Long-Term Care: Support For Elder Care Could Benefit the Government Workplace and the Elderly (Letter Report, 03/04/94, GAO/HEHS-94-64). Today, about six million older Americans living at home need help with day-to-day activities, such as eating, bathing, shopping, and house cleaning. Most disabled elderly get all their care informally, from family members and friends, mainly women. Greater geographic dispersion of families, small families, and more women working outside the home are straining the ability of informal caregiving. Some private and public-sector employers are now providing assistance known as "elder care" to alleviate work and caregiving conflicts. This assistance may include leave policies, alternative work schedules, and referral services to help employees care for their elderly relatives. Little is known nationwide about the extent and content of elder care generally--and even less is known about elder care in government, which employs 18 million people or 15 percent of the workforce. This report evaluates (1) the extent and nature of government practices facilitating elder care; (2) planned changes in these practices; and (3) their potential to further support informal caregivers. --------------------------- Indexing Terms ----------------------------- REPORTNUM: HEHS-94-64 TITLE: Long-Term Care: Support For Elder Care Could Benefit the Government Workplace and the Elderly DATE: 03/04/94 SUBJECT: Long-term care Elderly persons Aid for the elderly Flexible work schedules Personnel management Federal employees Working conditions Fringe benefits Labor-management relations IDENTIFIER: Medicaid Program Medicare Program Social Services Block Grant Supplemental Security Income Program OPM Work and Family Program Center ************************************************************************** * This file contains an ASCII representation of the text of a GAO * * report. Delineations within the text indicating chapter titles, * * headings, and bullets are preserved. 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We are unable to accept electronic orders * * for printed documents at this time. * ************************************************************************** Cover ================================================================ COVER Report to the Chairman, Subcommittee on Employment, Housing and Aviation Committee on Government Operations House of Representatives March 1994 LONG-TERM CARE - SUPPORT FOR ELDER CARE COULD BENEFIT THE GOVERNMENT WORKPLACE AND THE ELDERLY GAO/HEHS-94-64 Public-Sector Elder Care Abbreviations =============================================================== ABBREV AOA - Administration on Aging APHIS - Animal and Plant Health Inspection Service DCAP - Dependent Care Assistance Plan DOD - Department of Defense IRS - Internal Revenue Service OPM - Office of Personnel Management SSA - Social Security Administration USDA - U.S. Department of Agriculture Letter =============================================================== LETTER B-251010 March 4, 1994 The Honorable Collin C. Peterson Chairman, Subcommittee on Employment, Housing, and Aviation Committee on Government Operations House of Representatives Dear Mr. Chairman: Today, about 6 million older Americans living at home need assistance in everyday activities because of their disabilities. These elderly people need assistance with activities such as eating, toileting, bathing, house cleaning, moving about the house, shopping, managing money, and other activities most Americans take for granted. Population aging will significantly increase demand for this type of assistance, as the number of elderly needing long-term care reaches an expected 10 million or more by 2020. Most disabled elderly people get all their care informally from family members and friends, primarily women. However, greater geographic dispersion of families, smaller families, and the large percentage of women working outside the home are straining the capacity of informal caregiving. Employed caregivers often face challenges in balancing their work and caregiving responsibilities that can adversely affect both roles. Some private- and public-sector employers are responding to the needs of their employees with assistance known as "elder care" to alleviate work and caregiving conflicts. In this report, we define elder care as any employer-sponsored practice, policy, or program offered by federal, state, or local governments that directly or indirectly helps their employees or retirees care for elderly relatives and friends. Employer-sponsored elder care assistance may include leave policies, alternate work schedules, educational materials and seminars, information and referral services, financial arrangements, and other options to help employees care for their elderly relatives. Little is known nationwide about the extent and content of elder care generally--and even less is known about elder care in government, which employs 18 million people or 15 percent of the work force. Therefore, your subcommittee requested that we evaluate (1) the extent and nature of government practices facilitating elder care, (2) planned changes in these practices, and (3) their potential to further support informal caregivers.\1 -------------------- \1 We issued a separate report on the availability of elder care assistance to employees in the private sector, Long-Term Care: Private Sector Elder Care Could Yield Multiple Benefits (GAO/HEHS-94-60, Jan. 31, 1994). RESULTS IN BRIEF ------------------------------------------------------------ Letter :1 Currently, about two million working Americans, including government employees, are providing significant unpaid care to their elderly relatives in the community who need help with everyday activities. Surveys indicate that 3 to 5 percent of the federal work force have significant elder care responsibilities and that as many as 12 percent have some elder care responsibilities. According to the Office of Personnel Management (OPM), up to an additional 13 percent of federal employees without elder care responsibilities now expect to have such responsibilities within the next 5 years. Work and family responsibilities often conflict for caregivers living near their disabled elderly relatives and for the many caregivers who provide assistance long distance. To maintain both work and caregiving roles, caregivers identify both work schedule flexibility and information about community services for the elderly as the most useful options employers could offer. The federal government, state governments, and city governments with the largest work forces that we studied offer flexible schedule options and elder care information. OPM reports that federal employees can use 7 of 10 schedule flexibility options that we examined for elder care assistance purposes. These include leave without pay, flex-time, compressed work schedules, job sharing, flexplace, allowing temporary reductions in work hours, and part-time employment with benefits. We surveyed the states and 100 cities, and all 47 states that responded have at least two of these options and most had six or more. Seventy-three out of 80 large cities responding to our survey reported having two or more of these options, and 35 had at least six. However, managerial discretion may restrict actual schedule flexibility to employees at all levels of government in different agencies and in units of the same agency. Providing elder care information in the workplace is less common because elder care has only recently become recognized as a workplace issue. Nonetheless, information resources are developing. OPM, in collaboration with the Administration on Aging (AOA), is promoting awareness of a publicly available toll-free Eldercare Locator Number to federal employees to assist them in locating home and community-based services for the elderly wherever they live. In addition, OPM is sponsoring several other activities to encourage broader availability of elder care information resources in the federal government. Fifteen state governments and 24 big-city governments also reported having at least two of the elder care information options that we examined. These options include seminars on aging, information on services, and elder care reference materials. The federal government, as well as some state and big-city governments, plan to make additional support available or to expand availability of existing elder care programs, but many of these governments are uncertain of their future plans. This is partly because agency officials are often unsure of the extent of elder care needs or how they can be met inexpensively. Planned expansions include greater promotion of flexible schedule options for elder care and the provision of information on community services for the elderly. Government's greater recognition and promotion of existing schedule flexibility options for elder care purposes is an effective way to address these issues. Such promotion, coupled with information resources, can help caregivers balance their work and family responsibilities, help the elderly to live independently in their homes, and strengthen government's efforts to improve employee retention and productivity. OPM's efforts are a good start to promote elder care at the federal level. It is too early, however, to evaluate the effectiveness of these efforts in creating changes at other federal agencies. If agencies change policies, programs, and practices to promote elder care, determining their effectiveness will depend on how well the initiatives are implemented and the extent to which employees use them. BACKGROUND ------------------------------------------------------------ Letter :2 More and more Americans are facing the need for long-term care in their families. Among people 45 years of age or older, approximately two in five report some experience with long-term care in their families.\2 Approximately 13.3 million people have a disabled parent or spouse who may require long-term care services.\3 In most cases, these needs are primarily for nonmedical care provided outside of nursing homes and are met by using unpaid, informal assistance from family and friends. This assistance is instrumental in helping elderly disabled people with basic tasks of everyday living so that they can remain in their homes and communities. In addition, about 2 million elderly people receive formal, paid home and community-based long-term care services such as home health care, meals, and transportation.\4 These services are either purchased by the elderly and their families or paid for with public funds, primarily by Medicaid and Medicare. When families can no longer provide sufficient care alone or in combination with paid home and community-based services, elderly persons may be placed in nursing homes, the average annual cost of which was $34,000 in 1991. About half of these costs is paid for by the elderly and their families, and the other half is paid by federal and state governments. About 1.5 million older Americans, usually those with severe disabilities, live in nursing homes. While most care to the elderly is provided by unpaid family and friends, federal spending for long-term care to the elderly is substantial. In 1991, state and federal long-term care spending totaled more than $38 billion through the Medicare and Medicaid programs, primarily for institutional care. Other federal long-term care funds are provided through the Older Americans Act, the Social Services Block Grant, the Supplemental Security Income program, and several Department of Veterans Affairs programs. In addition, some proposals for health care reform, including the Administration's, include federal payment for additional long-term care services. -------------------- \2 Margaret K. Straw, Home Care: Attitudes and Knowledge of Middle-Aged and Older Americans. American Association of Retired Persons, (Washington, D.C.: 1991) , p. 2. \3 Robyn Stone and Peter Kemper, "Spouses and Children of Disabled Elders: How Large a Constituency for Long-Term Care Reform?" The Milbank Quarterly, Vol. 67, Nos. 3-4 (1989) pp. 485-505. \4 National Medical Expenditure Survey: Use of Home and Community Services by Persons Ages 65 and Older with Functional Difficulties, Research Findings 5; Agency for Health Care Policy and Research, Public Health Service, Department of Health and Human Services, (Washington, D.C.: 1990), p. 6. SCOPE AND METHODOLOGY ------------------------------------------------------------ Letter :3 To respond to the Subcommittee's request, we (1) reviewed the literature on elder care and government agencies' development of elder care assistance; (2) interviewed federal, state, and local officials and elder care experts; (3) reviewed documents concerning elder care practices from personnel, benefits, work/family, and line divisions of government agencies; (4) surveyed the 50 states, and the 100 city governments with the largest work forces; and (5) attended the federal Interagency Adult Dependent Care Working Group meetings sponsored by OPM in the past year. (See app. I for a full description of our methodology.) Our study is the first nationwide examination of elder care practices focusing on all levels of government. Although we did not survey all federal agencies, we collected extensive information from OPM's Work and Family Program Center, which has responsibility for promoting elder care in all federal agencies and from a variety of other federal sources. We also received survey responses from 47 of the 50 states and 80 of the 100 cities with the largest work forces (see app. II for the survey instruments used and data reported). The survey data do not include all state and big-city employees, however, because the principal reporting authority could not always respond for employees under other personnel systems. Our data on local governments generally are limited because they do not include comprehensive information on county governments, school districts, special districts, smaller municipalities, and townships, which employed about 8.7 million employees in 1987. Based on other information that we collected on these governments, however, we have no reason to believe that they have more comprehensive elder care coverage than other governments. INFORMAL CAREGIVING GROWING; CAN CONFLICT WITH WORK ------------------------------------------------------------ Letter :4 Because women's participation in the work force and the number of disabled elderly have grown, more employees are caring informally for older Americans in their homes and communities. Approximately two million working Americans provide informal caregiving assistance to their disabled elderly relatives, including help with eating, bathing, moving around the home, housework, and financial management. Nearly three-quarters of all caregivers are women, many of whom are employed outside the home. An additional six million employees have a disabled spouse or parent who may also require help with these or other activities. As the population ages, the number of employed caregivers is expected to grow. Potential caregivers, spouses and children of disabled elders, currently account for about 9 percent of the work force of full-time employees.\5 Employees' caregiving demands can adversely affect their work performance. Caregiving problems may lead to increased absenteeism, tardiness, work disruptions, turnover, and stress, with damaging effects on employee productivity and morale. Employed caregivers report making adjustments in both caregiving and at work to accommodate their dual roles. At work, many caregivers rearrange their schedules, reduce their overall hours, take leave without pay, and even forgo career opportunities or quit their jobs to fulfill elder care responsibilities. -------------------- \5 Stone and Kemper, p. 497. GOVERNMENT HAS INTEREST IN ENCOURAGING ELDER CARE ------------------------------------------------------------ Letter :5 Government has the same stake as private industry in recruiting and retaining productive employees. A GAO study that compared federal and nonfederal work/family programs and approaches concluded that the federal government's work/family efforts, including elder care, should be improved to respond to changes in the work force and to compete for high-quality employees.\6 State and local governments face similar pressures in recruiting and retaining high-quality employees. A GAO survey revealed that 65,000 employees, or 5 percent of the federal executive branch, excluding postal employees, have responsibilities for an adult dependent 65 years of age or older during the workday.\7 About 3 percent of federal employees responding to an OPM survey said that they spend 10 or more hours a week caring for an elderly person. Altogether, 12 percent of those responding to OPM's survey reported that they have some responsibility for an elderly dependent and that 13 percent without those responsibilities now expected to have such responsibilities within 5 years.\8 We did not find comparable information on state and local government employees. -------------------- \6 The Changing Workforce: Comparison of Federal and Nonfederal Work/Family Programs and Approaches (GAO/GGD-92-84, Apr. 23, 1992). \7 Information derived from survey data reported in Federal Employment: How Federal Employees View the Government as a Place to Work (GAO/GGD-92-91, June 1992) pp. 28-29. \8 A Study of the Work and Family Needs of the Federal Workforce: A Report to Congress by the Office of Personnel Management, Office of Personnel Management, (Washington, D.C.: 1992), pp. 15-18 (and more detailed information supplied by OPM on survey results). GOVERNMENT OFFERS MOST USEFUL OPTIONS BUT OFTEN DOES NOT ENCOURAGE THEIR USE FOR CAREGIVER ASSISTANCE ------------------------------------------------------------ Letter :6 Almost all governments offer at least one flexible schedule or elder care information option, and many governments offer several of these options. Experts and employees consider these options to be the most useful for employed caregivers.\9 Many of these options, however, were not designed specifically for elder care purposes. Managers and supervisors, therefore, may neither recognize their potential nor encourage their use by employees for elder care purposes. Other elder care options, such as financial assistance, are offered by a much smaller number of governments. -------------------- \9 Robyn Stone and Pamela Short, "The Competing Demands of Employment and Informal Caregiving to Disabled Elders," Medical Care, Vol. 28, No. 6, (1990) pp. 513-526; Andrew Scharlach, Eugene Sobel and Robert Roberts, "Employment and Caregiver Strain: An Integrative Model," The Gerontologist, Vol. 28, No. 6, (1991) pp. 778-787; Jeane Anastas, Janice Gibeau, and Pamela Larson, "Working Families and Eldercare: A National Perspective in an Aging America," Social Work, Vol. 35, No. 5, (1990) pp. 405-411; Florence Glasser, Solving The Workplace Puzzle-Fitting Work and Family Together in Government Workplaces of North Carolina, North Carolina Equity, (Raleigh, North Carolina, 1992) pp. 26-27. FLEXIBLE SCHEDULES PREVALENT BUT NOT WIDELY RECOGNIZED OR PROMOTED AS ELDER CARE ---------------------------------------------------------- Letter :6.1 The federal government, state governments, and big-city governments offer a variety of flexible schedule options that may be used for elder care though not designed for that purpose. These options vary by government but may include paid sick leave, leave without pay, compressed work schedule, flex-time, flex-place, and part-time employment with partial or full benefits (see app. II for a complete list of schedule options). The actual availability of these options to employees differs, however, by agency and by unit within the same agency.\10 Although not initially intended to address elder care needs, flexible scheduling options, when available to employees, can be a key element of employer-provided elder care assistance. These options can enable working caregivers to respond to the unpredictable, emergency needs of the elderly, such as acute health care episodes, as well as accommodate routine care requirements such as relieving another caregiver in the home after work. Employees can use these options to change their work hours, work fewer hours, or take unpaid leave. Schedule options vary among governments. OPM reports that 7 of the 10 options that we examined can be used for elder care purposes at the federal level. These include leave without pay, flex-time, compressed work schedules, job sharing, flex place, allowing temporary reduction in work hours, and part-time employment with benefits. The federal government does not, however, offer the use of sick leave for elder care purposes, although many states and localities do. The Report of the National Performance Review has called for all federal agencies to allow employees to use accrued sick leave to care for sick or disabled dependents, including the elderly.\11 This proposal is consistent with our recommendation that federal employment practices should be modernized to help employees balance work and family responsibilities.\12 Options for schedule flexibility that may be used for elder care purposes are also widely offered by state and big-city governments, although their actual availability varies by agency and by unit within agencies. All 47 states responding to our survey had at least 2 of the 10 schedule options we examined, 33 had 6 or more options, and 2 had all 10 (see fig. 1). Seventy-three of the 80 cities responding had at least 2 options, 35 had at least 6 options, but none had all 10 (see fig. 2). Figure 1: Number of States With Schedule Flexibility Options (See figure in printed edition.) Information is based on the 47 state responses to GAO's survey of states on elder care issues. Figure 2: Number of Large Cities With Schedule Flexibility Options (See figure in printed edition.) Information is based on the 80 responses to GAO's survey concerning elder care issues of the 100 cities with the largest work forces. The most common flexible scheduling practice among state governments is flex-time, followed closely by leave without pay, paid sick leave to care for an elderly person, and part-time employment with benefits--all of which were offered by more than 40 states. Among large cities, leave without pay was the most prevalent flexible schedule option (69 cities). The next most prevalent flexible schedule options were paid sick leave (54 cities) and flex-time (53 cities). Governments do not generally recognize and promote flexible schedules for elder care purposes, in part, because they were intended for broader purposes. Experts and managers engaged in elder care in the public and private sectors believe this diminishes the value of flexible scheduling options for helping balance work and caregiving responsibilities. Specifically, they believe that supervisors and managers must be aware and supportive of accommodating employees' caregiving needs. When employers identify and promote all elder care options, employees may be more likely to use them to effectively provide home care. -------------------- \10 GAO is completing a study of federal agencies' actual practices regarding flexible schedules. \11 Creating a Government That Works Better & Costs Less, Report of the National Performance Review, (Washington, D.C.: 1993), p. 85. \12 Management Reform: GAO's Comments on the National Performance Review's Recommendations (GAO/OCG-94-1 Dec. 3, 1993), p. 218. ELDER CARE INFORMATION LESS PREVALENT ---------------------------------------------------------- Letter :6.2 Governments also offer elder care information options, but these are not as prevalent as flexible schedules. This is not surprising because elder care is a relatively new workplace issue. Some information options are available, however. These options are especially valuable to working caregivers who need a ready source of information to help them handle the changing needs of the disabled elderly. In addition, many caregivers live far from the elderly person in need and provide long-distance assistance. When new needs arise, caregivers need to know what resources are available in the elderly person's community. Information and referral services reduce the amount of time and stress spent on elder care by enabling caregivers to more efficiently locate and use services even in other states. According to a 1992 OPM study on work and family needs, only 2.6 percent of federal employees with elder care responsibilities reported that their agencies offered information and referral services; 2.3 percent, educational workshops; 1.8 percent, resource libraries; and 1.5 percent, dependent care counselors.\13 Our state and big-city survey data also show that elder care information options are far less prevalent than work schedule flexibility. OPM and other federal agencies are taking important steps to improve the availability of elder care information (see fig. 3). The impact of these practices, however, will depend on how well they are implemented and on employee usage. OPM has taken the lead federal role in developing and promoting education and information options in other federal agencies and for its own employees. OPM has established a Work and Family Program Center with elder care responsibilities, sponsored regular Interagency Adult Dependent Care Working Group meetings on elder care to which representatives of all federal agencies are invited, held an elder care fair, and consulted on elder care issues with other federal agencies. OPM has also mounted a campaign, in cooperation with the AOA, to increase federal employees' awareness of the National Association of Area Agencies on Aging toll-free Eldercare Locator Number available to the public.\14 Callers to this number may speak to an elder care information specialist anywhere in the United States to identify the type of community services and agencies available to help an elderly person in his or her community. Services may consist of meal delivery, home chore services, or help with bathing and other personal care needs. In addition, some other federal agencies, such as the Department of Defense (DOD), the Social Security Administration (SSA), and the Animal Plant Health Inspection Service (APHIS) in the Department of Agriculture (USDA), have developed customized or more elaborate approaches to elder care for their own agencies. Figure 3: Some Governments Use Promotional Materials to Publicize Their Elder Care Programs to Employees (See figure in printed edition.) We did not find evidence to suggest that states or large cities have begun to implement comprehensive elder care, including flexible schedules and information and referral, or initiate broader campaigns to promote options for providing elder care as OPM has at the federal level. Some state and city governments reported, however, that they are considering developing and promoting a comprehensive approach to elder care. We did find that 15 state and 24 big-city governments offer at least two education and information options. Fourteen states and 27 cities reported that they offer employees a specific option for locating services for an elderly dependent. Experts say that this is the most useful information option needed by employed caregivers. The most prevalent information options among states in our survey are seminars on aging issues (15 states), elder care reference materials (12 states), and in-house information on community services (12 states). For cities in our survey, the most prevalent options are seminars on aging (29 cities), in-house provision of community service information (23 cities), and elder care reference materials (21 cities). -------------------- \13 A Study of the Work and Family Needs of the Federal Workforce: A Report to Congress by the Office of Personnel Management, p. 17. \14 The Eldercare Locator toll-free number, 1-800-677-1116, is part of AOA's National Eldercare Campaign. CERTAIN ELDER CARE OPTIONS ARE RARE OR LESS USEFUL ---------------------------------------------------------- Letter :6.3 Employee support services and financial arrangements are other employee options often associated with work and family issues. These options, however, are generally less prevalent than schedule flexibility and information options in government, or their usefulness in elder care is limited. The availability of these options also varies by level of government. Some federal agencies offer elder care services such as support groups and individual counseling, but these activities are limited. The federal government offers none of the financial arrangements that we examined such as a Dependent Care Assistance Plan (DCAP), cash subsidies for services, and private long-term care insurance. State and big-city governments also offer support services to employees with elder care responsibility; individual counseling, available in 15 states and 28 cities, is the most frequent option. State and big-city governments also offer financial arrangements to employees for elder care purposes. The most common such financial arrangement is a DCAP, offered by 29 states and 32 cities. A DCAP is a flexible spending arrangement that allows employees to exclude from taxable income expenditures for care of dependent children or adults. A few states and cities offer other options such as private long-term care insurance that covers dependents and cash subsidies for services. Although offered by many states and cities, the use of a DCAP for elder care is limited. Experts and employers believe that employed caregivers usually cannot use a DCAP for elder care because elderly dependents often cannot meet two Internal Revenue Service (IRS) tax code requirements--that they spend at least 8 hours a day with and receive more than half their financial support from their caregiver. FUTURE AVAILABILITY AND OTHER FACTORS WILL AFFECT MULTIPLE BENEFITS OF ELDER CARE ------------------------------------------------------------ Letter :7 Government elder care assistance has the potential to benefit employers and caregiving employees by reducing conflicts between work and family responsibilities. Caregivers with access to flexible schedules or elder care information may be better able to provide the informal care generally preferred by the elderly. Many factors, however, will affect the degree to which such benefits are realized, including the extent to which available elder care options are effectively recognized, promoted, and used, as well as future availability of elder care assistance. ELDER CARE ASSISTANCE COULD BENEFIT CAREGIVERS, EMPLOYERS, AND ELDERLY ---------------------------------------------------------- Letter :7.1 Assistance currently available to working caregivers through their government employers has the potential to help them provide care for the elderly at home. Such care helps prevent and postpone institutionalization, allowing the elderly to stay at home as they prefer. According to recent analyses, informal caregiving can reduce the risk of institutionalization for seriously disabled people by almost one-third. A spouse or adult child having the caregiving role for 3 or more years is the lead factor in reducing risk of nursing home admission.\15 At the same time, the burden on informal caregivers, including a lack of social and other support, places their care recipients at high risk for nursing home admission. Moreover, caregiver characteristics, including the quality of their support systems, better predict institutional placement than patient characteristics.\16 Providing elder care options could help governments enhance employee recruitment, retention, and productivity. For example, elder care information can help employees with long-distance caregiving and reduce absences from work that might otherwise be required for travel. In addition, some leave options such as leave without pay may temporarily increase absence from work but allow employees to return to the agency rather than have to resign. This can reduce the cost of additional recruitment and training to replace valuable employees. Government employers promoting all options that facilitate caregiving could therefore enhance workplace performance, support employees, and assist disabled elderly persons. The ultimate impact of elder care assistance, however, depends on the extent that caregivers recognize and use it effectively. -------------------- \15 Deborah Pearlman and William Crown, "Alternative Sources of Social Support and Their Impacts on Institutional Risks," The Gerontologist, Vol. 32, No. 4, (1992), pp. 527-535. \16 Elizabeth Coleric and Linda George, "Predictors of Institutionalization Among Caregivers of Patients with Alzheimer's Disease," Journal of the American Gerontological Society, No. 34, (1986), pp. 493-498; and Stephanie McFall and Baila Miller, "Caregiver Burden and Nursing Home Admission of Frail Elderly Persons," Journal of Gerontology, Vol. 47, No. 2, (1992), pp. S73-79. SOME GROWTH IN ELDER CARE LIKELY ---------------------------------------------------------- Letter :7.2 Some governments plan to expand elder care options or introduce new ones in the next 3 years. Most, however, are uncertain if they will increase elder care options. At the federal level, OPM plans to encourage more federal agencies to establish work/family and elder care programs, provide technical assistance to agencies to sponsor caregiver fairs, and provide information on expanding elder care options available at agencies. DOD expects to evaluate the effectiveness of its elder care initiatives as part of its continuous effort to improve troop readiness. SSA also plans to continue promoting elder care in the agency and using low-cost community resources to help its employees. The USDA's APHIS is sponsoring a demonstration to determine the best way to provide information and referral services by contracting for two different models of services. The IRS and the Environmental Protection Agency also are considering elder care initiatives. OPM encourages many of these efforts through its Work and Family Program Center and through information shared at the Interagency Adult Dependent Care Working Group meetings, which OPM leads. Seven states and 22 cities reported that they would expand or initiate their elder care efforts in the next 3 years. The areas of possible expansion that states reported include education and information and private long-term care insurance to cover dependents. City governments reported possibly expanding flexible schedules, education and information, support groups, and financial arrangements. Eleven states and 18 big cities reported no plans to expand or initiate elder care options. Some government employers may also plan to expand awareness of dependent elder care issues as a result of the federal Family and Medical Leave Act of 1993, which became effective for their employees on August 5, 1993. The act mandates that employers, including federal, state, and local government employers, provide leave without pay to employees to care for immediate family members with serious health conditions--including the elderly. The employee may take up to 12 work weeks of unpaid leave during any 12-month period for this purpose. The Family and Medical Leave Act will offer more schedule flexibility to government employees who did not previously have guaranteed access to leave without pay to care for elderly people.\17 -------------------- \17 States were the first to develop family leave laws, many of which had provisions for leave to care for elderly relatives. These laws covered state government employees, many local government employees, and certain private-sector employees in some states. SEVERAL FACTORS MAY LIMIT EXPANSION, IMPACT OF ASSISTANCE ---------------------------------------------------------- Letter :7.3 While overall access to government elder care assistance will probably increase, several factors will likely affect its growth and impact. In general, government officials do not believe that a great or very great need exists for elder care assistance today; only 8 states and 13 cities reported this level of importance for elder care. We found this to be generally true in the federal government as well. Consequently, most government officials do not see expanding elder care options as a top priority for the next several years. In fact, few governments have made any formal assessments to gauge the need for elder care. OPM stands out as an exception in this regard, having conducted a survey of federal needs in 1992. For the long term, most governments expect elder care to become more important as the population ages, but they have rarely assessed elder care needs or considered how to meet those needs. Additionally, many government officials have concerns about the perceived costs of offering elder care assistance. Many elder care options, however, such as publicizing the AOA's toll-free Eldercare Locator Number or promoting flexible schedules, are generally inexpensive. Nonetheless, cost concerns are the most frequently cited disincentives to initiating or expanding elder care assistance. Less common reasons for not expanding access to elder care assistance include lack of assessment of elder care need, difficulty in scheduling workers' hours, private long-term care insurance issues, and employees' and managers' lack of awareness about elder care as a work issue. CONCLUSIONS ------------------------------------------------------------ Letter :8 Federal, state, and local governments have an opportunity to offer enhanced elder care assistance to their employees, often at little cost. This assistance can benefit caregivers by easing work and family conflicts; the elderly, by maintaining their independence at home; and governments, by improving employee recruitment, retention, and productivity. OPM has begun a campaign to promote elder care programs among federal agencies. However, it is too early to evaluate the campaign's effectiveness in developing elder care in other federal agencies. When agencies develop elder care programs, their success will depend on how well the programs are implemented and the degree to which employees use them. Informal caregivers currently play a major role in caring for the elderly in their homes and communities. The prevalence and types of elder care policies, programs, and practices that we found in federal, state, and big-city governments have the potential to strengthen this essential informal care network. Employers that actively promote those options that caregivers find useful--especially schedule flexibility and information about elder care services--can strengthen the capacity of employed caregivers to balance their work and family roles, enabling them to continue providing valuable care. ---------------------------------------------------------- Letter :8.1 We have discussed a draft of this report with officials from OPM and the Department of Health and Human Services, and they generally agreed with our findings. We are sending copies of the report to the Director of the Office of Personnel Management, to the Secretary of Health and Human Services, and to the state and city authorities who responded to our survey. Should you or your staff have any questions concerning this report, please call me on (202) 512-7215. Other major contributors to this report are listed in appendix III. Sincerely yours, Jane L. Ross Associate Director, Income Security Issues OBJECTIVES, SCOPE, AND METHODOLOGY =========================================================== Appendix I This study is the first nationwide review of government elder care practices focusing on all levels of government. Our objectives were to determine (1) the extent and nature of government practices facilitating elder care, (2) planned changes in these practices, and (3) their potential to further support informal caregivers. For this report, we defined elder care as an employer-sponsored practice, policy, or program offered by federal, state, or local governments that directly or indirectly helps their employees or retirees care for elderly relatives and friends. To meet our objectives, we reviewed the literature on elder care and informal caregiving, interviewed experts, and visited federal, state, and local government agencies. We reviewed other information from federal, state, and local governments and conducted a mail survey of the 50 states and of the 100 cities with the largest work forces to get information on the options their employees can use in caring for elderly people. FEDERAL GOVERNMENT INFORMATION --------------------------------------------------------- Appendix I:1 At the federal level, we collected information and documents from the Office of Personnel Management's Work and Family Program Center and from other federal agencies to determine what schedule flexibility options federal employees are permitted to use to facilitate caregiving to the elderly and what elder care information initiatives federal agencies offer. We also visited or collected and reviewed additional information and documents from individual agencies that either have or are planning elder care initiatives including the Department of Defense, the Department of Agriculture's Animal Plant and Health Inspection Services, the Social Security Administration, the Environmental Protection Agency, and the Internal Revenue Service. In addition, we regularly attended the OPM-sponsored federal Interagency Adult Dependent Care Working Group, which brings together a wide range of federal agencies to discuss elder care issues approximately every 2 months. On the basis of these contacts and our briefing of OPM and Department of Health and Human Services officials at the conclusion of our work, we believe that this work covers the major elder care options available to federal employees. The extent to which these options are actually available to all employees, however, varies by agency and by unit. We are conducting a separate study to examine the extent to which alternative work schedules are actually available to federal employees for elder care and other purposes. STATE AND LOCAL GOVERNMENT INFORMATION --------------------------------------------------------- Appendix I:2 We used several different methods to collect information on state and local government elder care options. We visited the localities of Montgomery County, Maryland; Wake and Durham Counties, North Carolina; Baltimore, Maryland; Richmond, Virginia; Durham, North Carolina; New York City; and the state government of North Carolina. We collected information on employee options that might have elder care applications from 21 state personnel offices before we conducted our 50-state survey. We requested information from organizations such as the National Association of Counties, the National League of Cities, the National Governor's Association, the U.S. Department of Education, and the College and University Personnel Association. In addition, we mailed surveys to the 50 states and the 100 cities with the largest work forces. Our nationwide study of state and local elder care options is more comprehensive than any other study we found. Our work, however, does not include comprehensive information on county governments, school districts, special districts, townships, and smaller municipalities, which comprised about 8.7 million employees in 1987. The level of overall government employment grew to 18 million in 1992. Based on the information collected for these local governments, however, we have no reason to believe that these localities have more elder care options available to their employees than those governments for which we have more comprehensive information. GAO'S SURVEY METHODOLOGY FOR STATES AND LARGE CITIES --------------------------------------------------------- Appendix I:3 QUESTIONNAIRE DEVELOPMENT AND PRETESTING ------------------------------------------------------- Appendix I:3.1 In conjunction with a GAO study of elder care in the private sector, we designed a questionnaire to obtain information about current and future employer practices, policies, and programs that directly or indirectly help state and big-city government employees or retirees care for elderly relatives or friends. We discussed development of the questionnaire with academic experts at the University of California - Berkeley, the University of Southern California, and Portland State University. We also discussed it with representatives from organizations active in elder care research and consulting, including the New York Business Group on Health, the Washington Business Group on Health, the Families and Work Institute, the Creedon Group, and North Carolina Equity. In addition, some of these experts reviewed draft copies of the questionnaire. We pretested our questionnaire with officials at three state governments and three city governments. Using the pretest results, we reviewed the questionnaire to try to ensure that (1) respondents could easily provide the information requested and (2) all questions were relevant, clear, and free from bias. Our survey data show the general availability of various schedule flexibility and elder care options to state and city employees. However, we did not determine if all employees in those governments have access to these options. The actual availability of these options varies by and within departments or agencies. In addition, we did not independently verify the accuracy of governments' responses. Nor did we assess the quality of the elder care assistance they offered or the extent of its use by employees. SAMPLE DEVELOPMENT AND RESPONSE RATE ------------------------------------------------------- Appendix I:3.2 We surveyed all 50 states and the 100 cities with the largest work forces as determined by data from The 1987 Census of Governments (Washington, D.C., Department of Commerce, Bureau of the Census, Jan. 1991) and City Employment: 1990 (Washington, D.C., Department of Commerce, Bureau of the Census, Sept. 1991). In December 1992, we mailed the questionnaire to the states and cities selected. We sent a postcard follow-up to all nonrespondents 4 weeks later; additional reminders were sent in late January 1993. We sent a third reminder to the cities in March. In April, we called all those who had not responded to encourage their participation. Forty-seven of the 50 states responded. Eighty of the 100 large cities shown in table I.1 responded. Table I.1 GAO Elder Care Survey: 100 Cities With Largest Work Forces Number of Number of Number of Number of City employees City employees City employees City employees ------------------------ ------------------ ----------------------- ------------------ ------------------------ ------------------ ----------------------- ------------------ New York, New York 416,799 Cleveland, Ohio 9,453 Baton Rouge, Louisiana 5,291 Tampa, Florida 3,991 Washington, D.C. 48,338 Honolulu, Hawaii 9,284 Portsmouth, Virginia 5,286 Huntsville, Alabama 3,854 Los Angeles, California 45,566 San Diego, California 9,097 Colorado Springs, 5,285 Birmingham, Alabama 3,814 Colorado Chicago, Illinois 41,282 Milwaukee, Wisconsin 9,003 Newark, New Jersey 5,056 Cambridge, 3,770 Massachusetts Philadelphia, 33,042 Rochester, New York 8,966 Tucson, Arizona 4,979 Sacramento, California 3,636 Pennsylvania Baltimore, Maryland 31,645 Jersey City, New Jersey 8,507 Portland, Oregon 4,976 St. Paul, Minnesota 3,491 San Francisco, 23,338 Anchorage, Alaska 8,483 Paterson, New Jersey 4,917 Quincy, Massachusetts 3,439 California Memphis, Tennessee 21,663 St. Louis City, 8,311 Hampton, Virginia 4,882 Lincoln, Nebraska 3,378 Missouri Boston, Massachusetts 21,167 Atlanta, Georgia 7,891 Elizabeth, New Jersey 4,781 Jackson, Mississippi 3,265 Detroit, Michigan 20,044 Columbus, Ohio 7,026 Yonkers, New York 4,719 Tacoma, Washington 3,252 Houston, Texas 19,381 Hartford, Connecticut 6,873 New Haven, Connecticut 4,572 Anaheim, California 3,251 Nashville-Davidson, 17,880 Albuquerque, New Mexico 6,845 Alexandria, Virginia 4,501 Stamford, Connecticut 3,244 Tennessee Dallas, Texas 14,912 Syracuse, New York 6,777 Flint, Michigan 4,453 Amarillo, Taxas 3,191 San Antonio, Texas 12,953 Springfield, Illinois 6,727 Charlotte, North 4,386 St. Petersburg, Florida 3,184 Carolina Denver, Colorado 12,580 Worcester, 6,473 El Paso, Texas 4,336 Toledo, Ohio 3,151 Massachusetts Indianapolis, Indiana 12,461 Cincinnati, Ohio 6,389 Miami, Florida 4,323 Fall River, 3,150 Massachusetts Buffalo, New York 11,991 Newport News, Virginia 6,236 Orlando, Florida 4,318 Waterbury, Connecticut 3,122 Virginia Beach, Virginia 11,865 Pittsburgh, 6,176 Louisville, Kentucky 4,258 New Bedford, 3,115 Pennsylvania Massachusetts Norfolk, Virginia 11,146 Kansas City, Missouri 6,149 Roanoke, Virginia 4,242 Lexington-Fayette, 3,053 Kentucky Seattle, Washington 10,589 Minneapolis, Minnesota 6,064 Tulsa, Oklahoma 4,240 Omaha, Nebraska 3,043 Phoenix, Arizona 10,455 San Jose, California 6,054 Oakland, California 4,178 Portland, Maine 2,981 Austin, Texas 10,333 Chattanooga, Tennessee 5,650 Bridgeport, Connecticut 4,147 Wichita, Kansas 2,975 Richmond, Virginia 9,680 Chesapeake, Virginia 5,633 Trenton, New Jersey 4,041 Greensboro, North 2,935 Carolina New Orleans, Louisiana 9,814 Fort Worth, Texas 5,531 Oklahoma City, Oklahoma 4,039 Manchester, New 2,935 Hampshire Jacksonville, Florida 9,482 Long Beach, California 5,326 Providence, Rhode Island 3,999 Dayton, Ohio 2,934 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Source: 1987 Census of Governments, Department of Commerce, Bureau of the Census (Washington, D.C.: 1991), pp. 78-151, and City Employment: 1990, (Washington, D.C.: 1991), pp. 6-14. SURVEY INSTRUMENTS ========================================================== Appendix II This appendix presents our survey instruments and a summary of the responses. Forty-seven of the 50 states responded to our state elder care survey, and 80 of the 100 cities with the largest work forces responded to our city survey. The number of responses per question, however, varies because all respondents did not answer all questions. (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) (See figure in printed edition.) 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MAJOR CONTRIBUTORS TO THIS REPORT ========================================================= Appendix III HEALTH, EDUCATION, AND HUMAN SERVICES DIVISION, WASHINGTON, D.C. Cynthia A. Bascetta, Assistant Director, (202) 512-7207 Wayne Dow, Assistant Director James C. Musselwhite, Jr., Senior Social Science Analyst Luann Moy, Senior Social Science Analyst Benjamin C. Ross, Evaluator-in-Charge Edward J. Murphy, Computer Science Analyst OFFICE OF GENERAL COUNSEL George H. Bogart, Attorney-Advisor DETROIT REGIONAL OFFICE Sara Koerber Galantowicz, Evaluator