Annual Performance Plan and Report

Topics on this page: Goal 3. Objective C | Table of Related Performance Measures | Analysis of Results | Plans for the Future | Objective Progress Update Summary

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)

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)

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

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)

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

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)

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)

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 31.6 percent of caregivers in FY 2013.  This result missed the target by 3.6 percentage points.  Performance for this measure had been consistently improving and this finding may be an anomaly.  Sequestration is a factor that may have influenced this single year rise.  If supportive services availability declined due to reduced funding then caregivers would likely report more difficulties obtaining needed services.  FY 2008 was the last time that over 30 percent of caregivers reported difficulty a time in which appropriations and expenditures declined sharply.

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.  Ninety three percent of service participants report that the meals help them remain at home and live independently in the community.  Performance for FY 2013 was 89 percent reporting "good" to "excellent" service quality, an improvement over the FY 2012 results.  AoA expects the slight drop in positive rating of program quality in FY 2012 and FY 2013 to be temporary 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 97 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 94.6 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 2013 result is 43.5 percent, exceeding its target.

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.  Targets have been met or exceeded during FY 2013 and each preceding year.  

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.  Anticipation of its availability in the latter part of the year helps explain the drop in attendance at in-person trainings.        

Plans for the Future

ACL plans to reduce the percentage of caregivers who report difficulty getting services to 28 percent for FY 2014 and 27 percent for FY 2015 and 2016. 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) including the proposed Family Support program in the President’s FY 2016 budget request.  Longer term efforts include dissemination of results from the National Family Caregiver Support 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 insure 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.

ACL plans to maintain the current high performance for the measures of client satisfaction with the National Family Caregiver Support Program, transportation, and home delivered meals at current levels for FY 2014– 2016. The percentage of older persons with severe disabilities receiving home-delivered meals has increased year by year, despite stable funding and increased cost related to food, fuel, and labor.  States have increased their targeting of these clients at high risk of nursing home entry.  Consequently, ACL increased the FY 2014-2016 performance targets.

SAMHSA measures the percentage of complaints of alleged abuse, neglect, and rights violations not withdrawn by the client that resulted in positive change as a consequence of PAIMI involvement.  A positive change is an improvement in the client’s safety or welfare.  Although business costs continue to rise, SAMHSA plans to maintain its current performance levels for substantiated and not withdrawn complaints due to PAIMI involvement.

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.

Objective Progress Update Summary

HHS demonstrated progress toward this objective as shown by the representative performance measures described in the HHS Annual Performance Plan and Report. Further evidence of progress is described below.

• An AHRQ study of the On-Time Pressure Ulcer Prevention Program produced evidence that nursing homes implementing the program saw a 60 percent reduction in pressure ulcers.

• In 2013, CDC published the first comprehensive, cross-agency children's mental health surveillance (MMWR) report and convened a Children's Mental Health Forum with stakeholders to determine core directions and the scope of work for children's mental health at CDC. The resulting report is helping guide programmatic plans.

• More than 240,000 people have participated in the ACL Chronic Disease Self-Management Program.

• The Office of Civil Rights has entered into significant case resolution agreements with major health care providers to ensure that people who are deaf or hard of hearing have equal access to the health program through the provision of accessible health information.

• In January 2014, CMS published a regulation ensuring that individuals receiving home and community-based services have full access to the community and the right to dignity, privacy and respect in their home, and that states provide a person-centered planning process focused on the requests and needs of the individual thereby facilitating the integration of the social, emotional and medical aspects of an individual's life. CMS expects these regulations to improve access to employment, access to services, and coordination of services while allowing states a five-year period to bring these settings into compliance.

The Department is continuing to support and execute the programs contributing to this objective, monitoring progress, performance, and program integrity while adjusting to any budgetary constraints or changes to programmatic demands.