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  • Dedication Richard C. Ladd, 1939−2003

    Richard “Dick” Ladd, founding director of the Oregon Division of Aging Services, is an icon for home- and community-based services (HCBS). With steadfast vision, strategic program-building skills, and an awesome grasp of data, he demonstrated that HCBS were possible for elders with substantial disability levels.

    Dick joined the navy at age 18, serving on a submarine. During 1961 to 1975, he had various jobs, including a stint as a long-distance truck driver—a job through which he gained a precise understanding of United States geography, knowledge he retained while re-tracing the nation’s roads in outsized rental vehicles to promote HCBS. He earned a bachelor’s in experimental psychology and statistics in 1976 and a master’s in adult education and political science the next year. Dick rose meteorically in Oregon state government—in 1982 starting the first HCBS waiver. In 1992, he became Commissioner of the Texas Health and Human Services Commission, coordinating eleven agencies with a combined budget of $12 billion. His obituary in Salem, Oregon’s Statesman Journal said:

    …through his innovative approach, Oregon was able to serve more people in need of long-term care, with a full array of services directed toward preserving the dignity and quality of life of those served…. He proved he could change bureaucracies and bring special interests and politics together for the good of the most frail and needy citizens.

    After 1994, as director of Ladd & Associates (“The associates are my wife and our three gray hounds,” Ladd said), he wrote detailed analyses of long-term services and supports (LTSS) systems for eight state governments and consulted to many

  • others. From 1995, he co-directed the National LTC Balancing Project at the Univer- sity of Minnesota, using data to highlight discrepancies between nursing homes and HCBS expenditures for older people. In his blunt state ratings, he didn’t hesitate to identify those making “poor” or “very poor” progress in rebalancing LTSS systems toward HCBS.

    Dick tirelessly busted myths: that older people hold safety as their paramount life goal; that shared rooms in nursing homes provide appreciated companionship; that credentialed professionals can accurately determine an “appropriate” care level for people, thus prescribing where they should live; and that licensed nurses must do most homecare tasks. Dick advocated against the goal of a continuum of care along which older people are slotted, advocating instead for a repertoire of services from which people could select.

    Dick articulated three barriers to widespread HCBS for older people: logistical, political, and philosophical; he thought the last the most formidable. His hallmark program included combining state funding and authority for both HCBS and nursing home care; developing assessment and case management systems; permitting the delegation of nursing tasks to unlicensed personnel; aligning programs for older and younger people; developing senior advocacy constituencies; and creating capacity for livable group-residential alternatives.

    Many contributors to this issue of Generations still hear Ladd’s voice. Keren Brown Wilson says he spurred her to go national with her assisted living ideas at the risk of losing control of developments rather than “feeling good” about a rarefied program in Oregon. Susan Reinhard recalls him as “a mentor and cheerleader for those who sought to bring independence, dignity, and choice to their states.” Herb Sanderson, who considered Dick “a giant with a lot of us standing on his shoulders,” says his favorite Ladd quote is: “I never met a provider that had enough money or a bureaucrat that had enough staff.” Richard Browdie remembers him as a realist: “He knew that there was only so much money around, and that moving it would be hard. Dick accepted from the earliest days that changing the way the system treated older people was going to lead to conflict with the vested interests that benefit from the status quo. When confronted by those interests, he fought the good fight, usually winning and occasionally not…. He was a formidable, capable, and principled advocate for the right of older people to be able to choose the setting of their care as much as younger people with disabilities.”

    Dick Ladd was a savvy insider, a no-nonsense spokesperson, a planner, and a vision- ary. He did not let the perfect be the enemy of the good. A larger-than-life figure, literally and symbolically, Dick was a man of thought and of action. If not for his premature death, he would still be trying to make our LTSS systems better and expand HCBS for everyone, including older people.

    —Rosalie A. Kane, Guest Editor

  • Volume 36 .Number 1 | 1

    Peer review consists of the following practice: the Genera- tions editorial board invites a guest editor, selected because of prominence within his or her subject area, to organize an issue of the publication around themes identified by the board. Authors are then proposed by the guest editor and are evaluated by the board on the basis of demonstrated knowl- edge, achievement, and excel- lence in their respective fields. All manuscripts are reviewed by the guest editor, editor, and, when appropriate, members of the editorial board. As occurs in any peer review process, revisions may be required, and articles that do not meet the editorial standards of Genera- tions will not be published.

    Generations (ISSN 0738-7806) is published quarterly by the American Society on Aging, 71 Stevenson Street, Suite 1450, San Francisco, California 94105-2938.

    Subscription rates are as follows: for institutions, $105, either print or online; $131, both print and online (foreign, online only). For individuals, $60, both print and online (international, online only). For subscription information, single copies, and back issues, contact ASA at 800-537-9728 (phone), (e-mail). Back issues are available in various formats from ProQuest, 800-521-0600.

    For information about reprint permission, contact permissions, 415-974-9610 (phone), (e-mail). Reprint permission information is available at

    Advertising space in Generations is available. For information and rates, contact ASA’s marketing department, 415-974-9600 (phone), (e-mail).

    Postmaster: Send address changes to Generations, 71 Stevenson Street, Suite 1450, San Francisco, California 94105-2938.

    is the quarterly journal of the American Society on Aging. Each issue is devoted to bringing together the most useful and current knowledge about a specific topic in the field of aging, with emphasis on practice, research, and policy.

    The contents of Generations are indexed or abstracted in the following: Abstracts in Social Gerontology; AgeLine; CCCs Bibliographic Database; CARL UnCover/Ingenta; CINAHL Database; Cumulative Index to Nursing and Allied Health Literature; Current Contents Social and Behavioral Sciences; Elsevier Bibliographic Databases; ERIC; Family & Society Studies Worldwide; Institute for Scientific Information Basic Social Sciences Index; Microsoft Academic Search (MAS); MLA Interna- tional Bibliography; Research Alert; SAGE Family Studies Abstracts; SCIE CareData; Social Sciences Citation Index; Social SciSearch; Social Services Abstracts; Social Work Ab- stracts; Sociological Abstracts; Web of Science; Wilson Social Sciences Index/Abstracts.

    For digital access to the current and back issues of Generations, visit http://generations.metapress. com/content/120835.

  • GENERATIONS – Journal of the American Society on Aging

    2 | Spring 2012

    ASA Executive Committee

    Chair, Board of Directors Louis Colbert, Eddystone, PA

    Chair-Elect Lynn Feinberg, Washington, DC

    Immediate Past Chair John Feather, Arlington, VA

    Secretary Ouida Williams Simpson, Eagleville, PA

    Treasurer Patricia J. Volland, New York, NY

    ASA Board of Directors

    Tobi A. Abramson, Old Westbury, NY

    Dianne Belli, Los Angeles, CA

    William Benson, Silver Spring, MD

    Robert Blancato, Washington, DC

    Colette V. Browne, Honolulu, HI

    Mae R. Carpenter, Mount Vernon, NY

    Debra Cherry, Los Angeles, CA

    Yanira Cruz, Washington, DC

    Scott Dingfield, Omaha, NE

    Ken Dychtwald, San Francisco, CA

    Robert E. Eckardt, Cleveland, OH

    Mauro Hernandez, Clackamas, OR

    Michael Hodin, New York, NY

    Barbara Howard, Westport, CT

    Karyne Jones, Washington, DC

    Jonathan Lavin, Oak Park, IL

    Nancy Lewin, Hillsborough, NJ

    Peter Reed, Sacramento, CA

    Erlene Rosowsky, Needham, MA

    Laura Weber Rossman, Bowie, MD

    President and CEO Robert G. Stein, San Francisco, CA


    Publisher Robert G. Stein

    Editor Alison Hood

    Senior Editor Alison Biggar

    Copy Editor Kim Torgerson

    Typography & Production Acacia Graphics & Design, San Francisco

    Generations cover and book design by Lisa Rosowsky, Blue Studio.

    Generations Editorial Advisory Board

    Erlene Rosowsky Chair

    W. Andrew Achenbaum

    Robert Applebaum (Chair, 2002−2005)

    Mercedes Bern-Klug

    Richard Browdie

    Colette V. Browne

    Pearl Beth Graub

    Joanne Handy

    Mauro Hernandez