1 Modernizing & Strengthening Oklahoma’s Aging Network Interim Study IS11-102 October 18, 2011...

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Modernizing & Strengthening Modernizing & Strengthening Oklahoma’s Aging NetworkOklahoma’s Aging Network

Interim Study IS11-102Interim Study IS11-102October 18, 2011October 18, 2011

Lance Robertson, State Director OKDHS Aging Services Division2401 NW 23rd Street, Suite 40Oklahoma City, OK 73107(405) [email protected]

mailto:[email protected]

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Interim Study Overview Modernizing & Strengthening Oklahoma’s Aging NetworkModernizing & Strengthening Oklahoma’s Aging Network

Author IS11-102: Representative Pam Peterson

Description:“Study coordination and delivery of services for seniors, and examine thepossibility of more efficient allocation of services provided by the AreaAgencies 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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AGENDA

Critical QuestionsPartners, Advocates, Constituents – FeedbackDemographicsOverview of Oklahoma’s Older Americans Act Aging Network

History & BackgroundStructureOverall budgetConstituency served

ConsiderationsGeneral Four Interim Study Considerations

Funding breakdownNational comparatives

Data Sources Questions & Answers

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Critical Questions -

What is the structure of the aging network?– What’s 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 state’s 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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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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“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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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 AAA’s– Review structure of aging network to ensure

consistency – Ensure proximity of providers to consumers

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DemographicsModernizing & Strengthening Oklahoma’s Aging NetworkModernizing & Strengthening Oklahoma’s Aging Network

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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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Population Density per square mile of land for ages 60+


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Percent change from 2000-2010 for ages 60+


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10.2%26.9%

- 0.2%

60.0%50.0%

-20%

0%

20%

40%

60%

80%

100%While Oklahoma’s 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

0-17 18-64 65 + 85 +Total


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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• Political pressures• General awareness

ChallengesChallenges

ServiceServiceDemandDemand

DemographicsDemographics

BudgetBudget

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Older American’s ActModernizing & Strengthening Oklahoma’s Aging NetworkModernizing & Strengthening Oklahoma’s Aging Network

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 Oklahoma’s Aging NetworkModernizing & Strengthening Oklahoma’s Aging Network

Administration on Aging &State of Oklahoma

Area Agencies on Aging (11)

Program Partners

Network of Providers

State Unit on Aging =OKDHS Aging Services Division

“…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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Existing OAA NetworkExisting OAA Network • Established in 1973Established in 1973• State Unit on Aging: OKDHS Aging Services Division (ASD)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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21A Joint Proposal of NASUA and n4a 21

OAA = 0.066%

Total Federal Budget of

approximately$2.73 Trillion

Federal BudgetModernizing & Strengthening Oklahoma’s Aging NetworkModernizing & Strengthening Oklahoma’s Aging Network

http://www.whitcam.com/research/wp-content/uploads/2008/04/taxesgowhere.jpg

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SFY11 Oklahoma Budget Snapshot

Total: $26,931,272

Federal: $16,653,560State: $10,002,095• Required: $2,934,311• Overmatch: $7,067,784AAA Local match: $275,617

62%11%

26%

1%

Federal State Req State Overmatch Local

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Comparision of AAA Funding

$0

$5

$10

$15

$20

$25

$30

$35

SFY 2007 SFY 2008 SFY 2009 SFY 2010 SFY 2011 SFY 2012

Do

lla

rs i

n t

he

Mil

lio

ns

Federal Req'd State Overmatch Local Match (Rq'd Min) Total

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Interim StudyModernizing & Strengthening Oklahoma’s Aging NetworkModernizing & Strengthening Oklahoma’s Aging Network

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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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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• 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 committee’s 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 managethe 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 don’t 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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• 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


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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 AT&T 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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• 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


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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 Oklahoma’s 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 committee’s 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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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

Independent/ NP County GovCOG City GovOther

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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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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

OAA Title III Services

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Percentage of 60+ Served in PSA

0%

5%

10%

15%

20%

25%

AAA's

Pe

rce

nta

ge

38


Personnel

02468

101214

Areaw

ide

ASCOG

COEDD

EODD

Grand G

atew

ayKEDDO

NODA

OEDA

SODA

SWODA

INCOG (T

ulsa)

AAA's

Em

plo

yees

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Adm in as Percentage o f T o tal

1411 11 13 14 14 16 14 13

25

13 14

05

1015202530

A A A 's

Pe

rce

nt

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Percentage o f Ind irect to Adm in

911

25

2022

8

18

11

1614

24

16

0

5

10

15

20

25

30

AAAs

Pe

rce

nta

ge

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Cost per Unit o f Serv ice - Federa l and State Dollars

0

1

2

3

4

5

6

7

8

9

10

AAA's

Do

lla

rs p

er

Un

it o

f S

erv

ice

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AlabamaAlaska

ArkansasCalifornia

ConnecticutDelaware

District of ColumbiaFloridaGeorgiaHawaiiIllinoisIndiana

IowaMichigan

MinnesotaMissouriNevada

Comparative (state) census data shows 33 states have higher total populations and higher concentrations

of 60+ residents but fewer AAAs than Oklahoma

New HampshireNew JerseyNew Mexico

New YorkNorth CarolinaNorth Dakota

OhioRhode Island

South CarolinaSouth Dakota

TennesseeTexas

WashingtonWest Virginia

WisconsinWyoming

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

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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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Comparision of Pop. Avg of 33 States w/ Fewer AAA's

835,554

155,375

62,554

335,186

0100,000200,000300,000400,000500,000600,000700,000800,000900,000

Total Pop. Avg. 60+Pop. Avg.

Ave

rag

e P

op

ula

tion

33 States Oklahoma

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Comparison of Pop. Averages of Region VI States (AR,NM,TX,LA)

89,075

528,145

335,186

62,554

0

100,000

200,000

300,000

400,000

500,000

600,000

Total Pop. Avg. 60+Pop. Avg.

Ave

rag

e P

op

ula

tio

n

Avg. Region VI Oklahoma

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Comparision of Pop. Avg. of all States

488,086

88,277

335,186

62,554

0

100,000

200,000

300,000

400,000

500,000

600,000

T otal Pop. Avg. 60+Pop. Avg.

Av

era

ge

Po

pu

lati

on

All States Oklahoma

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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

62%

37%

1%

Federal State Local

40%

10%

50%

Federal State Local

OKLA

UNITEDSTATES

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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, I&A, 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 SYSTEMCURRENT SYSTEM

OKDHS ASDOKDHS ASD State Unit on AgingState Unit on Aging

AAA

COG COG COG COG COG COGCOG COG

AAA

COG

AAA AAA

Ombudsman(24)

AAA

OAA CM(1)

AAA AAAAAAAAA AAAAAA

Information & Assistance(14)

In-Home Services

Outreach Legal Services

Congregate/HDMNutrition ED

Nutrition CounselingHP/MM

TransportationFamily Caregiver Support Services

PERMANENT WAIVERS

LOCAL SERVICE PROVIDERS LOCAL SERVICE PROVIDERS

TEMPORARY WAIVERS

COG(COG)

STREAMLINED SYSTEMSTREAMLINED SYSTEM

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OK SUA

COG COG COG COGCOG COG

DHHS / AOA

OMB(24)

AAA

OAA CM(1)

AAA AAAAAAAAAAAA

I&A(14)

Transportation

PERMANENT WAIVERS

LOCAL SERVICE PROVIDERS LOCAL SERVICE PROVIDERS

Outreach

Congregate/HDMNutrition ED

Nutrition CounselingHP/MM

In-Home Services

Family Caregiver Services Legal Services

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AAA AAAAAA AAAAAA AAA AAAAAAAAA AAAAAA

Transportation(1)

SFY 2011 TEMPORARY WAIVERS

Health Promotion/Medication Management

(5)

Family CaregiverSupport Program

(5)

LegendState Fiscal Year (SFY)Area Agency on Aging (AAA)

CURRENT SYSTEMSTREAMLINED SYSTEM

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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 Division2401 NW 23rd Street, Suite 40

Oklahoma City, OK 73107(405) 521-2281

[email protected]

OKDHS ASD wishes to thank Oklahoma legislators for their time and for the opportunity to share the Modernizing & Strengthening Modernizing & Strengthening

Oklahoma’s Aging Network Oklahoma’s Aging Network presentation and to thank the partners, presentation and to thank the partners, advocates and constituents for their valuable contributions and advocates and constituents for their valuable contributions and

feedback.feedback.

mailto:[email protected]

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