West Central Florida Area Agency on Aging, Inc. Area Plan Program Module Update Planning and Service Area 6

Transcription

1 West Central Florida Area Agency on Aging, Inc. Area Plan Program Module Update Planning and Service Area 6 For the Period January 1, December 31, 2014 January, 2014

2 TABLE OF CONTENTS TABLE OF CONTENTS... 2 P. I. INTRODUCTION TO THE PROGRAM MODULE UPDATE... 3 P. II. PROGRAM MODULE CERTIFICATION... 4 P.III. (A) EXECUTIVE SUMMARY... 5 P.III. (B) MISSION AND VISION STATEMENT... 5 P.IV. NEEDS ASSESSMENT... 5 P.IV (A) PROFILE... 5 P.IV (B) UNMET NEEDS/GAPS... 5 P.V. TARGETING AND OUTREACH... 5 P.VI. GOALS AND OBJECTIVES APPENDIX 1: PROGRAM MODULE REVIEW CHECKLIST Each page is sequentially numbered and the location of each section has been listed in the Table of Contents. 2

3 P. I. INTRODUCTION to the PROGRAM MODULE UPDATE The AAA must submit parts of the Program Module that are required to be updated. The parts to be updated are listed below. Other sections will only need to be submitted if changes have been made to the original three-year plan. The Program Module Checklist has been shortened to only include the sections required for updating. 3

4 P. II. PROGRAM MODULE CERTIFICATION Program and Contract Module Certification 1. AREA AGENCY ON AGING INFORMATION: Executive Director: Maureen S. Kelly Legal Name of Agency: West Central Florida Area Agency on Aging, Inc. Mailing Address: 5905 Breckenridge Pkwy, Suite F, Tampa, FL Telephone: [813] GOVERNING BOARD CHAIR: (Name/Address/Phone) Dr. Lawrence Schonfeld, Chair 5905 Breckenridge Pkwy, Suite F, Tampa, FL / [813] ADVISORY COUNCIL CHAIR: (Name/Address/Phone) Laura Kingsley, Chair 5905 Breckenridge Pkwy, Suite F, Tampa, FL, [813] FEDERAL ID NUMBER: FUNDS ADMINISTERED: Check all that apply [X] OAA Title IIIB [X] CCE [ ] USDA [X] NSIP [X] OAA Title IIIC [X] HCE [X] ADA Waiver [X] ARC/ADRC [X] OAA Title IIID [X] ADI [X] ALE Waiver [ ] AoA Grant(s) [X] OAA Title IIIE [X] LSP [X] SHINE ( ) Identify [X] OAA Title VII [ ] RELIEF [X] EHEAP 5. CERTIFICATION BY BOARD PRESIDENT, ADVISORY COUNCIL CHAIR, AAA DIRECTOR: I hereby certify that the attached document: [X] Reflects input from a cross section of service providers, consumers, and caregivers who are representative of all areas and culturally diverse populations of the PSA. [X] Incorporates the comments and recommendations of the Area Agency s Advisory Council. [X] Has been reviewed and approved by the Area Agency s Board of Directors. [X] Signatures below indicate that both the Program Module and the Contract Module have been reviewed. I further certify that the contents are true, accurate, and complete statements. I acknowledge that intentional misrepresentation or falsification may result in the termination of financial assistance. I have reviewed and approved the Area Plan. Name: Lawrence Schonfeld Signature: Date: To be reviewed for approval and signature at (President, Board of Directors) upcoming Board Meeting, 2/4/14. Will Name: Laura Kingsley Signature: forward signed document Date: upon completion. (Advisory Council Chair) Name: Maureen Kelly Signature: Date: (Area Agency on Aging Director) Signing this form verifies that the Board of Directors and the Advisory Council understand that they are responsible for the development and implementation of the plan and for ensuring compliance with Older Americans Act Section

5 P.III. (A) EXECUTIVE SUMMARY This section is only required to be modified from the original plan if there have been significant changes in the needs assessment. Please see original Area Plan document for Executive Summary. P.III. (B) MISSION AND VISION STATEMENT This section is only required to be modified from the original plan if there have been significant changes in the needs assessment. Please see original Area Plan document for Mission and Vision Statement. P.IV. NEEDS ASSESSMENT This section is only required to be modified from the original plan if there have been significant changes in the needs assessment. Please see original Area Plan document for Needs Assessment Section. P.IV (A) Profile This section is only required to be modified from the original plan if there have been significant changes in the needs assessment. Please see original Area Plan document for Profile Section. P.IV (B) Unmet Needs/Gaps This section is only required to be modified from the original plan if there have been significant changes in the needs assessment. Please see original Area Plan document for Unmet Needs/Gaps Section. P.V. TARGETING AND OUTREACH An update to this section has been completed, as requested Targeting Report The purpose of the targeting report is to show how effective this organization has been with targeting efforts by reporting how many people in specific population groups were served during the 2012 calendar period. The following report provides this information: 5

6 Characteristic 2012 Targeting Report Number of PSA 60+ Population Count (1) % Registered* Service Recipients in PSA (2) % Goals for 2012 % of Goal Met All , % 10, % 2% 2.1% Below Poverty Level 47, % 4, % 9% 9.8% Living Alone 116, % 5, % 23% 4.8% Minority 108, % 4, % 21% 4.0% Minority Below Poverty Level (low-income minority) 18, % 3, % 4% 17.3% Rural areas 44, % 2, % 9% 5.9% Low-Income Minority Older Individuals with Limited English Proficiency 7, % 1, % 2% 18.9% Registered Services include personal care, homemaker, chore, home delivered meals, adult day/health care, case management, escort, and congregate meals. Data Sources: (1) The PSA 60+ population count data source is the 2012 County Profiles. (2) The PSA registered services recipients count is provided by the Department from the NAPIS report data. Targeting Plan Summary Update The following provides a narrative update of the targeting activities implemented since the January 2013 Area Plan was produced. 6

7 All 60+(unless otherwise specified) Achievement of 2012 Targeting BPL/LI Living Alone Minority Goal Achieved Goal Achieved Goal Achieved Goal Achieved 2% 2.1% 9% 43% 23% 51% 21% 40% Minority BPL Rural Low Income Limited English Proficiency for 65+ Population Goal Achieved Goal Achieved Goal Achieved 4% 30% 9% 24% 5% 13% PSA Targeting Plan Achievement Narrative Summary PSA 6 covers a very diverse region encompassing both urban and rural areas thus creating diverse conditions with considerable disparities of socio-economic factors that influence the needs of this PSA. A description of PSA 6 indicates the following (please see the Population Characteristics in the Area Plan for a more detailed discussion of socio-demographic and economic factors for consumers residing in PSA 6). Updated numbers for Calendar Year 2012 are based on the 2012 Florida PSA Profile provided by the DOEA (October and December 2013) for clients 60+ years of age: 515,703 elderly reside in PSA 6; 9% of elderly are below the poverty level (BPL) of Low-Income (LI); 23% of the elderly in PSA 6 live alone; 21% of elderly are minorities; 4% of elderly live BPL and are also a minority; 9% of elderly are residing in rural areas; Less than 5% of elderly are low income (BPL) with limited English speaking proficiency (2012 County Profile data indicates PSA 6 has 23,960 elderly with limited English Proficiency) Low Income Achievement (BPL): PSA 6's Goal was that a minimum of 9% of the total number of consumers served would be derived from those older Americans whose income was 125% of the poverty level of lower. PSA 6 used the DOEA provided Registered Service Recipient Data in NAPIS report to identify the number of consumers receiving services and their income levels. PSA 6 served 10,835 clients in The 7

8 report indicated that 4,671 or 43% of those clients were individuals with incomes of 125% of the poverty level or lower. PSA 6 achieved and surpassed our 2012 low income achievement goal Living Alone Achievement: PSA 6's Goal was that a minimum of 23% of the total number of consumers served would be targeted to consumers living alone. PSA 6 used the DOEA provided Registered Service Recipient Data in NAPIS report to determine a count of the number of minority consumers receiving services. PSA 6 served 10,835 consumers in 2012, of which 5,540 or 51% were living alone. PSA 6's achieved and surpassed our 2012 minority achievement goal Minority Achievement: PSA 6's Goal was that a minimum of 21% of the total number of consumers served would be minority consumers. PSA 6 used the DOEA provided Registered Service Recipient Data in NAPIS report to determine a count of the number of minority consumers receiving services. PSA 6 served 10,835 consumers in 2012, of which 4,373 or 40% were minority consumers. PSA 6's achieved and surpassed our 2012 minority achievement goal BPL Minority Achievement: PSA 6's Goal was that a minimum of 4% of the total number of consumers served would be minority consumers who also were living below the poverty level. PSA 6 used the DOEA provided Registered Service Recipient Data in NAPIS report to determine a count of the number of minority consumers receiving services. PSA 6 served 10,835 consumers in 2012, of which 3,237 or 30% were minority consumers. PSA 6's achieved and surpassed our 2012 minority achievement goal Rural Achievement: PSA 6's Goal was that a minimum of 9% of those clients receiving service would reside in designated rural county. In order to determine achievement, PSA 6 used the DOEA provided Registered Service Recipient Data in NAPIS report to identify the number of clients receiving services in the rural areas of our PSA. Using this methodology, PSA 6 determined that 2,606 clients or 24% of the total number of consumers served, resided in a rural setting. PSA 6 achieved and surpassed our 2012 consumers residing in a rural area achievement goal Low Income Elderly with Limited English Proficiency Achievement Population: PSA 6's Goal was that a minimum of 5% of the total number of consumers served would be derived from those older Americans whose income was 125% of the poverty level or lower and whose primary language was reported as something other than English.PSA 6 served 10,835 clients in 2012, of which 1,414 clients or 13% of the 8

9 total number of consumers served were low income seniors with Limited English Proficiency All 60+ Elderly in PSA 6 receiving needed service: PSA 6's Goal was that a minimum of 2% of the total number of elderly aged 60+ in our planning and service area in need of service, would be served. In order to determine achievement, PSA 6 used the DOEA provided Registered Service Recipient Data in NAPIS report to identify the number of elderly clients in the PSA and compared this population statistic to the number of clients that actually received a needed service. Using this methodology, PSA 6 determined that out of the 499, elders in the PSA, 10,835 clients or 2.1% of the total number of consumers served were age 60 and older. PSA 6 achieved and surpassed our 2012 goal for total number of 60+ receiving services. Planned Outreach and Education Activities for 2014 and Projected Achievement for 2013 In order to address the identified service needs of targeted populations the following activities are planned to occur during 2013 and are consistent with the targeting methodology described above: Nu-Hope of Highlands County- Highlands and Hardee Counties Nu-Hope is a lead agency and an EHEAP, OAA Title IIIB, IIIC1, IIIC2 and IIIE provider. As indicated in the Profile section of this plan, the areas being served by this provider are rural designated counties. Outreach (2013): This provider anticipates they will conduct 22 outreach activities in Highlands County and 16 outreach activities in Hardee County. Locations for outreach will include targeted neighborhoods, individual homes and highly visible public locations in order to identify the individual s service needs and to encourage the use of available resources. Education/Training (2013): This provider anticipates they will conduct 12 public education/training events in Highlands County and 6 public education/training events in Hardee County. Locations for education and training are to occur at various locations throughout the counties; such as at veterans groups, fraternal, civic, social service and charitable organizations, senior housing groups and associations and health fairs and other community events. 9

10 Education/Training Achievement 2013: The provider anticipates achieving 12 public education/training events in Highlands County and 6 public education/training events in Hardee County. Outreach (2014): The provider anticipates achieving 22 outreach activities in Highlands County and 16 outreach activities in Hardee County. Education/Training (2014): The provider anticipates achieving 12 public education/training events in Highlands County and 4 public education/training events in Hardee County. Polk County Elderly Services (PCES) - Polk County PCES is a lead agency and an EHEAP, OAA Title IIIB, IIIC1, IIIC2 and IIIE provider. Although Polk County has not been designated as rural, there are rural-like areas within the county that require specific attention in order to address unmet needs of seniors, along with other considerations as indicated in the Profile section of this plan. Outreach (2013): This provider anticipates they will conduct 350 units of outreach in Polk County. Locations for outreach will include targeted neighborhoods, individual homes and highly visible public locations in order to identify the individual s service needs and to encourage the use of available resources. Education/Training (2013): This provider anticipates they will conduct 4000 units of outreach in Polk County. Locations for education and training are to occur at various locations throughout the county; such as at veterans groups, fraternal, civic, social service and charitable organizations, senior housing groups and associations and health fairs and other community events. Outreach Achievement in 2013: The provider anticipates achieving 350 units of outreach in Polk County. Education/Training Achievement 2013: The provider anticipates achieving 4,000 units of education/training in Polk County. Outreach (2014): The provider anticipates achieving 448 outreach activities in Polk County. 10

11 Education/Training (2014): The provider anticipates achieving 6,000 units of public education/training events in Polk County. Hillsborough County Family and Aging Services (HCFAS) - Hillsborough County HCFAS is a lead agency and an EHEAP, OAA Title IIIB, IIIC1, IIIC2 and IIIE provider. Although Hillsborough County has not been designated as rural, there are rural-like areas within the county that require specific attention in order to address unmet needs of seniors, along with other considerations as indicated in the Profile section of this plan. Outreach (2013): This provider anticipates they will conduct 1000 units of outreach in Hillsborough County. Locations for outreach will include targeted neighborhoods, individual homes and highly visible public locations in order to identify the individual s service needs and to encourage the use of available resources.. Education/Training (2013): This provider anticipates they will conduct 300 in Hillsborough County. Locations for education and training are to occur at various locations throughout the county; such as such as at veterans groups, fraternal, civic, social service and charitable organizations, senior housing groups and associations and health fairs and other community events. Outreach Achievement in 2013: The provider anticipates achieving 1000 units of outreach in Hillsborough County. Education/Training Achievement 2013: The provider anticipates achieving 300 units of education/training in Hillsborough County. Outreach (2014): The provider anticipates achieving 1000 outreach activities in Hillsborough County. Education/Training (2014): The provider anticipates achieving 300 units of public education/training events in Hillsborough County. Meals on Wheels PLUS of Manatee, Inc. (MOW+) - Manatee County MOW+ is an OAA Title IIIB, IIIC1, IIIC2 and IIIE provider. Although Manatee County has not been designated as rural, there are rural-like areas within the county that require specific attention in order to address unmet needs of seniors, along with other considerations as indicated in the Profile section of this plan. 11

12 Outreach (2013): This provider anticipates they will conduct over 800 outreach contacts in Manatee County. Locations for outreach will primarily include community event settings within the targeted zip codes, through personal outreach visits or through contacting private homes within identified neighborhoods. Education/Training (2013): This provider anticipates they will conduct eight educational events in Manatee County. Locations for education and training are to occur at various locations throughout the county; such as at churches, community service groups, mobile home parks, community expos and health fairs and health care organizations. Outreach Achievement in 2013: The provider anticipates achieving 800 units of outreach in Manatee County. Education/Training Achievement 2013: The provider anticipates achieving 8 units of education/training in Manatee County. Outreach (2014): The provider anticipates achieving 600 outreach activities in Manatee County. Education/Training (2014): The provider anticipates achieving 8 units of public education/training events in Manatee County. Bay Area Legal Services (BALS) - Hillsborough County BALS is an OAA Title IIIB and IIIE legal services provider. Although Hillsborough County has not been designated as rural, there are rural-like areas within the county that require specific attention in order to address unmet needs of seniors, along with other considerations as indicated in the Profile section of this plan. Outreach (2013): Legal services are exempt from providing outreach activities. Education/Training (2013): This provider anticipates they will conduct 12 educational events in Hillsborough County. Locations for education and training are to occur at various locations throughout the county; such as at nutrition and recreation sites, hospitals, churches, senior housing complexes and community and senior organization and social services agencies. 12

13 Outreach Achievement in 2013: Legal services are exempt from providing outreach activities. Education/Training Achievement 2013: The provider anticipates achieving 12 units of education/training in Hillsborough County. Outreach (2014): Legal services are exempt from providing outreach activities. Education/Training (2014): The provider anticipates achieving 8 units of public education/training events in Hillsborough County. Gulfcoast Legal Services (GCLS) - Manatee County GCLS is an OAA Title IIIB and IIIE legal services provider. Although Manatee County has not been designated as rural, there are rural-like areas within the county that require specific attention in order to address unmet needs of seniors, along with other considerations as indicated in the Profile section of this plan. Outreach (2013): Legal services are exempt from providing outreach activities. Education/Training (2013): This provider anticipates they will conduct at least four educational events in Manatee County. Locations for education and training are to occur at various locations throughout the county; such as local churches, nursing homes, senior centers and care facilities as well as elder care agencies. Outreach Achievement in 2013: Legal services are exempt from providing outreach activities. Education/Training Achievement 2013: The provider anticipates achieving 4 units of education/training in Manatee County. Outreach (2014): Legal services are exempt from providing outreach activities. Education/Training (2014): The provider anticipates achieving 4 units of public education/training events in Manatee County. 13

14 Florida Rural Legal Services (FRLS) - Polk, Highlands and Hardee Counties FRLS is an OAA Title IIIB and IIIE legal services provider. This provider serves three counties within the PSA which contain highly rural areas that require specific attention in order to address unmet needs of seniors, along with other considerations as indicated in the Profile section of this plan. Outreach (2013): Legal services are exempt from providing outreach activities. Education/Training (2013): This provider anticipates that they will conduct a total of 12 educational events in Polk, Highlands and Hardee Counties. Locations for education and training are to occur at various locations throughout the county; such as congregate meals sites, nursing homes, mobile home parks, senior fairs and other social gatherings that provide educational opportunities to seniors. Outreach Achievement in 2013: Legal services are exempt from providing outreach activities. Education/Training Achievement 2013: The provider anticipates achieving 12units of education/training in Polk, Highlands and Hardee Counties. Outreach (2014): Legal services are exempt from providing outreach activities. Education/Training (2014): The provider anticipates achieving 12 units of public education/training events in Polk, Highlands and Hardee Counties. The Centre for Women - Hillsborough County The Centre is an OAA Title IIIB, IIIES home improvement provider. Although Hillsborough County has not been designated as rural, there are rural-like areas within the county that require specific attention in order to address unmet needs of seniors, along with other considerations as indicated in the Profile section of this plan. Outreach (2013): This provider anticipates they will conduct 25 outreach activities in Hillsborough County. Locations for outreach will primarily include community event settings within the targeted zip codes, through personal outreach visits or through contacting private homes within identified neighborhoods. Education/Training (2013): 14

15 This provider anticipates they will conduct 25 educational events in Hillsborough County. Locations for education and training are to occur at various locations throughout the county; such as at recreation sites, senior housing complexes and community and senior organizations and social services agencies. Outreach Achievement in 2013: The provider anticipates achieving 25 units of outreach in Hillsborough County. Education/Training Achievement 2013: The provider anticipates achieving 25 units of education/training in Hillsborough County. Outreach (2014): The provider anticipates achieving 25 outreach activities in Hillsborough County. Education/Training (2014): The provider anticipates achieving 25 units of public education/training events in Hillsborough County. Kinship Center at University of South Florida (USFKC) PSA 6 USFKC is an OAA Title IIIEG grandparent caregiver provider operating support groups throughout the entire planning and service area. Outreach (2013): This provider anticipates they will conduct 70 outreach activities in PSA 6. Locations for outreach will primarily include churches, schools, clinics and organizations serving older individuals, children and the disabled. Education/Training (2013): This provider anticipates they will conduct 203 educational events in the planning and service area. Locations for education and training are to occur at various communities, schools, faith-based and provider organizations. This provider also uses newsletters and provides educational materials to the community throughout the year. Outreach Achievement in 2013: The provider anticipates achieving 70 units of outreach in PSA 6. Education/Training Achievement 2013: The provider anticipates achieving 203 units of education/training in PSA6. 15

16 Outreach (2014): The provider anticipates achieving 95 outreach activities in PSA 6. Education/Training (2014): The provider anticipates achieving 245 units of public education/training events in PSA 6. Alzheimer s Association PSA 6 The Alzheimer s Association is an OAA Title IIIE caregiver provider operating support /groups for caregivers throughout the entire planning and service area. Outreach (2013): This provider anticipates they will conduct 360 outreach activities in PSA 6. Using a Memory Mobile this provider is able to outreach to various locations throughout the planning and service area. Using targeting criteria, this provider outreaches to shopping centers, senior centers, health fairs, multi-cultural events and professional providers. Education/Training (2013): This provider anticipates they will conduct 216 educational events in the planning and service area. Locations for education and training are to occur at various health fairs, cultural events, caregiver summits and other opportunities as they arise throughout the five county service region. Outreach Achievement in 2013: The provider anticipates achieving 360 units of outreach in PSA 6. Education/Training Achievement 2013: The provider anticipates achieving 216 units of education/training in PSA6. Outreach (2014): The provider anticipates achieving 360 outreach activities in PSA 6. Education/Training (2014): The provider anticipates achieving 216 units of public education/training events in PSA 6. 16

17 West Central Florida Area Agency on Aging, Inc. (WCFAAA)- PSA 6 Outreach (2013): WCFAAA anticipates conducting 1,000 outreach contacts in the five county planning and service area. Locations for outreach will include health fairs, community events and cultural events. Targeting criteria, such as zip codes, will be used to reach seniors in rural and low income areas, as well as areas of unmet need. Education/Training (2013): WCFAAA anticipates conducting 50 educational events in the five county planning and service area. Locations for education and training will occur at sites such as churches, senior housing, mobile home parks and caregiver support groups. Additionally, education and training will take place in health care organizations and social service agencies focused on senior needs. Targeting criteria, such as zip codes, will be used to determine potential sites for education and training in order to serve area of unmet need. Outreach Achievement in 2013: WCFAAA anticipates achieving 500 outreach contacts by the close of Education/Training Achievement 2013: WCFAAA anticipates achieving 30 educational events by the close of Outreach (2014): WCFAAA goals include achieving 500 outreach contacts. Education/Training Achievement 2014: WCFAAA goals include providing 30 educational events in the five county planning and service area. 17

18 P.VI. GOALS AND OBJECTIVES Updated January, 2014 GOAL 1: Empower older people, individuals with disabilities, their families, and other consumers to choose and easily access options for existing mental and physical health and long-term care OBJECTIVE 1.1: Provide streamlined access to health and long-term care options through the Aging and Disability Resource Centers EXPLANATION: The primary intent of this objective is to address ways you link people to information and services. Strategies should address ways to improve connecting people to information and services through the ADRC. Examples include building new relationships and/or partnerships and the effective use of technology. STRATEGIES/ACTION STEPS: 1. Implement a minimum of two information sessions for the general public and professionals (eldercare professionals and professionals serving the disabled) on accessing long-term care options information, including navigation of WCFAAA s website. (Completed and ongoing.) 2. Conduct a training session targeting Home Health Care case managers and/or social workers on navigating the aging network and making referrals to the WCFAAA s Aging and Disability Resource Center. (Completed and ongoing.) 3. Implement a system for SHINE volunteers to access client referrals from Data Entry Operators without having to retrieve voic s from the agency's phone system. (Completed.) 4. Add local access information, including WCFAAA s website to state-produced brochures. (To be completed in 2014.) OUTCOMES: OUTPUTS: 18

19 GOAL 1: Empower older people, individuals with disabilities, their families, and other consumers to choose and easily access options for existing mental and physical health and long-term care OBJECTIVE 1.2: Encourage individuals, including people under 60, to plan for future longterm care needs by providing access to information EXPLANATION: The primary intent of this objective is to get the message to people who are not yet 60 that planning for long-term care is needed. Strategies should address ways to increase public awareness of the costs of long-term care (LTC), the likelihood of the need for LTC services and the LTC options available. They should also dispel the myth that Medicare will meet all long-term care needs. STRATEGIES/ACTION STEPS: 1. Identify and train one SHINE Counselor per county to be certified as Long Term Care Specialists. (Removed - Strategy no longer aligns with current SHINE benchmarks.) 2. Identify and train SHINE counselors to be certified Medicare Savings Plan and Lowincome Subsidy Specialists. 3. Schedule, through a partnership with the Society of Human Resource Managers, a minimum of two educational sessions on long-term care options with a vision of reaching those who are starting to plan for retirement. (To be completed in 2014.) 4. Utilize WCFAAA s website to provide a link to other national or state websites that provide long-term care information, such as and MyFloridaCFO/Onguard. (Ongoing) 5. New Item: Provide long-term care information tools regarding facility and agency checklists through distribution to consumers in assisting with planning for long-term care options. 6. Post video clips on The Basics of Planning for Long-Term Care on WCFAAA s website. One video clip will include how to access the most from social security in longterm care planning. (Work in progress, due to be completed December 2014.) 7. Host one planning workshops on long-term care, including Ask an Expert sessions. (Removed - Other avenues will be utilized to disseminate information.) OUTCOMES: OUTPUTS: 19

20 GOAL 1: Empower older people, individuals with disabilities, their families, and other consumers to choose and easily access options for existing mental and physical health and long-term care OBJECTIVE 1.3: Ensure that complete and accurate information about resources is available and accessible EXPLANATION: The intention of this objective is to keep ReferNET current and to continue to enhance how people can connect to the information, such as through additional access points. Strategies should ensure that information in ReferNET is kept accurate and up-to-date. ReferNET should include services identified through the creation of new partnerships. STRATEGIES/ACTION STEPS: 1. Ongoing - Gain additional database resources for programs serving the disabled community through home health care agencies, the ADRC s local Coalition Work Group, and outreach efforts through Community services and outreach coordinators. 2. Establish three additional Access Points with local hospitals through efforts made with Care Transitions. To be completed in Establish two additional Access Points at local HUD residential facilities. To be completed in Rotate the responsibility of seeking additional database resources quarterly by I&R specialists, based on unmet need reports. To be implemented in OUTCOMES: OUTPUTS: 20

21 GOAL 1: Empower older people, individuals with disabilities, their families, and other consumers to choose and easily access options for existing mental and physical health and long-term care OBJECTIVE 1.4: Ensure that elders have access to free, unbiased, and comprehensive health insurance counseling EXPLANATION: The primary intent of this objective is to show how the AAA is supporting the SHINE program. Ways to show the support might be through establishing additional counseling sites. Strategies may include activities that expand the SHINE program and access more consumers. Example: increase the number of SHINE service sites. STRATEGIES/ACTION STEPS: 1. Provide an annual SHINE training to ADRC staff to foster a better understanding of the program and ensure appropriate referrals. (Completed and ongoing.) 2. Revised - Promote the use of the virtual phone Data Entry Operator referral system to SHINE volunteers as a means of easier access to the consumer. (Completed and ongoing.) 3. Revised - Partner with disease-specific support groups to disseminate SHINE information to consumers. Partner with disease-specific support groups or organizations to disseminate SHINE information to consumers. (Completed and ongoing.) 4. Conduct a minimum of five SHINE presentations at senior centers before the open enrollment period to encourage older adults to call SHINE during this critical period. (Completed and ongoing.) 5. Develop a media campaign (tv, radio and print) to promote the SHINE program. (Current and ongoing.) 6. Revised - Develop mobile SHINE sites, such as volunteers working episodically at Walmart, Publix, pharmacies, etc. with the Alzheimer s Association Memory Mobile. (Current and ongoing.) 7. Establish protocols to utilize current SHINE sites more effectively to disseminate information, promote events and provide face-to-face counseling. (To be completed in 2014.) OUTCOMES: OUTPUTS: 21

22 GOAL 1: Empower older people, individuals with disabilities, their families, and other consumers to choose and easily access options for existing mental and physical health and long-term care OBJECTIVE 1.5: Increase public awareness of existing mental and physical health and long-term care options EXPLANATION: The primary intent of this objective to help people become aware that they might benefit from mental and physical health services and that the services are available in the community. Strategies for this objective should include how to inform the public of available long-term care services. Examples: using websites, publications, or mailings. STRATEGIES/ACTION STEPS: 1. Identify critical long-term care service websites and provide a link on WCFAAA s website. To be completed in Provide information on available long-term care services to local libraries for dissemination to consumers. To be completed in 2014 and Ongoing. 3. In 2014 provide a training to ADRC staff on available evidence-based health programs that could be beneficial to ADRC consumers. The training would include identifying key indicators that would prompt a referral to the Health and Wellness Program. 4. Conduct a series of webchats on available mental and physical health services. On a quarterly basis, use social media (Facebook) to disseminate information on available mental and physical health services. To be completed in Utilize radio spots in rural counties to increase awareness of service options. To be completed in OUTCOMES: OUTPUTS: 22

23 GOAL 1: Empower older people, individuals with disabilities, their families, and other consumers to choose and easily access options for existing mental and physical health and long-term care OBJECTIVE 1.6: Identify and serve target populations in need of information and referral services EXPLANATION: The primary intent of this objective is for the AAA to detail how they plan to reach populations in need of information or referral services that might require more challenging outreach efforts. Strategies may include how to reach and serve individuals in need of I&R who have limited English proficiency, low-literacy, low-income in rural populations, disabled persons who receive Medicare but are under the age of 65, grandparents caring for grandchildren, individuals with disabilities, and dual eligibles across any Special Needs Population. STRATEGIES/ACTION STEPS: 1. Utilize the GIS mapping system to guide targeting efforts and identify potential locations for outreach. To be implemented in Conduct a direct mail to consumers in targeted areas identified through GIS. To be completed in Conduct outreach to a minimum of five churches located in the areas identified through GIS. To be completed in Submit quarterly public service announcements to identified community newspapers. Current and ongoing. 5. Train ADRC staff on services available to older refugees. To be completed in Ensure stronger targeting efforts to the Hispanic population by developing a partnership with the Latino Chamber of Commerce and strengthening the partnership with the Hispanic Needs Council. To be completed in Utilize an intern to continually review print and on-line media materials to identify current elder care issues that need to be addressed. (Removed as available interns will be utilized for other projects and resources will not be available to implement this strategy.) 8. Revised - Develop a targeted campaign of writing letters to the editor in response to the current senior care issues identified from the review of media materials. Write and submit letters to the editor on a quarterly basis to address relevant issues. OUTCOMES: OUTPUTS: 23

24 GOAL 1: Empower older people, individuals with disabilities, their families, and other consumers to choose and easily access options for existing mental and physical health and long-term care OBJECTIVE 1.7: Provide streamlined access to Medicaid Managed Care and address grievance issues EXPLANATION: The primary intent of this objective is for the AAA to provide detail on the role the AAA will assume as Medicaid Managed Care is implemented in the PSA. Strategies may include actions that will be taken to provide consumers with access to Medicaid Managed Care information and enrollment services. Strategies to address grievance issues in relation to Medicaid Managed Care should also be included. STRATEGIES/ACTION STEPS: 1. Develop ADRC Education protocols and procedures, including grievance procedures for the Medicaid Managed Care Long Term Care System. Work in progress, to be completed in Develop a managed care training for WCFAAA staff, Advisory Council and Board of Directors members with the goal of teaching key industry terms, industry standards, current issues and the integration of management care into the ADRC. (Completed and ongoing.) 3. Removed - Organize a Medicaid Managed Care Work Group with representatives from WCFAAA staff, Advisory Council, Board of Directors and Medicaid Managed Care organizations to review choice counseling functions of the ADRC. Unable to complete due to changes to the implementation of the SMMC LTC program services, possible conflict of interest issues and ADRCs were not provided with the responsibility to provide choice counseling. OUTCOMES: OUTPUTS: 24

25 GOAL 2: Enable individuals to maintain a high quality of life for as long as possible through the provision of home and community-based services, including supports for family caregivers OBJECTIVE 2.1: Identify and serve target populations in need of home and communitybased services EXPLANATION: The primary intent of this objective is twofold: 1) to address how the AAA will identify the target populations in the PSA and 2) to address how the AAA will provide services to the targeted populations who may be in hard-to-reach areas. Strategies should include how the PSA will identify and serve individuals who are in need of HCBS with limited English proficiency, low-literacy, low-income in rural populations, disabled persons who receive Medicare but are under the age of 65, grandparents caring for grandchildren, people with developmental disabilities, and dual eligibles across any Special Needs Population. Best practice should also include the PSA serving clients according to the Department s prioritization criteria. STRATEGIES/ACTION STEPS: 1. Utilize the GIS mapping system to identify hard-to-reach areas in order to target services to the most at risk seniors. (To be in use by 12/31/14.) 2. Ensure through provider service provider applications, contracting and monitoring efforts that the provider network is targeting appropriately and prioritizing service delivery with an emphasis on the priority criteria for HCBS delivery. (Completed and ongoing.) 3. Provide training to ADRC and aging network staff at least annually on services available, stressing the priority criteria and the target populations for HCBS funding. (Completed and ongoing.) 4. Provide training to provider network at least annually on required outcome measures to help ensure providers understand the measures and work toward 100% compliance. (Completed and ongoing.) 5. At least quarterly, monitor provider CIRTS reports to ensure outcome measures are being achieved. (Completed and ongoing.) OUTCOMES: Note: The AAAs will not be monitored on the measures listed in italics, though the AAA must still include strategies to address them in this section. Percent of most frail elders who remain at home or in the community instead of going into a nursing home Average monthly savings per consumer for home and community-based care versus nursing home care for comparable client groups Percent of new service recipients whose ADL assessment score has been maintained or improved Percent of new service recipients whose IADL assessment score has been maintained or improved Percent of customers who are at imminent risk of nursing home placement who are served with community-based services Percent of elders assessed with high or moderate risk environments who improved their 25

26 environment score Percent of new service recipients with high-risk nutrition scores whose nutritional status improved DOEA Internal Performance Measures: Percent of high-risk consumers (APS, Imminent Risk, and/or priority levels 4 and 5) out of all referrals who are served OUTPUTS: 26

27 GOAL 2: Enable individuals to maintain a high quality of life for as long as possible through the provision of home and community-based services, including supports for family caregivers OBJECTIVE 2.2: Ensure efforts are in place to fulfill unmet needs and serve as many clients as possible EXPLANATION: The primary intent of this objective is to address how the AAA oversees the service delivery system in the PSA. Strategies to address unmet needs/gaps can include partnerships and collaborations with other entities which have expertise in meeting the identified needs/gap. STRATEGIES/ACTION STEPS: 1. Ensure compliance with local established procedures that lead agencies must respond within a timely manner regarding the status of elders referred as at imminent risk. (Completed and ongoing.) 2. Conduct at least quarterly home visits to measure satisfaction with the quality of service being delivered in the Aged/Disabled Adult Waiver program. Item removed, no longer aligns with current Medicaid Waiver benchmarks. 3. New item: Conduct Joint ADRC Partnership and Local Coalition Workgroup Meetings to develop strategies to meet unmet needs/gaps. 4. Review and monitor the imminent risk designation on referrals from CARES and Lead Agencies. Update: Work in progress, WCFAAA staff currently adhere to the DOEA EMS Procedures which allow for immediate release of imminent risk designated referrals from CARES and Lead Agencies. 5. New item: Conduct SMMC LTC trainings at least quarterly with Nursing Homes and other community partners that may make referrals to WCFAAA for SMMC LTC Medicaid screening and information. 6. Conduct monthly ADA waiver care plan reviews in accordance with the DOEA approved Care Plan Protocol procedures to ensure authorized services are necessary and that all non-doea resources are utilized prior to the use of DOEA funded resources. Removed no longer aligns with Medicaid Waiver benchmarks, SMMC LTC. 7. Provide and promote training to encourage the utilization of non-doea resources and conduct client file reviews to evaluate the use of non-doea resources. Item removed, no longer aligns with current benchmarks. 8. New item: Ensure PSA 6 case management agencies participate in 701B training by October 1, 2013, a training which encourages the use of both formal and informal resources. 9. Facilitate at the local level, accurate targeting of available resources to clients who are at the greatest risk of nursing home placement. This includes encouraging providers to transfer Community Care for the Elderly funds to Medicaid Waiver. 10. Provide technical assistance and collaborative support for providers in the expansion of services through volunteer programs. 27

28 OUTCOMES: Note: The AAAs will not be monitored on the measures listed in italics, though the AAA must still include strategies to address them in this section. Percent of most frail elders who remain at home or in the community instead of going into a nursing home Average monthly savings per consumer for home and community-based care versus nursing home care for comparable client groups Percent of new service recipients whose ADL assessment score has been maintained or improved Percent of new service recipients whose IADL assessment score has been maintained or improved Percent of customers who are at imminent risk of nursing home placement who are served with community based services Percent of elders assessed with high or moderate risk environments who improved their environment score Percent of new service recipients with high-risk nutrition scores whose nutritional status improved OUTPUTS: Number of people served with registered long-term care services 28

29 GOAL 2: Enable individuals to maintain a high quality of life for as long as possible through the provision of home and community-based services, including supports for family caregivers OBJECTIVE 2.3: Provide high quality services EXPLANATION: The primary intent of this objective is for the AAA to detail quality assurance efforts in the PSA. Strategies can include evaluating service effectiveness using reliable and valid assessment instruments. STRATEGIES/ACTION STEPS: 1. Routinely advocate at the federal, state and local levels for additional funding for home and community-based services. (Completed and ongoing.) 2. Support will be offered to caregivers that assist, sustain and address the emotional and physical demands of care giving by continued implementation of the National Family Caregiver Support Program; this includes funding a variety of home and community based services, such as respite, personal care and homemaking. (Completed and ongoing.) 3. At least annually facilitate the development and coordination of a broader vendor base in PSA 6 in an effort to address unmet needs and improve the efficiency and effectiveness of the service delivery system. Update: As of September , WCFAAA halted provider enrollment for all new, potential providers for the Medicaid Waiver program. This includes halting all provider recruitment efforts. WCFAAA MWS staff currently advises all potential providers to contact Florida Medicaid and the SMMC LTC participating MCOs. 4. Routinely conduct quality assurance reviews of the ADRC operations to ensure the optimal effectiveness of the one-stop-shopping model, making it easier for seniors and caregivers to obtain services. (Completed and ongoing.) 5. At least quarterly, generate ad hoc reports from CIRTS to determine: priority status; adequacy of the service package provided; and the consistency in service delivery to those elders determined at risk of nursing home placement. (Completed and ongoing.) 6. Bi-monthly ensure compliance with local established procedures that lead agencies must respond within a timely manner regarding the status of elders referred as at imminent risk of nursing home placement as funding permits. (Completed and ongoing.) 7. At least quarterly, facilitate at the local level, accurate targeting of available resources to clients who are at the greatest risk of nursing home placement. This includes encouraging providers to transfer Community Care for the Elderly potential clients to Medicaid Waiver. (Completed and ongoing.) 8. New Item - As necessary, refer clients living in an intermediate or high risk environment to community agencies that assist with home improvements. If clients refuse home improvement assistance, provider agencies will encourage clients to seek counseling through community partners. OUTCOMES: Note: The AAAs will not be monitored on the measures listed in italics, though the AAA must still include strategies to address them in this section. Percent of most frail elders who remain at home or in the community instead of going into a nursing home Average monthly savings per consumer for home and community-based care versus nursing home care for comparable client groups Percent of new service recipients whose ADL assessment score has been maintained 29

30 or improved Percent of new service recipients whose IADL assessment score has been maintained or improved Percent of customers who are at imminent risk of nursing home placement who are served with community-based services Percent of elders assessed with high or moderate risk environments who improved their environment score Percent of new service recipients with high-risk nutrition scores whose nutritional status improved. OUTPUTS: 30

31 GOAL 2: Enable individuals to maintain a high quality of life for as long as possible through the provision of home and community-based services, including supports for family caregivers OBJECTIVE 2.4: Provide services, education, and referrals to meet specific needs of individuals with dementia EXPLANATION: This objective focuses on individuals with dementia to ensure that the specific needs of these individuals are not overshadowed by serving populations without dementia. Strategies should include the implementation of caregiver programs that adopt or expand state and federal volunteer respite program models and innovative projects that address caregiver needs and reduce their stress. Strategies should also include effective partnerships with organizations and providers who have dementia expertise, training Information & Referral Specialists and other staff to recognize possible cognitive impairment and person-centered services planning. STRATEGIES/ACTION STEPS: 1. On a routine basis, support provider network efforts and advocate for caregiver focused support programs and events such as: the annual caregiver s recognition and education event; training and education at the caregiver support group; and as funding is available provide caregiver scholarships to attend the Division s various community workshops, conferences and seminars. (Completed and ongoing.) 2. On a routine basis, provide information and referral to caregivers on additional resources in the community, and other programs that can benefit the caregiver. (Completed and ongoing.) 3. At least annually ensure that PSA 6 has an establish a broad base of providers (formal and informal) to meet the full array of service needs of clients by: developing partnerships within the faith based community to help build capacity in providing services; continue partnerships with universities and community providers to increase provider network capacity. (Completed and ongoing.) 4. Routinely review consumer care plans to ensure case managers make necessary adjustments to service planning as client needs shift and not only at required care plan update intervals. (Completed and ongoing.) 5. Continue to ensure staff receive at least annual training updates specific to issues related to individuals with dementia. (Completed and ongoing.) OUTCOMES: Note: The AAAs will not be monitored on the measures listed in italics, though the AAA must still include strategies to address them in this section. Percent of most frail elders who remain at home or in the community instead of going into a nursing home Average monthly savings per consumer for home and community-based care versus nursing home care for comparable client groups 31