Do We Have a "Disease Industry" Instead of a Health Care System?

Saturday, July 31st, 2010 - 12:16
Saturday, July 31, 2010 - 11:41
Stephen Schimpff, the retired CEO of the University of Maryland Medical Center, writes in an interesting blog post that we will never gain control of rising health costs unless our system changes from one that reacts to diseases to one that focuses on health and prevention. He calls this a "disease industry" instead of a health care system. Read his post here: The post reiterates a familiar theme that the health care system is driven by payments for a greater and greater number of procedures. Schimpff has two proposals to stem the tide:

Orszag's Departure Reignites Controversy Over Health Reform's Medicare Cost Cutting Panel

Thursday, July 29th, 2010 - 15:05
Thursday, July 29, 2010 - 14:27
Today's Kaiser Health news report ( summarizes articles about the departure of Peter Orszag as head of the Office of Management and Budget and a new effort by Republicans to repeal an independent Medicare cost-cutting panel that became a part of health reform.

Health Reform Message Still Not Getting to Seniors?

Tuesday, July 27th, 2010 - 11:17
Tuesday, July 27, 2010 - 10:20
Poll results released by the National Council on Aging show that most Americans 65 and older cannot correctly identify the major changes to be brought about by health reform.

Obama Uses Recess Appointment to Put Berwick at Head of CMS

Wednesday, July 7th, 2010 - 10:14
Wednesday, July 7, 2010 - 09:47
The White House communications director has announced in a blog post that President Obama will use a recess appointment to place Don Berwick at the helm of the Centers for Medicare and Medicaid Services. The GOP would certainly have put up a fight against Berwick, and the recess appointment tactic buys the administration some time to have Berwick make an impact at CMS before having to be confirmed by the Senate by the end of the next session of Congress.

CBO Shines Spotlight on Health Reform and the Debt

Thursday, July 1st, 2010 - 10:27
Thursday, July 1, 2010 - 10:07
The nonpartisan Congressional Budget Office’s recent long-term debt projections shine a harsh light back on the inescapable truth: the nation’s long-term debt situation is getting worse, the ballooning costs of government-funded health programs lie at the core, and the recently passed health reform bill isn’t making much of a dent in the problem. This unsurprising finding is, of course, setting up a nasty exchange of July

The "Doc Fix" is the Fix -- For Now

Friday, June 25th, 2010 - 8:02
Friday, June 25, 2010 - 07:48
The House on Thursday passed a bill, already approved by the Senate, that would avoid a 21 percent cut in the Medicare reimbursement rate for doctors for six months. Read more about the legislation in a New York Times story here.

"The Doc Fix" and Health Care Reform

Sunday, June 13th, 2010 - 12:30
Sunday, June 13, 2010 - 11:37
This week, the U.S. Senate will continue debating, and possibly vote, on a bill that has become a Christmas tree of tax provisions, unemployment benefit extensions, and the latest installment of a perennial debate over the Medicare "Doc Fix." Without action by the Senate, doctors who treat Medicare patients will see a 21-percent cut in their reimbursement rates.

Staffing the Health Care Overhaul

Tuesday, June 1st, 2010 - 7:55
Tuesday, June 1, 2010 - 07:39
The health reform law requires the US Department of Health and Human Services to go well beyond the important job of managing Medicare, Medicaid, and other government-sponsored health programs. The law calls upon HHS to set up a new high-risk pool, review insurance company rate increases, and provide assistance to states setting up Insurance Exchanges where people can buy coverage and receive federal subsidies.

Tom Allen: Improving Federal Financial Reporting

Tuesday, April 7th, 2009 - 10:40
Posted by: 
Annually, some $2.7 trillion of taxpayer money flows through the accounts of the U.S. federal government. Article 1 Section 9 of the U.S.

Josefina Carbonell interview

Friday, September 22nd, 2006 - 20:00
"Our mission is to provide services and support, and empower people to live independently with dignity in their older age. We're the largest provider of home and community based care in this country."
Radio show date: 
Sat, 09/23/2006
Intro text: 
In this interview, Carbonell discusses: the Mission and history of the Administration on Aging (AoA); Reauthorization and modernization of the Older Americans Act; Medicare prescription benefits program; Aging and Disability Resource Centers; Measuring...
In this interview, Carbonell discusses: the Mission and history of the Administration on Aging (AoA); Reauthorization and modernization of the Older Americans Act; Medicare prescription benefits program; Aging and Disability Resource Centers; Measuring AoA program results; and the Importance of collaboration and partnerships. Missions and Programs
Magazine profile: 
Complete transcript: 

Originally Broadcast Saturday, September 23, 2006

Arlington, Virginia

Mr. Morales: Good morning, and welcome to The Business of Government Hour. I'm Albert Morales, your host and managing partner of The IBM Center for The Business of Government. We created the Center in 1998 to encourage discussion and research into new approaches to improving government effectiveness. You can find out more about the center by visiting us on the web at

The Business of Government Radio Hour features a conversation about management with a government executive who is changing the way government does business. Our special guest this morning is Josefina Carbonell, Assistant Secretary for Aging at the Department of Health and Human Services. Good morning Josefina.

Ms. Carbonell: Thank you. Good morning to you all.

Mr. Morales: Also joining us in our conversation is Brenda Kunkel, managing consultant at IBM. Good morning Brenda.

Ms. Kunkel: Good morning.

Mr. Morales: Josefina, you have so much experience and passion for older adults. How did you get interested in this field of aging, and can you tell us how you got started on your career path?

Ms. Carbonell: Well, first of all, I started as a volunteer. Part of my family efforts have always been to volunteer and contribute to the community. And I started as a United Way volunteer many years ago, and with the Red Cross, in filling some of the needs, basically in emergency response, in '72, to an earthquake in South America.

Then they were developing all the Hispanic capacity building for community support and volunteering efforts, and I was asked to join the United Way in their efforts for recruitment of new volunteers. And of course then that transferred into really looking at community resources and public service mostly. And they developed a capacity to build new programs around the same time that the Older Americans Act was being created nationally as a pilot program. One of the first pilot programs for senior centers and Older Americans Act occurred in Miami, Florida. And I was asked to join that planning effort through United Way of Dade County at that time. That led, eventually, to my engagement in the first Hispanic aging organization in the country to be launched, at the end of '72, and then developed into a larger, mostly based in grass roots, and that led to a whole array of areas, both in health care and long-term care in the community.

Mr. Morales: Outstanding. Before serving at the Administration of Aging, you led an aging community services organization in Florida. How has your leadership style changed as you've taken the various positions you have in your career?

Ms. Carbonell: You know, like Secretary Leavitt likes to say, it depends on what seat you're sitting in, your role transcends that specific seat that you occupy. My perspective, the role that I come from is the community role. I am historically the first community provider, or business provider in the aging seat, ever. Mostly policy people have occupied university research -- persons. So I was the unlikely, but the right fit in that role as a leader. It was very clear to me as I came onboard that -- and having worked in the specific programs that the Administration on Aging administers throughout the states and local communities across this country, and I had done that work for over 30 years in the community.

It clearly gave me a very solid base on what our consumers were, what the role of the leadership role, and the functions of the U.S. administration was in a different level and a different perspective on how policy would drive, would impact the ability of providers in the community level, to be able to serve the ever-growing aging populations. So, you know, when I got into the role we realized that the role of the Administration on Aging needed really a quantum leap in the kind of modernization and getting up to speed to the rest of the health care transformation that was happening just around us, just in the immediacy of HHS.

I think the leadership of Secretary Tommy Thompson, which brought in incredible leadership, not only in welfare reform, but in aging services. He was the first one to develop the whole welfare reform change agent in the state models. He was also the first to develop the transformation of long-term care from institutional base to common community based in his own state.

So I was very attracted and very pleased and honored to serve under his tenure, and now under tenure of another very exciting governor, former governor, Mike Leavitt, both governors that had been chief operating officers for their own states. And as a chief operating officer from the community level in these programs, they gave me a distinct role and opportunity to shift, use my best talents, and modernize my talents to implement national programs and national policies, and transform really long-term care.

Mr. Morales: Excellent.

Ms. Kunkel: To clearly have an understanding of the impact of the policies that your administration is implementing on the community services, can you tell us a little bit about the mission and history of the Administration on Aging?

Ms. Carbonell: Well the Administration on Aging was created in 1965 by the Congress. The original mission -- you know, it's one of the unique pieces of legislation that I've seen. Our unique mission is, number one, to really develop the capacity to make sure that we provide services and supports and empower people to live independently and with dignity in their older age. But the second most important part of our mission is, we have a distinct charge to keep people out of nursing homes by allowing people to live independently.

So it has been a very -- in the kind of transformational change that I think that we're going through in health care reform in this country, and entitlement reform, and other kinds of challenges that we have for our older population, has given us a very important role and a very unique role for us to play within the changes. It developed a whole network, as the years progressed. It was born at the same time that Medicaid was born and Medicare, so it's 40 years old, 41 this year. It is a whole network that was developed locally based up, the other way around. So the capacity was built, unlike other agencies, in the department where you have -- you go all the way down to maybe just the regional level in the structure of the administration.

The greatest asset within our organization is that the bulk of all of our dollars are contracted out to the private sector and the local communities, the state units on aging and then the area agencies on aging, which sort of serve as our local planning and service areas, most of them privatized, run either by non-profits or also by public entities, counties, et cetera. And then you have over 29,000 providers, most of them in the private sector providers, either for profit or not-for-profit faith-based communities. And then you also have over 230 tribes that form part of the overall network that we contract with tribes across the country, so it has a tribal program alongside the states' programs.

So it really gave us the opportunity to have a system in place to be consumer centered. Most importantly it was locally designed. It means the planning efforts come from the local level up to the state plans, and then to the local, to the federal government, we set standards and basically monitor and improve the efficiency. But as the years progressed, we went from an agency that basically does grants, to positioning our agency and the services that we provide in a better role -- to take a central role in the transformation of health, and most importantly long-term care services in this country.

Ms. Kunkel: So for listeners who may not be familiar with the Administration on Aging, can you talk more about the current role of the organization?

Ms. Carbonell: The role of the organization -- we're the largest provider of home- and community-based care in this country. You have not only the meals-on-wheels programs, that -- one of the greatest achievements in volunteerism in this country has been led under the meals-on-wheels program and the nutrition services. But we are also -- home care, we run the adult daycare centers. We contract for services that support family caregivers, which was one of my responsibilities coming in, implementing the new family caregivers support program, knowing that family caregivers in this country are providing the bulk of the care for older people and disabled people in this country.

So our mainstay of long-term care and -- as our family caregivers. Also the role of prevention and health care promotion, and disease prevention in simple ways that we can implement it with simple tools so people can remain independent in their own communities. But most importantly also, being able to focus more on consumers versus services or service silos.

Ms. Kunkel: And what are your current priorities?

Ms. Carbonell: The current priorities are threefold: Ensure that we provide accurate and good access and information for people to access an integrated health and long-term care system. Less confusing, easily accessible, reduce duplication. We want to maintain -- give people the ability to maintain themselves healthier in their communities. And then we want to support family caregivers, to help their elderly remain at home, independent and living in their communities.

We also are focusing our efforts on promoting and preventing elder abuse, financial exploitation in areas of fraud and abuse that are perpetrating many of our vulnerable populations. We want to make sure that we do it in the best effective fashion that we maximize our taxpayer dollars. But most importantly that we assist people in using their own resources, empowering people using their own resources better, so they may age in place, and plan ahead much better for their long-term care needs.

Mr. Morales: How is the Administration on Aging supporting new Medicare and Medicaid programs for seniors? We will ask Assistant Secretary for Aging at HHS, Josefina Carbonell to share with us when the conversation about management continues on The Business of Government Hour.


Mr. Morales: Welcome back to The Business of Government Hour. I'm your host Albert Morales, and this morning's conversation is with Assistant Secretary for Aging at HHS, Josefina Carbonell. Also joining us in our conversation is Brenda Kunkel.

Josefina, we understand that the Older Americans Act is currently being reauthorized and modernized. How will this change aging services?

Ms. Carbonell: Well, I think that first before talking about reauthorization I want to put this in some kind of context as it relates to our current long-term care system. Currently, long-term care system is really institutionally biased. It really focuses on institutional care and chronic diseases, although, you know, the incidence of chronic disease is really on the way to decreasing for boomers. People are living longer than before. The reality is that the inevitable condition of aging would bring chronic condition is one of the biggest challenges in chronic care, one of the biggest challenges that we have for the demographics of aging in this country.

I think that the goal to keep people, and to assist people to live longer, is to assist them to take care of their chronic conditions or to manage their chronic conditions better. So our goal to modernize long-term care, which is basically the centerpiece of the reauthorization of the Older Americans Act, goes along with the reform and the transformation and the modernization that has occurred with Medicare, and it is simultaneous to the changes that we are trying to implement in Medicaid reform.

So again it will be a parallel movement to ensure that we transform the long-term care system from an institutional medical model only system to a more integrated model where we will have not only the supports but focusing instead of just on services or caretaking role to more of empowering people and assisting the people to plan ahead, and a more consumer-directed option of putting the consumer front and center.

So again, number one, the role of the reauthorization and our reform and transformation is really targeted at the capacity of our nation to respond to the aging of the baby boom generations, and then of course future generations as we look at that. And then of course to be able to reflect those changes, we need to really transform the act from an institutional based program, which obviously, unfortunately, it's financially unsustainable. Mostly due to the unintended consequence that Medicaid has become the primary payer for long-term services in this country. Yet it only covers 12 percent of the population. But the reality, it's unsustainable. And, it's really based on an old demographic model. We're living longer, so therefore that paradigm has changed and the goals should change alongside with it. Currently it's very complex, very fragmented, and difficult for people to understand, and most importantly, again it's heavily based on institutional care when we know that people want to remain in their communities, and in their homes independently as more if possible.

So there's three key approaches to that we're using, or three key principles that will drive the reauthorization proposal, which is called Choices for Independence. Again, we're shifting from institutional care to consumer-based and community-based care. Number one, most importantly is that we will empower individuals to make informed decisions about their care options, and to help them access the care that they need. And that includes not only dealing with the older people right now, because the act allows us to reach a younger population than retirement age. It gives us the opportunity to reach people at younger age or at middle age, there's still time to make some planning, changes in your -- both your financial security, but also in your long-term care planning goals to be able to meet the needs in the future.

We're also making sure that to enable to turn the tide around, both on spend-down of people to Medicaid or on a direct link between hospitalizations and nursing home. It's really provide and target services to those at highest risk of nursing home placement before they become eligible for Medicaid, but most importantly before they become disabled and on a down track to more dependence and spend-down.

And then thirdly we're trying to enable people to make behavioral changes that really reduce the risk of disease and disability as they age. We know that our older population and our seniors are much healthier than their former cohorts were. We want to keep that.

We want to be able to also deploy the best science and the best evidence-based prevention science that we have, that we invest through our institutes of health at the department, and our research and science institutions across this country, and the medical technology and health technology to be able to keep people at home and empower them with the right tools that they can simply be able to assist themselves. And then really target public dollars at those at a highest risk, and again at those that most need it.

Mr. Morales: Yeah, the theme of empowerment certainly comes through very clearly. How does the Administration on Aging support seniors on Medicare policies and programs?

Ms. Carbonell: One of the things that I found out early on is obviously their partnerships are so crucial to an agency such as Administration on Aging, because obviously aging crosses all the sectors that we work with; we can't do this alone. So one of the agencies that we have been closest to in partnering since the early times have been the Centers for Medicare and Medicaid Services, particularly on the Medicare portion.

Number one, most importantly, our network or the network of our providers provide the majority of the insurance counseling for both Medicare and Medicaid products throughout the country. And, most importantly, the network has worked very closely with the Centers for Medicare and Medicaid Services, most recently to help inform, educate, and assist in the enrollment for the new Medicare drug benefit that came online January this year.

And then the second portion of our work and our partnership with Medicare is and has been and will continue to take a more important role in the future with the new Medicare benefits in assisting people on how to make best use of the prevention, and the chronic disease prevention benefits that have been put online and have been brought into the new Medicare law in assisting people to make sure that they get their vaccines, that they have access to the kinds of new benefits that have come online, and that we assist them in how to navigate and access those new preventive benefits that keep people healthy in their communities.

Ms. Kunkel: Great. One of the areas of collaboration between AoA and the Centers for Medicare and Medicaid Services that you mentioned is the new federal benefits, prescription benefits program. How would you characterize the implementation of that new program?

Ms. Carbonell: We're very pleased with the outcome. We've worked very hard, the Administration on Aging and our partners in the community. It has been a tremendous effort where not only have the communications, the ads, and the efforts done under Medicare was important. I think the partnership that we developed with the Centers for Medicare and Medicaid Services gave us the grass roots local community support that was so needed for particularly our seniors, our older seniors, our seniors -- our low-income seniors, which are a very difficult population to reach and to assist in educating about this new benefit.

So the partnership that we developed early on, working together, adding value, and adding, most importantly, a very critical part of the work that we do, it was a natural for us at the Administration on Aging to partner. As part, not only of our statutory role as the lead aging advocate throughout the government, but most importantly as a very effective bringing down that personalized assistance to the individual Medicare beneficiaries played a very key role in achieving 90 percent enrollment of 38 million people by May 15th, and the work continues, it hasn't stopped. We're working through, particularly with our low-income communities, where we know that the majority -- about half of the people that still had not enrolled are eligible for the additional benefits.

So we continue to work with those communities and rural communities, in limited-English-speaking communities where we know that more people need to be assisted through this effort. And again, at the end of the year we will continue to work in the second phase of the enrollment period. So we're very pleased that even in those most vulnerable populations, we have achieved three-quarter percent enrollment in the Hispanic community, in the African American community, in the Asian American community where you have so many languages. It was very rewarding to see that the work had paid off, and most importantly that paid off because of that personalized assistance was there at the community level.

And also in the private sector, it created opportunities, greater opportunities for enriching the partnerships at the community level. Private and public partnerships where you saw municipalities coming together with banks and other business sector community in assisting people to enroll, either because they were lending them the computers at the community level to access or they were lending staff resources or volunteers, or they were partnering with community colleges and universities to bring their service down to the community.

So it was very exciting, and has been very exciting and has opened up other avenues of further collaboration that are going to very much serve us as we move forward with obviously creating better access, better information, and better consumer empowerment.

Mr. Morales: Josefina, we only have about a minute, but I want to touch upon something that you mentioned earlier, which I think is very important for seniors, and that's this whole issue around financial protection and financial security, and fraud. Can you tell us a little bit more about what you are doing in this area?

Ms. Carbonell: We've run the Medicare patrol programs, which are really another fantastic volunteer, and certified volunteers, which assist us in educating and preventing health care fraud and assisting people in understanding their Medicare bills and making sure that they get the kind of services what they purchase.

We also -- we know that the vulnerability of many of our seniors are tied directly to their functional status. So we know as people age and become frail and dependent and homebound and isolated, they're at highest risk of being abused financially, you know, whether it's a caretaker, whether it's a family member, or just -- the opportunities are abound, to be taking care of -- to be really taken advantage of.

We also run eldercare programs in the legal services to assist people, you know, about their rights, but most importantly to protect them. We have developed a whole -- we run the Nursing Home Ombudsman Program, which is another huge program that serves as the -- we serve as ombudsman for nursing home and long-term care independent living facility members, and we are the conduits, an independent body to assist the elders and their caregivers in problems that they're having in facilities, and we work very effectively to educate, but also to assist.

We worked again with Centers for Medicare and Medicaid Services in their implementation of their quality improvement initiatives, both in nursing home and in home healthcare. To use the ombudsman program as another avenue, another support, adding value at the community level, adding local resources that people could turn to, to be able to support them in questions or problems in challenges that they were encountering.

Mr. Morales: Great. How is the Administration on Aging tracking results? We will ask Assistant Secretary Josefina Carbonell to share the details when the conversation about management continues on The Business of Government Hour.


Mr. Morales: Welcome back to The Business of Government Hour. I'm your host Albert Morales, and this morning's conversation is with Assistant Secretary for Aging, Josefina Carbonell. Also joining us in our conversation is Brenda Kunkel.

Ms. Kunkel: Josefina, there is some points that we would like to follow up from our last segment. Starting with, how is the Administration on Aging supporting a more effective long-term care approach?

Ms. Carbonell: What we're doing is really we're looking at key models as strategies that we've been investing in as a segue to the implementation of the new reauthorization when it comes through, is really focusing on strategies that will improve our efficiency, but will allow us to transform from the current old system of care to a more integrated model.

And particularly we're focused on those areas, where we know that states have been successful in transforming their own long-term care system and home and community-based care, Wisconsin being one of the first ones, Utah, Washington, et cetera, et cetera. So we've invested in four program areas under the discretionary area that have led us to the point that we are right now.

One has been the investments in developing of the Aging and Disability Resource Centers, what we call the ADRCs or -- or for short, one-stop centers in which we are creating a single coordinated system of access and information to long-term care supports, for people -- for general people in this country.

Second is, using again our -- the best science that we have developed and best technology and making sure that that we implement the programs under an evidence-based science model, particularly in the area of prevention. So we're using our best science, which has already been proven, taking it off the shelves and putting it to test at the local level with people, and making sure simple tools for people can remain healthy and independent in their communities.

The third area is of course the most important, it's transforming from a siloed approach, service-oriented infrastructure, to a more consumer-driven and consumer-directed care approach model. And then of course our own -- your own future campaign, which is the whole -- insuring that we provide the right tools for people to plan ahead for their future and their future long-term care needs.

Ms. Kunkel: Great, and let's return to that first element, which is the Aging and Disability Resource Centers. Can you tell our listeners more about them?

Ms. Carbonell: Well, the Aging and Disability Resource Center initiative really represents a historic partnership, again between the Administration on Aging and the Centers for Medicare and Medicaid services where it had never been done before, that funding was put together jointly under the Systems Change Grants initiatives that occurred in the investments, since '01, to the current period, to really build the capacity to initiate system's change in access to long-term care. So what we're trying to is again, looking at the fragmented system, the duplication and the real difficult system of access to long-term care of different agencies, and develop a one-stop shop kind of programs, where they are virtual one stop, "no wrong door" kind of concept at the community level to assist people with disabilities of all ages to make informed decisions about the care supports that they might need.

Again, also provide the information assistance to all individuals regardless of income and serve as a single point of entry to all publicly administered supports including Medicaid, the Older Americans Act and state revenue programs. Since 2003, we've funded 43 ADRCs -- Aging and Disability Resource Centers or one-stops, and we have received grants. Currently it's being expanded and extended and it's exciting to see that many of the states are already taking these programs nationally.

States have also implemented their own state statutes to integrate the long-term care systems to again, reduce fragmentation, improve access, but most importantly, improve the efficiency of the programs and give people better choices to remain at home, including using their own resources. And we've really focused on performance and outcomes, and we define outcomes not only on financial side, but really define outcomes on a consumer perspective. So we want to make sure that we developed a whole array of tracking outcome information and sharing lessons learned across the centers.

Again, as we see the fragmentation between the different models in each states, we want to make sure that we give grantees the ability to not only set the guidelines at the federal level, but most importantly, to assist them in tracking those outcome data in areas such as program visibility, trust, effectiveness, and efficiency. And again, they must develop efficient ways of getting information to consumers again, as well as for sharing information across state agencies.

We know that in many states -- we know that the programs, the different long-term care services or supports are funded through different agencies and through different regulations and guidelines, and it just makes it a maze for people and their caregivers to access those kinds of care. One-stop centers have really brought that together with CMS -- brought one single point access into all publicly funded support systems. But it has allowed us to begin to develop the capacity and the infrastructure for taking on people in all income levels and assisting people to also plan ahead about their long-term care needs.

Mr. Morales: Josefina, on this topic of outcomes we understand that you focused efforts on measuring program results, especially focusing on outcomes in your management of the Administration on Aging including the development of new GPRA plan. Can you tell our listeners about this plan?

Ms. Carbonell: Well, the most important thing is that, of course, the key element of the President's management agenda, is the integration of performance measurements with the program budgeting. And at AoA, we know that our budget success really relies on the quality of our performance measures. And that was quite a surprise for folks looking at me -- coming from the private sector saying, "Why would you be passionate?" And one of the first things that I did when I got into office was to bring on someone with extensive experience in performance outcomes from the general department, the management and budget area, to come into the immediate office of the Assistant Secretary, not only because I was passionate about performance, but most importantly because we knew that how important performance was going to be to the success of our budget and our operation and our programs.

We've streamlined our performance measures to focus really on three broad areas that are critical and resonate not only with the OMB and Congress, but most importantly with us, and that's improving our program efficiency. To us it means increasing our return on investment, making sure that we have turned the agency around, increasing the number of people served for a million dollars. So not necessarily getting more money to do more work, it's really getting better efficient programs, better outcomes out of the existing dollar amounts that we have, so again, increasing our efficiency.

Efficiency to me also is defined in the way that we provide client outcomes. Not only are we serving a meal, are we keeping people healthier by serving that meal, are we assisting people to remain at home independent, versus institutionalization by providing home care supports that range not only from costlier home health care kinds of service, but then we have transportation and we have other modes of non-intensive or non-medical supports that are very practicable and very much needed by people to remain at home.

And again, increasing our targets to again, to vulnerable populations. If we are to prevent, you know, institutionalization, we really need to serve those at highest risk. So we want to make sure that we are serving the right people.

So those are the three areas where we really focused our investments, really improving our efficiency factor by 15 percent from 2002 to 2004. You know, we are paying attention to increasing our return on investment and that it's really not only doing better with the dollars that we have, but providing quality services. So we're tracking outcome by measuring results by consumer satisfaction, and also, most importantly, by assessing how effective are our services in keeping people in their homes and communities and assisting caregivers to care for their loved ones longer.

So those are the results that are very promising that are coming in. We are very encouraged. We'll continue to build upon them to improve. Of course, the targeting measures are really targeting in the sense of making sure that we are serving the right people and that we target those that are more vulnerable to nursing home placement, and being able to assist them immediately by the personalized service, and again by the partnerships that we develop in the community.

Mr. Morales: So in this arena it really is as much a question of effectiveness as it is about -- with efficiency?

Ms. Carbonell: Absolutely, and we're particularly proud of our outreach to consumers. Again, one of the most important things we did as a management tool and as an administration tool for the Administration on Aging was really focusing on who are our clients and who are we really trying to serve. Are we trying to just continue to build upon services infrastructures with actually no context of who our real customers are, then that's why consumers and providers that are really the ones that serve, you know, our customers to making sure that the senior remains at home independent, we wanted to make sure that we were doing the right things, and in the kinds of standards and policies that will facilitate that transformation from a service siloed approach to a more consumer-based approach. So again, giving them the right tools, investing in areas where it would improve the efficiency of the programs, but it would also improve the quality of the care and the transformational care that needs to happen in a long-term care.

Mr. Morales: We only have a minute, but this is such a critical topic -- along this theme of program success, we talk a great deal and you have mentioned this around collaboration. And this is a collaboration and partnerships between the agency, other governmental agencies, NGOs or even the private sector. How do you see this partnership evolving over the coming years?

Ms. Carbonell: Well, I think that almost virtually every significant initiative that the Administration on Aging has taken on has been based on partnerships. That tone was set early on in this administration. How -- we needed to look at how, you know, interdependent we were, but most importantly how important it was for us. I mean, for me coming from the community, it was clear that part of the fragmentation that we experienced at the community level, whether be it on an individual basis when an elderly or a family caregiver was trying to access those kinds of support or information and the fragmentation or a provider, like I was, to be able to serve that whole individual and all their needs was trying to see how we could collaborate better in not only the systems but in the implementation and the direction that we gave at the federal policy level and guidelines.

So again, collaboration is critical to our work, it's certainly collaboration with CMS on the implementation of the prescription drug benefit like we talked before, you know, has been able to be of critical importance to millions of people and that were educated and enrolled in the benefits as a result of the partnership. The partnership with CMS on the Aging and Disability Resource Center, the one-stop, has opened the door that will lead to the modernization, both the Older Americans Act and the Medicaid program and how important -- and we've begun to eliminate that fragmentation of access to long-term care at the national level because of our joint commitment. And that's translating down, channeling down to the local provider and most importantly to the consumers, which is where we're trying to impact the change.

Mr. Morales: Great. What does the future hold for the Administration on Aging? We will ask Assistant Secretary Josefina Carbonell to discuss this with us when the conversation about management continues on The Business of Government Hour.


Mr. Morales: Welcome back to The Business of Government Hour. I'm your host Albert Morales and this morning's conversation is with Assistant Secretary for Aging Josefina Carbonell. Also joining us in our conversation is Brenda Kunkel.

Josefina, it seems as though the very definition of retirement is changing. What do you predict for the future of the concept of retirement?

Ms. Carbonell: I think we have the first wave of baby boomers turning 60 this year. And we know we have two boomers that turned 60, President Bush and Sylvester Stallone. It really is defining the way that we look at age and retirement in this country. I think many people are choosing to continue to work past their age, and not so necessarily within their same job or same field. So we're looking at people taking pauses in their lives and doing career changes, or actually looking for non-traditional job structures where people will be working in different lifestyle changes along their lifespan.

I think we've talked about boomers and one of the thoughts for the future generations, and I think that as we learn from the past, we need to look towards the future. And I think the best advice is keep healthy. I think your best investment in your later life is to invest early in healthy -- adopting healthy lifestyle choices, and continuing to live them throughout your lives.

And second, most importantly, start saving early and planning early for when you're older, and also get back to your community. I think there is a great opportunity for people to give back and we know the great value that many of our older people are contributing to communities across this country.

Mr. Morales: Many of our guests share challenges in making sure that their staff have the best training and skill set for the future -- and I think this also ties to retirement and the amount of knowledge that is typically lost in organizations that have high rates of retirement. What is the administration doing to attract and retain highly qualified employees and to stem the tide of this brain drain?

Ms. Carbonell: I think the most important thing is that -- we looked at the appropriate mix of staff. I think the strategic human capital investments have been very important for us and they have really driven our reauthorization proposals and the principles of reauthorization. And that is to really retool our organization and agency from an agency that just had grants to an agency that's really leading change in long-term care reform, but most importantly in giving people and consumers the right information so they can have better choices to remain independent.

So the capacity of the shift in the strategic investments in our staffing, not only at the federal level, but also at the state and local level has been critical. I'd like to say that employers, I think in general, in both the private and public sectors really will be facing a great brain drain as a large segment of our workforce begins to retire. So this will create a powerful incentive really for employers to identify new ways of retaining, of retraining, and retooling, older workers and recruiting older workers. I think that certainly that's an opportunity for looking at some of the recent surveys that have come out from MetLife that found that half of adults aged 50 and 70 want to do jobs that help improve the quality of life in their communities. And I think that that's another wonderful opportunity to be able to actually attract a whole core of people to come in to the federal workforce as an opportunity.

Mr. Morales: That's fantastic. Josefina, you just have a wonderful personal career and I have to ask you this. Probably many people out there are interested in contributing in this field and so my question to you is what advice could you give to a person who is really interested in a career in public service or in community service?

Ms. Carbonell: Well, I think we need to continue to look at America as in transition. I think that the 21st century offers us some great opportunities and great challenges. I think that that's a wonderful time, a unique time to be in public service. I think more and more the business of government, there seems to be a thin transformation of that dividing line between private sector doing the government's business and government doing the government's business. And I think that it's coming closer together and it doesn't necessarily need to be in conflict with each other.

I see the opportunities for great public services, whether you're serving in that capacity in a government role or in inherent government capacity or you're serving in that role in the public sector as a private sector contractor to a government agency.

Mr. Morales: That's wonderful. Unfortunately we've reached the end of our time and so that will have to be my last question. I want to thank you for fitting us into your busy schedule. But more importantly Brenda and I would like to thank you for your dedicated service to the public and to our country in the roles that you've held at the Department of Health and Human Services.

Ms. Carbonell: Thank you. Thank you very much, and thank you for this wonderful opportunity to be with you. I think if I may, I'd like to -- obviously it's my role as the chief aging advocate in this country -- is to make sure that, you know, all of us have caregiving responsibilities. We either have our own families that we are trying to struggle, our jobs and struggle to deal with our loved ones as they age -- relatives or relatives-in-law, and I would like to put in a plug for our elder care locator number, which is what we're trying to do is improve the access of information to resources and supports of people -- can get the right choices to remain at home. And that number is 1 (800) 677-1116.

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