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California and Ohio Advancing Equity for Older Adults and Family Caregivers

Executive Summary

State administrators use state plans on aging and master plans on aging to inform policy to improve the lives of older adults and their family caregivers. These plans provide frameworks for states to develop aging-related policy, form targeted goals, and track outcomes both in the short and long term. Based on a NASHP review of all states’ state plans on aging, two states — California and Ohio — are at the forefront of incorporating equity into infrastructure, data collection, and collaboration to support policy for older adults and family caregivers within their states. The strategies have the following commonalities:  

  • The goals, outcomes, and strategies have integrated principles of equity and inclusivity, with a special focus on addressing the needs and priorities of underserved populations and communities.
  • The state plans were grounded in evidence and data and informed by collaborations and multiple voices from different stakeholders.
  • The state plans are dynamic documents that continue to evolve, influenced by a set of benchmarks and based on the needs of the older adult population in California and Ohio.

Introduction

To address the unique needs and challenges faced by a rapidly growing older population and their caregivers, many states have proactively used Older Americans Act-required State Plans on Aging as roadmaps for guiding and coordinating in-state efforts. These efforts can reach across various sectors, including health care, social services, housing, and transportation, to promote healthy aging and improve the quality of life of older populations. This brief provides an overview of how California and Ohio engaged multiple collaborators, partnered and collaborated with public and private entities, used data and evidence, and integrated equity and inclusivity to identify key priorities and set specific goals and outcomes to advance healthy aging for all and support for caregiving through 2030 and beyond.

California’s Master Plan for Aging

By 2030, California’s population of adults 60 and older is estimated to reach 10.8 million, constituting a quarter of the state’s total population. To prepare for this significant demographic shift, Governor Gavin Newsom called for the development of a Master Plan for Aging in 2019 for state government, local government, the private sector, a range of organizations, and philanthropy to support Californians as they age.

Launched in January 2021, the Master Plan presents a 10-year blueprint that outlines five Bold Goals and 23 strategies that mobilize collective action and shared implementation. The Master Plan’s development included more than a year of robust public engagement, community outreach, and local roundtables. The Master Plan also aligns with some of the governor’s key initiatives, such as the “California for ALL” vision and the Task Force on Alzheimer’s Prevention and Preparedness. This brief focuses on two of the state’s Bold Goals — “Inclusion and Equity, Not Isolation” and “Caregiving That Works” — to highlight California’s commitment to and developments in advancing inclusion and equity and supporting family caregiving.

California's Bold Goals on Advancing Inclusion and Equity and Supporting Family Caregiving

“We wanted to emulate (the National Strategy to Support Family Caregivers) at the state level and really see how our Area Agencies on Aging and Caregiver Resource Centers can both reach their optimal potential and ensure that they’re reaching deep into communities.”
- Susan DeMarois, director of California Department of Aging

California will pursue inclusion and equity, and prevent isolation, through six strategies:

  1. Inclusion and Equity in Aging
  2. Closing the Digital Divide
  3. Opportunities to Work
  4. Opportunities to Volunteer and Engage Across Generations
  5. Protection from Abuse, Neglect, and Exploitation
  6. California Leadership in Aging”

Source: California Master Plan for Aging

The state has made progress on advancing inclusion and equity and supporting family caregiving, as reported by the Master Plan’s Annual Report in January 2023.

California’s Master Plan recognized that social connection is an essential element of health. However, nearly 1 in 4 older adult Californians are socially isolated. Quarantine requirements of the COVID-19 pandemic worsened this isolation. As an effort to address social isolation among California’s older adults and caregivers, the state has:

  • Invested in expanding its broadband infrastructure and internet availability, especially in under-resourced communities
  • Prioritized the distribution of iPads, coupled with digital literacy training for older adults, including those who are served by the following agencies: 33 Area Agencies on Aging, Community-Based Adult Services program, Multipurpose Senior Services Program, and the Program of All-Inclusive Care for the Elderly
  • Continued to expand the Aging and Disability Resource Connection network statewide to assist individuals in accessing a range of information and supportive services that include referrals, counseling, and care transitions
  • Developed collaboration and partnerships among the California Department of Aging, California Department of Developmental Services, and Department of Rehabilitation to bridge the divide between aging and disability, as well as the California State Library to help older adults become digitally connected with the support of Digital Navigator services
  • Expanded opportunities for volunteer engagement, such as investing to expand foster grandparent and senior companion volunteer programs as well as other intergenerational volunteer programs

A key element of the state’s Master Plan for Aging is its accompanying Data Dashboard for Aging, implemented to track and evaluate outcomes of the Master Plan’s goals and strategies. The Dashboard was designed to assist California state leaders across different sectors implement policies that advance services and supports for older adults. For example, the Dashboard uses California Health Interview Survey data to monitor and track progress related to achieving “Caregiving that Works.”

In California, nearly 5 million family caregivers assist their loved ones in their homes and communities, usually with little support or training. There is a shortage of paid direct care workers, which compounds the challenges experienced by family caregivers, especially women caregivers from communities that include Black and Indigenous people and people of color. To address these caregiving needs, the California Master Plan outlined strategies under three categories: Family & Friends Caregiving Support, Good Caregiving Jobs Creation, and Virtual Care Expansion. Two landmark pieces of legislation were enacted in 2022 that increased family and disability leave among lower-wage workers and allowed family and friend caregivers to take paid sick or family leave. Also in 2022, the California Department of Social Services’ In-Home Supportive Services (IHSS) Career Pathways program launched its online and in-person classes for IHSS providers, many of whom are paid family members. The California Department of Aging has launched CalGrows to train and support the home and community-based services workforce, including unpaid family and friend caregivers.

In September 2022, the governor issued an executive order to establish the state’s first Racial Equity Commission. The commission directed state agencies and departments to embed equity analysis and considerations in their policies and practices.

A new initiative focused on developing a caregiver equity roadmap will further support California’s goal to be a lead state partner in the National Strategy to Support Family Caregivers. The California Department of Aging is working collaboratively with the 11 California Caregiver Resource Centers as well as the University of California at Davis to develop the caregiver equity roadmap to improve equity and quality of services and supports for family caregivers across the state. This investment will also examine how California’s efforts align with the 2022 National Strategy to Support Family Caregivers.

Ohio's State Action Plan for Aging

“This plan masterfully reframes how we view aging and the healthy aging process. It highlights the link between social determinants of health and longevity, prompting us to rethink our approaches to policymaking, service delivery, and investment priorities.”
- Ursel McElroy, director of Ohio Department of Aging

Ohio has also been a leader in advancing population health equity and inclusion, healthy aging, and family caregiving. Ohio’s current 60 years and older population is expected to increase by 33.4 percent and will constitute a quarter of the state’s population by 2030. This dramatic demographic shift, along with other key findings of the state’s Summary Assessment of Older Ohioans, informed the development of the state’s 2020–2022 Strategic Action Plan on Aging (SAPA). Key findings of the Summary Assessment highlight inequities preventing Ohioans, especially older Ohioans, from living a long and full life. For example, life expectancy at birth ranges from a low of 60 years to a high of 89 years among Ohioans, depending on where a person lives and influenced by social determinants of health.

The state’s 2023–2026 State Plan on Aging provides a comprehensive roadmap to address challenges the state identified in the Summary Assessment, with the overarching goal of improving the overall health and well-being of older Ohioans — especially those with greatest economic or social needs. The State Plan was developed through multi-sector collaborations, data collection using state and national secondary data sources, key informant interviews, collaborator engagement initiatives, a public hearing, and forums.

The State Plan outlines four outcomes associated with its overarching goal: (1) increased life expectancy, (2) reduced premature death, (3) improved health status, and (4) reduced elder abuse and neglect. The SAPA’s objectives and strategies have been culturally and linguistically adapted to meet the needs of priority populations. These priority populations were identified through data analysis as being most at risk for poor outcomes.

The State Plan also identified six priority areas undergirded by the principles of elder justice and equity and guided by federal priorities such as those in the National Family Caregiver Support Program (NFCSP): community conditions, healthy living, access to care, social connectedness, and population health, as well as preserving independence. These priority areas, including access to care and connectedness, overlap with the services and supports that the NFCSP, a federal grant program, funds to support family caregivers of older adults. The NFCSP’s priority areas include information, assistance in accessing services, caregiver counseling, support groups, and training, respite, and other supplemental services.

In each of these priority areas, the SAPA outlined outcomes and objectives to monitor progress and measure success. The state developed an Implementation Toolkit for public and private partners and collaborators. The toolkit provides guidance, best practices, tools, and resources needed to implement the SAPA.

Ohio’s Priorities to Address Disparities and Inclusivity and Support Caregiving

Ohio’s State Plan identified addressing disparities and inequities as a primary goal. This priority is highlighted in Ohio’s effort to support family caregiving by setting an outcome and objectives to “improve home care workforce capacity and caregiver supports.”

Ohio State Plan Outcome 12: Improve Home Care Workforce Capacity and Caregiver Supports

Objective 12.1: Increase the number of personal care and home health aides, per 1,000 adults, age 65 and older, with a disability from 149 (2018) to 224 (2029). (Data source: ACS via America’s Health Rankings).

Priority populations: Older Ohioans: who live alone | who live in rural or Appalachian regions | with low income | who are people of color.

Source: 2023–2026 Ohio State Plan on Aging

As a result, Ohio’s fiscal year 2024–2025 state budget includes $40 million for healthy aging grants. The State Plan also identified several evidence-based strategies to meet the benchmark established to improve home care workforce capacity and caregiving supports, including providing respite care, financial supports and investments in the direct care workforce, and caregiver support for those who have Alzheimer’s disease and dementia. The state is also developing a proposal to continue paying legally responsible adults of Medicaid beneficiaries as direct care workers, which was allowed during the COVID-19 public health emergency.

Lessons Learned

California and Ohio have emerged as frontrunners in advancing healthy aging and supporting family caregiving through comprehensive state plans and resources to implement the plans. These state plans have been carefully crafted with specific goals, priorities, and measurable outcomes, and informed by data, stakeholder engagement, and multi-sector collaborations. Key lessons learned in developing the state plans and master plan for aging include:

  • Emphasizing equity and reducing disparities to support their states’ populations across multiple state agencies
  • Acknowledging the disparities and challenges faced by communities of color and rural communities, which have been further highlighted by the COVID-19 pandemic, and usage of data to track disparities and success in addressing gaps
  • Providing a comprehensive set of tools and resources to empower individuals, groups, and communities to collaborate and implement the strategies

These states have used these approaches to support a range of organizations and networks to work together to realize their vision of supporting older adults and family caregivers through 2030 and beyond. Using these practices, states can incorporate support of different populations within their implementation of their state plans on aging, and their state aging and family caregiving policy activity, to support healthy aging for all older adults, people with physical disabilities, and their family caregivers.

About the Lead Author

Emerson Ea is clinical professor and associate dean for clinical and adjunct faculty affairs at New York University Rory Meyers College of Nursing. He is a 2022–2023 Health and Aging Policy Fellow working with the Administration for Community Living. He is co-investigator for the Community Engagement Core of the Rutgers-NYU NIH P50 Center for Asian Health Promotion and Equity and chair of Kalusugan Coalition, a community-based organization that aims to enhance the health and well-being of Filipino Americans in the New York/New Jersey area.

Acknowledgements

This project was part of Emerson Ea’s work as a 2022–2023 Health and Aging Policy Fellow with the Administration for Community Living. He wishes to thank the support of Greg Link, Director, Office of Supportive and Caregiver Services, Administration for Community Living; the National Academy for State Health Policy; Health and Aging Policy Fellowship Program; and The John A. Hartford Foundation. The brief’s authors also want to thank state officials from California and Ohio for providing input on this brief.

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