Policymakers, public health professionals, and others – in Maryland and nationwide – have become familiar with a compelling story about the burgeoning elderly population and daunting predicted costs to care for these elders.  By 2030, one in five Americans will be age 65 or older (U.S. Census Bureau, 2008), and their care will cost an estimated $760 billion if impairment levels remain the same. (Congressional Budget Office, 2004).  Despite these demographic and economic imperatives, as well as strong consumer demand for flexible services that meet individual preferences, there are not enough independence-enhancing options for people as they age and/or develop disabilities.  People rarely ask to live in a nursing home (Eckert, Morgan, & Swarmy, 2004), and we have significant evidence that people want to receive services in their homes and communities as they age (AARP, 2010, Carlson, Dale, Foster, & Brown, 2007).  Yet, families across this nation are struggling to help their aging parents obtain the services they need while staying in their homes.  Caregiving is likely to be even more challenging for middle class and low income Americans, and especially for those without relatives who live close by.  It is also well established that many caregivers experience high levels of stress (Feinberg, et al, 2011; CDC, 2008). 

There have been significant national efforts in recent years to expand publically-funded community services, including the now “suspended” Community Living Assistance Services and Supports (CLASS) Act that would have provided long-term services insurance benefits through the 2010 Patient Protection and Affordable Care Act (ACA) (Lindberg, 2011).  However, the majority of public funding for long-term services and supports (LTSS) is spent on nursing facilities (Kassner, et al, 2008).  Maryland lags behind most other states in efforts to shift the emphasis on LTSS spending from nursing homes to home and community-based options (HCBS). In fiscal year 2008 over 84% of publically-funded Maryland elderly/disabled long-term care was provided in nursing homes, compared to just under16% in community settings (State of Maryland, 2011). The national average for LTSS spending on HCBS for elders and adults with physical disabilities in 2009 was 33.8% (Milligan & Woodcock, 2011).        

To address the need for more community-based  LTSS options, and shift away from an emphasis on nursing home care, Maryland legislators passed the 2011 Maryland Communities for a Lifetime Act (Maryland SB 822). This legislation, based on recommendations from the 2009 Maryland Communities for a Lifetime Report (Statewide Empowerment Zone for Seniors Commission), proposes a “comprehensive, strategic state plan to address the aging-in-place preference of current and future seniors and to promote a state “communities for a lifetime” program that overcomes barriers in housing, transportation, health care, employment, and social and civic engagement.”  The interest indicated by this bill (despite the lack of funding to implement the legislation), along with ACA financial incentives to states to lower their institutional LTSS spending, and the significant need for expanded community-based options to help Marylanders age in their communities, create a timely opportunity to address this important issue.  This effort supports the President’s Year of Community Living (whitehouse.gov, 2009) and a call to make rapid expansion of community services “a national priority today so that tomorrow’s much larger cohorts of older people can look forward to aging with dignity and independence.” (AARP, 2010).

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