FY 2020 Annual Performance Plan and Report - Goal 3 Objective 4

Fiscal Year 2020
Released March, 2019

Goal 3. Objective 4: Maximize the independence, well-being, and health of older adults, people with disabilities, and their families and caregivers

Older adults and people with disabilities face a complex set of difficulties. About 1 in every 7, or 14.9 percent, of the population is an older American.  Approximately 12 percent of working-age adults in the United States have some type of disability.  Of these adults, 51 percent had a mobility disability, and 38.3 percent had a cognitive disability.

To support older adults, people with disabilities, and the system of friends, family, and community members that support them, the Department collaborates across the Federal Government, with states, tribes, territories , and faith-based and community organizations.  Aging and Disability Resource Centers provide a gateway to a broad range of services and supports for older adults and people with disabilities.  Centers for Independent Living are community-based centers that offer services to empower and enable people with disabilities to stay in their communities.  Every state and territory has an Assistive Technology Act program that can help people find, try, and obtain assistive technology devices and services.  Assistive technology includes resources ranging from “low tech” helping tools—like utensils with big handles—to higher-tech solutions like talking computers.

The Office of the Secretary leads this objective.  The following divisions are responsible for implementing programs under this strategic objective: ACF, ACL, CDC, CMS, HRSA, IHS, OASH, and SAMHSA.

Objective 3.4 Table of Related Performance Measures

Demonstrate improvement in nursing home health care quality by reducing the number of one-star nursing homes (Lead Agency - CMS; Measure ID - QIO7.2)40

  FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 FY 2018 FY 2019 FY 2020
Target N/A N/A N/A Baseline N/A 6.0% 5.0% TBD
Result N/A N/A N/A 8.0% 4.6% 10/31/19 10/31/20 10/31/21
Status N/A N/A N/A Historic Actual Historic Actual Pending Pending Pending

More than 3 million Americans rely on services provided by nursing homes each year.  There are 1.4 million Americans who reside in the nation’s 15,600 nursing homes on any given day.  Those individuals and their family members, friends, and relatives, must be able to count on nursing homes to provide reliable, high-quality care.  Current law requires CMS to develop a strategy that will guide local, state, and national efforts to improve the quality of care in nursing homes.  The most effective approach to ensure quality is one that mobilizes and integrates all available tools and resources and aligns them with a comprehensive, actionable strategy.

In December 2008, CMS added a star rating system to the Nursing Home Compare website.  This rating system serves three purposes: 1) to provide residents and their families with an assessment of nursing home quality, 2) to make a distinction between high and low performing nursing homes, and 3) to provide incentives for nursing homes to improve their performance.  The one-star rating is the lowest rating and the five star rating is the highest.  CMS tracks nursing home care quality using this rating system.

The Quality Innovation Network-Quality Improvement Organization (QIN-QIO), via recruitment of nursing homes and other activities, shall support the creation of a National Nursing Home Quality Care Collaborative (NNHQCC).  The purpose of the NNHQCC is to ensure, along with its partners, that every nursing home resident receives the highest quality of care.  The one-star recruitment measure assessed the ability of the QIN-QIO to gain participation in peer-to-peer quality improvement activities, measured by the percentage increase of one-star nursing homes participating in the NNHQCCs through 2018.  Participation ensures safer care received by Medicare beneficiaries residing in the lowest performing nursing homes.  Nursing homes participating in the NNHQCC focus on processes that improve their systems and measure individual tests of change.  Specifically, nursing homes look at their Plan-Do-Study-Act improvement cycle results, clinical outcomes measures such as falls with major trauma, and measures of quality improvement.  Nursing homes participating in the NNHQCC are encouraged to improve quality as a whole rather than focus on any one measure.  Therefore, the 16 measure total quality score appropriately reflects general quality improvement.  A reduction in the percentage of homes that receive the lowest quality score would indicate progress in the hardest-to-reach nursing homes.

Decrease the percentage of long-stay nursing home residents receiving an antipsychotic medication (Lead Agency - CMS; Measure ID - MSC5)41

  CY 2013 CY 2014 CY 2015 CY 2016 CY 2017 CY 2018 CY 2019 CY 2020
Target 20.3% 19.1% 17.9% 16.7% 16% 16% 15.5% 15.4 %
Result 20.3% 19.1% 17.1% 16.7% 15.4% 4/30/19 4/30/20 4/30/21
Status Target Met Target Met Target Exceeded Target Met Target Exceeded Pending Pending Pending

Antipsychotic medications have common and dangerous side effects when used for the behavioral and psychological symptoms of dementia.  A number of evidence-based non-pharmacological interventions and approaches have been reviewed by national scientists and thought leaders through the National Partnership to Improve Dementia Care.  These have been incorporated into clinical practice guidelines and various tools and resources and are now posted on the Advancing Excellence website (in the public domain) at www.nhqualitycampaign.org.  State Coalitions are reaching out to providers in every state and encouraging the use of these resources, as well as Hand in Hand, which is a CMS-developed training program for nursing home staff.

Success has varied by state and CMS region, with some states and regions seeing a reduction of greater than 40 percent.  CMS continues to have quarterly national calls with the public on aspects of good dementia care and the use of non-pharmacological approaches.  CMS is conducting focused dementia care surveys on those facilities that continue to have high rates of antipsychotic use, and has modified the regulations limiting the use of antipsychotic medications on an as needed basis.

Improve dementia capability of long-term support systems to create dementia-friendly, livable communities (Lead Agency ACL; Measure ID – ALZ.3)42,43

  FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 FY 2018 FY 2019 FY 2020
Target N/A N/A N/A N/A N/A Baseline 28% 33%
Result N/A N/A N/A N/A N/A 22% 1/31/21 1/31/22
Status N/A N/A N/A N/A N/A Historic Actual Pending Pending

Of the community dwelling individuals living with Alzheimer’s Disease and Related Dementias (ADRD), approximately one-third live alone, exposing them to numerous risks, which include unmet needs, malnutrition and injury, and various forms of neglect and exploitation.44 As the number of people living with ADRD in the United States is projected to grow by almost 300 percent by 205045, it is important to develop effective and coordinated service delivery and health care systems that are responsive to the needs of these individuals and their caregivers.

ACL’s Alzheimer’s Disease Program provides funding for the development and enhancement of dementia-capable, person-centered systems of services and supports through partnerships with public and private entities.  In 2017, ACL developed a new tool to measure the program’s success at improving the dementia capability of long-term services and support systems.  Through the tool, program grantees and their partners assess organizational activities in the following three areas:

  • Identification of people with possible cognitive impairment or dementia and their primary caregiver;
  • Staff training about cognitive impairment, dementia and dementia care, and
  • Provision of specialized services for people with a cognitive impairment or dementia and their caregivers.

In FY 2019 and 2020, ACL will develop and implement a plan for continued improvement of assessment results.

Increase the success rate of the Protection and Advocacy Program’s individual or systemic advocacy, thereby advancing individuals with developmental disabilities right to receive appropriate community based services, resulting in community integration and independence, and have other rights enforced, retained, restored and/or expanded (Lead Agency ACL; Measure ID – 8F)46

  FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 FY 2018 FY 2019 FY 2020
Target N/A N/A N/A N/A N/A N/A TBD TBD
Result N/A N/A N/A N/A 78.1% 1/31/20 1/31/21 1/31/22
Status N/A N/A N/A N/A Historic Actual Historic Actual Pending Pending

Under the Developmental Disabilities Assistance and the Bill of Rights Act of 2000 (DD Act), each state and territory has a Developmental Disabilities Protection and Advocacy (P&A) program designated by the state’s governor.  The DD Act and other authorizing statutes give the P&A authority to advocate for the rights of individuals with disabilities.  The DD Act states that each P&A has the authority to “pursue legal, administrative, and other appropriate remedies or approaches to ensure the protection of, and advocacy for, the rights of such individuals within the State."47  P&As provide a range of legal services and use a range of remedies, including self-advocacy assistance, negotiation, investigation, and litigation, to advocate for traditionally unserved or underserved individuals with developmental disabilities.  P&A authorities are critical to preventing abuse and neglect of people with disabilities and safeguarding individuals’ right to live with dignity and self-determination. 

In FY 2019 and 2020, ACL will develop and implement a performance plan for improving results.  The plan involves developing valid and reliable measures and a pilot to test the outcomes before full plan implementation.  The plan also includes methods for analyzing the data to identify trends and results.

40 The target for FY 2020 will be determined when the specific goals and aims of the 12th Statement of Work are finalized. These are still being developed at the time of publication of the FY 2020 Budget.

41 The purpose of including this measure as a CMS performance measure is to decrease the use of antipsychotic medications in nursing homes with emphasis on improving dementia care.

42 Program participants report annually on program progress in advancement of the dementia-capability of program partners and provide appropriate technical assistance to address areas of concern. Data reported include changes in the range of services and supports each grantee provides to people with dementia, grantee capacity to provide specialized services to people with a cognitive impairment or dementia and their caregivers, and the degree to which the grantee organizations have standardized their procedures or assessing dementia among their consumers. ACL uses grantee responses to calculate grantee level of improvement between reporting periods.

43 This is a developmental measure. ACL is currently collecting sufficient data to establish a baseline. To set a baseline, the agency relies on 3 years of data. This process ensures that the data are stable and show a clear trend.

44 Gould, E., Maslow, K., Yuen, P., Wiener, J. Providing Services for People with Dementia Who Live Alone: Issue Brief. Accessed April 14, 2014.

45 Alzheimer’s Association. 2017 Alzheimer’s Disease Facts and Figures. Accessed May 9th, 2017 at http://www.alz.org/alzheimers_disease_facts_and_figures.asp

46 This is a developmental measure. ACL is currently collecting sufficient data to establish a baseline. To set a baseline, the agency relies on 3 years of data. This process ensures that the data are stable and show a clear trend. The agency will set targets for this measure once a baseline is established.

47 42 U.S.C. 15043


Content created by Office of Budget (OB)
Content last reviewed