Family Assistance for Older Adults in Puerto Rico

Global aging is a growing issue in most countries, including Puerto Rico. The well being of the older adult population depends mainly on a collaborative government initiative that uses both public assistance and the engagement of family members. Puerto Rican policymakers are searching for alternatives to care for the expanding elderly population as well as to protect the country’s economy, avoid the financial cliff, and reduce the high cost of public assistance. The purpose of this article is to analyze The Act for the Improvement of the Family Assistance and for the Support of the Elderly, Act No. 193 of 2002, under the criteria-based model (Gallagher & Haskins, 1984) with a valuecritical appraisal (Chambers & Wedel, 2009). I suggest Act No. 193 of 2002 as a model for policymakers who are seeking ways to improve assistance for older adults, by promoting the following values: fairness, familism, fraternity, and accountability.

and assistance.As life expectancy in the population of adults age 60 years and older increases, the need for public policy also changes (Bearon, 2003;Shirley & Summer, 2000).
Older Adults' Reality with Social Security, Public Assistance, and Poverty: United States and Puerto Rico The United States provides Social Security benefits to assist older adults, and in 2005 research showed that almost 13 million U. S. senior citizens were lifted from the ranks of poverty because of Social Security (Sherman & Shapiro, 2005).Additionally, by 2010, this number increased to 36 million (Van de Water & Sherman, 2010).Other studies showed that about 9% of the population of the United States, age 65 years or older, is still living in poverty (DeNavas, Proctor, & Smith, 2010).Furthermore, for each 10% cut in public assistance, approximately 3% of America's older adult households slip into poverty (Center for Strategic and International Studies, 2010).
When considering income levels alone, at least 40% of people, age 65 years and older living in Puerto Rico are on the poverty borderline.(Ortiz, Abreu, Torres, & Vera, 2010b;Puerto Rico Community Survey, 2009).Puerto Rican older adults utilize Social Security, Medicare and public assistance as their main sources of income (Ortiz et al., 2010b).The United States Census Bureau (2009) has forecasted that Puerto Rican older adults will top 1 million in 10 years.The projection suggests that an additional one million Puerto Ricans will depend on public assistance, however, such support is questionable given cuts in federally funded programs.

Direct Relatives as Caregivers
It is projected that direct relative caregivers will pay more than they can afford for the care and living costs of older adults because of the economic downturn (Dobelstein, 2003;Shrieves, 2009).According to Shrieves (2009), around 78 million baby boomers were moving in with direct relatives because they lacked the financial resources to support themselves.Research has identified that around 52 million relatives, including adult children, spouses and relatives of aging adults have become caregivers in United States (Bearon, 2003).Additionally, caregivers are more likely to be adult children rather than spouses (Family Caregivers Alliance, 2005).Other studies indicated that the likelihood of receiving care from a spouse is higher as the age of an older adult increases.
Research found that ethnicity plays a role with respect to caregivers in the United States.Stewart, Russonello, and Belden (2005) used a sample of 1,247 caregivers who provided services to seniors over 80 years of age, and found that 21% of caregivers were white and African-American, 18% Asian American, and 16% Hispanic American.In another study, adult children whose progenitors were Hispanic were most likely to provide care to their older adults in their homes, while African American older adults were more likely to have non-family members providing care (Shirley & Summer, 2000).Care from significant others saved the U. S. government about $350 billion in services for older adults in 2006 (American Association of Retired Persons, [AARP] 2007).These results highlight the extremely important role of the caregivers in the lives of older adults and their positive contributions to the economy.

Puerto Rican Context
Although Puerto Rico has been a U.S. territory since 1898, the country's status since 1952 has been one of a commonwealth association with the United States (U.S.Department of the Interior, nd).Puerto Ricans became U.S. citizens in 1917, and have all of the same benefits, services, and privileges as any other U.S. citizen except that they cannot vote for the President, unless they live on the mainland (Deane, 2013;Levinson, 1998).
The Puerto Rican population is fairly homogeneous, yet it is made up of three cultures: the native Taíno (in Spanish), the Spanish, and the African (Levinson, 1998).This fusion of cultures has promoted essential cultural traits including spirituality, fraternity, familism, to mention but a few.Around 85% of Puerto Ricans are Roman Catholics (Culture Grams, 2009), and religion promotes community engagement with friends, neighbors, and family.Puerto Ricans are fraternal, which is evidenced by the way relatives and neighbors support each other; and they are resilient and pull together in times of need to support elders within the family structure.Puerto Rican caregivers are sons, daughters, and women from the community (Delgado & Tennstedt, 1997), who comparatively spend more time taking care of their elders than the mainland caregivers do (Sberna Hinojosa & Rittman, 2007).In Puerto Rico, many neighbors are also considered members of the extended family.Certainly, faith-based organizations, social service associations, government agencies, and public service agencies promote a culture of caring and accountability in the care of the elderly in Puerto Rico.
In the global arena, not all countries are prepared for global aging.The well being of the older adult population more often than not depends on public assistance.Consequently, policymakers are searching for alternatives to save their country's economy, avoid downturns, and reduce the high cost of public assistance, globally.This article presents the case of Puerto Rico.It analyzes the Act for the Improvement of the Family Assistance and for the Support of the Elderly, Act No. 193 of 2002, under the criteria-based model (Gallagher & Haskins, 1984) using a value-critical appraisal (Chambers & Wedel, 2009).The author suggests Act No. 193 of 2002 as a model for policymakers who are seeking ways to improve assistance for older adults, promoting the following values in the population of their country: fairness, familism, fraternity, and accountability.

Policy Selection: Act No. 193 Of 2002
The Government of Puerto Rico, in preparing for global aging, strives to attend to the population of older adults.For example, the creation of the position of the Advocate for Older Adults (Position of the Advocate for the Elderly Act No. 203 of 2004) and the Act for the Improvement of the Family Assistance and for the Support of the Elderly, Act No. 193 of 2002 are both efforts to deal with the issue.However, the economic downturn led to the passage of Act No. 7 of 2009 (Special Act Declaring a State of Fiscal Emergency and Establishing Comprehensive Fiscal Stabilization Plan to Save the Credit of Puerto Rico), which terminated employment for over 30,000 workers in public agencies, and affected programs within the Puerto Rico Department of Family and the Advocates for the Women, Patient, Veterans, Disabled, and OPPEA (Oficina del Procurador(a) de las Personas de Edad Avanzada).Despite all of these changes, the Program for the Support of People of Advanced Age (PROSPERA, in Spanish) was unaffected by Act No. 7 (Caro, 2009).
The Act for the Improvement of the Family Assistance and for the Support of the Elderly, Act No. 193 of 2002 created PROSPERA; one of the programs managed by the Administration for Child Support Enforcement and one of the five initiatives directed by the Puerto Rico Department of Family. Act No. 193 of 2002 is a public policy that addresses the duty of direct relative caregivers who provide assistance to their older adults, with consideration to their available resources.This policy borrowed Canadian regulations regarding financial assistance for older adults living in Canada (Ramos, 2008).

Proposed Models for Analyzing Act No. 193 Of 2002
The criteria-based model, which was proposed by James Gallagher and Ron Haskins (1984), served as a policy framework to develop a policy model to analyze Act No. 193 of 2002.This framework includes the following steps: (1) defining the problem with respect to available policy alternatives, (2) establishing universal and selective criteria for ordering the alternatives, (3) gathering data, (4) weighing the costs and benefits of each alternative against each criteria, and (5) recommending the alternative that maximizes the criteria.Gallagher & Haskins (1984) defined alternatives as policies available to address the social problem and to promote the desired criteria in the population.In addition, the value-critical appraisal, which was suggested by Chambers and Wedel (2009) helped to analyze the adequacy and cost-effectiveness of the education, mediation, and adversary processes proposed by Act No. 193 of 2002.
The criteria-based model incorporates three values: universal, selective, and efficiency.The universal criterion refers to the values promoted by the policy to address a social problem.The selective criterion refers to the values position promoted by the policy related to a particular aspect of a social problem.The efficiency criterion provides a summary to assess the value position of the policy.Dobelstein (2003) suggests that paradigms based on the criteria-based model match with policies addressing issues in the population of older adults.

Definition of the Problem with Respect to Available Policy Alternatives
Social indicators.Around 500,000 individuals over 60 years of age represent the population of older adults in Puerto Rico (Ortiz et al., 2010b).The percentage of Puerto Rican older adults has increased rapidly as a result of increases in life expectancy (on average 78 years of age) due to advances in medicine and improvements in diet and lifestyle (Ortiz et al., 2010b), as well as other demographic trends faced by the younger generation.A closer look shows that in Puerto Rico, almost 1,000 young people were murdered during 2010 (Figueroa & Hernández, 2011), and more than 100 died in the first month of 2011 (Colón, 2011), and, many young-and middle-age Puerto Ricans relocated to the United States for better employment opportunities (El Nasser, 2012), which contributed to a decrease in birth rates.
Puerto Rico has a higher proportion of older adults in comparison with all of the U. S. territories (Administration on Aging, 2010;United Nations, 2009).By 2015, the population of older adults will be greater than that of children aged 15 years or under (Ortiz et al., 2010a;Tendencias Project, 2006).Sadly, a recent survey notes that 16.5% of Puerto Rican older adults have been victims of maltreatment or abuse, 40 % are living below poverty standards, and 50.3% are disabled living in their homes (Puerto Rico Community Survey, 2009).If these trends continue, they will clearly affect the cultural assets of the families and neighborhoods.

Social problem.
As previously discussed, Puerto Ricans are family oriented and try to support each other in difficult times; however some direct relatives are unwilling and/or unable to support their older adults.Given societal shifts, the Puerto Rican government took a more active role to protect the elderly and developed the Civil Code of Puerto Rico, Article 143 (1930) and the Act No. 193 of 2002 to address the care of its older citizens.In sum, Article 143 defined the responsibility of relatives in sharing the duty of maintaining the welfare of the family, while Act No. 193 of 2002 particularly focuses on the duty that direct relatives have in taking care of their older adults.

Establishing Universal and Selective Criteria for Ordering the Alternatives
The policymakers used accountability, fairness, fraternity, and familism values as criteria for ordering alternatives.First the criterion of accountability is the value that both policies promote with direct relatives who are particularly unwilling to provide assistance to their older adults.Second, fairness is the value projecting what is right on the distribution of duties for taking care of older adults.Third, fraternity, a strong value among Puerto Ricans, represents brotherhood/sisterhood and upholds the concept of responsibility towards relatives and significant others.Last, familism holds the family members responsible for providing economic and emotional support to the elderly (Fried & Mebrotra, 1998).These four values were chosen to implement state public policy to improve support to the elderly.

Gathering Data
Civil Code Art.143.This Code instructs the direct relatives to address the needs of the older relatives, by defining the relatives who are responsible for providing alimony (e.g.spouses and adult children).According to this policy, alimony includes those items needed to maintain the well-being of the older adult such as food, clothing, and medical assistance, in accordance with the socioeconomic status of the family.In addition, family members can ask the government for alimony, if it is necessary for the welfare of a particular family member.This Code does not provide guidelines for how alimony would be claimed.The policy proposed the adversary process for dealing with this social problem, and grants power to the civil court for implementing alimony.Occurrences of the use of this policy are infrequent; however, Act No. 193 of 2002 recognizes the existence of civil suits under the Civil Code of P.R. Art.143 of 1930.
Act No. 193 of 2002.This Act presents three phases.The first is an administrative process known as mediation.Although any relative who wants to provide care to the older adult is welcomed, a mediator arranges an appointment with direct relatives to clarify roles.The second phase is known as the adversary process, which is implemented if the direct relatives cannot come to an agreement on who will care for the older adult.In the third phase, PROSPERA was created to implement an education program to promote the responsibility of direct relatives for the welfare of their older adults and to provide services to people age 60 years and older (Act No. 193, 2002).Older adults receive economic and non-economic assistance as Act No. 193 of 2002 defines alimony.Noneconomic assistance refers to any other type of support to promote an older adult's welfare.Examples of non-economic assistance are transportation, companionship, visitation, and attention.

Mediation process.
Mediation is an alternative dispute resolution approach to resolve conflicts between older adults and direct relatives.Participants receive help from a certified mediator to discuss their differences about an issue.The mediator does not decide what is right or wrong, but instead serves as a neutral moderator who takes into account the choices presented by participants.Mediation is an informal and confidential process (Coulson, 1996) that has helped resolve family disputes (Roberts, 2008).
Recognizing the power that mediation provides to reconcile disagreements, Puerto Rico practices mediation in courts and other public agencies.For example, in 2006, the Judicial Branch of Puerto Rico resolved 97% of 3,314 disputes through mediation, where PROSPERA, working under Act 193, resolved 80% (827 cases of 1,026 cases) of family disputes through mediation (Ramos, 2008), which resulted in alimony agreements for older adults.
Adversary process.Government, as an institution, regulates human behavior by determining what is right or wrong by exercising social power on human societies via the courts (Villalobos, 2005).For the most part, the government gives the court the power to distribute justice, and state agencies the responsibility to bring those not following the law before the court (Rivera, 2006).The adversary process brings before the court adult children, or direct relatives and a judge uses his/her recourse to make adult children comply with Act No. 193 of 2002.For example, if adult children do not follow court orders, they can go to jail for at least six months.In addition, they can be fined at least $500 U.S. dollars.On the other hand, the PROSPERA program administrators can fine direct relatives up to $5000 U.S. dollars.This Act also has an advocate position where a lawyer can represent the older adult before the court.Ramos (2008) reported that PROSPERA had 1,026 cases; 16% (171 cases) that were referred to the advocate for assistance, but only 3% (28 cases) were presented before the court.And of those 28 cases, gerontologist and social workers recommended the mediation process to achieve alimony agreements for each (Ramos, 2008).
Education process.Psycho-educational programs promote change in human functioning and coping skills (Dubanoski & Tanabe, 1980;Gerris, Van As, Wels, & Janssens, 1998;Lawrence, 1998).Act 193 of 2002 utilizes the psycho-educational concept to promote values such as familism, accountability, fairness, and fraternity, and to carry out its mandate of encouraging relatives to accept responsibility for their older family members.The educational process also includes the provision of public information by the agencies and organizations composing the aging network.For example, PROSPERA trains judges to be effective and efficient when working with older adults.In addition, social workers play a professional role by educating direct relatives on the values promoted by Act No. 193 of 2002. Act No. 193 of 2002 also includes a requirement to bring before the courts those direct relatives who were unwilling to deliver assistance to their older adults.This Act has an advocate position where a lawyer can represent the older adult before the court.Ramos (2008) reported that PROSPERA had 1,026 cases; 16% (171 cases) that were referred to the advocate for assistance, but only 3% (28 cases) were presented before the court.And of those 28 cases, gerontologist and social workers recommended the mediation process to achieve alimony agreements for each (Ramos, 2008).

Weighing the Costs and Benefits of Each Alternative Against Each Criteria
Although the implementation of the Civil Code of P.R. Art.143 of 1930 presents no cost to the Executive Branch of Puerto Rico, it does involve a cost to the Judicial Branch (e.g. the salary of judges).Older adults are expected to pay for their defense before the court.Even though this policy promotes all criteria, the question remains whether older adults can afford a civil suit, particularly when in Puerto Rico, 40% of the older adult population lives below poverty standards.Therefore, the benefit of implementing this alternative is questionable.
The implementation of Act No. 193 of 2002 through PROSPERA creates costs to the Executive Branch of Puerto Rico. Art. 10 (Act No. 193, 2002) makes available an advocate who provides legal services free of cost to older adults.However, PROSPERA contracts for professional services from mediators to help offset the costs to the Executive Branch.
The education phase varies in costs.Art. 8.1g (Act No. 193, 2002) includes the use of the media, which involves payments for advertisements on the radio, Internet, and television.Education also covers orientations, conferences, and presentations in different communities and public or private agencies.The cost of advertising on television and radio tends to be higher than promotional tours in public or private agencies and communities.

Selection: The Alternative that Maximizes the Criteria
The Act No. 193 of 2002 addresses the social problem despite the costs of PROSPERA.Indeed, the Civil Code of P.R. Art.143 of 1930 cannot be a policy alternative given that the majority of the population of older adults cannot afford legal services.Research suggested that older adults prefer the mediation process instead of the adversary one (Ramos, 2008).Mediation allows direct relatives to create a plan to share duties to increase the quality of life of their older adults.To enhance the clarity of the plan, Act.No. 193 of 2002 provides a definition of alimony which is preferable to older adults.

Equality and Adequacy
Act No. 193 of 2002 promotes equality through the creation of PROSPERA.The equality value in this policy represents a leveling approach for sharing duties between relatives and older adults, the government, and human service agencies.The education, the mediation, and the adversary processes address the roles and responsibilities of all parties involved.The processes mentioned above may have unintended consequences.For example, it has been observed that direct relatives may also bring unresolved past family conflicts to the mediation process, which may provide an opportunity to air, and in some cases, resolve old emotional wounds.
Social workers may play an important role by preparing direct relatives for the mediation process.This is also known as therapeutic mediation.In doing so, social workers serve as facilitators in the implementation of equality between direct relatives and older adults.

Cost Effective
Art. 19 (Act No. 193, 2002) assigns PROSPERA $500,000 U.S. dollars from the fiscal budget of Puerto Rico.In addition, Art.6 created a special fund for the program, which receives deposits from services, gifts, incentives, income, fines, charges, interest, penalties, costs, expenses, and fees.PROSPERA uses all of these funds to run the program and to pay professional service contracts.The administrator, who acts as chief of the Administration for Child Support Enforcement, provides the fiduciary oversight of these funds and determines how they are going to be distributed.
The cost-effective factor is a concern promoting equality under the Act No. 193 of 2002.Due to the demographic increase of older adults on the island, the currently assigned budget to run PROSPERA is insufficient to provide adequate services.Hence, the need for the special fund to supply the education program of PROSPERA and to provide better services for older adults.PROSPERA can also ask for assistance with creating practicum centers for bachelor and graduate social work students and certified mediators in training.These centers promote a community partnership approach between public agencies and the academic community.PROSPERA can also solicit non-profit organizations for volunteers to work with the older adult population.

Conclusion
Puerto Rico, as with other countries in the world, is experiencing significant increases in the number of people living longer due to a combination of factors.
Undoubtedly, longevity has created challenges in the care of older adults, particularly the very old, for family members, practitioners, and policymakers.This article offers an analysis of Act No. 193 of 2002 as a guide to partially address the challenges of promoting the responsible care of older adults by their direct relatives through a leveling approach with the involvement of the extended family, generous neighbors, and friends.In addition, the policy improves family assistance by bringing an innovative definition of alimony, and it introduces the concept of non-economic payments such as transportation, companionship, visitation, and attention.The application of the Act No.193 facilitates processes to safeguard the welfare of older adults by creating a partnership between families and public assistance.It should be said that PROSPERA needs to create job positions for social workers who can benefit by becoming certified as mediators for older Puerto Rican adults.In addition, social workers may contribute to program evaluation.
There is little question that Act.No. 193 is based on the four fundamental Latino values of: fairness, familism, fraternity, and accountability as discussed in the body of this manuscript.The older adult population will continue to grow in the near future, and it will be pertinent to continue searching ways to integrate existing resources at the grassroots and government levels, which promotes the well-being of older adults and lowers the costs of public assistance.