State Multisector Plans for Aging Can Promote a More Coordinated "Ecosystem" for Older Adults

Abstract

With increased uncertainty around federally funded programs, it is more important than ever for states to take the lead in ensuring that services and supports for their older populations are coordinated and efficient. To this end, more than half of U.S. states are developing Multisector Plans for Aging (MPA). These are state-led, cross-sector plans that that engage all state agencies, stakeholders, providers, payers, and the public sector to work together to achieve an ecosystem of age-friendly care, services, and workplaces. Each state’s MPA is unique and reflects the priorities and cultures of the state.

Key Words

aging, disability, state health policy, Medicaid, long-term services and supports, cross-sector planning, social needs

A system of coordinated and efficient health services, social care, and supports for older adults, people with disabilities, caregivers, and all of us who are working, caring, and aging—some call this an “age-friendly ecosystem.” This is a goal most can agree must be the outcome of any meaningful system transformation effort. With limited resources and a rapidly growing older adult population, streamlining services where we can and eliminating duplication should be the first step. It is critical for states to take the lead on this, given the current administration’s dismantling (or uncertainty) around federal programs and coordination.

One approach to developing this ecosystem is a state Multisector Plan for Aging (MPA). Underway in more than half of U.S. states, these are state-led strategic plans with the goal of elevating shared priorities through a 10-year blueprint for action across all of a state’s government agencies, as well as private sector partners, which have an impact on healthcare and social supports for older adults, caregivers, and everyone who is aging.

MPAs go by many different names, including Master Plans, Age-Ready Plans, Longevity-Ready Plans, and more. But in general, the process is the same. Typically, the Governor’s office, or one agency (often the state unit on aging, Department of Health, or Medicaid agency) leads the process of coordinating across the executive branch, state legislature, the private sector, stakeholders, aging and disability advocates, providers, and older citizens to create one unified plan that outlines a roadmap toward a more coordinated “ecosystem” of aging services, healthcare, and supports.

California was one of the first states, along with Massachusetts, Texas, and Colorado to identify the benefit of multisector planning for aging and disability. In 2019, California’s governor signed an executive order to begin the process of developing a Master Plan for Aging. By 2020, the California Department of Aging had partnered with other state departments (Medicaid, public health, emergency services, etc.) and a broad, diverse group of stakeholders (the disability community, private industry, caregivers, and other advocates), and consumers to identify 5 “big, bold goals” for California to work toward across the next 10 years.

Each goal had aligned strategies and initiatives (some funded, some aspirational) that partners agreed would move the state closer to those goals. Some initiatives identified were to become an “Age Friendly State” and to promote Age-Friendly Health Systems, No Wrong Door initiatives, and others. The initial plan was successful in elevating issues of aging, caregiving, and disability across the state, and encouraged local aging and disability planning. In the year after the plan was developed, there were significant increases in state investments on aging and disability. California has updated their plan with new initiatives, continued stakeholder engagement, and uses a data-dashboard, with a new equity index, to track its progress.

MPAs are gaining recognition as a way to elevate issues of aging and coordinate services to achieve an “Age-Friendly Ecosystem.” The number of states that have invested in MPAs has increased rapidly in the past few years. A recent national survey (Rauscher et al., 2024) showed that 16 states now have authorization (legislation, executive order, or decree) to initiate an MPA. Of those, 8 have completed at least the first draft and are implementing all or some of the plan. Also, 22 states without authorization are exploring or planning to develop an MPA.

At the federal level, the Administration for Community Living (ACL) has specifically indicated that states can use No Wrong Door grant funding to develop MPAs, and the U.S. Senate has introduced a bill to provide funding to states to develop these MPAs. Also on the federal level, an Inter-Agency Council has begun the process of developing a National Strategic Plan on Aging, using a similar approach as state MPAs (Administration for Community Living, 2024).

Why Is a Multisector Plan Needed to Create an Age-Friendly Ecosystem?

In the simplest sense, the way government is structured means different agencies, offices, and departments have “jurisdiction” over different parts of people’s lives. Federal and state legislation over the years creates programs and funding streams to provide needed services, but these are often siloed and not coordinated. For instance, the federal Older American’s Act programs are primarily social services administered by state Departments of Aging. Healthcare to older populations can be provided by Medicare (federal program) or Medicaid (state and federal), or both. Public health programs (local, state, or federal) can provide many health promotion or prevention programs for all ages, including “healthy aging initiatives” for older adults. There also are various housing, transportation, and emergency-preparedness programs at the local, state, and federal levels. Finally, the private sector includes nonprofit service organizations and a multitude of for-profit health and social services for those who have the means to pay.

All of the above, public or private, can serve different populations, have varied eligibility requirements by age, health status, income, or other factors. The (albeit ambitious) goal of an MPA is for the state to lead a process to bring these sectors together, to agree on shared goals, and then to identify initiatives where these sectors can work together in a coordinated way to achieve those goals.

To effectively develop an MPA that results in a more coordinated and navigable system, the lead agency must coordinate across all sectors. What do we mean by “all sectors” and how is this possible? (Graham & Hoffmaster, 2023). The lead agencies’ job is a daunting one. They must coordinate with:

• Government agencies: One successful approach is to develop a “cabinet workgroup” where leaders of different government sectors begin by sharing information and raising awareness about existing programs and services for older adults, including challenges they face, and sharing data. The lead agency also should gather strategic planning other agencies have developed, such as a State Plan on Aging (developed by the unit on aging) or a State Health Improvement Plan (from the public health department), workgroup or taskforce recommendations, and Age-Friendly plans, to ensure the MPA builds on these.
• Legislators: Many initiatives in the MPA may need legislation to be enacted. Engaging elected leaders in the development process allows them to buy into the MPA roadmap and plan their agendas to promote shared goals.
• Stakeholder groups: An MPA must elevate the fact that “all of us are aging” and engage stakeholders, including those who traditionally serve older adults and people with disabilities (aging and disability advocates) as well as groups that may not think of themselves as particularly focused on aging (e.g., housing, transportation, law enforcement, faith-based groups.) Many states do this through listening sessions, stakeholder advisory groups, and consumer surveys, with a focus on equity by including input and voices of all ethnicities, languages, and regions in their state.
• Private sector and industry: An MPA should include input from the state’s large employers whose workforce is aging and caregiving. Part of the process is to elevate ideas for employers to be more age inclusive, resist ageism in hiring practices, and learn how to bolster their workforce through age-inclusive management strategies. One strategy is to invite these interests to be part of stakeholder groups or submit recommendation letters.
• Healthcare and social services providers: An important part of the MPA process is to engage and “map” the various healthcare provider groups (Age-friendly health systems, safety net health systems) and social services (faith-based, charitable, publicly funded, etc.) to coordinate systems and ensure the MPA captures their important insights into gaps and duplications in services.
• Educators and Researchers: It’s important to include schools that train providers and direct care workers, and academic institutions researching aging and disability to inform the MPA and track progress during implementation.
• Older adults, caregivers, and all people aging in the state: Consumer engagement should be intentionally broad because to make the MPA relevant, it must start with the premise that “we are all aging.”

After the cabinet workgroup, stakeholder meetings, and governor’s approval of the plan, what is the result? This can vary by state, but MPAs typically include:

• Several (4–6) high level, shared goals that represent agreement on how best to age in the state. Most states end up with similar goals that represent aspirations for 1) living well in the community, 2) access to healthcare and social services that promote quality of life and dignity, and 3) economic security and safety.
• Each MPA is unique to each state. Every state can create their own plan with goals worded in a way that represents the unique priorities and cultures of the state.
  
  For example, Pennsylvania named their plan “Aging our Way, PA” and one of its goals is:
  
  Aging in Community: We will remediate barriers that prevent older adults from remaining in their own homes, maintaining familiar surroundings, staying connected to their communities, and living in secure dwellings (Commonwealth of Pennsylvania, 2023).
  
  North Dakota named its plan the “Multigenerational Plan for Aging” and has goals such as:
  
  Futures Planning: North Dakotans will receive widespread outreach and learning opportunities for legal, financial and healthcare planning (North Dakota Health & Human Services, 2022).
   
• Initiatives or strategies linked to each goal that have cross sector and executive agreement: Experts, stakeholders, the governor, and different agencies agree on the initiatives and recommendations that would make effective next steps.
• New or existing initiatives or programs: Recommendations or initiatives in the MPA can include those made by previous task forces, strategic plans, or age-friendly plans. They could be initiatives that are already funded, or already implemented (to signal support for continuation). Others may be more aspirational, with an imperative to continue to explore, study, and seek funding for an approach or program that all agree would move the state in the right direction.
• Accountability is baked in: Each initiative, strategy, or action that is in the MPA should have at least one (preferably more) lead government agency or department, and assigned stakeholders who will keep the state accountable for enacting the recommendations as soon as possible. It is very common for states to create data dashboards that track the implementation.
• Living document: Initiatives in the MPA are meant to be tweaked and updated on a regular basis, with ongoing stakeholder engagement, progress reports, and revisions to the plan. Many states also create opportunities for local or regional leaders to develop their own local MPA.

MPAs promote system change. An MPA is unique because it is a multisector plan that is led by the state government. As such, it has a more direct route toward legislation and funding for its initiatives than an age-friendly plan created by external groups. This model is based on the premise that it’s easier for government to lead a process and incorporate external stakeholders—and more difficult for external stakeholders to have the power to force system transformation.

Here are some examples of initiatives states have put in their MPAs to promote increased coordination:

• New Aging and Disability combined department (Tennessee, Nevada)
• New Office of Medicare Integration and Innovation and Integration (California)
• Grants and technical assistance for local implementation and regional aging/disability planning
• Coordination of direct care worker trainings across the state
• Nursing home reform that coordinates across private payers, providers, state survey agencies, and Medicaid
• Increased recognition and coordination of Age-Friendly health systems, Age-Friendly universities, and other programs into Age-Friendly ecosystems (Minnesota)

Conclusion

Multisector Plans for Aging hold the promise of building and sustaining high-level policy structures for coordinating comprehensive systems that prioritize the needs of older adults. They are unique because they start with states and stakeholders developing their own unique goals, rather than using a pre-established framework. However, there is tremendous potential to align MPA priorities with existing age-friendly frameworks, initiatives, and movements across the country.

Carrie L. Graham, PhD, is a research professor at Georgetown University, McCourt School of Public Policy, Center on Health Insurance Reforms, an adjunct professor at the UCSF Institute for Health and Aging, and director of Health Policy at Health Research for Action, a center in the UC Berkeley School of Public Health. She may be contacted at carrie.graham@georgetown.edu.

Photo credit: Shutterstock/Pond Saksit

References

Administration for Community Living. (2024). Aging in the United States: A Strategic Framework for a National Plan on Aging. https://acl.gov/sites/default/files/ICC-Aging/StrategicFramework-NationalPlanOnAging-2024.pdf

Commonwealth of Pennsylvania. (2023). Aging Our Way, PA: A Plan for Lifelong Independence. https://www.pa.gov/agencies/aging/aging-our-way-pa.html#accordion-7172a989a9-item-9bc7c6fdbf

Graham, C. & Hoffmaster, A. (2023). Developing a Multisector Plan for Aging. https://www.chcs.org/resource/developing-a-master-plan-for-aging/

North Dakota Health & Human Services. (2022). Multigenerational Plan for Aging. https://www.hhs.nd.gov/adults-and-aging/multigenerational-plan-aging

Rauscher, E., Phan, M. Graham, C. & Somers, S. (2024). The State of Multisector Plans for Aging in 2024. https://www.chcs.org/media/The-State-of-Multisector-Plans-for-Aging-in-2024_updated.pdf