--A Q&A with Heather Carroll, NH Alliance for Healthy Aging Advocacy Director

Q. In the midst of such a challenging time, how is the NH Alliance for Healthy Aging able to deliver so many policy wins?

Heather: People are starting to get used to the fact that the NH Alliance for Healthy Aging (NH AHA) is an entity working on issues that matter to older adults. Through AHA, we were able to put forward ideas on how to use incoming federal funds, reflecting community needs that we uncovered in listening sessions with the people who were actually delivering care. These are family caregivers trying hard to piece it together – often struggling to maintain a job and a home while caring for someone who may need 12 to 24 hours of support. That’s a challenge at any time and especially during the pandemic.

We're looking at different ways to engage with the NH Department of Health and Human Services, with the Commissioner, and with our elected officials in a time when it’s not necessarily safe to ask our advocates to come in person. We’ve strategized and found ways to conduct listening sessions, having calls directly with our legislators, postcard campaigns, and call-in actions, for instance. We're going to be doing some videos of folks who want to participate in the process and are fighting to have virtual access to their government. That's probably going to be our number one platform this year: access for all.

We’ve also been forging some cool partnerships with the public health and the disabilities communites, as well as with working moms, childcare providers, and teachers. People were able to participate in the process last year and our advocates were very excited. We helped each other across fields and got great results. We got items through the budget that we probably would not have been able to do if we didn't have that direct line of communication.

Q. How has NH AHA been pursuing federal funding opportunities?

Heather: We had the first installment of the Coronavirus Aid, Relief, and Economic Security Act (CARES) funding, parts of which directly tie to home and community-based services, bolstering the workforce and supporting caregivers in the community. We knew it was probably the beginning of what could potentially come down the road. We talked to the federal delegation and examined ways to partner with the Department of Health and Human Services Bureau of Elderly and Adult Services (BEAS).

We already understood the dynamics that are pushing our workforce and our caregivers to their limits during the pandemic. And we wanted to ensure that some of the incoming funds would support those needs. We’ve also been part of the conversation as New Hampshire prepared to ensure incoming funds go where they’re supposed to and don't hit any dissemination roadblocks.

We looked at it from two perspectives: What the federal government was putting in place for guidelines on how the money could be spent, and then looking at how funds would be brought into the state, whether it was through the CARES Act, Federal Medical Assistance Percentages (FMAP) funding, or the American Rescue Plan Act (ARPA). It was a tiered process. Some of the funding was short-term and immediate for COVID response. Other funding, such as that in the American Rescue Plan, focuses on longer-term preparedness for future public health emergencies and the resulting needs of specific populations.

Q. Were these new approaches to advocacy for NH AHA?

Heather: Yes. We’ve been vocal in explaining how our communities can be great for everybody, not just older adults. That has opened some doors for us. This was one of the first times we were able have an intergenerational conversation where moms with kids, telehealth providers, and older adults all needed accurate and predictable broadband access, for instance. We talked about paid family leave and workforce challenges as well. It entailed tapping into our advocates and then getting to the right tables.

New Hampshire lacks infrastructure to support older adults, and it drastically changes depending on where you are geographically. Supports that are in Coos County are very different than Hillsborough County. We talked to advocates across the state and looked at what we already had in place as well as gaps. One of those new tables was the Governor’s Office for Emergency Relief and Recovery (GOFERR). We also worked with NH DHHS, because a lot of the ARPA funding comes in through the Older Americans Act.

We submitted our recommendations to NH DHHS who in turn submitted a state request to the Centers for Medicare and Medicaid Services (CMS). After our listening sessions, we were able to make recommendations we knew would directly address the need. From there we determined what the Alliance for Healthy Aging could lead on. We were fortunate that the DHHS Bureau of Elderly and Adult Services included our letter in their requests to CMS. It meant that, in addition to the provider voice being put forward, we were also putting the consumer voice on equal footing.

Q. What have been some of the results of that advocacy around federal funding?

Heather: Through CARES Act funding, we saw a direct add to the Caregiver Respite Grant that the state oversees. So instead of a $1,500 allocation, caregivers can get up to $2000. That's a great program set up through ServiceLink and one of our best kept secrets. It's a small incremental change, but it's certainly a good thing. We're working on legislation for this session through the Senate that will redefine some of the language in the statute, to be even more inclusive.

The FMAP funding looks positive as well. We have requested and believe there is a good chance to pilot a program for presumptive eligibility in New Hampshire. Presumptive eligibility is a Medicaid policy option that permits states to authorize specific types of "qualified entities," such as federally qualified health centers, hospitals, and schools, to screen eligibility based on gross income and temporarily enroll eligible certain individuals in Medicaid or the Children's Health Insurance Program (CHIP). Presumptive eligibility serves a dual purpose of providing immediate access to needed health care services while putting people on a path to ongoing coverage.

Q. Talk about some of the headwinds you’ve faced this past year.

Heather: We had an uphill battle with a lot of ageism that came out of the pandemic through the media, through government officials, and through ridiculous op-eds claiming that everyone over 65 was holding the rest of the country hostage. We have worked to reframe the conversation to focus on the many societal and economic contributions made by older adults.

We’ve also had to respond to some curve balls. For instance, in the final minutes before the midnight budget deadline, a numeric allocation for the senior centers was removed. We had worked hard to build bipartisan support for it. The governor had put it forth in his initial budget. Then the House took it out, but the Senate put it back in. Our advocates fought really hard for it.

We could not figure out why senior center support was removed from the state budget at the last minute, especially since so many in the Senate championed it. Those resources would have supported senior centers across the state. They are the hub for older adults in almost every community. Throughout this pandemic, senior centers are reaching out to their community, holding classes online, helping with groceries, and sharing COVID protocols as well as where and how to get vaccinations.

By making the senior centers a more cohesive network in our state, we can benefit older adults across the board. So to have that allocation pulled was heartbreaking. We had 24 hours to be sad about it. And then we got right back to work on how to fix it. We’re now working in collaboration with the State Commission on Aging, emphasizing that the State Plan on Aging relies on the senior centers as an important resource to help older adults thrive in New Hampshire.

COVID has pushed healthcare workers to the edge. And a lot of our home health services are reporting that they have approved hours, but they don't have the staff to fill those hours. The county nursing homes have staffing shortages as well. They're closing wings and aren’t accepting new clients to short-term rehab. We must have a serious conversation about this very soon.

What happens if there's a 100-person waiting list for the county nursing home? What services will or will not be available? A large agency reports 18,000 hours of care per month going unfilled due to staffing shortages. That’s more than a headwind. It’s a crisis and we’ve got to address it now.

Q. What are NH AHA’s most significant policy wins recently?

Heather: We had a big win on the Adult Day reimbursement rate. That will go a long way to keeping Adult Day Care programs alive in our state. For families supporting loved ones, Adult Day Programs are often the last string holding their family and their loved ones together as a unit. When programs like these close, it’s often no longer possible for older adults to remain in their homes and communities. That was true pre-COVID and even more pressing now.

Our analysis showed that New Hampshire was far below the national average for Adult Day reimbursement rate per client. When we did the math, it was going to take a 38% increase to get the state closer to national par. For years, a 5% increase in the waiver programs or the reimbursement rate was considered a victory.

The thought of asking for a 38% increase to a program that is largely pushed aside, was audacious to say the least. But our thought was: if not now, when are we going to do this? We organized our advocacy strategy and took a bipartisan approach.

The result was that we got the 38% increase. The rate went from $56.40 up to $75. That’s closer to the national average of $77, although the actual cost is $120.

It was great to have our older advocates pull their family members and pull their caregivers into the mix to speak out about the importance of Adult Day Care. As a result, we’ve connected new people who want to be at the NH AHA table and roll up their sleeves in the various workgroups.

I’m also proud that our advocates have been trained using virtual platforms and are able to testify remotely. During a recent Senate hearing, we had the very first advocate testimony followed by 29 advocates in between and then we had the very last word on the budget. We had such a range of folks -- from the senior centers, adult day programs, recipients of the Choices for Independence program, and more.

Q. What’s Next for Policy and Advocacy in the Healthy Aging space?

Heather: The upcoming session is likely going to be a difficult one if we don't start setting some ground rules. We take an old-school approach and don't disrupt public hearings and public meetings. We will do it with grace and we will do it with our heads held high, continuing to show up regardless of what the political headwinds may be. It's becoming increasingly difficult to bring our policymakers together, but we find a common thread in aging, because we're all getting older. Our work is making an impact and our influence is growing. We have an incredible steering committee that is bringing new ideas and fresh approaches. There’s nothing more rewarding than helping build meaningful partnerships that support and promote healthy aging in communities throughout New Hampshire. It makes all the hard work and persistence so worth it.