• 1.1 Agency Mission and Long-Term Goals
• 1.2 Organization, Programs, Operations, Strategies and Resources
• 1.3 Partnerships and Coordination
• 1.4 Performance Report Summary

• 2.1 Community-Based Services
  • Intermediate Outcome Targeting Measures
  • Intermediate Outcome System Measures
  • Service Measures
  • Client and Program Outcome Measures
• 2.2 Vulnerable Older Americans
• 2.3 Services for Native Americans
• 2.4 Research and Development
• 2.5 Senior Medicare Patrols
• 2.6 Program Management

• Approach to Performance Measurement
• Changes and Improvements
• Linkage to the HHS Strategic Plan
• Linkage with the Budget

Introduction

With the Government Performance and Results Act (GPRA), the Congress established a management tool that compels Federal agencies and programs to focus on results. For AoA, GPRA is an opportunity to document results produced through the programs the agency administers under the authority of the Older Americans Act (OAA). It is the intent and commitment of AoA, in concert with State and local program partners, to use the performance measurement tools of GPRA to continuously improve OAA programs and services for the elderly.

AoA is the Federal advocacy agency for the elderly and the lead Federal partner of the aging network, which administers programs established under the OAA to support the well being, health and independence of older Americans. In addition to program partners within HHS, AoA works with other Federal Departments and agencies in support of the elderly, including the Departments of Agriculture and Labor, and the Social Security Administration. However, the heart of the aging network are the 56 State units on aging, 655 area agencies on aging, 335 tribal organizations, and thousands of service providers, which deliver program services to older individuals across the nation.

Through these extensive partnerships, the network produces the results that the Congress has sought through the OAA. Based on resources input by AoA, we track network output as measured by units of service provided. Intermediate outcome measures indicate that the network targets services to the most vulnerable elderly individuals in the country. Very high proportions of service clients are poor and disabled, many are minorities, and significant proportions reside in rural areas. The end outcome measures that are under development will allow AoA to demonstrate that: the network improves the lives of people served; the nutritional status of OAA clients is improved through the meals provided; and support services allow elderly individuals to stay in their homes. The network leverages funds from other sources in amounts that are higher than the OAA grants provided by AoA. Approximately half of the staff, who work for area agencies on aging to coordinate services for the elderly, are volunteers. More than half of the senior centers that serve elderly individuals in communities are also community “focal points” responsible for service coordination. Government entities and volunteers pursue excellence and the protection of the rights and well being of individuals in nursing homes. Through the network, the elderly themselves work to improve the integrity of the governmental health-care financing programs that support them.

In an attempt to make it more readable and user friendly, AoA has made a concerted effort to reduce the volume of this plan and report. Additionally, this allows AoA to focus on the analysis of the performance data that constitute the core of this plan and that are central to AoA’s proposed budget for Fiscal Year (FY) 2003.

Part I – Agency Context for Performance Measurement

1.1 Agency Mission and Long-Term Goals

The Administration on Aging was established in 1965 through the enactment of the Older Americans Act (OAA), in response to the growing number of elders and their diverse needs. The OAA focuses especially on those at risk of losing their independence. AoA seeks continuously to improve the quality of life for all older Americans, primarily by assisting them to remain independent, actively engaged, and productive. AoA works closely with the aging network to plan, coordinate and develop home and community-based systems of services that meet the unique needs of older persons and their families.

The OAA, reauthorized in 2000 for five years, has enabled AoA to be the Federal focal point for older persons, their many contributions and their concerns. AoA has the Congressionally mandated role of providing essential home and community-based programs across the country which help to keep America’s rapidly growing older population healthy, secure and independent. The Act also charges AoA to serve as the effective and visible advocate for older individuals within the Department of Health and Human Services and with other departments and agencies of the Federal Government.

Strategic Goals of the Administration on Aging

The Older Americans Act (OAA) defines for AoA and the aging network a compelling set of long-term goals focused on the quality of life of elderly individuals throughout the Nation. The following are OAA and agency-generated strategic goals and objectives that provide the foundation for the activities and performance objectives of AoA and the aging network.

• Provide a comprehensive array of community-based, long-term care services adequate to appropriately sustain older people in their communities and in their homes, including support to family members and other persons providing voluntary care to older individuals needing long-term care services.
• Support efficient community services, including access to low-cost transportation, a choice in living arrangements, and social assistance. Services will be provided in a coordinated manner and will be readily available when needed. The system will maintain a continuum of care for vulnerable older individuals.
• Support freedom, independence, and the free exercise of initiative to elderly individuals in planning and managing their own lives. Provide individuals full participation in the planning and operation of community-based services and programs provided for protection against abuse, neglect, and exploitation.
• Provide opportunities for better nutrition and improved health.
• Promote the development of comprehensive and coordinated service systems based on local needs.
• Provide the best possible physical and mental health services which science can make available without regard to economic status.
• Support activities that foster the participation of elders in the widest range of civic, cultural, educational, training and recreational opportunities.
• Provide opportunities for immediate benefit from proven research knowledge, which can sustain and improve heath and happiness.

Linkage with the HHS Strategic Plan

AoA participated actively in the development of the revised strategic goals and objectives of the Department of Health and Human Services (HHS), as published September 30, 2000. AoA program activities and strategies will continue to support HHS in the achievement of HHS goals and objectives, and AoA program performance measurement efforts will support HHS in its efforts to assess the progress of the Department in achieving the goals and objectives of the new HHS Strategic Plan. The detailed linkages of AoA goals and activities with the HHS Strategic Plan are presented in Appendix 3 of this plan.

1.2 Organization, Programs, Operations, Strategies and Resources

The Administration on Aging

The Administration on Aging provides leadership, coordination and support to the aging network on behalf of older Americans. AoA works to heighten awareness among other Federal agencies, organizations, groups, and the public about the valuable contributions that older Americans make to the Nation and alerts them to the needs of vulnerable older people.

In FY 2002, the Assistant Secretary for Aging reorganized the agency to focus on consumers. The new organizational structure streamlines the organization, consolidates and elevates AoA’s external communications functions, strengthens and centralizes its analytical and policy development activities, and focuses AoA’s programmatic efforts on those areas of greatest importance to older Americans.

AoA provides Federal administration of community services programs that are mandated under the Older Americans Act. The programs provide meals and various supportive services; they offer the elderly opportunities to enhance their health and to be active, independent contributors to their families, communities, and the nation. AoA funding supports in-home and community-based services including nutrition, transportation, health promotion, nursing home ombudsmen, outreach, elder abuse prevention efforts, and services in support of family caregivers.

Also under the authority of the Older Americans Act, AoA awards funds to support research, demonstration, and training programs. Research projects collect information about the status and needs of subgroups of the elderly, which is used to plan services and identify opportunities that will assist them. Demonstration projects test new program initiatives that better serve the elderly, especially those who are vulnerable.

The Aging Network

State, tribal and area agencies on aging ensure coordination and enhancement of services that help vulnerable older persons to remain in their own homes. Fifty-six State agencies on aging are allocated funds for support services based on a formula that reflects the number of older residents in their State. Funds are used to plan, develop, and coordinate in-home and community-based service systems in their States. All but nine States are divided into planning and service areas (PSAs). Each PSA is served by an area agency on aging. The 661 area agencies on aging (AAAs) receive OAA funds from their State unit on aging (SUA). In turn, AAAs contract with public or private providers for services. While there are well over 25,000 service provider agencies nationwide, some AAAs deliver services directly when no local contractor is available. AoA awards funds directly to 333 Indian tribal organizations and 2 organizations serving Native Hawaiian elders. These organizations are direct providers of services to older Native Americans living on or near Indian reservations, historical Indian lands, Alaska Native villages and Native Hawaiian communities. The State, local and tribal entities to which AoA awards grants under the authority of the Older Americans Act, and the service providers they support, comprise the aging network.

The Act was not intended, in and of itself, to establish a discrete, independent services program. Rather, the Act put into place a nationwide advocacy and 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 program gaps,” for example, by providing services to people in need who are ineligible for help through other programs.

The aging network is responsive to the diverse needs of older Americans. Meals are served in congregate settings such as senior centers, mostly to people who are poor and socially isolated. Many older people with mild functional impairments also 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 that 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.

1.3 Partnerships and Coordination

In addition to the fundamental partnerships within the aging network, AoA works closely with many Federal agencies on a wide range of issues.

In the area of nutrition, AoA has worked with the U.S. Department of Agriculture (USDA) on such issues as dietary guidelines used as standards for OAA programs. The USDA is also a partial funding agent for meals provided through the aging network. In fact, AoA recognizes the partnership between USDA and HHS in providing meals through the aging network; therefore, the Administration has proposed the consolidation of these funding activities in AoA in the FY 2003 budget. Within HHS, AoA works with the Office of Public Health and Science on Dietary Reference Intakes (DRIs), formerly known as Recommended Dietary Allowances and on nutrition performance measures related to the Healthy People 2010 Initiative. AoA also participates on such bodies as the Federal Food Safety Coalition chaired within the Food and Drug Administration; the HHS Nutrition Policy Board; the HHS Dietary Guidance committee; the HHS/USDA Food Security committee; and the HHS Dietary Reference Intake Working Group.

In the pursuit of improved transportation services provided through the aging network, AoA works closely with HHS officials and the U.S. Department of Transportation on the Coordinating Council on Access and Mobility to reduce barriers by coordinating approaches to specialized and human services transportation.

AoA is working with the Centers for Disease Control and Prevention (CDC) to expand CDC’s Racial and Ethnic Approaches to Community Health (REACH 2010). The purpose of these projects is to eliminate health disparities among older racial and ethnic minority populations. The initiative will target disparities in cardiovascular disease, diabetes, and immunizations among older racial and ethnic minority populations.

In the area of consumer protection and elder abuse, AoA and the Department of Justice (DOJ) are disseminating information on promising Federal, State and local approaches that empower older people to live healthy and safe lives. Featured approaches also address the coordination of public safety, health and social services that provide effective prevention and intervention strategies and reduce victimization. Specific areas of emphasis by AoA and DOJ include: (1) domestic elder abuse; (2) institutional elder abuse; and (3) fraud and exploitation, including consumer fraud issues such as telemarketing. Our shared objective is to foster enhanced collaboration between the justice, health, aging and human services networks.

AoA is developing a partnership with the Health Resources and Services Administration (HRSA) Bureau of Health Professions, Division of Nursing, to initiate a demonstration program to train nurses specifically to work with, educate and mentor caregivers. Although nurses are well trained in acute care for older persons, there is little or no preparatory training for follow-up care and continuing care of chronic conditions.

During FY 2001, AoA played a major role in advancing HHS’s initiative to help States implement the Supreme Court’s Olmstead decision. AoA joined the Department’s internal Olmstead work group comprised of CMS, OCR, ASPE, SAMHSA, and ADD and assisted in developing the Real Choice Systems Change Grants which will provide states with $70 million dollars to make their systems of long-term care more consumer directed and focused on home and community-based care. As part of this initiative, AoA worked with State units on aging to make sure the interests of the elderly were reflected in state planning efforts related to the System Change Grants. Finally, AoA co-sponsored a national conference on Consumer Direction in Long-Term Care in collaboration with ASPE, CMS, SAMHSA, ADD, and the Robert Wood Johnson Foundation.

1.4 Performance Report Summary

The following performance report summary updates that presented in the final performance plan for FY 2002. The most significant advancement in performance reporting for this report is that it includes final FY 1999 data earlier than originally anticipated, and preliminary data for FY 2000. AoA and State agencies have initiated the process of certification for FY 2000 data. The following chart illustrates the status of AoA reporting of performance measures included in previous performance plans.

The data for the performance measures identified throughout this plan present a story of performance indicating that the network produces the results intended by the Older Americans Act (OAA). The data for each of the four years show that the aging network successfully identified vulnerable elderly individuals, including the poor, minorities, and individuals from rural areas. Each year, the network leveraged funding from other sources in amounts that were 50% higher than the funding provided by AoA. The data presented throughout this plan and report show that the services financed with the funds leveraged from other sources are those services which allow vulnerable older individuals to remain in the community, in their homes. The data show a network that fosters extensive participation of volunteers, even in the local entities that help to administer the OAA programs. The data reflect that the aging network works systematically to improve service coordination, as demonstrated particularly by the high percentage of senior centers, which are “focal points” for community services.

Introduction — Budget Linkage

The core of GPRA planning and reporting is the presentation of performance measures that address the results that AoA and aging network produce with the program resources entrusted to them. There is a strong and intentional linkage between the presentation of program activities in this plan and the presentation of the AoA budget request. The performance measures that AoA presents were developed to cover the entirety of its program activities, and are intended, therefore, to support the entire budget request of the agency. AoA’s performance plan is not limited to measures associated with the incremental portion of the AoA budget.

The linkage of the AoA budget and performance plan is stronger than the routine justification of the total resources required for OAA program activities. The results that AoA reported in its last performance report were considered in the process of identifying budget initiatives for FY 2003, and the data presented in that and this report support the AoA budget initiatives that HHS has submitted to OMB in the FY 2003 budget.

• The data presented under targeting measures that document the effectiveness of the aging network in targeting services to vulnerable individuals are relevant to and support the AoA initiatives to enhance our support of the aging network.
• The data under system measures that indicate that the network is increasingly leveraging funds from sources other than AoA, especially for services targeted to the most vulnerable elderly individuals, support maintenance of AoA service funding.
• The data under systems measures and the measures for the Medicare Senior Patrols program, that document the reliance of the network on cost-effective volunteers, support the Agency’s initiatives to enhance our volunteer utilization efforts, especially in support of the caregiver program.
• The preliminary pilot-test data under outcomes measures that document the limited availability of services in support of family caregivers reinforce the Agency’s efforts to ensure adequate funding for the family caregiver program.

The AoA program categories identified for GPRA presentation purposes, with the budget line items they comprise are:

• Community-Based Services
  • Budget line items:
    • Supportive Services and Centers
    • Congregate Meals
    • Home-Delivered Meals
    • Preventive Health Services
    • National Family Caregiver Support Program (NFCSP)
• Vulnerable Older Americans
  • Budget line item:
    • Ombudsman Services
    • Prevention of Elder Abuse
• Native American Services
  • Budget line item:
    • Grants to Indian Tribes
• Research and Development
  • Budget line items:
    • Training, Research and Discretionary Projects
    • Alzheimer’s Disease Demonstration Grants to States
    • Aging Network Support Activities
• Senior Medicare Patrols
  • Senior Medicare Patrols (HCFAC)
• Program Management
  • Budget line item:
    • Program Administration

2.1 COMMUNITY-BASED SERVICES

Program Description and Context

(numbers in thousands)	FY 2000 Enacted	2001 Enacted	FY 2002 Enacted	FY 2003 President’s Budget
Community Based Services	$847,446	$1,149,512	$1,233,841	$1,236,286

The Community-Based Services program comprises AoA’s budget line items for programs administered by State and community agencies, with the exception of the Protection of Vulnerable Americans line, which we have elected to show separately for GPRA purposes. Beginning in FY 2001, this line item also included the National Family Caregiver Support Program. This performance plan identifies the first developmental performance measures to be used to assess performance for this new program activity.

State agencies on aging are allocated funds for State and community programs based on formulas that reflect the number of older residents in their State. AoA, other Federal, and outside source funds are used by State and area agencies on aging and service providers to coordinate and to provide services for elderly individuals.

The Community-Based Services program covers the bulk of the resources, services and activities of AoA and the aging network. The program provides “access” services, such as information and assistance, outreach, and transportation. The program covers “community” services, which include congregate meals, senior-center activities, adult day care, pension counseling, and health promotion and fitness programs. The program provides “in-home” services, including home-delivered meals, chores, home maintenance assistance, home-health, and personal care. Beginning in FY 2001, the program includes “caregiver” support, such as respite services and information and assistance to caregivers for the coordination of health and social services.

Goal-by-Goal Presentation of Performance

Building on the improvements instituted in AoA’s FY 2002 plan, this performance plan includes the following types of performance measures for community-based programs:

• Intermediate outcome targeting measures.  Does the network target services to vulnerable elderly individuals?
• Intermediate outcome system measures.  What do the State and local components of the network contribute to the elderly in the way of resources, coordination, and emphasis on the most vulnerable?
• Service output measures.  What level of services will the network provide to elderly individuals each year for meals, transportation, etc.?
• End outcome measures.  From the perspective of elderly consumers and their caregivers, what results do AoA and the network produce for the elderly?

Performance Measures Table—Intermediate Outcome Targeting Measures (Part 1)

Performance Measures Table—Intermediate Outcome Targeting Measures (Part 2)

(Note: The targeting measures are presented in two tables for ease in presentation.)

Performance Measures Analysis—Intermediate Outcome Targeting Measures

The OAA seeks to ensure and to support the well-being of elderly Americans, particularly those who are most vulnerable, including the poor, minorities, disabled, and the elderly in rural areas. It is not enough that the network provide services; the network must reach out to and serve the most vulnerable among the elderly.

AoA has identified a set of targeting measures to track the effectiveness of the network in meeting the intent of the OAA to serve vulnerable elderly individuals, and to target measurable improvements where appropriate. AoA and the network are also focusing on targeting services to caregivers to ensure the successful implementation of the new program.

To demonstrate that the network is targeting services to vulnerable individuals, data should show that the percentage of clients who are poor, disabled, minorities and those in rural areas is significantly higher than the percentage of all elderly persons who fit these characteristics.  This year, AoA has made two additional improvements to its targeting measures. First, AoA has made the performance targets for the targeting measures more rigorous for FY 2003. Second, the plan for FY 2003 includes three new measures to foster improved performance by committing to increase the percent of poor, rural, and disabled served by five program entities (States or Territories) that currently perform below the national average. To accommodate this increase in measures, AoA has deleted a developmental poverty measure that effectively duplicated the targeting measure introduced last year.

Results for Intermediate Outcome Targeting Measures

For the measures introduced in the FY 2002 performance plan, the tables above indicate that the aging network effectively targets services to the vulnerable elderly individuals in the Nation.

• Poverty Targeting Measures: In each year over 30% of aging network clients were poor. As figure 1 indicates, the percent poor among OAA clients substantially exceeds the percent poor for all elderly individuals (60 and over) in the U.S. Performance has declined in recent years—a trend that AoA is working to reverse.
  
  
  
• Rural Targeting Measure: One-third of OAA program participants in FY 1999 lived in rural areas, compared to less than one-quarter for the total population age 60 and above for 1998, the most recent year for which national estimates are available.
  
  
  
  
• Minority Targeting Measure:  Although the percent of OAA clients who were minorities was higher in all three years than the total percent of all elderly minority individuals, the portion of AoA minority clients has been decreasing in recent years. Figure 2 illustrates this characteristic of the OAA client population for fiscal years 1997 through 1999. Again, AoA is committed to increasing minority participation in future years.
  
  
• Disability Targeting Measure: Disability data for 42 entities show that a very high percentage of clients receiving home delivered meals have limitations in Activities of Daily Living (ADL’s) and in Instrumental Activities of Daily Living (IADL’s). This data indicates that reporting entities as a whole are successfully targeting services to disabled elderly individuals.
  
  
• Senior Elders Targeting Measure: Data on age categories for 42 states show that a high percentage of clients receiving registered services are aged seventy-five and above. This data indicates that reporting entities as a whole are successfully targeting registered services to elderly individuals aged seventy-five and above. For the 42 States reporting detailed client characteristics in FY 1999, over 60% of elderly clients were aged seventy-five and above.
  
  
• Caregiver Targeting Measure: The caregiver program was implemented in FY 2001. The Network has no results data to report thus far.

Goals and Targets

Performance targets for FY 2003 are based on the past and current performance of the network as reflected in the tables above. Because of the overall performance of the network in targeting services to vulnerable elderly individuals, at a minimum, AoA seeks to maintain performance at or near the levels established as national performance targets over the last few years. The national targets for FY 2003 for serving poor, minority and rural clients have been increased to reflect that intention

In its commitment to continuously improve program performance where it is needed, AoA is proposing to improve performance for primary service entities that do not perform at the national average for targeting services. To reflect AoA’s commitment to its targeting outcome measures, beginning with the FY 2003 performance plan, AoA proposes to improve performance in five primary service entities for which client service ratios are below national or multi-State service ratios for poverty, rural residence, disability status, and service to senior elders. 

AoA’s initial targeting measure for the National Family Caregiver Support Program reflects that this is a new program. The ratio presented in the table above will serve as an initial indicator of impact. We expect initially that the ratio of supported caregivers to registered elderly clients will be very low, probably far less than one caregiver to twenty registered clients. To demonstrate that the program is having an impact, even in the early years, this ratio should increase over time.

Performance Measures Summary Table— Intermediate Outcome System Measures (Part 1)

Performance Measures Summary Table—Intermediate Outcome System Measures (Part 2)

Performance Measures Analysis— Intermediate Outcome System Measures

Intermediate Outcome System measures data should show that: (1) there is a significant contribution above and beyond funding provided by AoA ; (2) there is a strong degree of coordination of services provided through the network; and (3) the network is community oriented and makes use of community resources.

One of the most significant intermediate outcomes for AoA is the effectiveness of the aging network to advocate, coordinate, and support services for elderly individuals in communities across the nation. AoA uses the intermediate outcome “system” measures related to the following network characteristics to track the effectiveness of Federal, State, area agencies on aging and community-service providers in serving, and advocating for, vulnerable elderly individuals:

• Funding leveraged by network entities,
• Program income and voluntary contributions generated by network entities,
• Senior centers as community focal points, and
• Volunteer staffing among local governmental entities.

AoA has made two significant improvements to its intermediate outcome systems measures. First, AoA has made the performance targets for the measures more rigorous for FY 2003. Second, the plan for FY 2003 includes two new measures to foster improved performance by committing to increase leveraged funding and program income performance for five program entities (States or Territories) that perform below the national average.

For the National Family Caregiver Support Program, our initial objective for the “system” is to develop a well-rounded program that serves the various needs of caregivers as envisioned by the OAA. The developmental measure identified above will address the extent to which State agencies develop comprehensive caregiver programs that provide the variety of services required by the OAA.

Results for Intermediate Outcome Systems Measures

The data reported above for AoA’s intermediate outcome system measures demonstrate the following:

1. The funds “leveraged” by the aging network are significant in total.



2. The leveraged funds substantially exceed the funding provided by AoA for home and community services to the elderly, particularly the most vulnerable.



3. The network does not rely solely on funds provided by other sources, but every year generates a significant amount of revenue, which is put back into the program for services.



4. The network is characterized by a strong community orientation, in which senior centers are not only places where elderly individuals receive services, but are places where services for the elderly are organized and coordinated.



5. The network is committed to local solutions and resources in support of the elderly, as reflected in data that show that almost 50% of area agency staff are volunteers.

In the above table, data is reported for multiple years. There is some variation in these reported numbers from year to year. This, however, does not represent a significant variation. The data indicates that the network has been successful in maintaining performance at a high level for each of the measures.

The following are systems measures performance highlights for fiscal years 1997 through 1999.

• Leveraged Funding Measures: For all three years reported, FY 1997 through FY 1999, funds leveraged by State and local agencies exceeded funds provided by AoA by more than 50% (See figure 3 below). 
  
  
  



• In each of the three fiscal years from 1997 to 1999, approximately three-quarters of the funding that supported personal care, home-delivered meals, and adult day care combined, came from sources other than AoA.



• Program Income Measure: Data for all three fiscal years indicate that revenue generated by the aging network (e.g., voluntary contributions for meals) is a significant funding source, representing approximately one-third of the amount provided by AoA each year.



• Senior Center Focal Point Measure: For FY 1997 through FY 1999, over half of all senior centers participating in the program were community-service “focal points.”



• Area Agency Volunteer Measure: The percentage of the staff of area agencies on aging that is made up of volunteers was between 40 and 50 percent in FYs 1997, 1998 and 1999.



• Caregiver Measure: For the National Family Caregiver Support Program, our initial objective for the “system” is to develop a well-rounded program that serves the various needs of caregivers as envisioned by the OAA. The developmental measure identified above will address the extent to which State agencies develop comprehensive caregiver programs that provide the variety of services required by the OAA.

To comply with GPRA requirements, the table above continues to present data for three discontinued measures that appeared in the AoA performance plan for FY 2000. Consistent with the guidelines on reporting analysis provided in A-11, part 2, AoA met its FY 2000 targets for information and assistance, substantially met the target for case management services, and preliminary data indicate that AoA did not meet its target for transportation. AoA discontinued these measures in favor of the more relevant and informative measures discussed above.

Goals and Targets

Performance targets for FY 2003 are based on the past and current performance of the network as reflected in the tables above. Because of the outstanding overall performance of the network for all of the defined intermediate outcome systems measures, AoA seeks to maintain performance at or near the levels established as national performance targets over the last few years. The national targets for FY 2003 for leveraging funds, program income, focal points and area agency volunteers have been increased to reflect that intention. 

AoA is committed to continuously improve program performance where it is needed. To reflect this commitment for its systems outcome measures, beginning with the FY 2003 performance plan, AoA proposes to improve performance in five primary service entities for which client service ratios are below national or multi-State service ratios for leveraged funding and program income.

Performance Measures Summary Table—Service Measures  (Part 1)

Performance Measures Summary Table—Service Measures  (Part 2)

Service Output Measures

The measures in this section of the plan are output measures that provide a basis for the fundamental tracking of the level of services that AoA and the other components of the network provide. Rather than encumber the plan with extensive counts for a variety of services, AoA will continue to report on major service categories identified in the table above, with the view that they are representative of AoA funded activity.

For FY 2003, AoA has added a developmental measure for the National Family Caregiver Support Program, which is consistent with the expectations of the Congress for the new program. Primarily, it is the objective of the program to reach out to caregivers. Thus, initially it is more relevant for AoA to identify the number of individuals served, rather than the units of service provided. In addition, AoA and the network must identify consistent definitions of service units prior to establishing measures of such units.

Service output data should show that over time performance outputs are consistent with the level of resources provided by AoA and the anticipated level of resources provided by other network entities.

Results for Service Output Measures

The preliminary data for FY 2000 indicate that AoA met service performance targets for one of the four output measures included in the FY 2000 annual performance plan. The data suggest that AoA and the network met the output levels targeted for congregate meals, but not for home-delivered meals, transportation, and information and assistance.

However, AoA is not prepared to conclude that output performance by the network is problematic on the basis of preliminary data.  AoA is not prepared to conclude that output performance by the Network is problematic for the following reasons: (1) the data is preliminary and preliminary data are subject to some understatement of service units because of under-reporting of some local entities across the country; (2) there was no basis for AoA to expect that States would match, in the same year, the increase that AoA provided in FY 2000 for home-delivered meals; and (3) AoA should not have expected the full increase in the number of home-delivered meals in one year (FY 2000) given that State and local entities have two years to expend funds.   The data for FY 2000 are undergoing State and Federal verification procedures. When final data are certified, we believe that performance for information and assistance may meet the target, and that performance for transportation services will be closer to the target than the preliminary data indicate.

• Home Delivered Meals Output Measures: We do not believe that the final data will reflect that AoA met the FY 2000 target for home-delivered meals, but the data will reflect a significant increase in the number of home-delivered meals provided in FY 2000.  The failure to meet the targeted result will reflect more the difficulty of accurately targeting the number of meals that will be served than performance expectations.  In the FY 2000 performance plan, AoA projected an over 30 percent increase in the number of home-delivered meals, consistent with the increase in Federal funding from FY 1999 to FY 2000 for home-delivered meals.  However, AoA funding for home-delivered meals is only 30% of the total provided for this service.  On analysis, we are likely to find that it was not accurate to assume that: 1) all entities could match the Federal increase for one service category in the same fiscal year; and 2) that ongoing cost increases would not have any effect on the level of services provided
• Congregate Meals Output Measure: Preliminary FY 2000 data indicate that the network exceeded its targets for congregate meals.  We consider that this will be maintained when the FY 2000 data are finalized.  In fact, the trend data in the table above indicate that output for congregate meals over the reported years is steady and consistent with stable funding.
• Transportation Output Measure: When final data are certified for FY 2000, the level of output performance for transportation service will be closer to but may not meet the FY 2000 target.  AoA overstated the FY 2000 target when it based the target solely on data for FY 1997.  In fact, when certified data are available, we believe that it will show that service output for transportation has also been stable over the last four years consistent with stable funding.
• Information and Assistance Output Measures: When final data for FY 2000 are certified, the level of output performance for information and assistance will be closer to but may not meet the FY 2000 target.  AoA overestimated the FY 2000 target when we established the target based solely on data from FY 1997.  Moreover, once the certified FY 2000 data is available, we believe that it will demonstrate that service output for information and assistance has also been stable over the last four years consistent with stable funding.
• Caregiver Output Measure: The caregiver program was implemented in FY 2001.  The network has no output measures to report thus far.

Goals and Targets for Service Output Measures

Performance targets for FY 2003 are based on the past and current performance of the Network as reflected in the tables above. Because the FY 2000 data are preliminary, and because AoA’s performance for FY 1999 was not out of line with performance targets, AoA will not propose to reduce the performance targets for its service output measures at this time. However, AoA also believes that it would be unrealistic to raise the service output targets any further until we have taken the opportunity to assess the processes used to project service levels for the program. Within the next year, AoA will reassess the methods that were used to develop these performance targets, and will ensure that future targets are better linked to projected resource changes. AoA will retain what it now believes are very high targets for both FY 2001 and 2002, and will project for FY 2003 that services will be maintained at the currently projected FY 2002 levels. This is consistent with the maintenance of Federal funding for these activities at the FY 2002 levels in the President’s Budget.

Performance Measures Summary Table—Client and Program Outcome Measures

Performance Measures Analysis—Client and Program Outcome Measures

IMPORTANT NOTICE: The Administration on Aging has entered into a contract with WESTAT, Inc. to conduct national performance outcome measures surveys for the following services in FY 2002: nutrition, transportation, home care, caregiver support, and information and assistance. This commitment, the summary table above, and the analysis that follows, constitute AoA’s response to the requirements of the Older Americans Act for the development of performance outcome measures for OAA programs. The surveys to be conducted this fiscal year will allow AoA and the network to begin the projection of national performance outcomes in the next AoA GPRA performance plan. 

The end outcome measures that are currently being developed will identify from the consumer perspective that network programs meet the needs of elderly individuals. It is AoA’s intention to begin to collect data through a National survey to demonstrate the following:

Nutrition Services:

• The extent to which the aging network targets services to elderly individuals at high nutritional risk.
• The extent to which nutritional risk is improved as a result of OAA meals programs.
• The level of disability for elderly participants in home-delivered meals programs.
• Overall consumer satisfaction with meals programs provided through the network.

Transportation Services:

• Impact of services on satisfying the needs of elderly individuals for transportation associated with medical visits and other essential needs.
• Adequacy of transportation services in terms of frequency, safety, comfort and reliability.
• Overall consumer satisfaction with transportation services.

Information and Assistance:

• Quality and timeliness of responses to consumer requests for information and assistance.
• The level of “human” response to consumer inquiries (calls).
• Overall consumer satisfaction with information and assistance services.
• The level of follow-up on consumer information requests.

Home Care Services:

• Overall consumer satisfaction with components of home care services such as personal care, home delivered meals, case management, and adult day care services.
• Establishment of a baseline for network entity comparisons on home care satisfaction.

Caregiver Support Services:

• Ability of the network to increase availability of caregiver services
• Caregiver assessment of impact of services to clients and caregivers on the ability of the client to remain independent at home and in the community.
• Caregiver assessment of network programs ability to reduce caregiver burden.

In partnership with the National Association of State Units on Aging and the National Association of Area Agencies on Aging, AoA continues the Performance Outcome Measures Project (POMP) to develop and field-test outcome measures suitable for ongoing use in assessing community-based services in support of elderly individuals. To measure performance outcomes, the aging network participants in the POMP, with technical guidance and financial support provided by AoA, have adopted a consumer-based, quality assessment approach, which is focused on local service-delivery activities. Through its contract with WESTAT, Inc., AoA has arranged for known researchers from the Scripps Gerontology Center, Boston University, and Florida International University, to participate extensively in the design and application of measurement instruments, and in the analysis of performance data.

In the past year, AoA and its partners in the POMP have developed survey instruments, implemented sampling procedures, and completed pilot surveys in the following program domains:

• nutritional status and risk (along with physical and social functioning and emotional well-being),
• transportation services satisfaction,
• home-care services satisfaction,
• caregiver support and satisfaction, and
• information and assistance satisfaction.  

Area agencies in 20 States have participated in the activities of the POMP, and initial data are available and presented here for four of the domains cited above. A significant aspect of the POMP, as it relates to the long-term potential of the aging network to assess program results through performance measures, is that local entities have taken the lead in developing the performance measurement instruments, in selecting the statistical samples for information gathering, and in administering the survey instruments to obtain the assessment data for their areas.

Because the initial focus of the POMP is on the usefulness of outcome measures for local program assessment, it should be noted that the data collected and the findings summarized here cannot be generalized beyond the program entities that participated in the pilots. The data referenced here are “test” data, and should not be viewed as definitive of program conditions. As planned, the results of these pilots have assisted AoA in preparing for the national survey of outcome measures. The data collection instruments, sampling procedures and methods, and information collection processes and procedures were all new and untested. As a result, the data presented as measures in the table above are illustrative of the types of measures that AoA and its partners are testing under the POMP.

Next Steps—National Data to Be Collected in FY 2002

AoA is committed to employ the performance outcome measures on a national basis as soon as possible. Satisfied that the instruments tested will yield performance data that will speak to important program results, AoA will conduct a national survey in FY 2002 utilizing elements of the performance measurement instruments tested under the outcome measures project. As reflected in the performance measures table presented above, AoA believes it is important to establish performance outcome baselines in the following areas as soon as possible: nutrition, transportation, caregiver, information and assistance, and homecare.

Results for Outcome Measures (Illustrative)

With the understanding that we cannot make definitive conclusions about service results on the basis of these data, we believe that the initial findings of the pilots are informative for purposes of moving forward in selecting more permanent measures, and seek to share results relative to that objective:

• Nutrition Measures:  The Nutritional Screening Initiative (NSI) and the Nutritional Risk (NR) surveys conducted for both home delivered meals and congregate meals begin to assess the level of nutritional risk of clients.  The data collected assisted AoA in processing performance measurements in two major categories.  First, the data received in the pilot surveys indicates that the information collection will serve as a targeting measure of AoA ability to reach individuals at high nutritional risk.   Test data for new OAA clients for home-delivered meals (HDM) indicate that 77% of surveyed clients are at high nutritional risk.   Second, and more significantly, the survey instrument, combined with existing program data, may allow us to provide a broad indicator of improvement in nutritional risk scores. 
  
  
• Transportation Measures:  Overall, the results were outstanding for the AoA-sponsored transportation services.  Respondents to the pilot surveys on transportation services reported a high degree of satisfaction with the services (82% rated them very good or better) and 90% reported that they felt safe and that the drivers were always polite. The pilot transportation surveys also provided information that will support program improvements, including the following:
  1. major trip purposes include doctor and other medical appointments, shopping, and visits to senior centers;
  2. the most recommended improvement was longer hours of service to better accommodate medical appointments; and
  3. one-fifth of the respondents depended entirely on the service for their transportation needs, and 60% reported they were able to move about more than before.
  
  
  
• Information and Assistance:  As the table above indicates, 95% of information and assistance clients surveyed reported their call was answered quickly, and 90% reported that they spoke to a person, not a machine. A large percentage of the clients interviewed (75%) were first-time callers.  The same percentage reported that they were provided the names of other places to call, and follow-up interviews indicated that two-thirds of these individuals made the necessary follow-up calls.  Eighty-percent of the individuals interviewed said they would recommend the service of their friends.

  Ninety-four percent of the clients who left messages had their call returned the same day, and over 82% of all clients said that they felt comfortable with the person they had spoken to.  The preliminary tabulations, which totaled 543 interviews, have shown positive results thus far in examining the perspective of older consumers regarding AoA-sponsored Information and Assistance services.
  

• Family Caregiver Support:  An important element of performance outcome measurement is AoA’s intent to measure the performance for the National Family Caregiver Support Program. As part of the Performance Outcomes Measures Project, AoA has initiated testing of consumer assessment measures of individuals who care for disabled older Americans with the caregiver support services that are available to them. The early pilot-test surveys promise to identify who the caregivers are, their satisfaction with services to them and to the elderly they serve, and the burden associated with care.

  Providing care for a friend or relative can be both rewarding and stressful. The following summary of results was gleaned from data collected at local sites in Arizona, Florida, Georgia, Hawaii, Indiana and Ohio. The results reflect the current reality that services in support of caregivers have not been universally available, that caregiving involves burden, but also that caregivers are committed to their role.

• Older people served by the caregivers surveyed were receiving a significant level of services from the Network: 
  • Case management – 88.5%
  • Home health -- 66%
  • Homemaker -- 49%
  • Respite care -- 35%
    
• Caregivers expressed satisfaction with services to elders:
  • Very satisfied -- 67%
  • Services helped a lot -- 84%
    
• Limited services were available for caregivers:
  • Support groups --13%
  • Training/education -- 6%
  • Counseling -- 4%
    
• The caregivers expressed interest in a variety of services as their “most desired” services:
  • Help line -- 43%
  • Tax break/stipend/direct financial support -- 32 to 33%
  • Housekeeping -- 28%
  • Transportation -- 24%
  • Respite Care -- 23%
  • Help with bathing/toilet/personal care -- 23%
    
• Noting that for this limited survey, 75% of those cared for were female, the following summarizes who the primary caregivers are:
  • Daughter -- 38%
  • Wife -- 15%
  • Husband -- 14%
  • Son -- 12%
    
• The caregivers provide the elderly a variety of services:
  • Tracking bills and finances -- 90%
  • Meals/laundry/shopping -- 85%
  • Medical support/personal care -- 75%
    
• Caregiver burdens are significant:
  • Caregiver hours per day -- 15 to 17
  • Sole caregiver -- 40%
  • One caregiver providing nearly all care -- 67%
  • No relief from caregiving -- 25%
  • Caregivers w/support from one other person -- 25%
  • Caregivers with full or part-time jobs -- 46%
    
    Job impacts:
    • Took off early/go in late -- 15%
    • Average work missed -- one day per month
    • Used vacation for care -- 12%
    • Quit work for care -- 11%
      
• Burdens cited as “nearly always” felt:
  • Not enough time to self -- 19%

  • Stress -- 18%
  • Problems with social life -- 12%
  • Neglecting family -- 11%
    
• Caregivers cite rewards of caregiving:
  • Caregiving generally rewarding -- 55%
  • Recipient “nearly always” appreciates care -- 49%
  • Helping family -- 38%

  Goals and Targets

  With the collection and analysis of National data in 2002, AoA will be prepared to establish performance targets for a varied set of outcome measures in the FY 2004 annual performance plan. AoA will continue to sponsor the development of national, State and local performance outcome measurement projects. As AoA has with the development of GPRA measures as a whole, decisions on outcome measures will be iterative, and the agency, with input and guidance from the network, will continue to improve outcome measures over time. AoA has worked with statistical consultants to determine how statistical tools can be employed to derive national data for the performance outcome measures that are approved for use for the aging network, and is prepared within the next year to conduct a national survey. The results of the outcome measures project will be used to improve performance measures for AoA administered programs, and the status of project implementation and findings will be provided in all updates of AoA's performance plan submissions.

2.2 Vulnerable Older Americans

Program Description and Context

AoA uses its measurement activity for the Ombudsman program to represent the broader budget activity “Vulnerable Older Americans,” which also includes funding for other activities associated with the protection of the rights of elder individuals. Long-term care ombudsmen are necessary advocates for residents of nursing homes, board and care homes, and adult care facilities. Since the Long-term Care Ombudsman Program began 25 years ago, thousands of paid and volunteer ombudsmen working in every State have made a dramatic difference in the lives of long-term care residents. Long-term Care Ombudsmen advocate on behalf of individuals and groups of residents and work to effect systems changes at a local, State and National level.

Ombudsman responsibilities outlined in Title VII of the Older Americans Act include:

• 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; and

• 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.

AoA provides national leadership to the States in carrying out their ombudsman programs. AoA funds the National Long-Term Care Ombudsman Resource Center, which provides training and technical assistance to ombudsmen throughout the country. The center provides essential support for the ombudsman network in its efforts to provide assistance to and empower long-term care residents, their families and other representatives of residents’ interests. Some of the major center objectives include:

• 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; and

• promoting public awareness of the ombudsman program.

Goal-by-Goal Presentation of Performance

Performance Measures Summary Table—Ombudsman Intermediate Outcome Measures

Performance Measures Analysis—Ombudsman Intermediate Outcome Measures

A major goal of the Ombudsman Program is to enable residents of long-term care facilities and their families to be informed “long-term care consumers” and to facilitate the resolution of problems regarding care and conditions in long-term care facilities. To demonstrate that the network is targeting services to vulnerable individuals, data should show that a significant percentage of complaints are resolved each year. AoA and the aging network will achieve its objectives by assisting residents, families, friends and others to resolve problems related to care and conditions in nursing homes.  For FY 2003, at the urging of the Office of Management and Budget and the Office of the Secretary of HHS, AoA has added a performance measure to foster improved performance by committing to increase resolution rates for five program entities (States or Territories) that currently perform below the national average.   To limit the number of measures presented in the AoA plan, AoA will not include measures from the CMS plan that were included in FY 2002.

Results for Ombudsman Intermediate Outcome Measures

• Complaint Resolution Measure: Consistent with the objectives of the network, nursing home Ombudsman programs continue to resolve a high percentage of nursing home complaints each year.   For each of the years included in the table above, the network has achieved a high combined resolution/partial resolution rate in excess of 70 percent.  For FY 1999 and 2000 the rate has risen to 74%. 

Goals and Targets

Performance targets for FY 2003 are based on the past and current performance of the network as reflected in the table above.  Because of the successful overall performance of nursing home Ombudsmen in resolving complaints, AoA seeks to maintain performance at or near the levels established as national performance targets over the last few years.  The national targets for FY 2003 for resolving complaints have been increased to reflect that intention. 

AoA is committed to continuously improve program performance where it is needed.  To reflect this commitment for its Ombudsman program intermediate outcome measure, beginning with the FY 2003 performance plan, AoA targets to improve performance in five primary service entities for which Ombudsman complaint resolution percents are below the national complaint resolution percentage.    

2.3 SERVICES FOR NATIVE AMERICANS

Program Description and Context

Between 213,000 and 395,000 American Indians and Alaska Natives over the age of 60 were identified in the 2000 Census. The lower number represents those individuals who identified themselves as “American Indian or Alaska Native alone” and the larger number represents those who identified themselves as “American Indian or Alaska Native alone or in combination with other races”. Although older adults represent only about eight percent of the total American Indian and Alaska Native population, their numbers are increasing rapidly. This increase is due to better health and living conditions as well as the increasing number of people self-identifying as American Indian or Alaska Native. Today, older American Indians, Alaska 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, Alaska 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 for home and community-based services, 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, Alaska Native and Native Hawaiian older adults living in the Title VI service area. In 2001, grants were awarded to 233 American Indian and Alaska Native tribal organizations representing nearly 300 tribes, and two organizations serving Native Hawaiian elders.

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, legal assistance, and the Native American Caregiver Support Program, established in the 2000 amendments to the OAA.

Performance Measures Summary Table—Native Americans Program

Performance Measures Analysis—Native Americans Programs

At the present time, a limited array of performance output measures is available for the analysis of AoA’s Native American programs under GPRA. Nevertheless the measures will be useful for analysis of the stability of program support and services for the programs. For future performance plans, AoA will pursue additional measures for Native American programs. In the interim, AoA will continue to supplement its basic measurement data with the following narrative description of additional program accomplishments. AoA will also review its performance targets for a selected number of the service categories included in the plan. With the support of AoA, tribal entities are meeting the greater demand for home-delivered meals by reducing the number of congregate meals provided. In effect, AoA believes that the agency is likely to continue to exceed its targets for home-delivered meals and fail to meet its targets for congregate meals. In future versions of this plan, AoA will modify the targets for these two service categories to reflect this acceptable phenomenon. AoA will also analyze and present greater detail on our observation that performance for “other services” is exceeding our expectations. We believe that this also positively reflects the exercise of greater flexibility by local tribal entities. AoA will provide a more detailed illustrative analysis of this phenomenon in future versions of this plan and report.

Performance Results for Native American Programs 

For the most part, Native American programs have maintained service levels, adjusted for inflation, in the face of level funding.  The preliminary FY 2000 data indicate successful results for all performance targets except for information/ referral services and congregate meals. AoA believes that finalized FY 2000 data will indicate that actual program performance for these two service areas is closer to the target than preliminary data indicate. Effectively, we believe that the overall indicator of stable service levels is confirmed for virtually all services. 

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.  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 235 grants provided by AoA, a variety of in-home support services were provided to tribes, tribal organizations and Native Hawaiian organizations during FY 2000:

• More than 61,000 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. 
• Approximately 700,000 rides were provided to older Native American adults to meal sites, medical appointments, grocery stores and other destinations.
• Nearly a million units of individual and family support services, such as visitation and respite, were provided to elders and their families.  More than 650,000 units of information and assistance on issues dealing with Social Security, food stamps, and other topics were provided to elders and their families.

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 information about their right to receive Social Security, food stamps and other services aimed at improving their health and standard of living.

In its commitment to continue to increase performance and establish outcome measures,at the annual Tribal consultation, AoA will discuss a pilot performance outcomes measure project for Native American Programs with tribal representatives in FY 2002.

2.4 AoA Research and Development

AoA’s Research and Development projects are intended to establish programs for model demonstrations, applied research and national resource centers to produce best practices, useful knowledge and systems improvements that point policy makers and program administrators to well-reasoned courses of action in the field of aging. Because these projects and other evaluation activities support the fundamental program characteristics of the aging network programs, AoA will not establish a separate set of performance measures for these activities. The ability of AoA and the network to achieve the service, outcome and systems performance goals of the OAA programs relies in part on the projects and activities carried out under this program category. Significant new program activity and program improvements have their roots in such research and development projects, including nutrition programs for the elderly, the new caregiver program, and the long-term care ombudsman program.

2.5 Senior Medicare Patrols & Technical Assistance Centers

Program Description and Context

HHS, particularly the Centers for Medicare and Medicaid Services (CMS) and the Office of Inspector General (OIG), has placed significant emphasis on the identification and reduction of billions of dollars of fraud and waste in the Medicare program. AoA has played an active role in addressing this national problem through two legislative sources.

Health Insurance Portability and Accountability Act (HIPAA) of 1996

Under the Health Insurance Portability and Accountability Act of 1996, AoA works in partnership with the Centers for Medicare and Medicaid Services (CMS), the Office of Inspector General (OIG), the Department of Justice, and other Federal, State, and local partners in a coordinated effort to educate and inform older Americans how they can play an important role in protecting the benefit integrity of the Medicare and Medicaid programs. AoA’s primary efforts under this initiative have been to: 1) fund State and local projects to train aging network professionals to recognize and report potential instances of waste, fraud, and abuse; 2) develop and disseminate consumer education materials to beneficiaries; and 3) support technical assistance efforts designed to share and replicate common strategies and successful practices among federal, state and local officials, health care professionals, community service providers who serve older Americans, and beneficiaries and their families. The funding from HIPAA is now primarily used to fund technical assistance centers that support the "Senior Medicare Patrols."

Omnibus Consolidated Appropriations Act of 1997

Beginning with the Omnibus Consolidated Appropriations Act of 1997 (P.L. 104-209), AoA has been charged with establishing innovative community-based projects that seek to utilize the skills and expertise of retired professionals in educating older Americans regarding how to help protect the benefit integrity of the Medicare and Medicaid programs. During FY 2001, AoA funded 52 such community-based projects, known as “Senior Medicare Patrol Projects,” in 47 States, plus the District of Columbia and Puerto Rico. These Senior Medicare Patrol Projects recruit and train retired professionals, such as doctors, nurses, teachers, lawyers, accountants, and others to work in their communities, teaching beneficiaries how to take an active role in protecting their Medicare numbers and their health care.

Goal-by-Goal Presentation of Performance

Performance Measures Summary Table — Senior Medicare Patrol Measures

Performance Measures Analysis—Senior Medicare Patrol Program

AoA has elected to employ a set of fundamental results measures that reflect the agency’s commitment of educating and informing older Americans how to take an active role in their health care, thereby helping to maintain the benefit integrity of the Medicare and Medicaid programs. The DHHS OIG collects performance data from AoA’s Senior Medicare Patrol Projects semi-annually.

To demonstrate that the network is educating older Americans how to take an active role in their health care and protect the integrity of the Medicare and Medicaid services, the data should show an increase in the number of trainers who educate beneficiaries, an increase in the number of beneficiaries educated by volunteer trainers, and an increase in the number of complaints that have been reported and acted upon as a result of the AoA programs.

Results for the Senior Medicare Patrol Program

For the measures presented in the table above, the data indicates that the aging network effectively educates and informs older Americans how to take an active role in their health care and maintain the integrity of the Medicare and Medicaid systems.

• Volunteers Trained Measure: The first measurement is directed at increasing the number of volunteers trained by AoA’s grantees, who in turn educate an increasing number of beneficiaries regarding how to take an active role in protecting their health care. In FY 1999, the Senior Medicare Patrol Projects were just beginning to develop their training activities and materials. However, by the end of FY 1999 we had trained 13,700 (on a cumulative basis) community volunteers under the HIPAA and Senior Medicare Patrol projects. During FY 2000 materials and effective training strategies were more widely utilized by the grantees, which meant that we could increase the target of the number of volunteers trained to 17,125.

The performance for FY 2001 exceeded the target, by reaching approximately 48,000 volunteers trained. We do not anticipate that the grantees will train as many new volunteers during FY2002 and later years because the effort will build on the large pool of experienced volunteers who will continue to conduct sessions during those years. 

• Beneficiaries Educated Measure: The second measurement is directed toward increasing the number of beneficiaries who are educated by the volunteer trainers. This measurement is new for FY 2002. It is the beneficiaries, who have to learn to detect possible fraud, waste and abuse in the Medicare payments. As of FY 2001, the “trainers” trained 570,000 beneficiaries for both HIPAA and the Senior Medicare Patrol projects. Preliminary trend data indicates that by the end of FY 2003 the trainers will have reached over 600,000 beneficiaries since inception of these projects.
• Inquiries Submitted and Acted Upon Measure: The third measurement consists of the number of inquiries submitted by AoA’s projects and volunteers to health care providers, Centers for Medicare and Medicaid Services (CMS), the OIG, and other appropriate sources that result in some action being taken. In FY 1999, this system of reporting was just beginning to be developed and AoA’s projects started with a baseline of 133 cases (for both the HIPAA and Senior Medicare Patrol projects) that resulted in some sort of corrective action being taken. In FY2001, the projects exceeded the projected target, with more than 2,100 cases that resulted in some action being taken.

Goals and Targets

Performance targets for FY 2003 are based on the past and current performance of the network as reflected in the table above. Because the network significantly exceeded performance targets in all three of the performance measures, AoA has increased the FY03 targets. AoA's commitment to increased performance is reflected in the increase in FY03 performance targets for the Senior Medicare Patrol Program.

2.6 PROGRAM MANAGEMENT

Program Description and Context

From the outset of GPRA implementation, AoA has agreed with the HHS principle that management challenges should be addressed in the GPRA context, and included two process measures in its original FY 1999 annual performance plan.  With the FY 2002 plan, AoA reestablished its commitment to include management measures in the annual performance plan by including additional management measures for financial management, program reporting, and workforce planning.  This Annual Performance Plan for FY 2003 takes an additional step in that commitment by adding new performance measures that are specifically related to the five management initiatives identified by the Office of Management and Budget and HHS for FY 2003.

AoA retains for FY 2003 the performance measures added for FY 2002, which commit the agency to a clean financial opinion, to using a formal workforce plan, and to improving the timeliness of program data reporting. With the FY 2003 plan, AoA defines a performance target for the workforce planning measure and adds two related measures: to increase the agency’s employee to supervisor ratio and to reduce the average grade of agency employees. AoA also adds a performance measure to make greater use of performance based contracting and another to reflect our implementation of the electronic submission and processing of selected agency grant applications.

AoA’s performance measures for management activities now cover the following areas:

• Financial Management
• Acquisitions/Grants Management/E-Government
• Workforce Planning and Restructuring
• Program Information Collection and Reporting

The areas covered and the measures employed track very closely with the management priorities of OMB and HHS.

Goal-by-Goal Presentation of Performance

Performance Measures Summary Table—Program Management Measures

Results for Program Management Measures

Financial Management Measures:  In FY 2001, AoA received a clean opinion on the audit of its FY 2000 financial statements (balance sheet).  As reflected in the management priorities circulated by OMB for the FY 2003 budget process, improving financial management is a significant management priority, and the achievement of a clean financial opinion is a fundamental indicator of financial management quality.  AoA is committed to expanding the annual audit to its full financial statements, and to receiving a clean opinion in the audit each year.  AoA will retain this measure as a fundamental indicator of financial management quality and commitment in its annual performance plans.

Strategic Management of Human Capital Measures: An extensive AoA review of workforce and structural conditions found that improvements are necessary and achievable in: 1) “delayering” the organization, 2) grade structure, and 3) skill mix. To track its accountability for implementing improvements, AoA has included three performance measures related to workforce planning and restructuring in its FY 2003 GPRA performance plan. AoA will improve span of control specifically by increasing the employee to supervisor ratio for the agency. The agency will achieve a measurable reduction in the average grade of employees over the next few years. Finally, further defining a “developmental” performance goal that appeared in the agency’s FY 2002 GPRA performance plan, eighty percent of AoA new-hires will be in strict conformance with the priorities of the agency’s formal workforce plan.

To achieve these measurable goals, AoA will be required to move forward with restructuring plans that significantly reduce management layers and supervisory positions and grades within the agency.  Achievement will also require that the agency maintain its formal workforce planning processes and conduct its hiring processes in conformance with that plan.

Acquisitions/Grants Management/E-Government Measures: AoA has initiated work to apply the efficiencies of electronic transactions to one of its most significant operational activities, and will pursue the application to a second such activity within the next year.   AoA has initiated work to apply e-government solutions to its grants processing efforts, and will work with State and local government entities to identify the feasibility of applying such technology to the submission of detailed program information requirements.

The grants application process is one of AoA’s most significant workload processes, and involves significant staff and related resources on the part of AoA and potential grantees. Believing that electronic processes offered a significant opportunity for improved efficiency for AoA and its grantees, AoA has developed and is prepared to test information technology that will allow grantees to apply for AoA funding electronically, including by way of the Internet. To ensure maintenance and the realization of these electronic process improvements, AoA has included a performance goal in its annual GPRA performance plan that calls for the agency to increase the percentage of discretionary applications that are submitted and processed electronically to 10 percent by FY 2003.

AoA is also committed to improve performance in an activity related to OMB’s initiative to expand electronic government, which is specifically referenced in section 31.9 of OMB Circular A-11 (2001). AoA has complied with an HHS initiative for improved agency planning to increase the use of performance-based contracts. Planned AoA activities include:

• Management review of contract areas that would benefit from performance-based contracting;

• Extensive staff training in the methods and processes of performance-based contracts; and

• Creation of integrated project teams to achieve broad participation in defining contract results, performance standards and measures, and quality assurance surveillance plans.

AoA has included a new performance measure for FY 2002 and 2003 in this GPRA performance plan to increase the use of performance-based contracts in its procurement activities to 20 percent of its procurement dollars.

Program Information Collection and Reporting:Reflecting the firm commitment of the agency to improve the quality, reliability, and timeliness of data from the National Aging Program Information System (NAPIS), and to reduce the burden that it imposes on the network, the FY 2002 plan included a developmental measure that reflects a necessary system outcome.

Recognizing the need for immediate improvement in the timeliness and quality of data provided under the State Program Report (SPR), AoA has engaged in the following during FY 2001:

• An extensive review of the SPR requirements particularly as they affect the timing of reporting and the quality of data, and
• An acceleration of the tabulation and certification of FY 1999 SPR data and the collection of the FY 2000 data.

The review has resulted in the following related to the SPR information collection system. 

• AoA accelerated the initial tabulation of FY 1999 data to make it available for the FY 2002 performance plan and report.
• AoA accelerated the final certification of FY 1999 data, to the effect of making the data available for this performance report submission and four months earlier than the FY 1998 data.
• AoA has accelerated the collection and certification of the FY 2000 data with the objective of making that data available for the FY 2003 annual performance plan and report, which will be submitted to Congress in February, two months earlier in the year than the FY 2002 plan was submitted.
• AoA has formed a team of AoA, state and area agency representatives to modify the SPR over the next year, with the principal objective of reducing the burden and complexity of reporting.

Finally, AoA has finalized the GPRA performance measure that appears in this annual GPRA performance plan.  It calls for AoA to reduce the time required for making data available for GPRA purposes and for the public from 26 months for the FY 1998 data to 15 months for the data for fiscal years 2001 and 2002.

Appendices

1. Approach to Performance Measurement
2. Changes and Improvements
3. Linkage to the HHS Strategic Plan
4. Linkage with the Budget

Appendix 1

Approach to Performance Measurement

Methodology and Rationale

The fundamental elements of AoA’s approach to performance measurement are consistent with the guidelines established by the Department of Health and Human Services because AoA shares many of the same measurement challenges that other HHS components face.  AoA is the lead HHS component for support programs for elderly individuals, which are administered day-to-day by State and local governmental entities and numerous business and non-profit service providers.  This fundamental program partnership dictates that AoA approach performance measurement mindful of the needs and constraints of the non-Federal partners that share program authority and responsibility. 

AoA has instituted performance measurement with the approach of utilizing existing information resources to the full extent possible, and reducing new and potentially burdensome information gathering to that which is important to program assessment and which is consistent with views of the partnership.  AoA was limited in its first performance plans by the lack of mature, reliable data because of the status of implementation of a new information management system:  The National Aging Program Information System (NAPIS).  As a result, performance measures in the early GPRA plans were limited for the most part to output measures associated with service unit counts. 

Beginning in FY 2002, AoA completely restructured its performance plan, particularly for its large State and community-based programs. To illustrate for that program, AoA defined performance measures that reflect the achievement of the aging network in:  targeting services to elderly individuals in need, establishing an effective system of services utilizing funding from multiple sources, maintaining service outputs across a variety of domains, and producing outcomes that are relevant to the network and focus on consumer assessment. 

Consistent with the improvements reflected in the FY 2002 performance plan, for FY 2003 AoA illustrates how its measures reflect a broad logic model that is comparable to that used by entities such as the United Way of America for social service programs.  In the model, AoA identifies a mix of output, intermediate outcome, and end outcome measures associated with inputs provided by AoA and other program entities.

AoA continues to face a number of performance measurement constraints that are common to HHS programs. 

• AoA relies on State and local governmental entities and service providers for the data required to measure performance.  Because of the complex relationships, AoA cannot expect to have data available for GPRA purposes within six months of the end of a fiscal year.  In previous years, AoA did not anticipate having data available for two years after the end of the fiscal year, but through our work within AoA and with the cooperation of State and local agency representatives, we have already reduced those time frames. 
• Like other HHS components, AoA is one of many providers of services to individuals, and can neither reasonably attribute broad changes in the characteristics and conditions of large population groups to its program activities, nor reasonably project measurable changes in significant population groups over short periods of time.  These factors limit both the choice of measures available to AoA for GPRA purposes and the performance targets the agency can reasonably expect to achieve. 
• Over the years, AoA has represented a relatively stable source of service support to elderly individuals across the country, and so cannot expect on an annual basis to produce broad based changes, increases or improvements in the results that are produced through the aging network.   As a result, AoA and the aging network are in the process of defining levels of performance that reflect significant performance year in and year out, and which, if not met would result in the need for evaluation and enhanced program support.

These constraints do not hinder AoA action to use GPRA and performance measurement as important tools for program assessment, but they force the Agency to recognize the limits and the proper uses of this assessment tool.  GPRA must be used in combination with other assessment mechanisms and information sources to “inform” program assessment and planning.  With reasoned use and realistic expectations for this assessment tool, program managers throughout AoA and the aging network will increasingly realize the value of ongoing performance measurement.  By facing and addressing these performance measurement challenges directly, AoA is developing a performance measurement program that has the potential to be useful to program managers and decision makers for years to come.  HHS has correctly fostered an “iterative” approach to the implementation of GPRA and performance measurement.   As AoA’s GPRA performance measures mature and performance trends emerge, program executives and managers throughout AoA and HHS, and decision makers outside the Department, can expect to use trend data to seek the coordinated improvement of AoA and related HHS programs on an ongoing basis.  The data will support agency efforts for:  1) assessing program activity and results, 2) engaging in program evaluation where deeper assessment is required, 3) redefining program strategies to produce improved results, and 4) modifying future performance targets to be consistent with available resources and up-to-date priorities and policy decisions.

Presentation

The presentation of this plan and report is organized in accordance with the standardized presentation format established by and for the agencies of the Department of Health and Human Services (HHS).  AoA fully supports HHS’s efforts to present performance measurement data under GPRA in a manner that is meaningful for Federal executive and legislative branch decision makers.  Since the enactment of GPRA in 1993, the Office of Management and Budget (OMB), the General Accounting Office (GAO), and HHS have provided leadership that will allow Federal program components to continue the development of meaningful, realistic and effective performance measurement programs.

Data Verification, Validation and Other Data Issues

AoA has continued to make progress in the two data initiatives highlighted prominently in the FY 2002 performance plan.  AoA and State agencies engaged in a formal assessment effort that has resulted in the certification of FY 1999 data months earlier than originally anticipated.  AoA has initiated certification of FY 2000 data, and we will revise routine information collection activities to reduce reporting burden, improve timeliness and reliability of data, and incorporate reporting for the National Family Caregiver Support Program into the standard data collection process.  AoA and the network continue to focus on the assessment of quality through the consumer, where it counts the most, at the community level, through the Performance Outcome Measures Project, and have initiated efforts to conduct a national survey of performance outcomes within the next year. 

As indicated in the introduction to this performance plan and report, AoA and the aging network face a significant challenge in obtaining data to measure performance for programs of this kind.  For the sake of context, it is important to reiterate those challenges here while addressing the extensive processes that AoA and the States utilize to improve the validity and reliability of the NAPIS data.  All levels of the aging network, from AoA through the state and area agencies on aging to local centers and service providers, know well the challenge of producing client and service counts by critical program and client characteristics for a program which coordinates service delivery through approximately 29,000 local providers.  Many OAA program services do not require a one-time registration for service on the part of clients; eligible clients may obtain services on an ad hoc and irregular basis.  This makes the tracking of services to individuals and the generation of “unduplicated” counts of clients a very difficult task at the local level, particularly if local entities lack information technology that simplifies client and service record-keeping and information management.  Federal and State reviews of data provided for FY 1997, 1998 and 1999 under NAPIS suggest that significant limitations in the adequacy of information infrastructure at the local level inhibit their ability to routinely and consistently produce the data that are required by law for the Older Americans Act programs and form the basis for many of AoA’s GPRA performance measures.  Extensive and repeated Federal and State efforts to provide technical assistance and to isolate and correct common data problems have been helpful for local areas in the majority of States and for most data elements required by the OAA through NAPIS.  Nevertheless, much remains to be done to ensure that local service providers and area agencies have the capacity to reliably provide important data without excessive burden.

Technical Assistance, Standard Software Packages, Electronic Edits

AoA and the State units on aging have long recognized the effects that local capacity limitations could have on the generation of reliable data for programs and services of this type, and have taken significant steps to support local entities in producing the NAPIS data.  There are at least two commercial packages now available to States and local entities to assist them in the preparation of the NAPIS data.  These packages have fostered far greater consistency in the data generated for NAPIS than was possible in the early years of implementation.  AoA developed an extensive set of electronic edits for all data elements, which are applied to the electronic submissions of State entities.  AoA contractors work with State data administrators to correct data elements that fail electronic edits to ensure that data meet standard logic checks.  Following standard electronic checks, knowledgeable AoA regional and central office staff conduct extensive reviews of edited data for “reasonableness,” to ensure that significant value changes from one year to another reflect program circumstances and not the limitations of the program data.  These processes have been extremely slow, burdensome and time consuming, and they must be modified.  AoA and State agency representatives are investigating ways to streamline the data verification and validation process without compromising data quality. 

Despite the data challenges that the network is addressing and the time-consuming validation processes that remain in place at the present time, AoA and the network have been able to certify the FY 1999 data cited in this report.  The FY 1999 data are final.   Nevertheless, AoA and the States must immediately engage in a comparable exercise of verification and validation before data for FY 2000 can be utilized for performance reporting purposes.  AoA and the States will review a significant number of individual data items, which are generated from data reported by local components, for accuracy and validity. 

AoA and its program partners have initiated an assessment of the data requirements of the OAA and will consider alternatives to the collection of the most complicated data that cause most of the burden and validity problems.  This will be done in conjunction with agency efforts to renew approval of NAPIS data collection efforts under the Paperwork Reduction Act.  AoA will work with State and local program representatives to improve their understanding of HHS’s performance measurement principles, and better demonstrate the constructive uses of performance information to improve programs.  AoA and State and local representatives will together assess the potential linkages of the performance outcome and service data that AoA will use for GPRA performance measurement purposes.  Together we will seek to identify the correlation between service measures and program outcomes to demonstrate the value of collecting data on client and service characteristics on an ongoing basis.

AoA and the aging network face a similar challenge with the measurement of outcomes.  Although we have made significant progress with the initial development and testing of outcome measures, we do not yet have national baselines for outcomes to set targets for FY 2003.  Because of AoA’s Performance Outcome Measures Project, which was expanded to approximately 30 area agencies in 16 pilot States in FY 2000, AoA is now able to commit to the conduct of a national performance outcome measures survey within the next year, which will allow the Agency to establish performance measure baselines for FY 2002, and performance measure targets for FY 2004. 

Because of the data limitations addressed in this Appendix, AoA classifies many of its GPRA performance measures as “developmental.”  This classification means that although AoA will immediately make use of available data in the context of the GPRA performance plan and report, the measures and the data on which they are based lack the maturity to directly support decision-making immediately.  In fact, this is not unusual for the assessment of performance for health and human service programs.  As the Department has observed in previous HHS performance plan and report summaries, performance measurement data will become more useful over time as performance measures mature and trends in performance can be observed.

Appendix 2

Changes and Improvements over the Previous Year

Because AoA made significant modifications to its GPRA performance plan for FY 2002, the modifications for FY 2003 are far less significant.  We believe strongly that it is important to maintain continuity in the performance plan, and repeated wholesale modifications are not warranted. 

AoA’s most significant changes for FY 2003 are the identification of initial developmental performance measures for the National Family Caregiver Support Program and the significant expansion of measures for program management to address the priorities of the Administration and the Secretary of HHS.  The initial FY 2003 plan includes targeting, systems and service measures for the plan, and retains the descriptive information related to the development of outcome measures for this and other programs as well. 

The agency has also significantly expanded its discussion of budget linkage in the introduction to Part 2 of the plan, adding significant analytical linkages between the agency’s performance measures and its FY 2003 budget initiatives.

Finally, the agency has focused intentionally on reducing the length of the performance plan and report.  In the past, we relied on narrative descriptions of accomplishments because quantitative measures were not compelling.  With the revisions incorporated for the FY 2002 budget cycle, AoA believes that such narrative presentations are no longer appropriate. 

Appendix 3

Linkage to the HHS Strategic Plan

Part 1 of this performance plan provides a summary presentation of the linkage between the AoA GPRA performance plan and the HHS Strategic Plan.  The following chart is intended to provide a more descriptive and definitive illustration of the detailed links between individual AoA program activities and the detailed goals and objectives in the HHS Strategic Plan. 

Appendix 4

Performance Measurement Linkage with the Budget
Budget Linkage Table ($ Amounts in 000’s)