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Table of Contents:

Part I – Agency Context for Performance Measurement
1.1 Agency Mission and Long Term Goals
1.2 Organization, Programs, Operations, Strategies and Resources
1.3 Partnerships and Coordination.
1.4 FY 1999 Performance Report
1.5 Performance Outcomes Measures Project

Part II – Performance Measures
Budget Level and Full-Time Equivalent Chart
Performance Measures by Performance Area

2.1.A Home-Delivered Meals
2.2.A Information and Assistance
2.3.A Long-Term Care Ombudsman
2.4.A State and Local Innovations and Projects of National Significance -- Mental Health Initiative

Part III -- Appendices
A.1 Approach to Performance Measurement
A.2 Changes and Improvements Over Previous Year
A.3 Linkage to HHS Strategic Plan
Budget Linkage Table

1.1 Agency Mission and Long-Term Goals

The Administration on Aging is the Federal agency whose goal is to improve the quality of life for all older Americans, primarily by assisting them to remain independent, actively engaged, and productive. Through the Older Americans Act, AoA works closely with its nationwide network of state, tribal and area agencies on aging to plan, coordinate and develop home and community-based systems of services that meet the unique needs of older persons and their families. The agency’s mission is reflected in statute. The Older Americans Act provides a broad organizing set of ten core national values and objectives for AoA’s programs in language that articulates a vision as well as transcendent, fundamental aspirations for America’s older population. The motivation for embracing these values and honoring the objectives is captured in the President’s statement in his proclamation for Older Americans Month 1999: This year’s theme “...reminds us of the profound debt of gratitude we owe to the generations of older Americans whose hard work, courage, faith, sacrifice and patriotism helped to make this nation great.

Strategic Goals of the Administration on Aging

• Provide opportunities for better nutrition and improved health;
• Provide access to services people need by reducing barriers; e.g., by utilizing culturally competent service delivery approaches and by increasing their participation and engagement;
• Provide opportunities to live with safety, independence and dignity; and at the systems level,
• Develop comprehensive and coordinated services systems based on local needs.

• Goal 1 -- Reduce the Major Threats to Health and Productivity of All Americans.
  • Strategic Objective 1.3: Improve the Diet and Level of Physical Activity of Americans.
• Goal 2 — Improve the Economic and Social Well-Being of Individuals, Families and Communities in the United States
  • Strategic Objective 2.5: Increase Opportunities for Seniors to Have an Active and Healthy Aging Experience
  • Strategic Objective 2.6: Expand Access to Consumer-Directed Home and Community-Based Long-Term Care and Health Services
• Goal 3 -- Improve Access to Health Services and Ensure the Integrity of the Nation’s Health Entitlement and Safety Net Programs
  • Strategic Objective 3.5: Enhance the Fiscal Integrity of HCFA Programs and Ensure the Best Value for Health Care Beneficiaries
  • Strategic Objective 3.6: Improve the Health Status of American Indians and Alaska Natives
• Goal 4 — Improve the Quality of Health Care and Human Services
  • Strategic Objective 4.1: Promote the Effective Use of Appropriate Health Services
  • Strategic Objective 4.2: Reduce Disparities in the Receipt of Quality Health Care Services
  • Strategic Objective 4.4: Improve Consumer Protection.

Along with statutory responsibilities and Departmental objectives, the agency’s mission is shaped by the agency’s strategic vision. In this regard, the Administration on Aging has adjusted its overall goals and priorities to respond to the phenomenon of dramatic longevity, which has become even more evident over the last decade. Such a reorientation is essential in light of growing societal recognition that America’s social practices, institutions and individuals will be required to respond to the fundamental demographic shift which is occurring because human life expectancy has increased more during the last century than over the last four millennia.
It is now evident that Americans of all ages must begin to anticipate and plan for the likelihood that they will live to be 80, 90, and 100. The opportunity to live a longer life heightens the importance of:

• keeping active and healthy
• earning and saving as much as possible in order to live comfortably in the ;ater years;
• being involved in work or activities that are satisfying; and
• maintaining rewarding relationships with family and friends.

1.2 Organization, Programs, Operations, Strategies and Resources

The Administration on Aging is an operating division of the Department of Health and Human Services, headquartered in Washington, D.C., with regional offices across the country. Total staffing is less than 150. This small size presents several challenges for the agency, not the least of which is assuring that staff continue to acquire the skills required to fulfill the agency’s mission. AoA has begun a workforce planning and implementation process to prepare the agency to meet the changing demands placed on it by an ever-larger and more diverse older population, and to strengthen the core competencies and technical skills of its present workforce to meet those demands. The workforce planning process identified the essential core competencies and technical skills which should underpin a functional model of the organization. The agency is utilizing the plan that was developed as an outcome of the process to ensure that both human resource development and recruitment activities result in the targeted generation and acquisition of those competencies and skills necessary to achieve the agency’s mission, goals, and future objectives.

Based on these efforts, AoA is requesting funding for several additional FTEs. These staff are needed to ensure that AoA can effectively lead important departmental and federal initiatives that respond to and prepare the nation for the challenges and opportunities which accompany increased longevity.

The Aging Network

AoA awards grants under the authority of the Older Americans Act, which provides funds for services and for basic administrative support of the State, tribal and area agencies in the aging network. Many services provided through the Aging Network are funded by pooling a variety of sources, including other Federal programs, State programs (often substantial), local funds and program income received as donations by people who, for example, receive meals at a congregate nutrition site.

This ability to leverage and use funds for services from sources other than the Older Americans Act illustrates an essential system outcome of the Aging Network. The Act was never intended, in and of itself, to operate a discrete, independent services program. Rather, the Act put into place a nationwide service delivery system, the Aging Network, which identifies service needs and necessary service system modifications, offers state and local plans to remedy needs, coordinates other funding streams, and then weaves the services funded by these into a comprehensive services system. Services funded under the Act frequently are used to "fill gaps" in other programs, for example, by providing services to people who are ineligible for other programs but who still need support. We use the proportion of "leveraged" funding as a performance indicator for community-based access services in this plan.

The Aging Network is responsive to the diverse population of older Americans, meeting a wide range of needs, as determined by state and local agencies through needs assessment processes. Meals are served in congregate settings such as senior centers, for example, to people who are poor and socially isolated. Many older people with mild functional impairments need such supportive services as transportation. For older people with more severe limitations, the Aging Network provides home and community-based long term care services through a system which it began to develop in the 1970’s. In communities throughout the nation, the home and community-based service systems led by the Aging Network provide a preferred alternative to nursing home care, enabling people to live as independently as possible for as long as possible.

The Older Americans Act

The Older Americans Act is currently being considered for reauthorization in the Congress, and AoA has attempted, through the Administration’s proposal, to present a new vision to enable America and its communities and its people to prepare for the growing longevity of our population. The reauthorization proposal is designed to offer strong support to the Aging Network of state, tribal and local entities to enable them to best meet emerging challenges.

To improve and strengthen the flexibility of the OAA programs, the Administration proposes to streamline the operations of state programs, add flexibility by eliminating unnecessary Federal requirements, and build a more responsive customer orientation.

Linkage Between Goals

Consistent with the requirements of the GPRA, AoA has established a linkage between performance goals and strategic goals. Each performance goal supports the achievement of one or more of AoA’s strategic goals. The successful pursuit of AoA activities contributes to the achievement of performance goals by helping assure excellence in the operation of state and area agency programs. 

Achievement of strategic goals is dependent on the successful achievement of performance goals.

Fiscal Year 2001 Budget Proposal

1.3 Partnerships and Coordination

Collaboration with the Aging Network

1.4.A Client Characteristics

Older Americans Act services reach a significant percentage of all the people 60 years of age or over in the country. The aging network targets scarce resources to people in the greatest social and economic need. Our programs serve members of minority groups, the poor and people with disabilities at a rate greater than their proportion in the general population.

AoA employs Census Bureau estimates for 1993 as these estimates correlate data for people 60 years of age and older by race or Hispanic origin, and by poverty. The number of people in the country 60 years of age and older was 41,399,000. The number who received services under the Older Americans Act in 1997 was 7,045,360, or 17 percent of the total population age 60 and over, and 6,891,416, or 16.6 percent in 1996.

The number of African American individuals 60 and above in the country was 3,704,000, or 8.9 percent of the population. The number of African American individuals who participated in our programs in 1997 was 738,519, or 10.7 percent of all participants. The number in 1996 was 703,076, or 10 percent.

The number of individuals of Hispanic origin 60 and above was 1,776,000, or 4.2 percent of the population. The number of individuals of Hispanic origin who participated in our programs in 1997 was 525,304, or 7.6 percent of all participants. The number in 1996 was 444,430, or 6.3 percent.

The number of people in poverty age 60 and over was 3,376,000, which was a percentage of 10.5. The number of people in poverty who participated in our programs in 1997 was 2,681,008, or 38.9 percent of all participants. The number in 1996 was 2,671,772, or 37.9 percent.

Disability figures from the Census Bureau’s Survey of Income and Program Participation show that in 1994 and 1995 14,679,000 people, or 47 percent of those age 65 and over, reported difficulty with one or more functional activities. Some 5 million people, or 16 percent, reported that they needed personal assistance with one or more of the instrumental activities of daily living or the activities of daily living.

Preliminary data from 16 states for 1997 show that people with limitations in the instrumental activities of daily living (IADLs) represent between 62.6 and 84.7 percent of all recipients of a group of “registered” services that includes personal care, chore, and homemaker services, home-delivered meals, adult day care and case management. People with limitations in the Activities of Daily Living (ADLs) represent between 57.6 and 77 percent of all recipients of registered services. Some of the people represented in the ADL chart also have IADL limitations, although this is not shown in the data.


1.4.B Performance Measures

Strategic Goal 1: Provide Opportunities for Better Nutrition and Improved Health

Our performance goal in this area was to maintain the provision of services with level funding. We expect to have data for fiscal year 1999 by September, 2000. The trend, however, between fiscal years 1995 and 1997, was that home-delivered meals increased while congregate meals decreased, which is consistent with the pattern of states transferring funding from the congregate and general services programs to the home-delivered meals program.

For the most part, Native American programs maintained the level of services, adjusted for inflation, in the face of level funding.

The baseline reported in the fiscal year 1999 performance plan, i.e., the level of service provision in 1995, has been updated in our data-collection system. Those figures, and those for 1996 and 1997, appear above. The data-collection system for the Native Americans program collects data on an April-through-March basis, rather than the October-through-September (Federal fiscal year) basis for the State Program Report.

Strategic Goal 2: Provide access to services people need by reducing barriers, bringing cultural competence to services, and providing opportunities for social engagement.

The Older Americans Act defines the following as “access services:” information and assistance; transportation; and case management. We chose to measure the provision of these services as representative of the strategic goal of providing access to services, and note that the receipt of access services often implies the receipt of other services.

In the area of information and assistance – often an individual’s first contact with the aging network – we saw consistent and continued growth, both in the network’s provision of services and their ability to “leverage” funding, that is, to obtain funds for the provision of the service from sources other than the Older Americans Act.

In the area of transportation, states chose to use less of their funding under Title III of the Older Americans Act for this service between fiscal years 1995 and 1996, while leveraged funding increased. Title III funding rebounded, however, between 1996 and 1997, and leveraged funding continued to increase. The decrease between 1995 and 1996 may be an artifact of the new data system. We expect some variation over the first three years of a phased, three-year implementation period for the State Program Report system. Fiscal year 1999 data will be available in September, 2000.

Case management services increased between fiscal years 1995 and 1996, both in provision of services and leveraged funding, but declined in 1997 in both areas to below 1995 levels. We believe this reflects practice in the field, where there is greater emphasis on “consumer directed” services -- where the individuals have relatively more influence over the services they receive, and agency-based case managers relatively less. As discussed in Section 2, we are discontinuing use of this measure based on consultation with state officials, who have commented that the continued use of this measure is inappropriate because of changes in the way the program is administered.

'Strategic Goal 3: Provide opportunities to live with safety, independence and dignity

Our program goal in this area is to assist residents, families, friends and others to resolve problems related to care and conditions in nursing homes. Our target for fiscal year 1999 is to resolve (or partially resolve) 71.48 percent of complaints involving nursing home care. Performance thus far has been generally consistent with this goal.

Strategic Goal 4: Develop comprehensive and coordinated services systems based on local needs.

See section 2.4.A for Accomplishments.

1.5 Performance Outcomes Measures Project

The fiscal year 2001 performance plan continues to rely primarily on output measures derived from the National Aging Program Information System (NAPIS). AoA has undertaken a project – the Performance Outcome Measures Project – to develop and test outcome measures related to the impact of Older Americans Act services on the lives of service recipients.

AoA has undertaken the Performance Outcome Measures Project in partnership with the National Association of State Units on Aging and the National Association of Area Agencies on Aging. Nineteen state and area agencies are collaborating on the Project.

Project participants have reached consensus on outcome measures that are relevant to the performance of the Aging Network that will be tested during FY2000. These measures emphasize individual characteristics of the people we serve – including their nutritional risk, physical functioning, emotional well-being, social functioning, and satisfaction with the services they receive. Other measures look at the impact of services that support caregivers and the degree to which caregivers are satisfied with the services they receive. In development are measures to assess the performance of the aging network in reducing barriers to services and in building the capacity of the aging services system.

AoA has contracted with researchers and academics who are regarded to have strong expertise in particular substantive areas to help develop data-collection instruments that proceed from the best available research. The participating state and local agencies and the national associations are full partners in the development of these instruments and will participate in the field-testing of performance outcome measures over the winter and spring. We expect to have data from the field tests by this time next year.

Participating agencies include:

The fiscal year 2001 GPRA performance plan is consistent with earlier performance plans which relied exclusively on program output information. Future plans which will rely more on both outputs (e.g., how many home-delivered meals were served) and program outcomes now being developed and tested. Both the 2001 performance plan and the 1999 performance report will be available on AoA’s web site following the release of the President’s fiscal year 2001 budget.

Part II – Performance Measures Budget Level and Full-Time Equivalent Chart

Performance Area	Request	FTE
Strategic Goal 1 : Provide opportunities for better nutrition and improved health	$560,992	58
Strategic Goal 2 : Provide access to services people need by reducing barriers; e.g., by utilizing culturally competent service delivery approaches and by increasing their participation and engagement	$331,052	60
Strategic Goal 3 : Provide opportunities to live with safety, independence and dignity	$149,849	33
Strategic Goal 4 : Develop comprehensive and coordinated services systems based on local needs	$ 26,162	16

Performance Measures by Performance Area

Strategic Goal 2.1: Provide opportunities for better nutrition and improved health

Introduction

OAA funded nutrition services are targeted to those in greatest economic and social need, with particular attention given to low-income minorities. Compared to the general U.S. population, meal program participants are older, poorer, more likely to live alone; are more often minorities; are at higher nutritional, and health risk; and experience greater functional impairment. These programs are often the primary, daily food source for many participants, who are typically economically disadvantaged. The meals provided to program participants generally supply a significant proportion of their daily nutrients -- 40 to 50 percent – which they need to maintain health and functionality. As a result of this, the level of meal service provided is used to indicate the impact of the nutrition program.

Fiscal Year 1999 Accomplishments

The Older Americans Act prescribes National Nutrition Standards that must be met in meals for older adults. These standards require that the meals served through the Elderly Nutrition Program (ENP) promote health, are culturally appropriate, and meet the special health needs of older adults. Each meal must contain 1/3 of the Recommended Dietary Allowances (RDAs) as established by the Food and Nutrition Board, Institute of Medicine, National Academy of Sciences. Also, each meal must meet the Dietary Guidelines for Americans from the Department of Health and Human Services (HHS) and the United States Department of Agriculture (USDA). Moreover, the standards require that meals programs comply with state, tribal, and local food service laws to ensure meals served are safe to eat.
AoA’s monitoring of nutrition service providers’ compliance with the National Nutrition Standards and other service activities, provides assurance that the meals delivered through the ENP contribute to improved nutritional intake and promote the improved health of recipients.

Partnerships to Help Ensure the Needs of Older Adults Are Met

AoA officials have participated on the following interagency committees that addressed issues related to nutrition and health issues:

• the Nutrition Objective Sub-committee for the HHS Healthy People 2000
• Healthy People 2010 National Health Objectives
• HHS Nutrition Policy Board
• HHS Dietary Guidance Committee
• HHS/USDA Food Security committee
• HHS/USDA Nutrition and Welfare committee
• HHS Dietary Reference Intake Working Group to insure the needs and special concerns of the older population are addressed.

During FY 1999, AoA issued specific requirements to grantees for reporting on the delivery of specific nutrition services. This was conducted as an initiative to determine target groups for nutrition services. SUAs were asked to collect and report data related to “nutrition risk” for program participants. The SUAs were requested to use check-listed criteria from the National Screening Initiative (NSI) to identify older adults who are at risk of becoming malnourished or who are in need of other nutrition-related services to maintain a healthy life-style. The information collected by the SUAs and reported to AoA was used by AoA to assist the National Aging Service Network to target ENP nutrition services such as congregate and home-delivered meals, nutritional counseling, and case management services to older adults with the greatest need.

Promotion of Service Needs Awareness

In order to encourage collaborative planning and service activities which can produce the most beneficial outcomes, AoA has identified opportunities and resources for the Network through which greater awareness of the service needs of older Americans can be realized.

During FY 1999, AoA participated in HHS Healthy People 2000 and 2010, a national prevention initiative that has established national health targets and that calls for community collaboration in their achievement. In order to expedite efforts to promote health and prevent illnesses among older persons, AoA has encouraged the national Aging Network to participate in the Healthy People initiative and to strive to meet national health targets.

AoA is also actively engaged in the deliberations of the HHS Dietary Reference Intake (DRI) Working Group to determine the areas of the Recommended Daily Allowance (RDAs), now known as the Dietary Reference Intakes (DRIs), that require revision. The DRI Working Group provides funding and direction to the Food and Nutrition Board of the Institute of Medicine in developing new approaches to DRIs. It also recommends experts for discussion panels and provides assurance that the informational needs of the federal government and other recipients are met.

Finally, AoA is an active participant on a federal interagency working group for food security measurement that resulted in the first-ever questionnaire to measure food security in America. This questionnaire is used in both HHS and USDA food and health surveys to determine food security and is used annually as part of the Current Population Survey conducted by the Census Bureau.

Direct Technical Assistance

AoA personnel provide direct technical assistance via telephone; on-site assistance; presentations at national, regional, state, and tribal conferences; and through professional meetings. During FY 1999, AoA personnel provided more than 20 presentations on nutrition at national meetings. Two of AoA’s regional offices held meetings on nutrition services that were attended by a total of 80 Indian tribes.

Technical assistance was directly provided to at least 30 Indian tribes on-site in conjunction with on-going program monitoring activities. Guidance has been provided to tribes via telephone technical assistance on issues such as: how to purchase blast freezing equipment; the implications of food service laws; constructing client and program outcome measures; interpretations of the OAA; the nutrient content of meals; and the nutrient needs of older adults.

As part of its information dissemination function, AoA supports a Nutrition Resource Center website that includes bibliographies on 45 topics related to nutrition and aging. The site is connected electronically to actual publication abstracts. The bibliographies include a wide range of topics including articles on service provision, innovations, minority issues, caregiver issues, and others. On a quarterly basis, the Center publishes an article in the general nutrition Newsletter which is read by approximately 2,500 nutritionists who work with programs that serve older adults. During the course of a year, Center personnel provide at least 20 presentations to various groups.

Introduction

The 1990 Census counted almost 166,000 American Indians and Alaskan Natives over the age of 60. Although older adults represent only about eight percent of the total American Indian and Alaskan Native population, their numbers are increasing rapidly. This increase is due to better health and living conditions. Today, older American Indians, Alaskan Natives and Native Hawaiians can expect to live well into their eighties and nineties. This recent, but welcome trend will place even greater demands on home and community-based service delivery systems.

AoA’s American Indian, Alaskan Native, and Native Hawaiian Program--Title VI of the OAA — is responsible for serving as the federal advocate on behalf of older Native Americans, coordinating activities with other federal departments and agencies, administering grants to Native Americans, and collecting and disseminating information related to the problems of older Native Americans.

Under Title VI of the OAA, AoA annually awards grants to provide supportive and nutrition services for American Indian, Alaskan Native and Native Hawaiian older adults living in the Title VI service area. In 1997, grants were awarded to 221 American Indian and Alaskan Native tribal organizations representing 300 tribes, and one organization serving Native Hawaiian older adults.

In addition to nutrition services, the Title VI program funds supportive services such as information and assistance, transportation, chore services, homemaker services, health aide services, outreach, family support, and legal assistance. Training and technical assistance in these areas is made available to Title VI grantees in a variety of ways, including on-site, telephone and written consultation, national meetings, newsletters, and electronically, by AoA staff and the Native American Resource Centers. Training and technical assistance are designed to further the development and strengthen the capacity of Title VI program directors and staff to manage comprehensive and coordinated systems of nutritional and supportive services for American Indian, Alaskan Native and Native Hawaiian older adults.

Fiscal Year 1999 Accomplishments

Providing Outreach, Training, and Expansion of Awareness of the Aging Process

With funding from AoA’s program for State and Local Innovations and Projects of National Significance, the University of Colorado and the University of North Dakota National Resource Centers on Native American Aging have provided outreach, training and heightened public awareness of the aging process as it relates to American Indians.

The University of Colorado disseminates information through a successful website. The University of North Dakota offered more than 12 Geriatric Leadership Seminars nationally in FY 1999, focusing on the empowerment of older Native Indian adults through enhanced services.

Results

During FY 1999, the University of Colorado website was contacted by 3500 individuals who subsequently accessed available training and outreach services aimed at improving quality of life in Indian communities. More than 250 individuals participated in the University of North Dakota’s Geriatric Leadership Seminars. Information obtained by seminar participants has enabled them to implement program enhancements in numerous Indian communities.

Providing Home, Transportation, Information and Assistance Support Services to Indian Communities

Locally administered home and community-based programs and services are an important component of the long-term care delivery system necessary to meet the needs of functionally-impaired older adults. In recent years, Indian tribes have pursued the development of appropriate home and community-based long term care services to enable their elders to remain as independent as possible in community settings of their choice. Through 227 grants provided by AoA, a variety of in-home support services were provided to tribes, tribal organizations and Native Hawaiian organizations during FY 1999:

More than 750,000 older American Indians, Alaska Natives and Native Hawaiians received a variety of in-home services including personal care services, homemaker services, health aide services, case management assistance, and family support.

Over 600,000 rides were provided to older Native American adults to meal sites, medical appointments, grocery stores and other essential community services.

More than 600,000 older Native American adults received information and assistance on issues dealing with social security, food stamps, and other topics.

Results

In-home services are permitting Native American older adults to remain in their homes for as long as possible, containing costs associated with the premature institutionalization of older adults.

Recipients of rides were able to increase their access to programs and services and maintain greater independence within their communities.

Recipients of information and assistance have increased awareness about their right to receive social security, food stamps and other services which is improving their health and standard of living in their communities.

The identification of Home and Community Based Long-Term Care (HCBLTC) needs in Indian communities and barriers to addressing these needs.

To date, the design and development of strategies for HCBLTC in Indian communities have proceeded with limited involvement of federal and state agencies. Historical differences among various tribes in the availability and use of federal, tribal and state programs have resulted in an erratic and, in some cases, an essentially nonexistent infrastructure for HCBLTC. AoA is addressing this in two ways:

1) To better identify HCBLTC needs, AoA and two resource centers funded by AoA -- the Native Elder Health Care Resource Center at the University of Colorado and the National Resource Center on Native American Aging at the University of North Dakota -- surveyed key tribal program administrators from 108 Federally recognized tribes. During FY 1999, information was collected about the availability of home and community-based long-term care programs and resources in American Indian and Alaska Native communities. Information was also collected about how the programs and services are funded and about barriers to establishing such programs and services in Indian communities.

2) Also, through a cooperative agreement, funded by AoA, the National Resource Center on Native American Aging has developed a “Health and Social Needs Assessment” for Native Elders for use at the community level. It is currently being pilot-tested at various sites. Workshops are also being conducted on its use. Barriers, identified in the survey by tribal officials, to addressing HCBLTC needs include fragmented and insufficient funds, minimal appreciation of local need, limited access to decision-makers, and excessive regulations.

Results

During FY 1999 AoA, the Native Elder Health Care Resource Center, and the National Resource Center on Native American Aging successfully used survey information to improve the capacity of tribes to develop responsive home and community based programs. Many tribes have since demonstrated increased understanding of the issues and of potential resources and have begun to tap into available funding sources and identify and pursue training opportunities that will help them develop and improve HCBLTC services in their communities.

AoA intends to work with tribes and use data from needs assessments to help them plan necessary HCBLTC programs and services in their communities.

Coordinate with Other Federal Agencies and Private Organizations to Assist Tribes in Overcoming Barriers and Facilitating the Establishment of Home and Community Based Long-Term Care Programs and Services.

AoA’s American Indian, Alaskan Native, and Native Hawaiian Program, Title VI of the OAA, is responsible for serving as an advocate on behalf of older Native Americans, coordinating activities with other federal departments and agencies, administering grants to Native Americans, and collecting and disseminating information related to the problems of older Native Americans.

A permanent Interagency Task Force comprised of representatives of Federal departments and agencies with "an interest in older Indians and their welfare" is mandated legislatively for the purpose of improving services to older Indians. The Director of the Office of American Indian, Alaskan Native and Native Hawaiian Programs chairs this Task Force. Task Force members focus on three areas of concern: health, transportation, and data. Three subcommittees gather and analyze information, offer recommendations to the Task Force to further interagency collaboration and enhance services to older Indians, and identify problems that prevent or diminish collaboration.

During FY 1999, as an outgrowth of the discussions of the Interagency Task Force for Older Indians chaired by AoA, a subcommittee was formed to address the need for the development of culturally appropriate material to be disseminated to the tribes. Participating members of the subcommittees include representatives from the Veterans Administration (VA) and the Health Care Financing Administration (HCFA).

During FY 1999, meetings were held with HCFA and AARP on home and community-based waivers (Medicaid 1915C), with an eye toward training family caregivers to be eligible to receive Medicaid 1915C-waiver reimbursements for providing home and community based services.

Also during FY 1999, contacts with and meetings involving the Home and Community-Based Care Office of the VA were held to discuss methods of reaching and assisting elderly veterans who reside on reservations. As a result of these meetings, AoA has invited representatives from the VA to join its ongoing Interagency Task Force on Older Indians.

Results

The FY 1999 Interagency Task Force on Older Indians Subcommittee’s efforts will lead to the dissemination of culturally appropriate materials to Indian tribes aimed at heightening their sensitivity to the needs of their elders and at increasing their understanding of changes in Medicare/Medicaid services.

Training and certification of family caregivers will empower them to care for their elderly family members in Indian communities in more culturally sensitive and acceptable ways.

The AoA-VA partnership has led to increased efforts to reach and assist elderly Indian veterans and to increase their knowledge of and access to services.

Strategic Goal 2.3: Provide opportunities to live with safety, independence and dignity

Introduction

• Identifying, investigating and resolving complaints made by or on behalf of residents;
• Providing information to residents about long-term care services;
• Representing the interests of residents before governmental agencies and seeking administrative, legal and other remedies to protect residents;
• Analyzing, commenting on and recommending changes in laws and regulations pertaining to the health, safety, welfare and rights of residents;
• Educating and informing consumers and the general public regarding issues and concerns related to long-term care and facilitating public comment on laws, regulations, policies and actions;
• Promoting the development of citizen organizations to participate in the program; and providing technical support for the development of resident and family councils to protect the well being and rights of residents.

• generating on-going communication with state and regional (local) ombudsman programs
• providing training and training materials directed at expanding ombudsman professional advocacy and management skills
• promoting public awareness of the ombudsman program

Results

Producing and Disseminating the National Ombudsman Report

AoA compiles the National Long Term Care Ombudsman Report from information submitted by the states. The information is submitted in response to reporting requirements, which were developed by AoA in the early 1990's to comply with the requirements of the OAA and recommendations by the Office of the Inspector General and the General Accounting Office. The report includes program highlights, data on cases and complaints made to ombudsmen, information on program structure and operation; and major long-term care issues identified by states. The report is a valuable source of information available at the national level on experiences of long-term care residents and operation of the state ombudsman programs. Information in this report is used by legislators, researchers, public policy analysts, state and federal government officials, and ombudsmen themselves for a variety of purposes, including:

• understanding what is happening to long term care residents,
• addressing emerging and long-standing institutional care issues,
• having knowledge of ombudsman program structure and operation in other states, and
• targeting training provided to staff and volunteers to address the most prevalent types of complaints and designing public information which best meets the public need, as reflected in calls to the ombudsman program for information.

Results

Information from the National Ombudsman Report is facilitating the improvement of many state and local ombudsman programs by enabling ombudsmen to target training in areas of need, concentrate volunteers and other resources in troubled areas, and to leverage statistical information to gain additional funding for programs from their state legislatures. .

Introduction

In the fiscal year 2001 budget proposal, AoA proposes to provide funding for caregiver support activities under the existing authority of Title III of the Older Americans Act. Help for caregivers is needed now more than ever. The population age 85 and over will continue to grow faster than any other age cohort, increasing by 50% from 1996 to 2010. Additionally, research has shown that caregiving exacts a heavy emotional, physical, and financial toll.

While the U.S. population is aging, the structure of the American family continues to evolve. More women are in the workforce, making it more difficult for them to be available as caregivers; family mobility has increased thus geographically separating older family members from younger ones; and family size has decreased resulting in fewer adult children being available to serve as caregivers. Thus, fewer family members will increasingly share caregiving responsibilities.

Support provided to informal caregivers can significantly benefit them while delaying the need of care recipients for nursing home services. For example, a recent NIH study found that caregiver stress is reduced when care recipients use adult day care and institutionalization of the care recipient is delayed.

Introduction

Fiscal Year 1999 Accomplishments

• best practice recommendations
• a bimonthly newsletter for grantees
• a limited access internet communication system for sharing information and answering questions
• a web page which includes training manuals, pamphlets and brochures
• bi-regional conferences which bring together experts from the Office of the Inspector General, HCFA, Medicare carriers and others to develop and institutionalize strategies for preventing waste, fraud and abuse in the healthcare systems
• an annual conference for providing technical assistance and information exchange.

• In FY 1999, AoA’s grantees, developed a brochure in partnership with doctors, hospitals, and health care providers which is provided to beneficiaries when they are discharged from the hospital to inform them about the steps they can take to protect themselves from fraudulent or unscrupulous practices.
• Also in FY 1999, a series of locally-based training manuals and consumer education materials were developed, including information on Medicare and Medicaid and examples of fraudulent health care practices. Training sessions were delivered through a coordinated effort with other federal, state and local agencies.
• Another major FY 1999 activity was the creation of a health care journal for Medicare/Medicaid beneficiaries, which AoA developed in partnership with its grantees.
• Also in FY 1999, AoA funded 50 public service announcements and 1250 media events to increase public awareness on ways to protect against health care waste, fraud and abuse.

Results

Strategic Goal 2.4: Develop comprehensive and coordinated services systems based on local needs.

Introduction

Under its program of State and Local Innovations and Projects of National Significance, AoA’s discretionary grants have developed, tested and incorporated innovative programs at the state and local levels. The contributions of several Title IV program initiatives (e.g., Operation Restore Trust and the Eldercare Locator) to the accomplishment of AoA’s FY 1999 goals have been presented in other sections of this report. The focus for the 2001 performance plan is AoA’s proposal to develop a mental health initiative.

Under this initiative, AoA will provide:

• Incentive-based competitive grants to states for the purpose of developing replicable models of innovations in mental health service delivery to older people. Preference for these incentive grants will be given to states that target Preventive Health funds for mental health activities.
• Development and provision of technical assistance and education to enhance the capacity of both the aging network and the mental health network to better serve older people. These capacity building efforts include:

Fiscal Year 1999 Accomplishments

Part III – Appendices

A.1.A Evaluations

Major program evaluations have been used to inform AoA’s GPRA efforts. For example, national program evaluations of the Elderly Nutrition and Long-Term Care Ombudsman Programs were completed in 1995 and 1996. These studies offered compelling evidence of the importance of performance measurement and the use of current research findings for professionals who manage and deliver these services. Furthermore, the studies helped to identify outcomes and areas where ongoing measurement can advance understanding of the relationship of particular interventions to desired outcomes. We believe the implementation of a program outcome information collection system would enable ongoing program evaluation, with basic performance information suggesting areas for policy inquiries answerable only by such formal evaluations.

A.1.B Data Verification and Validation

OMB approval to implement the State Program Report – mandated under the 1992 amendments to the Older Americans Act -- was obtained in time to establish a system which draws upon data from fiscal year 1995. AoA used a three-year phase-in of the system, with detailed client-registration data first required for fiscal year 1997.

Data verification has been accomplished through a labor-intensive data review process involving AoA regional staff, who also contact state officials to reconcile any inconsistencies. To reduce the amount of time required by this method, AoA has worked closely with states on implementation issues and is in the process of automating segments of the process.

Currently, the verification process takes more than a year. Data from fiscal year 1997 is available now. Preliminary data from fiscal year 1999 will be available in September, 2001.

A.1.C Performance Outcome Measures Project

As noted earlier, AoA is working in partnership with 17 State and Area Agency partners, which were selected in October 1998, and two national organizations which represent these components of the Aging Network. Major milestones completed under the Project include:

• November, 1998: Representatives of the 17 participating agencies (Partners) met to complete an in-depth review of the Project objectives and the four phases of work: data collection; determination of a core set of performance outcome measures; field-testing of the core set of measures; and dissemination and utilization activities.
• February, 1999: AoA convened an Expert Committee to advise the Project staff on such issues as the appropriateness of specific measures used by states and local agencies and their applicability for wider use throughout the aging network, and use of national data sets as indicators of program performance. The Expert Committee reviewed proposed outcome measures developed by the Partners. The Committee also requested that development of specific products to facilitate their work, including a literature review and annotated bibliography, as well as information about relevant data sets available through federal surveys. These products were completed by April, 1999.
• January through March, 1999: Project staff completed the administration of a semi-structured interview guide to document performance outcome measures currently in use or under development by participating agencies. The detailed results of this data collection are available in a document, “Performance Outcome Measures Project: Interim Report of Information Collection Activities.”
• March, 1999: A second meeting of the Partners was held to review the data collected, and to organize potential outcome measures suitable for inclusion in a core set around nine areas of concern, such as “access to services” and “social functioning.” Participants subsequently prioritized the proposed outcome measures by availability and usefulness.
• May, 1999: The second meeting of the Expert Committee involved the review and discussion of performance outcome measures suggested by the Partners, and the documented measures currently used by the Partners’ agencies. The Committee also deliberated over the use of data from national surveys as indicators of performance for programs for older Americans.
• June, 1999: Drawing from the recommendations received from the Expert Commmittee on the performance outcome measures suggested by the Partners, AoA and its contract researchers assembled and proposed a core set of performance outcome measures. The Project has adapted a theoretical framework developed by the United Way to guide its work.
• November, 1999: Commitments were secured by Partners to field-test select measures. Based upon the measures they are testing, the Partners are participating on a variety of technical support and discussion groups led by staff and by contract researchers. Final work is now underway on data-collection instruments. Data collection from the field test will be completed by September, 2000.

A.2 Changes and Improvements Over Previous Year

There are four significant improvements to AoA’s previous (FY 2000) Performance Plan. First, AoA restructured its plan to conform to the new HHS Department-wide format. HHS developed the standardized format to address GAO and OMB’s concerns; i.e., plan components were inconsistent and difficult to cross-reference. The standardized format also allows HHS to meet the requirements of the FY 2001 Annual Performance Plan, the FY 2000 Revised Final Performance Plan, and the FY 1999 Performance Report in one document. AoA chose to organize this document around four strategic goals.

Second, AoA has clarified several of its objectives to provide a single, concise statement of its program activities. Third, AoA has progressed on several of its developmental goals. While targets have not been identified for all of these goals, both baselines and objectives have been refined. Finally, AoA dropped the case management goal, as the measure is no longer appropriate, and adjusted several FY 2000 targets consistent with appropriations levels.