With major changes to long-term care for the elderly underway in Pennsylvania, the advocacy group Diane Menio leads is working on overdrive.

"The state is moving very quickly to change all of long-term services and supports to managed-care organizations," said Menio, 60, executive director of the Center for Advocacy for the Rights and Interests of the Elderly, a statewide advocacy group based in Philadelphia.

What the change means is that insurers will not only manage care for the elderly poor on Medicaid, but will also set up other supports, such as home or nursing-home care.

Those services are now handled by each county's Area Agency on Aging. The Philadelphia region will roll into the new Managed Long Term Services and Supports (MLTSS) system in 2018.

Insurers "are already geared up to do it," Menio said. "That train's already out of the station, so in terms of our advocacy, the best thing we can do at this point is try to make sure that the system works for consumers."

What kind of protections do the elderly need?

The right to choose the services they need. The right to get quality services, the right to choose their providers. The right to appeal. The right to have an advocate, if they have a problem.

How will it work?

The insurer will get a capitated [set] amount from Medicaid, and a capitated amount from Medicare to take care of these people.

Give me an example of what worries you about this change.

There are so many things. Suppose you have a person who has spent their money and is now in a nursing home. They may have to move, because [the insurer] may not have an agreement with that nursing home. That's very disruptive to peoples' lives.

How are those services handled now?

Now you have an agency that's in your community that's providing services. You have a person who comes to your house and sees you and assesses you, and knows you.

How will insurers like Independence Blue Cross or Aetna handle it?

I don't know what their plans are. Most insurance companies are not charitable organizations. They have to worry about their bottom line.

What's the problem this change is intended to fix?

In the last administration, we had changes in the way the [agencies] operated and people had to wait six months, sometimes, to get services.

That's a long time.

We had almost eliminated that kind of wait before. Now they tell us they're trying to fix that. But this [change] is the way they're trying to fix it, rather than going back to the way we used to operate when things were working well.

We're all getting older. How should we prepare?

I think any adult should be looking at your advance planning documents, including advance directives and powers of attorney. I think you should have frank discussions with your family about what your desires are. Those documents, as important as they are, [are not] important unless you really give thought to them.

Any guidelines?

There's an online tool called Five Wishes that we recommend people use. Of course, a power of attorney would take care of your business stuff. The discussion is not just about what your wishes are, but it's also about knowing where things are - your parents' bank accounts, for example.

These are tough conversations to have.

But in the end many of us end up in these situations where you're caring for family, and without more information, it's very challenging. The Five Wishes people had a campaign to do these discussions at Thanksgiving because families are together.

You began your social services career helping children in troubled situations.

Not long after [I started], I realized that I had almost zero sympathy for their parents.

What do you like about working with the elderly?

I've always felt comfortable with older people, and now I'm getting older myself, so it makes it easier.

Interview questions and answers have been edited for space.