NASW Submits Comments Regarding Strategic Framework for a National Plan on Aging

Chris Herman, MSW, LICSW
Senior Practice Associate–Aging

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October 2024

On September 15, 2024, NASW submitted comments to the Administration for Community Living in response to Aging in the United States: A Strategic Framework for a National Plan on Aging. The framework was developed by the Interagency Coordinating Committee on Healthy Aging and Age-Friendly Communities (https://acl.gov/ICC-Aging) and submitted as a report to Congress in May 2024. NASW’s comments follow.

1. What do you like about the Strategic Framework for a National Plan on Aging?

The National Association of Social Workers (NASW) commends the Interagency Coordinating Committee on Healthy Aging and Age-Friendly Communities (hereafter, “ICC”) for developing a Strategic Framework for a National Plan on Aging (hereafter, “framework”). We applaud the ICC not only for engaging directly with older adults through stakeholder interviews and listening sessions, but also with stakeholders such as the Leadership Council of Aging Organizations (https://www.lcao.org/), of which NASW is a member.

As the ICC acknowledges, the framework creation builds on state-level efforts (https://multisectorplanforaging.org/) to develop multisector plans for aging (MPAs), and coordination with these states MPAs will be critical as the ICC’s work progresses. Moreover, the framework complements international efforts such as the Madrid International Plan of Action on Ageing (United Nations [UN], 2002), commonly known as “MIPAA,” and the UN’s Decade of Healthy Ageing (2021–2030; https://www.decadeofhealthyageing.org/). The framework also complements work being done by individual regions and countries, such as the African Union (HelpAge International Africa Regional Development Centre & African Union, 2010), Asia and the Pacific (Asian Development Bank, n.d.), Australia (Commonwealth of Australia, 2001), Canada (Canada Institutes of Health Research, n.d.), Europe (UN Economic Commission for Europe, n.d.), Latin America and the Caribbean (UN Economic Commission for Latin America and the Caribbean, 2022), and New Zealand (UN Department of Economic and Social Affairs, n.d.).

Furthermore, the creation of the ICC and the framework illustrates that U.S. federal agencies understand the need to address the challenges associated with population aging. It can serve as a foundation for policy and programmatic planning, action, and evaluation, including collaboration across federal agencies. As the ICC has noted, the framework will need to adapt in keeping with population and infrastructure changes. Equally important, the framework recognizes population aging as a strength for both individuals and communities; such affirmation is essential for the individual and societal well-being.

NASW supports the vision expressed in the framework and the values in which the framework is rooted: person centeredness, inclusion, respect, and collaboration and innovation. We are pleased that the framework acknowledges and begins to address structural inequities that affect older adults as individuals and in communities. We concur that the framework’s four domains—(a) age-friendly communities, (b) coordinated long-term services and supports (LTSS) and housing, (c) increased access to LTSS, and (d) alignment of health care and supportive services—are extremely important. These domains, which address the importance of everyday necessities such as transportation, nutritious food, and safe, affordable housing—cohere with social work’s person-in-environment perspective, the ecological approach shared by social work and public health, and recent public- and private-sector efforts related to social determinants of health (SDOH) and health-related social needs (HRSNs).

2. What is missing from the Strategic Framework for a National Plan on Aging?

The following comments address concepts that are missing from the framework as a whole. NASW’s comments regarding content missing from the four identified domains are included within subsequent questions.

The framework acknowledges the impact of ageism on health and well-being as we age but misses the opportunity to promote the Reframing Aging and Reframing Elder Abuse initiatives. These initiatives, based on qualitative and quantitative research conducted by the FrameWorks Institute (https://www.frameworksinstitute.org/issues/aging/) and developed in collaboration with experts in the aging and elder justice fields, promote collective, solutions-focused communications strategies to address ageism and elder abuse. NASW strongly encourages the ICC to integrate these reframing practices as part of a national plan on aging and within the work of federal agencies and departments that serve older adults. Moreover, we recommend that the framework promote the two centers promulgating these reframing aging and elder abuse strategies—the National Center to Reframe Aging (https://www.reframingaging.org/) and the ACL-funded National Center on Elder Abuse (NCEA, https://ncea.acl.gov/), respectively—as resources for private-sector entities.

NASW commends the ICC for incorporating person centeredness within the strategic framework. At the same time, the framework does not acknowledge trauma, to which nine of ten older adults in the United States have been exposed in their lifetime (Kilpatrick et al., 2013). Veterans, survivors of crime, Holocaust survivors, and members of socially marginalized groups are especially likely to have experienced trauma. Even decades-old trauma can have adverse impacts on older adults, with a secondary impact on family caregivers. For nearly a decade, ACL has funded the Center on Aging, Trauma, and Holocaust Survivor Care (https://holocaustsurvivorcare.jewishfederations.org/) to study and promulgate person-centered, trauma-informed (PCTI) care for older adults and family caregivers. The center has developed multiple resources to educate service providers, policymakers, and the public about the PCTI approach. NASW recommends that the ICC either add trauma responsiveness as a distinct cross-cutting value or expand “person-centeredness” to “person centeredness and trauma responsiveness.” We refer the ICC to the report Aging with a History of Trauma: Strategies to Provide Person-Centered, Trauma-Informed Care to Older Adults and Family Caregivers (Rabin et al., 2023), published by the Center on Aging, Trauma, and Holocaust Survivor Care, for additional information and verbiage.

Although culture is implicit in the cross-cutting values of person-centeredness, inclusion, and respect, it is not named explicitly. Similarly, we understand the connotation of inclusion in the disability community; however, inclusion without equity—elimination of structural biases of all types—is of limited value. NASW recommends that the value of “inclusion” be renamed “inclusion and equity” and that culture be added to the inclusion statement on page 8 of the framework: “All people regardless of age, disability, other cultural identities, and life experience, should be able to live independently and participate fully in their communities.” (For additional information, please refer to NASW’s recent comments [NASW, 2022] responding to a request for information (RFI) from the Centers for Medicare & Medicaid Services [CMS] on advancing health equity.)

The framework names mistrust of government and cultural beliefs about accepting aid as are social and cultural factors that pose barriers to benefits access (page 35). NASW concurs with this concept; indeed, we believe it is relevant to all four domains within the framework. Emphasizing the need to infuse cultural competence, language access, and person-centered, trauma-informed approaches throughout policies and programs affecting older adults would strengthen the framework as a whole. (One related resource is NASW’s Standards and Indicators for Cultural Competence in Social Work Practice, 2015.) Moreover, the framework focuses heavily on independence for older adults, a goal shared by NASW. At the same time, the framework fails to acknowledge that interdependence is a necessity and a strength throughout the lifespan: All of us rely on services and supports throughout our lifetime. Similarly, we both provide and receive support within our relationships. Interdependence is our human reality; within that reality exists a continuum of independence and reciprocity. Each of us experiences degrees of independence, which fluctuate throughout our life course and in response to the presence or absence of the types of services and supports we need in any given circumstance. Likewise, levels and types of reciprocity fluctuate within each of our relationships. NASW urges the ICC to incorporate this perspective within the framework. Failure to acknowledge human interdependence across the lifespan is a social and cultural barrier to realizing the goals of the four framework domains. One way to address this concept would be to add text to the content addressing “maximiz[ing] the independence, well-being, and health of older adults” (page 5). The framework could build on this text while making clear that interdependence is both a necessity and strength throughout our lifetimes, and that we strive to maximize independence as we age within that lifespan context of interdependence.

Lack of funding for public programs serving older adults presents a predominant barrier to realizing the framework’s goals. NASW urges the ICC to add to the framework recommendations for funding at the most comprehensive level for programs impacting older adults. Particularly important is funding for programs and policies supporting socially marginalized groups, such as Black communities, Alaska Native communities, American Indian communities, Asian American and Pacific Islander communities, Latino communities, LGTBQIA2S+ communities, and rural and remote communities.

The federally funded National Center on Advancing Person-Centered Practices and Systems (https://ncapps.acl.gov/) is a valuable resource that is applicable to each domain and multiple focus areas within the framework. NASW encourages its incorporation.

NASW affirms the inclusion of elder justice as a focus area within Domain 3 (increased access to LTSS). However, elder abuse occurs across settings. Furthermore, given the widespread impact and severity of elder abuse, elder justice merits a distinct domain entitled “Elder Abuse and Elder Justice.” We recommend that this new domain incorporate not only the content from the current elder justice focus area, but also a focus on elder abuse intervention. We suggest the following additions:

• increased funding for elder rights programs for Alaska Natives, American Indians, and Native Hawaiians, as well as for the Adult Protective Services (APS), Long-Term Care Ombudsman, and abuse in later life programs
• widespread replication of shelters for people who experiencing elder abuse, neglect, or exploitation, such as the Weinberg Center Shelter (https://theweinbergcenter.org/the-weinberg-center-shelter/) and other shelters within the SPRiNG (Shelter Partners: Regional, National, Global) Alliance® (https://theweinbergcenter.org/start-a-shelter/), which the Weinberg Center convenes
• widespread screening for elder abuse—such as during the Welcome to Medicare visit, annual wellness visit, and in public health settings—as well as training in conducting to such screenings and responding if screening indicates suspected elder abuse
• funding for research of restorative justice approaches for elder abuse intervention and other remedies beyond incarceration of people who use abusive behavior toward older adults
• additional funding of research addressing best practices for elder abuse prevention and intervention
• funding to establish and support an Advisory Board on Elder Abuse, Neglect, and Exploitation composed of stakeholders from the field, as specified in the Elder Justice Act of 2009 (S. 795, passed as part of the Patient Protection and Affordable Care Act [ACA], P.L. 111–148, 2010) and initiated by the U.S. Department of Health and Human Services in 2010 (Establishment of the Advisory Board on Elder Abuse, Neglect, and Exploitation)
• increased focus on settings in which elder abuse is under addressed, such as assisted living, home health, hospice, and nursing homes
• increased attention to systems inequities as a strategy to prevent and mitigate intersectional elder abuse, as described in these publications by NASW (Herman, 2021) and NCEA (2024)
• acknowledgment of NCEA and the federally funded APS Technical Assistance Resource Center (https://apstarc.acl.gov/), National Adult Maltreatment Reporting System (https://namrs.acl.gov/), National APS Training Center (https://natc.acl.gov/), National Center on Law and Elder Rights (https://ncler.acl.gov/), National Long-Term Care Ombudsman Resource Center (https://ltcombudsman.org/), National Resource Center on Women and Retirement (https://wiserwomen.org/national-resource-center-on-women-and-retirement-2/), and the Native American Elder Justice Initiative (https://iasquared.org/naeji/)

Additionally, NASW encourages the ICC to address scams (including technology-assisted fraud), financial abuse, and exploitation within the proposed “elder abuse and elder justice” domain. Such a focus area could include prevention education for the public, private enterprise, and financial institutions. We support implementation and enforcement of the U.S. Department of Labor’s recently finalized “fiduciary rule”—which will help prevent financial advisors from misdirecting investors—and increased oversight of financial products such as reverse mortgages, which sometimes force older adults out of their homes.

The previously suggested focus area intersects with another critical topic: economic security. NASW applauds the ICC for including economic and financial security as a focus area within Domain 1, age-friendly communities. Given the centrality of this topic to health, well-being, and quality of life, however, we recommend that the ICC add a distinct domain focused on economic security while retaining existing complementary content in Domain 1 and other domains. We recommend that this new domain address the following goals:

• Strengthen the Social Security program by increasing benefits (such as a caregiver credit for individuals who leave the paid workforce to care for an older adult or a person with disabilities) and dedicated revenue. Adopt the Consumer Price Index for the Elderly (CPI-E) for Cost of Living Adjustment (COLA) to help Social Security beneficiaries keep pace with increased costs. Bolster administrative funding for the Social Security Administration to enhance service to beneficiaries and applicants.
• Acknowledge the Supplemental Security Income (SSI) program, which is absent from the framework; call for modernization and expansion of SSI by increasing the maximum benefit, indexing that benefit to inflation, updating the income disregards, increasing resource limits, and eliminating penalties for marriage and housing sharing.
• Promote access to and continuity of employment-based retirement savings by enabling payroll deduction retirement savings accounts for all workers and easing transitions of retirement savings plans between employers; support improvements to the pension registry to help retirees locate savings from previous jobs.
• Strengthen government employment training programs, including the Senior Community Service Employment Program, or SCSEP; strengthen federal policies protecting older workers in job eligibility, hiring, retention, and promotion.
• Restore the Earned Income Tax Credit for eligible workers 65 years and older.
• Enhance food security, such as by supporting inclusion of perishable prepared food in Supplemental Nutrition Assistance Program (SNAP) benefits; increase SNAP funding.
• Increase funding for the Low Income Home Energy Assistance Program (LIHEAP) and other programs targeting older adults with limited incomes.
• Facilitate access to benefits such as LIHEAP, SNAP, and SSI.
• Increase access to benefits and services for older adults who are reentering the community from carceral settings.

Another topic related to, yet distinct from, elder abuse and elder justice is nursing homes. Although NASW commends the ICC for prioritizing home and community-based services (HCBS) in the framework, nursing homes remain—and will always remain—an integral component of the LTSS continuum. Yet, the framework refers to nursing homes only as something to avoid and fails to address nursing home quality. NASW addresses this topic in greater detail within its comments on Domain 3.

The workforce is another topic that merits greater attention within the framework. NASW supports the framework’s focus on family caregivers (recognizing “family” as defined by each older adult) and the direct care workforce. Similarly, we appreciate the acknowledgment of the Geriatrics Workforce Enhancement Program and other programs that promote age-friendly communities. We encourage the ICC to underscore the importance of a well-trained, stable workforce in content for each domain. Realization of such a workforce necessitates three components:

• recruitment and retention of practitioners who specialize in working with older adults, such as geriatricians, gerontological nurses, and gerontological social workers, through financial incentives such as scholarships and loan forgiveness
• infusion of geriatrics and gerontological principles and knowledge throughout the workforce as a whole
• increased, ongoing investment and coordination in geroscience research—including not only biomedical, but also psychosocial research—across federal agencies, including the Advanced Research Projects Agency for Health (ARPA-H), Agency for Healthcare Research and Quality (AHRQ), National Institutes of Health (NIH), Patient-Centered Outcomes Research Institute (PCORI), and Veterans Administration (VA)

Moreover, we encourage the ICC to incorporate content specific to the social work profession within the framework. Social workers* support older adults in maximizing their dignity, health, and independence and help them stay engaged within their communities. They work with and on behalf of older adults in public, nonprofit, and for-profit sectors on the local, state, and national levels, as well as in Tribal communities. Social workers are integral personnel in numerous types of practice settings, such as those focused on elder justice, health care, housing, mental health, social services, and substance use, and provide services such as screening, biopsychosocial assessment, resource linkage, systems navigation, service coordination, advocacy, counseling, and psychotherapy. Such work often involves collaboration not only with and support for the people whom each older adult defines as “family,” but also with interdisciplinary colleagues in teams and across organizations and service systems.

* The term “social worker” is often applied inappropriately because the profession lacks federal title protection. Social workers possess baccalaureate or advanced degrees in social work from a program or school accredited by the Council on Social Work Education and comply with the licensing or registration requirements—including ongoing continuing education—of the state(s) or jurisdiction(s) in which they practice.

3. What could be added or changed to the Age-Friendly Communities domain in the Strategic Framework for a National Plan on Aging?

NASW strongly supports the focus areas identified within this domain and offers the following suggestions to strengthen them.

Purpose and Engagement

We are pleased that the framework includes the arts as part of purpose and engagement. Federal funding for nongovernmental initiatives that foster creative arts engagement for older adults could be useful; we refer the ICC to the Creative Aging Resource (https://creativeagingresource.lifetimearts.org/) for additional information regarding numerous such initiatives.

Social Connection

NASW encourages the ICC to address the relationship between social isolation and elder abuse and substance use, respectively, and to promote broadband as an essential utility for all. We also encourage incorporation of content addressing intergenerational programming in contexts beyond AmeriCorps Seniors, given that volunteerism is not possible for many older adults. Programs that bring together older people and younger generations could include, for example, programs in which older adults read to children in senior centers, assisted living residences, or nursing homes; oral history projects pairing high school or college students with older people; and colocated child care and adult day health services.

Accessibility and Universal Design

We encourage the ICC to promote funding for home modifications and repair to enable older adults to remain in their own homes.

Transportation

The actions in this focus area seem most relevant to urban and suburban communities. NASW encourages the ICC to address transportation within rural and remote areas. For many older adults in these areas, including in Indian Country, driving is a necessity; for older adults in urban and suburban areas, continued driving could be feasible with additional supports. NASW encourages the ICC to promote funding for and expanded access to driver rehabilitation programs (such as those certified by the Association for Driver Rehabilitation Specialists, https://www.aded.net/page/725) and vehicle adaptation–modification programs (such as those described by the National Highway Traffic Safety Administration (https://www.nhtsa.gov/vehicle-safety/adapted-vehicles). At the same time, improvements in paratransit are needed in urban and suburban communities. Furthermore, Non-Emergency Medical Transportation (NEMT) enables numerous older adults across communities to access health care services. NASW encourages the framework to address the need to promote NEMT service quality, monitoring, evaluation, and access.

Economic and Financial Security

Please refer to NASW’s recommendations in response to question 2.

Employment

We commend the ICC for underscoring SCSEP and age discrimination in employment. As the framework notes, flexible work models can enable older adults to maintain paid employment amid caregiving responsibilities and as their own health changes. Such flexibility necessitates funding for employer-based incentives. Furthermore, we urge the ICC to promote creation of an Older Workers Bureau to foster economic security for older adults.

Age-Friendly Health Systems

NASW recommends that the ICC add funding for replication and sustainability of geriatric emergency departments to the framework; we refer the ICC to the Geriatric Emergency Department Collaborative (https://gedcollaborative.com/), supported by the John A. Hartford Foundation and the Gary & Mary West Health Foundation, for additional information. We also encourage the ICC to promote preventive health for older adults, including through investments in evidence-based and evidence-informed interventions delivered by community-based organizations nationwide. Moreover, we recommend that the framework incorporate the Center of Excellence for Behavioral Health in Nursing Facilities (https://nursinghomebehavioralhealth.org/) and the National Resource Center on LGBTQ+ Aging (https://lgbtagingcenter.org/). Also important to include are federally funded centers of excellence that promote culturally competent behavioral health services for the following communities:

• African American (https://africanamericanbehavioralhealth.org/)
• American Indian and Alaska Native (https://7generationscoe.org/)
• Asian American, Native Hawaiian, and Pacific Islander (https://aanhpi-ohana.org/)
• Hispanic/Latino (https://hispaniclatinobehavioralhealth.org/)
• LGBTQ+ (https://lgbtqequity.org/)

Moreover, the Rural Centers of Excellence on Substance Use Disorders program (https://www.hrsa.gov/rural-health/opioid-response/rcoe-sud) merits inclusion in the framework, as do federally funded HIV technical assistance resources (https://bphc.hrsa.gov/technical-assistance/clinical-quality-improvement-resources/hiv-hepatitis-health-centers/hiv-resources-health-centers).

4. What could be added or changed to the Coordinated Housing and Supportive Services domain in the Strategic Framework for a National Plan on Aging?

NASW commends the ICC for incorporating this domain within the framework. We recommend that the domain be renamed “Affordable and Accessible Housing with Coordinated Services.” Our comments on the focus areas of this domain follow.

Housing Stability through Coordinated Services

Access to supportive services such as service coordination, case management, and housing counseling is important across the settings in which older adults live. We encourage the ICC to promote increased funding for affordable, accessible housing and increased flexibility in funding streams to support innovative housing and LTSS models, including the Program of All Inclusive Care for the Elderly (PACE) and Medicaid waiver programs. Centering health equity in this domain is essential to enabling older people to live and access services in their setting of choice.

Affordable Housing

We encourage a unified system of identifying available affordable housing units so that older adults don’t have to call numerous properties repeatedly.

Accessible Quality Housing

NASW urges the ICC to promote increased funding for broadband, technology access, and digital literacy as part of the framework. We also encourage incorporation of the concept of “housing fit”—that is, the relationship between the design of a home and an older adult’s abilities and needs (Scheckler, 2022)—and funding for home modification programs. Also important to promote is robust landlord and tenant education regarding fair housing laws and responsibilities, as well as funding for and access to pertinent legal services.

Preventing and Addressing Homelessness

NASW encourages incorporation of rental subsidy programs to prevent displacement of older adults. We also reiterate two of our recommendations from question 2: elder abuse shelters and protections against abuse of reverse mortgages.

5. What could be added or changed to the Increased Access to Long-Term Services and Supports domain in the Strategic Framework for a National Plan on Aging?

NASW concurs with the ICC that the United States lacks a system of comprehensive, affordable LTSS. We encourage promotion of a social insurance financing system to increase access to LTSS (including transportation, technology, and accessible, service-enhanced housing) that enable older adults to maintain maximal independence in the setting of their choice. NASW applauds the focus on home and community-based services in this domain. Yet, as noted in NASW’s response to question 2 of this survey, the framework does not address nursing homes. We encourage incorporation of the following actions to promote high-quality nursing home care:

• Implement and enforce minimum staffing standards for direct care nursing disciplines (certified nursing assistants, licensed practical–vocational nurses, and registered nurses) with an emphasis on robust assessment of staffing needs by each facility.
• Strengthen staffing standards—both ratios and qualifications—for social work, as described in NASW’s comments (Bedney, 2023c) on the 2023 nursing home staffing proposed rule (Minimum Staffing Standards, 2023) to promote quality of life and quality of care for all residents.
• Collect, analyze, and report data regarding the training, expertise, and staffing patterns of social workers and other disciplines and fund robust federal research to inform staffing ratios for social workers and other disciplines, as recommended by the National Academies of Sciences, Engineering, and Medicine (NASEM) in its recent report on nursing home quality (2022). (Please refer to NASW’s 2023 comments on the nursing home staffing proposed rule for additional information.)
• Expand access to mental health services for nursing home residents by removing the restriction that prohibits beneficiaries who receive skilled nursing facility (SNF) services under Medicare Part A from accessing mental health services provided by independent clinical social workers under Medicare Part B, as recommended by the NASEM report and described in NASW’s comments (Bedney, 2024) on the Medicare physician fee schedule proposed rule for calendar year (CY) 2025 (2024).
• Improve the quality and frequency of nursing home surveys.
• Consistently employ regulatory enforcement mechanisms for violations that cause harm to residents, violations in reporting of ownership and management structures, and misuse of public funds. For additional information, please refer to NASW’s comments (Bedney, 2023b) on the proposed rule addressing disclosure of nursing home ownership and spending patterns (2023).

Likewise, NASW encourages incorporation of policies to improve the quality of assisted living (a sector that lacks federal regulation) quality within the framework. Additionally, we suggest that the ICC add to the framework two LTSS models: (a) multipurpose senior centers, underscoring the Modernizing Senior Centers Resource Center (https://www.ncoa.org/professionals/senior-centers/modernizing-senior-centers-resource-center/), and (b) the Village Movement, as exemplified by the Village to Village Network (https://www.vtvnetwork.org/).

Moreover, we offers the following overarching recommendations for the LTSS domain: (i) Strengthen infrastructure to collect, analyze, and report data, thereby establishing baselines and setting federal standards for measuring LTSS access. (ii) Promote equitable access to culturally competent LTSS across the continuum. Relevant federally funded resources include not only the aforementioned National Resource Center on LGBTQ+ Aging, but also the American Indian and Alaska Native Resource Center for Brain Health (https://www.nrcnaa.org/native-aging-disability), the NICOA [National Indian Council on Aging] Compass: A Guide to Native Wellness (https://nicoacompass.org/), and the Resource Center on Native Aging and Disability (https://www.nrcnaa.org/native-aging-disability).

Our comments on focus areas within the LTSS domain follow.

Paid and Unpaid Caregiving

NASW recommends that the framework address the disproportionate impact of family caregiving in communities of color (particularly for women of color) and for people with low incomes. Promoting increased funding for the Older Americans Act (OAA) is one way to mitigate these disparities; of particular note are Title III-E National Family Caregiver Support Program and the Title VI-C Native American Caregiver Support Program. Moreover, we encourage the ICC to incorporate the work of the Recognize, Assist, Include, Support, and Engage (RAISE) Family Caregiving Advisory Council and the Advisory Council to Support Grandparents Raising Grandchildren to the framework. Of particular import for the framework are the councils’ jointly developed Cross-Cutting Considerations for Family Caregiver Support (2022), which identify the following four foundational principles: (a) placing the family and person at the center of all interactions; (b) addressing trauma and its impact on families; (c) advancing equity, accessibility, and inclusion for family caregivers in underserved communities; and (d) elevating direct care workers as family caregiving partners. Language from the Direct Care Worker and Family Caregiver Initiative (https://www.togetherincare.org/, led by PHI and the National Alliance for Caregiving) may also be useful in identifying policy solutions to improve supports for, and strengthen partnership between, that family caregivers and direct care workers. Furthermore, NASW recommends that the framework promote family caregiving tax credits and paid family leave.

Whole Person Health Financing

NASW recommends that the framework promote the following policy changes to strengthen the Medicaid program:

• elimination of asset limits or increases in asset limits with elimination of annual asset redeterminations
• increased income limits to bolster access to and streamline eligibility for Medicaid “aged and disabled” programs, medically needy pathways, and Medicare Savings Programs (MSPs)
• eliminating annual asset redeterminations
• prohibition of work requirements for 1115 waivers
• elimination, at the federal and state levels, of Medicaid estate recovery

We encourage the ICC to incorporate the Medicare role in LTSS financing and to propose policy solutions to improve the quality of SNF services. Similarly, NASW recommends that the framework propose solutions to strengthen and enforce the Medicare home health benefit, particularly in relation to (a) access to home health aide services, (b) access to social work services, and (c) mitigating disparities for people with disabilities and chronic conditions, such as multiple sclerosis. (Please refer to NASW’s comments [McClain, 2022b] on the CY 2023 Medicare home health proposed rule [CY 2023 Home Health, 2022] for additional information.) Another important topic to address is the need for Medicare–Medicaid coordination, including solutions to mitigate eligibility and enrollment barriers for Medicaid, Medicare, MSPs, and the Part D Low Income Subsidy (LIS) program.

Moreover, NASW encourages the ICC to implement or support the following recommendations to strengthen equitable access to Medicaid HCBS:

• Continue to reduce institutional bias in the Medicaid and Medicare programs, including setting goals to mitigate HCBS access disparities (both funding and utilization) based on age, disability type, race, ethnicity, and other demographic factors.
• Classify HCBS as a mandatory Medicaid benefit and increase HCBS funding.
• Make permanent the Medicaid Money Follows the Person program and HCBS spousal impoverishment protections.
• Monitor LTSS waiver waiting lists with particular attention to access inequities.
• Establish a 12-month continuous eligibility for adults enrolled in Medicaid.

Elder Justice

Please refer to NASW’s response to question 2 of this survey.

Person-Centered Access System—“No Wrong Door” and Other Statewide Access Systems

NASW recommends ongoing evaluation of and reporting on the efficacy of the programs named in the framework: Disability Information and Access Line (DIAL), Eldercare Locator, No Wrong Door system, and the 988 Suicide and Crisis Lifeline.

6. What could be added or changed to the Aligned Health Care and Supportive Services domain in the Strategic Framework for a National Plan on Aging?

As noted previously, nursing homes and other congregate care settings constitute an important part of the health care and social services continuum. Accordingly, the goal of Domain 4 needs to reflect all locations in which health care and supportive services are provided. Thus, NASW recommends that the language of the goal be edited to read, “All older adults maximize their health and reduce preventable disease and injury through comprehensive care that includes health and social services in the home, in nursing homes and other congregate care settings, and in the community.”

NASW’s comments on the focus areas associated with Domain 4 follow.

Benefits Access

NASW supports the ICC’s acknowledgment of underenrollment in programs such as MSPs and SNAP. We are also pleased that the framework supports the role of unbiased assisters, such as the State Health Insurance Assistance Program (SHIP), in facilitating beneficiary education and access to health coverage and supports. We encourage the ICC to add the following policy actions to the framework:

• simplification of Medicaid eligibility and enrollment, as noted in our previous comments
• aligning eligibility requirements for LIS and MSP
• improving Medicare–Medicaid integration and coordination, including by educating state Medicaid agencies about Medicare
• increased funding for the preceding efforts, for beneficiary outreach, and for enrollment assistance—especially through SHIP—for Medicare beneficiaries, Medicare-eligible individuals, and people who are dually eligible for Medicare and Medicaid
• access to Medicare and Medicaid (including LTSS) for older adults involved in the criminal legal system

Optimize Health, Well-Being, and Functioning

NASW strongly supports the framework’s focus on physical health, mental health, and substance use. We encourage the ICC to support the following policies and programs:

• funding of evidence-based and evidence-informed disease prevention, health promotion, and social care interventions delivered by Area Agencies on Aging (AAAs), Title VI Native American Aging Programs, and other community-based organizations
• funding of interventions for brain health
• mental health and substance use disorder (SUD) parity in the Medicare program (for which the Legal Action Center’s Medicare Addiction Parity Project [https://www.lac.org/major-project/mapp], in which NASW is involved, is a helpful resource)
• increased accountability (such as for provider network adequacy, prior authorization, and service denials) and decreased funding for Medicare Advantage plans (please refer to NASW’s comments [Bedney, 2023a, 2023d] responding to the proposed rules addressing prior authorization within Medicare Advantage [2022] and overpayments to Medicare Advantage plans [CMS, 2022], respectively, as well as to our comments [McClain, 2022c] on the Medicare Advantage RFI [2022])
• continued dissemination and integration of a person-centered, trauma-informed approach to service delivery, such as through the previously referenced Center on Aging, Trauma, and Holocaust Survivor Care
• coverage of dental, hearing, and vision services in traditional Medicare, along with expanded Medicare coverage of medically necessary dental care
• access to high-quality integrative primary care, including home-based care
• recruitment and retention of health professionals trained in aging and advancing the geriatrics and gerontological research base, as described in NASW’s response to survey question 2

Align Health and Human Services

NASW strongly supports this focus area. As described in NASEM’s 2019 report ,i>Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health and a related NASW issue brief (Dorn, 2020), social workers play key roles in enhancing population health. As members of both health care teams and human service organizations, social workers are well positioned and well trained to provide and coordinate services that address HRSN. The NASEM report recommends incorporating social workers in all health care teams, aligning financing mechanisms to support team members who provide social care, engaging social workers in interprofessional education efforts, and conducting further research related to integrating social care and health care, including the impact of various social care activities and staffing configurations on health and financial outcomes (NASEM, 2020). NASW urges the ICC to incorporate these actions in the framework. Similarly, NASW urges incorporation within the framework of the following policy changes: (i) Increase access to mental health services also includes continuing expanding the definition of “clinical social worker services” enabling Medicare beneficiaries to access clinical social workers, as described in a 2023 NASW issue brief. (ii) Acknowledge the significance of expanded beneficiary access to Health Behavior Assessment and Intervention (HBAI) services in the CY 2024 physician fee schedule final rule; support legislative efforts, such as those outlined in the Improving Access to Mental Health Act (S. 838/H.R. 1638, 2023; please refer, also, to NASW, 2024) and the Integrating Social Work Across Health Care Settings Act (H.R. 4638, 2023; please refer, also, to Coalition for Social Work and Health, 2023), to enable Medicare beneficiaries to access such as HBAI, advance care planning, and care management from clinical social workers. (iii) Increase beneficiary access to caregiver training services (CTS), community health integration (CHI), principal illness navigation (PIN), and SDOH risk assessment by enabling clinical social workers to bill Medicare directly for these services, as described in NASW’s comments (Bedney, 2024) on the CY 2025 physician fee schedule proposed rule (CY 2025 Medicare physician fee schedule, 2024).

Furthermore, NASW offers the following recommendations for this focus area:

• Identify the integral role of AAAs, Title VI Native American Aging Programs, and OAA Title III-D funding for health promotion and disease–injury prevention programs.
• Implement and enforce Section 1557 of the ACA and Section 504 of the Rehabilitation Act of 1973 to advance community integration, language access, and culturally competent services for Medicare beneficiaries and other people with federally funded benefits. (Please refer, also, to NASW’s comments [McClain, 2022a] regarding the 2022 proposed rule addressing ACA Section 1557 nondiscrimination protections.)
• Increase monitoring of supplemental benefits access within Medicare Advantage plans and ensure that any improvements in Medicare Advantage plans are incorporated within traditional Medicare coverage. (Please refer to NASW’s 2022 Medicare Advantage RFI comments [McClain, 2022c].)
• Strengthen access to mental health care and SUD services, such as through parity requirements and expanding access to clinical social work services. The latter includes removing the restriction that prohibits beneficiaries who receive SNF services under Medicare Part A from accessing mental health services provided by independent clinical social workers under Medicare Part B and increasing reimbursement rates for clinical social workers who participate in Medicare, as described in the previously referenced 2023 NASW issue brief.
• Demonstrate how the framework align with and expands findings and recommendations from other interagency committees, such as the Interdepartmental Serious Mental Illness Coordinating Committee (https://www.samhsa.gov/about-us/advisory-councils/ismicc) and the Interdepartmental Substance Use Disorders Coordinating Committee (https://www.samhsa.gov/about-us/advisory-councils/isudcc).

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