# DEPARTMENTof HEALTHand HUMANSERVICESFiscal Year2024Administration forCommunity Living*Justification ofEstimates forAppropriations Committees*

**

# 

# Letter from the Acting ACL Administrator

I am pleased to present the Administration for Community Living FY 2024 Budget, which includes a discretionary request for $3.0 billion in budget authority. The request reflects ACL’s continued prioritization of direct services for people with disabilities and older adults, as well as the critical need to establish adequate infrastructure for administering ACL’s programs. It also includes programmatic investments to address two urgent priorities: strengthening and supporting the caregiving infrastructure and preventing abuse and neglect. 

The populations served by ACL’s programs are growing rapidly, and the demand for ACL’s programs has grown steadily for many years. COVID-19 accelerated that increasing demand; today, more people need services, and many people need more services, than ever before. In recognition of that new baseline, ACL’s FY 2023 appropriation included increases for several programs that provide direct services. ACL’s FY 2024 request maintains those increases and proposes further investment across several programs to begin to address unmet needs.

For example, increases are requested for ACL’s Protection and Advocacy (P&A) program for people with intellectual and developmental disabilities and the Independent Living programs, which play critical roles in ensuring that people with disabilities have equal access and opportunity to fully participate in their communities. They are also at the forefront of helping disabled people move back to the community from nursing homes and other institutions. Increases also are requested for ACL’s Senior Nutrition and Home and Community-Based Supportive Services, and the corresponding programs that specifically focus on serving tribal elders, all of which similarly provide many of the core services that make it possible for millions of older adults to age in place. 

While increased funding for direct services is necessary, it is not sufficient to meet growing needs. A strong, well-supported caregiving workforce – which includes both families and other informal caregivers and paid professionals – is fundamental to making community living possible. However, both sides of the caregiving workforce are in crisis. Family caregivers do not have adequate support, which puts their own health, quality of life, and financial security in jeopardy. Long-standing shortages of paid caregivers have reached crisis levels during the pandemic; today, more than three-quarters of service providers are not accepting new clients and more than half have cut services – which, in turn, increases the demands on family caregivers.

These crises are converging to threaten the health and independence of older adults and people with disabilities.  When family caregivers become overwhelmed and paid services are not available, people who need assistance often have no options except moving to a nursing home or other institution, people who want to leave these facilities cannot, and the health and safety of those who live in the community is at risk. In addition, the cost of care increases significantly, with most of those costs borne by taxpayers. 

To address these crises, ACL proposes two initiatives to strengthen the caregiving infrastructure. The first will support implementation of the *National Strategy to Support Family Caregivers*, which recommends actions that federal agencies, states, and communities can take to better support families and other informal caregivers. The second supports actions to strengthen and expand the direct care workforce. 

ACL’s request also includes funding to continue programs that address abuse and neglect, which rob people of their fundamental human rights, erode equal opportunity, and harm health and well-being. In addition to the increased funding for the P&A program, ACL’s request includes funding for grants to support state adult protective services programs and increased funding for state long-term care ombudsman programs. 

Finally, the request reflects ACL’s need to establish adequate infrastructure to properly administer programs and meet its advocacy responsibilities. ACL has faced staffing challenges almost from its creation, and its portfolio and scope of responsibilities continues to grow. Addressing staffing gaps and other administrative needs remains critically important. 

Community living is overwhelmingly preferred, leads to better health outcomes, and is more cost-effective than living in institutions. In addition, our communities are stronger when everyone is included. With this budget, ACL will invest in solutions to the most pressing issues facing older adults and disabled people and address the most challenging barriers to equal opportunity and inclusion to make community living possible for all people.

Alison Barkoff

Acting Administrator and Assistant Secretary for Aging

**DEPARTMENT OF HEALTH AND HUMAN SERVICES		Administration for Community Living**

Washington, DC 20201

13

# Table of Contents

Organization Chartiv

Executive Summary5

Introduction and Mission5

Overview of the Budget Request6

Overview of Performance17

All Purpose Table25

Full Time Equivalents by Funding Source28

Mandatory Proposals Summary Table29

Appropriations Language30

Appropriations Language Analysis33

Amounts Available for Obligation37

Summary of Changes38

Budget Authority by Activity40

Authorizing Legislation42

Appropriations History45

Appropriations Not Authorized by Law47

Health and Independence for Older Adults48

Summary of Request48

Home and Community-Based Supportive Services52

Nutrition Services62

Preventive Health Services80

Chronic Disease Self-Management Education87

Falls Prevention90

Native American Nutrition and Supportive Services94

Aging Network Support Activities98

Caregiver and Family Support Services107

Summary of Request107

Family Caregiver Support107

Native American Caregiver Support Services120

Alzheimer’s Disease Program123

Lifespan Respite Care127

Protection of Vulnerable Adults131

Summary of Request131

Long-Term Care Ombudsman Program134

Prevention of Elder Abuse and Neglect142

Health Care Fraud and Abuse Control/Senior Medicare Patrol Program149

Elder Rights Support Activities154

Elder Justice/Adult Protective Services160

Disability Programs, Research, and Services171

Summary of Request171

State Councils on Developmental Disabilities173

Developmental Disabilities – Protection and Advocacy180

University Centers for Excellence in Developmental Disabilities190

Developmental Disabilities – Projects of National Significance196

Independent Living202

Limb Loss Resource Center215

Paralysis Resource Center218

Traumatic Brain Injury222

National Institute on Disability, Independent Living, and Rehabilitation Research229

Consumer Information, Access, and Outreach239

Summary of Request239

Aging and Disability Resource Centers241

State Health Insurance Assistance Programs245

Voting Access for Individuals with Disabilities252

Assistive Technology Programs259

National Technical Assistance Center on Kinship and Grandfamilies274

Medicare Improvements for Patients and Providers Act Programs (MIPPA)278

Program Administration291

Nonrecurring Expenses Fund297

Supplementary Tables299

Object Classification Table - Direct300

Object Classification Table - Reimbursable301

Salaries and Expenses – Direct302

Detail of Full Time Equivalents (FTE)303

Detail of Positions305

FTEs Funded by the Affordable Care Act306

Resources for Cyber Activities310

No Submission311

Legislative Proposals312

ACL Specific Requirements316

Text Description ACL Organizational Chart318

# Organization Chart

3

# Executive Summary

## Introduction and Mission

The Administration for Community Living (ACL) exists to make it possible for older adults and disabled people to live independently and participate fully in their communities.

To that end, ACL funds services and supports provided primarily by networks of community-based organizations; advocates to ensure the needs of disabled people and older adults are reflected in federal policy and programs; and invests in research, education, and innovation. This is critical given the number of people these programs serve:

· The U.S. population over age 60 is projected to increase by 12 percent between 2021 and 2025, from 77.1 million to 86.3 million 

· According to the U.S. Centers for Disease Control and Prevention, 61 million people in the United States – 26 percent of the population – live with disabilities [footnoteRef:2] [2:   CDC, “Disability Impacts us All.” Accessed 22 February 2023. ] 

· There are an estimated 3.9 to 5.4 million individuals with developmental disabilities [footnoteRef:3] [3:  Extrapolated from Developmental Disabilities Assistance and Bill of Rights Act of 2000, Section 101(a)(1) and U.S. Census Bureau, Annual Estimates of the Resident Population for Selected Age Groups by Sex for the United States, States, Counties, and Puerto Rico Commonwealth and Municipios: April 1, 2010 to July 1, 2017. Accessed 7 August 2023. ] 

· The number of people 65 and older with severe disabilities – who are at the greatest risk of nursing home admission – is projected to be 4.7 million by the year 2025 [footnoteRef:4] [4:  US Census Bureau Projections. (2017). Accessed 24 February 2023.  ] 

“Community living” means that older adults and disabled people live alongside people of all ages, with and without disabilities, and have the same opportunities as everyone else to participate in community life, earn a living, and make decisions about their lives. Community living is an exceptional value – people overwhelmingly prefer it to living in institutions, it is usually less expensive than institutional care, and it results in better health.  As the health care system shifts to one that pays for outcomes and prioritizes cost-effective care, community living – and the services and supports funded by ACL to make community living possible – will play an increasingly important role in the Department’s efforts to deliver more effective services at lower costs.

## Overview of the Budget Request

To make community living possible for millions of people with disabilities and older adults, ACL funds direct services and supports provided primarily through networks of community-based organizations; invests in training, education, research, and innovation; and advocates to ensure federal policy and programs consider the needs of both populations. ACL’s programs work together to encourage and support health, independence, and resilience throughout the lifespan and play a critical role in reducing costs of health care. ACL works closely with states, tribes, and the aging and disability networks, and – most important – with older adults and people with disabilities, to ensure that ACL’s programs are tailored to the unique needs of the people they serve. 

ACL’s FY 2024 budget request continues to prioritize programs that provide direct services for the rapidly growing populations ACL serves; initiatives that address the needs of both older adults and disabled people and which bring to bear the combined resources of the aging and disability networks; and the President’s priorities for expanding home and community-based services, supporting caregivers, and advancing equity. The request also reflects a continued focus on bolstering the organizational infrastructure that supports program administration and oversight, as well as ACL’s responsibilities as an advocate for older adults and people with disabilities. 

The FY 2024 discretionary request for ACL is $3,027,622,000 a net increase of $489,835,000 above the FY 2023 enacted level of $2,537,787,000. In addition to its request for budget authority, ACL is requesting $50,000,000 in funding for the Medicare Improvements for Patients and Providers Act funding. This is an increase of $2,850,000 over the sequestration level in FY 2023.

**Expanding Access to Direct Services**

**(+$386,135,000)**

The demand for the services provided through ACL’s programs has risen sharply in recent years and continues to grow. The rapidly aging population and an increasing number of people with disabilities had fueled many years of steadily increasing needs. The pandemic caused a spike in demand, particularly early in the pandemic, when many people with disabilities and older adults were cut off from the assistance provided by families and other informal supports. Needs have decreased from the peak, but they have stabilized at a much higher level than before the pandemic, as effects of prolonged isolation have left many people more dependent on services than they had been before. Because of the risks of COVID-19 in congregate settings, more people than ever are preferring to receive services in their own homes instead of in nursing homes, which also is increasing demand. In addition, fewer volunteers are available, which has increased the cost to operate many programs. 

Many of the innovations and adaptations developed to continue service delivery during the pandemic are continuing, which is expected to increase capacity and efficiency during normal operations. In addition, in FY 2023, Congress provided increased funding to further expand capacity of several programs, which has allowed them to begin to meet increased needs. However, additional investment is needed to further bolster capacity and maintain service levels. Specifically, ACL is requesting:

**Increasing Access to Direct Services for People with all Types of Disabilities (+40.079 million)**

Additional funding is requested for programs that provide direct services for people with disabilities, as follows:

· Independent Living programs (+$32.0 million) to both increase capacity of current service programs and to develop and test new approaches to service delivery. Independent Living programs provide a comprehensive range of services that support people with disabilities to live and fully participate in the community, such as: training and peer support for developing independent living skills; assistance with accessing transportation, personal care assistants and other community living services; help connecting to assistive technology; assistance with navigating state systems of services and supports, including determining eligibility and applying for programs; and support with moving from nursing homes and other long-term care facilities to homes in the community. To meet the increased and growing need for these services, requests: 

· Centers for Independent Living (+$29.7 million)

· Independent Living Services State Grants (+$2.4 million)

In addition, ACL proposes to establish a new program, Independent Living Projects of National Significance, to develop and test new interventions and program innovations, following the model that has been successfully used within ACL’s programs for older adults and people with developmental disabilities. This new program also will provide a mechanism to fund cross-program and cross-network demonstrations to address issues and needs that are common to both older people and disabled people of all ages. In FY 2024, ACL proposes to fund three such initiatives, which are described in subsequent sections. The funding increases for the initiatives also are included in those sections.  

· Assistive Technology (AT) programs (+$4.0 million) to meet increased demand across ACL’s portfolio of programs that work together to increase access to assistive technology (AT) for people with disabilities and their families. ACL’s request includes a combined increase of $6 million across three programs: the State AT Grants program, the AT Protection and Advocacy program, and AT National Activities.  It also eliminates the $2 million Alternative Financing Program (which duplicates resources available through the other programs).  

· Supporting People with Intellectual and Developmental Disabilities (+$4.0 million) to expand capacity and offset increased costs of service delivery. People with intellectual and developmental disabilities (I/DD) often experience increased barriers to community living. Upholding their right to fully participate in the community requires each state to develop and maintain a comprehensive and coordinated system that includes services and supports to meet specific needs; training, education, and resources to help people with I/DD advocate for themselves and to help families provide support across the lifespan; training, education, and advocacy to ensure accessibility of health care, education, transportation, recreation and other infrastructure systems; innovation to improve effectiveness and sustainability of programs and services; research to improve knowledge about and diagnosis of I/DD and to expand and improve interventions and support; and sharing of information across programs, networks, and states to advance best practices across the country. Specifically, ACL requests:

· University Centers for Excellence In Developmental Disabilities (UCEDDs) (+$3.0 million) to meet increased demands for training, technical assistance, research, and information sharing across states and to fund a round of competitive grants focused on improving diversity and advancing intersectional equity through partnerships between the UCEDDs and minority- and tribal-serving institutions 

· State Councils on Developmental Disabilities (+$1 million) to expand efforts to reduce fragmentation of state systems and increase community living opportunities

**Connecting People to Services (+$2.92 million)**

Even when services and resources are available to help people live in the community, it can be very challenging for people to access them. People often have questions about which programs are available in their states or communities, which will best meet their needs, whether they or their loved one are eligible, how to enroll in programs, and how to coordinate services. Without assistance to navigate these systems, people often do not receive help they need to live independently. ACL is proposing modest increases to several programs that work together to help people connect to services. Specifically:

· Developmental Disabilities Projects of National Significance (+$750,000)/Independent Living Projects of National Significance (+$250,000) to maintain the Disability Information and Assistance Line (DIAL). Launched in 2021 to help disabled people access COVID-19 vaccinations, DIAL also provides information about and connects people to essential services such as transportation, housing support, community services, legal assistance, and more. Established with supplemental funding from the U.S. Centers for Disease Control and Prevention, DIAL must be funded through ACL’s budget to maintain operation. 

· Aging Network Support Activities (+$1.5 million) to provide an additional $1 million to support the Eldercare Locator, which connects older adults and their families and caregivers to local resources to support aging in place. The request also provides an additional $539,000 to offset increased costs of operation for programs focused on innovation and sustainability within the aging network. 

· Aging and Disability Resource Centers (+$381,000) to increase capacity of services to provide objective information, advice, counseling, and assistance to help people make informed decisions about long-term services and supports and assist them with accessing both public and private programs

**Promoting Healthy Aging (+$2.6 million)**

Additional funding is requested to offset cost increases and maintain service levels for evidence-based programs that support healthy lifestyles and promote healthy behaviors to prevent chronic disease and reduce the need for most costly medical interventions, and to expand programs that that have been proven to reduce falls, fear of falling (which leads to inactivity and isolation), and fall-related injuries in older adults. Specifically, ACL requests:

· Preventive Health Services (+$60,000)

· Falls Prevention (+$2.5 million)

**Nutrition and Home and Community Based Supportive Services (+$339.576 million)**

The aging services network provides crucial supportive services that allow millions of older adults to age in place. The programs have always prioritized those in greatest need, including those who are most frail – which now includes a larger proportion of the older adult population as a result of prolonged isolation and corresponding reduced access to routine health and wellness services caused by the COVID-19 pandemic. To meet this sustained increase in demand, ACL proposes to increase funding as follows: 

· Nutrition Services (+$217.6 million) includes +$221.7 million for Congregate Nutrition Services and +$44 million for Home Delivered Nutrition Services to offset increased costs of service delivery and modestly expand services. The request also includes a decrease of $48.1 million for the Nutrition Services Innovation Program, which ACL believes will be offset by state and private funding as well as the requested increases in the two primary nutrition programs.   

· Native American Nutrition and Supportive Services (+$31.9 million) to begin to address unmet needs for services in tribal communities. The request reflects the higher levels of need faced by tribes due to the factors common to all of ACL’s programs for older adults, including higher numbers of elders who are now dependent on services and overall population growth, as well as the need for specific investment in programs that advance health equity for underserved populations. 

· Home and Community-Based Supportive Services (+$90 million) to increase capacity of an array of services that support community living for older adults, including in-home services, such as personal care and homemaker assistance, legal and mental health services, multi-purpose senior centers, and more.

**Strengthening and Supporting the Caregiving Infrastructure**

**(+$65.962 million)**

There are an estimated 81 million people who are 60 or older and at least 61 million people with disabilities living in the U.S., and both populations are growing.  A significant number of both will need assistance with things like transportation, personal care, and managing finances – more than two-thirds of Americans will need such assistance as they age. A strong, well-supported caregiving workforce – which includes both families and other informal caregivers and paid professionals – is absolutely crucial to making it possible for disabled people and older adults to live in the community. The Administration and HHS Secretary have made strengthening the caregiving infrastructure a priority, with funding requested as follows:

**Implementing the *National Strategy to Support Family Caregivers* (+$54.462 million)**

Family caregivers – who provide the overwhelming majority of long-term care in the U.S. – currently lack resources to maintain their health, well-being, and financial security while providing crucial support for others. Each year, around 53 million people provide a broad range of assistance to support the health, quality of life, and independence of a person close to them who needs assistance as they age or due to a disability or chronic health condition. Another 2.7 million grandparent caregivers – and an unknown number of other relative caregivers – open their arms and homes each year to millions of children who cannot remain with their parents. Millions of older adults and people with disabilities would not be able to live in their communities without this essential support – and replacing it with paid services would cost an estimated $470 billion each year. 

While family caregiving is rewarding, it can be challenging, and when family caregivers do not have the support they need, their health, wellbeing, and quality of life often suffer. Their financial future also can be put at risk; lost income due to family caregiving is estimated at $522 billion each year. When the challenges become overwhelming and family caregivers no longer can provide support, the people they care for often are left with no choice except moving to nursing homes and other institutions or to foster care against their desires and at a significant cost to taxpayers.

In September 2022, HHS delivered to Congress the *National Strategy to Support Family Caregivers*, which was developed jointly by the advisory councils established by the Recognize, Assist, Include, Support, and Engage Family Caregivers Act and the Supporting Grandparents Raising Grandchildren Act, with extensive input from family caregivers, the people they support, and other stakeholders. The strategy includes nearly 350 commitments from more than 15 federal agencies for actions to support family caregivers and more than 150 recommended actions that can be adopted at other levels of government and across the private sector to begin to build a system that ensures family caregivers have the resources they need to maintain their own health, well-being, and financial security while providing crucial support for others. With increased funding received in FY 2023, ACL will launch an initiative this fall to accelerate implementation of the strategy. 

ACL is requesting a total of just over $54 million to support states and tribes, public agencies, and other organizations to support implementation of the strategy, including expanding direct services to support caregivers today and building capacity to better support them in the future. 

Specifically, ACL requests: 

· Family Caregiver Support Services (+44.9 million) to expand the availability of a range of services to support family caregivers by increasing existing formula grants to states (+26.4 million) and to fund demonstration grants to develop, test, and scale models for implementing recommendations from the national strategy to expand and improve systems of support for family caregivers (+18.5 million)

· Native American Caregiver Support Services (+$3.8 million) to increase existing formula grants that fund a range of services to support family caregivers in tribal communities 

· Lifespan Respite Care (+$4.2 million)****to increase services that provide caregivers with a short break from caregiving responsibilities. Respite care is one of the services most often sought by caregivers, but lack of capacity and high costs make it unavailable to many. 

· Independent Living – Projects of National Significance (+$500,000)/Aging Disability Resource Centers (+$1 million) to ensure that protecting the rights and self-determination of the person receiving support from family caregivers is centered throughout the implementation of the caregiver strategy and to extend caregiver support services to family caregivers who do not meet the statutory criteria to participate in the Family Caregiver Supportive Services program authorized by the Older Americans Act.

**Expanding and Stabilizing the Direct Care Workforce (+$11.5 million)**

The paid professionals who form the direct care workforce provide vital services that make it possible for people with disabilities and older adults to live in their own homes and communities. Long-standing workforce shortages have reached crisis levels during the COVID-19 pandemic; today, more than three-quarters of service providers are not accepting new clients and more than half have cut services as a result of the direct care workforce shortage. High turnover – averaging nearly 44 percent across states – also means that people who are able to get services often experience service disruptions and receive inconsistent care. As a result, increasing numbers of people are left with no option but to move to nursing homes and other institutions, people who want to leave these facilities cannot, and the health and safety of those who live in the community is at risk. In addition to undermining people’s civil right to community living, this leads to poorer health outcomes and higher costs of care, which most often are borne by taxpayers.

In September 2022, ACL established a national technical assistance center to help strengthen the direct care workforce. With FY 2023 funding, ACL is beginning to build a hub through which state, private, and federal entities involved in the recruitment, training and retention of direct care workers can access model policies, best practices, training materials, technical assistance, and learning collaboratives. In FY 2024, ACL requests $11.5 million to fully fund operation of the resource hub and to support development of new approaches, as follows:

· Aging Network Support Activities – Direct Care Workforce (+$8 million) to fully fund hub operations and establish demonstration grants to test recruiting, retention, and training approaches that can be replicated and scaled across states

· Developmental Disabilities Projects of National Significance (+$3 million)/Independent Living Projects of National Significance (+$500,000) to extend the scope of the above described initiatives to the direct care workforce that supports people with disabilities who are not covered by the statutory authority of Older Americans Act

**Strengthening and Maintaining Adequate Infrastructure**

**(+$16.796 million)**

Ensuring the adequacy of the infrastructure that makes it possible for ACL and its networks to carry out program responsibilities – including during crisis response – remains a top priority for ACL. The significant increases in responsibilities that ACL has seen in recent years, combined with the increasing complexity and criticality of IT security requirements and increasing focus on ensuring information is accessible to diverse populations, have created needs that exceed staff capacity and current resources. 

The FY 2023 Omnibus Appropriations Act included an increase to fund FTE and increased investments in IT, accessibility, and stakeholder outreach, which will allow ACL to begin to mitigate its greatest operational risks. In FY 2024, ACL is requesting an increase of $16.8 million for Program Administration to sustain those investments and continue to address long-standing gaps in infrastructure. 

Specifically, ACL is requesting an additional $9.6 million to support additional staffing. In addition, ACL requests $3.9 million to offset mandatory built-in cost increases, which otherwise will require reductions in FTE to cover. Finally, ACL is requesting modest increases to make necessary investments in stakeholder outreach, accessibility, and technology. Specifically, in FY 2024, ACL is requesting a total of $3.3 million in additional funding for the investments, as follows:

· +$750,000 for an initiative to improve access to information and resources created by ACL, as well as by ACL’s grantee networks, for people with limited English proficiency and people who have disabilities with language access needs

· +$1.5 million for information technology to continue and sustain work in FY 2024 for the Security Mitigation and Enhancement Project that was begun with NEF funding

· +$250,000 to improve and increase stakeholder outreach, meet ACL’s communication responsibilities in interagency initiatives to increase awareness of federal programs and policies on key issues affecting older adults and people with disabilities, and build capacity to support cross-HHS initiatives

· +$800,000 for a workforce and organizational assessment. As described above, ACL has been significantly understaffed almost from its creation. With the funding received in FY 2023 and the increase requested in FY 2024, ACL will be able to address its most crucial staffing gaps. A comprehensive assessment of the agency’s structure and staff requirements is needed to determine appropriate FTE levels to enable ACL to operate effectively and efficiently going forward. The FY 2024 request includes funding for a contract to conduct this assessment.

**Protecting Rights and Preventing Abuse**

**(+$63.586 million)**

Abuse and neglect rob people of their fundamental human rights and erode their opportunity to participate as members of the community; equity and inclusion cannot be achieved in the face of abuse. ACL’s request includes additional funding for several programs that prevent and address abuse and neglect of disabled people and older adults, support recovery by those who experience either, and assist people with disabilities and older adults in exercising their right to participate fully in the community. Specifically, ACL is requesting:

· Elder Justice/Adult Protective Services (APS) Formula Grants (+$43.0 million) to continue to operate the state APS formula grants program at a very basic level.  The American Rescue Plan Act provided two years of start-up funding ($188 million in each year) to fund for the first time the nationwide APS formula grant program authorized by the Elder Justice Act in 2012.  That funding was used by states to expand or develop a variety of capabilities that were necessary to meet increased needs due to the pandemic, but which, if maintained, will significantly improve the reach and effectiveness of APS systems beyond the pandemic. The FY 2023 Omnibus Appropriations Bill provided, for the first time, $15 million in discretionary funding to prevent program termination as American Rescue Plan funds are exhausted. The FY 2024 requests additional funding to allow states to maintain service levels and avoid the loss of progress made during the programs’ start-up phase.

· Developmental Disabilities Protection and Advocacy (+$14.7 million) to begin to address increasing needs for services, such as monitoring for health and safety and investigating and addressing abuse and neglect; legal assistance to address a range of issues, such as equal access to employment, education and health care; ensuring accessibility of public places and programs; helping people avoid – or leave – institutions to live in the community; information and referral assistance to connect people with disabilities to other services and resources; and individual and systems advocacy. At current resource levels, protection and advocacy systems are able to serve only those in most dire need, and many are being forced to limit their work to crisis issues, such as addressing abuse. Most can provide only very limited assistance with things like ensuring equal access to employment, transportation, and public places. 

· Long-Term Care Ombudsman (+$5.1 million) to prevent loss of services as supplemental funding is exhausted.  Supplemental funding provided during the pandemic allowed for the expansion of ombudsman services to more people of all ages living in a wider variety of long-term care facilities. It also allowed ombudsman programs to play a greater role in helping people move from facilities into community settings if they wished to move. 

· Prevention of Elder Abuse (+$0.3 million)/Elder Rights Support Activities (+$0.5 million) to expand the ability of states and territories to provide legal assistance, train law enforcement officials, develop and distribute educational materials, and operate the National Care Center on Elder Abuse and the National Long-Term Care Ombudsman Resource Center.

### Requested Statutory Changes: 

In addition to the requested funding, ACL includes descriptions of legislative proposals in corresponding narratives. The full proposals can be found in the legislative proposal section.  The eight proposals would:

· Increase the allowance for program evaluation from 0.5 percent to 1 percent of funds appropriated under the Older Americans Act Title III

· Amend the Older Americans Act to allow funds to be used to cover the costs of acquisition, alteration, or renovation of any type of facility used to provide services under the OAA

· Amend the Elder Justice Act to permit all tribes and tribal organizations to be eligible for APS funding authorized under the statute

· Provide states with flexibility to determine how funds are distributed among Part C Centers for Independent Living to enable states to address population shifts or significant changes within their states

· Authorize grants, cooperative agreements, and contracts for Projects of National Significance that advance independent living and promote the philosophy of independent living across disabilities under the Rehabilitation Act of 1973

· Eliminate the requirement that compliance reviews of Centers for Independent Living under the Rehabilitation Act of 1973 occur onsite, allowing for remote approaches that are equally or more effective at a fraction of the cost

· Authorize program evaluation and performance measurement as an allowable activity with funds appropriated for training and technical assistance to Centers for Independent Living and Statewide Independent Living Councils under the Rehabilitation Act of 1973

· Reauthorize the Medicare Improvements for Patients and Providers Act program and direct all MIPPA funding to ACL

## Overview of Performance

The Administration for Community Living (ACL) was created around the fundamental principle that older adults and people with disabilities of all ages should be able to live where they choose, with the people they choose, and with the ability to participate fully in their communities.  By funding services and supports provided primarily by networks of community-based organizations, and with investments in research, education, and innovation, ACL helps make this principle a reality for millions of Americans. To measure the effective provision of high-quality services for older adults and people with disabilities, ACL focuses on two categories of performance measures: 1) supporting people’s ability to remain independent and live in the community, and 2) generating new knowledge about what works for older adults and people with disabilities. These measures support HHS Strategic Goal 3: *Strengthen Social Well-Being, Equity, and Economic Resilience of Americans* across the lifespan, with a particular focus on Strategic Objective 3.3, which is to “expand access to high-quality services and resources for older adults and people with disabilities, and their caregivers to support increased independence and quality of life." Several existing performance measures and newly proposed measures address HHS priority areas of equity. The existing measures (3.3 and 3.6) along with the proposed new measures (3.12, 3.13, and R4) are described below:

· 3.3: The percentage of participants in Older Americans Act (OAA) programs who live in rural areas (number of rural OAA participants/total number of OAA participants) is at least 15 percent greater than the percentage of all older adults in the U.S. who live in rural areas (number of older adults who live in rural areas/total population of older adults living in the U.S.)

· 3.6: The percentage of participants in OAA programs who live in poverty (number of OAA participants who live in poverty/total number of OAA participants) is 150 percent greater than the percentage of all older adults in the U.S. who live below the poverty level (number of U.S. older adults who live below the poverty level/total population of older adults in the U.S.)

· 3.12: The percentage of participants in OAA programs  who identify as members of racial/ethnic minority groups (number of OAA participants who identify as a member of a racial or ethnic minority group/total number of OAA participants) is at least 10 percent greater than the percentage of all  older adults in the U.S. who identify as members of racial/ethnic minority groups (number of U.S. older adults who identify as a member of a racial or ethnic minority group /total population of older adults in the U.S.)

· 3.13: Maintain at least 30 percent, the percent of OAA clients served who are assessed at being at high nutritional risk

· R4: By 2027, generate new research-based policies, practices, services, or interventions to reduce disparities in outcomes experienced by people with disabilities from underserved communities and communities of color 

**Overview of Performance**

ACL’s programs continue to perform despite fluctuations throughout the pandemic, and ACL programs are beginning to create a new baseline for what normal may look like in a post-COVID environment. Programs are finding new and innovative ways to demonstrate their adaptability, and ACL is monitoring these trends through our performance management approach, as well as continually assessing and analyzing our programs to understand the impact of changing norms. Additionally, this year ACL is examining how program performance measures stand up to economic shocks and programmatic changes that resulted from the pandemic.  

Performance results illustrate that ACL’s disability programs, research, and services continue to expand their reach; for example, through an increased percentage of individuals with developmental disabilities served by people who have been trained by University Centers for Excellence in Developmental Disabilities (measure 8D). 

ACL’s research programs consistently meet goals for the generation of new knowledge related to the treatment of opioid use disorders for people with disabilities (outcome R1b); the efficacy of interventions to improve employment outcomes for individuals with serious mental illness (outcome R2); and the joint impact of an Achieving a Better Life Experience account and financial management training on community living and participation of people with intellectual and developmental disabilities (outcome R3). These research measures contain targets through 2023, and ACL is proposing to replace them with measures of the generation of new research-based policies, practices, services, or interventions to reduce disparities in outcomes experienced by people with disabilities from underserved communities and communities of color (R4); new evidence-based practices and interventions to promote improved outcomes for people with spinal cord injury, traumatic brain injury, and burn injury (R5); and new evidence-based practices and interventions for implementation by employers, to promote improved employment outcomes among people with disabilities (R6). 

ACL’s aging programs are demonstrating improvements in several areas, including that service providers throughout the aging network are making a concerted effort to ensure that services target eligible individuals with the greatest economic need (3.6).  Additionally, a new measure reflecting the Administration’s priority on equity is focused on increasing the proportion of clients served who identify as members of racial/ethnic minority groups (3.12). Through technical assistance and ACL support, the aging network has been able to maintain excellent caregiver services. The aging services network is committed to providing high quality, person-centered, and integrated services that seamlessly address the needs of participants while maintaining operational excellence. 

To ensure ACL’s continued success in achieving targets and positive trends in the future, ACL will continue to closely monitor several indicators associated with service quality such as maintaining program participant satisfaction. For example, most caregiver program participants report that the services help them to be a better caregiver; feel less stressed due to the services; and believe that the care recipient benefits from the caregiver services received. This is reflected in a new measure focused on maintaining a higher quality of caregiving services (2.9f).

While many performance targets are being met or exceeded, ACL’s most recent performance results are demonstrating that while the performance measure data are accurate, the methodology to project future outcomes and outputs does not have the ability to account for dramatic changes to ACL’s programs due to the pandemic and unforeseen economic stressors such as temporary program closures, changing state and local contributions, increased fixed costs, and increased food prices.  After reviewing projections from some measures that appeared to be producing outlier data, an analysis of all measures that are sensitive to an expenditure per unit change were analyzed.  Measures that were found to produce unstable estimates of future program behavior were not used to develop targets. The analysis confirmed that ACL’s current methodology does not have the capacity to account for the pandemic disruptions and economic stressors that the U.S. has experienced since 2020. Given the limitations of ACL’s methodology up until now, ACL is providing outputs based on the most recent data available, but will not be providing targets for the following measures that are highly sensitive: 

· Output AB: Health Promotion and Disease Prevention

· Output C: Transportation Services

· Output D: Personal Care, Homemaker and Chore Services Units

· Output H: Number of Congregate Meals Served

· Output I: Caregivers Access Assistance Units 

· Outputs G and H: Total Number of Meals 

· Output L: Title VI Transportation Services

· Output M: Title VI Home Delivered Meals

· Output N: Title VI Congregate Nutrition Meals

· Output O: Title VI Information, Referral, and Outreach

ACL is refining a new methodology to account for outliers, and ACL will assess how to adjust given the changing dynamics of the economy and long-term program adjustments and innovations due to the pandemic. 

**ACL’s Internal Performance Management Process**

ACL’s performance data is reported and tracked for three primary reasons: 1) to monitor the administration’s progress towards achieving departmental and agency strategic goals, objectives, and priorities; 2) to support ACL’s budget justifications; and 3) to monitor program performance and support improvement. ACL employs a performance management strategy with multiple components.  The strategy reflects the continuous effort to build and enhance our repository of data and evidence, including high quality performance data in support of our mission and vision. This includes coordination and collaboration with other agencies and organizations, enhanced partnerships between aging and disability networks, and senior leadership involvement in performance management. The strategy presents a high-level approach to the planning and implementation of performance management and represents ACL’s commitment to providing rigorous, relevant, and transparent performance data. 

The National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) Long-Range Plan is a five-year agenda to support ACL’s research efforts in the areas of applied disability, independent living, and rehabilitation research and will guide the development and refinement of performance measurement for NIDILRR’s programs. The plan emphasizes consumer relevance and scientific rigor, presents a five-year agenda that is scientifically sound and accountable, and will contribute to the refinement of national policy affecting people with disabilities. A new plan will be developed for FY 2024 – FY 2028.

ACL’s senior management directly engages in performance management activities through grants and procurement planning. ACL’s Developmental Disabilities Act programs have implemented a quality review system that uses a three-tiered model to review program compliance, outcomes, and fiscal operations. ACL’s Older Americans Act Title III and VII state formula grant programs continue development of a formula-grant monitoring framework that combines assessments of each grantee’s progress towards program goals and objectives with identification of risk and instances of fraud, waste, and abuse. Older Americans Act programs are assessed by programmatic performance and financial operations. ACL uses the Aging Cluster Audit Compliance Supplement and interactions and engagements between program staff and states to assess fiscal and programmatic operations.  Results of these audits, interactions, and engagements are used to target and coordinate fiscal and programmatic technical assistance.  

In addition to monitoring grants, each program within ACL develops a program funding plan for senior management review and approval. The plans detail proposed grant and procurement activities and justify how the activity supports ACL’s mission and performance goals. ACL is enhancing this process by including formal reviews of notices of funding opportunity to ensure alignment with ACL’s priorities. All funding opportunities will identify measurable performance metrics, including requiring outcomes demonstrating the value of the program in both the grant application and progress reports.

Senior leadership has established processes for use of performance data for management decision-making, including a periodic grants dashboard, monthly reports for the Administrator/Assistant Secretary and Principal Deputy Administrator, quarterly reviews of operating budgets, weekly Leadership meetings and bi-weekly center director meetings. In collaboration with the aging and disability networks, ACL is committed to continuously creating and sustaining a culture of continuous learning, improvement, innovation, and growth through the understanding and use of credible, valid, and reliable high-performance data to accomplish our performance goals. 

**ACL’s Use of Performance Information for Management Purposes**

ACL grant awards are made, in part, based on the clarity and nature of proposed outcomes and whether the proposed project evaluation reflects a thoughtful and well-designed approach that will be able to successfully measure whether the project achieved its proposed outcome. This approach includes the qualitative and/or quantitative methods necessary to measure outcomes and is designed to capture “lessons learned” from the overall effort that might be of use to others, especially those who might be interested in replicating the project. ACL also works through its resource centers to help grantees use evidence to drive improvements in outcomes for older adults and individuals with disabilities. For example, ACL funds: 

· ACL funds 68 University Centers for Excellence in Developmental Disabilities Education, Research, and Service (UCEDDs) throughout the U.S. and its territories. UCEDDs serve as liaisons between academia and the community. One of many activities UCEDDS perform is conducting model demonstrations to build evidence for addressing issues, finding solutions, and advancing research related to the needs of individuals with developmental disabilities and their families. 

ACL supports grantees and the aging and disability networks in a variety of ways to ensure the provision of high-quality services. For example: 

· A retrospective evaluation of the Alzheimer’s Disease Initiative – Specialized Supportive Services will use existing data to assess the impact of grants with regard primarily to improvement of the quality and effectiveness of programs and services dedicated to individuals aging with intellectual and developmental disabilities with Alzheimer's disease and related dementia or those at high risk of developing dementia. 

· The National Resource Center on Nutrition and Aging helps build the capacity of senior nutrition programs in 56 states and territories to provide high quality, person-centered services and assists ACL and stakeholders with identifying issues and opportunities to enhance program sustainability and resiliency. The resource center provides technical assistance to grantees, enhances the availability of evidence-based approaches, and summarizes grantee accomplishments and outcomes.  

· The ARCH National Respite Network and Resource Center provides training and technical assistance to the Lifespan Respite Network, with a focus on performance measurement, sustainability, best practices, and research.   

· The National Alzheimer’s and Dementia Resource Center supports grantees as they implement evidence-based interventions and innovative practices designed to empower and assist caregivers of persons with Alzheimer’s disease and related disorders.

· Voluntary Consensus Guidelines for State Adult Protective Services Systems were developed by ACL to promote an effective adult protective services (APS) response across the country.  ACL is engaged in a study of states to understand how and to what extent the guidelines help states improve policy and practice of APS as states integrate the consensus guidelines into policy and practice. ACL will then refine and expand its support of APS systems so all older adults and adults with disabilities, regardless of the state or jurisdiction in which they live, have similar protections and service delivery from APS systems. 

ACL also has ongoing projects to improve its program administrative and performance data, which include: 

· ACL’s Data Council, started in October 2019, has begun to improve the coordination of ACL’s data governance.  The council’s work includes examining and enhancing processes and standards for defining, collecting, reviewing, certifying, analyzing, and presenting ACL data. This will strengthen the evidence available about the value of ACL’s programs to individuals, families, and communities. With better data, ACL plans to improve its performance reporting, evaluation, and other research planning and work more collaboratively with key stakeholders such as grantees, advocacy groups, and Congress. Topics for FY 2022 included developing educational training materials for ACL staff to enhance staff knowledge of data collection processes, data management and quality, and reporting as well as identifying needs among grantees for data quality tools. In 2021, the ACL Data Council extended the Data Quality series to include a Data Quality 201 and a Data Quality 202 document, produced a systems change brief, and improved the data governance primer.

· ACL’s newly developed Older Americans Act Performance System (OAAPS) was recently released for the collection of annual performance data for the OAA programs. This system improves performance data collection through an enhanced user interface, improved data validation tracking, and the inclusion of data error checks. In FY 2021 and FY 2022, OAAPS started the collection of OAA Tribal Grants program data, and in FY 2023, ACL has begun the collection of OAA Title III home and community-based services, nutrition services, and caregiver services data.

**Overview of ACL’s Evaluations and Other Evidence Building**

ACL is committed to conducting rigorous, relevant evaluations and using evidence from evaluations to inform policy and practice. ACL’s Evaluation Plan reflects Office of Management and Budget (OMB) guidance regarding evaluation standards and practices (M-20-12). Since FY 2021, ACL has started or continued evaluations of the following programs:

New and Ongoing Evaluations:

**Social determinants of health and ACL**. The purpose of this study is to begin looking at how the services provided by ACL grantees influence the social determinants of health. ACL’s programs address these conditions through grants designed to improve organizations and systems, and to mitigate their effects on individuals through the delivery of direct services such as providing nutrition, linking people to services, preventing/addressing abuse, health education, mobilizing community partnerships, providing transportation, investing in economic support, social integration, and education, among many others. Results from this study will be available in FY 2023.

**Older Americans Act fidelity evaluation**. The Fidelity Evaluation is an evaluation of the conformity with which ACL and its grantees under the Older Americans Act implement the required evidence-based programs. Results from this evaluation were published in FY 2023.

**Process evaluation of the aging network and its return on investment.**ACL is interested in understanding the current status of the aging network based on a comprehensive process evaluation of the aging network engaging all levels (federal, state, and local) and, from the information available, what are some feasible ways to evaluate the aging network with regards to its use of Older Americans Act funds, specifically with regards to return on investment. Results from this study will be available in FY 2023.

Continuing Evaluations:

· An adult protective services client outcomes study

· Model approaches for enhancing the quality, effectiveness and monitoring of home and community-based services for individuals with developmental disabilities grants

· Partnerships in employment systems change grants

· Evaluation of the longer-term outcomes of National Institute on Disability, Independent Living, and Rehabilitation Research programs and the effectiveness and efficiency of the grant-making process

In FY 2021, ACL published the OAA Title III Summary Highlight, the Profile of Older Americans, and a number of evaluation reports on its website. 

**Impact of Budget Changes on ACL’s Performance Targets**

Budget changes have a range of impacts on ACL performance targets. For targets that are highly sensitive to budgetary impacts, such as increasing the number of transportation services provided and congregate and home-delivered meals, as funding levels increase or decrease there is expected to be a related change in ACL’s projected levels of service delivery. As stated above, ACL is examining and refining our performance measure methodology to understand how we may need to adjust our approach to calculating targets in such a dynamic environment. We expect that FY 2022 performance measure data will continue to demonstrate sensitivity to changes in the economy and programmatic adjustments due to the pandemic. While these may not be directly related to the budget, they are impacted by changes in the economy despite any budgetary changes. 

## All Purpose Table

Administration for Community Living

(Dollars in Millions)

1/ Reflects amounts appropriated, and any reprogramming or reallocation notified to Congress except for the Nutrition Services Incentive Program transfer to USDA ($2.2 in FY 2023) which is shown for consistency with State funding tables.

2/ These programs are paid out of the Prevention and Public Health Fund.

3/ The FY 2023 appropriation states that SMP/Health Care Fraud and Abuse Control Program (HCFAC) can be paid for with discretionary CMS HCFAC appropriations and/or HCFAC Wedge funds, the amount based on the Secretary of HHS’s determination but no less than the $35M floor provided in appropriations language. The FY 2023 and FY 2024 amounts are placeholders for the Secretary’s final decision. 

4/ Amounts shown in FY 2022 and FY 2023 reflect a sequester of 5.7 percent for half of FY 2022 and the entirety of FY 2023. The FY 2024 level matches ACL’s request to reauthorize the Medicare Improvements for Patients and Providers Act program and direct all MIPPA funding to ACL. 

5/ Supplemental funding totaling $10M for the National Technical Assistance Center of Grandparents and Kinship Care is available until FY 2025.

## Full Time Equivalents by Funding Source

Administration for Community Living

1/ Totals may not add due to rounding.			

2/ Title II Section 201 of the OAA provides funding for Evaluation of OAA programs, with funding taken out of the base appropriations for Home and Community-Based Supportive Services, Nutrition Services, Preventive Health Services and Family Caregiver Support Services. 

3/ This is a long-standing interagency agreement with the Center for Medicare & Medicaid Innovation with the Centers for Medicare & Medicaid Services. 			

## Mandatory Proposals Summary Table

Administration for Community Living

(Dollars in Thousands)

## 

## Appropriations Language

Administration for Community Living

ADMINISTRATION FOR COMMUNITY LIVING

AGING AND DISABILITY SERVICES PROGRAMS

(INCLUDING TRANSFER OF FUNDS)

For carrying out, to the extent not otherwise provided, the Older Americans Act of 1965 ("OAA"), the RAISE Family Caregivers Act, the Supporting Grandparents Raising Grandchildren Act, titles III and XXIX of the PHS Act, sections 1252 and 1253 of the PHS Act, section 119 of the Medicare Improvements for Patients and Providers Act of 2008, title XX-B of the Social Security Act, the Developmental Disabilities Assistance and Bill of Rights Act of 2000, parts 2 and 5 of subtitle D of title II of the Help America Vote Act of 2002, the Assistive Technology Act of 1998, titles II and VII (and section 14 with respect to such titles) of the Rehabilitation Act of 1973, and for Department-wide coordination of policy and program activities that assist individuals with disabilities, **[**$2,482,545,000**]***$2,972,380,000*, together with $55,242,000 to be transferred from the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund to carry out section 4360 of the Omnibus Budget Reconciliation Act of 1990: *Provided*, That *of amount made available under this heading to carry out section 321 of the OAA up to one percent shall be available for grants to develop and implement evidence-based practices to enhance home and community-based supportive services: Provided further, That*of amounts made available under this heading to carry out sections 311, 331, and 336 of the OAA, up to one percent of such amounts shall be available for developing and implementing evidence-based practices for enhancing senior nutrition, including medically-tailored meals: *Provided further,*That notwithstanding any other provision of this Act, funds made available under this heading to carry out section 311 of the OAA may be transferred to the Secretary of Agriculture in accordance with such section: *Provided further, That notwithstanding section 206(h) of the OAA, up to one percent of amounts appropriated to carry out programs authorized under title III of such Act shall be available for conducting evaluations: Provided further,*That up to 5 percent of the funds provided for adult protective services grants under section 2042 of title XX of the Social Security Act may be used to make grants to Tribes and tribal organizations**[**: *Provided further,*That $2,000,000 shall be for competitive grants to support alternative financing programs that provide for the purchase of assistive technology devices, such as a low-interest loan fund; an interest buy-down program; a revolving loan fund; a loan guarantee; or an insurance program: *Provided further,*That applicants shall provide an assurance that, and information describing the manner in which, the alternative financing program will expand and emphasize consumer choice and control**]**: *Provided further,*That State agencies and community-based disability organizations that are directed by and operated for individuals with disabilities shall be eligible to compete: *Provided further, That of the amount made available under this heading, up to $1,250,000 shall be available for competitive grants to centers for independent living that have received a grant under part C of chapter 1 of title VII of the Rehabilitation Act of 1973, for the development of evidence-based interventions: Provided further, That the amounts made available in the preceding proviso may also be used for the evaluation of grants made under such proviso: Provided further,*That none of the funds made available under this heading may be used by an eligible system (as defined in section 102 of the Protection and Advocacy for Individuals with Mental Illness Act (42 U.S.C. 10802)) to continue to pursue any legal action in a Federal or State court on behalf of an individual or group of individuals with a developmental disability (as defined in section 102(8)(A) of the Developmental Disabilities and Assistance and Bill of Rights Act of 2000 (20 U.S.C. 15002(8)(A)) that is attributable to a mental impairment (or a combination of mental and physical impairments), that has as the requested remedy the closure of State operated intermediate care facilities for people with intellectual or developmental disabilities, unless reasonable public notice of the action has been provided to such individuals (or, in the case of mental incapacitation, the legal guardians who have been specifically awarded authority by the courts to make healthcare and residential decisions on behalf of such individuals) who are affected by such action, within 90 days of instituting such legal action, which informs such individuals (or such legal guardians) of their legal rights and how to exercise such rights consistent with current Federal Rules of Civil Procedure: *Provided further,*That the limitations in the immediately preceding proviso shall not apply in the case of an individual who is neither competent to consent nor has a legal guardian, nor shall the proviso apply in the case of individuals who are a ward of the State or subject to public guardianship**[**: *Provided further,*That of the amount made available under this heading, $41,644,000 shall be used for the projects, and in the amounts, specified in the table titled "Community Project Funding/Congressionally Directed Spending" included for this division in the explanatory statement described in section 4 (in the matter preceding division A of this consolidated Act): *Provided further,*That none of the funds made available for projects described in the preceding proviso shall be subject to section 241 of the PHS Act or section 205 of this Act**]**.****

GENERAL PROVISIONS

*SEC. 238. During this fiscal year, an Operating or Staff Division in HHS may enter into a reimbursable agreement with another major organizational unit within HHS or of another agency under which the ordering agency or unit delegates to the servicing agency or unit the authority and funding to issue a grant or cooperative agreement on its behalf: Provided, That the head of the ordering agency or unit certifies that amounts are available and that the order is in the best interests of the United States Government: Provided further, That funding may be provided by way of advance or reimbursement, as deemed appropriate by the order agency or unit, with proper adjustments of estimated amounts provided in advance to be made based on actual costs: Provided further, That an agreement made under this section obligates an appropriation of the ordering agency or unit, including for costs to administer such grant or cooperative agreement, and such obligation shall be deemed to be an obligation for any purpose of law: Provided further, That an agreement made under this section may be performed for a period that extends beyond the current fiscal year.*

## Appropriations Language Analysis

Administration for Community Living

ADMINISTRATION FOR COMMUNITY LIVING

AGING AND DISABILITY SERVICES PROGRAMS

(INCLUDING TRANSFER OF FUNDS)

GENERAL PROVISIONS

## Amounts Available for Obligation

Administration for Community Living

1/ Funding transferred to the Department of Agriculture is included within the Nutrition Services Incentives Program. Discretionary appropriations on this table will therefore differ by this amount from amounts listed on ACL’s APT.

2/ Includes carryover funding in FY 2022 and FY 2023.

3/ MIPPA Funding excludes $15,000,000 in Fiscal Years 2022, 2023, and 2024 that is directly appropriated to CMS for MIPPA-SHIP and then made available to ACL through an Intra-Departmental Delegation of Authority. Amounts include carryover in FY 2022 and FY 2023. 

4/ Amounts for FY 2023 is a placeholder pending a Secretarial decision on the final amount. FY 2022 and FY 2023 amounts include carryover. 

## Summary of Changes

Administration for Community Living

(Dollars in millions)

 1/ Does not include a breakout of program dollars allocated to the FY 2023 pay raise due to the lack of materiality of these amounts.

## Budget Authority by Activity

Administration for Community Living

(Dollars in thousands)

1/ Reflects FY 2022 and FY 2023 required and permissive transfers and rescissions, except the transfers to USDA in FY 2022 of $1,437,580 and in FY 2023 of $2,192,965 which are shown for consistency with State funding tables.

2/ Does not reflect all agency FTE, just FTE from budget authority.

## Authorizing Legislation

Administration for Community Living

1/ MIPPA Amounts are authorized and appropriated through 9/30/2023.

2/ Authorization is provided for both Prevention of Elder Abuse and Neglect and Legal Assistance

3/ Authorized and appropriated at $10 million to cover fiscal years 2021 through 2025.

4/ Excludes funding for $41,644,000 in Congressionally Directed Spending (CDS) projects.

## Appropriations History

Administration for Community Living

1/ Includes $2,549,334 in FY 2015 budget authority appropriated to ACL and transferred to the Department of Agriculture for commodities purchases pursant to Public Law 113-235.				

2/ Includes $2,214,429 in FY 2016 budget authority appropriated to ACL and transferred to the Department of Agriculture for commodities purchases pursant to Public Law 114-113.				

3/ Includes $2,553,916 in FY 2017 budget authority appropriated to ACL and transferred to the Department of Agriculture for commodities purchases pursuant to Public Law 115-31.				

4/ Includes $2,752,453 in FY 2018 budget authority appropriated to ACL and transferred to the Department of Agriculture for commodities purchases pursuant to Public Law 115-141.				

5/ House Allowance includes $300 million for the Senior Community Service Employment Program currently administered by the Department of Labor.				

6/ Includes $1,902,259 in FY 2019 budget authority appropriated to ACL and transferred to the Department of Agriculture for commodities purchases pursuant to Public Law 115-245.				

7/ Includes $1,381,186 in FY 2020 budget authority appropriated to ACL and transferred to the Department of Agriculture for commodities purchases pursuant to Public Law 116-94.				

8/ Includes $1,347,714 in FY 2021 budget authority appropriated to ACL and transferred to the Department of Agriculture for commodities purchases pursuant to Public Law 116-260.				

9/ Includes $1,437,580 in FY 2022 budget authority appropriated to ACL and transferred to the Department of Agriculture for commodities purchases pursuant to Public Law 117-103.				

10/ Includes $2,192,565 in FY 2023 budget authority appropriated to ACL and transferred to the Department of Agriculture for commodities purchases pursuant to Public Law 117-328.				

## Appropriations Not Authorized by Law

Administration for Community Living

EXECUTIVE SUMMARY

# Health and Independence for Older Adults

## **Summary of Request**

ACL’s Health and Independence for Older Adults programs provide an interconnected foundation of services that help older people remain healthy and independent in homes in their communities, avoiding expensive institutional care. These programs include Home and Community-Based Supportive Services, Senior Nutrition Programs (which provides meals served in congregate settings, as well as home-delivered meals), Preventive Health Services, Chronic Disease Self-Management, and Falls Prevention. Another program provides services specifically for American Indians, Alaska Natives and Native Hawaiians. Finally, the Aging Network Support Activities program funds development and testing of innovative service approaches and supports the aging services network in expanding capacity and improving effectiveness. 

These programs make a crucial difference in the lives of the people they serve. For example, according to data from the *2022 National Survey on Older Americans Act Participants*, 82 percent of people who participate in the congregate meals program and 92 percent of home-delivered meal recipients reported that meals received through the programs allowed them to continue to live independently. Additionally, 66 percent of older adults using transportation services rely on them for the majority of their trips to doctors’ offices, pharmacies, meal sites, and other critical daily activities that help them to remain in the community. 

These programs have never been more important. The U.S. population over age 60 is projected to increase by 12 percent between 2021 and 2025, from 77.1 million to 86.3 million. In addition, the number of older adults age 65 and older with severe disabilities (defined as 3 or more limitations in activities of daily living), who are at greatest risk of nursing home admission, is projected to be 4.7 million by 2025. 

With the population of older adults growing so quickly, the need for the services that make it possible for many of them to age in place also has been growing steadily for many years. The COVID-19 pandemic accelerated that increasing demand; today, more people need services, and many people need more services, than ever before. The FY 2023, enacted level included increases for several ACL programs that provide direct services for older people, which has allowed them to begin to meet increased needs. However, demand continues to outstrip capacity. ACL’s FY 2024 request therefore includes additional investments to further increase the reach of these key programs.  The request also includes an increase for an initiative to expand and stabilize the direct care workforce. 

ACL is requesting $1,938,992,000 for the Health and Independence for Older Adults programs, an increase of $351,675,000 above the FY 2023 enacted level. Specifically, ACL requests:

· $500,000,000 for Home and Community-Based Supportive Services (HCBSS), an increase of $90,000,000 above the FY 2023 enacted level, to address the significantly increased demand for services that support community living for older adults. HCBSS programs include transportation assistance, case management, personal care services, chore services, adult day care, information and referral services, and physical fitness and wellness programs. In addition, ACL is again including appropriations language that would allow up to 1 percent of HCBSS funding to be used for innovation grants to test new ways to address service challenges and the ongoing need to modernize.

· $1,284,385,000 for Nutrition Services (Congregate, Home-Delivered and Nutrition Services Incentives Program), an increase of $217,632,000 above the FY 2023 enacted level, to offset increased costs of service delivery and modestly expand services. The FY 2024 request continues to propose the use of up to 1 percent of the funds appropriated for nutrition programs to be used for innovations to improve service delivery  

· $26,399,000 for Preventive Health Services, an increase of $60,000 above the FY 2023 enacted level. Preventive Health Services funding promotes healthy and reduce the need for more costly medical interventions 

· $8,000,000 for Chronic Disease Self-Management (CDSME) programs, the same as the FY 2023 enacted level. CDSME programs help older adults manage health conditions, such as diabetes, heart disease, cancer, HIV, depression, and pain in order to maintain their health and independence

· $10,000,000 for Falls Prevention, an increase of $2,500,000 above the FY 2023 enacted level. This increase will expand successful, evidence-based programs that reduce falls, fear of falling (which leads to inactivity and isolation) and fall-related injuries in older adults.

· $70,208,000 for Native American Nutrition and Supportive Services, an increase of $31,944,000 above the FY 2023 enacted level, to expand services for Native American elders. The request also recognizes the need for specific investment in reducing health disparities for tribal elders, many of whom live in rural and other hard-to-reach areas.

· $40,000,000 for Aging Network Support Activities, an increase of $9,539,000 above the FY 2023 enacted level, to support an initiative to expand and stabilize the direct care workforce, expand the Eldercare Locator, and increase investment in efforts to coordinate health care and the services provided by the aging network

### Legislative Proposals:

ACL’s request includes two legislative proposals, specifically:

· Enhance Resources for Evaluation:****ACL proposes to increase the allowance for evaluation from 0.5 percent to 1 percent for enhanced evaluation and data collection. Currently, the Older Americans Act (OAA) permits the use of up to 0.5 percent of funds appropriated to OAA Title III to conduct evaluations of programs and to review their effectiveness. Due to the increasing demographics and complexity of needs of the aging population, the demand for information about the programs and their effectiveness is increasing. Additional resources are needed to review programs and provide data that supports administration and congressional actions for addressing changing needs more quickly and comprehensively.  

· Allow funds to cover the cost of acquisition, construction, or modernization of any type of facility providing OAA services:****ACL proposes to allow OAA funds to be used to cover the cost of acquisition, construction, renovation, or repair of any type of facility used to provide services under the OAA. Current statute limits funds for construction and modernization to multipurpose senior centers.  This change would allow for construction and modernization of facilities beyond multipurpose senior centers to fully implement the services provided under the OAA and would remove obsolete and confusing language in the statute.  This change would allow states, territories, tribes, tribal aging organizations, area agencies on aging, and local service providers flexibility to take the most effective approach to acquiring and maintaining facilities to providing services to older adults and family caregivers under the OAA.

### Outcome and Outputs Table: Health and Independence for Older Adults

*This is a developmental performance measure.  ACL is currently collecting sufficient data to establish a baseline.  To set a baseline, the agency relies on 3 years of data.  This process ensures that the data are stable and show a clear trend.  The agency will set targets for this measure once a baseline is established.

## Home and Community-Based Supportive Services

*BA is in thousands of dollars.

1/ Excludes $0 million in permissive transfers or allotments from the Public Health and Social Services Emergency Fund (PHSSEF) to ACL which are shown in PHSSEF. Includes appropriations and required transfers to ACL.

Original Authorizing Legislation: Section 303(a)(1) of the Older Americans Act of 1965, Public Law 89-73

Most Recent Authorizing Legislation: Supporting Older Americans Act of 2020, Public Law 116-131

Current FY Authorization:  	$490,733,346

Authorization Expiration Date	2024

Allocation Method	Formula Grant/Competitive Grant/Contract

### Program Description:

The Home and Community-Based Supportive Services (HCBSS) program, established in 1973, provides formula grants to states and territories based on their share of the population age 60 and over, to fund a broad array of low-cost services that enable older adults to remain in their homes for as long as possible. Programs like HCBSS serve older adults holistically. While each service is valuable, it is the combination of supports tailored to the needs of the individual that ensures clients remain in their homes and communities, instead of entering institutional care.

Services provided to older adults through the HCBSS program include access services, such as transportation, case management, and information and referral; in-home services, such as personal care, chore, and homemaker assistance; and community services, such as adult day care and physical fitness programs. The HCBSS program also funds multi-purpose senior centers, which coordinate and integrate services for older adults. Additionally, states and area agencies on aging have had the flexibility to provide specific services intended to mitigate any isolation as the result of illness, disability, or old age, including virtual friendly visiting, wellness checks, telephone reassurance, and the use of electronic communications technologies (e.g., Skype, FaceTime, Zoom) to promote face-to-face interaction with family members and program staff. 

In addition, the services funded by this program – particularly adult day care, personal care, homemaker, and chore services – also aid caregivers, who otherwise might have to be even more intensively involved with the care of their loved ones, taking time away from work and their other family responsibilities and further straining family budgets. 

While age alone does not determine the need for these services and supports, statistics show that both disability rates and the use of long-term supports increase with advancing age. According to the *2019 Medicare Beneficiary Survey*, among those aged 85 and older, 45 percent are unable to perform one or more critical activities of daily living and may require long-term support. Data also show that over 95 percent of older adults age 85 and older have at least one chronic condition and 84 percent have at least two. Providing a variety of supportive services that meet the diverse needs of these individuals is crucial to enabling them to remain healthy and independent in their homes and communities, and therefore avoid unnecessary, expensive nursing home care.

Data from ACL’s *2022 National Survey of OAA Participants* show that services such as transportation are providing older adults with the assistance and information, they need to help them remain at home.  For example, 66 percent of older adults using transportation services rely on ACL services for the majority of their transportation needs and would otherwise be homebound. 49 precent of passengers receiving HCBSS funded transportation are mobility impaired, meaning they do not own a car, or if they do own a car, they do not drive, and are not near public transportation. Over 83 percent of clients receiving case management also reported that, as a result of the services arranged by the case manager, they were better able to care for themselves. In addition, a study published in the Journal of Aging and Health shows that the services provided by the HCBSS program, specifically personal care services, play an important role in helping frail older adults remain in their homes and out of nursing home care. [footnoteRef:5] [5:  Chen, Ya Mei and Elaine Adams Thompson.  Understanding Factors That Influence Success of Home- and Community-Based Services in Keeping Older Adults in Community Settings.  2010.  Journal of Aging and Health.  V. 22: 267.] 

### Budget Request:

ACL requests $500,000,000 for Home and Community-Based Supportive Services (HCBSS), an increase of $90,000,000 above the FY 2023 enacted level. Increasing funding will allow ACL to continue to support this array of services, including an estimated additional 1 million rides for activities such as visiting the doctor, the pharmacy, or grocery stores; and an additional 0.8 million hours of assistance for seniors who are unable to perform daily activities. These estimates consider the state, local, and private funding streams that also support these activities.

To maximize the impact of the funding ACL provides, innovation is also needed to continually improve the capacity, effectiveness, and sustainability of interventions and service delivery. To this end, ACL is again proposing a change to appropriations language: the ability to use up to 1 percent of HCBSS funding to fund innovative demonstrations, the same authority that is currently available to the nutrition programs. Based on feedback over the years and ACL’s knowledge of needs and gaps in the field of aging, ACL anticipates testing innovative approaches in areas such as the following:

· Pandemic lessons learned – ACL is interested in identifying lessons learned as a result of changes required by the pandemic, including service models that work better and can be retained and incorporated going forward

· Transportation – key areas ACL has identified as in need for innovations include specialized transportation, volunteer transportation, mobility management, and travel training

· Senior centers – ACL is interested in exploring ways to transform and modernize senior centers to spark relevancy and the ability to attract new, younger participants and to expand into the area of overall wellness, as well as to position them as community hubs

· Intergenerational programming – there is substantial research about the benefits of intergenerational programming for both older individuals, as well as children. ACL is interested in testing it to combat social isolation, depression, and the benefits associated with civic engagement

· Use of technology – based on the roadmap outlined in the White House report, *Emerging Technologies to Support an Aging Population*, ACL is interested in exploring the practical uses of technology in providing HCBSS supports and in enhancing the ability of individuals to live independently in their homes and communities

· Home modification – ACL is interested in implementing and testing models in *The Home Modification Information Network*, developed with the support of ACL*,* by enhancing access to home modifications to make homes safer and more accessible

· Dementia innovations – ACL is interested in exploring the translation and expansion of the principles of dementia-friendly and dementia-capable communities

· Case management and care coordination – ACL is interested in testing the most effective means of providing care coordination, especially as the network interfaces with the healthcare sector in the provision of the social determinants of health

· Aging in place – ACL is interested in exploring flexible opportunities for community-based organizations to test or take to scale innovating approaches to serve older adults and their caregivers

### Funding History:

Funding for Home and Community-Based Supportive Services over the past ten years is as follows:

### Program Accomplishments:

Home and Community-Based Supportive Services (HCBSS) fund a broad array of services that enable older adults to remain in their homes for as long as possible. The services provided by HCBSS in FY 2021 include: 

· Transportation Services provided more than 8.9 million rides to doctor’s offices, grocery stores, pharmacies, senior centers, meal sites, and other critical daily activities (Output C).  93 percent of transportation clients report that the service helps them stay in their home for longer than would otherwise be possible without the transportation services 

· Personal Care, Homemaker, and Chore Services provided more than 46 million hours of assistance to older adults who are unable to perform activities of daily living (such as eating, dressing, or bathing) or instrumental activities of daily living (such as shopping or light housework) (Output D)

· Case Management Services provided over 4.0 million hours of assistance in assessing needs, developing care plans, and arranging services for older persons or their caregivers (Output F)

### Outcomes and Outputs Table: Home and Community-Based Supportive Services

* This is a developmental performance measure. ACL is currently collecting sufficient data to establish a baseline. To set a baseline, the agency relies on three years of data. This process ensures that the data are stable and show a clear trend. The agency will set targets for this measure once a baseline is established.

Note: For presentation within the budget, ACL highlighted specific measures that are most directly related to Home and Community-Based Supportive Services; however, multiple performance outcomes are impacted by this program because ACL’s performance measures (efficiency, effective targeting, and client outcomes) assess network-wide performance in achieving current strategic objectives.

*This is a developmental performance measure. ACL is currently collecting sufficient data to establish a baseline. To set a baseline, the agency relies on 3 years of data. This process ensures that the data are stable and show a clear trend. The agency will set targets for this measure once a baseline is established.

**Targets not defined per explanation in the Overview of Performance section. Please refer back to page 20-21.

### Grant Awards Tables:

Home and Community-Based Supportive Services – Innovation Grants

Home and Community-Based Supportive Services – Formula Grants

*Represents States and the District of Columbia

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON AGING**

**FY 2024 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER: Home and Community-Based Supportive Services (CFDA 93.044)

1/ Undistributed- Includes funds for Older American Act statutory requirements, including evaluation and disaster assistance; and grant and program reporting system costs, and innovation demonstration grants. Funds unused for these purposes at the end of the year are allocated to states.

## Nutrition Services

* BA is in thousands of dollars.

Original Authorizing Legislation: Sections 311, 331 and 336 of the Older Americans Act of 1965, Public Law 89-73

Most Recent Authorizing Legislation: Supporting Older Americans Act of 2020, Public Law 116-131

Current FY Authorization	$1,155,554,345

Authorization Expiration Date	2024

Allocation Method	Formula Grant/Competitive Grants/Contracts

### Program Description:  

The Nutrition Services program helps older adults remain healthy and independent in their communities by providing nutritious meals, nutritional screening, education, and counseling. The objectives of the program are to (1) reduce hunger, food insecurity, and malnutrition; (2) promote socialization; and (3) promote the health and well-being of older adults by facilitating access to other disease prevention and health promotion services that can help them avoid adverse health conditions. These services are provided in all 50 states, the District of Columbia, and five territories through a network of more than 7,400 local nutrition service providers. Formula grants for congregate nutrition services and home-delivered nutrition services are allocated to states and territories based on their share of the population age 60 and over. Nutrition Services Incentive Program grants are provided to states, territories, and eligible tribal organizations based on the number of meals served in the prior fiscal year.

The Nutrition Services Programs include:

· Congregate Nutrition Services (Title III-C1): Provides funding for meals and related services in a variety of community settings, such as senior and community centers, which help older individuals remain healthy and prevents the need for more costly medical interventions. Established in 1972, the program also presents opportunities for social engagement, health promotion activities, nutrition education, nutrition counseling, and meaningful volunteer and social engagement roles, all of which contribute to participants’ overall health and well-being.**Congregate Nutrition Services provided 25.4 million meals to more than 640,000 older adults in a variety of community settings in 2021. 

· Home-Delivered Nutrition Services (Title III-C2): Provides funding for the delivery of meals and related services to older adults who are unable to participate in the congregate program due to illness, disability, or geographic isolation. Established in 1978, home-delivered meals are often the first in-home service that an older adult receives and are often the primary access point for other home and community-based services. In addition to providing a meal, this service helps frail older adults combat isolation and maintain contact with the outside world. Home-delivered meals provided to spouses also represent an essential service, helping them maintain their own health and well-being while caring for their loved ones. Home-Delivered Nutrition Services provided 225.8 million meals to over 1.5 million individuals in FY 2021. 

· Nutrition Services Incentive Program (Title III-A): Provides a secondary source of funding that must be used exclusively to provide meals, and which can be applied to either congregate or home-delivered meals. Recipient organizations can elect to receive part or all their grants as commodities from the U.S. Department of Agriculture if they determine that doing so will enable them to better meet the needs of older adults. Five states elected to spend approximately $1,250,532 on commodities (plus $187,048 assessed by USDA as administrative expenses) in FY 2022.

· Under its authority to use up to 1 percent of nutrition appropriations for innovation demonstrations, ACL is investing $9.7 million in FY 2023 to fund nutrition innovations and test ways to modernize service delivery to better meet the needs of a changing senior population

The nutrition services programs assist over 2.2 million diverse participants with who are at higher risk for health care interventions as well as institutionalization. For example:

· The percentage of home-delivered meal recipients with severe disabilities (defined as substantial limitations in 3 or more activities of daily living) was 27 percent in 2022. This level of disability is frequently associated with nursing home admission and demonstrates the extreme frailty of a significant number of home-delivered meal clients. Approximately 58 percent of home-delivered meal recipients have annual incomes at or below $20,000. Nearly 57 percent of recipients of home-delivered meals, and 43 percent of participants in congregate meal programs, report these meals as half or more of their food intake for the day according to ACL’s *2022 National Survey of Older Americans Act Participants*. 

· The prevalence of multiple chronic conditions is higher among congregate and home-delivered meal program participants in comparison to the general Medicare population. In fact, data from ACL’s *2022 National Survey of OAA Participants* indicate that 49 percent of congregate, and 63 percent of home-delivered, meal participants have six or more chronic health conditions. 

### Budget Request:

The FY 2024 request for Nutrition Services programs is $1,284,385,000, a total increase of $217,632,000 above the FY 2023 enacted level, to offset increased costs of service delivery and modestly expand services. 

For the Congregate and Home-Delivered Nutrition programs, ACL requests an increase of $221,708,000 and $43,993,000 respectively, bringing the total requested amount to $762,050,000 for Congregate Nutrition and $410,335,000 for Home Delivered Nutrition. These increases reflect the elevated demand for services caused by the long-term effects of the COVID-19 pandemic. Specifically, the effects of prolonged isolation have left many people more dependent on services than they had been before. In addition, fewer volunteers are available, which has increased the cost to operate many programs, especially those providing meals. This requested level of funding is necessary to sustain the increased service levels that have become the “new normal.” This request also includes a $48,069,000 reduction to the Nutrition Services Incentive Program, which ACL believes will be offset by state and private funding, as well as the requested increases in the two primary nutrition programs.  

The FY 2024 request continues to allow up to 1 percent of the funds appropriated for congregate and home-delivered nutrition be used for nutrition innovations. Under this authority, ACL used $9.7 million in FY 2023 to fund nutrition innovations and test ways to modernize how meals are provided to a changing senior population. With the funding requested in the FY 2024 President’s Budget, ACL will maintain funding for these innovations grants at the same level (or higher). 

### Funding History:

Comparable funding for Nutrition Services over the past ten years is as follows:

### Program Accomplishments:

In FY 2021, 251.2 million meals were provided to seniors. Of that total, 225.8 million of were home-delivered meals and 25.4 million were served in congregate settings (which reflects the shift away from in-person services during the pandemic).

In addition, ACL is investing $9.7 million in FY 2023 to fund nutrition innovation projects to develop new service delivery practices to best meet the needs of the changing senior population. Examples of currently funded projects include: 

· Improving health outcomes*:*Projects are focusing on helping older adults manage diabetes to decrease related hospitalizations and emergency room visits; decreasing blood pressure in older adults through dietary interventions, combined with educational, social, and behavioral interventions; and enhancing the identification of, and support for, older adults with elevated suicide risk or in mental health distress

· Reducing malnutrition and food insecurity*:*Projects are focusing on improving quality of statewide delivery system with new medically tailored meal packages and meal delivery mechanisms, particularly for patients transitioning from hospital to home; and identifying nutrition indices related to functionality, quality of life, ability to age-in-place, and hospital readmission

· Improving overall service provision*:*Projects are testing a number of concepts, including creating an “Encore Café” approach to congregate meals, which proved effective in attracting baby boomers and increased donations to the program; developing a "virtual supper club" hosted by university students and youth Nutrition Ambassadors to decrease food insecurity and loneliness among congregate meal participants – enhancing food resource management and connection while fostering a supportive community to decrease loneliness; and implementing a nutrition education program that addresses food security, socialization, and perceived health and well-being of residents in low-income senior housing

Data consistently show that the program is effective in helping older adults improve their nutritional intake and remain independent. For example, according to data from the *National Survey of Older Americans Act Participants*:

· 71 percent of congregate meal participants, and 79 percent of home-delivered meal participants, say they eat healthier meals due to the programs

· 80 percent of congregate meal participants, and 92 percent of home-delivered meal recipients, say that the meals enable them to continue living independently

In addition, 95 percent of congregate meal clients, and 91 percent of home-delivered meal clients, rate service as good to excellent.

Annual performance data also indicate the programs help participants to live independently in the community, eat healthier foods, improve their health, and achieve or maintain a healthy weight. Similarly, a recent evaluation of the programs found that:

· Participants in the congregate meal program were less likely than non-participants to have a hospital admission or emergency department visit leading to a hospital admission or to be admitted to a nursing home over the next 12 months

· When compared to peers who did not participate in the congregate meals program, participants had greater food security, higher levels of socialization, and better diet quality. 

· Home-delivered meal program participants also had better diet quality than peers who did not participate in the program

ACL has completed a number of evaluations of the Nutrition Services Program:

· *Process Evaluation of Older Americans Act (OAA) Title III-C Nutrition Services Program* provides information to support program planning by analyzing program structure, administration, staffing, coordination, and service delivery. It evaluates the interactions between the many types of organizations that provide congregate meals, home-delivered meals, and collateral services under the OAA Nutrition Programs.

· *OAA Nutrition Programs Evaluation: Meal Cost Analysis* estimates the costs of program operations, the most important being the cost of the congregate and home-delivered meals provided using Title III. It also examines cost variation within the program by component and program characteristics.

· *Client Outcome Study: Part I* was released in two parts with Part I describing nutrition services program participants’ demographics, health status, mobility, eating behaviors, diet quality, food security, socialization, and other characteristics, as well as participants’ experiences with the program and their valuation of meals and supportive services received

· *Client Outcome Study: Part II* describes participants’ health and health care utilization and examines overall wellness measured using longer-term outcomes related to health and avoidance of institutionalization

### Outcomes and Outputs Table: Nutrition Services

*This is a developmental performance measure. ACL is currently collecting sufficient data to establish a baseline. To set a baseline, the agency relies on 3 years of data. This process ensures that the data are stable and show a clear trend. The agency will set targets for this measure once a baseline is established.

Note: For presentation within the budget, ACL highlighted specific measures that are most directly related to Nutrition Services. However, multiple performance outcomes are impacted by this program because ACL’s performance measures (efficiency, effective targeting, and client outcomes) assess network-wide performance in achieving current strategic objectives.

**Targets not defined per explanation in the Overview of Performance section. Please refer back to page 20-21.

### Grant Awards Tables:

Congregate Nutrition Programs Grant Awards

*Represents States, and the District of Columbia

Home-Delivered Nutrition Programs Grant Awards

*Represents States, and the District of Columbia

Nutrition Services Incentive Program Grant Awards

1/ Not including grants to tribes.

*Represents States, and the District of Columbia

Nutrition Innovation Grant Awards

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON AGING**

**FY 2024 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER: Congregate Nutrition Services (CFDA 93.045)

1/ Undistributed- Includes funds for Older American Act statutory requirements, including evaluation and disaster assistance, grant and program reporting system costs, and starting in FY 2022 the costs of conducting innovation grants. Funds unused for these purposes at the end of the year are allocated to states.

****

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON AGING**

**FY 2024 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER: Home-Delivered Nutrition Services (CFDA 93.045)

1/ Undistributed- Includes funds for Older American Act statutory requirements, including evaluation and disaster assistance; and grant and program reporting system costs, and innovation demonstration grants. Funds unused for these purposes at the end of the year are allocated to states.

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON AGING**

**FY 2024 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER: Nutrition Services Incentive Program (CFDA 93.053)

1/ State levels include transfers for distributions of commodities which are provided by USDA to grantees; in FY 2022, the amount that was transferred is shown for comparability purposes.

2/ Undistributed- Includes funds for Older American Act statutory requirements, including evaluation and disaster assistance and grant and program reporting systems costs. Funds unused for these purposes at the end of the year are allocated to states.

## Preventive Health Services

*BA is in thousands of dollars.

1/ Excludes $0 million in permissive transfers or allotments from the Public Health and Social Services Emergency Fund (PHSSEF) to ACL which are shown in PHSSEF. Includes appropriations and required transfers to ACL.

2/ No supplemental funding was provided in FY 2022 for this program.

Original Authorizing Legislation: Section 361 of the Older Americans Act of 1965, Public Law 89-73

Most Recent Authorizing Legislation: Supporting Older Americans Act of 2020, Public Law 116-131

Current FY Authorization	$31,665,971

Authorization Expiration Date	2024

Allocation Method	Formula Grant

### Program Description:

Preventive Health Services, established in 1987, provides formula grants to states and territories to support evidencebased programs that educate older adults about the importance of healthy lifestyles and promote healthy behaviors that can help prevent chronic disease and disability, thereby reducing the need for more costly medical interventions. Preventive Health Services funding is allocated to states and territories based on their share of the population age 60 and over, and the program provides flexibility to allocate resources to best meet local needs. Priority is given to providing access to programs for older adults living in medically underserved areas or those with the greatest economic need.

Due in large part to advances in public health and medical care, Americans are leading longer and more active lives. On average, an American turning 65 today can expect to live an additional 18.3 years.[footnoteRef:6]  The population of older Americans is also growing, particularly the population age 85 and over, which is projected to grow from 6 million in 2021 to 9.1 million by the year 2030.1 One consequence of this increased longevity is a higher incidence of chronic diseases such as arthritis, cancer, and diabetes.[footnoteRef:7] In addition, approximately 25 percent of older adults report falling each year, with 3 million falls resulting in emergency department visits. This percentage is increasing for all older adults, but especially for those age 85 and over.[footnoteRef:8] [6:  Arias E, Tejada-Vera B, Kochanek KD, Ahmad FB. Provisional life expectancy estimates for 2021. Vital Statistics Rapid Release; no 23. Hyattsville, MD: National Center for Health Statistics. Access 23 February 2023.]  [7:  Kingston, A., L. Robinson, H. Booth, M. Knapp, C. Jagger. 2018. Projections of multi-morbidity in the older population in England to 2035: estimates from the Population Ageing and Care Simulation (PACSim) model. Age and Ageing; 47: 374–380. Accessed 18 February 2023.]  [8:  Burns, E. R. Kakara. Deaths from Falls Among Persons Aged => 65 Years – United States, 2007-2016. MMWR Morb Mortal Wkly Rep 2018;67:509-514. Accessed 18 February 2023.] 

Evidence-based programs are interventions that have been proven through controlled trials to be effective at helping participants adopt healthy behaviors, improve their health status, and reduce their use of hospital services and emergency room visits. Programs can be offered in a variety of formats, in-person, videoconference, telephone, mailed toolkit, and/or a combination of these mediums. Examples of evidence-based interventions include:

· Physical Activity Programs: Physical activity programs are multi-component group exercise programs designed for community-based organizations to promote physical activity among older adults.  Components may include strength training using soft wrist and ankle weights; cardiovascular workouts using dancing, aerobics, or walking; and balance and posture exercises. Becoming more physically active has many positive benefits such as increased mobility and function, decreased pain and depression, and lower risk of type 2 diabetes, hypertension, coronary heart disease, obesity, and some cancers.

· Medication Management Programs: Medication management programs focus on reviewing the multitude of medications that older adults are prescribed, focusing especially on high-risk medications. Medication management programs have been shown to reduce cardiovascular problems and unnecessary duplication of prescriptions. These programs have also been shown to improve medication usage rates and decrease medication errors among older adults.

· Depression Care Management*:* Depression is not a normal part of aging, yet it is a prevalent and disabling condition among older adults.  Older adults with depression visit the doctor and emergency room more frequently, use more medication, stay longer in the hospital, and have substantially higher total health care costs than those without depression. Cost-effective, evidence-based interventions have been shown to reduce depressive symptoms and improve quality of life in older adults.

### Budget Request:

The FY 2024 request for Preventive Health Services is $26,399,000, an increase of $60,000 above the FY 2023 enacted level.

With the additional funding, the programs will reach more older adults, continue support for virtual programs that expanded their reach during the pandemic, and cover costs as grantees work with developers to create evidence-based interventions that work at home. 

ACL also will continue to provide guidance to grantees regarding what meets the evidence-based requirement for this program. ACL uses criteria for defining evidence-based interventions implemented through the Older Americans Act (OAA). The OAA Title III-D webpage contains definitions of evidence-based interventions, frequently asked questions, and program examples.[footnoteRef:9] [9:  ACL Health Promotion Webpage. Accessed 18 February 2023.] 

### Funding History:

Funding for Preventive Health Services over the past five years is as follows:

### Program Accomplishments:

Preventive Health Services funding promotes healthy behaviors to prevent chronic disease and disability, thereby reducing the need for more costly medical interventions. Preventive Health Services grants also allow states to fund the provision of evidence-based programs that educate older adults about the importance of healthy lifestyles and promote healthy behaviors that can help prevent chronic disease and disability. Each of the evidence-based programs for which states could use these funds have been rigorously evaluated and found to be effective. In FY 2021, 259,979 people participated in these health and disease prevention programs. 

### Output Table: Preventive Health Services

**Targets not defined per explanation in the Overview of Performance section. Please refer back to page 20-21.

### Grant Awards Table:

Preventive Health Services Grant Awards

*Represents States, and the District of Columbia

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON AGING**

**FY 2024 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER: Preventive Health Services (CFDA 93.043)

1/ Undistributed- includes funds for Older American Act statutory requirements, including program evaluation and disaster assistance and grant and program reporting systems costs. Funds unused for these purposes at the end of the year are allocated to states.

## Chronic Disease Self-Management Education

*BA is in thousands of dollars.

Authorizing Legislation: Section 411 of the Older Americans Act of 1965, Public Law 89-73.

Most Recent Authorizing Legislation: Supporting Older Americans Act of 2020, Public Law 116-131

Current FY Authorization	None Specified

Authorization Expiration Date	2024

Allocation Method	Competitive Grants/Cooperative Agreements

### Program Description:

Chronic Disease Self-Management Education (CDSME) programs are low-cost, evidence-based prevention models that use state-of-the-art techniques to help those with chronic conditions, such as diabetes, heart disease, cancer, HIV, depression, and pain, address issues related to the management and treatment of their condition, build self-confidence, improve their health status, and reduce their need for more costly medical care. CDSME programs emphasize an individual’s role in managing their condition though a series of workshops that are conducted one or more times per week over several weeks in remote settings (video conference, phone, and/or toolkit) and community settings (in hospitals, churches, libraries, YWCAs, YMCAs, senior centers, public housing projects, community health centers, and cooperative extension programs). People with different chronic health conditions attend together, and the workshops are facilitated by trained leaders - often non-health professionals or lay people with chronic diseases themselves. Core topics covered include: techniques to deal with problems such as frustration, fatigue, pain and isolation; appropriate exercise for maintaining and improving strength, flexibility, and endurance; appropriate use of medications; communicating effectively with health professionals; and nutrition.

In the U.S., 71 percent of Medicare beneficiaries age 65 and over have multiple (two or more) chronic conditions, placing them at greater risk for premature death, poor functional status, unnecessary hospitalizations, adverse drug events, and nursing home placement.[footnoteRef:10] Chronic conditions also impact health care costs, as 93 percent of Medicare expenditures are for beneficiaries with chronic conditions.[footnoteRef:11] [10:  Vogeli C, Shields AE, Lee TA, Gibson TB, Marder WD, Weiss KB, Blumenthal D. Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs. J Gen Intern Med 2007; 22 (Suppl 3):391–395. Accessed 18 February 2023.]  [11:  Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chartbook, 2012 Edition. Baltimore, MD. 2012. Accessed 18 February 2023.] 

Since FY 2012, ACL has supported competitive grants to state agencies, community-based organizations, educational institutions, and other non-profit organizations, as well as technical assistance, education, and resources for the aging and disability services network.

### Budget Request:

The FY 2024 request for the Chronic Disease Self-Management Education (CDSME) program is $8,000,000, the same as the FY 2023 enacted level. Funding for CDSME comes from the Prevention and Public Health Funds. With these funds ACL will continue existing comprehensive grant programs and maintain funding for the CDSME Resource Center.

### Funding History:

Funding for Chronic Disease Self-Management Education over the past five years is as follows:

### Program Accomplishments:

Continued support for this program will broaden older adults’ access to CDSME programs, in which, to date, more than 480,510 older adults have participated.[footnoteRef:12] This continued investment of resources will allow ACL, in coordination with its existing HHS partners, community-based organizations, and private philanthropists to continue work on low-cost, evidence-based prevention models and rigorous research studies that help individuals better manage their chronic conditions. Past investments in CDSME and on ACL’s existing service delivery infrastructure have furthered the goal of significant quality of care with physicians, increased health outcomes, and reduced hospitalizations, while allowing individuals to achieve a healthier standard of living. [12:  ACL CDSME National Database. Accessed on 16 January 2023.] 

CDSME programs have been shown repeatedly, through controlled research trials, to be effective at helping participants adopt healthy behaviors and improve their psychological and physical health status.[footnoteRef:13] Some evidence suggests that CDSME programs may also significantly reduce the use of hospital care and physician services and reduce health care costs.[footnoteRef:14] Moreover, in a national study of CDSME programs, participants reported significant improvements in aspects of their care (communication with their physicians, medication compliance, and health literacy), better health outcomes (self-assessed health, reduction in depression and quality of life), and reduced health care utilization (lower emergency room visits and hospitalizations), resulting in potential cost savings.[footnoteRef:15] [13:  Brady TJ, Murphy L, O’Colmain BJ, Beauchesne D, Daniels B, Greenberg M, et al. A Meta-Analysis of Health Status, Health Behaviors, and Health Care Utilization Outcomes of the Chronic Disease Self-Management Program. Prev Chronic Dis 2013;10:120112. Accessed 2 February 2023. ]  [14:  Ory, M. G., Ahn, S., Jiang, L., Smith, M. L., Ritter, P. L., Whitelaw, N., & Lorig, K. (2013). Successes of a National Study of the Chronic Disease Self-Management Program: Meeting the Triple Aim of Health Care Reform. Medical Care, 51(11), 992–998. Accessed on 2 February 2023.]  [15:  Ory MG, Ahn S, Jiang L, Lorig K, Ritter P, Laurent DD, Whitelaw N, Smith ML. National study of chronic disease self-management: six-month outcome findings. J Aging Health. 2013 Oct; 25(7):1258-74. Accessed on 2 February 2023. ] 

### Grant Awards Table:

Chronic Disease Self-Management Education Grant Awards

## Falls Prevention

*BA is in thousands of dollars.

Original Authorizing Legislation: Section 411 of the Older Americans Act of 1965, Public Law 89-73

Most Recent Authorizing Legislation: Supporting Older Americans Act of 2020, Public Law 116-131

Current FY Authorization	None Specified

Authorization Expiration Date	2024

Allocation Method........................................	Competitive Grants/Cooperative Agreements 

### Program Description:

Falls are the leading cause of fatal and nonfatal injuries among older adults[footnoteRef:16] and have a widespread and serious impact on their health**.**With an estimated one out of four older adults reporting falling each year [footnoteRef:17], falls may significantly reduce the ability of our older adult population to remain independent. Each year an estimated 3 million older adults are treated in emergency departments for falls injuries and more than 800,000 of these patients are hospitalized.[footnoteRef:18] In 2015, the estimated medical costs attributable to fatal and nonfatal falls totaled more than $50 billion.[footnoteRef:19] Those who have fallen may become afraid to fall again, which can lead to reduction in their everyday activities, causing them to become weaker and increasing the likelihood of a future fall.  [16:  WISQARS. Web-based Injury Statistics Query and Reporting System (WISQARS). National Center for Injury Prevention and Control, Centers for Disease Control and Prevention 2021 [cited 2021 June] Accessed 5 February 2023.]  [17:  Bergen G, Stevens MR, Burns ER. Falls and Fall Injuries Among Adults Aged ≥65 Years — United States, 2014. MMWR Morb Mortal Wkly Rep 2016;65:993–998. Accessed 5 February 2023.]  [18:  Moreland B, Kakara R, Henry A. Trends in nonfatal falls and fall-related injuries among adults aged ≥65 years —United States, 2012–2018. MMWR Morb Mortal Wkly Rep 2020;69:875–881. Accessed 5 February 2023.]  [19:  Centers for Disease Control and Prevention. (2016) Facts About Falls. Accessed 5 February 2023.] 

Research has shown that falls and fall risks can be addressed through risk assessment and targeted intervention, including a combination of clinical intervention and community-based programs.[footnoteRef:20] Evidence-based falls prevention programs help participants improve strength, balance, and mobility, and provide education on how to avoid falls and reduce fall risk factors. These programs also may involve medication reviews and modifications; provide referrals for medical care management for selected fall risk factors; and provide home hazard assessments of ways to reduce environmental hazards. [20:  U.S. Centers for Disease Control and Prevention. (2015). Compendium of Effective Fall Interventions: What Works for Community-Dwelling Older Adults. Accessed 5 February 2023.] 

Programs are conducted one or more times per week over several weeks in remote (video conference) and/or community settings (hospitals, churches, libraries, YWCAs, YMCAs, senior centers, public housing, community health centers, and cooperative extension programs). The programs are facilitated by trained leaders, and fidelity to the original research is tracked (to ensure participants benefit fully from the intervention).

### Budget Request:

The FY 2024 request for Falls Prevention is $10,000,000, an increase of $2,500,000 above the FY 2023 enacted level. Funding comes from both direct appropriation and the Prevention and Public Health Fund. At the requested level, ACL will be able to expand the successful evidence-based falls prevention programs in the community; educate more older Americans about ways to reduce their falls risk; undertake studies to reduce fatal and nonfatal fall injuries that are attributed to falling in adults aged 65 and over; and fund the National Falls Prevention Resource Center. The National Falls Prevention Resource Center supports the implementation and dissemination of evidence-based falls prevention programs and strategies across the nation. 

ACL is requesting this funding so that it can maintain the impact these programs have had on the community and on older Americans’ ability to live independently. ACL continues to align with and complement U.S. Centers for Disease Control and Prevention’s fall prevention efforts, which focus primarily on clinical providers and settings.

### Funding History:

Funding for Falls Prevention over the past five years is as follows:

1/All years include $5 million in Prevention and Public Health Fund funding.

### Program Accomplishments:

Since 2014, more than 173,595 individuals have participated in falls prevention programs supported by ACL grantees and their partners [footnoteRef:21] including *A Matter of Balance, Stepping On, Tai Chi: Moving for Better Balance*, and other evidence-based programs. [21:  ACL Falls Prevention National Database. Accessed 16 January 2023.] 

Evidence-based community falls prevention/management programs have demonstrated a reduction in falls through randomized controlled trials. For example, when compared with control groups, the risk of falling for participants in the *Tai Chi: Moving for Better Balance* intervention decreased by 55 percent;[footnoteRef:22] and the *Stepping On* program reduction was 31 percent.[footnoteRef:23] Numerous other studies also have documented the efficacy of these programs in reducing falls and/or falls risk,[footnoteRef:24] as well as their potential for cost savings and positive return on investment.[footnoteRef:25] [22:  Li F, Harmer P, Fisher JK, Mcauley E. Tai Chi: Improving Functional Balance and Predicting Subsequent Falls in Older Persons. Med Sci Sports Exerc. (2004) 36 (12): 2046-2052. Accessed 5 February 2023.]  [23:  Clemson L, Cumming RG, Kendig H, Swann M, Heard R, Taylor K. The Effectiveness of a Community-Based Program for Reducing the Incidence of Falls in the Elderly: A Randomized Trial. J Am Geriatr Soc. (Sept 2004) 52 (9): 1487–1494. Accessed 5 February 2023]  [24:  Fuzhong L, Harmer P, Fisher JK, Mcauley E. Tai Chi: Improving Functional Balance and Predicting Subsequent Falls in Older Persons. Med Sci Sports Exerc. (2004) 36 (12): 2046-2052. Accessed 5 February 2023]  [25:  Carande-Kulis, V., Stevens, J., Florence, C., Beattie, B.L., Arias, I. (2015). A cost-benefit analysis of three older adult falls prevention interventions. Journal of Safety Research, 52, 65–70. Accessed 5 February 2023] 

### Grant Awards Table:

Falls Prevention Program Grant Awards

## Native American Nutrition and Supportive Services

*BA is in thousands of dollars.

Original Authorizing Legislation: Sections 201, 613, and 623 of the Older Americans Act of 1965, Public Law 89-73

Most Recent Authorizing Legislation: Supporting Older Americans Act of 2020, Public Law 116-131

Current FY Authorization.............................................................................................$44,094,235

Authorization Expiration Date	2024

Allocation Method	Formula Grant/Competitive Grant/Contract

### Program Description:

The Native American Nutrition and Supportive Services program provides grants to eligible tribal organizations to promote the delivery of Nutrition and Home and Community-Based Supportive Services to American Indian, Alaskan Native, and Native Hawaiian elders. An estimated 1.1 million people age 60 and over identify themselves as American Indian or Alaskan Native alone or in combination with another racial group. American Indian and Alaska Native people have long experienced lower health status when compared with other Americans. [footnoteRef:26] Lower life expectancy results from a combination of disproportionate poverty, barriers in accessing healthcare services, unequal educational and employment opportunities, and cultural differences. American Indians and Alaska Natives experience death at higher rates than other Americans in many categories, including chronic liver disease and cirrhosis, diabetes mellitus, unintentional injuries, assault/homicide, intentional self-harm/suicide, and chronic lower respiratory diseases.  [26:  Indian Health Services (IHS) Health Disparities Fact Sheet, June 2019: Accessed 23 February 2023.] 

Native American Nutrition and Supportive Services grants support a broad range of services to older Native Americans, including adult day care; transportation; congregate and home-delivered meals; information and referral; and personal care, chore, and other supportive services. These programs, which help to reduce the need for costly nursing home care and medical interventions, are responsive to the cultural traditions of Native American communities and represent an important part of each community’s comprehensive services.

The Native American Nutrition and Supportive Services program also provides training and technical assistance to Tribal organizations to support the development of comprehensive and coordinated systems of services to meet the needs of Native American elders. Training and technical assistance is provided through national meetings, site visits, website, e-newsletters, telephone and written consultations, as well as through the Native American Resource Centers (funded under Aging Network Support Activities).

### Budget Request:

The FY 2024 request for the Native American Nutrition and Supportive Services program is $70,208,000, an increase of $31,944,000 above the FY 2023 enacted level. In addition to the higher levels of need faced by tribes due to the factors common to all of ACL’s programs for older adults, including higher numbers of elders who are now dependent on services and overall population growth, the request recognizes the need for specific investment in programs that advance health equity for underserved populations. Annual funding for tribal services has historically fallen well below Tribal needs. During the COVID-19 pandemic, Congress provided an additional $53.7 million in supplemental funding during the pandemic which helped to better align funding for Tribes with Tribal needs. The requested level maintains the Administration’s commitment to addressing historical underfunding of services, improving equity, and responding to the lower life expectancy and health status that American Indians and Alaska Natives experience.

### Funding History:

Funding for Native American Nutrition and Supportive Services over the past five years is as follows:

### Program Accomplishments:

ACL’s recent evaluation of the Native American Nutrition and Supportive Services found that these programs can provide opportunities for improved health and wellness for elders. ACL’s nutrition program services currently reaches 31 percent of eligible Native American older adults in participating tribal organizations through congregate and home-delivered meal services. The evaluation found that elders receiving any Title VI services experienced significantly fewer hospitalizations and falls per year in comparison with elders who did not receive or participate in Title VI services.[footnoteRef:27] The difference was even greater for elders from programs that provide a higher number of services compared to programs that provide fewer services. Elders from higher-level service programs experienced 53 percent fewer hospitalization and 45 percent fewer falls per year.  [27:  Administration for Community Living. (2021). Evaluation of the ACL Title VI Programs. Washington, DC.  Accessed 18 February 2023.] 

The services provided in FY 2020 include:

· Transportation Services**provided 202,512 units of services to Native American elders (Output L)

· Nutrition Services**provided 6.4 million home-delivered meals and 321,095 congregate meals to Native American elders (Output M&N)

· Information, Referral, and Outreach**provided 698,490 hours of services to Native American elders (Output O)

### Outcomes and Outputs Tables: Native American Nutrition & Supportive Services

**Targets not defined per explanation in the Overview of Performance section. Please refer back to page 20-21.

### Grant Awards Table:

Native American Nutrition & Supportive Services Formula Grant Awards

## Aging Network Support Activities

*BA is in thousands of dollars.

Authorizing Legislation: Section 202, 215, and 411 of the Older Americans Act of 1965, Public Law 89-73

Most Recent Authorizing Legislation: Supporting Older Americans Act of 2020, Public Law 116-131

Current FY Authorization	$22,252,073

Authorization Expiration Date	2024

Allocation Method	Competitive Grants/Co-operative Agreements and Contracts

### Program Description:

The Aging Network Support Activities (ANSA) program supports innovation and technical assistance to help states, tribes, and providers of aging services expand capacity and improve the effectiveness and efficiency of the systems that help older people live independently in their communities. ANSA funding also helps older adults and their families obtain information about care options and benefits, provides ongoing support for the national aging services network, and helps support the activities of ACL’s core service delivery programs.

Competitive grants, cooperative agreements, and contracts through ANSA are awarded to eligible public or private agencies, tribes and tribal organizations, states, area agencies on aging, institutions of higher learning, and other organizations representing and/or serving older people, including faith-based organizations. Grantees are generally asked to provide a match equal to 25 percent of the project’s total cost. Project proposals are reviewed by external experts, and awards are made for periods of one to five years.

#### National Eldercare Locator and Engagement and Older Adults Resource Center

Older Americans and their caregivers face a complicated array of choices and decisions regarding health care, pensions, insurance, housing, financial management, and long-term care. The Eldercare Locator, created in 1991, helps older adults and their families navigate this complex environment by connecting people needing assistance with state and local organizations that serve older adults and their caregivers. The Eldercare Locator can be accessed through a toll-free nationwide telephone line (800-677-1116) or website (http://www.eldercare.gov). The call center and website both connect those in need to providers in every zip code in the nation. This service is supplemented by an Information and Referral Support Center which provides technical assistance, training, and consultation to enhance the development of effective aging and disability information and assistance systems.

According to a recent report from the National Academies of Sciences, Engineering and Medicine, *Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System*, approximately one-quarter of older Americans living in the community are considered to be socially isolated, and a significant proportion of adults in the U.S. report feeling lonely.[footnoteRef:28]  Preventing social isolation and loneliness is critical to healthy aging, as social isolation increases risk of heart disease by about 30 percent, is associated with a significant increased risk of dementia, and increases risk of premature death at rates comparable to smoking, obesity and physical inactivity. ACL is working with the aging network to help older adults remain active, engaged and socially connected as they age. EngAGED, the national resource center for engaging older adults, provides technical assistance and serves as a repository for innovations designed to increase the aging network’s ability to tailor social engagement activities to meet the needs of older adults. [28:  National Academies of Sciences, Engineering, and Medicine. 2020. Social isolation and loneliness in older adults: Opportunities for the health care system. Washington, DC: The National Academies Press. Accessed 18 February 2023.] 

#### Strengthening the Direct Care Workforce 

Shortages in the direct care workforce have been building for many years, as low pay and lack of benefits have created consistently high turnover rates. The shortages reached crisis proportions during the pandemic, however, and today, more than 75 percent of providers are declining new referrals and 50 percent are closing services as a result. In September 2022, ACL established the national Direct Care Workforce Capacity Building Center to help respond to this crisis and strengthen the direct care workforce. With FY 2023 funding, ACL is beginning to build a hub through which state, private, and federal entities involved in the recruitment, training and retention of direct care workers can access model policies, best practices, training materials, technical assistance and learning collaboratives.

#### Pension Counseling and Retirement Information

The Pension Counseling program currently funds six regional projects covering 31 states to assist older adults in accessing information about their retirement benefits and helps them negotiate with former employers or pension plans for due compensation. Currently there are approximately 700,000 private (as well as thousands of public) pension and retirement plans in the U.S. Given that an employee may have worked for several employers, and these employers may have merged, sold their plans, or gone bankrupt, it is very difficult for the average person to know whether they are receiving all pension benefits owed to them. Pension Counseling projects also provide indirect services to tens of thousands of older adults and their families through information sharing, hosting websites, and conducting outreach, education, and awareness efforts.

ACL also supports the National Resource Center on Women and Retirement, which provides access to a one-stop gateway for women that integrates financial information and resources on retirement planning with information on health and long-term care. This project makes user-friendly financial education and retirement planning tools available to women, with a focus on traditionally hard-to-reach populations, including low-income women, women of color, women with limited English proficiency, women in rural areas, and other underserved women. Information is offered through financial and retirement planning programs, workshops tailored to meet women’s special needs, and is published in hard copy and web-based formats. This program helps create economic mobility for women who are most at risk of not having adequate savings for retirement.

#### National Resource Centers on Native American Elders

The National Resource Centers on Native American Elders enhance knowledge about older Native Americans to support improved delivery of services to this underserved population. Each resource center addresses at least two areas of primary concern specified in the Older Americans Act. These include health issues, long-term care (including in-home care), elder abuse, mental health, and other problems and issues facing tribal communities. The resource centers are administered under cooperative agreements by institutions of higher education. The resource centers partner with Native American organizations and communities, educational institutions (including tribal colleges and universities), and professionals and paraprofessionals in the field. 

Each resource center has specialized areas of interest. For example, the University of North Dakota Resource Center has assisted Title VI grantees in assessing needs of tribal elders to determine program planning and direction. This process has led to the development of a database of information about American Indian, Alaska Native, and Native Hawaiian Elders. The University of Hawaii Resource Center has focused on long-term care needs of Native Hawaiian Elders. Similarly, the University of Alaska Resource Center has focused on elder abuse and neglect issues within Native American or Alaskan Native communities.

#### Older Adult Equity Collaborative

The Older Adult Equity Collaborative is a group of five national minority aging technical assistance resource centers and a Coordinating Center for Minority Organizations that work together to enhance access and reduce health disparities among racial, ethnic, and other minority older individuals. These centers design and disseminate frontline health promotion and disease prevention information that is culturally and linguistically appropriate for older individuals of African American, Hispanic, Asian American and Pacific Islander descent, American Indian and Alaska Native elders, and older lesbian, gay, bisexual, and transgender (LGBT) adults. They provide targeted technical assistance and training to the aging services network, older adults and other stakeholders.

The goals of the Older Adult Equity Collaborative include promoting closer collaboration, coordination and cross-program efforts among minority aging organizations and other ACL-funded resource centers focused on older adults, family caregivers, and where applicable, people with disabilities. In addition, they coordinate with other stakeholders and entities to promote greater equity and cross-sectional work on behalf of diverse older adults and their caregivers who have historically been disenfranchised or had limited access to services and supports. The purposes and goals of the Collaborative are directly aligned with President Biden’s Executive Order On Advancing Racial Equity and Support for Underserved Communities

#### Holocaust Survivor Assistance

The U.S. is home to approximately 80,000 victims of Nazi persecution, approximately 25 percent of whom are living in poverty.[footnoteRef:29] Because of the experiences they endured early in their lives, Holocaust survivors are likely to have greater and more complex physical and mental health needs as they age. The nonprofit social service agencies that serve this population have projected that the need for supportive services will continue to grow and intensify over the next five to ten years. [29:   Hoffman, Y., and Weiner, M., (2019). When More than Half a Billion Dollars is Not Enough. Prepared for the Harry and Jeanette Weinberg Foundation National Convening on Jewish Poverty, March 19, 2019. Accessed 18 February 2023.] 

A cooperative agreement was awarded to a national organization with demonstrated expertise in working with Holocaust survivors to advance the development and delivery of person-centered, trauma-informed supportive services. The program focuses efforts on: 

· Expanding the capacity of community-based agencies to provide direct services to Holocaust survivors in a person-centered, trauma-informed (PCTI) manner

· Developing and implementing a national technical assistance center devoted to expanding the aging services network’s capacity to deliver person-centered, trauma-informed services

#### Program Performance and Technical Assistance

Program Performance and Technical Assistance (PPTA) supports cooperative efforts between ACL, selected states and area agencies on aging to develop tools, performance measures, and best practices that can be used to effectively and efficiently identify the results produced through OAA programs on an ongoing basis. These efforts include partnerships with national aging organizations to foster innovation and provide technical assistance in strategic planning, program development, and performance improvement for programs that serve older adults. 

PPTA also supports efforts to align health care and social care and to increase the capability and capacity of the community-based organizations within the aging network to contract with health care organizations to provide supportive services, needs assessments, case management, and more. Medicaid, Medicare, accountable care organizations, private insurers, and other private-pay models will offer increasing opportunities for community-based organizations to tap into new revenue streams outside of government grants. However, securing contracts and working with such payers requires thinking and operating differently. ACL is working with the aging and disability networks to strengthen community-based organizations from the inside, building their business skills and enhancing their effectiveness, efficiency, and sustainability.

#### Care Corps

The Care Corps program provides funding for grants to test innovative ways to place volunteers to provide non-medical care in communities to assist caregivers, older adults, and people with disabilities so they can maintain their independence. Through the Care Corps program, volunteers provide respite, transportation, meal preparation, minor home cleaning and modifications, education, caring calls/visits, and more. 

#### Research, Demonstration, and Evaluation Center for the Aging Network (RD&E Center)

The FY 2023 Appropriation was the first time ACL received funding for the RD&E Center. In FY 2023, ACL is focusing on developing the Aging Network Innovation Lab, which will provide a platform for the aging network to conduct research and share best practices for preventing falls and the health conditions that result from them (or increase risk for them). The Innovation Lab will award competitive grants to develop, test interventions, and build an evidence base about what works to reduce the risk of falls in older adults. The Innovation Lab also will develop a structured approach to collecting data and a taxonomy for falls prevention research in order to share the knowledge with others in the aging network and beyond. ACL will be establishing funding for the Innovation Lab by the end of fiscal year 2023; competitive grants will follow soon thereafter.

#### Interagency Coordinating Committee on Healthy Aging & Age-Friendly Communities 

The Interagency Coordinating Committee on Health Aging and Age-Friendly Communities was authorized under the Older Americans Act to focus on the coordination of aging issues across federal agencies. The Committee is charged with the development of a national set of recommendations to support the ability of older adults to age in place, with access to long-term services and supports, homelessness prevention services and preventive health care, and to promote age-friendly communities. With funding provided for the first time in the FY 2023 Appropriations, ACL is now establishing the Committee.  The Committee will begin its work by reviewing ongoing federal activities and interagency coordination and seek input from experts and stakeholders to identify gaps and determine areas of focus for the report and recommendations it will provide to Congress. 

### Budget Request:

ACL’s FY 2024 request for Aging Network Support Activities is $40,000,000, an increase of $9,539,000 above the FY 2023 enacted level, to support an initiative to expand and stabilize the direct care workforce, expand the Eldercare Locator, and increase investment in strengthening aging network.  

More than two thirds of Americans will need assistance with things like transportation, personal care, and managing finances as they age. A strong, well-supported caregiving workforce – which includes both family caregivers and professional direct care workers – is crucial to making it possible for older adults and people with disabilities to live in the community.  However, due to significant challenges to recruiting and retaining direct care workers, including low wages and a lack of benefits, a shortage of direct care workers has been building for many years. That shortage reached crisis proportions during the pandemic; today, three-quarters of service providers are turning down new referrals and more than half have cut services. This is rapidly reversing gains in serving people in the community, as many people have been forced to move to, or remain in, institutions because workers are not available to provide the services they need to live in the community. The shortage also is placing the health and safety of older adults and people with disabilities who live in the community at risk and putting further strain on family caregivers.  

Of the increase requested for Aging Network Support Activities, $8,000,000 will be used to build upon the work begun in 2022 and 2023 to expand and stabilize the direct care workforce. Specifically, ACL will fully fund the operation of the resource hub through which state, private, and federal entities involved in the recruitment, training and retention of direct care workers can access model policies, best practices, training materials, technical assistance and learning collaboratives. In addition, ACL will establish demonstration grants to test recruiting, retention and training approaches that can be replicated and scaled across states. This initiative will be jointly funded with $3.5 million from ACL’s programs for people with disabilities. 

Of the remaining increase for Aging Network Support Activities, $1 million will expand the capacity of the Eldercare Locator, and $539,000 will be used to offset increased costs of operation for programs focused on innovation and sustainability within the aging network.

### Funding History:

Comparable funding for Aging Network Support Activities over the past five years is as follows:

Aging Network Support Activities 

(Dollars in thousands)

### Program Accomplishments:

The Aging Network Support Activities (ANSA) program funds a collection of initiatives focused on innovation and technical assistance to expand the capacity and effectiveness of systems that help older adults live independently, as well resources that help connect older adults to the services and supports available through those systems. Highlights of the impact of the ANSA program include:

· Strengthening the direct care workforce*:* In fall 2022, with joint funding from the Developmental Disabilities Projects of National Significance program, ACL awarded a five-year grant to establish a national technical assistance and resource center to expand and strengthen the direct care workforce across the country. This center will support recruitment, retention, and professional development of workers who provide home and community-based services. The center will serve as a hub, providing tools, resources, and training to assist state systems and service providers and to support the development and coordination of policies and programs that contribute to a stable direct care workforce. 

· Connecting older adults to resources in their community*:*In 2022, the Eldercare Locator expanded the call center hours to add an additional hour in the morning and in the evening to accommodate more callers seeking assistance. The Eldercare Locator received almost 409,000 calls in 2022. 

· Supporting retirement security*:*In 2021, pension counseling projects helped 1,898 people and recovered approximately $10.6 million in retirement income that otherwise would have been lost. Since the program’s inception:

· Pension counseling projects have successfully recovered approximately $288.4 million in client benefits, representing a return of more than nine dollars for every federal dollar invested in the program. For many older adults, the recovered funds are the difference between dependence on government support and having sustainable income

· Projects have cumulatively directly served over 68,000 individuals, providing hands-on assistance in pursuing claims through administrative appeals processes, helping older adults to locate pension plans “lost” as a result of mergers and acquisition, answering queries about complex plan provisions, and making targeted referrals to other professionals for assistance.

In addition, ACL’s National Resource Center on Women and Retirement has conducted approximately 200 workshops per year on strategies to access financial and retirement planning information, since its founding. It has also developed and published over 175 fact sheets tailored to the specific needs of hard-to-reach women. 

· Advancing health equity*:* The Older Adult Equity Collaborative has addressed health disparities among older adults from minority older individuals through a variety of ways, including:

· Bilingual webinars, bi-monthly technical assistance chats, blog posts and learning collaboratives for English and Spanish speaking older adults and caregivers. 

· A multi-language call center program aimed to serve the Asian American/Pacific Islander older adults with low English proficiency on topics such as Medicare, social security and general information and assistance. 

· Various certificate training courses and tool kits for the aging network in working with diverse older adults in the LGBTQ+ community. 

· A culturally appropriate manual/toolkit for American Indian and Alaskan Native on disabilities and working with tribes.

· Supporting Holocaust survivors*:*Since its inception in 2015, the Holocaust Survivor Assistance program has been working to advance the principles of person-centered, trauma-informed care (PCTI) for survivors and their family caregivers. In 2020, the program began expanding its reach to serve other older adults with histories of trauma and their family caregivers. To date, the program has touched the lives of more than 35,000 Holocaust survivors with PCTI services and supports; trained nearly 16,000 professionals and volunteers in the principles and practice of PCTI; provided tailored supports to more than 6,200 family caregivers; and provided PCTI services to nearly 5,000 older adults with histories of trauma. 

· Preventing social isolation and loneliness*:*In 2022, the National Resource Center on Engaging Older Adults held a series of webinars to provide the aging network with information on innovative strategies to engage older adults and people with disabilities.  In August 2022, the center hosted a two-day virtual summit that brought together researchers and national, state and local leaders for discussions regarding the current state of social isolation research. 

· Supporting volunteer programs: Since 2020, the Care Corps program has awarded 79 grants to organizations serving a mix of urban, suburban, rural, and tribal communities across the country to support volunteer programs that provide a wide range of non-medical services to people living in the community. These include respite care, transportation, meal preparation, minor home cleaning and modifications, education, caring calls/visits and training. During the first 2 years of the project, more than 24,000 older adults, people with disabilities, and caregivers have been served.

### Grant Awards Table:

Aging Network Support Grant Awards

HEALTH AND INDEPENDENCE FOR OLDER ADULTS

# Caregiver and Family Support Services

## Summary of Request

Families and informal caregivers are the backbone of our nation’s system of long-term care – each year, more than 53 million informal caregivers provide the majority of support that makes it possible for older people and people with disabilities to live in the community. Another 2.7 million grandparent caregivers – and an unknown number of other relative caregivers – open their arms and homes each year to millions of children who cannot remain with their parents.

When family caregivers do not have the support they need, their health, well-being and quality of life often suffer. Family caregivers experience higher rates of depression than non-caregivers of the same age, and research indicates that family caregivers have a mortality rate that is 63 percent higher than non-caregivers.[footnoteRef:30] Their financial future also is at risk – informal caregivers lose an estimated $522 billion in wages each year due to caregiving. The American economy also is affected; employers are losing an estimated $33 billion per year due to employees’ caregiving responsibilities.[footnoteRef:31] [30:  Schulz R, Beach SR. Caregiving as a risk factor for mortality. The Caregiver Health Effects study. JAMA December 15, 1999;282:2215-9. Accessed 18 February 2023.]  [31:  The MetLife Caregiving Cost Study: Productivity Losses to U.S. Business, Page 17. Accessed 18 February 2023.] 

Replacing the support informal caregivers provide with paid services would cost an estimated $470 billion – if paid workers were available to provide them. As discussed in the Aging Network Support Activities chapter, long-standing shortages in the direct care workforce have become a crisis in recent years, and nearly three-quarters of service providers are turning away new referrals. In many cases, the support provided by family caregivers is irreplaceable.  

When the challenges become overwhelming and families and other informal caregivers are unable to continue to provide support, the person they have been assisting often is left with no options except moving to a nursing home or other institution. In addition to negatively affecting the health and well-being of the individual who has moved from the community, institutional care also carries a tremendous financial cost – most of which is borne by taxpayers. Ensuring family caregivers have the resources they need to continue to support older adults and disabled people in the community is critical both to upholding the rights of older people and people with disabilities and to containing the rising costs of health care.

ACL’s Caregiver and Family Support programs provide services that help family caregivers balance caregiving with work and other responsibilities. Nearly three-quarters the people served by these programs report that these services allow them to provide care longer than they otherwise could have. Several of ACL’s family caregiver programs also help states and communities strengthen their family caregiving infrastructure through training of respite care providers and establishment of dementia-capable systems of support.

In addition, ACL implements the Recognize, Assist, Include, Support, and Engage (RAISE) Family Caregiver Act and the Supporting Grandparents Raising Grandchildren (SGRG) Act, which includes support to the advisory councils established by each. In September 2022, ACL delivered to Congress the *National Strategy to Support Family Caregivers*, which was developed jointly by the advisory councils, with extensive input from family caregivers, the people they support and other stakeholders. The strategy includes nearly 350 commitments from more than 15 federal agencies for near-term actions to support family caregivers. It also includes more than 150 recommended actions that can be adopted at other levels of government and across the private sector. 

As populations of older adults and people with disabilities increase, the number of family caregivers also are increasing. The programs that support family caregivers already are unable to meet demand, particularly for respite care. Recognizing these unmet and growing needs, ACL’s FY 2024 request includes a total of $311,462,000 for family caregiver support programs, an increase of $52,962,000 above the FY 2023 enacted level. The increase will support implementation of the strategy, support direct services, and continue investments to increase capacity and improve sustainability of caregiver support programs. The request includes:

· $249,936,000 for Family Caregiver Support Services, an increase of $44,936,000 above the FY 2023 enacted level. Of this increase, $26.4 million will be dedicated to increasing formula grants to states, and $18.5 million will be dedicated to demonstration grants to develop, test, and scale models for the implementation of the**caregiver strategy.  

· $15,806,000 for Native American Caregiver Support Services, an increase of $3,806,000 above the FY 2023 enacted level. The increase will help expand services to Native Americans living in rural areas, addressing a long-standing challenge to providing direct services for this population; increase the range of services to this marginalized and underserved population; and complement and amplify the requested investment in the implementation of the**caregiver strategy, which includes actions focused on Native American caregivers.

· $31,500,000 for the Alzheimer’s Disease Program Initiative, the same as the FY 2023 enacted level. The Alzheimer’s Disease Program Initiative funds grants to help states develop/improve the dementia capability of their home and community-based service systems; help dementia-capable providers of community-based services expand capacity and address specific identified service gaps; and support tribes in increasing dementia-capability in Indian Country. In addition, these funds support a training and technical assistance resource center and a national call center.

· $14,200,000 for Lifespan Respite Care, an increase of $4,220,000 above the FY 2023 enacted level. Respite care is one of the services most often sought by caregivers, but a shortage of respite care services, coupled with high costs of services and lack of awareness of how to access them, make them unavailable to many. The increased funding will expand respite services at the state level; expand outreach, particularly to underserved communities; and increase assistance to underserved populations.

Supporting families and other informal caregivers is an issue that affects everyone. Nearly all of us will either need assistance to live independently at some point in our lives or provide assistance to help someone else live in the community – or both. Expanding support for families and other informal caregivers has become an urgent public health imperative, and it is a critical component of advancing the Biden-Harris Administration’s priority of strengthening the care economy. 

### Legislative Proposals:

ACL’s request includes two legislative proposals, specifically:

· Enhance Resources for Evaluation: ACL proposes to increase the allowance for evaluation from 0.5 percent to 1 percent for enhanced evaluation and data collection. Currently, the Older Americans Act (OAA) permits the use of up to 0.5 percent of funds appropriated to OAA Title III to conduct evaluations of programs and to review their effectiveness. Due to the increasing demographics and complexity of needs of the aging population, the demand for information about the programs and their effectiveness is increasing.  Additional resources are needed to review programs and provide data that supports administration and congressional actions for addressing changing needs more quickly and comprehensively.  

· Allow Funds to Cover the Cost of Acquisition, Construction, or Modernization of Any Type of Facility Providing OAA Services:****ACL proposes to allow Older Americans Act (OAA) funds to be used to cover the cost of acquisition, construction, renovation, or repair of any type of facility used to provide services under the OAA. Current statute limits funds for construction and modernization to multipurpose senior centers.  This change would allow for construction and modernization of facilities beyond multipurpose senior centers to fully implement the services provided under the OAA and would remove obsolete and confusing language in the statute.  This change would allow states, territories, tribes, tribal aging organizations, area agencies on aging, and local service providers flexibility to take the most effective approach to acquiring and maintaining facilities to providing services to older adults and family caregivers under the OAA.

## Family Caregiver Support 

*BA is in thousands of dollars.

Original Authorizing Legislation: Section 371 of the Older Americans Act of 1965, Public Law 89-73.

Most Recent Authorizing Legislation: Supporting Older Americans Act of 2020, Public Law 116-131

Current FY Authorization	$230,901,105

Authorization Expiration Date	2024

Allocation Method	Formula Grants/Competitive Grants/Contracts

### Program Description:

The Family Caregiver Support Program provides formula grants to states and territories (based on population) to fund a range of services for families and other informal caregivers. The program includes five basic components: information, access assistance, counseling and training, respite care, and supplemental services. These services work in conjunction with other Older American Act programs to provide a coordinated set of supports to help older adults age in place.

In addition, through the Family Caregiver Support program, ACL implements the Recognize, Assist, Include, Support, and Engage (RAISE) Family Caregiver Act and the Supporting Grandparents Raising Grandchildren (SGRG) Act, which includes support to the advisory councils established by each. The program also supports implementation of the *National Strategy to Support Family Caregivers*, which was released in September 2022. 

The program has never been more important. As the populations of older adults and people with disabilities increase, the number of family caregivers also are increasing. In addition, family caregivers have had to take on more informal care as a result of the direct care workforce crisis that is impacting the availability of paid services. Family caregivers provide assistance with a wide variety of tasks, ranging from personal care and homemaker services to more complex health-related support, like medication administration and wound care. According to data from ACL’s *2022 National Survey of OAA Participants*, nearly a quarter of family caregivers are assisting two or more people. In addition, their tasks are growing in both number and complexity, making training for family caregivers imperative to the health and well-being of the people they support.  

Research has shown that caregiving can exact a heavy emotional, physical, and financial toll. For example, family caregivers often experience conflicts between work and caregiving, with 65 percent reporting that providing care interfered with their job. In addition, 75 percent of participants in the Family Caregiver Support Program are 60 or older, making them more susceptible to a decline in their own health. Direct assistance for caregiving tasks, respite care, and other services are crucial to helping family caregivers maintain their own health, well-being, and financial security. Without that support, the challenges of caregiving can become overwhelming. When family caregivers are no longer able to provide support, the person they have been assisting often is left with no choice but institutional care. Without them, millions of older adults and people with disabilities would be forced to move to nursing homes and other institutions, and many more children would enter the foster care system.[footnoteRef:32] [32:  Reinhard, S. C., Feinberg, L. F., Houser, A., Choula, R., & Evans, M. (2019). Valuing the Invaluable: 2019 Update. AARP Pubic Policy Institute. Accessed 23 February 2023.] 

### Budget Request:

For the FY 2024 request, ACL requests $249,936,000 for the Family Caregiver Support program, an increase of $44,936,000 above the FY 2023 enacted level. The request maintains support for implementing the RAISE Family Caregivers Act at $400,000 and the SGRG Act at $300,000. It also supports funding for several activities to support implementation of the 2022 *National Strategy to Support Family Caregivers*. 

Specifically, the request provides an additional $26,400,000 through state formula grants, an increase of more than13 percent over FY 2023 enacted, to support states in increasing direct services for caregivers to meet the growing unmet need. It also provides $18,500,000 to build upon an initiative ACL will launch at the end of FY 2023 to accelerate implementation of the strategy. In FY 2024, the initiative will be jointly funded with $1,000,000 from the Aging and Disability Resource Centers program and $500,000 from a proposed new program, Independent Living Programs of National Significance.

· Award innovation and demonstration grants to states and tribes, public and nonprofit agencies, higher education, healthcare systems, and other organizations to foster improvements in support for family and older relative caregivers

· Establish a learning collaborative to ensure state systems for accessing family caregiver supports are responsive to the needs of caregivers from diverse backgrounds

· Promote peer-to-peer assistance for all types of family caregivers (i.e., spouse caring for a spouse, child caring for a parent, parent caring for a child with a disability, or grandparent caring for a grandchild)

· Establish a national resource center to provide comprehensive technical assistance and support to grantees, as well as states, communities and other stakeholders working to improve support to family caregivers

· Fund a robust third-party program evaluation

### Funding History:

Funding for Family Caregiver Support over the past five years is as follows:

### Program Accomplishments:

Studies have shown that the types of support provided through the Family Caregiver Support Services Program can reduce caregiver depression, anxiety, and stress, and enable them to provide care longer, often while continuing to work, thereby avoiding or delaying the need for costly institutional care for their loved ones. For example, one study indicates that counseling and support for family caregivers of individuals with Alzheimer’s disease can permit the care recipient to stay at home, at significantly less cost, for an additional year.[footnoteRef:33]   [33:  Mittelman MS, Ferris SH, Shulman E, Steinberg G, Levin B. A Family Intervention to Delay Nursing Home Placement of Patients with Alzheimer’s Disease. A randomized controlled trial. Aging and Dementia Research Center, New York University. Journal of the American Medical Association. December 4, 1996. Accessed 23 February 2023.] 

In 2020, the latest year for which data is available, nearly three-quarters of caregivers who responded to ACL’s National Survey of Older Americans Act Participants reported that ACL-funded services enable them to provide care for longer than otherwise would be possible. Thirty-seven percent of family caregivers indicated that the care recipient would be unable to remain at home without their support, and a significant majority of those (65 percent) indicated that the care recipient would most likely be living in a nursing home or assisted living had ACL’s family caregiver support services had not been available (see chart below). 

In 2020 (the most recent year for which data is available):

· *Respite Care Services* provided over 50,245 family caregivers with nearly 4.9 million hours of temporary relief from their caregiving responsibilities (Output K)

· *Access Assistance Services* provided nearly 1.5 million contacts to caregivers, assisting them in locating services from a variety of public and private agencies (Output I)

· *Counseling and Training Services* provided over 92,865 family caregivers with counseling, peer support, and training to help them better perform caregiving tasks and cope with the stresses of caregiving (Output J)

In addition, in September 2022, ACL delivered the first *National Strategy to Support Family Caregivers*, which was developed jointly by the RAISE and SGRG Advisory Councils. With nearly 350 commitments from more than 15 federal agencies, and more than 150 ways states, communities, and other stakeholders can work together to improve support to family caregivers, the National Strategy serves as a roadmap for the nation to build an infrastructure that ensures family caregivers have the resources they need to maintain their own health and well-being. With increased funding received in FY 2023, ACL is beginning to build a foundation for its implementation. Supporting families and other informal caregivers is an issue that affects everyone. Nearly everyone will either need assistance to live independently at some point in their lives or provide assistance to help someone else live in the community. Many will do both. Expanding support for families and other informal caregivers has become an urgent public health imperative, and it is a critical component of advancing the Biden-Harris Administration’s priority of strengthening the care infrastructure.

### Outcomes and Outputs Table: Family Caregiver Support

*This is a developmental performance measure.  ACL is currently collecting sufficient data to establish a baseline.  To set a baseline, the agency relies on 3 years of data.  This process ensures that the data are stable and show a clear trend.  The agency will set targets for this measure once a baseline is established.

Note: For presentation within the budget ACL highlighted specific measures that are most directly related to Family Caregiver Support services; however, multiple performance outcomes are impacted by this program because ACL’s performance measures (efficiency, effective targeting, and client outcomes) assess network-wide performance in achieving current strategic objectives.

*This is a developmental performance measure.  ACL is currently collecting sufficient data to establish a baseline.  To set a baseline, the agency relies on 3 years of data.  This process ensures that the data are stable and show a clear trend.  The agency will set targets for this measure once a baseline is established.

** Targets not defined per explanation in the Overview of Performance section. Please refer back to page 20-21.

### Grant Awards Tables:

Family Caregiver Projects of National Significance Grant Awards

Family Caregiver Support State Grant Awards

*Represents States, and the District of Columbia

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON AGING**

**FY 2024 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER: Family Caregivers Support (CFDA 93.052)

1/ Undistributed- includes funds for Older American Act statutory requirements, including program evaluation and disaster assistance and grant and program reporting systems costs. Funds unused for these purposes at the end of the year are allocated to states.

CAREGIVER AND FAMILY SUPPORT SERVICES

## Native American Caregiver Support Services

*BA is in thousands of dollars.

Original Authorizing Legislation: Section 631 of the Older Americans Act of 1965, Public Law 89-73

Most Recent Authorizing Legislation: Supporting Older Americans Act of 2020, Public Law 116-131

Current FY Authorization	$12,815,237

Authorization Expiration Date	2024

Allocation Method	Formula Grant

### Program Description:

An estimated 1.1 million people age 60 and over identify themselves as Native American or Alaskan Native, alone or in combination with another racial group. The 2020 survey by the National Resource Center on Native American Aging, *Identifying Our Needs: A Survey of Elders,* shows that 33.7 percent of tribal elders have a family member as a caregiver.

The Native American Caregiver Support Services program provides grants to eligible tribal organizations to support family and informal caregivers of American Indian, Alaskan Native, and Native Hawaiian elders. Funding is allocated to eligible tribal organizations based on their share of the American Indian, Alaskan Native, and Native Hawaiian populations aged 60 and over. Organizations must receive a grant under the Native American Nutrition and Supportive Services program to receive funding. 

This program helps tribal elders age in place with dignity, reduces the need for costly nursing home care and medical interventions, is responsive to the needs of Native American communities, (many of which are geographically isolated) and represents an integral part of each community’s comprehensive services. A core value of the Native American Caregiver Support Services program is that it does not replace the tradition of families caring for their elders. Rather the program seeks to provide support that strengthens the family caregiver role.

The Native American Caregiver Support Services program provides a variety of direct services that meet a range of needs, including information and outreach, access assistance, individual counseling, support groups and training, respite care, and other supplemental services. Studies have shown that providing assistance to family caregivers can help them cope with the emotional, physical, and financial toll associated with caregiving, thereby enabling them to provide care for their loved ones longer and avoid or delay the need for costly nursing home care. 

Another critical component of the program is support to grandparents who are raising grandchildren. According to the *Identifying our Needs* survey mentioned above, nearly one-third of Native American older adults are caring for grandchildren, and of those 11 percent are the primary caregiver.  The program provides support, counseling training, and supplemental training to reduce the financial and emotional burden placed on these elders. 

### Budget Request:

The FY 2024 request for Native American Caregiver Support Services is $15,806,000, an increase of $3,806,000 above the FY 2023 enacted level. 

This increase is needed for three reasons.  First, years of relatively flat funding have resulted in a program that has struggled to serve even those most in need.  Second, Native Americans are located in more rural areas where caregiver services, including virtual services, are fewer and less accessible. This community has also experienced health inequities including poorer health and quality of life indicators, when compared to those in other rural caregiving settings. Finally, Native Americans as a group have been disproportionately affected by the impact of COVID-19, which caused a spike in the demand for services.  The pandemic affected the ability of caregivers and volunteers to offer services to the American Indian/Alaskan Native and Native Hawaiian elders living on reservations, given the lack of infrastructure to deliver services virtually. The effects of prolonged isolation have left many Native American elders more dependent on services and supports than they had been before, which has caused the need for services to stabilize at a level that is higher than before the pandemic. ACL’s request will allow the program to begin to meet these increased needs. 

### Funding History:

Funding for the Native American Caregiver Support Services over the past five years is as follows:

### Program Accomplishments:

Performance data indicates that these programs are an efficient means to help Native American Elders remain independent and in the community. In FY 2023, funding for the Native American Caregiver Support Program will continue to expand support to family and informal caregivers, whose assistance is critical to enabling Native American elders to remain at home, in the community, and/or on the reservation; while working to close the gaps with infrastructure and the ability to receive direct care and virtual services in times of public health emergencies. In FY 2021, the most recent year for which data is available, more than 1.3 million units of family caregiver – related services, including respite care, information and referral, caregiver training and support groups, were provided through the program. With an increase of approximately six percent in FY 2023, the program is expanding services and outreach, particularly to tribal caregivers in hardest to reach areas, to begin to address the increased needs described above.  

### Grant Awards Table:

Native American Caregivers Supportive Services Grant Awards

## Alzheimer’s Disease Program 

*BA is in thousands of dollars.

Authorizing Legislation: Section 411 of the Older Americans Act of 1965, Public Law 89-73 

Most Recent Authorizing Legislation: Supporting Older Americans Act of 2020, Public Law 116-131

Current FY Authorization	None/Expired

Expiration Date	2024

Allocation Method	Competitive Grants/Cooperative Agreements and Contracts

### Program Description:

The effects of Alzheimer’s Disease and Related Dementias (ADRD) can be devastating both for people living with the disease and for their family caregivers. Because dementia is a progressive condition, people with ADRD often need more support and assistance over time. Meeting the needs of people with ADRD typically requires significant levels of medical care, as well as a range of person-centered, dementia-capable home and community-based services, not to mention support from family caregivers. The complexity of care required by people living with dementia contributes significantly to caregiver stress. Moreover, approximately one-third of individuals with ADRD living in the community live alone, exposing them to numerous risks, including malnutrition, injury, and various forms of neglect and exploitation.[footnoteRef:34]  [34:  Gould, E., Knowles, M., Wiener, J. Handbook for Helping People Living Alone with Dementia Who Have No Known Support. Accessed 23 February 2023.] 

With the number of people 65 and older rapidly increasing, the number of people living with ADRDs is expected to reach 13.8 million by 2060.[footnoteRef:35] The majority of these people will need long-term, community-based services and supports to maintain quality of life and independence, and their caregivers will also need support and assistance. To meet this pressing need, ACL is working with states and communities, through the Alzheimer’s Disease Programs Initiative, to test, develop, and bring to scale “dementia-capable” home and community-based service systems. Such systems are designed to identify people with ADRD – and their caregivers – and to offer effective and coordinated service supports and services that are responsive to their unique needs. [35:  Alzheimer’s Association. 2022 Alzheimer’s Disease Facts and Figures. Accessed 19 January 2023.] 

Specifically, ACL issues grants to states, communities, and tribal organizations to develop and/or expand the dementia capability of their home and community-based service systems to address unmet needs and underserved populations or to expand their existing services to reach previously unserved populations. These services are often offered through partnerships between public and private entities to ensure they are effectively embedded in the community and are sustainable once federal funding ends. While each grant reflects the community it is designed to serve, a key focus of the ADPI involves piloting programs for people with ADRD who live alone, people with intellectual and developmental disabilities and ADRD, those who are at increased risk of ADRD, and caregivers who are learning to manage the behavioral challenges that may develop with ADRD. Collectively these grants seek to:

· Create state-, community- and tribe-wide, person-centered, dementia-capable home and community-based service systems

· Translate and implement culturally competent, evidence-based supportive services for people living with ADRD and their caregivers at the community-level

· Work with public and private entities to identify and address the special needs of people living with ADRD and their caregivers

· Offer direct services and supports to people living with ADRD and their caregivers

To support this work, ACL also funds the National Alzheimer’s and Dementia Resource Center. The resource center develops and disseminates resources, builds awareness of ADRD, and provides educational opportunities to providers of home and community-based services and family caregivers. 

### Budget Request: 

The FY 2024 request for the Alzheimer’s Disease Programs Initiative is $31,500,000, the same level as the FY 2023 enacted level. With the number of people with ADRD growing, the need for specialized support for their caregivers also will continue to grow. Maintaining the increase provided in the FY 2023 appropriation is critical to expanding the number of dementia-capable service delivery system across the nations so that people with ADRD have the support they need to live safely in their own homes and communities. 

### Funding History:

/1 All years include $14.7 million in funding from the Prevention and Public Health Fund. 

### Program Accomplishments:

Alzheimer’s Disease Programs Initiative grants have supported states, communities, and tribes, to develop and test promising practices to support people living with ADRD and their caregivers. These programs are evaluated for their impact, with the goal of scaling successful programs beyond federal funding. Outcomes of grants funded through the programs include, but are not limited, to: increases in the range of services and supports communities provide to people living with dementia, improved capacity to provide specialized services to people with a cognitive impairment or dementia and their caregivers, implementation of dementia training for staff, and the adoption of standardized, measurable and replicable procedures for screening for dementia among people living in the community to increase diagnoses and uptake of appropriate supports and services. 

The program also delivers direct services to people with ADRD. In 2021, more than 5,000 people living with ADRD, and more than 13,000 caregivers benefitted from direct service programs. However, these numbers reflect only one impact of the program. In addition to providing critical services to support currently affected by ADRD, these programs also service providers increase their dementia capability, ensuring that communities will continue to benefit from these grants long after the period of federal funding ends. Many grantees also develop and deliver training for professionals, including primary care providers, registered nurses, social workers, and community health workers; in 2021, more than 14,500 professionals participated in in-person and virtual training to better serve those with ADRD in their practices and their local communities now and well into the future. These unduplicated numbers of people served reflect represent more than 118,000 hours of services and education provided. Collectively, the Alzheimer’s Disease Programs Initiative programs make it possible for those living with ADRD across the nation to live in their own communities safely and with dignity.

### Outcome and Outputs Table: Alzheimer’s Disease Program

*This is a developmental performance measure.  ACL is currently collecting sufficient data to establish a baseline.  To set a baseline, the agency relies on 3 years of data.  This process ensures that the data are stable and show a clear trend.  The agency will set targets for this measure once a baseline is established.

### Grant Awards Tables:

Alzheimer’s Disease Program

1/ FY 2023 does not reflect grants awarded from carryover funds. 

****

## Lifespan Respite Care

*BA is in thousands of dollars.

Original Authorizing Legislation: Lifespan Respite Care Act of 2006, Title XXIX of the Public Health Service Act

Most Recent Authorizing Legislation: Lifespan Respite Care Act of 2006, Title XXIX of the Public Health Service Act

Current FY Authorization	Expired

Expiration Date	2011

Allocation Method	Competitive Grants

### Program Description:

Respite care services are among the most frequently requested supportive services for family caregivers.[footnoteRef:36] Respite is second only to direct financial assistance as a key priority of surveyed family caregivers.[footnoteRef:37] Even though respite services are often the preferred mode of family caregiver support, they are often difficult to find and access, unaffordable, or in short supply.  As a result, nearly 90 percent of family caregivers receive no respite services at all.18 The barriers to accessing and using respite services are often particularly high for caregivers of people with significant support needs, such as family caregivers of people with intellectual and developmental disabilities,  Alzheimer’s disease, spinal cord injuries, multiple sclerosis, and serious emotional disorders, as well caregivers providing support to veterans and people who are autistic.[footnoteRef:38] [36:  Still in the Shadows with Their Future Uncertain: A Report on Family and Individual Needs for Disability Supports (2011). Accessed 23 February 2023.]  [37:  Care Giving in the United States (2021). Accessed 23 February 2023 ]  [38:  National Alliance for Caregiving. Multiple Sclerosis Caregivers. (2012). Accessed 23 February 2023.] 

The Lifespan Respite Care program focuses on easing the impact of caregiving by providing grants to eligible state organizations to improve the quality of, and access to, respite care for family caregivers. The program provides resources to develop and test infrastructure changes and to fill gaps by putting in place coordinated systems of accessible, community-based respite care service; training and recruitment of respite care workers and volunteers; and the provision of information, outreach, and access assistance. The program also recognizes that family caregiving and the need for respite care are not only aging issues; families provide the majority of support for people with disabilities, and that support often is needed throughout the disabled person’s life. Accordingly, the program’s focus includes family caregivers of both older adults and people of all ages with disabilities.  

The Lifespan Respite Care program also supports technical assistance activities, such as training to state, community, and nonprofit respite care programs; support to advance state systems and capacities to deliver respite care and address the systemic infrastructure necessary to mitigate gaps in respite care services; and public information, referral, and education programs on respite care, as well as maintenance of national database on respite care. Special emphasis is placed on implementing or enhancing lifespan respite care statewide and building or improving the capacity of their long-term care systems to respond to the comprehensive needs of care recipients.

### Budget Request:

The FY 2024 request for the Lifespan Respite Care program is $14,220,000, an increase of $4,220,000 from the FY 2023 enacted level. The increase will begin to address gaps in respite services at the state level; support development of more efficient, cost-effective methods of providing respite services; increase outreach to historically underserved communities to populations. 

### Funding History:

Funding for the Lifespan Respite Care program during the past five years is as follows:

### Program Accomplishments:

Since its creation in 2009, the Lifespan Respite Care program has made 101 grants to 38 states to develop, expand, integrate, and sustain their respite care systems, and funded a National Technical Assistance Resource Center. In that time, the program has provided an estimated 12,000 family caregivers with more than 313,000 hours of respite care, and an estimated 12,345 family caregivers have participated in 469 respite training events. Additional examples of grantee accomplishments include:

· Creation and adoption of statewide respite plans and/or policies to guide further development of respite and family caregiver support programs

· Development or enhancement of training programs for respite care providers to expand the cadre of trained respite professionals

· Replication and expansion of respite delivery modalities with a particular focus on person-centered planning and consumer direction

· Expansion of toll free “helplines,” dedicated websites, and statewide respite registries, to provide caregivers with information about available respite programs

· Development and deployment of marketing and awareness campaigns designed to educate family caregivers about the importance of their work and the necessity to take a break

· Development of data collection methodologies to track service provision and programmatic outcomes

· Broadening stakeholder collaborations to ensure representation of all age and disability groups, as well as the broadest possible cross section of the provider network

· Capacity building and network development at the local level to recruit and train volunteers to fill gaps in respite services, particularly in rural areas

· Provision of direct respite services to family caregivers of children with intellectual and developmental disabilities, adults with physical disabilities, and older Americans

### Output Table: Lifespan Respite Care: Measure Discontinued

### Grant Awards Table:

Lifespan Respite Care Grant Awards

CAREGIVER AND FAMILY SUPPORT SERVICES

CAREGIVER AND FAMILY SUPPORT SERVICES

146

# Protection of Vulnerable Adults

## Summary of Request

Protection of Vulnerable Adults consists of several distinct, but complementary, programs that uphold the rights of older adults and prevent, detect, and respond to elder abuse, neglect, and exploitation, both in homes in the community and in residential facilities, such as nursing homes. 

As the population of older adults increases, the problem of elder abuse, neglect, and exploitation continues to grow. Data from state adult protective services (APS) agencies show an increasing trend in reports of adult maltreatment. Prior to the COVID-19 pandemic, research suggested that that at least 10 percent of older adults in the United States, or approximately five million people, experience abuse each year, and many experience it in multiple forms.[footnoteRef:39] A study conducted in 2020 estimated that the prevalence of elder maltreatment during the pandemic increased by an astounding 84 percent.[footnoteRef:40] These increases are particularly concerning given that as few as one in 23 cases of elder abuse and one in 44 cases of financial exploitation are reported. [footnoteRef:41] [39:  Acierno, R., Hernandez, M. A., Amstadter, A. B., Resnick, H. S., Steve, K., Muzzy, W., & Kilpatrick, D. G. (2010). Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: The National Elder Mistreatment Study. American Journal of Public Health, 100(2), 292–297. Accessed 23 February 2023.]  [40:  Chang, E., Levy, B. (2021). High Prevalence of Elder Abuse During the COVID-19 Pandemic: Risk and Resilience Factors. American Journal of Geriatric Psychiatry. Accessed 18 February 2023.]  [41:  New York City Dept for the Aging; Lifespan of Greater Rochester, Inc., & Weill Cornell Medical Ctr of Cornell University. (2011). Under the Radar: New York State Elder Abuse Prevalence Study. Rochester: Lifespan of Greater Rochester, Inc. Accessed 18 February 2023.] 

The negative effects of abuse, neglect, and exploitation on the health and independence of older adults are extensive. Research has demonstrated that victims of even modest forms of elder abuse have dramatically higher (300 percent) morbidity and mortality rates than older people who have not experienced abuse.[footnoteRef:42] Abuse, neglect, and exploitation also increase the likelihood of heart attacks, dementia, depression, chronic diseases, and psychological distress. These unnecessary health problems result in a growing number of older adults who are accessing the healthcare system more frequently (including emergency room visits and hospital admissions) and are ultimately forced to leave their homes and communities prematurely.[footnoteRef:43]  [42:   Baker, M. W., LaCroix, A. Z., Wu, C., Cochrane, B. B., Wallace, R., & Woods, N. F. (2009).Mortality risk associated with physical and verbal abuse in women aged 50 to 79. Journal of the American Geriatrics Society, 57(10), 1799–1809. Accessed 18 February 2023.]  [43:  Dong X, Simon MA. Association between elder abuse and use of ED: findings from the Chicago Health and Aging Project. AmJEmergMed. 2013;31:693–698. Accessed 18 February 2023.] 

ACL’s programs that focus on Protection of Vulnerable Adults work together to prevent these outcomes for older people and adults with disabilities and to uphold their basic human right to live free from abuse. 

The total FY 2024 request for Protection of Vulnerable Adults is $144,459,000, an increase of $48,927,000 above the FY 2023 enacted level $95,532,000. The bulk of the increase funds state APS formula grants at a very basic level. It also increases funding for the state long-term care ombudsman program to maintain service expansion to include people who live in assisted living facilities and to maintain increased support to residents who wish to transition from nursing homes and other congregate settings back to the community. The rest of the increases cover increasing costs for programs which have not received increases in years. The budget also maintains support for elder justice and adult protective services infrastructure to address opioid misuse and to advance guardianship reform. Specifically, the request includes:

· $73,000,000 for the Elder Justice/APS program, an increase of $43,000,000 above the FY 2023 enacted level. The American Rescue Plan Act provided two years of start-up funding ($188 million in each year) to fund, for the first time, the nationwide APS formula grant program authorized by the Elder Justice Act in 2012. That one-time funding was used by states to expand or develop a variety of capabilities that were necessary to meet significantly increased needs due to the pandemic and to strengthen APS systems.  The FY 2023 Omnibus Appropriations Bill provided, for the first time, $15 million in discretionary funding to prevent program termination as American Rescue Plan funds are exhausted. Beginning in FY 2024, additional funding is needed to allow states to maintain service levels and to sustain the significant improvements to the programs during the start-up phase. The requested $58 million for APS state grants will begin to fund the program at a more sustainable ongoing national level. The request also maintains support for Elder Justice/APS infrastructure work and targeted efforts to address opioid misuse and to advance guardianship reform.

· $27,000,000 for the Long-Term Care Ombudsman program, an increase of $5,115,000 above the FY 2023 enacted level. The increase will allow the program to continue to extend long-term care ombudsman services to people living in assisted living facilities and maintain increased support to residents who wish to move from nursing homes and other congregate settings back to the community. 

· $5,059,000 for Prevention of Elder Abuse and Neglect, an increase of $286,000 above the FY 2023 enacted level. This program provides formula grants to state units on aging to support training, education, and public awareness activities to prevent elder abuse. The request would help offset costs that have increased over the last ten years, during which time the program has received no significant increases in funding.

· $35,000,000 for the Health Care Fraud and Abuse Control/Senior Medicare Patrol/ program (HCFAC/SMP), the same level as the FY 2023 enacted. The FY 2024 placeholder is the same amount of funding that was provided in FY 2023. HCFAC/SMP funds competitive grants and related infrastructure to support a network of older adult volunteers who are trained to help to prevent and combat healthcare fraud and abuse, which helps to preserve the financial integrity of the Medicare and Medicaid programs.

· $4,400,000 for Elder Rights Support Activities, an increase of $526,000 above the FY 2023 enacted level. The program provides information, training, technical assistance and resources to states and communities to promote the rights of older adults to live where they wish, whether in their own homes or in long-term congregate housing, free from abuse, neglect, and exploitation. The requested increase would help cover increases in the cost of services for a program that has been level-funded for the past five years. 

PROTECTION OF VULNERABLE ADULTS

PROTECTION OF VULNERABLE ADULTS

Together, these programs provide a foundation and establish best practices for states to expand and improve the protection of older people living in their communities and in long-term care settings. These programs (1) increase the information and technical assistance available to the public, states, and localities in preventing and addressing abuse; (2) protect the rights of older adults and people with disabilities and prevent and address abuse, neglect and exploitation; (3) reduce health-care fraud and abuse; and (4) provide assistance to states and tribes in developing elder justice systems. This multifaceted approach to resolving elder abuse, neglect, and exploitation is essential to fulfilling the shared mission of the Older Americans Act and the Elder Justice Act.

## Long-Term Care Ombudsman Program

*BA is in thousands of dollars.

Original Authorizing Legislation: Section 702 and 712 of the Older Americans Act of 1965, Public Law 89-73.

Most Recent Authorizing Legislation: Supporting Older Americans Act of 2020, Public Law 116-131

Current FY Authorization	$21,518,027

Authorization Expiration Date	2024

Allocation Method	Formula Grant

### Program Description:

The Long-Term Care (LTC) Ombudsman program is a consumer advocacy program that works to improve the quality of life and care for the estimated three million individuals of all ages who reside in over 75,700 long-term care facilities (over 15,800 licensed nursing facilities and 59,900 assisted living/board and care facilities). Formula grants to states and territories are based on the number of individuals age 60 and older, and provide funding for the training, travel, and other operating costs of 6,051 designated staff and volunteers. Ombudsmen resolve complaints with, and on behalf of, these residents, while advocating for systemic improvement of long-term services and supports, including routinely monitoring the condition of long-term care facilities.

A primary duty of an ombudsman is to identify, investigate, and resolve complaints that are made by or on behalf of residents. These complaints relate to action, inaction, or decisions of providers, public agencies, and others that may adversely affect residents’ health, safety, welfare, or rights. 

Ombudsmen also advocate on behalf of residents by representing their interests before government and administrative entities, providing information to residents and families about long-term services and supports and educating the public about issues related to long-term services and supports policies and regulations.

The efficiency of the LTC Ombudsman program is due in part to a strong reliance on volunteers who visit residents regularly and assist with problem resolution. These trained and designated volunteer ombudsmen donated over 149,135 hours in FY 2021. 

Federal and state policy changes – including the promotion of Medicaid Home & Community Based Services (HCBS) through waivers, the increase of Medicaid managed LTSS, and demonstration projects to serve persons receiving both Medicare and Medicaid – are creating opportunities, as well as some new challenges, for LTC Ombudsman programs. As these services expand and provide more options for residents, ombudsmen work to represent their interests and concerns and to ensure that strong beneficiary support systems are in place.  

Increasingly, people are choosing to live in residential settings other than nursing homes, such as assisted living and other residential care communities (known by various names under state laws). As a result, LTC Ombudsman programs report increasing work, both at the individual complaint and the systems levels on behalf people living in these types of residential settings. Responding to their concerns and resolving complaints during COVID-19 required each LTC Ombudsman program to maneuver state-level health department guidance to access and provide services to residents.   

### Budget Request:

The FY 2024 request for the LTC Ombudsman program is $27,000,000, an increase of $5,115,000 above the FY 2023 enacted level of $21,885,000, to maintain service expansion to include people who live in assisted living facilities and maintain increased support to residents who wish to transition from nursing homes and other congregate settings back to the community. 

Ombudsmen advocate to protect the health, safety, welfare and rights of residents of long-term care facilities. Ombudsman activities complement ACL’s successful elder rights programs to create a full array of services that prevent, detect, and resolve elder abuse, neglect, and exploitation. Ombudsmen also support people who choose to transition out of nursing homes and other facilities into more integrated settings. They also advocate for quality care, individual rights, and well-being in other congregate long-term care settings, such as assisted living/board and care facilities, but need funding for staff, volunteers, and PPE to cover these facilities.  Ombudsmen serve long-term care residents regardless of their eligibility for Medicaid or other public benefits. Ombudsmen also advocate for quality care, individual rights, and well-being in other congregate long-term care settings, such as assisted living and board-and-care facilities and are the only federally funded entity providing services to all these residents. 

To maintain services across all of these congregate settings, additional funding is needed to cover the costs of staff, volunteers, and PPE., 

Outcome data (displayed in the summary tables at the end of this section) demonstrate the success of this program in protecting older Americans every year. State LTC Ombudsman programs provide effective oversight. The percentage of the complaints processed by ombudsmen that were fully or partially resolved to the satisfaction of the resident was 71 percent in FY 2021.77 Reducing the number of complaints not resolved to the satisfaction of the resident is one indicator of program effectiveness.

### Funding History: 

Funding for the Long-term Care Ombudsman program over the past five years is as follows:

1/ The amount listed does not include $18 million provided out of funding for Elder Justice in FY 2022 in the American Rescue Plan Act of 2021.

### Program Accomplishments:

Trained and LTC ombudsman-designated volunteers returned to facilities after COVID-19 visitation restrictions and individual choice led to decreased engagement in 2020. In 2021, volunteer ombudsman representatives donated 149,135 hours. The number of complaints LTC Ombudsman programs handle is a proxy measure of how accessible the program is to residents. In 2021, ombudsman representatives worked on 164,299 complaints, partially or fully resolving 71.3 percent. 

### Outcomes and Outputs Tables: Long-Term Care Ombudsman Program

*This is a developmental performance measure.  ACL is currently collecting sufficient data to establish a baseline.  To set a baseline, the agency relies on three years of data.  This process ensures that the data are stable and show a clear trend.  The agency will set targets for this measure once a baseline is established.

*This is a developmental performance measure. ACL is currently collecting sufficient data to establish a baseline. To set a baseline, the agency relies on 3 years of data.  This process ensures that the data are stable and show a clear trend. The agency will set targets for this measure once a baseline is established.

### Grant Awards Table:

Long-Term Care Ombudsman Program Formula Grant Awards

1/ Includes $10 million in supplemental funding from the American Rescue Plan for directly provided to the Long-Term Care Ombudsman program.

2/ Excludes $18 million provided by the American Rescue Plan for Elder Justice Services in FY 2022 that were then targeted to Ombudsman grants.

*Represents States, and the District of Columbia

****

PROTECTION OF VULNERABLE ADULTS

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON AGING**

**FY 2024 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER:   Long-Term Care Ombudsman Program (CFDA 93.042)

1/ Undistributed – includes funds for Older Americans Act statutory requirements, including disaster assistance, and grant and program reporting systems costs. Funds unused for these purposes at the end of the year are allocated to states.

## Prevention of Elder Abuse and Neglect

*BA is in thousands of dollars.

Original Authorizing Legislation: Section 702(b) of the Older Americans Act of 1965, Public Law 89-73.

Most Recent Authorizing Legislation: Supporting Older Americans Act of 2020, Public Law 116-131

Current FY Authorization	$6,082,650

Authorization Expiration Date	2024

Allocation Method	Formula Grant

### Program Description:

The Prevention of Elder Abuse and Neglect program provides formula grants to states units on aging based on their share of the population 60 and over, to train state and local officials and promote public awareness of elder abuse. The program also supports state and local elder abuse prevention coalitions and multi-disciplinary teams. These activities are important elements of ACL’s activities related to elder rights and elder justice.  The program coordinates activities with state and local Adult Protective Services programs (over half of which are directly administered by State Units on Aging) and other professionals who work to address issues of elder abuse and elder justice.  The importance of these services at the state-level and local-level is demonstrated by the fact that states significantly leverage Older Americans Act (OAA) funds to obtain other funding for these activities. 

The Prevention of Elder Abuse and Neglect program is a crucial piece of ACL’s ongoing commitment to protecting the rights of older adults and promoting their dignity and autonomy. Through education efforts, exposing problems that would otherwise be hidden from view, and providing a voice for those who cannot act for themselves, the program helps ensure that all older Americans are able to age with dignity in a safe environment.

### Budget Request:

The FY 2024 request for the Prevention of Elder Abuse and Neglect program is $5,115,000, an increase of $286,000 above the FY 2023 enacted level. This will be the first increase states will receive from the program in the past decade. This increase will maintain the ability of states and territories to train law enforcement officials, develop and distribute educational materials, conduct public awareness campaigns, and create community coalitions and multidisciplinary teams to investigate and respond to elder abuse and neglect.  States and area agencies on aging will also use this funding to coordinate their activities with fraud and crime prevention partnerships organized by sheriffs, police chiefs, and community organizations.

Elder Abuse Prevention activities are important elements of ACL’s elder rights and elder justice activities and complement by funding the infrastructure in which best practices may be developed and evaluated.

### Funding History:

Funding for Prevention of Elder Abuse and Neglect over the past five years is as follows:

### Program Accomplishments:

In FY 2020, over $38 million of the Elder Abuse Prevention services expenditures was leveraged from non-OAA funds, a ratio of more than $9.00 of non-OAA funds for every $1 investment of ACL funds.  States use their OAA Title VII, Section 721 funding for a number of different activities, including:

· In 2022, the Connecticut State Unit on Aging has used a portion of the Elder Abuse Prevention funds to support the work of the Coalition for Elder Justice in Connecticut.  The Coalition has worked collaboratively with the Attorney General’s Office to support the new “Elder Justice Hotline,” present at the Connecticut Coalition to End Homelessness Annual Training Institute, promote the Walk for World Elder Abuse Awareness Day; hosting weekly walks across the state to raise awareness, provide training to state and municipal police through partnership with the Connecticut Police Academy, appear on AARP’s monthly “Fraud Fighting Fridays” webinars, and provide monthly webinars geared toward attorney and social workers that are appointed as conservators in collaboration with the Office of Probate Administration and the Connecticut Bar Association, Elder Law Section.

· The Idaho Commission on Aging’s held a three-day collaborative titled “Better Together” in 2021 with the purpose of strengthening partnerships and providing education to prevent abuse, neglect and exploitation of vulnerable adults. Participants included individuals and organizations interacting with vulnerable adults, such as social services, first responders, health care providers, guardians and fiduciaries, legal and public health community, judiciary, and elected officials.

Examples of state elder abuse prevention activities include:

· Nebraska hosts an annual elder justice training that is livestreamed for regional and national participation with a dedicated website to distribute all shared resources, and was able to develop statewide reporting that has the capacity to create and share reports that highlight case data, education events, and provide story telling annually

· The South Dakota State Unit on Aging uses a portion of OAA Section 721 funding to provide training to staff and allied professionals on identifying and reporting adult maltreatment

### Output Table: Prevention of Elder Abuse and Neglect

****

### Grant Awards Table:

Prevention of Elder Abuse, Neglect, and Exploitation Grant Awards

*Represents States, and the District of Columbia

****

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON AGING**

**FY 2024 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER: Prevention of Elder Abuse & Neglect (CFDA 93.041)

1/ Undistributed – includes funds for Older Americans Act statutory requirements, including disaster assistance, and grant and program reporting systems costs. Funds unused for these purposes at the end of the year are allocated to states.

##  Health Care Fraud and Abuse Control/Senior Medicare Patrol Program

*BA is in thousands of dollars, FTE is a whole number.

1/ The FY 2023 appropriations language states that SMP/Health Care Fraud and Abuse Control Program (HCFAC) is paid out of discretionary CMS HCFAC appropriations based on the Secretary of HHS’s determination of the amount needed to provide funding but not less than the floor of $35 million provided in appropriations language. 

2/ The FY 2024 amount is being shown comparably with the FY 2023 funding level.

Original Authorizing Legislation: Sections 201, 202, and 411 of the Older Americans Act of 1965, Public Law 89-73 and the Health Insurance Portability and Accountability Act (HIPAA) of 1996, P.L. 104191 

Most Recent Authorizing Legislation: Supporting Older Americans Act of 2016, Public Law 116-131

Current FY Authorization	None Specified

Authorization Expiration Date	2024

Allocation Method	Competitive Grant/Contracts

### Program Description:

The Senior Medicare Patrol (SMP) program empowers and assists Medicare beneficiaries, their families, and caregivers to prevent, detect, and report health care fraud, errors, and abuse through outreach, counseling, and education. ACL supports 54 SMP grantee projects with one in each state, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. The SMPs provide education to Medicare beneficiaries and the public through in-person and virtual outreach events, media activities, and one-on-one assistance to those who contact the program with questions or suspected cases of Medicare fraud. The SMPs teach Medicare beneficiaries to take proactive steps to protect themselves and the Medicare program from potential fraud, errors, and abuse.  They also actively disseminate fraud prevention and identification information through the media, outreach campaigns, community events, and one-on-one beneficiary support. SMPs help individuals and their loved ones understand how to review their health care statements and bills for accuracy, as well as how to identify and avoid potential fraud schemes. If suspicious activity is identified or suspected, SMPs can help answer questions, resolve errors, or report suspicious activity for further investigation.

One key role of the SMPs is to assist beneficiaries by referring potential fraud complaints on to other investigate entities, as appropriate. This process can include facilitating referrals to the Department of Health and Human Services (HHS)-Office of Inspector General (HHS-OIG), the Centers for Medicare & Medicaid Services (CMS), Federal Bureau of Investigations (FBI), Federal Trade Commission (FTC), state Medicaid fraud control units (MFCUs), state attorneys general, and other organizations. Capturing SMP program activity data is also a key function of the projects, including tracking, analyzing, and reporting of beneficiary complaints, referrals, potential savings, and other outcomes. 

### Budget Request:

The FY 2024 request is not less than $35,000,000, the same amount as provided in the FY 2023 enacted level used to support the Senior Medicare Patrol (SMP). The requested level supports an estimated 4 FTE.  

The $35,000,000 assumed in the requests for each of these years will be used to maintain funding at current levels for SMP projects in each state, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. SMP projects will continue to provide education to Medicare beneficiaries and the public through in-person and virtual outreach events, media activities, and one-on-one assistance to those who contact the program with questions or suspected cases of Medicare fraud.  Continued funding at this level will also enable SMPs to operate more effectively and efficiently, while better meeting the increasing demands for SMP services. Even during the pandemic, Medicare fraud schemes have been on the rise. This reflects the complexity of Medicare and the virtual environment that we live in which in turn has driven the need to increase SMP education and prevention efforts.

### Funding History:

Comparable funding for SMP discretionary appropriations over the past five years is as follows:

1/ Does not include an additional $2,000,000 in funding allocated to this program from Health Care Fraud and Abuse Control Program (HCFAC) wedge funding in FY 2022 and $1,300,000 in FY 2023.

### Program Accomplishments:

SMPs remain in the forefront in providing education and prevention to combat Medicare fraud, as they did in early 2019 when SMP grantees were the first to alert ACL, the HHS OIG, and CMS of genetic testing schemes that were emerging across the country.  SMP worked closely with ACL, CMS, and the OIG to provide cases and complaints directly to investigators upon receipt to ensure the cases were getting in the right hands as quickly as possible.  These efforts led to the September 27, 2019, takedown that resulted in charges against 35 individuals for their alleged participation in health care fraud schemes involving $2.1 billion in losses.  

In addition, SMP has created several consumer fraud alerts targeting new and emerging fraud schemes warning beneficiaries about potential fraud schemes.  Two examples include: 

· Hospice fraud alert released in 2021 warning beneficiaries about unsolicited marketing tactics to enroll beneficiaries in hospice services.  It advises beneficiaries to be sure that their doctor has assessed their condition and certified that they are terminally ill.  In 2021 SMPs conducted 304 group education events covering hospice fraud, reaching a total of 11,795 people.  In addition, they conducted 101 instances of media outreach on this topic reaching 17.3 million people. 

· COVID-19 fraud alert also released in 2021 warning beneficiaries to be suspicious of strangers offering free COVID-19 testing, supplies, treatments, or vaccines.  The SMPs conducted 645 group education events on this topic, reaching 26,704 people.  In addition, they conducted 454 instances of media outreach on COVID-19 schemes, reaching 21.4 million people. 

Additional data obtained from the SMP data system, the SMP Information and Reporting System (SIRS) for calendar year 2021 shows that Senior Medicare Patrol projects:

· Maintained 5,346 active SMP team members who worked over 442,263 hours to educate beneficiaries about how to prevent Medicare fraud, errors, and abuse

· Educated 556,980 individuals during 12,660 group outreach and education events

· Responded to 239,625 individual inquiries for information or assistance from Medicare beneficiaries, family members, and caregivers related to Medicare fraud, errors, and abuse

Since the Senior Medicare Patrol program’s inception, SMP projects have received more than 3.3 million inquiries from Medicare beneficiaries about preventing, detecting, and reporting billing errors, potential fraud, or other discrepancies. SMPs also have educated more than 41.7 million people through group presentations and community outreach events.  The primary focus of these sessions is on education, prevention, and teaching beneficiaries how to protect themselves and avoid fraud in the first place; this is the true value of the SMP program.

As HHS-OIG indicated in their June 2022 report on the SMP program:

*“We note that the projects may not be receiving full credit for recoveries, savings, and cost avoidance attributable to their work. It is not always possible to track referrals to Medicare contractors or law enforcement from beneficiaries who have learned to detect fraud, waste, and abuse from the projects.  In addition, the projects are unable to track the potentially substantial savings derived from a sentinel effect whereby Medicare beneficiaries’ scrutiny of their bills reduce fraud and errors.”*

While SMPs make numerous referrals of potential fraud to CMS and the OIG, there are challenges to evaluating the investigation, prosecution, and collection that is required to calculate the full savings to the government as a result of SMP referrals. HHS-OIG has documented over $141.3 million in savings attributable to the program as a result of beneficiary complaints since the program’s inception in 1997.

### Output Table: Senior Medicare Patrol Program

### Grant Awards Table:

Senior Medicare Patrol Grant Awards

*Represents states and the District of Columbia

147

## Elder Rights Support Activities

*BA is in thousands of dollars, 

Authorizing Legislation: Sections 201, 202, 411, 751 and 752 of the Older Americans Act of 1965, Public Law 89-73, Title XX of the Social Security Act, Subtitle B, as amended by the Affordable Care Act.  

Most Recent Authorizing Legislation: Supporting Older Americans Act of 2020, Public Law 116-131

Current FY Authorization (OAA)	$20,299,621

Authorization Expiration Date	2024

Allocation Method	Competitive Grants/Co-operative Agreements and Contracts

### Program Description:

Elder Rights Support Activities provide information, training, technical assistance, and resources to states and communities to promote the rights of older Americans to live where they wish, whether in their own homes or in long-term congregate housing.  These activities assist individuals to obtain necessary and appropriate health care, especially including care and services in their own homes; and to live free from abuse, neglect, and exploitation. The National Center on Elder Abuse, the National Long-Term Care Ombudsman Resource Center, the National Center for Law and Elder Rights, and the Legal Assistance Enhancement Grant Program comprise an interconnected framework for carrying out ACL’s Protection of Vulnerable Adults competitive grant programs.

To promote the rights of older Americans and to combat the increasing frequency of elder abuse, neglect, and exploitation in America, ACL’s goal is to put in place, in coordination with its Elder Justice/Adult Protective Services programs and the Elder Justice Coordinating Council, a comprehensive approach that provides a coordinated and seamless response system that includes the Long-term Care Ombudsman Program, the national network of local legal assistance providers and other community services and alliances. The Elder Rights Support Activities described below are key components of ACL’s ongoing elder rights programs.

#### National Center on Elder Abuse

To support and enhance the activities of state and local programs to prevent elder abuse, neglect, and exploitation, ACL funds the National Center on Elder Abuse (NCEA). NCEA disseminates information to professionals and the public; collaborates on research; provides consultation; identifies and provides information about promising practices and interventions; answers inquiries and requests for information; operates a listserv forum for professionals; and advises on program and policy developments.  NCEA also facilitates the exchange of strategies for uncovering and prosecuting fraud in areas such as telemarketing and sweepstakes scams.  Examples of past NCEA activities include:

· Responding to individual public inquiries and requests for information regarding elder abuse

· Providing cost-effective trainings to professionals though live Webcast forums on issues relevant to elder justice, training professionals through presentations at national conferences, and creating and disseminating research-themed training podcasts to promote continual learning

· Continuing to support systems change by identifying local elder justice community coalitions and reaching out to them to learn how they leverage local resources and expertise to prevent and combat elder abuse, neglect, and exploitation, as well as offering technical assistance on operating, invigorating, and sustaining coalitions

#### National Long-Term Care Ombudsman Resource Center

The National Long-Term Care Ombudsman Resource Center (NORC) provides training and technical assistance to support the activities of state and local long-term care ombudsmen. The Center works to enhance the skills, knowledge and management capacity of the statewide ombudsman programs to enable them to address resident complaints and represent resident interests.  The Center also provides information to consumers and links them to ombudsmen who can help consumers navigate the long-term care system and resolve problems in nursing facilities, board and care homes, and assisted living facilities.

#### Legal Assistance and Support

Legal Assistance and Support provides funding for two distinct yet related initiatives: the National Center on Law and Elder Rights (NCLER) and the Legal Assistance Enhancement Program (LAEP).  NCLER provides technical assistance, training and capacity-building supports for the nation’s Older Americans Act-funded and other legal assistance providers and their partners in the aging and disability networks. This network includes a wide range of legal and aging services professionals, including Title III-B legal services program professionals, legal aid staff, legal assistance developers (LADs), long-term care ombudsman, social workers, service coordinators, Area agencies on aging staff, state unit on aging staff, protection and advocacy organization staff, adult protective services staff, law enforcement, and other professionals working with older adults to promote elder rights.  LAEP supports legal assistance programs and community partners working on replicable and sustainable innovations to expand the resources available to support elder rights by delivering full-range legal assistance, from legal advice through representation.

### Budget Request:

The FY 2024 request for Elder Rights Support Activities is $4,400,000, an increase of $526,000 above the FY 2023 enacted level. The request is needed both to maintain the operations of the National Center on Elder Abuse, continue to provide Legal Assistance and Support, and to complement ACL’s request for the Long-Term Care (LTC) Ombudsman program by doubling the support for the LTC Ombudsman Resource Center.  Caregivers (many of whom are thrust into that position for the first time) often struggle to get the information they need to navigate the long-term care system. Expanding resources for the National Long-Term Care Ombudsman Resource Center would improve the depth of information that can be provided, allowing consumers to more easily link to ombudsmen who can help them navigate the long-term care system and resolve problems in nursing facilities, board and care homes, and assisted living facilities.

### Funding History:

Comparable funding for Elder Rights Support Activities over the past five years is as follows:

**Elder Rights Support Activities**

(Dollars in thousands)

### Program Accomplishments:

The National Center on Law and Elder Rights NCLER’s webinar series on shifting to the remote practice of legal assistance and remote engagement with courts and administrative appeals forums was the earliest (March 2020) provision of technical assistance during COVID-19 received by ACL’s legal assistance providers, and NCLER’s webinars on this and other cutting-edge issues of elder rights consistently garner audiences of 3,000 to 4,000 participants. 

National Center on Law and Elder Rights Accomplishments 

NCLER carries out a number of different activities, including training, information resources, and tools dissemination.

· TRAINING: NCLER disseminated critical and timely information relevant to supporting older Americans. NCLER produces at least 24 trainings per year. Topics are focused on the priority legal issues in the OAA and are designed to be responsive to changing legal landscapes and emergencies. Trainings were rated as “good or excellent” by 99 percent of respondents, and 97 percent of respondents said the trainings helped contribute to the successful resolution of a case. In 2020, with the onset of the COVID-19 pandemic, NCLER responded in the first weeks of the shutdown by training over 3,000 advocates on remote service delivery to help them continue to reach and serve older adults. Similarly, NCLER prepared the network for assisting older adults in the winddown of the Public Health Emergency, with a training reaching over 1,300 advocates last year. Since 2020, NCLER has also held trainings to equip attorneys and advocates to respond to emerging issues, such as the eviction crisis, by training a combined audience of over 10,000 on topics covering eviction defense, diversion, and rental assistance to help keep older Americans housed.  NCLER has also provided trainings on responding to natural disasters and long-COVID. In FY 2022, NCLER had over 31,000 training participants and over 41,000 visitors to the NCLER website.  

· SUPPORTING ELDER RIGHTS AND AUTONOMY:

· In 2022, NCLER worked in collaboration with ACL to produce a two-part training series on *Strengthening Rights and Ensuring Accountability in Guardianship Systems and Practices*. These trainings reached a combined audience of over 1,400 advocates and provided tools for courts and attorneys to use to promote less restrictive options, due process, and accountability. ACL Elder Justice Innovations Guardianship Grantees from 10 states are also being supported by NCLER, and their projects are designed to create new models for courts to use to respond to guardianship abuse, implement improved monitoring, and address problematic guardianship pipelines.  

· Targeted technical assistance to states on Home and Community Based Services (HCBS) has been another way that NCLER supports choice to age in place. This assistance included helping with the implementation of the American Rescue Plan Act (ARPA) HCBS funding. For example, NCLER worked with advocates in Missouri and assisted them with ensuring that assessments for levels of care were in compliance with the Olmstead Supreme Court decision requiring supporting people to live in the least restrictive setting, preferably in communities and not institutions, as well as the Maintenance of Effort provision in ARPA. NCLER also maintained an Appendix K waiver tracker, which was available to legal assistance providers across the country and monitored state actions taken under Section 1915(c) home and community-based waiver authority, designed to respond to emergency situations. 

· TOOLS FOR SERVING OLDER ADULTS WITH THE GREATEST SOCIAL AND ECONOMIC NEED:  

· In 2021, NCLER introduced a series of trainings, resources, and capacity building support in a series called Advancing Equity for Older Adults designed to support advocates to reach underserved older adults with the greatest economic and social need, as emphasized in the Older Americans Act. This included two webinar trainings presented to a combined audience of over 2,100 advocates which shared strategies for legal and aging services organizations to use to reach underserved communities and advance equity for older adults. NCLER also provided intensive technical assistance support to legal assistance advocates in Alabama, California, Minnesota, and Pennsylvania to help them implement a person-directed and equity focused project within their organization. Learnings and models developed were shared with NCLER’s national network though a webinar training in 2022 and distribution of resources, including a step-by-step equity tool. 

· NCLER also supports ACL Legal Assistance Enhancement Grantees from 10 states, who are tasked with improving access to and quality of legal assistance for older adults. Projects include improvements to outreach, partnerships, and intake and can serve as replicable models for other states and programs. NCLER provides training, technical assistance, and peer to peer leaning opportunities to advocates working on these grant projects that span a range of focus areas from kinship care, medical-legal partnerships, and disaster response. 

Legal Assistance Enhancement Program (LAEP) Accomplishments

The initial set of LAEP grantees (FY 2019 – FY 2023) are concluding their grant work.  They addressed key objectives in elder rights including:

· Coordinating a statewide approach to legal assistance in rural and frontier areas

· Legal disaster response to natural disasters and to the COVID-19 pandemic

· Legal support for grandparents raising grandchildren

· Supporting the rights of applicants and beneficiaries of Medicaid home and community-based services

· Applying the Medical-Legal Partnership model through a Federally Qualified Community Health Center partnership with a legal assistance program to focus legal remedies specifically older adults that adversely impact the social determinants of health

· Easily accessible legal-social services responses to financial exploitation

In 2022, ACL awarded four (4) LAEP cooperative agreements with three-year terms totaling $819,455.00. These grants seek to achieve quantifiable and sustainable enhancements that build upon existing programmatic work to increase the effectiveness of legal assistance for older Americans with social or economic need.

### Grant Awards Table:	

Elder Rights Support Activities Grant Awards

## Elder Justice/Adult Protective Services

*BA is in thousands of dollars. FTE is in whole numbers, FTE for this activity are supported by program dollars.

/1 Does not include supplemental funding of $188 million. 

Authorizing Legislation: Sections 411 of the Older Americans Act of 1965, Public Law 89-73 and Title XX of the Social Security Act, Subtitle B, Section 2042, as amended by the Affordable Care Act.  

Most Recent Authorizing Legislation: Supporting Older Americans Act of 2020, Public Law 116-131 and Title XX of the Social Security Act, Subtitle B, Section 2042 as amended by the Affordable Care Act.

Current FY Authorization (OAA)	None Specified in the OAA/Title XX-B is Expired

Authorization Expiration Date	OAA—FY 2024/Title XX-B—FY 2014

Allocation Method	Competitive Grants/Co-operative Agreements and Contracts

### Program Description:

Elder Justice and Adult Protective Services support programs and systems change initiatives focused on upholding the rights of older people and preventing and address abuse, neglect and exploitation. Key areas of focus include establishing a nationwide system of adult protective services, guardianship reform, and addressing the opioid crisis. In addition, this program provides modest funding to support ACL in convening the Elder Justice Coordinating Council on behalf of the Secretary of HHS. 

#### Adult Protective Services (APS)

APS systems play a critical role in supporting older adults and adults with disabilities facing abuse, neglect, self-neglect, or financial exploitation. State APS systems investigate reports of abuse and exploitation, provide support and case management, and connect those facing abuse to a variety of protective, emergency, and support services.

Unlike child protective services, which has benefitted from federal leadership and infrastructure support since 1974, and thus has a lexicon, standards, and practices that are consistent across the country, APS has been designed and administered wholly at the state or local level until recently. Consequently, there is wide variation in APS services and practices between, and even within, states. Historically, APS programs and administrators have lacked reliable information and guidance on best practices and standards for conducting case investigations and for staffing and managing APS programs. In addition, a number of GAO reports from 2011 to 2020 identified challenges faced by APS programs across the country in recruiting and training staff to collect, maintain, and report statewide case-level data. These challenges include lack of funding and increasing caseloads, as well as the growing complexity of cases due to factors such as increasing opioid misuse. These challenges have impaired states’ ability to respond in an effective and timely way to reports of elder abuse, neglect, and exploitation and to assess client outcomes and the effectiveness of the services they are providing.[footnoteRef:44] Nationally, this results in a fragmented and unequal system that can hinder coordination and lead to the absence of critical support for some people experiencing abuse. [44:  U.S. Government Accountability Office. (2011). ELDER JUSTICE: Stronger Federal Leadership Could Enhance National Response to Elder Abuse. (GAO-11-208). Washington, D.C.: U.S. Government Printing Office. 18 February 2023.] 

In FY 2015, ACL received its first dedicated appropriation, totaling $4 million, to support states in enhancing their APS systems infrastructure statewide. Since that time, funding has grown to between $12 million and $14 million annually. With this funding, ACL has awarded discretionary grants to states to test innovations and improvements in APS practices, services, data collection, and reporting; facilitated sharing of lessons learned and promising practices across APS systems; and provided technical assistance to support states in developing APS systems that reflect a person-centered approach (i.e., practices and services that are tailored to the needs, goals, culture, and preferences of the person being served). In addition, this funding supported the development and implementation of ACL’s National Adult Maltreatment Reporting System (NAMRS). NAMRS is the first comprehensive, national reporting system for state APS programs. Although reporting is voluntary, 100 percent of states and territories have participated, almost from the system’s launch. 

ACL also is conducting research and evaluation activities to build the evidence base for APS. This includes updating the National Voluntary Consensus Guidelines on the two-year schedule established at launch and identifying areas where additional research on APS practice is needed. ACL plans to implement an outcome evaluation study to document the difference that APS makes in the lives of older adults and adults with disabilities.

In FY 2021 and FY 2022, the American Rescue Plan Act provided two years of start-up funding ($188 million in each year) to fund – for the first time – the nationwide APS formula grant program that was authorized by the Elder Justice Act in 2012. That one-time funding was used by states to expand or develop a variety of capabilities that were necessary to meet significantly increased needs due to the pandemic and to strengthen APS systems. For example, states improved reporting systems; improved responses to scams and fraud (especially related to COVID-19); increased personnel; covered increased costs of training, outreach, travel and investigations; expanded remote work capabilities of APS staff; secured emergency housing for clients; acquired personal protective equipment for in-person investigations; and funded a variety of direct services for APS clients. 

Additional ongoing funding is critical to maintaining these improvements, which have significantly increased the reach and effectiveness of APS systems. As the population of older adults increases, the problem of elder abuse, neglect, and exploitation continues to grow. Data from state adult protective services (APS) agencies show an increasing trend in reports of adult maltreatment.[footnoteRef:45] Prior to the COVID-19 pandemic, research suggested that that at least 10 percent of older adults in the U.S., or approximately five million people, experience abuse each year, and many experience it in multiple forms.[footnoteRef:46] A study conducted in 2020 estimated that the prevalence of elder maltreatment during the pandemic increased by an [45:  National Research Council. (2003). Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America. Washington, D.C.: The National Academies Press. Accessed 18 February 2023.]  [46:  Acierno, R., Hernandez, M. A., Amstadter, A. B., Resnick, H. S., Steve, K., Muzzy, W., & Kilpatrick, D. G. (2010). Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: The National Elder Mistreatment Study. American Journal of Public Health, 100(2), 292–297. Accessed 18 February 2023.] 

#### Addressing the Opioid Crisis

Opioid misuse and substance use disorders have adversely affected older adults in several ways. First, older adults have access to opioids prescribed for pain relief and may be at risk for misuse or addiction themselves. Second, family members or others may abuse, neglect, or exploit older adults in order to gain access to opioids that were legally prescribed for the older person. Last, grandparents have increasingly found themselves raising their grandchildren when parents are unable to fulfill the parent role due to opioid abuse or other substance use disorders. 

ACL funds grants focused on developing ways for state APS systems to effectively respond to abuse, neglect and exploitation originating in opioid misuse or disorder. These grants are specifically targeted to the most affected communities and aim to address gaps that hinder APS from securing adequate services for clients affected by opioid and other substance abuse. Further, these grants will identify home and community-based social, health, and mental/behavioral health services needed for APS clients impacted by the opioid epidemic. Finally, results from these grants will be shared widely for replication across states

#### Guardianship Reform

Self-determination and preservation of decisional rights of all adults is a top priority of ACL, and guardianship reform is a key area of focus.  ACL has provided leadership on guardianship reform and alternatives to guardianship by supporting the development and implementation of Working Interdisciplinary Networks of Guardianship Stakeholders (WINGS). WINGS is the prevailing national model for guardianship reform and the identification of appropriate alternatives to guardianship. In addition, ACL has provided technical assistance and training to partners and stakeholders on empowering self-determined decision-making.

In 2017, the Elder Justice Prevention and Prosecution Act amended the Elder Justice Act to add Section 2042(c)(2)(E), which authorizes grants to the highest state courts to better understand, monitor, and reform guardianship proceedings.  These grants were funded in the first time in FY 2021, for projects that include:

· Developing systems to audit conservator and guardian accountings to verify accuracy, completeness, and the appropriateness of expenditures

· Creating and maintaining case management systems to track cases for timely adjudication and monitoring of the well-being of wards

· Establishing and producing judicial training programs and curricula

· Developing and implementing initiatives to prevent and/or mitigate abuse by conservators and guardians

· Exploring how judicial systems may coordinate with the Social Security Administration and the Department of Veterans Affairs to identify and remove abusive fiduciaries

· Creating independent ombudsman programs for wards to voice concerns and seek redress from abuse

· Reviewing and considering guardianship reforms based on the research and models developed by WINGS and other training, technical assistance, and capacity building tools, methods and approaches, including those developed by ACL’s National Center for Law and Elder Rights.

#### Elder Justice Coordinating Council 

The Elder Justice Act of 2009 established the Elder Justice Coordinating Council (EJCC) to coordinate activities related to elder abuse, neglect, and exploitation across the federal government. Today, 16 federal agencies are members of the EJCC. As chair of the EJCC, the Secretary of HHS has lead responsibility for identifying and proposing solutions to elder abuse problems; ACL implements the EJCC on the Secretary’s behalf. 

### Budget Request:

In FY 2024, the request for Elder Justice/Adult Protective Services (EJ/APS) is $73,000,000, an increase of $43,000,000 over the FY 2023 Enacted level, to fund state APS formula grants at a very basic level. The request maintains the appropriations language from the FY 2023 appropriation, which allows up to five percent of state grants to be allocated for tribes and tribal organizations. In addition, the request maintains support for existing EJ/APS infrastructure efforts, focused efforts on guardianship reform and addressing opioid misuse, and training and technical assistance to state grantees. Specifically, the request includes:

· *APS Formula Grants:*The FY 2024 request for APS formula grants is $58 million, an increase of $43 million over the FY 2023 enacted level, to continue operating the programs at a very basic level. 

The American Rescue Plan Act provided two years of start-up funding ($188 million in each year) to fund, for the first time, the nationwide APS formula grant program authorized by the Elder Justice Act in 2012.  That funding was used by states to expand or develop a variety of capabilities that were necessary to meet increased needs due to the pandemic, and ongoing funding is necessary to maintain the improved reach and effectiveness of APS systems beyond the pandemic. The FY 2023 Omnibus Appropriations Bill provided, for the first time, $15 million in discretionary funding to prevent program termination as American Rescue Plan funds are exhausted. Beginning in FY 2024, additional funding is needed to allow states to maintain service levels and avoid reversal of improvements made to state systems during the pandemic. The requested $58 million APS will begin to fund the program at a more sustainable ongoing national level.

The start-up funding provided in FY 2020 and FY 2021 gave states the building blocks for the foundation of a sustainable ongoing program. Before APS state formula grants became available, state APS systems logged 1.3 million calls that merited additional review but were only able to investigate the 767,000 most egregious cases. Data is not yet available for the years covered by the new grants, but anecdotal information indicates that the formula grants have made a substantial impact on the number of people served. Continuing to fund the state formula grants will help to close this gap, reduce the need to triage due to a lack of resources for services, and ensure that a greater percentage of all cases of abuse can be addressed.

Further, protecting people with disabilities and older adults from abuse and neglect in community settings is a critical to ACL, HHS and Administration priorities for advancing equity, elder justice, disability rights, and protecting vulnerable populations.

· *Infrastructure, Guardianship, and Opioids*: The request continues to support ongoing investments that ACL has made over the last seven years, including approximately $10 million in FY 2023 for ongoing investments in APS infrastructure, $2 million in support for guardianship reform grants, and $3 million in grants to address the opioid crisis. This funding supports the improvement in reporting systems (including improved linking to the National Adult Maltreatment Reporting System), ongoing improvement in responses to scams and fraud, and expansion of remote work capabilities

*Legislative Proposals:* ACL’s request includes one legislative proposal, specifically:

· Amend the Elder Justice Act to Permit All Tribes and Tribal Organizations to the Eligible: ACL proposes to amend the Elder Justice Act to strengthen, enhance, and support adult protective services programs by allowing tribes and tribal organizations to be eligible for funding authorized under the statute. Currently, the statute restricts the grants to states.  Despite the prevalence of tribal elder abuse, elder protection codes and adult protective services programs within Indian Country vary widely, and many tribes have neither.  Additional social supports, outside of family, for elders experiencing abuse, neglect, and exploitation are a critical need in Indian Country. 

### Funding History:

Comparable funding for Elder Justice and Adult Protective Services over the past five years as follows:

1/ Funding was available until expended, but $188 million of this amount was available for activities in FY 2021 and the remaining $188 million is available for activities in FY 2022.

2/ FTEs are shown in whole numbers.

### Program Accomplishments:

***Adult Protective Services (APS)***

The National Adult Maltreatment Reporting System is the first comprehensive, national reporting system for state APS programs.  Although reporting is voluntary, 100 percent of states and territories have participated, almost from the system’s launch. The quality of the database continues to improve, with 62 percent of programs providing detailed, case level data for FY 2021, the highest to date.

In FY 2022, ACL concluded a process evaluation and outcome evaluation study of APS to improve our understanding of APS programs and practice, and to document the difference that APS makes in the lives of older adults and adults with disabilities. Nearly three-quarters of APS clients who responded to the study survey said they were satisfied with the help they received from APS. 

With their initial APS formula grants, states were able to make significant investments to address gaps in their APS systems. For example, state APS systems increased staffing, expanded training and outreach, expanded investigation capacity and invested in technology infrastructure to enhance their ability to serve clients and coordinate with other providers. In addition, states have been able to provide food, clothing and other supplies to support people in their homes on a short-term, emergency basis until they could be connected to programs that provide longer-term assistance. 

***Opioid Crisis***

Beginning in 2020, funding was allocated for grants to the APS programs to address maltreatment originating in opioids misuse. An example of the work funded is Nevada’s APS, which provided an opioid misuse training for entities that are mandated to report suspected abuse and neglect. More than a hundred community partners attended. Ninety-four percent (94 percent) indicated “the information was understandable and accessible,” and 86 percent indicated “I learned new information that is relevant to my work.” The grantee also conducted an opioid outreach campaign using social media. 

***Guardianship Reform***

The FY 2022 “highest state court” grants were awarded in September 2022 and are in the planning stage.  The FY 2021 “highest state court” grantees have helped drive significant progress in the reform of guardianship in their states.  For example:

· The Minnesota Judicial Branch has piloted a process to improve access to complaint processes for people subject to guardianship

· The New York State Unified Court System has converted 20 motion-and- order forms into user-friendly, fillable PDFs with instructions for lay guardians

· The Oregon Office of the State Court Administrator is establishing processes that will enable courts to better detect financial mismanagement of protected persons’ assets and conduct a comprehensive study of the Oregon court’s guardianship and conservatorship monitoring practices

### Grant Awards Table:

Elder Justice/Adult Protective Services Grant Awards

Elder Justice/Adult Protective Services State Grant Awards

1/ Funding was provided in the Coronavirus Response and Relief Supplement and the American Rescue Plan.

*Represents States, and the District of Columbia

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES**

**FY 2024 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER: Elder Justice/ Adult Protective Services (CFDA 93.630)

1/ Funding was provided in the Coronavirus Response and Relief Supplement and the American Rescue Plan.

2/ Undistributed funding includes technical assistance, support programs, and grants, and contracts, which support the Elder Justice efforts but were not provided by formula to states or tribes.

# Disability Programs, Research, and Services

## Summary of Request

ACL’s Disability Programs, Research, and Services fund direct services, research, capacity-building and systems change efforts to ensure that people with disabilities have access to the services and supports they need to lead self-determined lives and fully participate in all facets of community life. A hallmark of these programs is that people with disabilities themselves play a central role in program planning, design, and implementation.

ACL’s FY 2024 budget request for Disability Programs, Research, and Services is $512,308,000, an increase of $55,738,000 above the FY 2023 enacted level. The request maintains increases provided to most programs in FY 2023 to begin to address the significantly increased demand for direct services for people with all types of disabilities. The request also includes new investments that will work together to expand community living opportunities for disabled people.  

Increasing numbers of people with disabilities, and an increasing focus on upholding their rights to live in the community, created steady growth in the need for the services provided by ACL’s programs. The COVID-19 pandemic caused a sharp spike in demand, particularly in the early days, when many people with disabilities were cut off from the assistance provided by families and other informal supports. The effects of prolonged isolation have left many people more dependent on services than they had been before, and more people than ever are preferring to receive services in their own homes, due to the risks of COVID-19 in congregate settings, such as nursing homes. Consequently, although the need for services has decreased from the peak, it has stabilized at a level that is significantly higher than before the pandemic. In addition, costs to operate many programs have decreased. These higher needs and costs make increased investment in these programs critical to ensuring people with disabilities can access the supports they need to live in the community. 

To that end, ACL requests:

· $82,000,000 for State Councils on Developmental Disabilities (DD Councils), an increase of $1,000,000 above the FY 2023 enacted level to expand DD Council efforts to improve and streamline state systems for supporting people with I/DD

· $59,659,000 for Developmental Disability Protection and Advocacy (P&As) systems, an increase of $14,659,000 above the FY 2023 enacted level. The increased funding will expand P&A efforts to address the barriers to inclusion and equal access faced by people with I/DD; monitor and address abuse; assist people in transitioning from institutions to the community; provide technical assistance to government entities, businesses, and other organizations; and advocate for system change to improve inclusion of people with disabilities in all facets of American life

· $46,173,000 for University Centers for Excellence in Developmental Disabilities (UCEDDs), an increase of $3,054,000 above the FY 2023 enacted level to meet increased demands for training, technical assistance, research, and information sharing across states and to fund a round of competitive grants to advance equity for people with disabilities through partnerships between UCEDDs and tribal- and minority-serving institutions 

· $16,000,000 for Developmental Disabilities Projects of National Significance an increase of $3,750,000 above the FY 2023 enacted level, to fund an initiative to strengthen the direct care workforce (jointly funded with the Aging Network Support Activities program) and to continue operation of the Disability Information and Assistance Line 

· $161,458,000 for Independent Living programs, an increase of $33,275,000 above the FY 2023 enacted level. This increase will build on the capacity of current service programs and develop and test new approaches in service delivery. In addition, ACL proposes to establish a new program, Independent Living Projects of National Significance, to develop and test new interventions and program innovations. This new program will provide a mechanism to fund cross-program and cross-network demonstrations to address issues and needs that are common to both older people and disabled people of all ages. This includes: 

· Centers for Independent Living (+$29.680 million)

· Independent Living Services State Grants (+$2.345 million)

· Independent Living Projects of National Significance (+$1.250 million)

The request maintains funding at the FY 2023 enacted level for:

· $4,200,000 National Limb Loss Resource Center

· $10,700,000 Paralysis Resource Center

· $13,118,000, for the Traumatic Brain Injury (TBI) program

· $119,000,000 for the National Institute on Disability, Independent Living and Rehabilitation Research 

****

## State Councils on Developmental Disabilities

*BA is in thousands of dollars,

Original Authorizing Legislation: Section 129(a) of the Developmental Disabilities Assistance and Bill of Rights Act (DD Act), Public Law 106-402

Most Recent Authorizing Legislation: Section 129(a) of the Developmental Disabilities Assistance and Bill of Rights Act of 2000, Public Law 106-402

Current FY Authorization	Expired

Authorization Expiration Date	2007

Allocation Method	Formula Grant

### Program Description:

People with intellectual and developmental disabilities (I/DD) often experience increased barriers to community living. Upholding their right to fully participate in the community requires each state to develop and maintain a comprehensive and coordinated system that includes services and supports to meet specific needs; training, education and resources to help people with I/DD advocate for themselves and to help families provide support across the lifespan; training, education and advocacy to ensure accessibility of health care, education, transportation, recreation and other infrastructure systems; innovation to improve effectiveness and sustainability of programs and services; research to improve knowledge about and diagnosis of I/DD and to expand and improve interventions and support; and sharing of information across programs, networks and states to advance best practices across the country. 

State Councils on Developmental Disabilities (DD Councils) are part of a network of programs authorized by the DD Act that work together to build and strengthen these systems. Funded through formula grants, DD Councils are charged with identifying the most pressing needs of people with developmental disabilities in their state or territory and developing plans to address them. While DD Councils can perform the work to implement these plans “in house,” in the recent year data was available, 50 councils in FY 2021 redistributed all or a portion of the funding received through ACL’s grant to network partners, such as their state’s University Center of Excellence in Developmental Disabilities or Protection and Advocacy agencies, as well as other community-based organizations to support implementation.

DD Councils create partnerships, collaborations, innovative programs, and equal opportunities to improve the lives of people with I/DD; spark community change by bringing together people and partners to create equity in education, health, employment, and life; empower self-advocates and family leaders; influence law and policy; and educate and protect people with I/DD; and educate decision-makers using research and lived experiences to improve the lives of people with I/DD. 

There are 56 DD Councils, with volunteer members appointed by the governor. They are led by people with I/DD, families, and other key stakeholders; at least 60 percent of each council’s governor-appointed volunteer members must be people with I/DD and their family members. 

### Budget Request: 

The FY 2024 request for DD Councils is $82,000,000, an increase of $1,000,000 above the FY 2023 enacted level to offset increasing costs and maintain the councils’ capacity improve and streamline state systems supporting people with I/DD and to expand access to essential community services, individualized supports, and other forms of assistance that promote self-determination, independence, productivity, integration, and inclusion in all facets of community life.  

This work is increasingly critical. The number of people with I/DD has been growing for many years, and people with I/DD are living longer, both of which are increasing the need for systems that can effectively, efficiently, and sustainably provide the support people with I/DD need to live in the community. 

### Funding History:

Funding for the program over the past five years is as follows:

### Program Accomplishments:

DD Councils are catalysts for positive change. Their work removes barriers and increases opportunities for people with I/DD so they can:

· Participate fully and live in the community

· Become leaders and self-advocates, creating their own paths, and helping others

· Access healthcare to live longer, healthier lives

· Complete secondary (grades 6-12) and postsecondary (after grade 12) education 

· Find and succeed in jobs that fit their individual interests and goals

· Stay connected and safe during emergencies and disasters

· Enjoy recreational and social activities

Examples of how DD Councils advance community living for people with I/DD include:

· *Health*- The Iowa DD Council developed an informational campaign to help educate Iowans with I/DD about protecting themselves from COVID-19.  The campaign included flyers, social media posts, radio ads, and a toolkit to help DD network partners and other stakeholders share the information.  The campaign reached an 800,000 Iowans with disabilities, and 99 percent of partner organizations that responded to the council’s annual survey indicated that the campaign was helpful in supporting their work. 

· *Employment* – The New York State DD Council has been funding a technology-based training grant called *Tech Launch* to help individuals with I/DD learn in-demand technology skills. Participants in this program receive career exploration mentoring services and assistance to navigate the job application process. In addition, a web- and data-based system was developed to record training certificates and help employers identify candidates with the skills needed to fill job openings.  

The Kansas DD Council’s Family Employment Awareness Training is focused on helping discouraged job seekers with I/DD identify and create new employment goals. The program connects people with I/DD and their families to training and services to support the person with I/DD through their journey to competitive, integrated employment. Training is provided in both English and Spanish.  

· *Guardianship* – The Wyoming Governor’s Council on Developmental Disabilities commissioned a study of the administration of guardianship statutes in the courts.  The study found that a guardian ad litem – an impartial official appointed to advocate for the best interests of the person for whom a guardian may be appointed – was appointed in only 102 of the state’s 256 guardianship cases. The study also found that protection of the rights of the person with I/DD varied significantly by county. Armed with these results, the council has launched focused advocacy and outreach efforts to increase public awareness and educate state legislators and other policy makers about alternatives to guardianship and options that preserve the individual’s rights to self-determination.  

· *Housing*– The Washington State DD Council co-funded a three-year pilot project with the state’s Developmental Disabilities Administration on a project to use smart home technology solutions to provide a variety of assistance, such as reminders to take medication, support for cooking, and other assistance with activities of daily living to help people with I/DD live more independently.  The project matched technology to the needs and skills of the participants. This year, a detailed evaluation is being conducted to examine the project’s impact and identify opportunities to expand and refine the initiative to meet needs across the state.

· *Disaster Response* – The California State DD Council has worked with public health and emergency response agencies to improve outcomes for people with I/DD in disasters and emergencies.  In collaboration with FEMA, the American Red Cross, and the Governor’s Office of Emergency Services, the Council provided training, tools, and resources to first responders to help build their capacity to address the unique needs of people with I/DD and developed a plain language emergency response toolkit for people with I/DD.  The council also provided over 6,000 emergency “go-kits” to people with I/DD, to support individual emergency preparedness efforts. The kit contained essential items, such as a flashlight and first aid kit.  

### Outputs and Outcomes Table: State Councils on Developmental Disabilities

*This is a developmental performance measure. ACL is currently collecting sufficient data to establish a baseline.  To set a baseline, the agency relies on 3 years of data.  This process ensures that the data are stable and show a clear trend.  The agency will set targets for this measure once a baseline is established.

### Grant Awards Tables:

State Councils on Developmental Disabilities Grant Awards

*Represents States, and the District of Columbia.

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON DISABILITIES**

**FY 2024 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER:  State Councils on Developmental Disabilities (CFDA 93.630)

1/ Undistributed- includes funds for technical assistance and/or minority set-asides; grant systems and review, and program reporting systems costs.

## Developmental Disabilities – Protection and Advocacy

*BA is in thousands of dollars.

Original Authorizing Legislation: Section 145 of the Developmental Disabilities Assistance and Bill of Rights Act, Public Law 106-402  

Most Recent Authorizing Legislation: Section 145 of the Developmental Disabilities Assistance and Bill of Rights Act of 2000, Public Law 106-402

Current FY Authorization	Expired

Authorization Expiration Date	2007

Allocation Method	Formula Grant

### Program Description:

Developmental Disabilities Protection and Advocacy systems (P&As) play a critical role in protecting the safety and welfare of people with intellectual and developmental disabilities (I/DD) and ensuring they can exercise their rights to make choices, fully participate in society, and live independently. P&As have the authority to pursue a range of appropriate remedies or approaches, including the authority to investigate incidents of abuse and neglect. 

P&As play an important role in providing legal representation and assistance to people with disabilities who live in the community, as well as to people who live in institutions or other congregate settings. Supporting transitions from institutions to community settings and protecting the rights of people with disabilities who live in nursing homes and other congregate settings is a primary focus for P&As. For people living in the community, P&As help ensure equal opportunities and access in workplaces, schools, healthcare facilities and public places.

P&As also play a key role as advocates and advisors, providing technical assistance to support implementation of federal, state, and local initiatives to expand community living options. For example, they have been an important partner as states have implemented the Medicaid Home and Community-Based Services (HCBS) Settings Rule, which protects basic rights of people receiving HCBS services, such as the right to visitors and access to food, to choose with whom they live, and to participate in community activities of their choosing. Similarly, P&As often provide training and technical assistance to service providers, state legislators and other policymakers; conduct self-advocacy trainings; and raise public awareness of legal and social issues affecting people with I/DD and their families.

People with I/DD are at heightened risk of abuse and neglect, and ensuring their health and safety – whether they live in the community or in residential facilities – is a central function for every P&A. P&As conduct regular monitoring to identify instances of individual or systemic abuse or neglect, often speaking with individuals to assess their health and safety. They investigate allegations of abuse and neglect, including cases in which people with I/DD have died. Their monitoring and investigation activities often lead to changes in policies and practices that will ensure health and safety.

There are 57 P&A systems: one in each state, territory, and the District of Columbia, as well as a Native American Consortium.

### Budget Request: 

The FY 2024 request for the Developmental Disabilities Protection and Advocacy (DD P&A) program is $59,659,000, an increase of $14,659,000 above the FY 2023 enacted level to begin to address unmet needs.  

As with ACL’s other direct-services programs, demand for P&A services is higher than ever and continuing to grow. The number of people with intellectual and developmental disabilities (I/DD) living in the community (instead of in institutions) and being supported through Medicaid HCBS programs has steadily increased in recent years. This has increased the need for P&A monitoring of the quality of settings operated by community providers and the health and safety of people living in them. P&As also are increasingly working with states and communities to develop and implement policies and strategies to effectively provide quality HCBS that meets the range of needs of people with I/DD. The increase in people with I/DD living in the community also has created more demand for P&A legal advocacy and assistance to ensure equal access to employment opportunities, inclusive education, and quality healthcare. In addition, the significantly increased COVID-19 risks faced by people living in congregate settings has increased the number of people who would like to move from institutional settings to homes in the community, increasing the need for support from P&As. 

At current resource levels, P&As are only able to serve a fraction of people seeking their assistance. Many must limit their work to the most urgent issues, such as addressing abuse, and can provide only very limited assistance with things like ensuring equal access to employment, transportation and public places. 

### Funding History:

Funding for the program over the past five years is as follows:

### Program Accomplishments:

With the help of P&A services, people with I/DD are living the lives they want to lead in the community in growing numbers. They are increasingly working alongside people without disabilities, at competitive wages. P&As ensure that people with I/DD receive the services and supports they need to succeed in school; have equal access to health care, including life-saving treatments; and are able to move from institutions to homes in communities if they want to. Together with partners across the disability networks, P&As are at the frontlines of disability rights, advancing inclusion and increasing opportunities for people with I/DD. 

A hallmark of P&As is that they both work toward systemic change that will improve access and inclusion for all people with I/DD and work to uphold the rights and support the well-being of individual people with I/DD. By definition, P&As’ individual advocacy is highly individualized and dependent on the needs and preferences of the individual seeking assistance from the P&A. Cases are accepted based on priorities set annually based on stakeholder input.  In FY2021, P&As provided services to nearly 8,400 people with I/DD to address a variety of issues. 

Following are examples of how the DD P&As support the rights of people with I/DD and advocate for their inclusion:

*Abuse and Neglect*: P&As across the country play a crucial role in addressing abuse and neglect of people with I/DD.  For example:

· Disability Rights Connecticut (DRCT) investigated the deaths of two individuals with I/DD and the hospitalization of several others. The investigation found that they were inappropriately transferred to nursing facilities from their private intermediate care facility (ICF) because the ICF failed to provide sufficient staffing. DRCT worked with several state agencies to make changes to protect people with I/DD from inappropriate placements. These included: changing a state law to include ICFs in requirements for emergency staffing plans; improving the state’s pre-admission screening process for nursing home admissions; and requiring prior approval by the Commissioner of the Department of Developmental Services for nursing home admissions for people with I/DD. DRCT is currently monitoring the implementation of these changes and is working to improve quality assurance measures to ensure that people with I/DD, particularly those with complex medical needs, safely receive the care and services that they need.

· After their investigation found that being improperly restrained contributed to the death of a 22-year-old man with I/DD, Disability Rights District of Columbia (DRDC) worked with the D.C. Developmental Disabilities Agency to develop and implement guidelines for the safe use of restraints during crises. They worked together to improve training for residential service providers on developing and executing behavior support plans (BSPs) for residents with I/DD (including ensuring that BSPs are appropriate for the individual’s health conditions), and DRDC is monitoring to ensure ongoing compliance with the guidelines.  

*Education*: P&As advocate to resolve a variety of education-related issues, including seclusion and restraint of students with disabilities and ensuring students’ access to services, supports, and other resources they need to attend school. For example: 

· On behalf of students with disabilities who are incarcerated in state-run adult prison facilities, Disability Rights New Mexico (DRNM) filed an administrative complaint with the New Mexico Public Education Department (PED) regarding the prison system’s failure to provide legally required special education and related services. The PED’s investigation substantiated DRNM’s complaint on all grounds, finding that the adult prison facilities were non-compliant with state and federal standards of special education and requiring the facilities to take corrective action. This systemic corrective action plan will lead to greater accommodation and protection of the rights of incarcerated youth with disabilities.

· The Arizona Center for Disability Law (ACDL) represented a deaf high school student with I/DD, whose school intended to graduate her, even though she was failing her classes and had not received the required services to facilitate her transition to adult life in the community. American Sign Language (ASL) interpreter services also had not been provided in some of her classes, resulting in a denial of effective communication that contributed to her failing. ACDL negotiated with the school district to delay graduation for a year and to ensure the student received the accommodations required by her Individualized Education Program, including ASL interpretation, as well as appropriate transition services and planning support during that additional year of school 

· The Native American Disability Law Center represented a 12-year-old Hopi boy with Down syndrome, following complaints from his mother that  the school was not appropriately implementing his Individual Education Plan. The P&A worked with the child’s family for nearly two years, initially attempting to work with the school to resolve the mother’s concerns and intervening legally when that failed. The P&A supported the family in negotiating a comprehensive resolution agreement that ensured the school provided legally required services and supports for the child, improved communication with the child’s mother, and provided compensatory education services to address the impact of the school’s failure to implement the child’s IEP for two school years. The P&A then ensured compliance with the agreement, supporting the family at meetings with the school when issues arose. 

· At the request of a parent whose child had been improperly restrained and secluded at school in violation of Colorado’s Protection of Persons from Restraint Act (PPRA), the Colorado Disability Law Center (DLC) worked with a school to implement a resolution strategy that included: training on the PPRA and how restraint and seclusion can violate a student’s rights; providing to staff written clarification of the school’s policy and the PPRA’s requirements; and eliminating use of  a “reset room.” 

*Housing*: P&As support people with disabilities in finding and maintaining affordable, accessible housing in the community and addressing housing discrimination. For example:

· Disability Rights Wisconsin (DRW) represented a 60-year-old client with cerebral palsy to resolve accessibility issues at their apartment building. A new building manager began routinely failing to post important information by the accessible entrance, only posting it by the inaccessible entrance. In addition, the sole accessible entrance to the building was often blocked by snow and ice, leaving the client stranded at home. The landlord did not respond to the clients’ requests for changes. When the requests were submitted by DRW on the client’s behalf, the landlord immediately granted the requested accommodations. 

· Disability Rights Kentucky (DRKY) helped a 20-year-old woman with I/DD secure safe housing in the community. The woman lived at a homeless shelter and had been financially and sexually exploited.  Although she was at risk for additional abuse,  she had been denied the emergency services needed to leave the shelter for stable housing. DRKY worked with her case manager to strengthen her case, ultimately helping her secure housing and the supportive services she needed. 

*Employment:*Employment in integrated settings, at competitive wages, is an important part of community inclusion for people with disabilities. P&As advocate – both for individuals and at the system level – and provide a range of services that support employment for people with I/DD. For example:

· Equip for Equality, the Illinois P&A, collaborated with disability advocates and community organizations to educate policymakers and provide technical assistance as both the city and state considered phasing out sub-minimum wages for people with I/DD. Ultimately, a Chicago city ordinance was proposed to include elimination of sub-minimum wages for people with disabilities in the city’s larger effort to increase wages for all workers, and the governor of Illinois issued an executive order to prohibit new State Use contracts with entities that pay sub-minimum wages.  The P&A is continuing to work with the city, state, and other disability advocates on implementation, including ensuring people with I/DD who had worked in sub-minimum wage jobs are transitioned to competitive, integrated employment.   

Oftentimes, a P&A’s work on behalf of an individual leads to change that benefits everyone with I/DD. For example:

· A teenager with I/DD who does not speak sought help from the Delaware Community Legal Aid Society when a medical facility denied him the accommodations he needed to complete a vision exam. The P&A filed a complaint under the state’s equal accommodations law (which typically results in faster processing and resolution of disputes than the federal complaint process). The state agency responsible for investigating dismissed the complaint, holding that the state law does not require modifications or accommodations for people with disabilities. The Delaware Superior Court disagreed, ruling in favor of the P&A on appeal. Between the original ruling and the appeal, the P&A worked with other disability advocates to educate legislators about the issues with interpretation of the bill and provide technical assistance as they worked to clarify the law.  As a result, House Bill 311, which clarified and slightly expanded the scope of the state equal accommodations statute, passed almost unanimously and was signed into law in October 2022.

### Outputs and Outcomes Table: Developmental Disabilities Protection and Advocacy

### Grant Awards Tables:

Developmental Disabilities – Protection and Advocacy Formula Grant Awards

1/ Not including grants to tribes.

*Represents States, and the District of Columbia.

****

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON DISABILITIES**

**FY 2024 DISCRETIONARY STATE FORMULA GRANTS/**

PROGRAM/CFDA NUMBER:  Developmental Disabilities – Protection and Advocacy (CFDA 93.630)

1/ Undistributed- includes funds for technical assistance and/or minority set-asides; grant systems and review, and program reporting systems costs.

DISABILITY PROGRAMS, RESEARCH, AND SERVICES

## University Centers for Excellence in Developmental Disabilities

*BA is in thousands of dollars. 

Original Authorizing Legislation: Section 156 of the Developmental Disabilities Assistance and Bill of Rights Act, Public Law 106-402

Most Recent Authorizing Legislation: Section 156 of the Developmental Disabilities Assistance and Bill of Rights Act of 2000, Public Law 106-402

Current FY Authorization	Expired

Authorization Expiration Date	2007

Allocation Method	Competitive Grant

### Program Description:

University Centers for Excellence in Developmental Disabilities (UCEDDs) are a national resource for increasing knowledge about the needs of people with intellectual and developmental disabilities (I/DD) and their families; identifying barriers to community living and addressing them; and increasing our nation’s capacity and capability to support people with I/DD. The 68 UCEDDs across the country form a network of independent, but interlinked, centers with a wide range of projects, such as providing training on meeting the needs of people with I/DD as part of the undergraduate, graduate, and continuing education programs for a wide variety of professionals, such as health care professionals, teachers, and others; providing community-based services for people with I/DD and their families; conducting research; disseminating information; and providing technical assistance to improve the systems that support people with I/DD.

ACL’s grants support the basic infrastructure costs of operation for each UCEDD. Each center then leverages that foundational investment to secure funding to underwrite their individual project portfolios; project funding comes from a variety of sources, including federal, state, and local agencies; private foundations; donations; and fee-for-service earnings. In FY 2021, UCEDDs received $17 in funding from other sources for every federal dollar ACL invested.

ACL also funds competitive grants to UCEDDs to develop national training initiatives to address specific unmet needs of people with I/DD. Projects funded through these grants have focused on improving our national capability to address the critical needs of: babies born with neonatal abstinence syndrome; individuals with co-occurring I/DD and mental illness; and people with I/DD who also come from underserved communities. Other projects have provided post-secondary education opportunities for people with I/DD, training for people with I/DD to enhance self-determination skills, and training on building partnerships with tribal- and minority-serving institutions.

### Budget Request: 

The FY 2024 request for University Centers for Excellence in Developmental Disabilities Education, Research and Services (UCEDDs) is $46,173,000, an increase of $3,054,000 above the FY 2023 enacted level, to offset increases in operational costs and begin to meet increased demands for training, technical assistance, research, and information sharing across UCEDDs. In addition, the request also will fund a new round of competitive grants focused on improving services to underserved communities through partnerships between UCEDDs and minority- and tribal-serving institutions. These new grants will build on previous efforts to ensure that the needs of the full spectrum of the diverse population of people with I/DD are considered by the systems that support them, and that people from historically underserved communities have equitable access those systems and the services they provide.   

### Funding History:

Funding for the program over the past five years is as follows:

### Program Accomplishments:

UCEDDs have played a key role in several advances in the disability field over the past five decades. Many services, such as early intervention, health care, community-based services, inclusive education, transition from school to work, employment, housing, assistive technology, and transportation have been directly improved by the services, research, and training provided by UCEDDs.

UCEDD’s equip future professionals – and policymakers – with specialized expertise in developmental disabilities. That expertise will inform their work, and be shared with those they encounter, as they build their careers. UCEDD training pays particular dividends as these professionals move into leadership roles, which many do. In fact, of the UCEDD trainees who graduated 5 to 10 years ago, nearly a third now serve in leadership roles in academia, public health and clinical settings, public policy, and advocacy. 

UCEDDs positively affect the lives of individuals with developmental disabilities and their families in a variety of ways. Examples of the impact of their work that is made possible by ACL’s grants include:

· *Increasing access to home and community-based services-*The Utah State University’s Institute for Disability Research, Policy and Practice implemented several initiatives to expand and strengthen the workforce of direct support professionals (DSPs) who assist people with I/DD and their families. These included training nearly 1,300 DSPs; creating an online hub where DSPs can access more than 70 webinars and other tools and resources to support on-demand professional development; developing manuals to help DSPs understand key issues affecting people with I/DD, including the HCBS Settings Rule; and sharing information and building partnerships within Utah and across the country. 

· *Improving health equity for people with I/DD*– The Institute on Disability at the University of New Hampshire is working to improve the capability and capacity of healthcare professionals to effectively treat people who have co-occurring I/DD and mental health disabilities. The UCEDD published the first edition of *Integrated Mental Health Treatment Guidelines for Prescribers in Intellectual and Developmental Disabilities* and is using the guidelines as a training tool for a community of practice that includes 68 doctors from 52 organizations who meet monthly to learn together. The guidelines also are used to train medical students and community health care providers. 

· *Family Support* – The Center for Excellence in Developmental Disabilities at the UC Davis MIND Institute in California developed a program to support families who have a child diagnosed with autism or a developmental delay. This program provides peer-to-peer support to reduce feelings of stigma, empower families to advocate for the child, and help them navigate complex service systems. The mentors in the program are people of all ages with neurodevelopmental disabilities and their family members and trainees in the HRSA Leadership Education in Neurodevelopmental and other Related Disabilities (LEND) program. Services are currently available in English, Hindi, Spanish, and Vietnamese. Since its formation, the program served a total of 530 families and is now serving an average of 80 families at one time. 

· *Transportation–*Recognizing that the ability to drive can significantly increase a person’s independence, the University of Kentucky Interdisciplinary Human Development Institute (HDI) worked with partners to develop a program that provides driver training and evaluation for people with disabilities, including I/DD. The UCEDD works with each participant to identify and overcome their individual barriers to driving.

· *Reaching underserved populations*– The University of Miami Mailman Center for Child Development worked with several partners to develop new outreach tools and information materials to ensure people with I/DD from underserved populations had equitable access to early childhood intervention services that became scarce during the pandemic. The project also provided targeted, culturally competent information and resources to support these populations in protecting themselves from COVID-19. Tools included an app that helped parents find child-care centers and Head Start/Early Head Start centers that remained open and animated videos narrated in multiple languages to educate young children, families, and teachers about COVID-19.   

· *Increasing cultural competence:* In keeping with the DD Act’s mandate to ensure that services and supports are provided in a culturally competent manner, ACL funded five UCEDDs and their partner minority-serving institutions (MSIs) to implement training and knowledge exchange strategies and foster greater collaboration with MSIs across the UCEDD network. For example, the Northern Arizona University - Institute for Human Development and Navajo Technical University partnered to develop a program that helps Native American scholars to secure jobs and assume leadership positions in I/DD-related fields.

Similarly, ACL funded 14 UCEDDs to develop fellowship programs to recruit and retain trainees from underserved backgrounds. In addition to participating in the UCEDD’s training program to increase their own knowledge about meeting the needs of people with I/DD, these fellows also conducted projects focusing on building  cultural and linguistic competence throughout the UCEDD network to better reach underserved populations  For example, a fellow at the Institute for Community Inclusion at the University of Massachusetts developed a curriculum to inform parents and families of children with I/DD from the local Somali community about child development, disability stigma, and early intervention. The university has built upon that curriculum, adding a Somali parent group and translated materials to their resources for the Somali community. Similarly, two fellows at the Rural Institute for Inclusive Community at the University of Montana developed a course for graduate students enrolled in health care programs to help future health care professionals understand the unique issues facing American Indians with disabilities who reside on American Indian reservations, in order to improve the students’ ability to meet their needs when they graduate. 

### Outcomes and Outputs Table: University Centers for Excellence in Developmental Disabilities

### Grant Awards Table:

University Centers for Excellence in Developmental Disabilities Grant Awards

DISABILITY PROGRAMS, RESEARCH, AND SERVICES

## Developmental Disabilities – Projects of National Significance

*BA is in thousands of dollars. 

Original Authorizing Legislation: Section 163 of the Developmental Disabilities Assistance and Bill of Rights Act, Public Law 106-402

Most Recent Authorizing Legislation: Section 163 of the Developmental Disabilities Assistance and Bill of Rights Act of 2000, Public Law 106-402

Current FY Authorization	Expired

Authorization Expiration Date	2007

Allocation Method	Competitive Grants and Cooperative Agreements/Contracts

### Program Description:

More than seven million people in the United States have intellectual and developmental disabilities (I/DD).  The Developmental Disabilities Projects of National Significance (DD PNS) program funds work to address the most pressing issues affecting them and their families. The program funds grants, contracts, and cooperative agreements to develop and test approaches for expanding national capacity of the systems that provide I/DD support services, improving the quality of those services, and increasing access to them for all people with disabilities. It also funds projects to addresses systemic issues, such as discrimination in health care and knowledge gaps amongst health care providers, to uphold the civil rights of people with I/DD.  ACL has used DD PNS funds to support projects addressing national priorities such as supporting families, promoting competitive integrated employment, addressing health disparities, enhancing cultural competency of services, and strengthening the direct care workforce.

### Budget Request:

The FY 2024 request for Developmental Disabilities Projects of National Significance (DD PNS) is $16,000,000, an increase of $3,750,000 above the FY 2023 enacted level to support two cross-program initiatives. $3,000,000 will be combined with funding from programs authorized under the Older Americans Act and with the newly created Independent Living Projects of National Significance (IL PNS) to address the direct care workforce crisis. In addition, $750,000 will be invested along with IL PNS funding to continue operations of a national hotline that connects people with disabilities to local resources. 

Strengthening the Direct Care Workforce

The paid professionals who form the direct care workforce provide vital services that make it possible for people with disabilities and older adults to live in their own homes and communities. Long-standing workforce shortages have reached crisis levels during the COVID-19 pandemic; today, more than three-quarters of service providers are not accepting new clients and more than half have cut services as a result of the direct care workforce shortage. High turnover – averaging nearly 44 percent across states – also means that people who are able to get services often experience service disruptions and receive inconsistent care. As a result, increasing numbers of people are left with no option but to move to nursing homes and other institutions, people who want to leave these facilities cannot, and the health and safety of those who live in the community is at risk. In addition to undermining people’s civil right to community living, this leads to poorer health outcomes and higher costs of care, which most often are borne by taxpayers.

In September 2022, ACL established a national capacity-building center to help expand and strengthen the direct care workforce. With FY 2023 funding, ACL is beginning to build a hub through which state, private, and federal entities involved in the recruitment, training and retention of direct care workers can access best practices, training materials, technical assistance and learning collaboratives. With the funding requested in FY 2024, ACL will fully fund operation of the resource hub and support development of new approaches for recruiting, retention and training that can be replicated and scaled across states through demonstration grants.

This issue affects older adults and people with all types of disabilities. As such, this investment will be jointly funded by the Older Americans Act Aging Network Support Activities program ($8 million) and the Independent Living Projects of National Significance program ACL has proposed to establish ($ 0.5 million). 

Disability Information and Access Line

Even when services and resources are available to help people live in the community, it can be very challenging for people to access them. People often have questions about which programs are available in their states or communities, which will best meet their needs, whether they or their loved one are eligible, how to enroll in programs, and how to coordinate services. Without assistance to navigate these systems, people often do not receive help they need to live independently. 

The Disability Information and Access Line (DIAL) complements the Eldercare Locator, which for many years has played a critical role in helping older adults find the local help they need to age in place. Until DIAL was launched in 2021, there was nothing similar to meet the needs of people with disabilities. Initially established to help people with disabilities access COVID-19 vaccinations and tests, DIAL connects people with disabilities to essential services such as transportation, housing support, community services, legal assistance, and more to support independent living in the community. DIAL was created and funded through 2023 with supplemental funding from the Centers for Disease Control and Prevention (CDC); in 2024, DIAL must be funded through ACL’s budget if it is to continue operating. 

This resource serves people with all types of disabilities. Accordingly, ACL proposes to fund its operation with investments from both DD PNS ($750,000) and IL PNS ($250,000) to ensure a cross-disability focus.

### Funding History:

Funding for the program over the past five years is as follows:

### Program Accomplishments: 

People with intellectual and developmental disabilities often experience increased barriers to community living. Upholding their right to fully participate in the community requires:

· Comprehensive and coordinated systems of support to meet individual needs. 

· Training, education and resources to help people with I/DD advocate for themselves and to help families provide support across the lifespan

· Training and technical assistance of professionals and policymakers to ensure accessibility of health care, education, transportation, recreation and other infrastructure systems. 

· Innovation to improve effectiveness and sustainability of programs and services

· Research to improve knowledge about I/DD and to expand and improve interventions and support

· Sharing of information to advance best practices across the country 

The Developmental Disabilities Project of National Significance (DD PNS) program is part of a network of programs authorized by the DD Act that work together to meet those needs.  

DD PNS funds projects to address issues that affect people with I/DD across the country, such as the direct care workforce crisis, health and safety of people with I/DD living in the community; quality of community living services; employment of people with I/DD in integrated settings at competitive wages; and health care discrimination. DD PNS projects contribute to an evidence base of interventions and approaches that have proven effective and can be adapted to meet state and community needs. They also provide technical assistance and resources and facilitate collaboration and sharing of best practices and lessons learned across the DD network. 

DD PNS projects ultimately create opportunities for people with I/DD to increase independence, social capital, self-determination, community integration, productivity, and participation in the community. Examples of DD PNS activities include:

*Promoting health, safety, and quality community living:* Living well in the community requires access to home and community-based services (HCBS) that ensure health and safety and support self-determination and independence. ACL has a number of DD PNS investments aimed at strengthening HCBS:

· Strengthening the direct care work force: The shortage of direct care workers has become a national crisis that is significantly limiting community living opportunities for many people with I/DD. ACL’s Direct Care Workforce Capacity Building Center was launched at the end of 2022 to begin to address this critical issue. With FY 2023 funding, ACL is beginning to build a hub through which state, private, and federal entities involved in the recruitment, training and retention of direct care workers can access model policies, best practices, training materials, technical assistance and learning collaboratives.

· The Center on Youth Voice, Youth Choice: The Center is an initiative to educate young adults with I/DD and their families about less restrictive alternatives to guardianship. The initiative is led by the people it serves – at least three-quarters of the program’s advisory board must be youth with I/DD. The Center on Youth Voice, Youth Choice provides information and resources for people with I/DD and their families, including through a plain-language website; conducts research; leads a national coalition of organizations that are working together to advance alternatives to guardianship; and works with communities of practice and trains youth ambassadors to do the same within their states. Now in its third year, the project has teams in eight states and has trained 34 youth ambassadors within those states. The Center will launch three additional state teams in 2023 and train an additional 10 youth ambassadors by 2025.  

· Living Well Grants:**Living Well grants focus on developing model approaches for enhancing the quality, effectiveness and monitoring of HCBS. The projects have implemented protocols to improve community monitoring systems; improved collection and analysis of health and safety data; provided training on abuse and neglect, health, safety, and human rights; provided leadership opportunities, peer support, and outreach to help people with I/DD and their families build advocacy skills; and improved the quality and availability of services by providing training providers on individual choice and rights, fostering provider collaboration, and advocating for changes in policy and practice to increase capacity of service providers.

*Reducing Health Disparities:*People with I/DD routinely confront discrimination and other barriers to health care, which results in high occurrence of preventable diseases and comorbidities and poorer health outcomes than their peers without disabilities. The PNS program is addressing these issues through several projects:

· National Resource Center for People with I/DD and Co-occurring Mental Health and Related Conditions: About 35 percent of people with I/DD mental health disabilities. They face significant barriers to accessing services and supports and are often the hardest to support in the community. Launched in October 2022, this national center will improve access to needed services, as well as coordination of services, with a particular focus on people from underserved communities.   

· Partnering to Transform Health Outcomes with Persons with Intellectual and Developmental Disabilities: This project is improving healthcare for people with I/DD by training students in health care fields – future doctors, nurses, pharmacists, dentists, physician assistants, occupational therapists, speech language pathologists and others – about the unique needs of people with I/DD. The project developed high-impact learning materials suitable for multiple professional specialties that are currently being used at nine academic institutions. People with I/DD serve on the program’s advisory committee and participate in training to ensure that the entire program is infused with the lived experience of people with I/DD. They also serve as mentors for the trainees.  In every program, students either interact directly with people with I/DD or hear from them through video recordings. 

*Promoting competitive, integrated employment:*Although most want to work, people with disabilities are unemployed and underemployed at higher rates than their peers without disabilities. In 2021, only 19.1 percent of people with disabilities were employed, compared 63.7 percent of those without a disability. ACL is working to create more competitive, integrated employment (CIE) opportunities through a number of projects. For example

· The Disability Employment Technical Assistance Center (DETAC): DETAC provides evidence-based technical assistance to ACL’s disability programs to increase competitive, integrated employment and improve economic mobility of people with I/DD. The DETAC leads a national community of practice and peer action e-learning communities focused on fostering new partnerships; provides on-demand technical assistance; develops new resources; and makes information and resources readily available through its website.  

· Community Collaborations for Employment (CCE):**In 2021, ACL awarded seven CCE grants to increase and enhance collaborations across local systems to improve outcomes for underserved youth with I/DD as they transition between school and working in the community. The *Finds Their Way: Communities for Youth Transition*project in Arizona is focusing on Native American youth across the 22 reservation communities and urban areas in Arizona. The *My Transition, My Career*project in Kansas is partnering American Job Centers and the Kansas Hispanic and Latino American Affairs Commission to provide career skill development and work-based learning opportunities for young people with I/DD in Latinx communities. The *Partnership for Transition to Employment*in Massachusetts is improving collaboration across community partners to better serve youth in a community with a large immigrant population and extensive socio-economic challenges. Minnesota’s *Community-Based Collaborative Transition Model for Minnesota Youth with I/DD*is involving stakeholders from diverse cultural backgrounds (e.g., Somali, Native American, Hmong, etc.) in order to reach a wide range of youth from urban, suburban, and rural communities

### Grant Awards Table:

Developmental Disabilities – Projects of National Significance Grant Awards

## Independent Living

*BA is in thousands of dollars, FTE are whole numbers. 

Original Authorizing Legislation: Rehabilitation Act of 1973, Parts B and C, and Chapter 2, Public Law 93-12

Most Recent Authorizing Legislation: Workforce Innovation and Opportunities Act of 2014 (WIOA), Public Law 113-128

Current FY Authorization:

Independent Living State Grants	Expired 

Centers for Independent Living	Expired

Expiration Date: 	2020

Allocation Method	Formula and Discretionary Grants

### Program Description:

ACL’s Independent Living (IL) programs support community living and independence for people with disabilities across the nation. These programs are based on the IL philosophy of self-determination, peer support, equal access, and individual and systems advocacy. The aim of IL is to maximize the leadership, empowerment, independence, and productivity of individuals with disabilities, and to promote their full inclusion into the mainstream of American society. To that end, IL programs provide training, resources, and other supports to help people with disabilities live the lives they want to lead in their communities. The programs also support statewide networks of centers for independent living (CILs) and Statewide Independent Living Councils (SILCs) and foster partnerships between programs and organizations that support community living. 

#### Independent Living Services State Grants

The Independent Living Services (ILS) State Grants program funds formula grants to states and territories to support provision, expansion, and improvement of independent living services for people with disabilities, particularly in underserved areas. Specifically, the program supports the operation of SILCs, as well as training and technical assistance. SILCs work with the state’s centers for independent living to develop a State Plan for Independent Living (SPIL), which is the state’s three-year roadmap for executing, expanding, and improving independent living services. Other SILC functions vary between states, but include coordination of ILS, capacity-building of organizations to deliver ILS, resource development activities, and research to support enhancement of ILS in the state. 

Federal grant funds are allocated to the states based on total population, and states must match 10 percent of their grants with non-federal cash or in-kind resources. At least 70 percent of funding must be used to fund activities included in the state’s SPIL. 

#### Centers for Independent Living

The Centers for Independent Living (CIL) program provides grants to more than 350 community-based, nonprofit agencies that provide a comprehensive range of services that help people with all types of disabilities live and fully participate in their communities. A hallmark of CILs is that they are designed, operated, and led by people with disabilities. They provide training and peer support; assist with navigating systems that provide services and supports, including determining eligibility and applying for programs; and help connect people to local services and resources, such as housing, transportation, personal care attendants, food, and other important benefits. In addition, CILs support young people with disabilities who are transitioning to adult life following high school and provide a range of supports to help people who want to move from institutions to the community and to prevent institutional admissions for people currently in the community. 

CILs also play a critical role in emergency preparedness and disaster response, advocating and providing technical assistance to federal, state, and local officials to ensure that the needs of people with disabilities are considered at every stage of emergency planning, response, and recovery. They also provide emergency services to support people with disabilities to safely shelter in place; when evacuation is required, they help people find and move to accessible emergency shelter – and to return to their homes and communities promptly when it is safe to do so.

A population-based formula determines the total amount that is available for grants to centers in each state. Statute requires that grants be awarded to any eligible agency that received a grant the preceding fiscal year. In most cases, awards are made directly to centers for independent living.

### Budget Request:

The FY 2024 request for Independent Living is $161,458,000 an increase of $33,275,000 above the FY 2023 enacted level, to both increase capacity of current service programs and to develop and test new approaches to service delivery. 

Like ACL’s other programs that provide direct services, the Independent Living (IL) programs have seen a steady increase in demand in recent years, and needs continue to grow. In FY 2023, Congress provided increased funding to expand capacity of the programs, which has allowed them to begin to meet increased needs. However, additional investment is needed to further bolster capacity and maintain service levels. To begin to meet those needs, the request includes:

· *Independent Living Services State Grants:* $28,423,000, an increase of $2,345,000 above the FY 2023 enacted level, to support expansion and improvement of independent living services, including training, technical assistance, coordination, and evaluation activities. ACL will continue to reserve, in accordance with statute, at least 1.8 percent of funding to cover technical assistance to CILs and state IL programs. 

· *Centers for Independent Living:*$131,785,000, an increase of $29,680,000 above the FY 2023 enacted level, to support the expansion of information and referral services, independent living skills training, peer counseling, individual and systems advocacy, and support for transitions.

In addition, ACL proposes to establish a new program, Independent Living Projects of National Significance, to develop and test new interventions and program innovations, following the model that has been successfully used within ACL’s programs for older adults and people with developmental disabilities. This new program also will provide a mechanism to fund cross-program and cross-network demonstrations to address issues and needs that are common to people with all types of disabilities; it also will be able to be combined with Older Americans Act demonstration authorities to address issues that are common to both older adults and disabled people of all ages. 

· *Independent Living Projects of National Significance:*****$1.25 million, to jointly fund three initiatives. 

· *Disability Information and Assistance Line (DIAL)*: $250,000 will be combined with $750,000 from Developmental Disabilities Projects of National Significance to maintain the Disability Information and Assistance Line (DIAL). Launched in 2021 to help disabled people access COVID-19 vaccinations, DIAL also provides information about, and connects people to, essential services such as transportation, housing support, community services, legal assistance, benefits programs and more. Established with supplemental funding from CDC, DIAL must be funded through ACL’s budget if it is to continue operating.

· *National Strategy to Support Family Caregivers*: $500,000 will join $18.5 million from the Older Americans Act Family Caregiver Support program and $1 million from the Aging and Disability Resource Centers for an initiative to implement the caregiver strategy. The Independent Living funding will support work to ensure that upholding the rights and supporting the self-determination of people who receive support from family caregivers is centered throughout the implementation of the strategy. 

· Strengthening the Direct Care Workforce: $500,000 will join $3 million from Developmental Disabilities Projects of National Significance and $8 million from Aging Network Support Activities support an initiative to strengthen the direct care workforce. The paid professionals who form the direct care workforce provide vital services that make it possible for people with disabilities and older adults to live in their own homes and communities. Long-standing workforce shortages have reached crisis levels during the COVID-19 pandemic; today, more than three-quarters of service providers are not accepting new clients and more than half have cut services as a result of the direct care workforce shortage. High turnover – averaging nearly 44 percent across states – also means that people who are able to get services often experience service disruptions and receive inconsistent care. As a result, increasing numbers of people are left with no option but to move to nursing homes and other institutions, people who want to leave these facilities cannot, and the health and safety of those who live in the community is at risk. In addition to undermining people’s civil right to community living, this leads to poorer health outcomes and higher costs of care, which most often are borne by taxpayers. In September 2022, ACL established the national Direct Care Workforce Capacity Building Center to help strengthen the direct care workforce. With FY 2023 funding, ACL is beginning to build a hub through which state, private, and federal entities involved in the recruitment, training and retention of direct care workers can access model policies, best practices, training materials, technical assistance and learning collaboratives. This initiative would fully fund operation of the resource hub and support development of new approaches through competitive grants.

### Appropriations Proposals:

· Allow ACL to establish IL Projects of National Significance: Under Title VII of the Rehabilitation Act of 1973, to authorize grants, contracts, or cooperative agreements for projects of national significance that advance independent living and promote the philosophy of independent living, including a philosophy of consumer control, peer support, self-help, self-determination, equal access, and individual and system advocacy, in order to maximize the leadership, empowerment, independence, and productivity of individuals with disabilities.

### Legislative Proposals: ACL’s request includes three legislative proposals. Specifically:

· Provide State Flexibility to Determine Funding Distribution to Part C Center for Independent Living: ACL proposes to provide states with flexibility to determine (with ACL review and approval) how funds are distributed between Part C Centers for Independent Living (CILs) to enable states to address population shifts or significant changes within their states.  Currently, the Rehabilitation Act of 1973 requires existing CILs to be funded at the level of funding for the previous year with no provision to change allocations

· Removal of the Requirement that Compliance Reviews of CILs Must Occur Onsite: ACL proposes to remove the requirement that a prescribed number of grantee compliance reviews must be conducted onsite each year. As demonstrated by pilot remote reviews conducted in FY 2019 and reviews conducted during the pandemic, today’s technology enables ACL to thoroughly review most program components remotely; onsite reviews can be reserved for more complex situations or concerns that require physical inspection.  This cost-effective approach to monitoring allows ACL to focus resources on services that directly support people with disabilities in their communities.   This proposal gives the Administrator the authority to determine the most effective method for conducting annual compliance reviews, including allowing for remote reviews, while continuing to ensure that CILs are monitored and complying with the Rehabilitation Act. 

· Allow Funding of Program Evaluation and Performance Measurement Activities with Reserved Training and Technical Assistance Funds: ACL proposes adding a new Part to Title VII, Chapter 1 – Individuals with Significant Disabilities, under the Rehabilitation Act of 1973, to authorize grants, contracts, or cooperative agreements for projects of national significance that advance independent living and promote the philosophy of independent living. Innovation, evaluation, and knowledge translation are essential to meeting the evolving independent living needs of people with disabilities.  Currently, the statute does not provide for discretionary, competitive grants, contracts, or cooperative agreements. Such authority would allow ACL to explore new and more effective ways to support the independent living goals of people with disabilities, across all types of disabilities.

### 

### Funding History:

Funding for Independent Living activities over the past five years is as follows:

#### Centers for Independent Living

#### Independent Living State Grants

1/ FTEs are in whole numbers. 

#### Independent Living – Projects of National Significance

### Program Accomplishments

Designed and operated by individuals with disabilities, Centers for Independent Living (CILs) provide tools, resources, and peer support for promoting independent living and integrating people with disabilities fully into their communities. In FY 2021, CILs funded by ACL served nearly 240,000 people with disabilities with more than 1.2 million independent living services to help people with disabilities achieve more than 200,000 independent living goals they had established for themselves, increasing their independence, integration, and full inclusion in society with each achievement. 

Examples of how CILs and the other Independent Living Services programs support people with disabilities in living self-determined lives in the community include: 

· *Facilitating transitions and diversion from nursing homes and other institutions:* CILs provide comprehensive support to help people move from nursing homes and other institutions to homes in the community. CILs provide peer mentorship; facilitate assessment of the individual’s needs, concerns and preferences and development of a plan to meet them; assist the individual with connecting to the services and supports they will need, which may include helping with applications for services; assist with the actual move; and provide critical follow up support after the transition.  Similarly, CILs provide a wide range of services and assistance to help people with disabilities who are at risk of institutionalization continue to live the community. For example, CILs reach out to hospitalized people who have acquired a disability through injury or illness to provide peer mentorship and access to resources to help them navigate a return to their home following their hospital stay. They also work with other agencies, such as Adult Protective Services to address acute needs that otherwise could lead to a move to a congregate setting. The following represent the kind of individualized support provided by CILs to support transition and diversion from institutions:

· LIFE Inc., a CIL in Lubbock, Texas, partnered with other CILs and managed care organizations to help an annual average of 200 individuals transition from hospitals or nursing homes back home, with very few returning. They credit their success to strong partnerships with state agencies, housing programs, and the CIL network. 

· The Independence Center (IC) in Colorado Springs, Colorado partnered with the University of Colorado Health Memorial Hospital to facilitate successful transitions home for patients with a complex or difficult discharge. The IC provides an assessment of the patient’s needs and coordinates services provided by a network of local community-based organizations to meet them, helping them to   successfully thrive at home.

· The Texas State Independent Living Council partnered with two centers for independent living to train people with developmental disabilities to serve as peer support specialists who work with people living in institutions to build their self-advocacy skills and educate them about their rights, including to vote.

· *Re-entry following incarceration:* CILs are increasingly receiving requests for support for people with disabilities who are re-entering the community from jail or prison.  CILs are helping connect these individuals to work programs, housing, and most important, peer support. For example, the Center for Independent Living for Western Wisconsin worked with the Dunn County Criminal Justice Collaborating Council to reduce recidivism of people with disabilities through peer mentoring. A peer mentor with lived experience in both mental health and the criminal justice system met disabled inmates prior to release to assist them with planning, setting goals, connecting with resources, and mentoring to make their transition a successful one. 

· *Supporting people with disabilities during the COVID-19 pandemic:*The IL programs were crucial to ensuring people with disabilities had access to COVID-19 testing, treatment and vaccines and to other resources and supports to help them continue to live safely in the community during the pandemic. SILCs and CILs provided information in accessible formats; worked with public health officials to ensure the needs and concerns of people with disabilities were understood and addressed; facilitated peer support; provided emergency services and supports when people lost access to the support provided by families; and more. For example:

· The Arizona SILC used ILS state grant funding to implement the Candid Conversations series – an online forum for people with disabilities to provide information and support to other people who have disabilities and established online forums for the Arizona disability community to submit concerns and questions to the Department of Health Services 

· Recognizing that lack of transportation was preventing vaccination for many, the Self-Reliance CIL in Tampa, Florida partnered with the Florida Health Department to host vaccine events. Door-to-door transportation was arranged for eligible consumers, and bus passes were provided to riders of the public transit system

· *Independent Living Skills Training Services*: CILs help people learn to manage their personal assistants, improve their communication skills, develop and manage their budgets, write resumes and apply for jobs, use adaptive equipment, develop basic computer skills and more. Independent living skills training can be provided one-on-one in the home, in the community, and virtually. CILs also work to ensure that services meet the specific needs of the people they serve. During FY 2021, CILs provided IL skills training to more than 77,000 people with disabilities.

· *Advocacy and Systems Change Services:*CILs work with individuals to build the advocacy skills that promote individual empowerment. They also work in partnership with people with disabilities, advocates, and others to improve access to health care, education, employment, public places, recreation, transportation, and all other facets of community life. This advocacy work has been particularly important during COVID-19; CILs have been instrumental in ensuring equal access to COVID-19 testing and vaccination. 

· *Housing Assistance:* In FY 2019 and 2020, CILs helped a total of 102,091 individuals access shelter, home modification programs, information on affordable and accessible housing units, and education of fair housing laws and protections. 

· *Information and Referral Services:*CILs help to connect people with disabilities to current information on programs, equipment and community resources and services to help them pursue their goals. In FY 2020, more than 570,000 people received information and referral services to meet a variety of needs. For example, Able South Carolina provided information, resources, and referrals to people with disabilities on how to access COVID vaccinations and personal protective equipment. Bainbridge Advocacy Individual Network in Bainbridge, Georgia assisted consumers in gaining access to transportation to get to their medical appointments and to out-of-town specialty medical appointments. This assistance enabled many individuals who were on very limited incomes to get the proper medical advice and testing done to maintain their health.

· *Ensuring the needs of people with disabilities are addressed in disaster planning:*Many SILC are working to improve their states’ disaster planning and preparation to ensure the unique needs of people with disabilities are met during emergencies. For example, the Washington SILC works with the state’s emergency planner to develop comprehensive plans that include and address the needs of people with disabilities. The Alaska SILC coordinates with the state Office of Emergency Management, FEMA, and community organizations across the state on matters of emergency preparedness, response and recovery.

· *Facilitating the transition to adult life following secondary education for young people with significant disabilities:*CILs play an important role in helping youth prepare for the transition from school to adult life. For example:**

· Center for Independence of the Disabled in New York (CIDNY) worked with 298 young adults to teach workplace readiness and independent living skills. The curriculum is designed to increase self-confidence, self-advocacy, and leadership skills to help students transitioning to adulthood to become as independent as possible.

· Walton Options for Independent Living in Augusta, Georgia assisted a 19-year-old man with bipolar disorder transitioning from incarceration.  The CIL facilitated his release; arranged accessible, affordable housing; coordinated transportation for behavioral health services; helped him apply for Medicaid; and supported him securing employment and working toward his GED. The young man became a certified peer support volunteer with the CIL, worked two part-time jobs, and completed two of the four GED test sessions.

### 

### Outcome and Output Table: Independent Living

ACL has revised the grantee program performance reports to improve overall data quality, reduce grantee reporting burden, and increase reporting of program outcomes. These reports form the basis of performance measures. ACL is in the process of analyzing baseline data and developing a new performance measure.

### Grant Awards Tables:

Independent Living Services State Grant Awards

1/ Independent Living State Grants are awarded to 77 entities across 56 state and territory jurisdictions because some states have separate divisions for vocational rehabilitation and services for the blind.

*Represents States, and the District of Columbia.

Centers for Independent Living Grant Awards

Independent Living Projects of National Significance Grant Awards

****

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**FY 2024 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER:  Independent Living State Grants (CFDA 84.169A)

1/ Undistributed – includes funds for statutory technical assistance and/or minority set-asides; grant systems and review, and program reporting systems costs.

## Limb Loss Resource Center

*BA is in thousands of dollars. 

Original Authorizing Legislation: Public Health Service Act Section 301 (a) and Section 317, as amended, 42U.S.C. 241 (a); 42 U.S.C. 247 (b)

Most Recent Authorizing Legislation: N/A

Current FY Authorization	 N/A 

Expiration Date: 	 Expired 

Allocation Method	Competitive Grant 

### Program Description:

The National Limb Loss Resource Center (NLLRC) works to improve the health, well-being and quality of life of people with limb loss and limb difference, reduce unnecessary medical expenditures, and provide support to families and caregivers. The NLLRC ensures the availability and accessibility of the most current comprehensive, high-quality, evidence-based information, resources, and services so people with limb loss and limb difference can live, learn, work, play, and prosper in their communities. 

Limb loss is the amputation of all or part of an arm or leg due to trauma, infection, diabetes, heart diseases, cancers, or other diseases. A limb difference is a congenital issue affecting one or more of a person’s limbs. An estimated two million people live with limb loss and/or limb difference in the U.S.,[footnoteRef:47] and an estimated 185,000 amputations are performed in the country every year.83 People with limb loss and limb difference experience many barriers to successful community integration and full participation. Following limb loss, many people report reduced participation in recreational activities, lower satisfaction at work, and difficulty navigating their community.83 People with limb loss and limb difference often experience anxiety and psychological distress, low rates of workforce participation, and co-morbidities associated with the amputation of a limb (e.g., back pain, arthritis, phantom limb pain).  [47:  Ziegler-Graham K, MacKenzie EJ, Ephraim PL, Travison TG, Brookmeyer R. Estimating the Prevalence of Limb Loss in the United States: 2005 to 2050. Archives of Physical Medicine and Rehabilitation 2008;89(3):422-9. Accessed 18 February 2023.] 

Peer support, access to assistive technology and supportive services, having enough information to make informed choices, resources to support healthy living, and effective rehabilitation support can create better outcomes. However, many people receive little information about their rehabilitation from their healthcare provider either before or after their amputation.[footnoteRef:48] [48:  Seaman JP. Survey of individuals wearing lower limb prostheses. Journal of Prosthetics and Orthotics 2010;22(4):257-65. https://www.researchgate.net/publication/232116343_Survey_of_Individuals_Wearing_Lower_Limb_ProsthesesAccessed 18 February 2023.] 

The NLLRC was created to address these issues. The center serves as a resource hub for people living with limb loss/difference and their families, as well as health care professionals, service providers, and other stakeholders. Trained information specialists can provide referrals to services available in the local community. 

### Budget Request:

The FY 2024 request for the National Limb Loss Resource Center (NLLRC) is $4,200,000, the same level as the FY 2023 enacted level. The request will allow the NLLRC to sustain service levels for people with limb loss/difference and to continue programming developed during the pandemic to benefit people with limb loss after the pandemic’s end.

### Funding History:

Funding for the program over the past five years is as follows:

### Program Accomplishments:

The National Limb Loss Resource Center’s comprehensive website provides answers to common questions; information on pain management, mental health, and other key issues associated with limb loss/differences. The website also connects people to peer mentors, support groups, local services, and other resources. The center also distributes education materials to more than 100,000 people each year, including the popular *First Step* magazine and the *Your New Journey* information kit, both of which provide information and support to help people adjust to life following amputation. 

A key component of the NLLRC is peer support; their national program trains more than 1,500 Certified Peer Visitors each year to support people with limb loss/difference and those about to undergo an amputation.  The NLLRC offers peer support in a variety of forms that include more than 400 community support groups, hospital partnership programs, and a national youth camp. Through the NLLRC’s peer support programs, more than 2,000 people each year receive information on how to recover from limb loss, how to reduce and prevent chronic health conditions, and how to promote health and wellness of people living with limb loss and limb difference. 

The NLLRC’s Youth Engagement Program program provides life skills resources, education and training; workforce development; mentorship and a youth camp to empower and support young people (ages 10 to 17) living with limb loss and limb difference.

The NLLRC also hosts an annual conference attended by approximately 1,200 people, 75 percent of whom are people living with limb loss or limb difference. The conference offers more than 85 workshops, opportunities to network with peers across the country, and opportunities to interact with vendors and explore prosthesis options to help inform health care decisions. 

Finally, the NLLRC also conducts virtual and in person trainings at local agencies and organizations and organizes Limb Loss Education Days to provide training and information for healthcare professionals and community stakeholders.

### Grants Awards Table:

Limb Loss Resource Center Grant Awards

## Paralysis Resource Center

*BA is in thousands of dollars. 

Original Authorizing Legislation: Christopher and Dana Reeve Paralysis Act, title XIV of the Omnibus Public Land Management Act of 2009, P.L. 111-11; Sections 311 and 317(k)(2) of the Public Health Service Act [42 U.S.C. 243 & 247b(k)(2)], as amended.

Most Recent Authorizing Legislation: Christopher and Dana Reeve Paralysis Act, title XIV of the Omnibus Public Land Management Act of 2009, P.L. 111-11; Sections 311 and 317(k)(2) of the Public Health Service Act [42 U.S.C. 243 & 247b(k)(2)], as amended.

Current FY Authorization.................................................................................................... Expired

Expiration Date......................................................................................................................... 2011

Allocation Method	 Competitive Grant

### Program Description:

Nearly 5.4 million Americans, or one in 50, report having some form of paralysis, and there are an estimated 17,500 new spinal cord injuries every year in the United States. Paralysis is defined as a central nervous system disorder resulting in difficulty or inability to move the upper or lower extremities.[footnoteRef:49] Typical causes include motor vehicle crashes, strokes, falls, acts of violence (primarily gunshot wounds), and sports/recreational accidents. People living with paralysis often face health and other disparities, which often translate into exclusion from participation in their communities. [49:  Armour, Brian S., Elizabeth A. Courtney-Long, Michael H. Fox, Heidi Fredine, and Anthony Cahill. Prevalence and Causes of Paralysis—United States, 2013. Issue brief. Christopher and Dana Reeve Foundation, 23 Aug. 2016. Accessed 18 February 2023.] 

The Paralysis Resource Center offers a free, comprehensive, national source of informational support for people living with paralysis, their families, and caregivers.  The primary goals are to foster the involvement of people with paralysis in the community, promote their health, and improve their quality of life. 

In FY21, ACL awarded a new 5-year cooperative agreement to continue support for this national resource and to improve quality of life across all contexts: home, community, work, and recreation for people with paralysis, families and caregivers, and with a particular emphasis on racial minorities, children and adolescents, and those from rural communities.

### Budget Request:

The FY 2024 request for the Paralysis Resource Center program is $10,700,000, the same level as FY 2023 enacted level. The request continues support for PRC’s work for people with paralysis and other physical disabilities to promote health and wellness that enhances full participation, independent living, and self-sufficiency for people with paralysis and other physical disabilities.

### Funding History:

Funding for the program over the past five years is as follows:

### Program Accomplishments: 

The Paralysis Resource Center provides a variety of services, communities, and programs, including:

· A comprehensive website providing information on health care costs and insurance, rehabilitation, wheelchairs, home and travel, a section for caregivers and other key issues associated with living with paralysis. The website also connects people to peer mentors, support groups, local services, and other resources. 

· Distribution of education materials, such as the Paralysis Resource Guide distributed to more than 227,000 people. The free guide is one of the most comprehensive manuals on living with paralysis. 

· An annual summit to foster collaboration, independence, health promotion and innovation. The summit covers on topics and themes relevant to the paralysis community and gives everyone a chance to hear from experts, ask questions and share experiences on many aspects of life with paralysis. 

· Trained information specialists who are available to help anyone living with paralysis and their support networks to connect to services, supports and referrals. This individualized support service is available in over 170 languages. Paralysis Resource Center specialists have served over 120,000 individuals and families since its launch in 2002. Specialized services are also available to clients free of charge, such as case management, pre-employment benefits analysis. 

· The Accessible College program provides up to three hours of one-on-one consultation for students with disabilities – at no cost to the student – to help them transition to college. 

· The Peer & Family Support Program provides support from trained and certified mentors who also live with paralysis and understand the day-to-day realities and long-term challenges that people living with paralysis face. More than 22,530 people have received support from over 530 certified peer mentors.

· The Quality of Life Grants Program has awarded over 3,600 grants in all 50 states, totaling more than $37 million in financial support for nonprofit organizations serving individuals living with paralysis. The grants support programs and projects that foster community engagement and involvement, while promoting health and wellness for people living with paralysis.

· The Military & Veterans Program supports the unique needs of service members and veterans, regardless of when they served or how their injury was sustained. Goals of the program include identifying and defining the needs of the military community; determining how to best reach and aid them; and helping to leverage, develop and maintain collaborative relationships and partnerships with other national and local organizations that serve the military and veteran community. Veteran projects and activities are given priority for the Quality of Life Grants program, and there are dedicated sections on the website and in the Paralysis Resource Guide.  

### Grant Awards Table:

Paralysis Resource Center Grant Awards

DISABILITY PROGRAMS, RESEARCH, AND SERVICES

165

## Traumatic Brain Injury

*BA is in thousands of dollars, FTEs are in whole numbers. 

Original Authorizing Legislation: Traumatic Brain Injury Act of 1996, P. L. 104-166

Most Recent Authorizing Legislation: The Traumatic Brain Injury Program Reauthorization Act of 2018, P.L. 115-377

Current FY Authorization	 $11,321,000

Expiration Date	 2024

Allocation Method	Formula Grant / Competitive Grant / Contract

### Program Description:

The Traumatic Brain Injury (TBI) program develops comprehensive, coordinated family- and person-centered service systems at the state and community level for people with TBI. 

According to the CDC there were approximately 223,135 TBI-related hospitalizations in 2019 and 64,362 TBI-related deaths in 2020.[footnoteRef:50] Incidence is generally higher among men, Native Americans, African Americans, children younger than five, and adults over 75. [50:  Centers for Disease Control and Prevention, TBI Data. Accessed 6 February 2023.] 

Many people with TBI live the rest of their lives with a resulting disability, which often creates a need for a variety of services and supports, including rehabilitation, counseling, academic and vocational accommodations, independent living assistance, transportation assistance, and vocational training. These services and supports often are fragmented across different state systems of care, making access to them difficult; the purpose of ACL’s TBI program is to strengthen and streamline these state systems to improve access for people with TBI and their families to improve outcomes. The TBI Program includes two grant programs: State Protection and Advocacy (P&A) Systems Grants (formula grant) and the TBI State Partnership Program (competitive grant).

#### Protection and Advocacy Systems Grants

TBI P&A grants are awarded to P&A organizations in every state, territory, the District of Columbia, and one Native American consortium to provide support people with TBI and their families. Grantees use these funds to develop plans and provide P&A services – including individual and family advocacy, self-advocacy training and assistance, information and referral services, and legal representation – to people who have experienced a TBI. The average award of these formula grants is $50,000 for state grantees and $20,000 for territory grantees. 

People with TBI often have an array needs including assistance finding, maintaining, or succeeding in employment; finding a home; and accessing needed supports and services (such as personal attendant services, assistive technology, and appropriate mental health, substance abuse, and rehabilitation services). They often need assistance to move back into homes in the community following hospitalization. 

P&As educate people with TBI, community members, and service providers about alternatives to institutionalization, including available community-based services and supports and how to access them; investigate allegations of abuse and neglect and advocate for appropriate corrective action; provide a range of legal support to promote and protect the right to self-determination and community integration and to enable people with traumatic brain injury to receive the accommodations and supportive services to make it possible for them to live in the community; advocate for the successful inclusion of people with TBI in community life; and more. P&As served 1,100 clients with TBI in FY 2021.

A vital part of P&A activities is providing training and education to consumers and service providers. Training is tailored to meet the needs of specific audiences and is intended to increase awareness about legal concerns and individual rights around TBI, provide information on identification and funding of services, and provide support to facilitate full participation in all aspects of life. 

The P&A programs play a crucial role in making it possible for people with TBI to continue to live independently; many people, including veterans with service-connected TBI, are forced to remain in expensive institutional settings until they receive advocacy assistance from their P&A agency.

#### State Partnership Program Grants

The TBI State Partnership program helps states expand and improve state and local capability to provide comprehensive and coordinated services for people with TBI and their families. Each state must establish and maintain an advisory board on TBI to identify and report on gaps in resources and services for people affected by TBI and recommend solutions. Each grantee also must create a state plan to clearly define goals and actions for the state to increase its capacity to provide comprehensive and coordinated services that are culturally competent, person-centered for people with TBI, across their lifespan. Grantees also collaborate across states to address a variety of critical issues, such as the disproportionate number of people with TBI in the criminal justice system, healthy living with a TBI, expanding the principles of person-centered design to systems that support people with TBI, and employment challenges and solutions.

### Budget Request:

The FY 2024 request for the Traumatic Brain Injury (TBI) program is $13,118,000, the same as the FY 2023 enacted level. The FY 2024 request maintains funding for the TBI P&A to continue to play a critical role in protecting the rights, safety, and welfare of people with TBIs. The services they provide are instrumental in ensuring that people with TBI have equal access and opportunity to fully participate in society. They provide a range of services, including both individual and systems advocacy; monitoring for health and safety and investigating allegations of abuse and neglect; legal assistance to address a range of issues, such as equal access to employment and education; ensuring public places and programs are accessible; ensuring equal access to health care, including life-saving treatments; helping people avoid – or leave – institutions to live in the community; assistance with accessing assistive technology services and devices; and information and referral assistance to connect people with TBIs to other services and resources. 

### Funding History:

Funding for the program over the last five years is as follows:

1/ FTE are shown in whole numbers.

### Program Accomplishments:

In FY 2020, TBI P&A grantees provided training to more than 38,000 people, and more than 2,800 people with TBI received information, technical assistance, and referral services. 

In FY 2021, the TBI program supported:

· Partnerships to improve systems of support for people with TBI: The majority of TBI grantees funded partnerships with affiliates of national brain injury organizations. Other more frequently funded partners included community-based service organizations and State Departments of Public Health.

· Screening for TBI*:*The subset of grantees focused on screening reported a total of 17,972 people being screened for a TBI, which is critical to connecting to resources and services 

· Training for all parts of the TBI ecosystem*:*TBI grantees focused on training physicians, EMTs, and other clinical or medical providers; family, friends, and caregivers of people with TBI; university, college and school staff; military staff; members of law enforcement; and people with TBI

· Information and referral assistance: Grantees focus on I&R reported over 17,100 contacts, which help people with TBI connect to resources that can help them live independently, in the community

### Grant Awards Tables:

Traumatic Brain Injury: Protection and Advocacy Grant Awards

1/ Not including grants to tribes.

2/ Range of awards only covers States and the District of Columbia.

Traumatic Brain Injury: State Implementation/Mentor Partnership Grant Awards

1/ All grants forecasted to be $200,000 each.****

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**FY 2024 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER:  TBI Protection and Advocacy State Grants (CFDA 93.873)

1/ Undistributed – includes funds for grant systems and review, and program reporting systems costs.

## National Institute on Disability, Independent Living, and Rehabilitation Research

*BA is in thousands of dollars. 

Original Authorizing Legislation: Title II of the Rehabilitation Act of 1973, Public Law 93-112

Most Recent Authorizing Legislation:  Title II of the Rehabilitation Act of 1973, as amended in 2014 by the Workforce Innovation and Opportunity Act (WIOA), Public Law 113-128

Current FY Authorization:	 Expired

Expiration Date: 	 2019

Allocation Method:	Discretionary Grants and Contracts

### Program Description:

The mission of the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) is to generate new knowledge and promote its effective use to improve the abilities of people with disabilities to perform activities of their choice in the community, and to expand society’s capacity to provide full opportunities and accommodations for its citizens with disabilities. NIDILRR sponsors comprehensive and coordinated programs of research, training, knowledge translation and capacity building to maximize the full inclusion, social integration, employment, and independent living of individuals with disabilities of all ages.

NIDILRR-sponsored research and development aims to improve outcomes for people with disabilities in three life domains: health, employment, and community living. NIDILRR also systematically translates and broadly disseminates research findings. The knowledge generated through NIDILRR funding results in an evidence base that can inform development of programs, policies, services and supports, assistive technology and other products, and interventions to improve health and function, competitive integrated employment options, and full access and participation in the community for people with disabilities across the lifespan. 

NIDILRR engages stakeholders and obtains input through an array of in-person, virtual, and electronic mechanisms to identify real-life problems and challenges faced by people with disabilities. That stakeholder input informs the development of research priorities to address these identified needs and problem areas. NIDILRR conducts research through a network of individual research projects and centers of excellence across the nation. Research funding is awarded through competitive grants, and most of the funds are awarded to universities or providers of rehabilitation or related services.

As required by the Rehabilitation Act, NIDILRR operates under a Long-Range Plan.  The current plan covers FY 2018 – FY 2023, a new plan will be put in place to cover FY 2024 – FY 2028.

The primary grant mechanisms under which NIDILRR makes awards are:

· Rehabilitation Research and Training Centers (RRTCs). RRTC research improves rehabilitation methodologies and service delivery systems, alleviates or stabilizes disabling conditions, and promotes maximum social and economic independence for persons with disabilities. RRTCs also provide training to help rehabilitation personnel deliver more effective rehabilitation services.

· Rehabilitation Engineering Research Centers (RERCs).**RERCs focus on rehabilitation technology, including rehabilitation engineering and assistive technology devices and services designed to diminish barriers to independence.  RERCs also train individuals, including those with disabilities to become researchers and practitioners in the field of rehabilitation technology.

· Model Systems. NIDILRR funds model systems networks in three rehabilitation areas: spinal cord injury, traumatic brain injury, and burn injury. In addition to participating in research, model systems grantees collect and contribute long-term community integration and functional outcomes data to their respective national databases. These model systems programs have become platforms for conducting multi-site research studies.

· Spinal Cord Injury (SCI) Model Systems. The SCI program funds research and dissemination activities to address the needs of SCI individuals, their family members, caregivers and other stakeholders. The NIDILRR SCI Model Systems longitudinal dataset is the largest of its kind in the world.

· Traumatic Brain Injury (TBI) Model Systems. TBI projects are research grants to improve TBI rehabilitation outcomes. The NIDILRR TBI model systems is the largest non-military TBI service delivery/research network participating in various intergovernmental efforts to improve treatment and outcomes for veterans.

· Burn Model Systems. BMS projects improve treatment and outcomes for burn injury survivors. In addition to data contributions and research, the four Burn Model System centers provide information and resources to individuals with burn injuries; their families, caregivers, and friends; health care professionals; and the public.

· Field-Initiated Projects*.*Field-Initiated Projects supplement NIDILRR’s directed research and development, capacity building and knowledge translation efforts by addressing a wide range of topics identified by investigators

· Disability and Rehabilitation Research Projects*.* Grantees focus on addressing problems encountered by people with disabilities through any combination of activities, including research, training, dissemination, and technical assistance

· ADA National Network Centers*.* The network centers support technical assistance, information, and training to promote increased understanding, awareness, and enforcement of the ADA

· Advanced Rehabilitation Research Training (ARRT)*.* The ARRT program funds grants to institutions of higher education to recruit and train qualified persons with doctoral or similar advanced degrees and prepare them to conduct independent research in areas related to disability and rehabilitation

· Small Business Innovation Research (SBIR). NIDILRR awards SBIR grants to small businesses to support the development of new rehabilitation technologies that promote increased accessibility and independence

· Switzer Research Fellowships*.*The Switzer program awards 1-year fellowships to individuals to carry out research projects in areas of importance to the disability and rehabilitation community

NIDILRR funding also supports other activities, including knowledge translation; collaborative projects; development and maintenance of grantee reporting systems; program review; and reporting, evaluation, and long-range planning.

### Budget Request:

The FY 2024 request for the National Institute on Disability, Independent Living and Rehabilitation Research (NIDILRR) is $119,000,000, the same level as the FY 2023 enacted. The request maintains NIDILRR’s ability to support research and translate and disseminate findings to foster innovation to afford people with disabilities the opportunity to gain their highest functional health status, live and fully participate in the community, and to gain and sustain competitive, integrated employment. 

ACL’s FY 2024 request also continues to include a provision that addresses two important and longstanding challenges for many ACL programs, including NIDILRR’s. The provision would simplify the accounting processes used when one HHS operating division (OPDIV) has agreed to issue and manage a grant on behalf of a second OPDIV. This provision would allow HHS to use the reimbursable processing features within the accounting system, rather than the more cumbersome execution process currently used, to allow agencies to work together to address shared objectives. This provision also would explicitly provide authority for HHS OPDIVs to collaborate with organizations outside of HHS to issue grants or cooperative agreements. Currently, the lack of specific authority precludes such collaboration. Specifically, the proposed language would provide HHS OPDIVs with the authority to transfer funds via reimbursable agreements from one agency to another for the purposes of making grants, allowing NIDILRR to collaborate on a wider scale to fund projects. For example, NIDILRR could partner with the U.S. Department of Veterans Affairs to fund research projects to address the needs of disabled veterans; currently each agency must fund this work separately. Collaboration creates synergy that cannot be realized when working in silos, which brings opportunities and resources to people with disabilities with greater speed and impact. This provision also reduces administrative burden on grantees by combining application and reporting requirements, which allows a greater proportion of grantee resources to be focused on the substantive work of the project. NIDILRR had this authority when it was part of the U.S. Department of Education.

### Funding History:

Funding for NIDILRR over the last five years is as follows:

### Program Accomplishments:

NIDILRR’s goal is to produce research toward the development of new knowledge and innovative technological devices, prototypes, measurement tools, interventions, and other informational products to enhance community living, health and function, and employment among people with disabilities. Grantees produce peer-reviewed publications, intervention protocols, software, databases, and a wide range of other outputs and outcomes across NIDILRR’s three domains: health and function, community living and participation, and employment. 

Toward that end, in FY 2022, NIDILRR grantees produced 591 peer reviewed publications, 216 non-peer reviewed publications, 180 information products, 56 tools, measures and information protocols and 37 technology products and devices. As well as, supporting 245 grant awards supporting 1,569 discrete projects. 

In addition to research, NIDILRR grants directly supported 576 graduate students and post-doctoral fellows. Sixty-five principal investigators (PIs) self-identified as disabled which represents 19.8 percent of currently active PIs, of NIDILRR grants and 499 staff members work on NIDILRR grants.

Selected examples of grantee accomplishments in FY 2022 with broad impacts include:

****

NIDILRR grantees helped to advocate for people with disabilities by providing the basis for the inclusion of target metrics for recovery of people with traumatic brain injury in  Healthy People 2030. Healthy People 2030 is the nation’s current 10-year plan for addressing the most critical public health priorities. NIDILRR grantees not only provided the basis for inclusion but funds the National Database which is the approved source for monitoring progress towards the goal “Increase the percentage of adults who can resume more than half of their preinjury activities (with or without supports) 5 years after receiving acute inpatient rehabilitation for traumatic brain injury.” ***This specific outcome is expected to greatly improve the lives of approximately 3.2–5.3 million people in the U.S. living with a TBI-related disability and 1.5 million individuals who acquire new TBIs each year.***

· The results from NIDILRR’s SCI, TBI, and Burn  Model Systems grants are disseminated broadly through our award-winning Model Systems Knowledge Translation Center (MSKTC).  During FY 2022 alone the MSKTC website received over 1,700,000 visitors, and the top 10 fact sheets alone were downloaded 825,000 times.

· The NIDILRR-funded Rehabilitation Engineering Research Center on Universal Design and the Built Environment (RERC-UD) focused on the development of Touch Responsive Models – 3D representations of buildings and plans. This work used interactive touch model technology developed by an earlier NIDILRR-funded RERC (2015 – 20). Touch responsive models are a common way of presenting spatial information to help orient people with visual impairments. Initially used in schools for the blind, the technology has more recently been placed in locations such as commercial buildings, campuses, museums, hospitals, and other public places where pedestrians need orientation and wayfinding information in an accessible format. The adoption of this technology benefits the nearly one million Americans that are blind and millions more who experience low vision. This technology is expected to directly impact the lives of nearly 1 million Americans who are blind. This is one of 21 engineering center grants NIDILRR supports to develop technologies that support people with disabilities in their daily lives.   

· A grant that developed Touch Responsive Models – 3D representations of buildings and plans. Touch responsive models replace common ways of presenting spatial information such as “you are here maps” to 3D touch models which help orient individuals with visual impairments. Followed that successful research into a grant that further adapted the technology for more broadly, in this case starting with installation in various schools for the blind, followed by installation in locations that attract more diverse populations. To date, they have been adopted for use in commercial spaces, campuses, museums, hospitals and other public places where pedestrians need orientation and wayfinding information in an accessible format. The adoption of this technology benefits the nearly 1 million Americans are blind and millions more who experience low vision (this is one of 21 grants NIDILRR supports which the development of technologies that support people with disabilities in daily life).   

· NIDILRR research generates cutting edge knowledge to inform policy and practice from individual providers to the U.S. Senate.  An example is a recent study that ended in FY 2022 focused on reducing the costs for families and states by increasing access to home and community-based services which was highlighted during a Senate Aging Committee hearing. Findings from this research were shared with congressional staff, submitted in the Congressional Record for the hearing, and underscored by a Senator during closing remarks. 

### Outcomes and Output Table: NIDILRR

*This is a developmental performance measure.  ACL is currently collecting sufficient data to establish a baseline.  To set a baseline, the agency relies on 3 years of data.  This process ensures that the data are stable and show a clear trend.  The agency will set targets for this measure once a baseline is established.

### Grant Awards Table:

National Institute on Disability, Independent Living, and Rehabilitation Research Grant Awards

DISABILITY PROGRAMS, RESEARCH AND SERVICES

216

# Consumer Information, Access, and Outreach

## Summary of Request

Many older people and people with disabilities need an array of services and supports to live and fully participate in their communities. The complexity of navigating programs and selecting services that best address the needs of each individual can create challenges, especially for people who have not previously used such services and supports. Consumer Information, Access, and Outreach (CIAO) programs provide people with disabilities, older adults, families, and caregivers with the information they need to make informed decisions and access these resources.

The FY 2024 request for CIAO programs is $171,242,000, which includes an extension of $50 million in authority for Medicare Improvements for Patients and Providers Act (MIPPA) funding. This is a combined increase of $8,231,000 above the FY 2023 enacted level. Of the increase, $2,850,000 appears as an increase for MIPPA; however, the MIPPA request is the same as the FY 2023 level but shows an increase because the FY 2023 sequestration will not apply to the FY 2024 request.

The request focuses on expanding and improving access to direct services and implementing the  *National Strategy to Support Family Caregivers*. The request includes: 

· $10,000,000 for Aging and Disability Resource Centers (ADRCs), an increase of $1,381,000 over the FY 2023 enacted level. $1 million of the increase will be used to support implementation of the caregiver strategy, particularly to extend caregiver support services to family caregivers who do not meet the statutory criteria to participate in the Family Caregiver Support program authorized by the Older Americans Act. That initiative will be jointly funded with $18,500,000 million from the OAA program $500,000 from a proposed new program, Independent Living Projects of National Significance.  The remainder of the increase will help to offset the increased costs of delivering ADRC services, which connect older adults and people with disabilities to the services they need to live in the community. The request also maintains the increases provided in FY 2023. 

· $55,242,000 for State Health Insurance Assistance Programs (SHIP), the same level as the FY 2023 enacted. The FY 2023 increase allowed to SHIPs to expand capacity, support program innovation, and accelerate adoption across states of new technologies and promising practices that were developed to address challenges to service delivery that arose during the COVID-19 pandemic, but which will continue to improve program reach and effectiveness after the pandemic has ended. 

· $10,000,000 for the Voting Access for People with Disabilities program, maintaining the increases included in the FY 2023 enacted level. The program funds a voting access protection and advocacy system in each state and territory, which provides a range of services to ensure full participation in the electoral process for people with disabilities, including assistance with registering to vote, casting votes, and accessing polling places. 

· $44,000,000 for Assistive Technology (AT) programs, an increase of $4,000,000 above the FY 2023 enacted level. The request helps to meet the increased demand across ACL’s portfolio of programs that work together to increase access to assistive technology for people with disabilities and their families. 

· The National Technical Assistance Center on Kinship and Grandfamilies will spend $2 million of the $10 million received in the American Rescue Plan Act (P.L. 117-2), which is available through FY 2025. That funding will provide, at a national level, training, technical assistance, and resources for government programs, community-based organizations, and tribes and tribal organizations, including urban Indian organizations, that serve grandfamilies and kinship families. No additional funding is requested for this program. 

· ACL is requesting a five-year extension through FY 2028 at the existing level of $50,000,000 per year for the Medicare Improvements for Patients and Providers Act (MIPPA) programs, which were funded from FY 2021 through FY 2023 by P.L. 116-260. This appears as an increase of $2,860,000 because the request does not assume a sequestration is applied to it. These grants to states and tribes help low-income older adults, people with disabilities, and caregivers apply for special assistance through Medicare.

· 

## Aging and Disability Resource Centers

*BA is in thousands of dollars.

Original Authorizing Legislation: Sections 202(b) and 411 of the Older Americans Act of 1965, Public Law 89-73.

Most Recent Authorizing Legislation: Supporting Older Americans Act of 2020, Public Law 116-131

Current FY Authorization	 $10,346,749

Authorization Expiration Date	 2024

Allocation Method	 Competitive Grants/Cooperative Agreement and Contracts

### Program Description:

Aging and Disability Resource Centers (ADRCs) support states in streamlining access to the long-term services and supports many older people and people with disabilities need to live and participate in their communities. With grants from ACL, states have developed and/or expanded “No Wrong Door” (NWD) systems in which state agencies retain responsibility for their respective services but coordinate to integrate access to those services through a single, standardized process (currently 56 states and territories have NWD systems). Community-based organizations like ADRCs deliver oneon-one, person-centered counseling and serve as consumer-friendly entry points to the system.  

Without these services, people who need long-term services and supports (LTSS) often do not have access to accurate and complete information, which can lead them to select options that are more expensive than necessary.[footnoteRef:51] By helping them connect to the services they need to live in the community, ADRCs/NWD systems help divert individuals from more costly forms of care, such as nursing homes, as well as help them avoid unnecessary hospital admissions and readmissions.  A recent study of Medicaid beneficiaries found that less than five percent of people who initiated LTSS in the community subsequently experienced a long institutional stay. In contrast, 73 percent of people initiating care in an institution subsequently experiencing a long stay.[footnoteRef:52] Since institutional care can cost three times as much as in-home supports, NWD systems are critical to decreasing health care utilization costs and are a key component in transforming states’ long-term services and support programs.  [51:  Bowen NB and Fox-Grage W. 2017. No Wrong Door: Person- and Family-Centered Practices in Long-Term Services and Supports. Accessed 18 February 2023.]  [52:  Close J. Does Early Use of Community-Based Long-Term Services and Supports Lead to Less Use of Institutional Care? Accessed 18 February 2023.] 

Services provided by ADRC/NWD systems include:

· Targeted discharge planning, care transition, and nursing home diversion support that integrates the medical and social service systems to help older adults and disabled people remain in their own homes and communities, particularly after a hospitalization, rehabilitation, or skilled nursing facility visit

· One-on-one, person-centered counseling to help consumers, families, and caregivers fully understand their options for long-term services and supports, including private pay options

· Streamlined access to publicly supported long-term services and support programs for people who appear to be eligible for such programs

· Outreach and assistance to Medicare beneficiaries on their Medicare benefits, including prevention benefits and low-income subsidies (funded by the Medicare Improvements to Patients and Providers Act)

Since 2003, ACL (or its predecessor agencies) and CMS have entered into cooperative agreements with states to develop the infrastructure for these NWD systems. In 2008, the Veterans Health Administration also began participating as a key partner. 

### Budget Request:

The FY 2024 Aging and Disability Resource Centers (ADRCs) request is $10,000,000, an increase of $1,381,000 over the FY 2023 enacted level. The increase supports ACL’s efforts to connect people to services. ADRCs provide objective information, advice, counseling, and assistance to help people make informed decisions about long-term services and supports and accessing both public and private programs. ACL is leveraging the existing ADRC program’s ability to connect people to services with a $1,000,000 increase supporting the *National Strategy to Support Family Caregivers*.

This initiative will be jointly funded with $18.5 million from the Family Caregiving Support Services program and funding from the Developmental Disabilities Projects of National Significance, Independent Living Projects of National Significance programs. In September 2022, ACL delivered the strategy to Congress. The strategy includes more than 300 recommended actions that federal agencies, states and tribes, communities, and others can take to address the challenges of caregiving and better support the families and other informal caregivers who form the backbone of our national system of caregiving. 

In addition, ACL requests an additional $381,000 in support of ACL’s efforts to increase access to direct services. ADRCs provide objective information, advice, counseling, and assistance to help people make informed decisions about long-term services and supports and accessing both public and private programs, easing access for those who need services. 

### Funding History:

Funding for Aging and Disability Resource Centers over the last five years is as follows:

### Program Accomplishments:

Currently, 56 states and territories have NWD activities. The 2020 AARP LTSS State Scorecard reflected ongoing growth and sustainability of the LTSS access points in state NWD systems across the country. Thirty-three states showed meaningful improvement in their overall scores between 2017 and 2020 as measured by criteria across five areas:

· State governance and administration

· Target populations

· Public outreach and coordination with key referral sources,

· Person-centered counseling

· Streamlined eligibility for public programs[footnoteRef:53]  [53:  AARP. (June 2017). Picking Up the Pace of Change, 2017: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers. Accessed 18 February 2023.] 

Additional data will be available through the fourth iteration of the Scorecard, which includes an indicator on Affordability and Access. Data is currently being analyzed for 2023, measuring state progress towards state governance and administration, public outreach and coordination, person centered counseling, and streamlined eligibility.

During FY 2022 (from October 1, 2021 through September 30, 2022), state NWD systems and local ADRCs reported serving over 4.9 million unduplicated individuals. Of those served, over 1.2 million received assistance with applications for Medicaid, VA programs, and other programs, and 928,000 received person-centered counseling to help them make informed decisions.

· From April 2020 through September 2022, state NWD systems and local ADRCs helped almost 75,000 people transition safely from hospitals, nursing homes, and other congregate settings to home in the community

· From April 2021 through September 2022, state NWD systems and local ADRCs engaged almost 2.2 million people through COVID-19 vaccine access efforts. This included outreach and information, as well as assistance with scheduling appointments, securing accessible transportation, coordination with assistive technology programs, and more

Through the Veteran-Directed Care (VDC) program, a partnership between the Veterans Health Administration and ACL, ADRCs and other local aging and disability network agencies provide integrated options counseling and access points to care transition and diversion support to help veterans with disabilities continue living in the community. Veterans and caregivers value the program because it gives veterans control over the care and support they receive in the community. The program enables them to design their care to fit their life rather than designing their life to fit the care provided. The VDC program is available in 37 states, plus the District of Columbia and Puerto Rico and is serving 4,344 veterans through 71 VA medical centers and 249 aging and disability network agencies.

### Grant Awards Table

Aging and Disability Resource Centers Grant Awards

## State Health Insurance Assistance Programs

* BA is in thousands of dollars, FTEs are in whole numbers.

Original Authorizing Legislation: Section 4360 of the Omnibus Budget Reconciliation Act of 1990 (42 U.S.C. 1395b-4), P.L. 101-508

Most Recent Authorizing Legislation: Section 4360 of the Omnibus Budget Reconciliation Act of 1990 (42 U.S.C. 1395b-4), Public Law 101-508

Current FY Authorization	 Expired

Authorization Expiration Date	N/A

Allocation Method	Formula and Competitive Grants/Contracts

### Program Description:

State Health Insurance Assistance Programs (SHIPs) provide unbiased education and assistance to Medicare beneficiaries, their families, and caregivers. SHIPs conduct public outreach in local communities and also provide in-depth one-on-one assistance (by phone, online, and in person) based on the unique needs of the beneficiary. 

The assistance provided to Medicare beneficiaries helps them in accessing, understanding, and connecting to the healthcare system, thus improving their customer service experience with Medicare. Accessing affordable health insurance can be difficult even for those with Medicare. SHIPs help Medicare beneficiaries to fully understand the Medicare choices available to them so that the beneficiaries can make informed enrollment and benefit decisions that ultimately reduce costs to both the beneficiary and Medicare. CMS, as well as Medicare Advantage and Part D plans, refer beneficiaries to SHIPs when their cases are too complicated for the 1-800-MEDICARE call center.

Additionally, SHIPs conduct public education and media outreach activities to educate beneficiaries on a variety of topics related to Medicare, including providing plan comparisons, enrollment assistance, and assistance with understanding and navigating benefits. As described below, SHIPs support the Secretary’s objective of addressing the costs and availability of health insurance.

The ACL provides SHIP grants to all 50 States, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands to fund the infrastructure, training, and administration needed to support nearly 12,500 SHIP team members, many of whom are volunteers, in over 2,200 community-based organizations. Nearly two-thirds of the 54 state SHIP programs are administered by State Units on Aging, with the remaining programs administered by State Departments of Insurance. At the community level, many SHIPs are either housed in or create local partnerships with Area Agencies on Aging. Similarly, almost 50 percent of the SHIPs are co-located with the Senior Medicare Patrol program and work collaboratively with them to educate beneficiaries and help deter or prevent Medicare fraud and abuse.

Helping illustrate the complexity of the assistance provided to SHIP beneficiaries, the average time spent on one-on-one counseling continues to increase annually, reflecting the on-going need for and complexities of the questions and help requested by Medicare beneficiaries. It was 28 minutes in 2014 and 37 minutes in 2019. The SHIP program is the only place that provides this level of unbiased, in-depth counseling and one-on-one to older adults and people with disabilities who struggle to navigate the complexities of their financial and medical needs.

### Budget Request:

The FY 2024 request for State Health Insurance Assistance Programs (SHIP) is $55,242,000, the same level as the FY 2023 enacted level. This level of funding would allow the SHIPs to continue to provide unbiased help at current levels to older adults and people with disabilities who are Medicare eligible or dually eligible for Medicare and Medicaid (including newly enrolled beneficiaries), as well as their families and caregivers, and to build on recent innovations, including:

· Expanding the capacity to conduct virtual outreach, enrollment assistance, and one-on-one counseling to enhance customer service experiences in the wake of the pandemic. This reflects the Administration’s dedication to not only having Medicare beneficiaries find the right plan for them, but also providing a level of customer service support that meets or exceeds that provided by the private sector.

· Providing in-depth information and assistance to Medicare beneficiaries in understanding and accessing Inflation Reduction Act changes to Medicare including helping beneficiaries make informed Medicare Plan decisions to ensure access to the $35 copay for insulin implemented January 1, 2023 

· Educating Medicare beneficiaries on the importance of getting their COVID-19 vaccine booster as part of their ongoing Medicare education and counseling 

· Partnering with pharmacies and pharmacy schools in response to the opioid crisis, to check prescription medication lists of Medicare beneficiaries for potential drug interactions and over-prescribing of opioids

· Rethinking business practices in the wake of conditions imposed by COVID-19, including practices for managing, recruiting, training, and retaining program team members

### Funding History:

Funding for the State Health Insurance Assistance Program over the past five years is as follows: 

### Program Accomplishments:

The SHIP program provides needed in-depth assistance to Medicare beneficiaries through the extensive use of trained team members. Providing a national network of over 12,500 highly trained SHIP team members, half of which are volunteers, the SHIP program is able to provide twice as many trained team members than it could if only hiring paid staff. The network provides local community-based assistance to the ever-increasing number of Medicare beneficiaries. In Grant Year 2021 (Apr. 1, 2021-Mar. 31, 2022), over 4,400,000 Medicare beneficiaries used SHIP services. SHIP team members provided direct one-on-one services for nearly 1,770,000 contacts with beneficiaries, their families, and caregivers. Additionally, SHIP reached over 2,600,000 people in educational events explaining Medicare and its benefits. 

SHIP counselors’ average session times with clients was 37 minutes in 2019, more than three times the 9.5 minute average call to the 1-800 Medicare call center. This reflects the greater complexity of issues handled by SHIPs in comparison to 1-800 Medicare.  

Accessing affordable health insurance can be difficult even for those with Medicare. SHIPs help Medicare beneficiaries to fully understand the Medicare choices available to them so that the beneficiaries can make informed enrollment and benefit decisions that ultimately reduce costs to both the beneficiary and Medicare. CMS, as well as Medicare Advantage and Medicare Part D plans, refer clients to SHIPs when their cases are too complicated for the 1-800-MEDICARE call center. Many beneficiaries utilize SHIP every year because of the complexity of their situations, including prescription needs, and the counseling can help to save them thousands of dollars per year.  

### Grant Awards Table:

State Health Insurance Assistance Programs Grant Awards

*Represents States, and the District of Columbia

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**CENTER FOR INTEGRATED PROGRAMS**

**FY 2024 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER:  State Health Insurance Assistance Program (CFDA 93.324)

1/ Undistributed- reflects the amount used from the SHIP appropriation for the staff and overhead, support contracts, training assistance, data systems, grant systems, and grant review costs.

## Voting Access for Individuals with Disabilities

*BA is in thousands of dollars.

Original Authorizing Legislation: Section 291 of the Help America Vote Act of 2002, Public Law 107-252

Most Recent Authorizing Legislation: Section 291 of the Help America Vote Act of 2002, Public Law 107-252

Current FY Authorization	Expired

Authorization Expiration Date	2006

Allocation Method	Formula Grant

### Program Description:

The Voting Access for Individuals with Disabilities program authorized by the Help America Vote Act (HAVA) provides formula grants to support Protection and Advocacy (P&A) systems in each state and territory and the American Indian consortium, as well as competitive grants to organizations that assist P&As in this work. HAVA P&A programs help to ensure that individuals with disabilities are able to exercise their rights to register to vote, cast a vote, and access polling places. They provide direct services to people with disabilities to support them with all aspects of voting, advocate at the community and state levels to ensure voting accessibility and monitor and address accessibility issues. 

For example, HAVA P&As work with states and communities to improve information on the location of accessible polling places and to encourage adoption of voting procedures that enable individuals with disabilities to vote privately and independently. Grantees also educate election officials, poll workers, and election volunteers on the rights of voters with disabilities and best practices. P&As survey polling places, recommend modifications to make specific polling places accessible, and develop criteria for identifying accessible polling places.

ACL also makes discretionary grants to nonprofit organizations to provide technical assistance to support HAVA P&As in developing proficiency in the use of voting systems; identifying and implementing technologies to assist individuals with disabilities in voting; and demonstrating and evaluating the use of such systems and technologies. P&As receive training and technical assistance for providing non-visual access in the voting process. These TA grants are authorized under section 291 of HAVA as a seven-percent set-aside of the HAVA appropriation. 

### Budget Request:

The FY 2024 request for the Voting Access for Individuals with Disabilities Protection and Advocacy (P&A) program is $10,000,000, the same as the FY 2023 enacted level. The request maintains the P&As support for training on voting rights, making sure polling places are accessible, and assisting with the adoption of voting procedures that enable individuals with disabilities to vote privately and independently. In his remarks on his Executive Order to Promote Voting Access, President Biden highlighted the need for these services, saying, “People with disabilities face longstanding barriers in exercising their right to vote, especially when it comes to legally required accommodations to vote privately and independently.”[footnoteRef:54] [54:  White House Fact Sheet. Accessed 22 August 2023. ] 

P&As play a critical role in protecting the rights, safety and welfare of people with disabilities. The P&As have been at the forefront of fighting discrimination against people with disabilities and ensuring their needs have been considered at every stage of response and recovery efforts. This included ensuring that people with disabilities, who faced significantly increased risks from COVID-19, have been able to exercise their voting rights during elections held during the pandemic. 

### Funding History:

Funding over the past five years is as follows:

### Program Accomplishments:

According to 2021 data from the U.S. Election Assistance Commission, nearly 18 million Americans with disabilities voted in 2020, many with assistance from their state’s P&A.  Examples of the work of the Help America Vote Act (HAVA) P&As to ensure access to the electoral process and support people with disabilities in exercising their right to vote include: 

· Information and outreach: HAVA P&As provide plain-language materials, in multiple formats, and host a variety of educational events to help people with disabilities understand the voting process and their voting rights. For example: 

· The Disability Rights Center of the Virgin Islands hosted a series of voter registration drives, including a two-day event hosted in collaboration with the Board of Elections and AARP that included demonstrations for using voting machines and assistance with registering to vote, for people with and without disabilities.

· Disability Rights Wisconsin created a resource to help people with disabilities navigate the absentee voting process and a webpage providing information about guardianship and voting rights, including the legal process for restoration of voting rights.

· Improving accessibility of the voting process:**HAVA P&As work with communities, states, and voting officials to address barriers to voting and increase voting by people with disabilities. For example, the Arizona Center for Disability Law (ACDL) works closely with the Arizona Secretary of State’s office, as well as county recorders and elections departments throughout the state throughout the year to identify and address barriers in the voting process.  In addition, ACDL has facilitated connections between these agencies and disability service provider agencies to help agencies meet their obligations to provide reasonable accommodations.

· Direct assistance on election day: P&As are actively engaged throughout in-person voting to help people with disabilities overcome obstacles they encounter. For example, Disability Rights California operates a voting hotline during city, county, state, and federal elections to assist callers in resolving access issues. Assistance ranges from advice to the voter to help them resolve the issue to direct advocacy with election offices and polling places to address barriers. 

· Training and education for people with disabilities*:*HAVA P&As host a variety of educational events and conduct training in multiple formats.  For example, the Arizona Center for Disability Law (ACDL) partnered with other organizations to host events on National Voter Registration Day and during National Disability Voter Registration Week, including a training event that included an overview of Arizona’s new voting-related laws. ACDL also collaborated with other organizations in the disability networks to conduct virtual trainings throughout the year to provide a basic overview of voting rights along with detailed information on voting options and the process for requesting accommodations to access the polls.

### Grant Awards Table:

Voting Access for Individuals with Disabilities Grant Awards

*Represents States, and the District of Columbia.

****

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES**

**FY 2024 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER: Voting Access for Individuals with Disabilities (CFDA 93.618)

1/ Undistributed- includes funds for statutory technical assistance and/or minority set-asides; grant systems and review, and program reporting systems costs.

## Assistive Technology Programs

1/ The Alternative Financing Program was added by Congress in the ACL Appropriations Acts in FY 2022 and FY 2023.  

*BA is in thousands of dollars, FTEs are in whole numbers.

Original Authorizing Legislation: Technology-Related for Individuals with Disabilities Assistance Act of 1988, Public Law 100-407 

Most Recent Authorizing Legislation: 21st Century Assistive Technology Act (of 2023), Public Law 117-263 

Current FY Authorization	 Expired

Authorization Expiration Date	2010

Allocation Method	Formula and Competitive Grants and Contracts

### Program Description:

Assistive Technology (AT) programs maximize the ability of individuals with disabilities of all ages and their family members, guardians, advocates, and authorized representatives to obtain AT devices and AT services. AT devices are any item, piece of equipment, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities. Examples of such devices include computer or technology aids, modified driving controls, threshold ramps, sensors, and durable medical equipment such as wheelchairs or walkers. AT helps people remain stably housed and engage in all aspects of community living. Grants support comprehensive statewide programs that increase the:

· Availability, funding, access, provision, and training for AT devices and services

· Ability of individuals with disabilities of all ages to secure and maintain possession of AT during periods of transition, such as transition between school or to post-school employment or education or maintaining or transitioning to community living

· Capacity of public and private entities to provide and pay for AT devices and services

· Involvement of individuals with disabilities in decisions about AT devices and services

· Coordination of AT-related activities among state and local agencies and private entities

· Awareness and facilitation of changes in law, regulations, procedures, policies, practices, and organizational structures, in order to improve access to AT

· Awareness of the benefits of AT among targeted individuals and entities in the general population

#### Assistive Technology (AT) State Grants

The AT State Grant program, authorized under section 4 of the 21st Century Assistive Technology Act, is a population-based formula grant program to support comprehensive statewide programs that maximize the ability of individuals with disabilities of all ages to access and acquire AT. States must establish consumer- responsive advisory councils with a majority membership of individuals with disabilities who use AT to advise on the planning, implementation, and evaluation of these statewide programs.

Under the formula, states and territories are initially allocated a base amount that is not less than the amount the State or outlying area received under the grants provided under section 4 of the AT Act as in effect on the day before the effective date of the 21st Century Assistive Technology Act for Fiscal Year 2022. Funds appropriated in excess of the base year appropriation are initially distributed among the eligible entities with 50 percent of available funds distributed equally amongst them and 50 percent distributed according to the population of the state until each state receives at least $410,000. If any appropriated funds remain after each State receives this minimum, they are further distributed with 20 percent divided equally amongst the states and 80 percent distributed according to their populations.  

When appropriations for section 4 exceed $40,000,000, allotments are made to states as described above, from the remaining funds allot to each outlying area an amount of such funds until each outlying area has received an allotment of exactly $150,000 and from a portion of the remainder of the funds from 50 percent of the portion allot to each State an equal amount and from 50 percent of the portion, allot to each state an amount that bears the same relationship to such 50 percent of the population of the State bears to the population of all states until each state has received an allotment of not less than $450,000. If any appropriated funds remain after each State receives this minimum, they are further distributed with 20 percent divided equally amongst the states and 80 percent distributed according to their populations.

States must implement each of the activities required under the program, which include state-level activities and state leadership activities. States must spend a minimum of 60 percent (unless the state elects to comply with the state flexibility provision in section 4(e)(6) of the AT Act, as described below) of their formula grant funds on four state-level activities: state financing programs, device reutilization programs, device loan programs, and device demonstrations. States may, however, direct their funds towards these activities in varying amounts if they use other state or non-federal funds to support these activities at a comparable or greater level.

States may use up to 40 percent of their AT State Grant program funding on state leadership activities. The state leadership activities include the provision of technical assistance and training to targeted individuals and entities focused on promoting the general awareness of the benefits of AT; skills development for persons involved in the assessment of the need for AT; the appropriate application of AT; and the integration of AT devices and services in plans required to be developed under other federal laws.

States must also use a portion of their grant funds on public awareness activities, including the continuation and maintenance of a statewide system of information and referral, and coordination and collaboration activities amongst entities in the states that are responsible for the provision of AT. The law provides states with flexibility to decide to carry out only two or three state-level activities, rather than all four. If a state elects to carry out two or three state--level activities, it must spend a minimum of 70 percent of its funds on those activities, while spending not more than 30 percent on the state leadership activities.

Section 4 AT Act State AT programs continue to provide a set of integrated state level and state leadership activities/services that directly benefit individuals with disabilities, older adults, Veterans, caregivers, professionals, schools, vocational rehabilitation agencies, healthcare providers and agencies by providing unique access to, and acquisition of, assistive technology devices including durable medical equipment. Section 4 State AT program data continues to show increased program use and performance. 

#### Protection and Advocacy for Assistive Technology Grants

The Protection and Advocacy for Assistive Technology (PAAT) grants program uses the Protection and Advocacy (P&A) organizations network established by the Developmental Disabilities Assistance and Bill of Rights Act to expand assistive technology access to individuals with disabilities. The formula grants utilized by the P&A systems, authorized under section 5 of the AT Act, support their service to assist individuals with disabilities of all ages in the acquisition, use, or maintenance of AT services or devices. P&As in every state and territory receives a PAAT grant, as authorized by the 21st Century Assistive Technology (AT) Act. The funds are distributed on a state population basis, with a minimum annual grant of $50,000. Territories must receive not less than $30,000 annually. The Act also requires a minimum award of $30,000 to the P&A system serving the American Indian consortium. For each fiscal year for which the total amount appropriated to carry out the PAAT grant program is $8,000,000 or more and such appropriated amount exceeds the total amount appropriated to carry out the PAAT grant program for the preceding fiscal year, the minimum grant amounts of each PAAT grant will be increased by a percentage equal to the percentage increase in the total amount appropriated for the PAAT grant program for the preceding fiscal year and such total amount for the fiscal year for which the determination is being made.

P&As play an important role both in providing representation and assistance to individuals with disabilities who live in the community, as well as people who live in institutional or other congregate settings. Protecting the rights of people with disabilities who live in nursing homes and other congregate settings is a core function, and supporting transitions from institutions to community settings is a primary focus for P&As. For people living in the community, P&As help ensure equal opportunities and access in workplaces, schools, healthcare facilities and public places.

P&As also play a key role as advocates and advisors, providing technical assistance to support implementation of federal, state and local initiatives to expand community living opportunities. Similarly, P&As often provide training and technical assistance to service providers, state legislators and other policymakers; conduct self-advocacy trainings; and raise public awareness of legal and social issues affecting people with disabilities and their families. 

P&As also engage in a full range of other efforts to promote the rights of individuals with developmental disabilities.  P&As often provide information and referrals, as well as training and technical assistance to service providers, state legislators and other policymakers.  They also conduct self-advocacy trainings and raise public awareness of legal and social issues affecting individuals with developmental disabilities and their families. 

#### National Activities Grants

Section 6 of the AT Act provides authority for the provision of technical assistance and the development and implementation of data collection and reporting systems—through grants, contracts, or cooperative agreements awarded on a competitive basis—to individuals with disabilities of all ages, to AT state program grantees, and to protection and advocacy systems. The AT Act also requires the Secretary to make an award to renovate, update, and maintain the National Public Internet Website https://catada.info/ and AT3 Center.

#### Alternative Financing Program

The Assistive Technology Alternative Financing Program provides grantees one-year grant awards to assist individuals with disabilities of any age to obtain financial assistance for AT devices and services.

### Budget Request:

The FY 2024 request for Assistive Technology (AT) programs is $44,000,000, a $4,000,000 increase over the FY 2023 enacted level. The request provides increases for State AT grants, AT protection and advocacy activities, AT National Activities, to expand services to meet heightened demand. Funding for these activities will be distributed consistent with the 21st Century Act distributions. Within the totals funding is provided to cover administrative expenses including 1 FTE. No funding is requested for the Alternative Financing program, which duplicates other financing activities in their primary state AT program that allow states to make decisions to best meet specific financing needs. 

### Funding History:

Funding for the Assistive Technology Programs over the past five years is as follows:

1/Funding level includes $2 million in funding directed to the alternative financing program.

### Program Accomplishments:

Section 4 AT Act State AT programs continue to provide a set of integrated activities and services that directly benefit individuals with disabilities, older adults, Veterans, caregivers, professionals, schools, vocational rehabilitation agencies, healthcare providers and agencies by providing unique access to, and acquisition of, assistive technology devices including durable medical equipment. Section 4 State AT program data shows increased program use and performance. In fiscal year 2021, the 56 State AT program Section 4 grantees, achieved the following:

· 37,322 individuals participated in assistive technology device demonstrations exploring devices to support decision-making about consumer-AT match

· 38,507 AT devices were provided on short-term loan to individuals with disabilities, service providers and agencies through the “try-before-you-buy” approach to AT decision-making

· 68,061 AT devices were reutilized, saving consumers $28,430,104 by obtaining a gently used or refurbished AT device rather than a new one

· 796 financial loans totaling $8,423,340 at an average interest rate of 4.2 percent were made to enable consumers to purchase needed AT

· 15,162 AT devices at a value of $6,774,681 were provided to consumers through externally funded programs administered by State AT Programs

· 9,659 AT devices were acquired by consumers at a savings of $3,899,673 over full retail price through externally funded innovative programs administered by State AT programs that are designed to reduce the cost of AT such as cooperative buying programs

· 98,736 individuals participated in training events on AT products/services, AT funding, accessible information and communication technology, AT within transition from school to work and congregate care to community living and related AT topics

### Outcomes and Outputs Table: Assistive Technology

### Grant Awards Tables:

Assistive Technology Act - State Grants

  *Represents States, and the District of Columbia.

Assistive Technology Act - Protection and Advocacy Grants

  *Represents States, and the District of Columbia.

Assistive Technology Act – National Grant Activities

Alternative Financing Grant Competition for Assistive Technology

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**FY 2024 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER:  Assistive Technology State Grants (CFDA 93.464)

1/ Undistributed-- includes funds for grant systems and review, and program reporting systems costs.****

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**FY 2024 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER:  Assistive Technology Protection and Advocacy (CFDA 93.843)

1/ Undistributed-- includes funds for grant systems and review, and program reporting systems costs.

## National Technical Assistance Center on Kinship and Grandfamilies

1/ The American Rescue Plan Act, P.L. 117-2 provides $10 million to establish this technical assistance center, with the funding available for five years, from FY 2021 through FY 2025.  Projected obligations are $2 million a year. 

2/ Levels shown are for comparability purposes only, funding was provided in the American Rescue Plan Act. 

Original Authorizing Legislation: American Rescue Plan Act of 2021, Subtitle L, Section 2922, P.L. 117-2.

Most Recent Authorizing Legislation:  American Rescue Plan Act of 2021, Subtitle L, Section 2922, P.L. 117-2.

Current FY Authorization of Funds..........................................................$10,000,000 

Authorization Expiration Date..................................................................... FY 2025 

Allocation Method.................................Competitive Grants/ Formula Grants or Contracts

### Program Description:

The National Technical Assistance Center on Kinship and Grandfamilies, first funded in FY 2021, provides, at a national level, training, technical assistance, and resources for government programs, nonprofit and other community-based organizations, and Indian Tribes, tribal organizations, and urban Indian organizations that serve grandfamilies and kinship families.  The Center supports the health and well-being of members of grandfamilies and kinship families, including caregivers, children, and their parents. The Center in intended to focus primarily on serving grandfamilies and kinship families in which the primary caregiver is an adult age 55 or older, or the child has one or more disabilities.

The Center provides support for the following key activities:

· Engage experts to stimulate the development of new, and identify existing evidence-based, evidence-informed, and exemplary practices or programs related to health promotion (including mental health and substance use disorder treatment), education, nutrition, housing, financial needs, legal issues, disability self-determination, caregiver support, and other issues to help serve caregivers, children, and their parents in grandfamilies and kinship families

· Encourage and support the implementation of the evidence-based, evidence-informed, and exemplary practices to support grandfamilies and kinship families and to promote coordination of services for them across the systems that support them

· Facilitate learning and provide technical assistance, resources, and training to individuals and entities across systems that directly work with grandfamilies and kinship families

· Promote collaboration and coordination of OAA services in conjunction with programs that ACL already provides, including family caregivers, the LTC Ombudsman program, Elder Justice, and Nutrition where appropriate   

· Plan and coordinate disaster response to assist grandfamilies and kinship families during emergencies and disasters by supporting coordination and collaboration across grandfamily-serving government programs, nonprofit and community-based organizations, and Indian tribes, tribal organizations, and urban Indian organizations

· Assist government programs, and nonprofit and other community-based organizations, to promote racial equity, enhance services, and implement culturally and linguistically appropriate approaches as the programs and organizations serve grandfamilies and kinship families

### Budget Request: 

Funding has been appropriated and is available through FY 2025.

### Funding History:

The National Technical Assistance Center on Kinship and Grandfamilies received $10 million in initial funding with availability for five years (FY 2021-FY 2025).

### Program Accomplishments:

The program began in FY 2021; it has already:

· Launched a website (www.GKSNetwork.org), which includes a technical assistance request form and a searchable resource repository in FY 2022

· Held 53 individual virtual meetings with leaders from each state, District of Columbia, Puerto Rico, and the U.S. Virgin Islands in FY 2022 

· Hosted five virtual half-day regional convenings as well as half-day virtual tribal convening. All states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and more than 40 tribes were represented at the convenings, with an average of 95 participants per convening in FY 2022.

· Held two webinars in FY 2022. Two held (with an average attendance of 360) and three more scheduled in FY 2023

· Responded to over 180 individual technical assistance requests in FY 2022

· Distributed a monthly newsletter to more than 2,700 subscribers in FY 2022

### Grant Awards Table:

National Technical Assistance Center on Kinship Families and Grandfamilies

CONSUMER INFORMATION, ACCESS, AND OUTREACH

CONSUMER INFORMATION, ACCESS, AND OUTREACH

## Medicare Improvements for Patients and Providers Act Programs (MIPPA)

1/ Individual lines may not add to total due to rounding errors. Amounts shown in FY 2022 and FY 2023 reflect a sequester of 5.7 percent for half of FY 2022 and the entirety of FY 2023.

2/ FY 2024 reauthorization of the Medicare Improvements for Patients and Providers Act (MIPPA) program and direct all MIPPA funding to ACL. 

*BA is in thousands of dollars, FTE is a whole number.

Original Authorizing Legislation: Medicare Improvements for Patients and Providers Act of 2008, Section 119, Public Law 110-275

Most Recent Authorizing Legislation: Consolidated Appropriations Act, 2021, Division CC, Title I, Subtitle A, Section 103, Public Law 116-260. 

Current FY Authorization of Funds	$50,000,000

Authorization Expiration Date	FY 2023

Allocation Method	Competitive Grants/Formula Grants and Contracts

### Program Description:

The Medicare Improvements for Patients and Providers Act (MIPPA) programs provides funding to key segments of ACL’s network of community-based service providers – including area agencies on aging (AAAs), Aging and Disability Resource Centers (ADRCs), and State Health Insurance Assistance Programs (SHIPs) – to undertake additional activities, above and beyond their basic one-on-one assistance to Medicare beneficiaries. MIPPA grantees educate beneficiaries about the Low-Income Subsidy (LIS) program for Medicare Part D, Medicare Savings Programs, and Medicare Preventive Services while also providing in-depth application assistance to eligible Medicare beneficiaries to help them apply for benefit programs that help lower their healthcare costs. MIPPA funds also support the National Center for Benefits Outreach and Enrollment.  

For beneficiaries who qualify, the Medicare Savings Programs pay their Medicare Part A or/and Part B premiums and co-insurance costs while the LIS (also known as “Extra Help”) helps reduce Medicare beneficiary prescription drug costs, including Part D premiums, prescription deductibles and co-pays.  Medicare beneficiaries are eligible for these programs if they have limited incomes and assets. Medicare Preventive Services help beneficiaries stay healthy and prevent disease. These services include vaccinations for illnesses such as COVID-19 and the flu.

MIPPA grants provide support for education and application assistance so that Medicare beneficiaries can access MSP and LIS programs that they qualify for but are not yet enrolled in. MIPPA funding is not used to support the day-day services of AAAs, ADRCs, and SHIPs.  Instead, it supports additional in-depth one-on-one assistance that goes beyond the help what would normally be provided, both to identify older Americans and those with disabilities in need, and to provide much more intensive counseling to these specific populations.

MIPPA funds also support the National Center for Benefits Outreach and Enrollment (NCBOE) coordinates efforts to inform older adults and beneficiaries with disabilities about the benefits available under Federal and state programs, with an emphasis on providing information on programs available to those with limited incomes and/or assets. The NCBOE accomplishes its mission by providing tools, resources, and technology that help local, state, and regional organizations find, counsel, and assist seniors and younger adults with disabilities in applying for and enrolling in the benefits for which they may be eligible. It also works to generate and disseminate new knowledge about best practices and cost-effective strategies or benefits outreach and enrollment. In addition, the NCBOE supports a nationwide network of over 80 local Benefit Enrollment Centers which provide in-depth low-income benefits information and enrollment assistance to those in their communities.

### Budget Request:

Funding is provided through mandatory appropriations. ACL is requesting mandatory funding for FY 2024-FY 2028.  Existing funding has been appropriated and is available through FY 2023. The FY 2022 sequestration results in the lower FY 2022 and FY 2023 levels. ACL is seeking to reauthorize the Medicare Improvements for Patients and Providers Act (MIPPA) program and direct all MIPPA funding to ACL. 

### Funding History:

In each of fiscal years 2019 through 2023, MIPPA was funded through mandatory appropriations included in the CARES Act COVID-19 Supplemental, P.L. 116-136, as follows:

1/ Includes a sequestration of 5.7 percent in the second half of FY 2022 and the entirety of FY 2023.

2/ FY 2024 reauthorization of the Medicare Improvements for Patients and Providers Act (MIPPA) program and direct all MIPPA funding to ACL. 

### Program Accomplishments:

In Grant Year 2020 (Sept. 1, 2020 – Aug. 31, 2021), MIPPA State Grantees educated over 750,000 beneficiaries at nearly 16,000 group outreach events and conducted over one million one-on-one contacts with Medicare beneficiaries, their families, or caregivers. Additionally, they helped nearly 87,000 beneficiaries with applications for MSP and LIS and educated over 97,000 beneficiaries on Medicare preventive services.

Based on most recent reporting data (Mar. 1, 2021 – Aug. 31, 2021) the NCBOE Benefit Enrollment Centers assisted nearly 69,000 individuals and submitted just over 119,000 applications for LIS, MSP and other low-income benefits worth an estimated $207 million.

### Grant Awards Tables:

MIPPA – Aging Disability and Resource Centers

*Represents States, and the District of Columbia

MIPPA – Area Agencies on Aging

*Represents States, and the District of Columbia

MIPPA – National Center for Benefits Outreach and Enrollment

MIPPA – State Health Insurance Assistance Programs

*Represents States, and the District of Columbia

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON AGING**

**FY 2024 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER:  MIPPA - ADRC (CFDA 93.071)

1/ Undistributed- reflects the amount used from the MIPPA appropriation for staff and overhead, support, contracts, training, technical assistance, data systems, grant systems, and grants review costs.

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON AGING**

**FY 2024 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER:  MIPPA - AAA (CFDA 93.071)

CONSUMER INFORMATION, ACCESS, AND OUTREACH

CONSUMER INFORMATION, ACCESS, AND OUTREACH

1/ Undistributed- reflects the amount used from the MIPPA appropriation for staff and overhead, support, contracts, training, technical assistance, data systems, grant systems, and grants review costs.

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON AGING**

**FY 2024 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER:  MIPPA - SHIP (CFDA 93.071)

CONSUMER INFORMATION, ACCESS, AND OUTREACH

CONSUMER INFORMATION, ACCESS, AND OUTREACH

1/ Undistributed- reflects the amount used from the MIPPA appropriation for staff and overhead, support, contracts, training, technical assistance, data systems, grant systems, and grants review costs.

299

309

# Program Administration

1BA is in thousands of dollars; FTE is a whole number. Remaining ACL FTE are charged to reimbursable, mandatory and program funding sources. (FTE numbers do not necessarily match the number of staff on board at the end of the year; actual staff numbers may be higher or lower due to late in the year hiring and attrition.) 

Authorizing Legislation: Older Americans Act of 1965, P.L. 89-73, the Developmental Disabilities Assistance and Bill of Rights Act), the Help America Vote Act, the Assistive Technology Act of 2004 (including but not limited to AT Act Sections 4-6 authorized programs), the Rehabilitation Act of 1973, the Public Health Services Act, Elder Justice Act, the Recognize, Assist, Include, Support, and Engage (RAISE) Family Caregivers Act, and the Supporting Grandparents Raising Grandchildren Act.

Most Recent Authorizing Legislation: Supporting Older Americans Act of 2020, Public Law 116-131; the RAISE Family Caregivers Act, Public Law 115-119; the Supporting Grandparents Raising Grandchildren Act, Public Law 115-196; the Developmental Disabilities Assistance and Bill of Rights Act of 2000, Public Law 106-402; the Help America Vote Act of 2002, Public Law 107-252; Assistive Technology Act of 2004, Titles II and VII of the Rehabilitation Act of 1973, as amended in 2014 by the Workforce Innovation and Opportunity Act, Public Law 113-128 the Public Health Service Act, Public Law 78-410; and the Elder Justice Act (Title XX-B of the Social Security Act), Public Law 111-148. 

Current FY Authorization	N/A

Authorization Expiration Date	N/A

Allocation Method	Direct Federal/Contract

### Program Description:

Program Administration funds the direction and support of programs established under multiple statutes to support the health, well-being, and rights of older adults and people of all ages with disabilities. These funds cover a range of expenditures, the largest of which are salaries and benefits, rent, security (both physical and IT), and shared services. Most of these costs are relatively fixed in the short term. 

In FY 2022, Program Administration funding supported 157 of ACL’s 184 FTE. Funding for FTEs also is provided by the following reimbursable and mandatory funding sources: the Health Care Fraud and Abuse Control account, Medicare Improvements for Patients and Providers Act funding, and money received from the Centers for Medicare & Medicaid Services for activities performed on behalf of dual Medicare/Medicaid beneficiaries. ACL also supports a limited number of FTE with funding from various program line items. 

### Budget Request:

The FY 2024 request for Program Administration is $63,859,000, an increase of +$16,796,000 above the FY 2023 enacted level, to support and strengthen ACL’s infrastructure. This increase includes $9.6 million to support additional staffing, $3.9 million to offset mandatory built-in cost increases and $3.3 million for new initiatives. 

Following its creation in 2012, ACL’s responsibilities increased significantly, especially in its first three years. A number of programs were transferred to ACL from other HHS divisions and from other departments. In most cases, however, these new programs did not come with sufficient corresponding staff or budget increases to cover the full costs of their administration. Consequently, infrastructure gaps – and operational risk – began to develop as each new program was added. 

The problem has been exacerbated in recent years by FTE losses. Funding remained essentially level at a time when fixed costs were sharply increasing, which required ACL to shift resources from funding FTE to covering these mandatory expenses. As a result, ACL often was unable to fill many vacancies created by attrition, and in some years, staff numbers decreased. ACL’s FTE peaked at 196 (funded from all sources) in FY 2018 but dropped significantly in subsequent years.

However, requirements have increased dramatically over the last several years, creating additional urgency for addressing the problem. For example, in FY 2019, ACL awarded a total of just over 3,600 grants totaling $2.16 billion. In FY 2021, that grew to more than 5,500 grants for a total of $4.13 billion – a 53 percent increase in the number of grants and almost double the total amount awarded. The challenges created by that growth have been magnified by a decrease in the number people to do the work. In 2019, seven people managed just over 2,200 mandatory grants; in FY 2021, ACL only had four people to manage more than 4,000. In addition, many of these new grants now have more extensive monitoring and oversight requirements, which has magnified the stress on ACL’s already stretched infrastructure. 

ACL’s other responsibilities also have continued to grow, creating additional urgency for addressing the problem. For example, since the end of 2021, ACL:

· Has assumed leadership roles on initiatives and interagency approaches to issues that affect people with disabilities and older adults, such as long COVID, expanding the HCBS workforce, and addressing social determinants of health  

· Launched a partnership with the Department of Housing and Urban Development to improve access to affordable, accessible housing and supportive services, which continues to grow in scope

· Partnered with the Centers for Disease Control & Prevention to accelerate vaccination of older adults and people with disabilities, particularly those in underserved communities and others who are hard to reach. This partnership began with almost $100M in new grants to support COVID-19 vaccination efforts and is continuing with support for broader vaccination initiatives.

· Awarded $150M in new grants to expand the public health workforce across its aging and disability networks, $125 million in new grants for expanded vaccine efforts, and needs additional staff in order to award 82 Congressionally Directed Spending grants in FY 2023

· Partnered with HRSA to provide an opportunity for ACL’s networks to collaborate with HRSA-supported health centers and Medicare-certified rural health clinics to distribute at-home COVID-19 tests and N95 masks to people with disabilities and older adults 

As a result, requirements now significantly exceed staff capacity. 

With the increased funding received in FY 2023, ACL is beginning to address its most crucial staffing gaps. In FY 2023, ACL received a $5 million increase in Program Administration funding. About half will be used to hire new staff; the remainder is needed to cover fixed costs (such as shared services increases) and to fund critical investments in IT. The agency currently is on track to end FY 2023 at 204 FTE (with 168 funded by Program Administration). 

However, even with this handful of these new hires, ACL continues to need additional staff to meet basic oversight and monitoring requirements. To effectively meet its expanding responsibilities, ACL is requesting $9.6 million in Program Administration funding dedicated to staffing to bring ACL to a total of 246 FTE. Of these, 208 would be funded by Program Administration; the remaining 38 FTE are funded from program funds. With the additional FTE, ACL will be able to mitigate its greatest operational risks, such the need for increased program oversight and processing of grants.

ACL also is requesting an additional $3.9 million to cover increases in fixed costs, such as shared services, the projected FY 2024 pay raise, and ACL’s share of costs for resources that benefit the department as a whole. In the last several years, costs have significantly increased for shared services (such as human resources, contracting and grants support, and other services that are provided centrally for smaller HHS divisions to capitalize on economies of scale). At the same time, ACL’s Program Administration funding has remained relatively flat, leaving ACL no choice but to cover the increases with funding that otherwise would have gone to hiring. In FY 2024, shared services costs are projected to increase by more than ten percent, to a total of more than $10 million. Without the increase requested for FY 2024, ACL will again have to cover them by shifting funding allocated for additional FTE, largely reversing recent progress toward adequate staffing. 

Finally, ACL is requesting modest increases to make necessary investments in stakeholder outreach, accessibility, and technology. Specifically, in FY 2024, ACL is requesting a total of $3.3 million in additional funding for Program Administration for these investments, as follows:

· +$750,000 for an initiative to improve access to information and resources created by ACL, as well as by ACL’s grantee networks, for people with limited English proficiency and people who have disabilities with language access needs. Building on initial efforts funded in FY 2023, ACL will expand capacity to translate consumer-facing materials into Standard Spanish and formats that are accessible for people with different types of disabilities, as well as bolster existing contract support for real-time translation (including American Sign Language (ASL)) and captioning during ACL events and meetings. The initiative also will include a needs assessment to help ACL prioritize languages for translation of materials and inform ongoing language access improvements. Finally, this request will fund a language access resource center to support ACL’s aging and disability grantee networks. The center will develop and disseminate best practices, provide technical assistance for language and communication access, and support real-time translation and translation of written materials to help grantees communicate with – and better serve – people with limited English proficiency.  

· +$1,500,000 for investments in information technology to continue the Security Mitigation and Enhancement (SME) project that began in FY 2021 with Non-recurring Expense Fund (NEF) funding. In FY 2024, the SME project will assess, document, and begin to implement necessary technical changes and security controls for all current operating systems; implement DHS- and HHS-mandated Continuous Diagnostics and Mitigation software, as well as other software and services to ensure real-time monitoring of ACL’s systems by ACL, HHS, and DHS security teams; complete ACL’s implementation of a zero-trust architecture as required by the *Executive Order on Improving the Nation’s Cybersecurity*, and mitigate vulnerabilities found in the OIG audit of the security posture of the Office of the Secretary and the small operating divisions served by the HHS Office of the CIO. Without this additional funding in FY 2024 and subsequent fiscal years, ACL will not be able to sustain the adequate monitoring, oversight, incident response, and vulnerability mitigation, putting the systems that underpin ACL’s operations and ACL’s data at risk of compromise and leaving ACL with little capacity to respond when issues arise.

· +$250,000 to meet ACL’s communication and outreach responsibilities in interagency initiatives focused on key issues affecting older adults and people with disabilities; build capacity to support cross-HHS communication initiatives; and provide communications support to ACL’s FY 2024 program initiatives, including stakeholder outreach, creation and maintenance of  web sites and content, dissemination of effective practices and lessons learned to and across ACL’s networks (including ensuring accessibility of content created by grantees), and more.

· +$800,000 for a workforce and organizational assessment. As described above, ACL has been significantly understaffed almost from its creation. With the funding received in FY 2023 and the increase requested in FY 2024, ACL will be able to address its most crucial staffing gaps and begin to establish an adequate infrastructure for fulfilling its responsibilities. ACL anticipates a need for additional staff beyond what is requested in FY 2024; however, a comprehensive assessment of the agency’s structure and staff requirements is needed to determine appropriate FTE levels. The FY 2024 request includes funding for a contract to conduct this assessment and establish a blueprint for the future that will enable ACL to operate effectively and efficiently going forward.

### Funding History:

Funding for ACL Program Administration over the last five years is as follows:

PROGRAM ADMINISTRATION

PROGRAM ADMINISTRATION

# Nonrecurring Expenses Fund

Administration for Community Living

1 Pursuant to Section 223 of Division G of the Consolidated Appropriation Act, 2008, notification is required of planned use.

2 Notification submitted to the Committees on Appropriations in the House of Representatives and the Senate on June 17, 2021.

3 Notification submitted to the Committees on Appropriations in the House of Representatives and the Senate on September 23, 2022.

4 HHS has not yet notified for FY 2024.

*BA is in thousands of dollars.

Authorizing Legislation............. Section 223 of Division G of the Consolidated Appropriations Act, 2008

Allocation Method.................................................. Direct Federal, Competitive Contract 

### Program Description:

The Nonrecurring Expenses Fund (NEF) permits HHS to transfer unobligated balances of expired discretionary funds from FY 2008 and subsequent years into the NEF account. Congress authorized use of the funds for capital acquisitions necessary for the operation of the Department, specifically information technology (IT) and facilities infrastructure acquisitions. 

Since FY 2013, the NEF provided approximately $35 million to ACL to modernize and secure ACL’s technology portfolio which supports ACL’s aging and disability programs. Examples include the ACL Cloud, which enables rapid development and deployment of technology solutions. ACL used NEF funding to develop the Older Americans Act Performance System to support updated performance reporting for ACL’s aging programs and simplify and reduce grantee burden for submitting annual performance reports. Using NEF funding, ACL will continue work to replace its Aging, Independent Living, and Disability data portal, to meet the requirements of the Evidence Act. Finally, the ACL Cloud has allowed the Office of Elder Justice to demonstrate the use Artificial Intelligence and Machine Learning with the Predicting Risk of Adult Maltreatment projects, through which ACL analyzes publicly available data sets to identify both community and individual risk factors for abuse, neglect, and exploitation of older adults and people with disabilities.

### Budget Allocation FY 2023:

In FY 2023 HHS issued a notification to Congress to direct $6,000,000 from the NEF for use in FY 2023. In FY 2023, the allocated NEF funds will support two high priority ACL projects:

· Digital Platform Initiative for Communications, Training, and Technical Assistance 

· Information and Referral Platforms and Services

#### The Digital Platform Initiative

This project directly supports several Secretarial and Presidential priorities – including caregiving, equity and expanding access to home and community-based services. 

The project addresses efforts to improve administrative and management efficiencies, analyses, dissemination of data and information, and provision of services, all of which benefit both ACL’s program management and oversight and ACL grantees, stakeholders, and older adults, people with disabilities, and caregivers directly served by ACL grants. The NEF funding supports a set of projects intended to establish a framework of technology and business practices to improve and ensure consistent communication internally and externally across ACL's portfolio of programs; and ensures that websites and systems developed by ACL and on ACL's behalf are accessible, secure, and provide information on their effectiveness and outcomes. 

#### Information and Referral Platforms and Services

Information and Referral Platforms and Service project creates the services to enable and sustain the collection and dissemination of information about services available for older adults, people with disabilities, and caregivers. 

The projects in this initiative will create practices and platforms to collect, manage, and disseminate information about aging and disability services. The technology solutions include developing and publishing REST APIs to collect information on services available to older adults, people with disabilities, and caregivers from grantees, subgrantees, and service providers contracted with funds from ACL grants. The information on services available to older adults, people with disabilities, and caregivers will be validated by a distributed network of knowledgeable experts and AI tools, including machine learning and remote process automation. The aggregated directory of aging and disability services will be made available to local providers of information and referral services, as well as supporting ACL’s existing Eldercare Locator and Disability Information and Access Line information and referral services.

SUPPLEMENTARY TABLES

NONRECURRING EXPENSES FUND

Work related to the Social Care Referral Challenge, the standup of the Disability Information Assistance Line, and ongoing enhancements to Eldercare Locator this last year will allow for planning of projects with greater scope and impact across ACL in FY 2022 and FY 2023.

# Supplementary Tables

## Object Classification Table - Direct

Administration for Community Living

(Dollars in Thousands)

## Object Classification Table - Reimbursable

Administration for Community Living

(Dollars in Thousands)

## Salaries and Expenses – Direct

Administration for Community Living

(Dollars in Thousands) 

## Detail of Full Time Equivalents (FTE)

Administration for Community Living

## Detail of Positions

Administration for Community Living

## FTEs Funded by the Affordable Care Act

Administration for Community Living

## Resources for Cyber Activities

Administration for Community Living

(Dollars in millions)

1/ Note:  Two of the M-22-16 Cybersecurity resource categories, "Technology Ecosystems" and "Zero Trust Implementation" were not included in the OMB MAX table.  BDR 22-39 Addendum 1 advises Agencies to include Zero-Trust Implementation resources in a number of NIST Cybersecurity Framework Capability resource categories; there is not similar technical assistance for distributing the Technology Ecosystem resources in the NIST Cybersecurity Framework Capability resource categories. ACL has included these as "non-add" expenses in the Total Cyber Request.

## No Submission

Administration for Community Living

ACL does not have anything to submit for the following requests:

· Summary of Proposed Performance Changes

· Drug Control Programs 

· Programs Proposed for Elimination 

· Physicians Comparability Table

· Significant Items in Appropriations Committee Reports will be provided under separate cover

SUPPLEMENTARY TABLES

### 

# Legislative Proposals

**FISCAL YEAR 2024 HHS LEGISLATIVE PROPOSAL**

Administration for Community Living 

**Provide State Flexibility to Determine Funding Distribution to Part C Center for Independent Living**

ACL is seeking to provide states with flexibility to determine (with ACL review and approval) how funds are distributed between Part C Centers for Independent Living (CILs) to enable states to address population shifts or significant changes within their states.  Currently, section 722(e) of the Rehabilitation Act of 1973 (Rehab Act) (29 U.S.C. 796f-1(e)) requires existing CILs to be funded at the level of funding for the previous year with no provision to change allocations.[footnoteRef:55], [footnoteRef:56]  Section 704 (29 U.S.C. 796c) establishes requirements for a State Plan for Independent Living (State Plan), and subsection (a)(3) of that section provides for the periodic review and revision “...to ensure the existence of appropriate planning, financial support and coordination, and other assistance to appropriately address, on a statewide and comprehensive basis, needs in the state...”   [55:  The order of priorities at 29 U.S.C. 796f-1(e), to the extent that funds are available, are to (1) support existing CILs, at the level of funding for the previous year; (2) provide for a cost-of-living increase for existing CILs; and (3) fund new CILS.]  [56:  Section 723 (29 U.S.C. 796f-2) establishes grants to CILs in states in which state funding equals or exceeds federal funding.  In those instances (Massachusetts and Minnesota), ACL awards funds to the states.  The state in turn allocates the funding to the CILs.  Unlike Section 722, section 723 includes a provision for altering the allocation between CILs in the state.] 

Adding new language to section 704 (29 U.S.C. 796c) and 722 (29 U.S.C 796f-1), would allow the Statewide Independent Living Council (SILC) and Part C CILs, through the State Plan, to propose changes to funding allocations for review and approval by ACL.  Statewide networks of people with disabilities (CILs and SILCs) would have the means to create a more equitable distribution of funds and ensure the needs of people with disabilities are being met statewide. This would increase the efficient use of funds by providing states with the flexibility to target funding where it is needed most.  For those states that opt not to make any changes to their funding distributions, ACL would fund CILs at the level of funding for the previous year with cost-of-living increases if funds allow per the current section 722(e) language.

**Establish Authority for Projects of National Significance under Title VII of the Rehabilitation Act of 1973**

ACL is seeking to add a new Part (i.e. Part D) to Title VII, Chapter 1 – Individuals with Significant Disabilities, under the Rehabilitation Act of 1973, to authorize grants, contracts, or cooperative agreements for projects of national significance that advance independent living and promote the philosophy of independent living. Current statute authorizes grants to Designated State Entities and Centers for Independent Living through formulas.  The statute does not provide for discretionary, competitive grants, contracts, or cooperative agreements. 

Innovation, evaluation, and knowledge translation are essential to meeting the evolving independent living needs of people with disabilities to live where they choose, with the people they choose, and with the ability to participate fully in their communities.  Authority for discretionary grants, contracts, and cooperative agreements would allow ACL to explore new and more effective ways to support the independent living goals of people with disabilities, across all types of disabilities, and advance the independent living philosophy. 

**Removal of Requirement that Annual Grantee Compliance Reviews Must Occur Onsite**

ACL is seeking to amend Section 706(c)(1) of the Rehabilitation Act of 1973 ("Rehabilitation Act"), 29 U.S.C. 796d-1(c)(1), to remove the requirement that Center for Independent Living annual grantee compliance reviews must be conducted “onsite,” allowing the Administrator to determine the most effective method for annual grantee compliance reviews.  To ensure appropriate program oversight, ACL created a more efficient risk-assessment based process to monitor program compliance, outcomes, and fiscal operations that uses remote, onsite, or a combination of approaches.  

As demonstrated by pilot remote reviews conducted in FY 2019 and reviews conducted during the pandemic, today’s technology enables ACL to thoroughly review most program components remotely; onsite reviews can be reserved for more complex situations or concerns that require physical inspection.  This cost-effective approach to monitoring allows ACL to focus resources on services that directly support people with disabilities in their communities, while continuing to ensure that CILs are monitored and complying with the Rehabilitation Act.  

**Inclusion of Program Evaluation and Performance Measurement Activities with Reserved Training and Technical Assistance Funds**

ACL is seeking to eexplicitly authorize program evaluation and performance measurement as an allowable activity of funds currently appropriated for training and technical assistance to Centers for Independent Living and Statewide Independent Living Councils (section 711A(a) and section 721(b) of the Rehabilitation Act of 1973).  This change would provide ACL with information needed to address compliance and oversight of the programs and better target training and technical assistance activities. 

**Authorization of Tribal Adult Protective Services Grants**

ACL is seeking to amend section 2042 of the Elder Justice Act to strengthen, enhance, and support adult protective services programs by allowing tribes and tribal organizations to be eligible for funding authorized under the statute. Section 2042 of the Elder Justice Act (42 U.S.C. 1397m-1) authorizes grants to enhance the provision of adult protective services.  However, the statute restricts the grants to states and does not allow for ACL to provide the grants to Indian tribes and tribal organizations. 

There is a critical need in Indian Country for additional social supports outside of family for elders experiencing abuse, neglect, and exploitation.  A number of studies have identified that tribal elder abuse continues to be observed at higher rates than non-tribal populations.  Despite this prevalence, elder protection codes and adult protective services programs within Indian Country vary widely, and many tribes have neither.  

**Enhance Resources for Evaluation under the Older Americans Act**

ACL is seeking to increase the allowance for evaluation from a 0.5 percent to 1 percent for enhanced evaluation and data collection. Section 206(h) of the Older Americans Act (OAA) permits the use of up to a 1⁄2 percent of funds appropriated to OAA Title III to conduct evaluations of programs and to review their effectiveness.  Due to the increasing demographics and complexity of needs of the aging population, the demand for information about the programs and their effectiveness is increasing.  In addition, COVID-19 altered the way the aging network served older adults, in many cases instituting innovative programming that can be beneficial beyond the pandemic. As a result, additional resources are needed to review programs and provide data that supports administration and congressional actions for addressing these changing needs more quickly and comprehensively.  

**Repair, Alteration, Renovation, Modernization, Acquisition and/or Construction of Facilities under the Older Americans Act**

ACL is seeking to allow Older Americans Act (OAA) funds to be used to cover the cost of acquisition, alteration, or renovation of facilities used to provide services under the OAA. Sections 306(a)(1), 312, and 321(b)(1)-(2) of the OAA limit funds for construction and modernization to multipurpose senior centers.  The OAA also contains reference to “a program for making grants to States...for the acquisition, alteration, or renovation of existing facilities, including mobile units, and, where appropriate, construction or modernization of facilities to serve as multipurpose senior centers” (sec. 321(b)(1)).  That program is implemented under the Title III Part B, supportive services grant, and is not operated as a stand-alone program under the OAA.  This change would allow for construction and modernization of facilities beyond just multipurpose senior centers to fully implement the services provided under the OAA and would remove obsolete and confusing language that references a program that is not operated or granted as a stand-alone program under the OAA as currently authorized.  Additionally, this change would allow states, territories, tribes, tribal aging organizations, area agencies on aging, and local service providers to take advantage of opportunities where acquisition of a facility is a lower cost and a more effective approach to providing services to older adults and family caregivers under the OAA.

**Medicare Improvements for Patients and Providers Act (MIPPA) Program- Reauthorization**

ACL is seeking to reauthorize the Medicare Improvements for Patients and Providers Act (MIPPA) program and direct all MIPPA funding to ACL.  MIPPA provides additional funding to State Health Insurance Assistance Programs (SHIPs), Area Agencies on Aging (AAAs), and Aging and Disability Resource Centers (ADRCs) to conduct one-on-one counseling and enrollment assistance to Medicare beneficiaries with limited income and assets specifically targeting hard-to-reach beneficiaries; and to support the National Center for Benefits Outreach and Enrollment (NCBOE).  

The MIPPA funding structure provides ACL the funding to support the AAAs, ADRCs, and the NCOBE while the Centers for Medicaid & Medicare Services (CMS) receives the fourth funding stream to support the SHIPs.  The base SHIP program was transferred to ACL from CMS in 2014 via the Balanced Budget Act of 2014, however, the MIPPA authorization language was not updated at the same time. Since the MIPPA-SHIP funding has continued to be directed to CMS an Inter-Agency Agreement must be executed annually to transfer the MIPPA-SHIP dollars to ACL for administration.  Updating the MIPPA reauthorization language to direct the MIPPA-SHIP dollars to ACL instead of CMS would streamline the administration of the program and reduce delays in allocating the MIPPA funding.

# ACL Specific Requirements

Administration for Community Living

**Meals Served for Congregate and Home-Delivered Nutrition Services: Total Funding, Meals Served, Persons Served FY2015-FY2021**

FY 2024 Instructions: For congregate and home-delivered nutrition services, create separate tables that capture the total funding available to states, meals served, and persons served from FY 2017 to FY 2024.  The total funding line should include the following non-add lines: post-Title III transfer for congregate and home-delivered nutrition services, including the amounts initially allotted and amounts transferred in or out, state and local funding other than from ACL nutrition programs, private contributions (to the extent available), and NSIP expenditures.  If you are aware of any other sources of funding available to states to provide meals to seniors, please discuss with your ASFR analyst before adding to this table. 

**Congregate Nutrition Services**

Numbers presented for 2015-2021 are actuals. Actual data from 2021 are too unstable to develop projections that match the underlying assumptions of the FY2024 ACL budget, namely that 2024 will not be in a pandemic year. ACL is currently refining its methodology to account for the 2021 actual data, which include severe outliers.

****

**ACL Specific Requirements - Continued**

Administration for Community Living

**Home Delivered Nutrition Services**

Numbers presented for 2015-2020 are actuals. Actual data from 2021 are too unstable to develop projections that match the underlying assumptions of the FY2024 ACL budget, namely that 2024 will not be in a pandemic year. ACL is currently refining its methodology to account for the 2021 actual data, which include severe outliers.

# Text Description Administration for Community Living Organizational Chart

**(shown on Page iv)**

The U.S. Administration for Community Living (ACL) is led by the Administrator, who also serves as the Assistant Secretary for Aging. The Administrator is directly supported by the Principal Deputy Administrator.  The following report to the Office of the Administrator:

· Administration on Aging, which includes four offices:

· Office of Supportive and Caregiver Services

· Office of Nutrition and Health Promotion Programs

· Office of Elder Justice and Adult Protective Services

· Office of American Indian, Alaskan Native and Native Hawaiian Programs

· Administration on Disabilities, which includes three offices:

· Office of Intellectual and Developmental Disability Programs

· Office of Independent Living Programs

· Office of Disability Services Innovations

· Center for Innovation and Partnership, which includes three offices:

· Office of Interagency Innovation

· Office of Network Advancement

· Office of Healthcare Information and Counseling

· Center for Management and Budget, which includes four offices:

· Office of Budget and Finance

· Office of Grants Management

· Office of Administration and Personnel

· Office of Information Resources Management

· Center for Policy and Evaluation, which includes two offices:

· Office of Policy Analysis and Development

· Office of Performance and Evaluation

· Center for Regional Operations, which includes ten regional offices

· National Institute on Disability, Independent Living, and Rehabilitation Research, which includes two offices:

· Office of Research Administration

· Office of Research Sciences

· Office of External Affairs

The Deputy Assistant Secretary for Aging also serves as the Director of the Office of Long-Term Care Ombudsman Programs, consistent with Section 201 of the Older Americans Act.

The Administration on Disabilities is headed by a Commissioner who also serves as:

· Commissioner of the Administration on Developmental Disabilities, as described by the Developmental Disabilities Act 

· Director of the Independent Living Administration, reporting directly to the ACL Administrator in carrying out those functions, consistent with Section 701A of the Rehabilitation Act.

Where Care Recipient Would Live if Unable to Have Family Caregiver's Supportive Services

In Caregiver's Home, 8%

In the Home of Another Family Member/Friend, 13%

In an Assisted Living Facility, [VALUE]In a Nursing Home, [VALUE]Care Recipient Would Have Died, 1%Other, 3%In Caregiver's Home	In the Home of Another Family Member/Friend	In an Assisted Living Facility	In a Nursing Home	Died	Other	0.08	0.13	0.32	0.43	0.01	0.03	
308
image1.wmfimage3.pngimage2.png