship between having a baccalaureate degree and volunteering more often, a higher sense of efficacy in the community among women, and a lower sense of efficacy in the community by people in middle age (50 to 64 years old). These findings support the need for new ways to engage older adults in community activities. The statistics prompted the Maine Community Foundation to submit a proposal a number of years ago to the global foundation Atlantic Philanthropies. The funder wanted to work through community foundations throughout the United States to change attitudes about aging. Rather than thinking about older people as needy, frail elderly, the funder wanted to start viewing older adults as community assets with time and talent to give back to their communities. More details about 123

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ENCorps, a partnership with the University of Maine Center on Aging, appears in a companion article in this issue (Crittenden and DeAndrade 2015). Is there a special role that you see philanthropy playing in promoting the experience of positive aging in Maine communities? If yes, what is it? If not, why not? The most valuable roles philanthropy can play in promoting positive aging is to achieve greater effectiveness by encouraging more collaboration among the nonprofits serving this population and to encourage innovation by investing in promising programs and activities that respond to the changing dynamics and needs of today’s elders. While there is a link between being successful in securing funding and the ability to demonstrate impact, the truth is that over time the tendency is toward redundancy, greater irrelevance, and increasing overlap of services. With increasingly finite public resources and growing demand, now is the time to encourage greater collaboration and coordination. What strategies, broadly speaking, do you think are likely to be most successful in promoting the wellbeing of older adults in Maine, the oldest most rural state in the nation? And, does philanthropy have the power to create age-friendly communities? Aging is important to all of Maine—to the entire Northeast for that matter. The issues we aging Mainers face are not unique. Irrespective of our age, ethnicity, or economic status, we want to live in communities that offer safe and affordable housing and ready access to quality health care. We want town centers that have places to shop, eat, and provide entertainment. We want communities that are safe, have diverse houses of worship and social clubs that encourage volunteerism, and good schools to educate future generations. We want access to quality employment opportunities—if not for ourselves, for our friends and neighbors. So yes, the work of many Maine-based foundations supports the creation of age-friendly communities since our foundations focus on many of these issues.

levels who have the knowledge and skills to help make our communities vibrant and sustainable over the long term. We all want to live and thrive in supportive communities. And one person can, indeed, make a difference. REFERENCES Crittenden, Jennifer A., and Lelia DeAndrade. 2015. “Never Too Old to Lead: Activating Leadership among Maine’s Older Adults.” Maine Policy Review 24(2): 80–85. Maine Philanthropy Center. 2015. Giving in Maine: 2015 Update of Foundation Giving. Maine Philanthropy Center, Portland. https://www.mainephilanthropy.org /sites/default/files/resources/2015%20Foundation %20Giving%20Report%20Final%201.pdf Weil, Gordon. 2013. “Maine, the Oldest State: Causes and Possible Cures.” Pine Tree Watchdog, Maine Center for Public Interest, Hallowell.

Meredith Jones is the president and CEO of the Maine Community Foundation, a statewide public foundation. There, she previously served as the vice president of programs and helped create the Maine Compact for Higher Education and ENCorps, a volunteer leader program for civic-minded baby boomers. Before joining the Maine Community Foundation, she worked for the Maine Health Care Association and for the Maine Development Foundation.

If an anonymous benefactor wrote your foundation a blank check to address the challenges of aging in Maine, what would you consider doing? In addition to inviting members of Maine’s aging community to tell funders what they want and need, I would place my biggest bets on supporting leaders at all MAINE POLICY REVIEW

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The Role of Foundation Grantmakers in Responding to Community Aging: Maine Health Access Foundation by Wendy J. Wolf

Foundations respond to a variety of compelling needs. How do you reconcile the responsibility of addressing the needs of Maine’s aging citizens in light of other competing issues? As the oldest state in the nation, Maine serves as the tip of the spear in determining how our society will meet the needs of our aging population. We typically view the issue of aging in terms of the increasing proportion of elderly (or retired) people plus the growing number of very old persons who may require individualized and community supports, depending on their state of health. However, the International Social Security Association helps broaden this lens so that addressing aging also means how we cope with the change in the balance of all age groups. This is a phenomenon that we are already talking about in Maine. Throughout human history, older people have comprised a relatively small proportion of the population, yet the United States is just one of many industrialized countries where the proportion of older people is projected to grow to a point where it may equal the proportion of younger, working adults. This demographic shift has profound implications for the future of our economy that reach far beyond planning for the higher demand for medical, social, and safety net services that older people may require. Under our bylaws, the Maine Health Access Foundation (MeHAF) is required to focus our funding and program work on health and health care. Two years ago, MeHAF started a new initiative, called “Thriving in Place” (TiP), which aims to improve the health and community supports for people with chronic illness (which includes many older Mainers) so they can live healthy and independent lives in their community. TiP was not designed to focus solely on Maine’s aging population, but the people served by TiP grantees are disproportionately older Mainers. TiP serves as a complement to the activities that many other public,

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private, governmental agencies, and other funders are advancing to help address the needs of Maine’s aging residents. Through TiP, we are part of a larger movement to address aging, with a primary focus on how health and health care can evolve to meet these needs. Other funders may be compelled, either by their mission or donor wishes, to complement our health-related efforts by promoting other issues, such as working to eliminate food insecurity, promoting senior-friendly affordable housing, or combating social isolation. For example, the Maine Community Foundation can direct grant funding and resources across a broad array of focus areas that support positive aging such as providing intellectual engagement and learning through senior colleges or promoting the best use of the skills and talents that seniors bring to communities through their ENCorps program. This diversity of mission and program focus among funders can make it challenging for foundations to work together, but it can also enhance and leverage our impact because we approach issues from a variety of perspectives. Is there a special role that you see philanthropy playing in promoting the experience of positive aging in Maine communities? If yes, what is it? If no, why not? When you talk about the role of philanthropy, most people will assume that providing grants and other funding support is our primary role. Grants can be catalytic in promoting innovation and helping spread good ideas. Yet philanthropic organizations can do much more than grantmaking to address the complex issues that can shape a culture that supports positive aging. Funders can support environmental scans and policy research to inform and guide our approach to positive aging. We can also tap our convening power to invite disparate groups together and support and facilitate work on common issues. Although many public,

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private, and governmental groups are highly vested in working on aging issues, MeHAF is one of the few participants at the discussion table who doesn’t “have a dog in the fight.” Our revenues and spending are not affected by the outcome. Foundations can therefore serve as honest brokers to push the tough conversations that are required to drive fundamental change that leads to better alignment and collaboration between organizations for the more efficient use of resources and better impact. One of philanthropy’s most important roles is to ensure that the voices of everyday Maine people inform how we think about positive aging and what it will take to reach this vision. For example, our TiP initiative (see related articles by Bradney [2015] and Boober [2015]) requires that grantees routinely solicit the advice and input of people who are the intended recipients of this work. At the beginning, we assumed the community members served by TiP grantees would be most concerned about limited access to health care services and home care supports. But we were wrong. People felt that access to health care services was generally good, but gaps in support services such as assisting with adequate food and transportation options, helping with routine home maintenance (like shoveling snow off walks and driveways), and combating social isolation were the issues that community members felt were essential for positive aging. Funders should ensure that community voices are at the center of our work. In particular, we need to encourage and support input from people with lower incomes who may be less likely to attend community forums or sign up for consumer advisory groups. If our efforts to promote positive aging work for the most vulnerable, they are likely to work for us all. What strategies, broadly speaking, do you think are likely to be most successful in promoting the wellbeing of older adults in Maine, the oldest and most rural state in the nation? Too often the issues surrounding aging are viewed as problems that can be solved by narrow, technical fixes, but older people have skills, expertise, and experiences that make them valuable assets to our communities and state. MeHAF strives to build on these assets by identifying and amplifying what currently works well. As a statewide organization, we’ve seen first hand that there are innovative, creative people across our state who are designing and implementing MAINE POLICY REVIEW

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strategies to promote the well-being of older people, but there are few ways to share and build upon these success stories. To share strategies and learn about what’s working (and what’s not), MeHAF routinely brings grantees together to learn from both national and local experts and from each other as well. These quarterly learning sessions help knit together organizations that are working on common issues so good ideas can spread across the state. We also work with grantees to identify public policy issues that need to be addressed so this work can be supported and sustained at the state and federal levels. Advances in technology can also help spread innovation and connect people, particularly those in rural areas. However, building a culture that promotes positive aging goes far beyond deploying technology and focusing on meeting the health needs of older Mainers. Funders need to invest in initiatives that promote opportunities for continued learning, engagement in meaningful paid and volunteer work, and promote healthy and vibrant communities that encourage cross-generational interactions as a counterpoint to the social isolation that many older Mainers feel. Does philanthropy have the power to create agefriendly communities? Philanthropy can be a catalyst to start communities on this course, but creating age-friendly communities requires a shift in our culture that goes far beyond philanthropy’s reach and resources. However, funders are ideally positioned to help bring people together to have the conversations about what being an age-friendly community means. I suspect if younger people were asked to define this, their vision for the community might differ from that of older adults (think skate-board park vs curb cuts), yet communities should strive to be age-friendly across the lifespan. The things that make shopping easy for a young mother with an infant in a stroller may be equally important to an 80-year-old, but we need to solicit opinions from both. Funders can help turn those conversations into community-wide plans and action steps, but it is unlikely philanthropy will have the staff or grantmaking resources to bring this transformation to full fruition. If an anonymous benefactor wrote your foundation a blank check to address the challenging of aging in Maine, what would you consider doing? 126

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The most strategic investment would be to convene and support cross-generational conversations about what our communities should look like in the future and how this vision will be mutually supportive of children, families, and older people. These ideas should serve as the framework for an advocacy and public policy agenda that holds municipal, state, and federal officials accountable for helping achieve that vision. REFERENCES Boober, Becky Hayes. 2015. “Keep Them Rocking at Home: Thriving in Place.” Maine Policy Review 24(2): 111–112. Bradney, James. 2015. “The Emergence of Age-Friendly Communities: Highlighting the Town of Bucksport.” Maine Policy Review 24(2): 60–61.

Wendy Wolf is founding president and CEO of the Maine Health Access Foundation, the state’s largest health philanthropy. As a pediatric cardiologist, Wolf spent two decades providing clinical care, teaching, and conducting research. She also served as senior advisor to the administrators for the Health Resources and Services Administration and the Agency for Healthcare Research and Quality in the U.S. Department of Health and Human Services.

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Thanks to Our Reviewersâ&#x20AC;Ś

We would like to extend our sincere thanks and appreciation to all those who took time to review articles submitted for consideration to Maine Policy Review. Their insights and recommendations assist us in our editorial decision-making, and provide valuable feedback to authors in revising their articles to be suitable for publication in the journal. The following individuals reviewed articles for Volume 24 (2015):

Cathleen Bauschatz Mary Alice Crofton John Dorrer Richard Judd Lenard Kaye Laurie LaChance Peter Mills Greg Payne Barbara Pincus Liam Riordan Linda Silka Wendy Wolf

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