FY 2017 Annual Performance Plan and Report - Goal 3 Objective C

Fiscal Year 2017
Released February, 2016

Goal 3.  Objective C:  Improve the accessibility and quality of supportive services for people with disabilities and older adults

HHS is committed to strategies that streamline access to a full complement of integrated services for the elderly and persons with disabilities.  Over the past decade, a number of policy reforms and initiatives have improved the effectiveness of efforts to promote home and community-based services and to decrease unnecessary reliance on institutional care.  The Supreme Court’s landmark 1999 Olmstead ruling requires states to place qualified individuals with disabilities in community settings whenever such placements are appropriate.  ACL provides a number of services to older adults including those with disabilities; for example, transportation, personal care, meals, supportive services for family caregivers and elder rights services (including by not limited to legal services, pension counseling, prevention and protection from abuse, neglect, and exploitation).  Through grants, technical assistance, and information-sharing, the Administration on Intellectual and Developmental Disabilities (AIDD) within ACL works with a network of state Developmental Disabilities Councils, state Protection and Advocacy Systems, national University Centers on Excellence in Developmental Disabilities, and Projects of National Significance to ensure that individuals with developmental disabilities and their families have access to culturally competent services and supports that promote independence, productivity, integration, and inclusion in the community.  SAMHSA has been working with homeless clients who have mental health and/or substance abuse problems to overcome these circumstances and permanently improve their living situation.

Among the agencies and offices contributing to the achievement of this objective are ACL, AHRQ, ASPE, CDC, CMS, OCR, OASH, and SAMHSA.  The following performance measures exemplify how HHS is improving the quality and accessibility of supportive services for seniors and people with disabilities.  The Office of the Secretary led this Objective’s assessment as a part of the Strategic Review.

Objective 3.C Table of Related Performance Measures

Reduce the percent of caregivers participating in the National Family Caregiver Support Program who report difficulty in getting services.  (Lead Agency - ACL; Measure ID - 2.6)

  FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017
Target 28% 28% 28% 27% 27% 26.8%
Result 26% 31.6% 36% Dec 31, 2016 Dec 31, 2017 Dec 31, 2018
Status Target Exceeded Target Not Met Target Not Met Pending Pending Pending

Maintain at 90% or higher the percentage of clients receiving home delivered meal who rate services good to excellent.  (Lead Agency - ACL; Measure ID - 2.9a)

  FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017
Target 90% 90% 90% 90% 90% 90%
Result 88% 89% 88% Dec 31, 2016 Dec 31, 2017 Dec 31, 2018
Status Target Not Met Target Not Met but Improved Target Not Met Pending Pending Pending

Maintain at 90% or higher the percentage of transportation clients who rate services good to excellent.  (Lead Agency - ACL; Measure ID - 2.9b)

  FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017
Target 90% 90% 90% 90% 90% 90%
Result 98.5% 97% 95.1% Dec 31, 2016 Dec 31, 2017 Dec 31, 2018
Status Target Exceeded Target Exceeded Target Exceeded Pending Pending Pending

Maintain at 90% or higher the percentage of National Family Caregiver Support Program clients who rate services good to excellent.  (Lead Agency - ACL; Measure ID - 2.9c)

  FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017
Target 90% 90% 90% 90% 90% 90%
Result 93.8% 94.6% 93.6% Dec 31, 2016 Dec 31, 2017 Dec 31, 2018
Status Target Exceeded Target Exceeded Target Exceeded Pending Pending Pending

Increase the percentage of older persons with severe disabilities who receive home-delivered meals.  (Lead Agency - ACL; Measure ID - 3.5)

  FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017
Target N/A 39% 44.3% 44.8% 45% 45.1%
Result 43.5% 43.5% 42% Dec 31, 2016 Dec 31, 2017 Dec 31, 2018
Status Historical Actual Target Exceeded Target Not Met Pending Pending Pending

Increase percentage of complaints of alleged abuse, neglect, and rights violations substantiated and not withdrawn by the client that resulted in positive change through the restoration of client rights, expansion or maintenance of personal decision-making, elimination of other barriers to personal decision-making, as a result of Protection and Advocacy for Individuals with Mental Illness (PAIMI) involvement (Lead Agency - SAMHSA; Measure ID - 3.4.21)

  FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017
Target 87.0 % 87.0 % 87.0 % 87.0 % 87.0 % 88.0 %
Result 87.0 % 88.3 % 72.6 % Jul 31, 2016 Jul 31, 2017 Jul 31, 2018
Status Target Met Target Exceeded Target Not Met Pending Pending Pending

Increase the number of Projects for Assistance in Transition from Homelessness (PATH) providers trained on SSI/SSDI Outreach, Access, Recovery (SOAR) to ensure eligible homeless clients are receiving benefits (Lead Agency - SAMHSA; Measure ID - 3.4.20)

  FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017
Target 5,420 5,420 4,591 4,360 2,296 2,296
Result 4,781 4,360 2,296 1,676 Dec 31, 2016 Dec 31, 2017
Status Target Not Met but Improved Target Not Met Target Not Met Target Not Met Pending Pending

Analysis of Results

The National Family Caregiver Support Program provides grants to states and territories to fund a range of supports that assist family and informal caregivers.  Since 2003, ACL has been working to reduce the stress of caregivers and has set ambitious targets to reduce the number of caregivers who have had difficulty obtaining services from a high of 64 percent caregivers in 2003 to the current reported level of 36 percent of caregivers in FY 2014, missing the target of 28 percent.  While results in FY 2013 and FY 2014 reflect a significant improvement since the beginning of the National Family Caregiver Support Program, the increasing challenges faced by family caregivers may be a reflection of the impact of sequester and stagnant budgets.

ACL's Administration on Aging (AoA) funds home delivered meals for elderly individuals who are too ill or too frail to be able to prepare their own meals.  Obtaining adequate nutrition is key to recovery from recent illness or hospitalization, and important in managing chronic conditions including diabetes and heart disease.  Over 40 percent of home delivered meal clients have 3 or more Activity of Daily Living (ADL) limitations, the same level of disability that is required for nursing home placement.  Performance for FY 2014 was 88 percent reporting “good” to “excellent” service quality, falling just short of the target, but consistent with previous year’s results.  Of the other 12 percent of respondents, the majority rated specific indicators positively, e.g. nearly 60 percent report liking the meals they receive.  AoA expects the slight drop in positive rating of program quality to be transient as specific indicators of program quality are all rated above 90 percent.

ACL has a number of performance measures related to maintaining high levels of service quality while also serving frail, elderly individuals most in need of assistance to remain in their own homes.  In general, ACL strives for service quality that meets or exceeds 90 percent of consumers rating services “good” to “excellent.”  ACL's AoA funds transportation services for elderly individuals who have mobility challenges including those who are no longer able to drive their own car or who do not have access to public transportation.  The quality ratings by transportation consumers are exceptionally high with greater than 95 percent of consumers indicating the services are “good” to “excellent,” exceeding the target.  ACL's National Family Caregiver Support Program enables family members who have a loved one with disabilities or conditions which require assistance to use an array of supportive services.  Caregivers served by the National Family Caregiver Support Program reported a 93.6 percent rating of services “good” to “excellent,” also exceeding the target. 

ACL’s AoA provides home-delivered meal services to individuals who are too ill or frail to prepare their own meals.  High level of limitations in Activities of Daily Living (ADLs), i.e. three or more, is a risk factor for nursing home entry and loss of independence.  Increasing the percent of older persons with severe disabilities who receive home-delivered meals is a new measure created in FY 2014.  Historical results indicate that while the overall number of people served by the program has been declining due to a stable budget and increasing costs related to food, fuel, and labor, the percentage of program participants at high risk for losing their independence has been increasing.  The FY 2014 result is 42 percent.  This unexpected decline was partially due to at least one state losing all ADL assessment data for clients during the transition to a new data system.

SAMHSA programs use different approaches to address the needs of individuals with serious mental illness and other behavioral health challenges.  For example, the Protection and Advocacy for Individuals with Mental Illness (PAIMI) helps individuals with serious mental illness (adults) and serious emotional impairments (children/youth) who are at risk for abuse, neglect, and/or right’s violations.  Legal-based advocacy services are provided to vulnerable individuals with mental illness, including those residing in public and private residential care and treatment facilities.  PAIMI advocates for the rights of vulnerable individuals so that they are free from abuse and placed in appropriate, least restrictive, community-based settings.

SAMHSA strives to help those with serious mental illness maintain or restore their rights and concerns related to housing by assisting with complaints and working to resolve issues.  This supports an individual’s personal decision-making.  The PATH program provides SOAR training to mental health professionals.  Once trained, PATH providers are better able to assist PATH clients in applying for and receiving the income benefits for which they are eligible.  This assists individuals who apply for Social Security (SSI) or Social Security Disability (SSDI) payments and related benefits including health insurance.  There was a significant drop in the number of people trained in 2014 as a result of a transition to a standardized online training This change standardized high quality training.  The use of technology may ultimately assist with access while managing costs.  States were made aware of the pending availability of the new SOAR online curriculum approximately mid-way through FY 2013.  This has had short term performance implications.  Overall, performance for this program has been stable and improving.  FY 2015 was a challenging year but program improvements are expected during 2016.  The targets are being increased starting in 2017 to be more ambitious. 

Plans for the Future

National Family Caregiver Support Program performance has reduced caregivers reporting difficulty to such a low level that further reductions are expected to be modest.  Performance improvement will be achieved through ACL Central and Regional Office provision of technical assistance to state grantees; collaboration and sharing across caregiver programs (e.g. Lifespan Respite).  Longer term efforts include dissemination of results from the Program’s evaluation.  The process evaluation component is underway and the outcome evaluation component data collection is to be complete in FY 2017.  ACL will continue its efforts to enhance support services for people with disabilities and older adults.  ACL’s AoA will continue to provide technical assistance to state grantees through individualized technical assistance and webinars conducted by OAA nutrition program staff and the National Resource Center on Nutrition and Aging (established FY 2012) to ensure meal delivery program quality remains high.  The President's budget request for a Nutrition Innovation Demonstration is another mechanism whereby nutrition programs will be strengthened and improved.  ACL has invested significant resources in program evaluations including an evaluation of the Title III-C Elderly Nutrition Services Program.  In addition, ACL/AoA and CMS have entered into an inter-agency agreement that will enhance this evaluation to include prospective analysis of healthcare utilization and cost.  Data collection for the process study is scheduled to be complete in Spring 2015, currently 100 percent of state Units on Aging and 80 percent of Area Agencies on Aging (AAAs) have completed both parts of their data request (92 percent responded to the survey and 83 percent responded to a separate data form).  The outcome study data collection is expected to be complete in late FY 2016.  The results of the evaluation will be disseminated to the National Aging Network and used for program improvement and planning.

SAMHSA fills gaps in community resources in ways that address the complex issues surrounding mental illness, substance use disorders, and housing.  SAMHSA’s PATH program funds community-based outreach, mental and substance use disorder treatment services, case management, assistance with accessing housing and support services to vulnerable individuals in need of sustainable stable housing as well as social connections and other services and supports.  SAMHSA has reduced its targets for the number of PATH providers trained in the SOAR process for FY 2015 and 2016 due to more stringent requirements for completion as part of the online program.  With the full implementation of the new online curriculum in FY 2015, SAMHSA expects that the number of people trained at in-person venues will continue to trend downward.  The completion requirements of the online curriculum are more stringent than the in-person training.  While there will be smaller numbers trained, they will be better equipped and more likely to complete applications.  It is expected that this will positively impact outcomes.

The PAIMI Program continues to pursue excellence in assuring that the most vulnerable individuals with mental illness, especially those residing in public and private residential care and treatment facilities are free from abuse.  PAIMI addresses such issues as inappropriate restraints and seclusion, neglect, and rights violations.  A PAIMI Program Peer Review process is in place for the Annual Program Performance Report which assesses and provides specific feedback regarding strengths and weaknesses of the program as well as specific recommendations for ongoing quality improvement.  The PAIMI Programs within each State Protection & Advocacy (P&A) agency are monitored via on-site reviews on a regular schedule.  These on-site monitoring reviews are conducted by independent consultants and provide SAMHSA with an assessment of key areas: governance, legal, fiscal and consumer/constituent services/activities of the State's PAIMI Program.  Following these site visits, the consultants issue a report that summarizes its program findings and when appropriate, may include recommendations for technical assistance and/or corrective action.  These steps are expected to improve performance so that annual and long-term targets can be met.

FY 2014 Strategic Review Objective Progress Update Summary

Please note that this section summarizes the result of the FY 2014 HHS Strategic Review process, limiting the scope of content to that available prior to spring of 2015.  Due to this constraint, the following may not be the most current information available.

Conclusion:  Progressing

Analysis:  At a national population level, progress on this objective is being made.  The primary driver for accessibility and quality of long-term services and supports is the Medicaid program.  In 2008, 42 percent of Medicaid long-term services and supports expenditures were for home and community-based services (HCBS).  The most recent data from 2012 indicates that this has increased to nearly 50 percent.  Nearly half of the states expend 50 percent or more of their Medicaid long-term service and supports on home and community-based services.  The activities driving change in access to care include Money Follows the Person, Balancing Incentives Program, and Community First Choice – 1915(k) waivers.  The primary quality drivers in long-term care services and supports include HCBS final rule and the National Quality Forum quality measure initiative.

Nearly every state is implementing Money Follows the Person and while the most recent target was missed, more than 10,000 individuals transitioned in 2013.  Currently 21 states are approved under BIP, which is targeted at the states that have a low percent of long-term services and supports expenditures compared to institutional services.  Over a 4-year period $3 billion is available to these states and will likely have a significant impact in rebalancing long term care.  The 1915 (k) waiver is small with five states approved but growing as six additional states are in the planning stage.

The National Quality Forum quality measure initiative is an early milestone in the Department’s efforts to improve quality.  The lack of standard, reliable and valid measures is a primary barrier to quality improvement.  While each of the above accomplishments may be making a difference or are a milestone with great potential there are challenges and areas for improvement that can be identified for each.

HHS is working to strengthen quality measures, disseminate evidence-based interventions, and evaluate programs to improve our ability to serve seniors and people with disabilities.  A challenge facing the future development and endorsement of HCBS quality measures is the lack of organizational capacity for measures stewards to foster measures through the rigorous process.  Another challenge is the difficulty of dissemination of evidence-based interventions in nursing homes.  It is difficult for a number of reasons: there is high turnover of staff and leadership, nursing homes have a number of quality deficits that need to be dealt with, and it is difficult to engage in more than one or two interventions at one time.  Consequently, interventions need to compete with other interventions for attention.  In addition, delays in availability of Medicaid data required for the evaluation of the Financial Alignment Initiative for Medicare-Medicaid Enrollees may impact the timeframe for access to a complete, preliminary set of results necessary to comprehensively evaluate and disseminate best practices associated with the expanded services provided under the capitated financial alignment model demonstration.  In addition, states are working to transition from submitting Medicaid Statistical Information System (MSIS) data to instead submitting data through the new, transformed-MSIS (tMSIS) process.  During this transition period, some states are currently not submitting Medicaid data in either format, which may result in significant delays in data availability for evaluation purposes.

In the near term, the HCBS final rule has the potential to significantly impact quality of long-term service and supports in the community.  Challenges persist around implementation but federal partners are working with states to ensure the regulation results in improvements for beneficiaries.  With the dissemination of the On-Time pressure ulcer prevention intervention in 50 nursing homes the Department will assess the success of the new training materials, the ability to recruit nursing homes, successfully implement the intervention, and show that the intervention continues to prevent pressure ulcers and is sustainable.  Upcoming findings on the Financial Alignment Initiative will include the first state-specific annual reports for the three state demonstrations implemented in 2013. 



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