Department  of  Health  and Human  Sefices 
ADMINISTRATION  ON  AGING 
AND 
OFFICE  OF 
INSPECTOR  GENERAL 
I 
I 
i 
APRIL  19%  ADMINISTIWTION ON AGING 
The Administration on Aging (AoA)  is the principal Federal  agency  designed to carry out the 
provisions of the Older Americans Act (O&!).  It advises the Secretary of Health  and Human 
Services and other  Federal agencies on the characteristics, circumstances and needs of older 
individuals.  Further,  it develops policies, plans, and programs designed to promote  their 
welfare. 
AoA administers three  grant programs under the Older Americans Act.  The  largest program -
- Title III of the Act --consist of formula grants to States to establish State and community-
based programs for older individuals with the purpose of preventing the premature 
institutionalization  of older individuals.  The second program -- Title W -- consists of 
discretionary grants with the same purpose as Title III, but to meet the unique needs of older 
Native Americans.  The third program --Title IV -- is also discretionary.  Its purpose is to fund 
research, demonstration,  and training activities to elicit knowledge and techniques to improve 
the circumstances of older Americans.  (The 1992 Amendments to the OAA created  a fourth 
program -- Title VII --which provides funds for State activities to protect  the rights of 
vulnerable older people.  Prior to the 1992 Amendments, Title III of the OAA provided the 
funds for these activities.) 
OFFICE  OF INSPECIOR GENERAL 
The mission of the Office of Inspector General  (OIG), as mandated  by Public Law 95-452, as 
amended, is to protect  the integrity of the Department  of Health  and Human Services (HHS) 
programs as well as the health  and welfare of beneficiaries served by those programs.  nis 
statutory mission is carried out through a nationwide network of audits, investigations, and 
inspections conducted  by three OIG operating components:  the Office of Audit Services, the 
Office of Investigations, and the Office of Evaluation and Inspections.  The OIG also informs 
the Secretary of HHS of program and management problems and recommends courses to 
correct them. 
The OIGS Office of Evaluation  and Inspections (OEI) conducts short-term  management and 
program evaluations  (called inspections) that focus on issues of concern to the Department, 
the Congress, and the public.  The findings and recommendations  contained  in these inspection 
reports generate  rapid, accurate, and up-to-date information on the efficiency, venerability, 
and effectiveness of departmental  programs. 
THIS REPORT 
This report  is the result of a joint effort between AoA and OIG/OEI  to assess the 
implementation  of Title III of the Older Americans Act.  OIG staff in the New York and 
Dailas regional offices provided technical support to the joint project.  AoA staff in New y~r~ 
and Dallas directed  the project with all regional offices participating in the development Of 
instruments and data collection. 
For additional information, please contact: 
AoA  John Dia~ Regional Program Director-Dallas  214-767-2971 
OIG  Jack Molnar, Project Leader-New York  212-264-1998  Department  of  Health  and Human  Services 
ADMIN  STRATION  ON  AG  NG 
AND 
OFFICE  OF 
INSPECTOR  GENERAL 
STATE  IMPLEMENTATION  OF  THE 
TARGETING  REQUIREMENTS  OF  THE 
OLDER  AMERICANS  ACT 
I  e 
A  EXECUTIVE  SUMMARY 
PURPOSE 
To review  State  Units  on Aging  (SUA)  implementation  of the  targeting  requirements 
of Title  III of the  Older  Americans  Act  (oAA). 
BACKGROUND 
In an effort  to  strengthen  its stewardship  of the  0~  the  Commissioner  of the 
Administration  on Aging  (AoA)  requested  technical  assistance  from  the  Office  of 
Inspector  General  (OIG)  in designing  a review  of their  primary  Title  III grantees  --
SUAS.  After  reviewing  traditional  and  current  stewardship  activities,  and  discussing 
potential  approaches  for future  efforts,  we agreed  that  a review  of individual  States 
would  be  instituted  in such  a way as to provide  the  Commissioner  with  an overview  of 
how States  are  implementing  key components  of Title  111. In order  to conserve 
limited  travel  funds  the  reviews would  be  conducted  on a sample  of States  and  would 
focus  on only five programmatic  areas  -- stewardship,  targeting,  ombudsman,  nutrition, 
and  financial  management. 
This  report  on targeting  addresses  the  requirements  that  special  consideration  be  given 
to providing  services  to those  of greatest  economic  or social  need,  with  special 
emphasis  on low-income  minorities.  It focuses  on issuing guidance  on and  monitoring 
implementation  of the  key requirements  of Title  III of the  O- including  the  area 
planning  process. 
METHODO~GY 
The  reviews  were  conducted  in a stratified,  random  sample  of 20 States  based  upon 
the  population  of individuals  over  60 years  of age in each  State.  In the  first step  of 
the  sampling  process,  States  were  divided  into  four  strata  based  upon  the  number  of 
older  individuals  in each  State.  In the  second  stem  five States  were  selected  from 
each  stratum.  This  stratified,  random  sample  perrnits a generalization  of findings  from 
the  20 sample  States  to the  Nation.
FINDINGS 
Ta~eting  Hw  Become  Common  I%actice Among  State  And  Area  Agencies 
State  agencies  conduct  meetings  and  coordinate  with  other  agencies 
 
Area  Agencies  rely on outreach,  specialized  services,  and  provider  and  site 
 
selection 
i  Littlk  Attention  Is Given  To Evalzuztikg  Ta~eting  Acfivitkx 
Only 40 percent  of States  and  half of area  agencies  evaluate  outreach 
 
State  Agencies  Repfl  -~   In Meeting  Requirements  On Ihdividudk  With  Limited 
Englkh  Speaking  Ability 
While  only one-third  of States  have  established  designation  criteria,  half  of the 
 
States  designate  area  agencies  as having  substantial  individuals  with  limited 
English-speaking  ability 
Whzk  States  Unddake  Ta~eting  Initiatives,  Z7iey Report  Baniem  To Impkmenation 
States  see  lack  of funding  and  data  on low income  minorities  as the  primary 
 
barrier  to effective  targeting 
State  Agencies  Are  I?ovidikg  Technical  Assktance  And  Seeking  It From  AoA 
 Three-quarters  of States  provide  area  agencies  with technical  assistance 
Two-thirds  want  more  guidance  from  AoA 
 
ii  TABLE  OF  CONTENTS

EXECUTIVE  SUMMARY  . . . . . . 
. . . . . . . . . . . . . . . . . . . . . ...=...  ...o~oooi 
INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
.....=..001 
FINDINGS

Targeting  Is Common  Practice  . . . . . . . . . . . . . . . . . . . . . . . . . . . ...===
 4 
 
Little  Attention  GivenTo  Evaluation  . . . . . . . . . . . . . . . . . . . . ...  ..-
 6 
 
Requirements  On  Individuals  With  Limited  English-Speaking  Ability  Present

 
Problems  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  =. . . ..=.  === ==oooo  O
7 
States  Report  BarriersTo  Targets  . . . . . . . . . . . . . . . . . . . . . . . . .  .=..-=
 8 
   
State  Agencies  Provide  Targeting  Technical  Assistance  . . . . . . . . . . . . . . . . . . .
 8 
 
APPENDICES

A  Appendix  A  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..=  ..0  A-l
 INTRODUCTION 
PURPOSE 
To review  State  Units  on Aging  (SUA)  implementation  of the  targeting  requirements 
of Title  III of the  Older  Americans  Act  (OAA).  In this report,  the  term  targeting 
refers  to the  requirements  that  special  consideration  be given to providing  services  to 
those  of greatest  economic  or social  need,  with special  emphasis  on low-income 
minorities.  It focuses  on issuing guidance  on and  monitoring  implementation  of the 
key targeting  requirements  of Title  III of the  OAA,  including  the  area  planning 
process. 
BACKGROUND 
Under  the  0~  the  Administration  on Aging  (AoA)  serves  as the  principal  Federal 
advocate  for older  individuals,  providing  national  leadership  in the  development  of 
programs  to address  their  needs.  Through  Title  III of OAA  (Grants  for  State  and 
Community  Programs  on Aging),  AoA  encourages  and  assists SUAS and  area  agencies 
on aging  (AAAs)  to implement  a system  of coordinated  community-based  services  to 
prevent  the  premature  institutionalization  of older  individuals  by allowing  them  to 
remain  in their  own community. 
Under  Title  III, AoA  distributes  approximately  $765 million  in formula  grants  to States 
based  on the  age  60+  population  within  each  State.  The  SUAS use  about  S percent 
of the  grant  on administration,  and  then  fund  AA%  who  then  contract  for the 
supportive  services,  nutrition  services  and  multipurpose  senior  centers.  The  single 
largest  component  of Title  III, the  nutrition  program,  provides  approximately  $450 
million  for congregate  and  home-delivered  meals.  Other  key program  components 
include  supportive  services  (i.e., access  services,  in-home  services  and  legal  assistance) 
and  the  Ombudsman  program  which  serves  as an advocate  for residents  in long term 
care  facilities. 
One  of AoAs major  administrative  responsibilities  is to provide  stewardship  over  the 
States  implementation  of the  Title  III program.  However,  AoAs capacity  to carry  out 
its stewardship  responsibilities  declined  substantially  during  the  1980s due  to a 
significant  reduction  in resources.  More  specifically,  AoA  sustained  a 47 percent 
reduction  in staff and  75 percent  reduction  in travel  funds.  Each  regional  office  had 
only $2,000 annually  for travel.  Because  they  could  not  monitor  SUAS, AoA  became 
further  and  further  removed  from  the  activities  of the  SUAS and  their  area  agencies 
on aging. 
In efforts  to  strengthen  its stewardship  of the  OAA,  the  Commissioner  of AoA 
requested  technical  assistance  from  the  Office  of Inspector  General  (OIG)  in 
designing  a review  of their  primary  Title  III grantees  -- SUAS.  In response  to the 
Commissioners  request,  OIG  staff met  with key AoA  headquarters  and  regional  staff 
1  to identi~  traditional  and  current  stewardship  activities,  and  to discuss potential 
approaches  for future  efforts.  As a result,  we agreed  that  the  review  of individual 
States  would  be  instituted  in such a way as to provide  the  Commissioner  with  an 
overview  of how States  are  implementing  key components  of Title  III.  The  OIG 
agreed  to assist AoA  in developing  national,  standardized  review  instruments  for key 
components  of Title  III and  in writing  a report  summarizing  States  implementation  of 
the  Act.  We  also  agreed  that  in order  to conserve  limited  travel  funds  the  reviews 
would  be  conducted  on a sample  of States  and would  focus  on only five programmatic 
areas  -- stewardship,  targeting,  ombudsman,  nutrition,  and  financial  management. 
Designing  the  review  began  with the  meeting  of a review  team  of OIG  and  selected 
AoA  regional  staff.  They  brainstormed  approaches,  identified  Federal  reporting  and 
operating  requirements  for SUAS and  AA&  and  drafted  instruments  containing  the 
review  questions  and  criteria.  The  draft  instruments  were  shared  with AoA 
headquarters  staff and  each  regional  office for comments,  and  then  revised  to reflect 
comments. 
The  OIG/AoA  review  teams  pre-tested  the  instruments  and  data  collection 
methodology  by conducting  reviews  for each  of the  five instruments  in six States 
located  in four  different  Federal  regions.  The  pre-test  identified  that  a great  deal  of 
time  was lost explaining  criteria  (interpreting  law and  regulation)  and  searching  for 
documentation.  Accordingly,  the  review  team  modified  each  of the  instruments  and 
changed  the  data  collection  methodology.  The  most  significant  change  to the 
methodology  required  the  sharing  of the  review  instruments  with the  States  prior  to 
the  site visit in the  belief  that  if States  are  aware  of and  understand  the  review  criteria 
being  used  during  the  review,  they will be better  prepared  to provide  required 
documentation  and  to discuss  specific  issues. 
METHODOIXIGY 
The  reviews  were  conducted  in a stratified,  random  sample  of 20 States  based  upon 
the  population  of individuals  over  60 years  of age  in each  State.  These  are  the  same 
data  used  to allocate  Title  III funds  among  States.  In the  first step  of the  sampling 
process,  States  were  divided  into  four  strata  based  upon  the  number  of older 
individuals  in each  State.  In the  second  step,  we selected  five States  from  each 
stratum.  This  stratified,  random  sample  permits  us to generalize  findings  from  the  20 
sample  States  to the  Nation.  Table  I indicates  those  States  selected  for the  review 
process  (See  Table  I). 
We  also used  sampling  techniques  during  site visits to each  State  for the  reviews  of 
specific  area  plans  and  assessments.  In these  instances,  we selected  a simple,  random 
sample  of 10 AAAs  prior  to the  visit to review  on-site.  For  those  States  with less than 
10 AAAs,  all AAAs  were  included  in the  review. 
2
 TABLE  I 
SAMPLE  STATES 
Stratum 1  Stratum 2  Stratum  3  Stratum 4 
California  Michigan  Wisconsin  New Hampshire 
Pennsylvania  Indiana  Colorado  North  Dakota 
New York  Massachusetts  Oklahoma  Nevada 
Texas  Georgia  Maine  District 
Florida  North  Oregon  of Columbia 
Carolina  Montana 
The  data  collection  was conducted  in two phases  -- an AoA  regional  office  desk 
review  and  an on-site  review  at the  SUA.  During  the  desk  review  phase,  we looked  at 
area  plan  guidance  and  program  instructions,  as well as the  States  assessment 
instruments  for AAAs  to determine  if they  are  consistent  with Federal  law and 
regulations.  We  also reviewed  priority  services  waivers  and  targeted  populations 
participation  data  from  the  State  Program  Report  for Title  III. 
Following  the  desk  review,  each  State  was sent  a proposed  agenda  for the  site visit, a 
listing of the  AAAs  whose  area  plans  and  assessment  reports  will be  reviewed,  a copy 
of the  targeting  review  instrument  (Appendix  A), and  the  findings  from  the  desk 
review  to be  discussed  during  the  site visit. 
The  review  instrument  focused  on the  guidance  SUAS issued  to AAAs,  on key 
requirements  of Title  III, and  on the  instruments  and  procedures  they  use to assess 
AAAs  with those  requirements.  A review  of area  plans  and  assessment  reports 
determine  whether,  and  to what  extent,  they  reflect  OAA  requirements.  The 
instruments  also focus  on the  issues  of SUA  operating  procedures,  and  on training  and 
technical  assistance  activities. 
We  entered  data  from  the  targeting  review  instruments  into  three  databases.  One 
database  contained  the  responses  to the  open- and  closed-ended  questions  on the 
instrument  and  the  other  two contained  the  reviews  of 151 area  plans  and  assessments. 
The  number  of responses  to questions  vary because  some  questions  did not  apply  to 
the  four  States  in Stratum  4-- NH,  ND,  NV, & DC  -- which  are  single  planning  and 
service  area  (SPSA)  States. 
The  percentages  cited  in this report  are  based  on the  responses  to specific  questions 
contained  in the  review  instrument.  The  responses  are  weighted  to reflect  the  sampling 
plan  and  are  projected  to the  Nation.  The  precision  at the  90-percent  confidence 
intervals  vary for each  question  from  plus  or minus  6 to 21 percent  based  upon  the 
nature  of the  question  (categorical  or continuous)  and  the  number  of respondents  to 
each  question. 
3  FINDINGS 
TARGETING  HAS  BECOME  COMMON  PRACIICE  AMONG  SUAs  AND  AAAs 
While  all persons  age  60 or over  are  eligible  for services  under  the  Older  Americans 
Act  (OAA),  the  act  requires  that  special  consideration  be  given to targeting  services  to 
those  in greatest  economic  or social  need.  Special  emphasis  is given  to low-income 
minority  older  persons.  This is achieved  through  specific  planning,  evaluation  and 
delivery  of services  outlined  in the  Act. 
State  Activik 
Virtually  all States  (95 percent)  have  undertaken  specific  activities  in support  of 
targeting  within  the  last two years. State agency activitiesinclude  both  State  level 
initiatives  and  those  directed  at AAAs.  The  most  common  State  level initiatives  are 
coordinating  activities  with other  organizations  (90 percent)  and  conducting  meetings 
and  conferences  (88 percent). 
The  SUAs  coordinate  with a range  of other  organizations,  on multiple  issues  related  to 
targeting.  This  includes  organizations  for minority,  disabled  and  rural  individuals,  as 
well as organizations  for older  individuals,  such as the  American  Association  for 
Retired  Persons  (AARP).  It also includes  national  organizations  like National 
Association  for the  Advancement  of Colored  People  (NAACP)  and  the  National 
Association  of State  Units  on Aging  (NASUA),  and  local groups  such as minority 
churches  and  technical  colleges.  The  organizations for the  disabled  most  commonly 
represent  the  blind,  deaf  and  developmentally  disabled,  or focus  on rehabilitation. 
Rural  organizations  addressed  such concerns  as health,  transportation,  eldercare,  or 
the  needs  of migrant  farm  workers. 
The  meetings  and  conferences  SUAs  host  on targeting  take  two forms  -- periodic  and 
one-time  events.  The  periodic  meetings  most  often  are  in-service  training  for State 
staff or regular  conferences  for AAAs.  The  regular  W  conferences  could  be  for 
specific  staff,  such as planners,  outreach  workers,  volunteers  or nutritionists,  or for the 
AAA  association.  In single planning  and  service  area  (SPSA)  States,  these  are 
meetings  for providers.  The  one-time  conferences  are  most  often  State-wide  events 
open  to all members  of the  States  aging network.  These  conferences  seem  to focus 
on either  specific  target  groups  such as minority  women,  Indians,  disabled,  and 
minorities  in general,  or on specific  subjects  including  SS1 outreach,  health  promotion, 
information  and  referral  (I&R),  and  elder  abuse. 
Among  the  less frequently  noted  State  targeting  activities  is altering  the  intra-state 
funding  formula  (24 percent).  This is lower  than  anticipated  given AoA  policy in the 
form  of AoA  Program  Instruction  (PI)  90-01 which  establishes  review  criteria  for intra-
state  funding  formula.  The  PI notes  the  value  of using the  intra-state  formula  to 
promote  targeting  and  seeks  to determine  if formula  reflect  the  proportion  among  the  PSAS of persons  age  60 and  over  in greatest  economic  or social  need,  with particular 
attention  to low-income  minority  individuals. 
State  agency  targeting  activities  with M  most  frequently  include  providing  technical 
assistance  (90 percent),  monitoring  AAAs targeting  efforts  (86 percent),  and  issuing 
policy guidance  (84 percent). 
State  agency  provide  technical  assistance  on targeting  to both  AA/M  and  providers. 
This is done  through  site visits, newsletters,  and  the  above  noted  conferences.  Some 
of the  topics  for this technical  assistance  include:  affirmative  action;  Spanish  language 
training  opportunities;  alzheimer  services;  outreach  to Indians;  and  information  on 
best  practices. 
The  SUAS monitoring  of AAA  targeting  efforts  takes  two forms  -- use  of reporting 
systems  and  reviewing  area  plans.  Regarding  reporting  systems,  70 percent  of States 
said they  used  standard  reports  from  M  and  providers  to monitor  targeting  efforts. 
Most  frequently  these  provide  program  participation  data  on a quarterly  or semi-
annual  basis.  States  compare  rates  of participation  with such indicators  as area  plan 
goals,  previous  year  participation,  or State  targets.  Related  to the  latter,  we noted 
that  52 percent  of States  have  established  participation  rates  for AAAs.  Generally, 
the  goals  are  to  serve  target  groups  in at least  the  same  proportion  they  represent  in 
the  total  population  at large  or the  60+  population. 
In using the  area  planning  process  to monitor  targeting  efforts,  SUAS focus  on both 
the  actual  plan  and  updates,  and  on periodic  assessments  of implementation  of the 
plan.  With  regard  to the  area  plan,  SUAS either  have  targeting  review  criteria, 
establish  targeting  objectives,  or add  a targeting  exhibit  to the  area  plan  format.  Also, 
targeting  criteria  are  often  included  in assessment  instruments  or in performance 
reports.  Less  often  SUAS conduct  special  analyses  of AAA  or provider  targeting 
efforts  or review  the  annual  evaluations  of the  effectiveness  of outreach. 
State  policy  issuances  on targeting  are  used  to establish  responsibilities  and  standards, 
or operating  procedures.  Examples  include  listing AAA  and  provider  responsibilities, 
defining  target  populations,  and  establishing  performance  standards  for outreach.  We 
noted  operating  procedures  for affirmative  action  in hiring  staff  and  for giving 
preference  to minority  providers. 
Local  Activities 
All States  noted  local  targeting  activities.  The  targeting  activities  of AAAs  and 
providers  most  often  include  outreach  (100 percent),  specialized  services  (96 percent), 
site selection  (86 percent),  and  provider  selection  (77 percent). 
Under  the  broad  rubric  of outreach,  States  reported  traditional  activities  such a door-
to-door  canvasing  and  information  and  referral  (I&R),  but  they  also  reported  other 
activities.  These  include  recruiting  minority  and  bilingual  staff, working  with  other 
5  organizations,  and  using media.  The  media  efforts  range  from  public  service 
announcements  and  pamphlets  to public  speaking  engagements.  Recruiting  minority 
and  bilingual  staff is seen  as an  effective  way to bridge  cultural  barriers.  The 
strategies  using  other  organizations  ranged  from  working  with AARP,  churches, 
doctors,  and  discharge  planners  to seeking  to educate  leaders  in the  minority 
community. 
Specialized  services  is a broad  term  referring  to services  for specific  populations.  The 
most  commonly  reported  specialized  service  is ethnic  meals  used  to  attract  older 
individuals  to congregate  meal  sites where  they  can be  referred  to other  services. 
Specialized  services  also include  translatinghealth,utilityand  other  public  service 
announcements  or pamphlets,  and  running  literacy  programs.  For  the  frail  elderly, 
specialized  services  include  transportation,  companion  services  and  adult  day care, 
mobile  health  screening,  and  legal  and  representative  payee  services. 
Provider  selection  is an effort  to recruit  minority  providers  into  the  aging  network, 
because  they  are  seen  as being  better  able  to serve  target  populations.  The  AA&  use 
a number  of tactics  to recruit  these  providers.  They  invite  minority  providers  to pre-
request  for proposal  conferences  designed  to help  them  quali~  for the  contract  and 
then  widely advertise  the  request  for proposal  in minority  newspapers.  They  also ask 
minority  providers  to help  draft  the  request  for proposals.  Others  use  administrative 
procedures  such  as using  sole-source  contracts,  issuing policy giving preference  to 
minority  providers,  or establishing  a set-aside  fund  for targeting  services. 
Site  selection  is the  practice  of locating  services  in the  target  community;  most 
frequently  this is a minority  or low-income  community,  or a senior  citizen  housing 
project.  While  site selection  is a generally  effective  form  of targeting,  it can  present 
service  providers  with  difficult  decisions.  For  example,  in an era  of level funding, 
providers  of service  often  must  de-fund  an established  site in order  to create  a new 
one  in a more  suitable  location. 
LITILE ATTENTION  GIVEN  TO EVALUATING  TARGETING  ACHWTIES 
While  SUAs report  numerous  targeting  efforts,  they  have  little  documentation  of their 
effect.  When  asked  to identify  the  AAA  targeting  activities  that  were  the  most 
successful  in increasing  target  populations,  SUAS cited  outreach  (44 percent),  site 
selection  (43 percent),  specialized  services  (30 percent),  and  recruiting  minority 
providers  (24 percent).  SUAs  further  noted  site selection  (60 percent)  and  having 
minority  or bilingual  staff  (38 percent)  as the  most  successful  methods  used  by service 
providers  to address  the  service  needs  of low-income  minorities.  About  half  (55 
percent)  of the  States  determine  the  success  of their  M  targeting  efforts  or methods 
to serve  low-income  minorities  through  reported  increases  in program  participation 
rates.  Others  (17 percent)  who  offered  an opinion  on successful  methods  report  that 
they  rely on anecdotal  information  as an indicator.  For  example,  one  of these  States 
said, its assumed  they  [targeting  efforts]  are  successful.  Another  20 percent  of 
States  report  that  they  did not  know  how to determine  the  success  of targeting. 
6  While  most  States  rely on program  participation  reports  to  assess targeting  efforts, 
they  note  weakness  in that  data.  States  report  the  primary  factors  affecting 
participation  trends  are  improved  reporting  which  provides  a more  accurate  count 
than  in previous  years  (35 percent)  and  demographic  changes  (34 percent). 
Improvements  to a reporting  system  cause  a lower,  albeit  more  accurate,  count.  Other 
factors  include  an increase  in target  populations  (20 percent),  level  funding  coupled 
with increased  costs, resulting  in fewer  people that can &  served (19 percent), and  the 
aging-in  place  process  (13 percent). 
Another  potential  key to assessing  targeting  efforts  are  the  required  evaluations  of 
outreach.  Sections  306 (a)(6)(A)  and  307(A)(8)  of OAA  require  an annual  evaluation 
of the  effectiveness  of outreach.  Only 39 percent  of States  report  conducting  the 
annual  evaluation  of the  effectiveness  of outreach  to targeted  populations  required 
under  Section  307.  Those  States  that  did the  evaluation  said the  use of media, 
meeting  with  minority  groups,  and  setting  program  goals were  the  most  effective 
outreach  activities.  Among  the  remaining  States,  31 percent  of States  did not  conduct 
the  annual  evaluation  and  30 percent  did not  know if the  evaluation  was conducted. 
Regarding  the  Section  306 requirement  that  AAAs  evaluate the effectiveness  of their 
outreach,  only 49 percent  of States  report  all their  AAAs  conducted  the  evaluation. 
Another  29 percent  of States  indicate  that  they  did not  know if their  AAAs  conduct 
this evaluation,  and  the  remaining  States  report  a range  of 13 to 85 percent  of their 
AAAs  conduct  the  annual  evaluation.  The  probable  reason  for AAAs  not  doing  these 
evaluations  is that  some  SUAS are  not  making  them  aware  of the  requirement.  Our 
review  of area  plan  guidance  found  that  36 percent  of SUAS do not  include  the 
requirement  for an  annual  evaluation  of the  effectiveness  of outreach  in their  guidance 
to AAA.  We  also noted  that  47 percent  of SUAS assessment  instruments  failed  to 
monitor  compliance  with this requirement. 
SUAS REPORT  DIFFICULTY  IN MEETING  REQUIREMENTS  ON 
INDIVIDUALS  WITH LIMITED  ENGLISH  SPEAKING  ABILITY 
Under  Section  307(a)(20)  of OAA,  SUAS  must require that their  AAAs  address  the 
unique  needs  of their  clients  with limited  English  speaking  ability.  Specifically,  SUAS 
must  identi~  AAAs  with  substantial  numbers  of older  individuals  with  limited  English 
speaking  ability who  reside  in their  planning  and  service  area.  Those  AAAs  must  then 
use bilingual  outreach  workers  and  must  designate  an employee  or have  an individual 
available  to them  to counsel  and  assist such individuals.  We  found  that  only 37 
percent  of States  have  developed  criteria  to make  that  determination,  29 percent  did 
not  define  substantial  numbers,  and  34 percent  report  they  do not  know.  The  SUAS 
without  criteria,  report  that  they  needed  guidance  from  AoA  in order  to make  an 
assessment  of substantial  numbers  of older  individuals.  The  SUAS with  criteria 
defined  substantial  as more  than  50, more  than  100, 5 percent  of the  population,  any, 
and  a greater  percent  in the  county  than  in the  State. 
7  We further  determined  that  only 54 percent  of States  actually  identified  AAAs  with 
substantial  numbers  of older  persons  with  limited  English  speaking  ability. 
Interestingly,  half  of these  States  had  no definition  or did not  know if they  had  a 
definition  for substantial.  Forty-eight  AAAs  among  the  sample  States  were  identified 
as having  substantial  numbers  of target  individuals  with limited  English-speaking 
ability.  For  these  AAAs,  42 have  bilingual  outreach  workers,  but  only 22 have  a full-
time  worker  or access  to a person  to counsel  and  assist such individuals. 
WHILE  STATES  UNDERTAKE  TARGETING  INlTIATJS7ES, THEY  REPORT 
BARRIERS  TO IMPLEMENTATION 
States  report  that  the  most  common  barrier  to effective  targeting  is a lack  of funds. 
More  specifically,  63 percent  of States  report  funding  as a major  obstacle  to their 
targeting  efforts  and  47 percent  of States  say funding  is the  most  common  deficiency 
of AAA  targeting  efforts.  They  report  that  Federal  funding  has  not  increased  during 
this period  of increased  attention  to targeting.  The  funds  are  needed  to pay for the 
increase  in participation,  to open  new sites,  and  to contract  with minority  providers. 
They  also note  that  one  of the  target  groups,  the  frail  elderly,  is more  expensive  to 
serve.  Yet  States  are  realists.  Only 30 percent  expect  AoA  to make  additional  funds 
available  for  targeting  efforts. 
There  are  other  obstacles.  States  report  that  they  still must  address  attitudes  toward 
targeting  (47 percent),  staff turnover  (30 percent),  and  the  need  for training  and 
guidance  on effective  targeting  (14 percent).  Other  less frequently  noted  deficiencies 
of AAA  targeting  efforts  are  a lack  of minority  and  bilingual  staff,  a low priority  of 
management,  and  a lack  of transportation  for the  frail  elderly. 
In a separate  question,  60 percent  of States  report  they  have  difficulty  in obtaining 
data  on low-income  minorities,  and  53 percent  report  their  AAAs  have  the  same 
problem.  Most  cite inadequate  census  data  as the  cause.  They  note  that  the  inability 
to identify  these  individuals  is a barrier  to successful  targeting. 
States  also identified  a number  of barriers  confronting  AAAs  or their  providers  in 
meeting  the  specific  service  needs  of low-income  minorities.  These  barriers  include 
funding  limitations  (40 percent),  cultural  barriers  (31 percent),  lack of transportation 
(29 percent),  lack  of minority  service  providers  (23 percent),  and  problems  in 
identi~ng  and  locating  target  populations  (13 percent). 
SUAS ARE  PROVIDING  AAAs  WIITITECHNICAL  ASSISTANCE  AND 
SEEKING  IT FROM  AoA 
Three-quarters  of States  report  providing  training  and  technical  assistance  (T/A)  to the 
AAAs  to address  identified  targeting  deficiencies.  Most  frequently  these  efforts  take 
the  form  of conferences  and  written  material. 
8  States  are  seeking  targeting  guidance  from  AoA.  Sixty-two percent of States  want 
technical  assistance  and  training,  with  a major  emphasis  on effective  and  practical 
targeting  techniques  for  addressing  specific  targeted  populations.  One  State 
recommended  that  AoA  develop  a targeting  technical  assistance  manual  that  would 
delineate  AoAs  expectations  and  policies,  and  highlight  effective  strategies. 
A third  of the  States  request  policy and  programmatic  guidance  and  direction  on 
AoAs expectations  of the  network  in targeting.  For  example: 
What  is effective  targeting? 
What  does  AoA  mean  by preference  to low-income  minorities, 
substantial  numbers  of, and  frail? 
What  are  the  most  effective  strategies  that  States  and  AAAs should 
undertake  that  would  best  address  the  service  needs  of targeted  groups? 
How  should  the  network  address  their  mission  of serving  all 60+  and 
target  efforts  to those  of greatest  need  in a time  of limited  funds? 
Another  third  of the  States  reported  a need  for AoAs  assistancein obtaining  timely 
data  (e.g., number  of low-income  and  low-income  minorities)  from  the  Bureau  of 
Census  or other  sources. 
9  APPENDIX  A 
Review  Instrument  For  Targeting 
  TARGETING  COMPLIANCE  REVIEW 
Department  of Health  and Human  Services 
Administration  on Aging 
State  Date 
Primary  Respondent  Telephone 
Review  Team  Leader  Telephone 
---------------------------- -,.----------,------------ --
1.  In our earlier  interview  on stewardship,  we discussed  how your assessment  instrument 
addresses  targeting.  What  other procedures  do you use to review and evaluate  each Area 
Agency  on Agings (AAAs) performance  in targeting?  (eg.  on-site/desk  review)? 
a. 
b.  if applicable) 
2.  Did the State Agency  undertake  specific  in  targeting  during  the last two 
Federal  fiscal years? 
a.  Yes (If  Yes,  go  to  question  3) 
b.  No  (If No,  go  to  question  4) 
c.  Dont Know  (If Don t Kkow,  to  question 
A-1  3.  Describe  and give examples  of the following  activities  undertaken  by the State Agency  in 
SUppOrtof targeting  during  the last two fiscal years.  (Read  list and  check  those  with 
affinn~-ve  responses.  For  each  affirrn~ve  response,  identi~  2 examples  of th~  activity, 
where  applicable.  NOTE  tha  for  each  activi~  checked,  there  is a question in the  example 
box  to ascertmn how  the  activities  improved/suppotied  targeting.  Get  documenttiion  of 
the  effect  (e.g.,  the  increase  j%om  10?io to 25%  minority  popultion).) 
~CTIVITY  EXMIPLES OF ~CTIVITY 
a.  Altered  funding  formula  Not ~pplicable 
b.  Monitored/assessed  AAAs  (1) 
(4 
(3)  How  did  these  activities 
improve/support  targeting? 
c.  Conducted  training  conferences.  meetings,  (I) 
workshops 
(2) 
(3)  How  did these  activities 
improve/support  targeting?  ACTIVITY  EX~,WPLESOF ~CTIVITY 
d.  Disseminatedtechnicalassistance/information  (1) 
(2) 
(3)  Howdid th~seactivities 
improvelsupporttar~etin:? 
e.  Conducteddata analysis  Not ~pplieable 
f.  FormedState-leveltask forceor advisory  (1)
committee 
(2) 
(3)  How  did  these  activities 
improvw  support  targeting? 
~  Implemented  specific  objectives  in the State  (1) 
Plan 
(2) 
(3)  How  did  these  activities 
improve/support  targeting? 
A-3  ~CTIVITY  EXXVIPLESOF ~CTIVITY 
h.  Issuedpolicyguidanceto AAAs  (1) 
(2) 
(3)  Howdid  these  activities 
improve/support  targeting? 
i.  Developed  and implemented  a State-wide  (1) 
tqetin:  initiative 
(~) 
(3)  How  did  these  activities 
improve/support  targeting? 
j.  Coordinated  activities  with  national,  state.  and  (1) 
local  minority  organizations 
(2) 
(3)  How  did  these  activities 
improve/support  targeting? 
A--i  ~CTIVITY  EX~NiPLESOF ACTIVITY 
k.  Coordinatedactivitieswith national,state,and  (1) 
localrural organizations 
(2) 
(3)  Howdid thes~activiti~s 
improv~/supporttar~~tin~? 
1.  Coordinatedactivitieswith national,state,and  (1) 
localdisabilityorganizations 
(~) 
(3)  How  did  these  activities 
improve/support  targeting? 
m.  Staffing  (1) 
(2J 
(3)  How  did  these  activities 
improve/support  targeting? 
A-5  ACTIVITY  EX~l~PLES OF ~CTIVITY 
n.  Establishedparticipationtargets  (1) 
(~) 
(3)  Howdid theseactivities 
improve/supporttar~etin~? 
o.  Other, (ldetlti!J:  nl(l) 
nl. 
nI(2) 
n~. 
n2( 1) 
n2( 2) 
(3)  How  did  these  activities 
improve/support  targeting? 
A-6  4.  Describe  and give  examples  of activities  implemented  by  increase  the participation 
AAAs  tc) 
of targeted  populations.  (Probe for  informmon on: outreach,  speciali~on  of  services 
designed  for  specific  target  groups,  staffing,  provider  and  site  selection).  NOTE  thti  for 
each  activity  checked,  there  is a queshon in the  example  box  to ascertain  how  the 
activities  increased  pa~cipaton  of targeted  populations.) 
T~RG~T ACTIVITnZS  EX~31PLESOF TARGET ACTIVITIES 
a.  Outreach  (1) 
(~) 
(3)  Howdid theseactivitiesincreaseparticipationof 
targetedpopulations? 
b.  Specializationof ServicesDesignedfor  (1)
SpecificT~rqetGroup 
(~) 
(3)  Howdid theseactivitiesincreaseparticipationof 
targetedpopulations? 
c.  Staffing  (1) 
(3 
(3)  Howdid theseactivitks increaseparticipationof 
targetedpopulations? 
A-7  TARGET .4CTIV1TIES  EXX~PLES OF TARGET ~CTIVITIES 
d.  ProviderS~Iectjon  (1) 
(3)  How  did  these  activities  increase  participation  of 
targeted  populations? 
e.  Site  Selection  (1) 
p) 
(3)  How  did  these  activities  increase  participation  of 
~rgeted  populations? 
f.  fl(l) 
fl . 
fl(2) 
f2. 
f2(l) 
fn(q) 
(3)  How  did  these  activities  increase  participation  of 
targeted  populations? 
A-8  5.  Of those targeting  activities  used by the  which were found to be the most successful 
AAAs, 
in increasing  the participation  of targeted  populations? 
a. 
b. 
c. 
d.  Dont Know  (Checki~applictile) 
6.  Prior  to this visit,  we sent you a table entitled  Target  Population  Participation.  The data 
come  from  your State Progmrn  Reports  for the last three  years.  What  factors  affect  your 
trends? 
d. 
b. 
c. 
d. 
7.  The next few questions  focus on the service  needs of low-income-minoritim.  Does the 
State Agency  have difficulty  in obtaining  the required  low-income-minority  data? 
a.  Yes, Please  explain  the difficulties  being encountered  by the State Agency: 
b.  No 
c.  Dont Know  (Check  i applicable) 
8.  Do the AAAs have difficulty  in obtaining  the required  low income-minority  data? 
a.  Yes,  Please explain: 
b.  No 
c.  Dont Know (Check  if applicable)  9.  What are examples  of the  successful  methods  used  by  service  providers  to  satisfy the 
service  needs of low-income  minority  individuals  @  contained  in the  service  plan  of 
providem  complying  with  OAA  Sec.  306(a) (5)(A)(ii)  and  l?egulhtion  1321. 65(b))? 
:: 
;:  Dont Know  (If Don t Khow  is checked,  skzp to  question  11) 
10.	 How did you determine  the success of these methods?  (Probe for  analyses,  trend  studies, 
etc.) 
11.	 Has the State Agency  identified  barriers  confronting  AAAs or their providers  in meeting  the 
service  needs of low-income  minorities? 
a.  yes  (If  Yes)  What are the main barriers  which have been identified? 
:: 
:: 
e.  Dont Know  (Check  Z~  applicable)
b.  No 
c.  Dont Know  (Check  if applicable) 
12.  How does the State Agency  define  
...substantial  number  of older  individuals ...who are of 
limited  English-speting  ability? 
a. 
b.  Dont Know  (Check  1~applicable) 
A-10  13.	 HOW  many AAAs  (if any) have been determined  by the State Agency to have a substantial 
number  of older  limited  English-speting  individuals  residing  in the planning  and service 
area?  [Sec. 307(a)(20)] 
a.  (Indic&e  number) 
(1)	 Of these,  how  many  of them  use  the  sewice  of workers  fluent  in the 
language  spoken in the delivery  of outreach  services? 
(a)

@)  Dont Know  (Check  if applicable)

(2)	 Of these  which  have  designated  an  individual  empIoyed  by  or available  to 
the ~  on  a full-time  basis  to counsel  and  assist  older  individuals  of 
limited  English-speting 
ability  and  to provide  guidance  to  service 
providers  with  regard  to  linguistic  and  cultural  sensitivities?  [Sec. 
307(a) (20)(A) & (91 
(a) 
(b)  Dont  Know  (Check  if applicable) 
b.  Dont  Know  (Check  if applicable) 
14.	 What  are  some  examples  of  successful  outreach  techniques  used  by AAAs  in reaching 
targeted  populations? 
d.  Dont Know  (If Don t how  is checked,  skip  to question  16) 
15.	 HOW do you determine  the  success  of these  techniques?  (Probe for  anaZyses,  trend  studies, 
etc.) 
A-11  . 
16.  If identified,  how  does  the  State  Agency  of the  AAAs? 
a. 
b.  Dont Know  (Check  if amlica.ble)
,  .# 
xx  , 
17.  Did  the  State  Agency  conduct  an  annual  evaluation  last  year  of  its effectiveness  in outreach 
to targeted  populations,  as  stipulated  in Section  307(a)(8)? 
a.  Yes (If  Yes)  What  outreach  activities  were  found  to be most  effective? 
(1) 
\/ 
(2)  Dont Know  (Check  if applicable) 
b.  No 
c.  Dont Know  (Check  if applicable) 
18.  What  are  the  most  common  deficiencies  of  your  AAAs  targeting  efforts? 
a. 
b. 
c. 
d. 
e. 
f.  Dont Know  (Check  if applicable) 
A-12  19.  What  formal  technical  assistance  and training  has the Stite  Agency provided  to AAAs in 
order  to address  these deficiencies? 
a. 
b.  Dont  Know  (Check  if applicable) 
20.  What  kind  of technical  assistance  and  training  on targeting  isneeciedby the  State  Agency? 
a. 
b.  Dont  Know  (Check  if applicable) 
21.  What  do  you see as the major success of the  State  Agencys  targeting  effort? 
a. 
b.  Dont Know  @ieck  if applicable) 
A-13  22.  What  are  the  major  obstacles  to effective  targeting  that  still  must  be addressed  (at  the 
State  or A&4  level)? 
a. 
b. 
c. 
d. 
e. 
f.  Dont  Know  (Check  if appkdde) 
23.  What  specific  should  AoA  undertake  to assist State Agencies  and  AAAs  targeting 
efforts? 
a. 
b. 
c. 
d. 
e. 
f.  Dont  Know  (Check  Zf  applicable) 
24.  Are  there  any  other  issues  or  regarding  targeting  you  would  like  to  share  with  us? 
~NTERVIEW  COMPLETED] 
A-14  ATTACHMENT  A 
STATE  TARGET  POPULATION 
(This  attachment  was provided  as  an  enclosure  to a letter  sent  to the  State  Agency  prior  to the 
on-site  visit.  Pick  it up  at the  time  of  the  on-site  visit.) 
1.  Please  provide  the  most  current  information  that  the  State  Agency  has  availab[e  on  targeted 
populations.  Enter  the  applicable  data  below: 
a.  Total  60+  population: 
TARGETEDPOPULilTIONS  TOTAL  PERCENTOF 
NUMBER  60+ 
POPUL~TION 
b.  Minorities 
(1)  American  Indian/Alaskan  Native 
(2)  Asian/Pacific  Islander 
(3)  African  American,  not  Hispanic  in origin 
(4)  Hispanic 
c.  Frail/Disabled 
d.  Residents  of Rural  Areas 
e.  Low-income  Non-iMinority 
f.  Low-Income  Minority 
~  Other,  Specify: 
(1) 
(2) 
(3) 
2.  For populations  listed under  other  (1g.),  provide  an explanation  for the designation  of 
the  specified  population  as a target  population  in your  State. 
a. 
A-15  b. 
c. 
3.  Foreach  targeted  population,  identify  the  source  of thedata  and  the  year  that  the  data  was 
available.  (For  example,  a source  could  be identified  as  the  Bureau  of  Census,  1990). 
TARGETED  POPULATIONS  DATA  SOURCE  DATA  AVAKLABLE 
a.  60+  population 
b.  Minority  population 
c.  Frail/Disabled 
d.  Rural 
e.  Low-income  non-minority 
f.  Low-income  minority 
i?  Other.  Spectfi: 
(1) 
(2) 
(3)  ATTACHMENT  B 
TARGET  POPULATION  PARTICIPATION 
(l_his ~achment  is to be  completed  by AoA  during  the  in-house  review  process.  The  data  will 
be discussed  with  the  State  Agency  ti  the  time  of the  on-site  visit.) 
1989  1990  1991 
A.  Total  60+  Population  (#) 
B.  Total  Participants  (#) 
C.  Participant  Percent  of Population(B/A)  %  %  % 
D.  Total  Participants  by Program  Title: 
1.  Title B 
2.  Title  C I 
3.  Title  C II 
4.  Title  D 
5.  Title  G  NA  NA 
POPULATION  Title  B  Title  C 1  Title  C2  Title  D  Title  G 
E.  American  Indian  89  NA 
Alaskan  Native  90  NA
91 
F.  Asian/Pacific  89  NA 
90  NA
91 
G.  African  American  89  NA 
90  NA 
91 
H.  Hispanic  89  NA 
90  NA 
91 
A-17  I.  Frail/Disabled  89  NA 
90  NA 
91 
J.  Rural  89  NA 
90  NA 
91 
K .  Low-Income  89  NA 
Non-Minority  90  NA 
91 
L.  Low-Income  89  NA 
Minority  90  NA 
91 
A-18