Area Agencies on Aging (AAAs) are entering a new phase marked by a heightened focus on social determinants of health. With a mission, a history, and a legislative mandate to serve as the local hub for a coordinated system of health- and independence-enhancing services, AAAs are well-positioned to address needs related to the social determinants of health. Contracting with healthcare partners to meet these needs is an opportunity to expand their role in the communities, protect their mission, and communicate and reinforce their unique areas of expertise.
Area Agencies on Aging, social determinants of health, healthcare contracting
Established in a 1973 amendment to the Older Americans Act (OAA), Area Agencies on Aging (AAAs) were designated as local entities charged with overseeing a comprehensive and coordinated system for the delivery of social, nutrition, and long-term services and supports (LTSS) to older individuals (EveryCRSReport.com, 2021). In its nearly 50-year history, this local component of the aging network has continuously evolved in response to OAA reauthorization priorities, diverse needs of a heterogeneous aging population, and initiatives to improve upon fragmented systems of health and long-term care.
To capture some identifiable shifts in focus, Applebaum and Kunkel (2018) identified three phases in the history of the aging network. The age-mitigating phase reflected the view that age equated to need. OAA services such as transportation, nutrition, socialization, and employment were designed to compensate for age-based losses and challenges thought to be common and predictable. In the next phase, called vulnerability-mitigating, these core services remained in place, but the assumption that age directly and universally equates to need was moderated by a commitment to target services to older adults who were at higher risk for needing them. The third phase, identified as care-integrating, emerged with the Medicare Modernization Act, the creation of the Centers for Medicare & Medicaid Services Office of Integrated Care, and the rise of managed care models for home- and community-based services.
During this era, the aging network maintained its focus on vulnerability, and included new efforts to coordinate and integrate social, health, and long-term care. This care-integrating phase also saw a new emphasis on partnerships and collaborations across multiple sectors that serve older adults, including long-term care, healthcare, mental health, and legal and protective services.
While the chronological boundaries and names for these phases are open to discussion, it is clear that AAA positioning has moved from the “age equals need” assumptions underlying the initial OAA legislation to more multifaceted roles and a broader range of partners, services, and populations served. The mandated responsiveness of AAAs to local needs, as well the agility required to respond to policy and system-level changes have fueled this evolution.
‘The pandemic dramatically altered the extent and nature of the needs of older adults.’
Two recent developments provide another pivot point for AAAs that may point to a new phase characterized by a new level of partnerships and responsiveness: delivery system transformations related to the COVID-19 pandemic, and an increasing emphasis on social determinants of health (SDOH) across multiple sectors. The pandemic dramatically altered the extent and nature of the needs of older adults. Recent research by Gallo and Wilber (2021) and others (e.g., Wilson et al., 2020) documents the key role played by AAAs in quickly responding to an increased demand for services such as meals and setting up new delivery modes. AAAs and their local service providers adapted their delivery systems for nutrition assistance from congregate meals to a range of home-delivered options; also, they began providing more telephone-based and virtual socialization options.
We note that the ability of AAAs to respond effectively and quickly to changing needs was related to an expanded use of technology, an infusion of new federal funding for food assistance, and a web of partnerships, collaborations, and contracting relationships between AAAs, other community-based organizations (CBOs), and healthcare entities. This literature, as well as pre-pandemic research (Brewster et al., 2017), suggests that AAA partnerships help to mobilize community responses and can play a key role in community health.
Connections to Healthcare Partners
The most recent national survey (n4a [now USAging] & Miami University, 2020) of AAAs describes a high prevalence of partnerships between AAAs and a range of healthcare entities. In 2019, 80% had formal and/or informal partnerships with mental health/behavioral health organizations, nearly three-quarters reported a partnership with a hospital or health system, 62% had partnerships with a health plan, and 60% partnered with community health clinics.
Formal contracts are a specific kind of partnership based on legally binding agreements set up to exchange payment for services or programs. The most recent in a series of national surveys of CBOs about their contracting relationships with healthcare entities found that in 2021, 47% of AAAs had at least one contract with a healthcare partner and another 12% reported that they were in the process of pursuing contracts at the time of the survey.
Healthcare partners: payers and providers
CBO healthcare partners cover a range of government and non-government payers and providers. The most common healthcare partners contracting with CBOs are Medicaid Managed Care Plans, state Medicaid that is not pass-through via a managed care organization, commercial or employer-sponsored health insurance, and hospital or health systems.
Contracts between AAAs and healthcare partners align with the growing need for health systems that better understand aging and can better achieve effective coordination and integration of care. These contracts also directly reflect SDOH as a fundamental component of social and healthcare systems. It is well established that individual health status is not determined primarily by specific healthcare interventions received; rather, the primary drivers of health are the circumstances in which we live our lives. Economic security, education, health care access and quality, neighborhood, and social and community context are all tied to risks for poor health and shortened life expectancy.
In their “Mapping Life Expectancy” project, researchers at Virginia Commonwealth (2016) show vast differences in life expectancy across adjacent neighborhoods, based on SDOH factors such as housing, average income, opportunities to exercise, residential segregation, and access to affordable healthy foods. Two examples of these patterns are a 12-year difference in life expectancy between two adjacent ZIP Codes in Cleveland, and a 25-year gap for neighborhoods only a few miles apart in New Orleans.
Some of the specific risks and needs that arise from unfavorable SDOH circumstances are food insecurity, lack of transportation, poor access to preventive health services, and social isolation. The services provided through AAAs address these needs and risks. Given the services they provide, and the centralized coordination role AAAs hold in their communities, they are logical partners for systems responding to risks and needs arising from unfavorable SDOH circumstances. While contracting with healthcare partners is not without challenges (as discussed below), these arrangements have served to solidify some areas of expertise of AAAs and have continued to broaden their client populations.
Services provided and populations served under contracts with healthcare partners
In a recent survey (Kunkel et al., 2020) of CBOs that serve older adults (a respondent group composed primarily of AAAs), the most common service provided under contract with a healthcare entity was care management/care coordination; 42% of CBOs contracting with healthcare organizations were providing this service.
Evidence-based programs, hospital-to-home care transitions, and nutrition services were provided by 30% of CBOs in their contracts with healthcare partners. Nearly 80% were serving older adults under these contracts; 57% were also serving individuals of any age with chronic illness, and 29% were serving veterans. Nearly 90% of the contracts involved targeting high-risk or high-need groups such as individuals at high risk for nursing home placement, emergency department use, or hospital readmission.
The populations served by AAAs and other CBOs under contract with healthcare partners are consistent with the broadened client base reported by AAAs for all of their services, including OAA-funded programs. In the 2019 national survey of AAAs cited above, 85% of respondents were serving people younger than age 60 who had disabilities, and 66% served veterans of all ages. These data suggest that contracting with healthcare partners supports the expanded role that AAAs have already taken in their communities to respond to changing needs, policies, and initiatives.
Implications for AAA momentum
Healthcare contracting has moved the aging network forward in its business acumen—a positive development with or without healthcare contracts, and a trend that has been underway among some AAAs for decades. The Aging and Disability Business Institute at USAging provides resources to support the organizational capacity of CBOs to respond to new opportunities in a changing healthcare environment. Tools and resources focus on topics such as thinking beyond government grants and programs, making a business case, and payment model options.
In addition to the potential value of healthcare partnerships for strengthening the business acumen and positioning of AAAs in their community, revenue is also important. The extent to which these contracts contribute new and net positive revenue will figure into calculations about the overall success of these endeavors. The series of surveys about CBO contracting mentioned above are showing noticeable increases in the proportions of contracts that generate revenue (partially a function of referral volume and efficient billing payment systems), and movement toward revenue-neutral or revenue-positive status.
A 12-year difference in life expectancy was found between two adjacent ZIP Codes in Cleveland.
Another noteworthy trend within the aging network is an interest in developing standards and credentialing processes that preserve the local responsiveness central to their mission and enhance the business case for AAAs. These discussions preceded the significant move to healthcare contracting but are gaining momentum because of the importance of clear messaging to potential partners on the professional expertise of AAAs.
Finally, an enhanced focus on the inclusiveness and equity of OAA service delivery positions the aging network to provide support for these efforts within healthcare systems. Equity analyses conducted by some AAAs, as well as ongoing monitoring of the extent to which each AAA is reaching all segments of their target population are examples of the aging network momentum that can come into play in healthcare contracting.
The momentum-enhancing possibilities of healthcare contracting are related to the context within which AAAs operate. In particular, state policies can make a difference. Forthcoming research shows that the existence of managed LTSS reduces the likelihood that AAAs will contract with the healthcare delivery system, while the likelihood was higher in states with a higher number of integrated delivery system innovations and policies.
Implications for the AAA mission
It seems clear that healthcare contracting does not necessarily undermine the mission of AAAs. It certainly does not negate, and could even enhance, their ability to serve as local hubs for access and coordination of services to support living in the community with health, independence, and dignity.
That said, it would be naïve to suggest that AAA contracting with healthcare partners is nothing more than a natural progression of their changing roles in a changing landscape. Because that landscape is dominated by healthcare entities, even in the presence of an SDOH emphasis there can be a disconnect between the social service mission of a AAA and the culture and structure of healthcare organizations.
Taylor and Byhoff (2021) analyzed many facets of this tension. They note, for example, the potential discordance between arguing for the distinctiveness of the work of a community-based social services organization and adopting new ways of working driven by healthcare partners. Performance metrics and definitions of effectiveness are one place where distinct perspectives likely come into play. Envisioning a best-case scenario, Polivka and Polivka (2019) argue that the mission-centered positioning of the aging network is key to “more comprehensive, community-based models guided by an ‘ethic of care’ rather than maximization of profits” (Taylor and Byhoff, 2021. P. 103).
From existing research on partnerships and contracting between AAAs and healthcare entities, there is clear momentum forward. Further research with AAAs that successfully navigate these new waters will reveal strategies for how their distinctive mission can co-exist with new ways of working with healthcare partners.
Suzanne R. Kunkel, Ph.D., is executive director, Scripps Gerontology Center, and University Distinguished Professor, Department of Sociology & Gerontology at Miami University in Oxford, OH.
Applebaum, R., & Kunkel, S. (2018). The Life and Times of the Aging Network. Public Policy & Aging Report 28(1): 39–43. https://doi.org/10.1093/ppar/pry007
Brewster, A. L., Brault, M. A., Tan, A. X., Curry, L. A., & Bradley, E. H. (2017). Health Services Research 53(S1): 2892–2909. https://doi.org/10.1111/1475-6773.12775
EveryCRSReport.com. (2021). Older Americans Act: Overview and Funding. Retrieved on February 3, 2022 from https://www.everycrsreport.com/reports/R43414.html.
Gallo, H. B., & Wilber, K. H. (2021). Transforming Aging Services: Area Agencies on Aging and the COVID-19 Response. The Gerontologist 61(2): 152–58. https://doi.org/10.1093/geront/gnaa213
Kunkel, S. R., Wilson, T. L., Lackmeyer, A. E., & Straker, J. K. (2020). Strengthening Ties: Contracting Between Community-Based Organizations and Health Care Entities. Oxford, OH: Scripps Gerontology Center. https://sc.lib.miamioh.edu/bitstream/handle/2374.MIA/6675/strengthening-ties-contracting-between-CBOs-health-care-entities.pdf?sequence=4&isAllowed=y&_ga=2.174222886.542912048.1643913960-284204946.1643913960
n4a (now USAging) and Miami University. (2020). AAA National Survey Report: Meeting the Needs of Today’s Older Adults. Retrieved February 3, 2022 from https://www.usaging.org/Files/AAA-Survey-Report-2020%20Update-508.pdf.
Polivka, L. & Polivka-West, L. (2019). The Changing Role of Non-Profit Organizations in the U.S. Long Term Care System. Journal of Aging & Social Policy 32(2): 101–7. https://doi.org/10.1080/08959420.2019.1642693
Taylor, L. A., & Byhoff, E. (2021) Money Moves the Mare: The Response of Community-Based Organizations to Health Care’s Embrace of Social Determinants. The Milbank Quarterly March 2021(99). https://www.milbank.org/quarterly/articles/money-moves-the-mare-the-response-of-community%E2%80%90based-organizations-to-health-cares-embrace-of-social-determinants/
Virginia Commonwealth University. (2016). Mapping Life Expectancy: Cleveland, June 17. Center on Society and Health. Retrieved on February 3, 2022 from https://societyhealth.vcu.edu/work/the-projects/mapscleveland.html.
Wilson, T. L., Scala-Foley, M., Kunkel, S. R., & Brewster, A. L. (2020). Fast-track Innovation: Area Agencies on Aging Respond to the COVID-19 Pandemic. Journal of Aging & Social Policy. 32(4–5): 432–8. https://doi.org/10.1080/08959420.2020.1774313