Modernizing

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Modernizing Strengthening Oklahomas Aging
Network Interim Study IS11-102October 18, 2011

• Lance Robertson, State Director
• OKDHS Aging Services Division
• 2401 NW 23rd Street, Suite 40
• Oklahoma City, OK 73107
• [phone]
• lance.robertson_at_okdhs.org

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Interim Study Overview Modernizing
Strengthening Oklahomas Aging Network

• Author IS11-102
• Representative Pam Peterson
• Description
• Study coordination and delivery of services for
  seniors, and examine the
• possibility of more efficient allocation of
  services provided by the Area
• Agencies on Aging (AAA)
• Goals Expectations
• Look at modernizing the Older Americans Act
  service delivery system to provide essential,
  high-quality services more efficiently to older
  Oklahomans.
• Realize possible efficiencies in administrative
  costs (dollars) as well as practice/structure
  (contracting, monitoring, etc.)
• Any savings should be diverted back into services
• Preserve current service level and quality
• Include aging network in the development of a plan

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Interim Study Overview Modernizing
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• AGENDA
• Critical Questions
• Partners, Advocates, Constituents Feedback
• Demographics
• Overview of Oklahomas Older Americans Act Aging
  Network
• History Background
• Structure
• Overall budget
• Constituency served
• Considerations
• General
• Four Interim Study Considerations
• Funding breakdown
• National comparatives
• Data Sources
• Questions Answers

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Interim Study Overview Modernizing
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• Critical Questions -
• What is the structure of the aging network?
• Whats happening demographically and are we
  prepared to respond?
• How many AAAs are aligned with Council of
  Government (COG) and why?
• What is our service penetration rate (how many
  are served)?
• How many employees work in the AAA system?
• How is the aging network in the state funded?
• Is the states network sufficiently funded?
• How does funding flow through the COGs and AAAs?
• How much money (and what percentage of overall
  funding) goes towards administrative costs?
• How much money (and what percentage of admin)
  goes towards indirect costs?
• Are there guidelines on how much indirect can be
  charged?
• What is the approximate cost per unit for
  services delivered?

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Interim Study Overview Modernizing
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• Critical Questions
• Has the network ever been updated, looked at
  critically or modernized?
• Is there a way to deliver services more
  efficiently?
• Could a plan be put together that saves money but
  ensures service delivery remains at present
  level?
• How much money could be saved if redistricting
  occurred?
• What changes would require federal approval?
• Are there easier, lower-hanging fruit type
  changes that could be made?
• How does Oklahoma compare to other states?
• What have other states done to modernize their
  network and has that worked?
• How dependent are we (OK) on state funds versus
  other states?
• If redistricting occurred, how much funding could
  be diverted to services?

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Interim Study Overview Modernizing
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• The plan shall be developed in coordination with
  aging network partners
• Information solicited from partners
• Oklahoma Association of Regional Councils (OARC)
• Area Agencies on Aging (AAA)
• State Council on Aging
• Advocacy Groups
• Silver Haired Legislature (OSHL)
• Oklahoma Alliance on Aging
• Various Constituents
• Fellow State Agencies (Insurance, Commerce)
• Aging Network Providers
• Legal Aid Services of Oklahoma
• Dieticians Nutrition Projects

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Interim Study Overview Modernizing
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• Advocate Feedback
• Continuation of nutrition, direct care services,
  caregiver, case-management services, consumer
  advocacy, transportation
• Development of partnerships to ensure that older
  Oklahomans stay in touch with their worlds
• Optimization of grant opportunities and adoption
  of best practices
• Ensure current number of OSHL representatives
• Ensure adequate support of OSHL activities
• Review degrees of success of different AAAs
• Review structure of aging network to ensure
  consistency
• Ensure proximity of providers to consumers

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DemographicsModernizing Strengthening
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DemographicsModernizing Strengthening
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DemographicsModernizing Strengthening
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DemographicsModernizing Strengthening
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• 694,024 Oklahomans 60 (20th in US)
• 19.3 of population
• By 2030, 24.45 of population (954,795)
• 1 in 5 are minorities
• 70,555 age 85 (rank of 25th in US)
• 99,559 by 2030
• Raw number has increased twelve times since 1900
• Life expectancy of 65 is now 19.1 years
• Entitlements and state/federal programs
• Baby Boomers

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DemographicsModernizing Strengthening
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DemographicsModernizing Strengthening
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DemographicsModernizing Strengthening
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While Oklahomas total population will grow at a
relatively slow pace (10.2), 65 and older will
increase by over 60 by 2030 Source US Census
Bureau, Population Estimates Program
DemographicsModernizing Strengthening
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65
85
0-17
18-64
Total
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DemographicsModernizing Strengthening
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• Challenges within population
• High poverty rate (19th in US) 9.8 of 65
• Larger number of rural dwellers
• Very poor health indicators
• High disability ratio (8th in US)
• High Old-Age Dependency Ratio (14th in US)
• Leading state for Grandparents Raising
  Grandchildren (6th in US) 44,000
• Reliance on public programs
• Income/Lack of savings
• Poor LTC planning
• Challenges within service delivery system
• Budget Fragility
• Competition for resources
• Creating a brand
• Present capacity of network
• Ability to expand network on a dime

Budget
Challenges
Demographics
Service Demand
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Older Americans ActModernizing Strengthening
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• 1965- Older Americans Act (OAA)
• Established U.S. Administration on Aging (AoA)
  state agencies on aging (SUA) to address social
  services needs of older people
• Mission maintain maximum independence and
  promote continuum of care
• Seven (7) titles
• Title III Grants for State and Community
  Programs on Aging
• Title IV Activities for Health, Independence,
  and Longevity (Program Innovations)
• Title VII Vulnerable Elder Rights Protection
• Note collaboration with V (Community Service)
  and VI (Nat Amer)
• Funds are distributed via formula
• 66.7 of total funding is Title III
• Targeting
• Greatest economic or social need/means testing
  prohibited
• Voluntary contributions for services
• Cost-sharing policies for certain services-
  sliding scale
• No denial of services for failure to contribute

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OK Aging NetworkModernizing Strengthening
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a unifying force at the state level through
which the broad policy objectives of the Older
Americans Act ultimately come to pass. An agency
designated by the Governor as the focal point on
all matters relating to the needs of older
adults.
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OK Aging NetworkModernizing Strengthening
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• Existing OAA Network
• Established in 1973
• State Unit on Aging OKDHS Aging Services
  Division (ASD)
• Designated by Federal Government and Governor of
  Oklahoma as the sole agency for administering the
  Older Americans Act (OAA) programs
• State Plan development every four (4) years
• Area Agencies on Aging - planning, advocacy, and
  development of OAA services in regional service
  area
• Program Partners Meals on Wheels, Regional
  Councils, Dept of Commerce, Insurance Dept, etc.
• Network of Providers (subcontractors) service
  delivery at local level

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OK Aging NetworkModernizing Strengthening
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Federal BudgetModernizing Strengthening
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Total Federal Budget of approximately 2.73
Trillion
OAA 0.066
A Joint Proposal of NASUA and n4a
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OK Aging NetworkModernizing Strengthening
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• SFY11 Oklahoma Budget Snapshot
• Total 26,931,272
• Federal 16,653,560
• State 10,002,095
• Required 2,934,311
• Overmatch 7,067,784
• AAA Local match 275,617

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OK Aging NetworkModernizing Strengthening
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Interim StudyModernizing Strengthening
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• General Considerations
• Reminder of purpose, goals and expectations
• Stress efficiency while ensuring service delivery
• Recent conversations date back to spring 2011
• General legislative inquiries date back to
  SFY2008
• Any plan will be discussed and approved by the
  federal government
• Appreciate ability to discuss
• Many states are looking at changes or have
  recently made state network adjustments
• All considerations have merit
• Some are larger, structural in nature
• All would result in some form of
  modernization/efficiency
• Must fully explore pros/cons

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Interim StudyModernizing Strengthening
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• Consideration 1 Is there a way to more
  efficiently manage the LEGAL AID Services system?
• Overview
• Statewide, non-profit organization providing free
  legal services to 60
• Provides general civil legal services to all 77
  counties
• Contracts with each of the 11 AAAs
• LASO is only entity bidding
• Other activities often performed by trained
  paralegals
• Funding
• Funded through Title III of OAA
• Represents about 5 of AAA budget
• Challenges
• Disparate service areas complicates and makes
  more difficult bookkeeping and billing
• Some communities are excluded from coverage
• Repetitive and variable application process,
  reporting, requirements

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Interim StudyModernizing Strengthening
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• Consideration Explore the viability of
  consolidating this statewide service under a
  single contract
• Potential results
• More efficient, uniform service delivery
• Less redundancy in reporting
• Reduction in administrative costs for
  contracting, monitoring, reporting, etc.
• One contract versus eleven
• Full statewide coverage
• Better coordination
• Connectedness to statewide hotline
• Uniform oversight by lawyer (Legal Services
  Developer)
• Next step At the committees pleasure, the
  aging network looks into the possible
  implementation of this idea
• No statutory mandate required
• Will not require federal approval

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• Consideration 2 Is there a more efficient way
  to manage
• the role REGISTERED DIETICIANS play within the
  network?
• Overview
• Presently, 20 contracts statewide for Registered
  Dieticians (RD)
• RDs provide training for nutrition project staff,
  develop menus, provide nutrition counseling
• State policy allows either AAA or nutrition
  project to contract
• OAA provides for solicitation of dietitian or
  other with comparable expertise in planning of
  nutritional services
• No instances of food poisoning since beginning of
  nutrition programs
• Funding
• 280,108 - cost of services in SFY11
• Challenges
• Some duties dont require RD licensure
• Little time to perform nutrition counseling or
  other critical duties
• Rural areas have little access to RDs and more in
  travel costs
• RD training- minimal due to limitations of high
  hourly cost
• (25-60/hr)

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Interim StudyModernizing Strengthening
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• Consideration Explore the viability of
  consolidating this statewide service under a
  single contract
• Potential results
• More efficient use of limited available resources
• Overall possible reduction of cost
• Service Provision consistency
• Consistency of training and oversight
• Next step At the committees pleasure, the
  aging network looks into the possible
  implementation of this idea
• No statutory mandate required
• Will not require federal approval

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• Consideration 3 Should the SENIOR INFO LINE
  remain in place?
• Overview
• Established in 2004 by OKDHS/ASD
• 1-800 dedicated phone line to increase access
• Serves all 77 counties/connects callers with
  closest AAA
• Trained Information Specialists answer the Senior
  Info-Lines
• 569 completed calls/1435.80 minutes in duration
  (September 2011)
• Funding
• OKDHS pays minimal monthly costs
• September 2011 45.66 (annual costs range between
  600-800)
• Challenges
• Recurring problems with proper transfers to the
  appropriate AAA
• Uses ATT trunk lines (archaic)
• Routing problems exist when new area codes are
  added
• Information Specialists not available to answer
  the phones/use voice mail/impersonal
• Duplicates services provided by 2-1-1
• (Social Services hot-line refers callers to AAA)

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Interim StudyModernizing Strengthening
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• Consideration Explore the viability of tying
  line into other existing referral sources
• Potential results
• More efficient use of limited available resources
• Overall possible reduction of cost
• Service Provision consistency
• Consistency of training and oversight
• Next step At the committees pleasure, the
  aging network looks into the possible
  implementation of this idea
• No statutory mandate required
• Will not require federal approval

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• Consideration 4 Should Oklahoma explore
  realigning Planning and Service Areas (PSAs)
  within the state to create a more modern,
  stronger and efficient service delivery system?
• Overview
• Present structure was put into place in 1973
• Most AAA are under the umbrella of COG - 10 of 11
• Some AAAs have Direct Service Waivers (DSWs)
• Funding
• SFY11 26,655,655 (state/federal)
• Pass Through vs. Administrative monies
• Indirect as part of Administrative monies
• Administrative costs 3,645,870
• Indirect 593,821
• Challenges
• Some have expressed concerns about system that
  has not been modernized since established
• Is there sufficient funding in network to fund 11
  AAAs?

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• Challenges (cont.)
• Indirect costs
• How will population shifts impact funding and/or
  formula?
• Funding formula needs to be updated
• Is present system efficient (are 11 AAAs needed?)
• With budget constraints, will PSA shifting
  inevitably occur?
• Consideration Explore the viability of
  modernizing, streamlining and strengthening
  Oklahomas aging network
• Potential results
• More efficient use of limited available resources
• Overall possible reduction of cost
• Service provision consistency
• Consistency of training and oversight
• Next step At the committees pleasure, the
  aging network looks into the possible
  implementation of this idea
• No statutory mandate required
• Could require federal approval if structure is
  changed

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OK Aging NetworkModernizing Strengthening
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• National Data on AAA
• organizational infrastructure
• Independent/NP 42
• Part of County Gov 29
• Part of COG 23
• Part of City Gov 2
• Other 4
• Reminder in Oklahoma, all but one of the 11 are
  in COGs
• Some COGs provide additional support that is
  difficult to track

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• An Area Agency on Aging (AAA) develops an Area
  Plan to receive Older Americans Act funding from
  the State Agency
• Establish advisory councils
• Develop and administer area plans
• Develop and coordinate resources
• Advocate for older Oklahomans
• Fund and monitor local projects
• Provide technical assistance and training
• Designate community focal points
• While no 2 are necessarily the same, have common
  responsibilities

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OAA Title III Services

• Information and Assistance
• Supportive Services (service provider
  contractors)
• Homemaker
• Personal care
• Chore
• Transportation
• Assisted Transportation
• Outreach
• Home repair
• Legal assistance
• Health promotion
• Case management

• Senior Nutrition
• Congregate HDM
• Nutrition education
• Nutritional Counseling
• Family Caregiver Support Services
• Counseling, Support Groups, Training
• Respite Care
• Information Services
• Access Assistance
• Supplemental Services
• Ombudsman

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Comparative (state) census data shows 33 states
have higher total populations and higher
concentrations of 60 residents but fewer AAAs
than Oklahoma
State Total Pop Divided by AAA 60 Pop Divided by AAA of AAA
AZ 1,319,156 239,212 5
AR 361,181 71,611 8
IA 601,571 120,385 5
MN 752,316 133,587 7
MO 598,758 114,072 10
NM 669,890 122,803 3
OK 335,186 62,554 11
TN 699,583 132,301 9
WA 605,835 106,145 11
WV 454,944 100,275 4
WI 1,884,924 352,446 3

• Alabama
• Alaska
• Arkansas
• California
• Connecticut
• Delaware
• District of Columbia
• Florida
• Georgia
• Hawaii
• Illinois
• Indiana
• Iowa
• Michigan
• Minnesota
• Missouri
• Nevada

New Hampshire New Jersey New Mexico New
York North Carolina North Dakota Ohio Rhode
Island South Carolina South Dakota Tennessee Texas
Washington West Virginia Wisconsin Wyoming
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• State Comparative Date (cont.)
• Statistically, 33 states (66) serve more people
  with fewer AAAs
• Average of 33 states
• Total Pop Avg 835,554 (OK 335,186) 249
• 60 Pop Avg 155,375 (OK 62,554) 249
• Average of 4 other states in Region VI
  (AR,NM,TX,LA)
• Total Pop Avg 528,145 (OK 335,186) 158
• 60 Pop Avg 89,075 (OK 62,554) 143
• Average of all states in the US
• Total Pop Avg 4843438,086 (OK 335,186) 146
• 60 Pop Avg 88,277 (OK 62,554) 143

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• Restructuring efforts
• Recent activities in other states IA, NM, GA,
  MN, WI, OR (amongst others)
• 50 of states are exploring or implementing some
  sort of local or regional restructuring
• Fiscal fragility
• 60.5 of AAAs cut budgets in all or some
  departments
• 39 reorganized
• Dependency on state vs. local funds
• OKLAHOMA 62 fed, 37 state, 1 local
• IOWA (example) 50 fed, 10 state, 40 local

OKLA
UNITED STATES
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• Reasons states are restructuring
• Economy
• During economic downturns, state leaders and
  policy makers strategize about ways to become
  more administratively efficient
• Focus on Function
• Able to carry out three basic functions
  effectively Grant management, Information and
  assistance (ADRC), Resource development
• Vision
• Changes based on how best to meet needs of the
  people served
• Fewer AAAs but stronger
• Better communication and stronger relationship
  between SUA and AAA
• Resources
• Consolidation will give regions more resources in
  total
• Streamlining AAAs will make them capable of
  taking on new grants and provide additional
  services
• Local network changes have a profound impact on
  oversight, pricing, and contact with consumers in
  states with large rural regions

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• Ways States Have Become More Administratively
  Efficient/Possible changes
• State or regional contracting for service
  delivery to achieve better unit cost pricing
• Reduction in administrative workload
• Coverage of rural areas which may not have
  providers of some services
• Evaluation of the Intra-state Funding Formula
  (IFF)
• Impact of fewer contracts with AAAs
• Evaluation of indirect costs
• Establish a floor and ceiling for allowable
  indirect costs
• Define allowable indirect costs and
  administrative costs

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• Examples of State Streamlining
• Minnesota
• Impetus
• Fourteen (14) AAAs, some so small (1.5 staff),
  they were unable to carry out all three basic
  functions effectively- grant management, IA, and
  resource development
• Outcomes
• Began process in 2001 completed in 2005
• Reduced the number of PSAs and AAAs from 14 to 7
• Increased capacity of each AAA and more resources
  in total
• Stronger relationship between the SUA and AAAs

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• Examples of State Streamlining
• Georgia
• Impetus
• Proposed redesign of all DHR Planning and Service
  Areas (PSA) to all be the same
• Outcomes
• Began in 1994 completed in 1996
• Reduced the number of AAAs from 18 to 12
• Oregon
• Impetus
• SUA concerned small AAAs not able to serve as
  single points of entry for Aging and Disability
  Resource Centers (ADRCs)
• Outcomes
• Began in 2009
• Process not completed/ to be completed in 2013
• Reduce number of small AAAs so that all are able
  to serve as single points of entry for fully
  functioning ADRCs

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• Thoughts by constituents, partners, etc
• No loss of services
• Key assurance with any proposed plan -full
  continuation of services presently offered
• Entire network would need to work together in
  assuming collective responsibility
• Most likely, core services (like nutrition) would
  still be delivered through the same present
  network of contractors
• Saving lots of money
• While some financial efficiencies could be
  gained, the truest savings may be
  programmatic/process efficiencies
• Focus would be on more efficient use of
  administrative dollars/no reduction on
  pass-through funding
• Any savings would go back into services

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• Thoughts by constituents, partners, etc
• No loss of local presence if the structure is
  changed
• Any accepted plan would preserve current presence
• Recognize fresh programs/initiatives like 2-1-1
  and the Aging Disability Resource Consortium
  (ADRC), information access is growing more
  efficient and seamless
• Existing, local providers would still likely be
  in place
• End result could be more served for less
  administrative cost
• No slippage in quality assurance of programs
• Accepted plan would ensure quality of services
• Costs would not climb much higher (ex travel)
  if the structure is changed
• Any accepted plan would address travel expenses
• Understandably, some costing may shift (some up,
  some down) but at the very least the plan should
  be cost neutral with greater programmatic
  efficiencies being realized

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• Possible efficiencies in contemplated
  streamlining
• Efficiencies realized
• Increase in competition amongst service providers
• Increase in quality of services
• Use of limited available resources more
  efficiently
• Potential reduction of costs
• Consistency of provision of services
• Consistency of training and oversight
• Example - ASCOG nutrition consolidated three
  nutrition programs into one successfully

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CURRENT SYSTEM
STREAMLINED SYSTEM
OKDHS ASD State Unit on Aging
COG
COG
COG
COG
COG
COG
COG
COG
COG
COG
(COG)
AAA
AAA
AAA
AAA
AAA
AAA
AAA
AAA
AAA
AAA
AAA
OAA CM (1)
PERMANENT WAIVERS
TEMPORARY WAIVERS
Ombudsman (24)
Information Assistance (14)
LOCAL SERVICE PROVIDERS
LOCAL SERVICE PROVIDERS
In-Home Services
Outreach
Legal Services
Congregate/HDM Nutrition ED Nutrition
Counseling HP/MM
Transportation
Family Caregiver Support Services
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DHHS / AOA
OK SUA
COG
COG
COG
COG
COG
COG
AAA
AAA
AAA
AAA
AAA
AAA
OAA CM (1)
PERMANENT WAIVERS
OMB (24)
IA (14)
LOCAL SERVICE PROVIDERS
LOCAL SERVICE PROVIDERS
Transportation
Outreach
Congregate/HDM Nutrition ED Nutrition
Counseling HP/MM
In-Home Services
Family Caregiver Services
Legal Services
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STREAMLINED SYSTEM
CURRENT SYSTEM
AAA
AAA
AAA
AAA
AAA
AAA
AAA
AAA
AAA
AAA
AAA
SFY 2011 TEMPORARY WAIVERS
Transportation (1)
Health Promotion/ Medication Management (5)
Family Caregiver Support Program (5)
Legend State Fiscal Year (SFY) Area Agency on
Aging (AAA)
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• Data Sources
• U.S. Administration on Aging
• U.S. Census Bureau
• National Association of States United for Aging
  Disability (NASUAD)
• National Association of Area Agencies on Aging
  (n4a)
• State Unit on Aging
• AIM Database
• Fiscal Data
• Office of Planning, Research and Statistics
  (OPRS)

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• Lance Robertson, State Director
• OKDHS Aging Services Division
• 2401 NW 23rd Street, Suite 40
• Oklahoma City, OK 73107
• [phone]
• lance.robertson_at_okdhs.org
• OKDHS ASD wishes to thank Oklahoma legislators
  for their time and for the opportunity to share
  the Modernizing Strengthening Oklahomas Aging
  Network presentation and to thank the partners,
  advocates and constituents for their valuable
  contributions and feedback.