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Part I: Agency Context for Performance Measurement
1.1 Agency Mission and Long Term Goals
1.2 Organization, Programs, Operations, Strategies and Resources
1.3 Partnerships and Coordination
1.4 FY 1999 Performance Report

Part II: Performance Measures
2.1 Community Based Services
2.2 Ombudsman Services
2.3 Services for Native Americans
2.4 Research and Development
2.5 Senior Medicare Patrols
2.6 Program Management

Part III: Appendices
Approach to Performance Measurement
Changes and Improvements
Linkage to the HHS Strategic Plan
Linkage with the Budget and Other Functions

Introduction

With the Government Performance and Results Act (GPRA), the Congress has established a management tool that compels Federal agencies and programs to focus on results. Since the passage of GPRA in 1993, program managers of the Administration on Aging (AoA) have accepted GPRA as an opportunity to document each year the results that are produced through the programs they administer 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. The heart of the Aging Network, however, is the 56 State Units on Aging, the 661 Area Agencies on Aging, and the approximately 29,000 paid and volunteer service providers, which deliver program services to older individuals throughout the U.S.

In fact, the documentation of results, which is initially illustrated for OAA programs with the new “developmental” performance measures included in this plan and report, indicates that the “Network” itself is a prime factor in the past success and the future potential for these support programs for the elderly. The Aging Network of Federal, State and local program managers and service providers is effectively reaching out to vulnerable older Americans and coordinating services from a variety of sources to ensure that their needs are met.

Through extensive partnerships at the Federal, State and local levels, the Network is producing the results that the Congress has sought through the OAA. The Network is targeting services to the most vulnerable elderly individuals in the country. Very high proportions of service clients are poor and disabled. Many are minorities, and a significant proportion resides in rural areas. 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; the program income generated by the Network is one-third of the amount provided by AoA. Approximately half of the employees, who work for Area Agencies on Aging to coordinate services for the elderly, are volunteers. The additional services provided because of funding leveraged by the Network support personal care and other services that help the most vulnerable elderly individuals remain independent in their homes. 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. The Network now is focusing on the assessment of quality through the consumer, where it counts the most, at the community level.

This presentation of AoA’s GPRA performance plan and report reflects a significant improvement over previous plans and reports because of the efforts of the Network to improve the availability of data from the National Aging Program Information System (NAPIS) and the Performance Outcome Measures Project (POMP). These two data initiatives, which rely totally on the contributions of State and Area Agencies on Aging and service providers, have allowed AoA to identify far more relevant program performance measures than were included in previous AoA plans, and provide initial evidence of the effectiveness of the coordination activity and programs of the Aging Network. Nevertheless, as this plan will also demonstrate, significant improvement is needed before we can achieve a level of data reliability that will best serve to assess OAA program outcomes. Because of the “distributed” nature of program service delivery for OAA programs, the Network often relies on very small entities for the maintenance and reporting of the data needed to demonstrate the continuous effectiveness of OAA programs. Many of these entities simply lack the capacity to manage data in a way that will allow for consistency and reliability across the Network. The data limitations that AoA and the Network must address are presented in more detail below and in Appendix 1.

Because of the value of performance information for demonstrating the Network’s effectiveness, AoA and its program partners will actively pursue support to modernize information generating capacity across the Network, to expand performance outcome measurement, which is now required under the OAA, and to refocus the NAPIS data series toward a more limited and less burdensome data set that will generate the type of GPRA program assessment that is introduced in this plan.

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 Challenges

It is important in the introduction to this performance plan and report to disclose the significant challenge that AoA and the Aging Network face in obtaining data to measure performance for programs of this kind. A more detailed presentation of data issues is included in Appendix 1. 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. For example, 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. 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 National Aging Program Information System (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.

Because of the data challenge that the Network is addressing, the FY 1999 data cited in this report must be classified as “preliminary” data. This means that AoA and the States are still reviewing a significant number of individual data items, which were generated from data reported by local components, for accuracy and validity. Agencies in two small States have not yet been able to generate program data for FY 1999, and so we have used FY 1998 data for those States to allow us to provide preliminary national estimates for this performance report. It should be noted that potential error for all national data elements caused by the use of FY 1998 data for these two States is less than one tenth of one percent, so it is not a significant limitation. Still, it reflects that the data are not complete. In the body of this plan and report, we cite data limitations in instances where we believe that known data errors may have affected the totals shown for selected performance measures. While AoA and the Network must confront this data challenge, this expanded performance plan and report clearly indicates that data on client and service characteristics are very valuable to AoA and the Aging Network in the context of GPRA. Over time, the data that are collected will continuously document the value and effectiveness of OAA programs and the Network that coordinates services to elderly Americans. So, it is AoA’s intention to fix the data problems that exist.

The Administration on Aging is committed to using the tools offered by the Government Performance and Results Act to improve its service to the Aging Network and improve the service of AoA and the Network to elderly Americans. AoA is equally committed to accelerating progress toward the development of a rich and comprehensive set of measures that will inform program decision-making in the years to come.

Part I Agency Context for Performance Measurement

1.1 Agency Mission and Long-Term Goals

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

The agency’s mission is reflected in statute. The Older Americans Act provides a broad organizing set of core national values and objectives for AoA’s programs in language that articulates a vision as well as transcendent, fundamental aspirations for America’s older population. Since 1965, the Older Americans Act has been re-authorized six times. The latest was in November 2000 when the Older Americans Act Amendments of 2000 were signed as Public Law 106 – 501, which extends the Act’s programs through FY 2005.

Since the Older Americans Act was first enacted over 35 years ago, it 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 in communities all across the country which keep America’s rapidly growing older population healthy, secure and independent.

Strategic Goals of the Administration on Aging

The Older Americans Act (OAA) is also effective in defining 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. For AoA, these are prominent among the strategic goals of the Agency and the Network. The following are OAA and agency-generated goals and objectives, which 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 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, which provide a choice in supported emphasis living arrangements and social assistance in a coordinated manner and which are readily available when needed, with emphasis on maintaining a continuum of care for vulnerable older individuals.
• Support freedom, independence, and the free exercise of individual initiative in planning and managing their own lives, full participation in the planning and operation of community-based services and programs provided for their benefit, and protection against abuse, neglect, and exploitation.
• Provide opportunities for better nutrition and improved health.
• Develop 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 which foster the participation of elders in the widest range of civic, cultural, educational and 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. AoA will work with the HHS Office of the Assistant Secretary for Management and Budget (ASMB) to ensure continued presentation of AoA program strategies and performance measures that support HHS goals in the HHS Annual Performance Plan and Performance Report Summary. AoA programs, activities and performance measures will be particularly relevant to HHS efforts to meet the following HHS strategic goals and objectives:

• Goal 1 -- Reduce the Major Threats to the Health and Productivity of All Americans.
  Strategic Objective 1.3: Improve the Diet and Level of Physical Activity of Americans.
  
  
• Goal 2 -- Improve the Economic and Social Well-being of Individuals, Families and Communities in the United States
  Strategic Objective 2.5: Increase the Proportion of Older Americans Who Stay Active and Healthy
  Strategic Objective 2.6: Increase the Independence and Quality of Life of Persons with Long-term Care Needs
  
  
• Goal 3 -- Improve Access to Health Services and Ensure the Integrity of the Nation’s Health Entitlement and Safety Net Programs
  Strategic Objective 3.5: Enhance the Fiscal Integrity of HCFA Programs and Purchase the Best Value for Health Care Beneficiaries
  Strategic Objective 3.6: Improve the Health Status of American Indians and Alaska Natives
  
  
• Goal 4 — Improve the Quality of Health Care and Human Services
  Strategic Objective 4.1: Enhance the Appropriate Use of Effective Health Services
  Strategic Objective 4.4: Develop Knowledge That Improves the Quality and Effectiveness of Human Services Practices

Along with statutory responsibilities and HHS objectives, the agency’s mission is shaped by the agency’s strategic vision. The Administration on Aging’s goals and priorities respond to the phenomenon of dramatic longevity, which has become ever more evident over the last decade. America’s social practices, institutions and individuals will be required to respond to a fundamental demographic shift because human life expectancy has increased more during the last century than over the last four millennia.

We value the knowledge we have gained from previous generations of older Americans. AoA will build on this base of knowledge to address pressing issues arising as a result of the longevity revolution. We expect that advances in science, ubiquitous technology, and a heightened demand for accountability will be significant factors that will also shape new policy and program directions in the coming years.

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.

AoA provides Federal administration of community-services programs that are mandated under the Older Americans Act. Primarily, these programs seek to ensure the coordination and enhancement of services that help vulnerable older persons to remain in their own homes. The programs provide meals and various supportive services to help vulnerable older persons remain in their own homes. They also offer older Americans opportunities to enhance their health and to be active contributors to their families, communities, and the nation. Funding by AoA supports in-home and community-based services including nutrition, transportation, health promotion, nursing home ombudsmen, outreach, and elder abuse prevention efforts.

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

Just as AoA coordinates federal activity to ensure the well-being of older Americans, State and area agencies on aging ensure State and local 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 approximately 27,000 service provider agencies nationwide, some AAAs deliver services directly when no local contractor is available. 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 never 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 population of older Americans, meeting a wide range of needs, as determined by State and local agencies through needs assessment processes. Meals are served in congregate settings such as senior centers, 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 which it began to develop in the 1970’s. In communities throughout the nation, the home and community-based service systems led by the Aging Network provide a preferred alternative to nursing home care, enabling people to live as independently as possible for as long as possible.

1.3 Partnerships and Coordination

In addition to the fundamental partnership with State and local agencies, which comprises the basic operating structure of the Aging Network, AoA works closely with many Federal agencies on a wide range of issues.

In the area of nutrition, AoA works with the U.S. Department of Agriculture (USDA) on such issues as food security measurement and dietary guidelines used as standards for our programs. This is in addition to USDA’s participation as a partial funding agent for meals provided through the Aging Network. HHS work with USDA supports and enhances AoA and HHS objectives to improve the nutritional status of program participants and the elderly as a whole. Within HHS, we work 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. We also are a participant in the Federal Food Safety Coalition chaired by the Center for Food Safety and Applied Nutrition within the Food and Drug Administration. AoA is also represented on such bodies as 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, we work closely with officials of our Department and the U.S. Department of Transportation on the Coordinating Council on Access and Mobility – which works 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) to four additional communities that develop science-based, community demonstration projects for elderly populations. The purpose of these projects is to eliminate health disparities among older racial and ethnic minority populations, including African-American, Asian American and Pacific Islander, Hispanic American and American Indian or Alaskan native 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 HRSA’s (Health Resources and Services Administration) 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 2000, AoA and HCFA joined forces to improve the quality of care in Nursing Homes. Funding was provided to the National Long-Term Care Ombudsman Resource Center, the National Center on Elder Abuse, the National Policy and Resource Center on Nutrition and Aging and the National Association of Area Agencies on Aging. The activities of these grantees have resulted in the identification, development, and demonstration of effective methods to assure that nursing home staff, residents, family members and communities at-large understand the types and causes of malnutrition, dehydration and abuse as well as actions they can take to prevent them.

1.4 Performance Report Summary

Because of the availability of preliminary data for FY 1999 for the performance measures included in AoA’s FY 1999 Annual Performance Plan and for the new measures that AoA will utilize in the future, this submission constitutes AoA’s first significant GPRA Annual Performance Report. The following chart illustrates the status of AoA reporting of performance measures included in its FY 1999 GPRA performance plan. The time needed for the collection of data from State and local entities does not allow AoA to report on the performance measures included in its FY 2000 performance plan. However, whereas AoA had indicated last year that FY 2000 data would not be available until FY 2003, AoA commits to report the data in the next GPRA performance report to Congress in February 2002.

Even before FY 1999 data were available for reporting against the FY 1999 performance plan, AoA became aware that the measures utilized in the original FY 1999 plan would not satisfactorily reflect the program results produced by the Aging Network. For example, the four FY 1999 performance targets which AoA did not meet were related to counts of clients served and selected service units. In analyzing data from FY 1997 and FY 1998, AoA determined that not meeting these targets reflected an inability to project these numbers accurately, and was not a matter of program performance. In fact, performance overall for all of the output measures reflect consistent, stable service performance across the service areas. The major changes in the performance measures AoA has added to the performance plans for FY 2001 and 2002 correct the serious limitation that the service output measures alone are not indicative of the results produced on an ongoing basis through the Aging Network.

The data for the new performance measures identified throughout this plan, which were tabulated from the National Aging Program Information System (NAPIS) for FY 1997, FY 1998 and FY 1999 (preliminary), present a story of performance by the components of the Aging Network that indicates that the Network produces the results intended by the Older Americans Act (OAA). The data for each of the three 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.

Beginning with this submission, AoA has begun to identify developmental measures, which better address the results generated each year by the activities of AoA and the Aging Network. The table above includes counts of those measures for which we have provided performance targets for FY 2001 and 2002. As we move forward with fuller implementation of the Performance Outcomes Measures Project, the count of measures will be expanded to include targets for all of the 36 measures identified for FY 2002. Although outcome, client and service measures must remain the center of AoA’s performance measurement efforts, other relevant measures such as targeting measures, systems measures and program management measures are proposed for the first time, and will be made available each year. AoA will continue to enhance the coverage of its programs and activities to increase the body of data available for performance measurement annually.

Part II Program Planning and Assessment

Introduction

The core of GPRA planning and reporting is the presentation of performance measures that address the results that AoA and Aging Network produce for the program activities entrusted to them. This Program Planning and Assessment presentation focuses on the performance story that emerges from the performance measures AoA uses for the assessment of each of the program activities included in the AoA budget. Accordingly, AoA organizes the Annual Performance Plan and Performance Report to reflect the overall program structure of the agency. For each major program activity listed below, AoA presents performance targets and results in the context of program objectives and strategies. 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 results of the Aging Network reflect the financial support of programs for the elderly administered under the OAA. Similarly, the strategies that are supported annually in AoA budget requests will contribute to the continued success of the Aging Network in producing results for older Americans. The AoA program categories identified for GPRA presentation purposes, with the budget line items that comprise them, are:

1. Community-Based Services

• Supportive Services and Centers
• Congregate Meals
• Home-Delivered Meals
• Preventive Health Services
• Caregivers (NFCSP)

1. Vulnerable Older Americans

• Ombudsman Services
• Prevention of Elder Abuse

1. Native American Services

• Grants to Indian Tribes

1. Research and Development

• Research and Development
• Alzheimer’s Disease Demonstration Grants to States
• Aging Network Support Activities

1. Senior Medicare Patrols

• Operation Restore Trust (HCFAC)

1. Program Management

• Program Administration

2.1 Community-Based Services

AoA’s GPRA program category, Community-Based Services, comprises the agency’s State and Community budget line items 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 includes a new program created under the OAA: the National Family Caregiver Support Program. As indicated above in section 1.2, 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. These and other Federal funds and funds from other sources are used by State and area agencies on aging and service providers to coordinate and to provide services for elderly individuals.

The services provided under this program activity are extensive and address the multiple needs of elderly individuals. The program addresses “access” services, which include information and assistance, outreach, case-management and transportation. The program covers direct “community” services, which include congregate meals, senior-center activities, adult day care, pension counseling, and health promotion and fitness programs. This program activity also covers “in-home” services, which include home-delivered meals, chores, home maintenance assistance, home-health, and personal care. With the reauthorization of the OAA, this program also 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

The Community-Based Services Programs cover the vast majority of the resources, services and activities of AoA and the Aging Network. To improve our communication of the potential and the effectiveness of these programs in this performance plan and report, AoA has developed an expanded and mixed set of performance measures for its Community-Based Services Programs. This performance plan commits for the first time to the development of performance measures associated with targeting services to vulnerable elderly individuals. The plan retains the important and fundamental service output measures that have appeared in previous performance plans for nutrition, transportation, and information services, and includes measures that track federal and other contributions to the services provided through the Aging Network. This plan also presents more prominently the developmental performance outcome measures that AoA and the Aging Network are testing under the Performance Outcome Measures Project. Finally, the plan introduces selected developmental “systems” measures that reflect the importance of tracking the capacity of the Aging Network to support the service activities of the program.

For ease of analysis of performance measures and data in this section of the plan, AoA provides a summary table for each category of performance measure for its community services programs, followed by an analysis of the performance measures and data. The performance measure categories for this program are 1) targeting measures, 2) system measures, 3) the measures for the traditional units-of-service, and 4) client and program outcome measures. The narrative analysis of FY 2000 program accomplishments is provided under the “service measures” section where the major program activities under community services are addressed.

Performance Measures Summary Table—Targeting Measures

Performance Measures Analysis—Targeting Measures

The OAA seeks to ensure and to support the well-being of elderly Americans, and particularly those who are most vulnerable: the poor, minorities, disabled, and the elderly in rural areas. AoA has identified an initial set of targeting measures to track the effectiveness of AoA and the Network in meeting the intent of the OAA to serve vulnerable elderly individuals. Because the measures are new, and AoA and the Network have not had significant opportunity to analyze trends associated with these measures and, more significantly, the data on which they are based, we classify these measures as developmental. Nevertheless, we believe that ongoing analysis of the targeting of services to vulnerable individuals is a fundamental requirement for the Network.

Performance Results for Targeting Measures

Even though the targeting measures are new and developmental, the data associated with these measures for FY 1997 and FY 1998, as well as preliminary data for FY 1999, reflect that the AoA and the Aging Network have produced results by targeting services to vulnerable elderly individuals. The new AoA targeting measures presented above provide evidence that the Aging Network of Federal, State, and community agencies and providers have developed program strategies and mechanisms that allow them to identify and provide services to the individuals who are most vulnerable.

• For all three years, over 30% or more of Aging Network clients had incomes below the poverty level. 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. For the three years, the Aging Network served nearly 50% of the poor elderly individuals in the nation. Although it appears in the chart that the poor among service clients are declining, we have identified likely errors in preliminary FY 1999 data, which when corrected are likely to demonstrate that the percent of clients in poverty is stable.

• For minority individuals, the percent minority among OAA clients in all three years (FY 1997 through FY 1999) was higher than the percent minority of all elderly individuals. Figure 2 illustrates this characteristic of the OAA client population for fiscal years 1997 through 1999. We should note that the percent minority shown for FY 1999 is preliminary and is likely to be understated. We have identified likely reporting errors which are likely to have understated elderly minorities for FY 1999.

• Nearly 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.

As the performance targets for FY 2001 and 2002 reflect, AoA will not attempt to “force” annual changes in these indicators; the stability of program funding argues against predicting annual changes in such broad indicators. We have selected conservative “developmental” targets based on past performance to allow the Network to observe changes over time and to determine how best to establish ongoing performance targets.

It is AoA’s intention to use these measures for planning purposes as they mature. AoA believes that failure to maintain defined target levels would necessarily generate greater scrutiny and corrective action. For now, we believe that the target levels selected are indicative of effective performance by the Aging Network, and it is AoA’s objective to support the Network to ensure that this performance is maintained. For example, the data above indicate that the percent of OAA clients who are minorities is not significantly higher than the percent of all individuals 65 and over who are minorities, even though the preliminary data for FY 1999 are subject to known errors. This indicator warrants that AoA conduct a more thorough evaluation of the data on which the indicator is based to determine whether the circumstance is true.

AoA will seek to add additional targeting measures to this set. At the present time, available data on the “disability” characteristics of the OAA service population are not adequate for analysis on a national basis. As improvements in administrative data systems are implemented, AoA will develop performance measures and targets related to the levels of disability of the client population.

Performance Measures Analysis—System Measures

One of the most significant factors in the effectiveness of the Aging Network is its capacity to coordinate support, advocacy, and services from multiple sources for elderly individuals in communities across the nation. In previous performance plans, AoA has utilized total dollars leveraged by the Aging Network as an indicator of performance, and this plan includes the first results for that indicator. With this plan, however, AoA modifies and expands the “system” measures that illustrate the effectiveness of Federal, State and area agencies on aging and community-service-providers in serving, and advocating for, vulnerable elderly individuals across the nation.

Performance Results for Leveraged Funding Measures

The data reported above for AoA’s expanded system measures (Part 1) demonstrate not only that the funds “leveraged” by the Aging Network are significant in their total, but they exceed the funding provided by AoA for home and community services to the elderly. In addition, the measures indicate that the funding leveraged by the Network supports the vast majority of services to the most vulnerable individuals, services that allow the weakest to remain at home, services such as: personal care, home-delivered meals, and adult day care. Finally, 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. The following are financial performance highlights for fiscal years 1997 through 1999.

• 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%.

• 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.
• 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.

AoA has selected these developmental measures because they are indicative of the results that the State and local entities of the Aging Network produce on an annual basis in coordinating services and financing in support of elderly individuals and in serving as advocates for the elderly. Service coordination is a fundamental necessity for programs that serve individuals. It is reflective of the need to avoid duplication of effort and wasteful spending. The activities of the Aging Network, including those of Federal, State and local entities, are represented in these measures. For example, the vast majority of the funds that are counted under leveraged funding were generated through the coordination of other Federal and State programs. The funding covers services supported by Medicaid waivers, Social Services block grants and USDA funding for meals. Funds from AoA support services, but they also support the Network, which is responsible for the coordination that has enhanced service support for elderly individuals. AoA’s initial performance targets for these developmental measures reflect the view that the past performance of the Network that has been observed for FYs 1997 through 1999, reflects effective systems performance that should be maintained.

Performance Results for Other New Systems Measures

Other measures that AoA has selected as system measures represent the strong community orientation of the program. Senior centers are not only places where elderly individuals receive selected services. Reflecting the importance of service coordination to OAA program managers throughout the Network, over half of the senior centers participating in the program are community “focal points” for the coordination of a full range of services to elderly individuals. Also reflecting community responsibility in the management of the Aging Network are data that show that almost 50% of the staff that serve area agencies on aging directly are volunteer staff.

• For all three years, from FY 1997 through FY 1999, over half of all senior centers participating in the program were community-service “focal points.”
• 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.

AoA seeks to maintain the level of performance observed for these two measures to demonstrate on an ongoing basis that OAA programs are community based and are organized to ensure service coordination. The “focal point” measure in particular demonstrates the intent of the Network to coordinate services. The volunteer staff measure for area agencies on aging demonstrates that these critical entities of the Network are more than a governmental presence at the local level. The significant level of volunteer staff working in area agencies on aging indicates that these entities are also community organizations committed to the service of individuals in need.

Consistent with its conviction of the effectiveness of the Network, AoA is committed to provide infrastructure support to the local components of the Network. As a measure of AoA support of the local components of the Network over the coming years, AoA will establish a performance measure to increase the Internet connectivity and capacity of area agencies on aging. This measure will serve not only as a service capacity indicator, but also as an indicator of improved capability to address the complex data and record-keeping requirements associated with generating reliable data on the characteristics of the clients and services of the Aging Network.

Performance Results for Original Systems Measures

AoA has modified its measures related to leveraged funding, but recognizes the importance of reporting on the performance targets, which were included in the FY 1999 performance plan. The data provided in Part 2 of the systems measures table serve that purpose. The level of leveraged funds for these community-based service programs is significant, and the funds taken as a whole enhance the total level of services that the Aging Network is able to provide to elderly Americans. The variations in the data from year to year reflect the developmental nature of performance measurement, and demonstrate that the “absolute value” of dollars leveraged was not indicative of program effectiveness. In our view the data illustrate the limitation of the measure itself. Absolute dollars of leveraged funds do not reflect a story of performance that is relevant for the Network. As explained above, AoA will utilize the measures presented in Part 1 of the systems table and discontinue those in Part 2.

Performance Measures Summary Table—Service Measures

Performance Measures Analysis—Service Measures

For this plan, AoA has retained the same service measures that it has employed in performance plans for previous years. The measures in this section of the plan are output measures that reflect the intention of the agency to meet the requirements of GPRA to provide a mix of performance measures that are relevant to program results. These measures also provide a basis for the fundamental tracking of the level of services that we 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. The following descriptions of these service activities provide important context to this set of measures and to the nature of the basic services the Aging Network provides. It is followed by an analysis of the data, particularly for FY 1999, and by an explanation of planned performance for FY 2002.

Nutrition Services

AoA provides congregate and home-delivered nutrition services to older adults at risk of poor nutrition, poor health, social isolation and loss of independence. Although these services often include nutrition assessment, education, and counseling, the primary service provided is meals. The purpose of both nutrition services programs is to improve the dietary intake of participants, offer them opportunities for social participation and engagement and for the development and maintenance of informal support networks, and to link participants to other health and social services, as needed and as appropriate. Nutrition services improve nutritional status, decrease the risk of disease and disease-related disability, help maintain cognitive and physical functioning and decrease food insecurity.

Scientific evidence supports the relationship between good nutrition, health, and functionality. Four of the ten leading causes of death and disability (heart disease, cancer, stroke, and diabetes) among older adults are tied to poor nutrition. Prevention of decline in cognitive functioning and a reduction of the risk of coronary artery disease are linked to adequate intake of vitamins B6, B12, and folic acid. The prevention and treatment of osteoporosis and the maintenance of mobility are tied to the consumption of adequate amounts of calcium and vitamin D. Evidence indicates that the development of blindness due to cataracts or age-related macular degeneration may be retarded if there are adequate amounts of the antioxidants -- vitamin E, beta-carotene and other carotenoids, and ascorbic acid -- in diets. Research has also found that antioxidants may play a role in the prevention of central nervous system disorders such as Alzheimer’s, Parkinson’s Disease and arteriosclerosis. Obesity caused by the interaction of poor nutrition and lack of physical activity decreases mobility, increases the risk of chronic diseases and disability and ultimately decreases the life span.

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

Transportation Services

As America’s population ages and experiences longevity in record numbers, the issue of mobility rises in importance. Since 1900, the percentage of Americans age 65 and older has more than tripled. By 2030, there will be about 70 million older persons, more than twice their number in 1997. According to a 1997 study, one-fourth of the 75-and-older age group does not drive. This number is expected to increase as our population ages, creating an even greater need for alternative transportation services, including public transportation systems or specialized transportation services.

AoA supports the development of more options for access to transportation by:

• providing grants to States and territories to maintain service levels and, where possible, to leverage funding to increase these services;
• advocating for the coordination of transportation services;
• offering technical advice and guidance; and,
• funding demonstrations of promising alternatives.

Formula grants to 57 States and territories maintain service provision levels for supportive services assessed as needed and deemed most appropriate within each community. Supportive services include transportation services which offer older persons access to senior centers, adult day care, doctor’s offices, hospitals, clinics, grocery stores, congregate meal sites, and other programs and destinations. Besides helping older persons to meet the obligations and responsibilities which are part of daily life, transportation services make possible social engagement and participation, important components of quality of life. National studies show that, for older persons, the greatest problem caused by the lack of transportation is a sense of loneliness and uselessness. A person overcome with these feelings is more likely to be a candidate for depression, declines in physical health, and early institutionalization, a costly and preventable fate.

The Supportive Services funds allocated to the 57 State and territories are distributed, following a needs assessment based State plan, to 655 area agencies on aging, that in turn award grants or contracts to local service providers in keeping with a comparable area plan. Services are targeted to persons 60 years of age and over, with a focus upon those individuals with the greatest economic and social needs. Particular attention is given to low-income minorities.

Information and Assistance Services

Social and demographic trends are making the need for information services increasingly important to the average American family. Today, older Americans and caregivers face a complicated array of choices and decisions about services and programs available to assist them. Many need support and assistance to navigate the complex environment of public and private sector benefits and services. Information and Assistance (I&A), established by the 1973 Amendments to the OAA, is a federally required service intended to inform, guide, and link older adults to available, appropriate, and acceptable services to meet their needs. Currently, there are I&A programs operated by each State and area agency on aging, covering all geographic areas of the country.

Often the first point of contact for assistance, I&A programs receive the broadest range of inquiries for older persons. I&A programs assist older persons and caregivers by assessing their needs, identifying the most suitable services, given these needs, and linking them to service providers. Knowing that I&A services are the key to keeping older adults and their caregivers connected to other essential services, AoA remains actively involved in stimulating improvements to the operation of I&A systems.

Performance Results for Service Measures

The preliminary data for FY 1999 indicate that AoA met service performance targets for three of the five measures included in the FY 1999 annual performance plan. AoA did not meet the performance target for congregate meals, and provides two observations related to that phenomenon. First, AoA has noted in performance plans for FY 2000 and 2001 that States have the flexibility, and have been encouraged, to transfer funding from congregate to home-delivered meals to ensure that vulnerable home-bound individuals can remain in their homes if they choose. Second, after AoA obtained data for FY 1997, which more accurately reflected the extent to which congregate meals would be reduced because of this phenomenon, the Agency lowered its performance targets for FY 2000 and 2001 accordingly. AoA will utilize the same service target for FY 2002 as well.

Corresponding to the actions that lowered the level of congregate meals, preliminary data for FY 1999 indicate that AoA substantially exceeded its performance target for home-delivered meals. AoA will retain the higher performance targets for home-delivered meals, which were established for the FY 2000 and 2001 plans.

AoA will closely follow up on the preliminary FY 1999 data, which indicate that units of transportation services were above our FY 1999 performance targets, but below the levels reported for both FY 1997 and FY 1998. Because the data are preliminary, we must first determine if reporting problems are the cause of the discrepancy. Nevertheless, because it is not the intention of the Agency to reduce transportation services, AoA will retain the higher level performance targets identified for FY 2000 and 2001 in the FY 2002 performance plan, and will seek to explain and reverse declines if they have occurred. AoA does not consider the preliminary FY 1999 data for Information and Assistance services to be significantly below the performance target in the FY 1999 performance plan, and will retain the higher performance targets for FY 2001 and 2002.

FY 2000 Accomplishments—Community Service Activities

Because service activity is so fundamental to OAA program results, it is important for AoA to also describe the recent achievements of the Aging Network while data systems and GPRA performance measures mature. Therefore, we have provided the following narrative summary of FY 2000 accomplishments for each of the significant community services program activities. These accomplishments delineate the contribution of AoA and the agency’s performance partners, and communicate more clearly than summary measures the ongoing program performance results that the Aging Network produces on an ongoing basis. It is not the intention of AoA to minimize the importance of meaningful quantitative performance measures. Rather, the information enhances the performance story of the Aging Network for important program constituents.

Nutrition Services

National Nutrition Standards

The Older Americans Act prescribes National Nutrition Standards that must be met in meals for older adults. These standards require that the meals served through the ENP promote health, are culturally appropriate, and meet the special health needs of older adults. Each meal must contain 1/3 of the Recommended Dietary Allowances (RDAs) as established by the Food and Nutrition Board, Institute of Medicine, National Academy of Sciences. Also, each meal must meet the Dietary Guidelines for Americans from the Department of Health and Human Services (HHS) and the United States Department of Agriculture (USDA). Moreover, the standards require that meals programs comply with State, tribal, and local food service laws to ensure meals served are safe to eat.

AoA’s monitoring of nutrition service providers’ compliance with the National Nutrition Standards and other service activities provides assurance that the meals delivered through the ENP contribute to improved nutritional intake and promote the improved health of recipients.

Partnerships to Help Ensure the Needs of Older Adults Are Met

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

• The Nutrition Objective Sub-committee for the HHS Healthy People 2000/2010
• HHS Nutrition Policy Board
• HHS Dietary Guidance Committee
• HHS/USDA Food Security Committee
• Federal Food Safety Coalition
• HHS Dietary Reference Intake Working Group to insure the needs and special concerns of the older population are addressed
• HHS/USDA Working Group for the National Nutrition Summit
• USDA/ Center for Nutrition Policy and Promotion (CNPP) 2000 Millennium Symposium Lecture Series, Nutrition and Aging: leading a Healthy, Active Life
• USDA/Food Safety and Inspection Service and HHS/Food and Drug Administration review of materials for food safety for seniors
• HHS Health Care Financing Administration (HCFA) Nutrition and Hydration Campaign
• HHS/IHS Congressionally-mandated paper on obesity in American Indians

Efforts to Target Specific Recipient Groups

During FY 2000, AoA continued to target nutrition services to high-risk groups including those at high economic risk, nutritional risk and those who are minorities who have significantly higher rates of health disparities. The old-old and those with functional impairments are also at high risk. Data from selected states for home-delivered meals indicate that participants demonstrate particular risk. This data indicate that 72 percent of all home-delivered participants are older women and about 25 percent of the older women are over the age of 85. Of all home-delivered participants, 70 percent indicate that they have three or more impairments in instrumental activities of daily living that includes the ability to shop for food as well as the ability to prepare simple meals. In addition, 31 percent are even more significantly impaired and have three or more impairments in activities of daily living which is a severe level of disability and includes such activities as being able to feed oneself, bathe, dress, etc.

In addition under Title III, States collect data on the nutritional risk of participants. This is done to help target nutrition services to the most “nutritionally needy.” The States are requested to use check-listed criteria from the Nutrition Screening Initiative (NSI) to identify older adults at risk of malnutrition or in need of other nutrition-related services to maintain a healthy life-style. The information collected by the SUAs and reported to AoA is used by AoA to assist the National Aging Service Network to target ENP nutrition services such as congregate and home-delivered meals, nutritional counseling, and case management services to older adults with the greatest needs.

To help end health disparities among older racial and ethnic minority populations, the AoA awarded $1 million in demonstration grants to four community coalitions that serve older members of racial and ethnic minority groups. The grants are intended to develop initiatives that eliminate the high rates of diabetes and cardiovascular disease—diseases in which appropriate nutrition plays both a prevention and treatment role-- in the African-American, Latino, American Indian and Asian communities. These grants will address these two chronic diseases through culturally appropriate prevention activities and the adoption of healthy lifestyles that acknowledge and integrate appropriate cultural practices and diets.

Promotion of Service Needs Awareness

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

• During FY 2000, AoA participated in HHS Healthy People 2010, a national prevention initiative that has established national health targets and that calls for community collaboration in their achievement. In order to expedite efforts to promote health and prevent illnesses among older persons, AoA has encouraged the national Aging Network to participate in the Healthy People initiative and to strive to meet national health targets.
• AoA is also actively engaged in the deliberations of the HHS Dietary Reference Intake (DRI) Working Group that provides funding and direction to Food and Nutrition Board of the Institute of Medicine of the National Academy of Sciences to determine the quantifiable amounts of nutrients necessary for health. It also recommends experts for discussion panels and provides assurance that the informational needs of the Federal government and other recipients are met. These values, known as the Dietary Reference Intakes, include the Recommended Daily Allowances (RDAs) as a category. The OAA requires that a meal contain one-third of the RDA. In addition, these values provide the basis for dietary recommendations for both health promotion/disease prevention for federal policy as well as the basis for modifying diets for both acute and chronic disease management.
• AoA actively par