Since the early 1980s, service providers and area agencies on aging, that is, the aging network, have developed a number of strengths as they built a community-based long-term-care system in most states. Many area agencies and providers now have the capacity to assess the needs of older persons, identify appropriate services, and administer cost effective community programs while operating within fixed, capped budgets. They have also been able to identify and maintain roles for informal caregivers, draw on community resources through donations and the use of volunteers, and create substantial political support. In this article we argue that the aging network should draw on these strengths to develop integrated long-term-care systems designed to shift the balance of state long-term-care systems from institutional to home and community-based services. We also argue that the nonprofit aging network, because it is made up of area agencies on aging and service providers, provides a potentially more effective framework for the integration of long-term-care resources than do proprietary managed care organizations.
Over the past several years, many states have made improvements in their long-term-care systems for elderly persons by funding private and public nonprofit aging services organizations to provide home- and community-based alternatives to nursing home care. An accumulating body of research tends to indicate that these community programs are, on the whole, relatively cost effective in comparison with nursing home care, which now costs $60,000 or more annually in most states (Grabowski, 2003; Wiener & Lutzky, 2001; Wiener, Tilly, Alecxih, & Mario, 2002). Most states, however, are still spending 70% to 80% of their long-term-care funds for the elderly population on nursing facility care (Kaiser Family Foundation, 2006). Relatively few states have achieved balanced long-term-care systems that are responsive to the overwhelming preferences of frail elderly persons for community-based care (Wiener, 2006). Shifting the focus of public long-term-care systems from nursing home care to home and community-based care is the major long-term-care policy issue confronting state and federal policy makers; continuing dependence on nursing homes will make Medicaid long-term-care costs increasingly less affordable and resources for home- and community-based services (HCBS) programs less available.