DEPARTMENT 

of HEALTH 

and HUMAN

SERVICES

FY 2013 Report to Congress: 

Older Americans Act 

Prepared by

ADMINISTRATION 

ON AGING

ADMINISTRATION FOR 

COMMUNITY LIVING
 

1 
FROM THE ADMINISTRATION FOR COMMUNITY LIVING

The Administration for Community Living (ACL) is the single agency charged to work with 

states, localities, Tribal organizations, nonprofit organizations, businesses, and families to help 

older adults and people with disabilities live in their homes and fully participate in their 

communities. Those with disabilities or functional limitations of any type, regardless of age, 

have a common interest: access to home and community-based supports and services that help 

individuals fully participate in all aspects of society, including having the option to live at home, 

which can be vital to an individual’s well-being, instead of moving into an institutional setting. 

ACL brings together the efforts and achievements of the Administration on Aging (AoA), the 

Administration on Intellectual and Developmental Disabilities (AIDD), and the HHS Office on 

Disability to serve as the federal agency responsible for increasing access to community 

supports, while focusing attention and resources on the unique needs of older Americans and 

people with disabilities across the lifespan.

As part of this important mission, I am pleased to present AoA’s Report to Congress for Fiscal 

Year (FY) 2013. AoA advances the concerns and interests of older people, whether living in 

their own home or in a long-term care facility, and works with and through the national aging 

services network to promote the development of comprehensive and coordinated systems of 

home and community-based care that are responsive to the needs and preferences of older people 

and their caregivers. 

The aging services network is comprised of 56 state and territorial units on aging (SUA), 618 

area agencies on aging (AAA), 264 Indian tribal and Native Hawaiian organizations, nearly 

20,000 direct service providers, and hundreds of thousands of volunteers. AoA’s core programs, 

authorized under the Older Americans Act (OAA), help seniors remain at home for as long as 

possible and advocate for quality of care and promotion of rights for individuals who live in 

long-term care facilities (nursing homes, board and care, assisted living and similar settings). 

These services complement efforts of the nation’s public health network as well as existing 

medical and health care systems, help prevent hospital readmissions and support some of life’s

most basic functions, such as bathing or preparing food. AoA and the national aging services 

network annually serve nearly 11.5 million Americans aged 60 and over and their caregivers.1

 

The population served through OAA programs and activities will grow at unprecedented rates

over the next 20 years. An estimated 62.8 million older adults age 60 and over resided in the 

U.S. in 2013, comprising almost 20 percent of the population.

2

 By 2020, this age group is 

estimated to increase by 23 percent and reach 77.6 million seniors.

3

 During this period, the 

1

 AoA FY 2013 State Program Report. 2

 U.S. Census Bureau, Population Division. 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, 2013. Release Date: June 2014. (https://www.census.gov/popest/data/national/asrh/2013/index.html). 

Accessed 27 August 2014. 3

 Ibid and U.S. Census Bureau, “2014 National Population Projections,” Table 1. Projected Population by Single 

Year of Age, Sex, Race, and Hispanic Origin for the United States: 2014 to 2060. Released December 2014, 

http://www.census.gov/population/projections/data/national/2014/downloadablefiles.html. Accessed 08 January 

2015.

2 

 
number of older adults (age 65 and older) with severe disabilities – defined as 3 or more 

limitations in activities in daily living - who are at greatest risk of nursing home admission will 

increase substantially. If current trends continue this population is projected to increase by 26 

percent by the year 2020.

4 Ten years later, in 2030, when the last of the baby boomers turn age 

65, twenty-one percent of the population, or one in five Americans will be age 65 or over and the 

number with severe disability will have increased by over 65 percent since 2013.

5

 As these 

baby boomers age, the ranks of the oldest old (age 85+) who are frequently the most frail will 

continue to swell. 

Maintaining support for home and community-based services for assisting this growing 

population is important. Reports indicate that making reductions in these services could lead to 

higher government expenditures in areas such as Medicaid.6 Several state efforts to measure the 

impact of home and community-based programs on Medicare and Medicaid funding have shown 

signs of potential for savings.7 AoA’s services assist people to remain independent and in their 

communities, thereby having the potential to prevent or delay institutionalization. If even a 

small percentage of service recipients are able to delay institutionalization, it would have a 

significant impact on Medicaid expenditures. 

The goal of the OAA, and the mission of AoA, is to ensure that older Americans have the 

opportunity to live independently, with dignity, in their homes and communities for as long as 

they are able to do so. We look forward to working with the Congress to strengthen these critical 

programs and further build the capacity of the national aging services network to continue to 

deliver high-quality services that improve the health, safety, and well-being of older Americans. 

Kathy Greenlee

Assistant Secretary for Aging

Administrator, Administration for Community Living

4

 Ibid and Centers for Medicare & Medicaid Services, The characteristics and perceptions of the Medicare 

population. Data from the 2012 Medicare Current Beneficiary Survey. [data tables 2.5a and 2.6a]. 

http://www.cms.gov/Research-Statistics-Data-and-Systems/Research/MCBS/Data-Tables-Items/2012CNP.html. 

Accessed 23 October, 2014. 5

 Ibid. 6

 Muramatsu, N., H. et al 2007. “Risk of Nursing Home Admission among Older Americans: Does States’Spending 

on Home- and Community-Based Services Matter?” Journals of Gerontology. Series B, Psychological Sciences 

and Social Sciences 62 (3): S169–78. 

Kaye, H. S., M. P. LaPlante, and C. Harrington. 2009. “Do Noninstitutional Long-Term Care Services Reduce 

Medicaid Spending?” Health Affairs 28 (1): 262–72. 7

 Thomas, K. S. and Mor, V. 2013. “The Relationship between Older Americans Act Title III State Expenditures 

and Prevalence of Low-Care Nursing Home Residents.” Health Services Research 48 (3): 1475-6773. 

Shapiro, A. and Loh, C-P. August 2010. “Advanced Performance outcome Measures Project (POMP): Estimates 

of Medicaid and General Revenue Cost-Avoidance from HCBS Utilization: Final Report (Contract #XQ867)”. 

Tallahassee, FL: Florida Department of Elder Affairs.

https://www.gpra.net/ppt/POMP2010_UNF_Final_Report.pdf

Chapin, R. et al. 2003. “Examination of the Use of Medicare Home Health Services and Informal Caregiving and 

Their Relationship to Successful Community Tenure and Appendices”. Lawrence, KS: University of Kansas

School of Social Welfare Office of Aging and Long Term Care. http://crado.ku.edu/publications/reports

3 

 
Table of Contents

 Page Number

 

Introduction 2

Executive Summary 6 

• National Program Data on Services Provided 9 

 

Part I: Health and Independence 11 

• Home and Community-Based Supportive Services 11 

• Nutrition Services 14 

• Preventive Health Services 18 

• Chronic Disease Self-Management Program 20 

• Behavioral Health 22 

• Caregiver Services 24 

• National Family Caregiver Support Program 25 

• Lifespan Respite Care 28 

• Alzheimer’s Disease Supportive Services Program 31 

Part II: Older American Indians, Alaska Natives & Native Hawaiians 33 

• Nutrition and Supportive Services 33 

• Caregiver Support Services 34 

 

Part III: Protection of Vulnerable Older Americans 36 

• Prevention of Elder Abuse & Neglect 37 

• National Legal Assistance and Support Projects 38 

• Model Approaches to Statewide Legal Assistance Systems 40 

• Pension Counseling and Information 42 

• Senior Medicare Patrol Program 44 

• Health Care Fraud and Abuse Control 45 

• Long-Term Care Ombudsman Program 47 

Part IV: Supporting the National Aging Services Network 57 

• Aging and Disability Resource Centers 57 

• Aging Network Support Program Activities 61 

Appendix: Formula Grant Funding Allocation by 64 

 State, Territory and Tribal Organization

4 
5 
EXECUTIVE SUMMARY 

AoA’s core programs, authorized under the Older Americans Act (OAA), help older adults 

remain healthy and independent. These services complement efforts of the nation’s public health 

networks as well as existing medical and health care systems and support some of life’s most 

basic functions, such as bathing or preparing meals. These programs also support family 

caregivers, address issues of exploitation, neglect and abuse of older adults, and adapt services to 

the needs of Native Americans. The most recent data available show that AoA and its national 

network rendered direct services to 11.5 million elderly individuals age 60 and over (nearly

20 percent of the country’s elderly population) and their caregivers, including nearly

three million clients who received intensive in-home services.8 Critical supports, such as respite 

care and a peer support network, were provided to over one million caregivers.9

In the ongoing management of its programs and strategic planning process, AoA is guided by a 

set of core values in developing and carrying out its mission. These values include listening to 

older people, their family caregivers, and AoA partners who serve them; responding to the 

changing needs and preferences of our increasingly diverse and rapidly growing elderly 

population; producing measurable outcomes that significantly impact the well-being of older 

people and their family caregivers; and valuing and developing AoA staff. 

Overview of Performance 

The fundamental purpose of OAA programs, in combination with the legislative intent that the 

national aging services network actively participate in supporting community-based services 

with particular attention to serving economically and socially vulnerable elders, led AoA to 

focus on three measures of performance: 1) improving efficiency; 2) improving client 

outcomes; and 3) effectively targeting services to vulnerable elder populations. Each measure is 

representative of several activities across OAA programs, and progress towards achieving each

measure is tracked using a number of indicators. The efficiency measure and corresponding 

indicators are reflective of the Office of Management and Budget (OMB) requirements to 

measure efficiency for all program activities. The client outcome measure includes indicators 

focusing on consumer assessment of service quality and outcome indicators focusing on nursing 

home predictors, successful caregiver program operation and protection of the vulnerable 

elderly. The targeting measure and indicators focus on ensuring that states and communities 

serve the most vulnerable elders. Taken together, the three measures and their corresponding 

performance indicators are designed to reflect AoA’s goals and objectives and in turn measure 

success in accomplishing AoA’s mission. 

An analysis of AoA’s performance trends shows that through FY 2013, most outcome indicators 

have steadily improved and demonstrate that services are continuing to be effective in helping 

older persons remain at home. Some key successes are indicative of the potential of AoA and the 

national aging services network to meet the challenges posed by the growth of the vulnerable 

older adult population, the changing care preferences of aging baby boomers, the fiscal 

8 AoA’s FY 2013 State Program Report. 9 Ibid.

6 

 
difficulties faced by federal and state budgets, and the expanding needs of both older Americans 

and their caregivers. Below are some examples of these successes: 

• OAA programs help older Americans with functional limitations remain independent 

and in the community: Older adults who have three or more impairments in Activities of 

Daily Living (ADL) are at a high risk for nursing home placement. Measures of the national 

aging services network’s success at serving this vulnerable population is a proxy for success 

at nursing home delay and diversion. In FY 2005, one-third of home-delivered nutrition 

clients lived with three or more ADL impairments and by FY 2013 the proportion grew to 

43.5% percent, a 30 percent increase.10 Another approach to measuring AoA’s success is the 

nursing home predictor score. The components of this composite score are predictive of 

nursing home admissions based on scientific literature and AoA’s Performance Outcomes 

Measurement Project (POMP) which developed and tested performance measures. The 

composite score is a weighted average; the components include such items as the percent of 

clients who are transportation disadvantaged and the percent of congregate meal clients who 

live alone. As the score increases, the prevalence of nursing home predictors in the OAA 

service population increases. In 2003, the nursing home predictor score was 46.57. Data 

indicate it has increased to 64.2 in FY 2013, a 38 percent improvement over the FY 2003 

baseline. 

• OAA programs are efficient: The national aging services network is providing high quality 

services to the neediest elders and doing so in a very prudent and cost-effective manner. Over 

the past decade, the number of clients served per million dollars of OAA Title III funding has 

increased significantly. During FY 2013, the national aging services network served 9,753 

people per million dollars of OAA Title III funding. Since this measure’s introduction in FY 

2005, AoA and the national aging services network have met or exceeded efficiency targets. 

• OAA programs build system capacity: OAA programs stay true to their original intent to 

“encourage and assist state agencies and area agencies on aging to concentrate resources in 

order to develop greater capacity and foster the development and implementation of 

comprehensive and coordinated systems.” (OAA Section 301). This is evident in the 

leveraging of OAA funds with state/local or other funds (between two to three dollars in 

other funds for every dollar of OAA funds expended), as well as in the expansion of projects 

such as the Aging and Disability Resource Center (ADRC) initiative, over 500 ADRC sites 

have been established across 50 states, two territories, and Washington, DC. 

• OAA clients report that services contribute in an essential way to maintaining their 

independence and they express a high level of satisfaction with these services. In 2013, 

93 percent of home-delivered nutrition clients reported that the services help them to 

continue living at home. And, case management service clients report the service has 

enabled them to better care for themselves.11 Clients across all services rate the quality of 

these services extremely high and are satisfied with OAA services. For example, 97 percent 

of transportation clients rated services good to excellent and 95 percent of caregivers rated 

services good to excellent12. To help ensure the continuation of these trends in core 

10 AoA’s FY 2013 State Program Report. 11 2014 National Survey of Older Americans Act Participants. http://www.agid.acl.gov, 12 Ibid.

7 

 
programs, AoA uses its discretionary funding to test innovative service delivery models for 

state and local program entities that show promise for generating measurable improvements 

in program activities. For example, AoA has worked with the Centers for Medicare & 

Medicaid Services (CMS) and the Department of Veterans Affairs to better integrate funding 

for long-term care service delivery, eliminate duplication and improve access to services 

through Aging and Disability Resource Centers. 

The tables on the next page provide a summary of the persons served during FY 2013 through 

the OAA’s programs. Additionally, a listing of grant funding allocations by state, territory and

tribal organization can be viewed in the Appendix. 

8 
FY 2013 National Program Services Summary Report

FY 2013

Total Clients 11,484,509

Total Registered Clients 2,755,948

% Minority Clients 28.26%

% Rural Clients 35.93%

% Clients Below Poverty 31.6%

# Senior Centers 10,284 (5,546 receive OAA funding)

Service Persons 

Served

Units of 

Service13

Title III 

Expenditure

Total 

Expenditure

Personal Care 107,479 15,317,426 $48,658,391 $277,041,663 

Homemaker 149,670 13,602,359 $27,894,976 $268,016,553 

Chore 34,176 926,656 $4,522,539 $19,024,932 

Home Delivered 830,187 135,954,081 $250,155,904 $799,336,748

Adult Day Care 19,025 7,950,947 $13,802,761 $87,609,746 

Case Mgt. 437,840 4,017,890 $25,801,820 $251,783,529 

Assisted Trans. 31,989 1,147,587 $4,092,150 $15,896,869 

Congregate 1,575,207 83,411,432 $272,854,675 $632,939,643

Nutrition Counseling 24,275 42,910 $1,305,999 $2,836,310

Transportation 24,206,274 $68,650,739 $199,969,768

Legal Assistance 878,374 $26,089,078 $48,436,875

Nutr. Education 3,099,943 $3,794,382 $7,077,408 

I&A 12,610,209 $57,475,350 $166,006,427

Outreach 1,527,709 $10,099,347 $20352969

Health Promotion and 

Disease Prevention 1,534,983 $19,324,619 $42,660,275

Self-Directed Care 938

Other $75,507,224 $655,801,124

13 Service Units Definitions:

Personal Care = 1 Hour

Homemaker = 1 Hour

Chore = 1 Hour 

Home-Delivered Meal = 1 Meal. 

Adult Day Care/Adult Day Health = 1 Hour 

Case Management = 1 Hour 

Assisted Transportation = 1 One Way Trip 

Congregate Meal = 1 Meal

Nutrition Counseling = 1 session per participant

Transportation = 1 One Way Trip

Legal Assistance = 1 hour

Nutrition Education = 1 session per participant

Information and Assistance = 1 Contact 

9 

 
National Family Caregiver Support Program Title III-E 

Service Caregivers 

Served

Service 

Units14

Title III 

Expenditure

Total 

Expenditure

Counseling, Support 

Groups, Training

125,948 470,045 $19,763,801 $28,761,250

Respite 63,080 5,852,890 $58,080,517 $99,334,047

Supplemental Services 36,798 742,894 $11,214,513 $15,840,804

Access Assistance 810,592 1,148,615 $30,328,922 $42,749,384 

Self-Directed 2,012 $1,126,757 $1,670,505

Information Services 13,403,326 787,027 $12,129,954 $16,748,187

Unduplicated Caregivers 

Provided Service or Access 203,392 

14 Title III-E service units definition:

Counseling = 1 session per participant

Respite Care = 1 hour

Supplemental services = variable

Access Assistance = 1 contact

Self-Directed = variable

Information Services = 1 activity

10 

 
PART I: HEALTH AND INDEPENDENCE

AoA’s Health and Independence Programs provide a foundation of supports that assist older 

individuals to remain healthy and independent in their homes and communities, avoiding more 

expensive nursing home care. For example, 61 percent of congregate and 93 percent of homedelivered meal recipients reported that the meals enabled them to continue living in their own 

homes and 52 percent of seniors 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.15

Between 2013 and 2020, the number of Americans age 60 and older will increase by over 14.8 

million older adults, to reach 77.6 million seniors.16 During this period, the number of seniors 

age 65 and over with severe disabilities (defined as 3 or more limitations in activities of daily 

living) who are at greatest risk of nursing home admission and Medicaid eligibility (through the 

“spend down” provisions) will increase by more than 26 percent.17 AoA’s Health and 

Independence programs help seniors in need maintain their health and independence. 

In concert with other OAA programs, these services assist nearly 11.5 million elderly individuals 

and caregivers. AoA’s services are especially critical for the nearly three million seniors who 

receive intensive in-home services, over half a million of whom meet the disability criteria for 

nursing home admission. These services help to keep these individuals from joining the 

1.9 million seniors who live for extended periods of time in nursing homes.18 

Home and Community-Based Supportive Services

(Title III-B of OAA; FY 2013: $347,724,000) 

The Home and Community-Based Supportive Services (HCBSS) program, established in 1973, 

provides grants to states and territories based on their share of the population age 60 and over to 

fund a broad array of services. AoA’s programs, including the HCBSS program, serve seniors 

holistically; while each service is valuable in and of itself, it is often the combination of supports, 

15 2014 National Survey of Older Americans Act Participants. http://www.agid.acl.gov. 16 U.S. Census Bureau, Population Division. 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, 2013. Release Date: June 2014. (https://www.census.gov/popest/data/national/asrh/2013/index.html). 

Accessed 27 August 2014 and U.S. Census Bureau, “2014 National Population Projections,” Table 1. Projected 

Population by Single Year of Age, Sex, Race, and Hispanic Origin for the United States: 2014 to 2060. Released 

December 2014, http://www.census.gov/population/projections/data/national/2014/downloadablefiles.html. 

Accessed 08 January 2015. . 17 Ibid and Centers for Medicare & Medicaid Services, The characteristics and perceptions of the Medicare 

population. Data from the 2012 Medicare Current Beneficiary Survey. [data tables 2.5a and 2.6a]. 

http://www.cms.gov/Research-Statistics-Data-and-Systems/Research/MCBS/Data-Tables-Items/2012CNP.html. 

Accessed 23 October, 2014. 18 Centers for Medicare & Medicaid Services, The characteristics and perceptions of the Medicare population. Data 

from the 2012 Medicare Current Beneficiary Survey. [Table 1.2 Demographic and Socioeconomic 

Characteristics of Medicare Beneficiaries, by Age and by Gender and Age, 2012]. 

http://www.cms.gov/Research-Statistics-Data-and-Systems/Research/MCBS/Data-Tables-Items/2012CNP.html. 

Accessed 23 October, 2014..

11 

 
when tailored to the needs of the individual that helps older persons remain in their own homes 

and communities instead of entering nursing homes or other types of institutional care.19 

The services provided to seniors 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. In addition to these services, the HCBSS program also funds 

multi-purpose senior centers, which coordinate and integrate services for the elderly.

While age alone does not determine the need for these long-term care supports, statistics show 

that both disability rates and the use of long-term supports increase with advancing age. Among 

those aged 85 and older, 58 percent are unable to perform critical activities of daily living and 

require long-term support.

20 Data also show that over 90 percent of seniors have at least one 

chronic condition and 75 percent have at least two.21 Providing a variety of supportive services 

that meet the diverse needs of these older individuals is crucial to enabling them to remain 

healthy and independent in their homes and communities, and therefore to avoiding unnecessary, 

expensive nursing home care. 

Services provided by the HCBSS program in FY 2013 include:22 

• Transportation Services provided over 24.2 million rides to doctor’s offices, grocery 

stores, pharmacies, senior centers, meal sites, and other critical daily activities. 

• Personal Care, Homemaker, and Chore Services provided nearly 30 million hours of 

assistance to seniors 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).

• Adult Day Care/Day Health provided nearly eight million hours of care for dependent 

adults in a supervised, protective group setting during some portion of a twenty-four hour 

day. 

• Case Management Services provided four million hours of assistance in assessing needs, 

developing care plans, and arranging services for older persons or their caregivers. 

Continuing AoA’s commitment to provide services to those in most need, 47 percent of riders on 

OAA-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.23 Many of these individuals 

19 Brock, D et al. “Risk Factors for Nursing Home Placement Among OAA Service Recipients: Summary Analysis 

from Five Data Sources” Westat; U.S. Administration on Aging Contract No. 233-02-0087. 

http://www.aoa.gov/AoARoot/Program_Results/POMP/docs/Risk_Factors.pdf

20 Centers for Medicare & Medicaid Services, The characteristics and perceptions of the Medicare population. 

Data from the 2012 Medicare Current Beneficiary Survey. [data tables 2.5a]. http://www.cms.gov/ResearchStatistics-Data-and-Systems/Research/MCBS/Data-Tables-Items/2012CNP.html. Accessed 23 October, 2014.

21 Ibid. 22 AoA’s FY 2013 State Program Report.

23 2014 National Survey of Older Americans Act Participants. http://www.agid.acl.gov, select AGID.

12 

 
cannot safely drive a car, as 75 percent of transportation riders have at least one of the following 

chronic conditions that could impair their ability to navigate safely:24

 

• 67 percent of riders had a doctor tell them they had vision problems (including glaucoma, 

macular degeneration or cataracts); 

• 7 percent have Alzheimer’s or dementia; 

• 2 percent have Multiple Sclerosis; 

• 14 percent have had a stroke;

• 3 percent have epilepsy; and 

• 2 percent have Parkinson’s disease. 

 

Of the transportation participants, 96 percent take daily medications, with 12 percent report 

taking 10 to 20 medications daily.25 Data from AoA’s national surveys of elderly clients show 

that HCBSS services are providing these seniors with the assistance and information they report

helps them to remain at home.26 For example, 81 percent of clients receiving case management 

reported that as a result of the services arranged by the case manager they were better able to 

care for themselves.27 In addition, a study published in the Journal of Aging and Health shows 

that the services provided by the HCBSS program, what the article calls “personal care services,” 

are the critical services that enable frail seniors to remain in their homes and out of nursing home 

care.28 

Nationally, almost 25 percent of individuals 60 and older live alone.29 AoA programs serve a 

disproportionate number of people who live alone compared to the general population. For 

example, 67.5 percent of transportation clients live alone30. Living alone is a key predictor of 

nursing home admission, and HCBSS services are critical for enabling them to remain at home, 

especially for those who do not have an informal caregiver to assist with their care. Recent 

research has also shown that childless seniors who live in a state with higher home and 

community-based service expenditures had significantly lower risk of nursing home 

admissions.31 

Federal support for OAA programs is not expected to cover the cost of serving every older 

American. These programs have strong partnerships with state and local governments, 

philanthropic organizations, and private donations that contribute funding. States typically have 

leveraged resources of $2 or $3 per every OAA dollar, significantly exceeding the programs’ 

match requirements. 

24 Ibid 25 2014 National Survey of Older Americans Act Participants. http://www.agid.acl.gov, 26 Ibid.

27Ibid. 28 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. Available: http://jah.sagepub.com/cgi/content/abstract/22/3/267. 29 Administration for Community Living, http://www.agid.acl.gov/DataGlance/. Data-at-a-Glance: American 

Community Survey (ACS) Public Use Microdata Sample (PUMS) 1-Year Files (2012), accessed January, 08, 

2015. 30 2014 National Survey of Older Americans Act Participants. http://www.agid.acl.gov 31 Muramatsu, Naoko. “Risk of Nursing Home Admission Among Older Americans: Does States’ Spending on 

Home and Community-Based Services Matter?” May 2007. Journal of Gerontology: Psychological Sciences. 

13 

 
Nutrition Services

Nutrition Services help seniors remain healthy and independent in their communities by 

providing health-promoting meals and related services in a variety of settings (such as senior 

centers, public housing locations, religious buildings or community centers) and via homedelivery to seniors who are homebound due to illness, disability, or geographic isolation. 

Nutrition Services include: 

• Congregate Nutrition Services (Title III-C1; FY 2013: $416,104,000): Provides funding 

for the provision of nutritious meals and related services in a variety of congregate 

settings, which helps to keep older Americans healthy and prevents the need for more 

costly medical interventions. Established in 1972, the program centers around serving 

health-promoting meals, but it also presents opportunities for social engagement, health 

and wellness activities and meaningful volunteer roles, all of which contribute to overall 

health and well-being. 

• Home-Delivered Nutrition Services (Title III-C2; FY 2013: $205,489,000): Provides 

funding for nutritious meals, the delivery of meals and in most cases an informal ‘safety 

check’ for frail or isolated seniors who are homebound. Established in 1978, home 

delivered meals are often the first in home service that an older adult receives and serve 

as a primary access point for other home and community based services. 

• Nutrition Services Incentive Program (Title III-A; FY 2013: $146,718,000): Provides 

additional funding to states, territories, and eligible tribal organizations that is used 

exclusively to procure food products for use in the Title III- C-1 and C-2 and Title VI 

meal programs, and cannot be used to pay for other nutrition-related services or for

administrative costs. Funds are awarded to states and tribes based on the number of 

meals served in the prior federal fiscal year. States and tribes have the option to purchase 

commodities directly from the U.S. Department of Agriculture (USDA) with any portion 

of their award if they determine that doing so will enable them to better meet the needs of 

seniors. 

The meals provided through these programs fulfill the standards set by the current Dietary 

Guidelines for Americans and provide a minimum of 33 percent of the Dietary Reference Intake, 

as established by the Food and Nutrition Board of the Institute of Medicine of the National 

Academy of Sciences. 

Nutrition Services help 2.4 million older adults receive the meals they need to stay healthy and 

decrease their risk of disability.32 Due in part to advances in public health and medical care, 

Americans are living longer and more active lives. The average life expectancy of an American 

has increased dramatically over the last century and one consequence of this increased longevity 

is the higher incidence of chronic conditions. Multiple chronic conditions negatively affect 

quality of life, contribute to declines in functioning and the ability to remain in the community, 

adversely impact individuals’ health, and contribute to increased hospitalizations and health care 

32 AoA’s FY 2013 State Program Report.

14 

 
costs.33 Many of the most common chronic conditions such as hypertension, heart disease, 

diabetes, and osteoporosis are related to nutrition as a primary prevention, risk reduction, or 

treatment modality. Medicare beneficiaries with multiple chronic conditions are the heaviest 

users of health care services. For example, two-thirds of beneficiaries with two or more chronic 

conditions account for 93 percent of Medicare spending, and one-third of beneficiaries with 4 or 

more chronic conditions account for almost three-fourths of Medicare spending.34

Because the prevalence of multiple chronic conditions is higher among congregate and homedelivered program participants than for the general Medicare population, the provision of healthy 

meals, access to lifestyle modification programs, and evidence-based advice such as nutrition 

education and counseling are important. Overall, 76 percent of community-living Medicare 

beneficiaries age 65 or older have multiple conditions.35 Data from AoA’s national survey of 

older adult participants indicate that 95% of home-delivered and congregate participants have 

multiple chronic conditions and large numbers of chronic conditions are common with 45 

percent of congregate and 63 percent of home-delivered participants have six or more illnesses or 

conditions.36 Over 30 percent of congregate and 51 percent of home-delivered participants take 

over 6 medications per day and some take more than 20 medications.37 The congregate and 

home-delivered program participants are significantly less healthy than the general Medicare 

population and access to adequate healthy meals is essential to their well-being. 

Older adults served in the congregate and home-delivered nutrition programs demonstrate a need 

for healthy prepared meals, rather than simply access to food. While the 75 year-old and over 

cohort makes up 31 percent of the U.S. population age 60 and over, more than half (51 percent)

of congregate and almost two-thirds (66 percent) of home-delivered meal participants are aged 

75 years or older.38 

Approximately 11 percent of congregate and over 40 percent of home-delivered participants 

indicate that they have three or more impairments in instrumental activities of daily living 

(IADLs)39. The data also indicate that about 16 percent of congregate and 51 percent of homedelivered participants need help in getting outside the house, thus limiting their ability to shop 

for food themselves.40 The number of home-delivered meal recipients with severe disabilities 

(three or more Activities of Daily Living) totaled nearly 330,000 in FY 2013. This level of 

33 Lochner KA, Cox CS. Prevalence of Multiple Chronic Conditions among Medicare Beneficiaries, United States, 

2010. Prev Chronic Dis 2013; 10:120137. DOI http://dix.doi.org/10.5888/pcd10.12037. 34 Ibid. 35 Centers for Medicare & Medicaid Services, The characteristics and perceptions of the Medicare population. Data 

from the 2012 Medicare Current Beneficiary Survey. [Table 2.6a Self-Reported Health Conditions and Risk 

Factors of Non-institutionalized Medicare Beneficiaries, by Living Arrangement and Age, 2012]. 

http://www.cms.gov/Research-Statistics-Data-and-Systems/Research/MCBS/Data-Tables-Items/2012CNP.html. 

Accessed 23 October, 2014. 36 2014 National Survey of Older Americans Act Participants. http://www.agid.acl.gov. 37 Ibid. 38 U.S. Census Bureau, Population Division. 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, 2013. Release Date: June 2014. (https://www.census.gov/popest/data/national/asrh/2013/index.html). 

Accessed 27 August 2014 and AoA’s 2013 State Program Report 

39 2014 National Survey of Older Americans Act Participants. http://www.agid.acl.gov. 40 Ibid. 

15 

 
disability is frequently associated with nursing home admission, and demonstrates the extreme 

frailty of a significant number of older adults receiving home-delivered meals. 

Nationally, almost 25 percent of individuals age 60 years and older live alone.41 However, due 

to OAA’s requirement to target services to older adults most in need to help them maintain their 

health and independence, 39 percent of congregate and 51 percent of home-delivered participants 

live alone.42 Living alone is a risk factor for social isolation, poorer health and nursing home 

placement.

Data from AoA’s national surveys of older adult participants show that Nutrition Services are 

effectively helping older adults improve their nutritional intake and remain at home. For 

example, data indicate that 77 percent of congregate and 84 percent of home-delivered meal 

participants say they eat healthier meals due to the programs, and 61 percent of congregate and 

93 percent of home-delivered meal recipients say that the meals enable them to continue living in 

their homes.43 The extra support provided by these programs can help older adults avoid more 

costly institutional care. Independent research has found that states that invest more in delivering 

OAA home-delivered meals to older adults’ homes have lower rates of “low-care” seniors in 

nursing homes after adjusting for several other factors.44 For every $25 per year per older adult 

that states spend on home-delivered meals, the state reduces their percentage of low-care nursing 

home residents by one percent when compared to the national average.45 

AoA’s annual performance data further demonstrate that these programs are highly valued by 

older individuals who need assistance in order to remain healthy and independent in their homes 

and communities. Nearly 90 percent of home-delivered meal clients and over 90 percent of 

congregate participants rate the meal as good to excellent

46. The most recent data on how these 

nutrition programs are helping seniors remain healthy and independent in their homes include: 

• Home-Delivered Nutrition Services provided 136 million meals to over 830,000 

individuals in FY 2013.47

• Congregate Nutrition Services provided over 83.4 million meals to 1.6 million seniors in 

a variety of community settings in FY 2013.48

Consistent with the OAA’s requirement to target services to those most in need to help them 

maintain their health and independence, approximately 66 percent of home-delivered meal 

recipients have annual incomes at or below $20,000.49 Meals are especially critical for the 62 

41 Administration for Community Living, http://www.agid.acl.gov/DataGlance/. Data-at-a-Glance: American 

Community Survey (ACS) Public Use Microdata Sample (PUMS) 1-Year Files (2012), accessed January, 08, 

2015. 42 AoA’s FY 2013 State Program Report. 43 2014 National Survey of Older Americans Act Participants. http://www.agid.acl.gov.. 44 Thomas, K & Moe, V. The relationship between Older Americans Act Title III State Expenditures & Prevalence 

of Low-Care Nursing Home Residents. Health Services Research. 12.3.12. 

http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12015/abstract 45 Ibid. 46 2014 National Survey of Older Americans Act Participants. http://www.agid.acl.gov. 47 AoA’s FY 2013 State Program Report. 48 Ibid.

49 2014 National Survey of Older Americans Act Participants. http://www.agid.acl.gov. 

16 

 
percent of home-delivered and 58 percent of congregate recipients who report these meals 

provide half or more of their food intake for the day.50 

Federal support for Nutrition Services is not expected to serve every senior. These programs 

have strong partnerships with state and local governments, philanthropic organizations and 

private donations that contribute funding. In FY 2013, state and local funding comprised 

approximately 69 percent of all the funding for home-delivered meals and 57 percent for 

congregate meals.51 Though all programs funded through the OAA rely on state and local 

funding in some part, funding for congregate and home-delivered meals leverages more state and 

local financial support than many other OAA services.

State and Territory Flexibility

Under the core state formula grant programs for Home and Community-Based Supportive 

Services and Nutrition Services, states and territories have the flexibility to allocate resources to 

best meet local needs through intra-state funding formulas which distribute funds to area 

agencies on aging (AAAs). These formulas vary by state and allow states to take into account 

their own local circumstances to best serve their population. States are required to submit their 

formulas to AoA for approval and must take into account the geographic distribution of older 

persons and the distribution of older persons in greatest social and economic need. AAAs 

administer these grants and provides grants or contracts to local service providers based on 

identified needs. 

The OAA allows a state to transfer up to 40 percent of the funds between congregate and homedelivered meals for use as the state considers appropriate to meet the needs of the area served. 

Additionally, for any fiscal year in which the transferred funds are insufficient to satisfy the need 

for nutrition services, the assistant secretary for aging may grant a waiver that permits the state to 

transfer an additional 10 percent of the funds to meet those needs. The OAA provides further 

flexibility to states by allowing them to transfer up to 30 percent for any fiscal year between 

Supportive Services programs and Nutrition Services programs, for use as the state considers 

appropriate. These are options open only to states and territories. A state agency may not 

delegate to an area agency on aging or any other entity the authority to make such transfers. 

In FY 2013, states transferred nearly $74 million from congregate nutrition to home and 

community-based services and home-delivered meals, as illustrated in the table below. 

Table 1. FY 2013 Transfer of Federal funds within Title III of the OAA 

Part B –

Home and CommunityBased Supportive Services

Part C1 – 

Congregate Nutrition

Part C2 – 

Home-Delivered Meals

Initial Allotment $345,665,953 $413,640,501 $204,272,497

Final Allotment after 

Transfers $381,403,215 $339,871,695 $242,304,041

Net Transfer +$35,737,262 (-$73,768,806) +$38,031,544

Net Percent Change 10.34 (-17.83) 18.62

50 Ibid. 

17 

 
Preventive Health Services

(Title III-D of OAA; FY 2013: $19,849,000) 

Preventive Health Services, established in 1987, provide formula grants to states and 

territories based on their share of the population aged 60 and over to support evidencebased disease prevention and health promotion programs. Older Americans are 

disproportionately affected by chronic disease. Evidence-based programs can mitigate 

the negative impact of chronic diseases and related injuries, such as falls. Preventive 

Health Services provide states and territories with the flexibility to allocate resources 

among the preventive health programs of their choice to best meet local needs. Priority 

has been given to providing services to those elders living in medically underserved areas 

of the state or who have the greatest economic need. 

Due in large part to advances in public health and medical care, Americans are leading 

longer and more active lives. Average life expectancy has increased from less than 50 

years at the turn of the 20th century to over 78 years today.

52 On average an American 

turning age 65 in 2010 can expect to live an additional 19.2 years.

53 The population of 

older Americans, particularly the population age 85 and over, which is growing very 

rapidly, totaled six million in 201354 and is projected to reach 9.1 million by the year 

2030.55 One consequence of this increased longevity is the higher incidence of chronic 

diseases such as obesity, arthritis, diabetes, osteoporosis, and depression, as well as the 

greater probability of injury from a fall, which quickly limits physical activity. 

Evidence-based programs empower older adults to take control of their health by 

maintaining a healthy lifestyle through increased self-efficacy and self-management. 

Evidence-based initiatives provide the greatest impact given available funding. Before 

the Preventive Health Services evidence-based requirement was implemented in 2012, 

states had already begun to shift their Preventive Health Services funding towards 

evidence-based approaches to achieve better results for their limited funding. Since 2012, 

all Preventive Health Services funding has been used for evidence-based approaches. 

Since evidence-based programs have demonstrated their effectiveness, AoA expects that 

states will be able to maximize the impact of these limited dollars. At the same time, if 

states wish to continue funding other health services, such as health screenings, they still 

52 National Center for Health Statistics. Health, United States, 2013: With Special Feature on Prescription 

Drugs. Hyattsville, MD. 2014. [ Web update: Table 18 Life expectancy at birth, at age 65, and at age 75, 

by sex, race, and Hispanic origin: United States, selected years 1900–2011] Updated data when 

available, Excel, PDF, and more data years: http://www.cdc.gov/nchs/hus/contents2013.htm#018. 

Accessed 12 January 2015. 53 Ibid. 54 U.S. Census Bureau, Population Division, 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, 2013. Released June 2014, accessed 27 August 2014. 55 U.S. Census Bureau, “2014 National Population Projections,” Table 1. Projected Population by Single 

Year of Age, Sex, Race, and Hispanic Origin for the United States: 2014 to 2060. Released December 

2014, http://www.census.gov/population/projections/data/national/2014/downloadablefiles.html. 

Accessed 08 January 2015.

18 

 
have the flexibility to continue to use funds provided under the HCBS program for this 

purpose. 

Evidence-based programs are interventions that have been tested through randomized 

control trials and have been shown to be effective at helping participants adopt healthy 

behaviors, improve their health status, and reduce their use of hospital services and 

emergency room visits. Some examples of evidence-based interventions are: 

• Physical activity programs: EnhanceFitness is an example of a multi-component 

group exercise program designed for community-based organizations and 

intended to promote physical activity among older adults. Strength training using 

soft wrist and ankle weights; cardiovascular workout using dancing, aerobics, or 

walking; and balance and posture exercises are used to increase the physical 

health of older adults. This program was developed by the Healthy Aging 

Research Network of the Prevention Research Centers Program of the Centers for 

Disease Control and Prevention. 

• Falls prevention: Falls prevention programs help participants achieve improved 

strength, balance, and mobility; provide education on how to avoid falls and 

reduce fall risk factors; involve medication reviews and modifications; provide 

referrals for medical care management for fall risk factors; and provide home 

assessments of ways to reduce environmental hazards. In the United States, more 

than one-third of adults age 65 and over fall each year. Of those who fall, 20 to 

30 percent will experience serious injuries, such as head trauma, broken bones, or 

hip fractures. These injuries may limit their ability to get around or live 

independently. Many people limit their activity after a fall, which may reduce 

strength, physical fitness, and mobility. 

• Medication management: 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 unnecessary duplication of prescriptions and cardiovascular problems.56

These programs have also been shown to improve medication usage rates and 

decrease medication errors among older adults.57

• Depression Care Management: Depression is not a normal part of aging, yet it is 

a prevalent and disabling condition among older adults. A recent national study 

found that 11.1 percent of Medicare beneficiaries age 65 and older living in the 

community reported feeling “sad or depressed much of the time over the previous 

56 Meredith, S., Feldman, P., Frey, D., Giammarco, L., Hall, K., Arnold, K., ... Ray, W. A. (2002). 

Improving medication use in newly admitted home healthcare patients: A randomized controlled trial. 

Journal of the American Geriatrics Society, 50(9), 1484–1491. PubMed abstract available at 

http://www.ncbi.nlm.nih.gov/pubmed/12383144. 57 A summary of these studies can be found at:

http://www.acl.gov/Programs/CDAP/OPE/ADEPP.aspx. 

19 

 
year”.58 Older adults with depression “visit the doctor and emergency room more, 

use more medication, and stay longer in the hospital” than those without 

depression.59 Those with depression and certain chronic conditions have been 

shown to have substantially higher total health care costs than those with these

conditions but no depression ($22,960 vs. $11,956 per year).60 Cost-effective, 

evidence-based interventions, such as the Program to Encourage Rewarding Lives 

for Seniors (PEARLS), developed in CDC’s Prevention Research Centers, have 

been shown to reduce depressive symptoms and improve quality of life in older 

adults.61

Chronic Disease Self-Management Education Programs 

(FY 2013: $7,086,000) 

Chronic Disease Self-Management Education (CDSME) programs, such as the Stanford

University Chronic Disease Self-Management Program (CDSMP), are low-cost, 

evidence-based disease prevention models that use state-of-the-art techniques and lay 

leaders in the community to help individuals with chronic disease address issues related 

to the management and treatment of their condition, improve their health status, and 

potentially reduce their need for more costly medical care.62 In addition to the CDSMP,

which is appropriate for any type of chronic condition, there are other proven CDSME 

programs, including the Spanish CDSMP, the Diabetes Self-Management Program

(DSMP), Spanish DSMP, Chronic Pain Self-Management Program, Positive SelfManagement Program for HIV, Arthritis Self-Management Program, and online versions 

of the CDSMP and DSMP.

In the United States, over 76 percent of community-living, older adults have multiple 

(two or more) chronic conditions,

63 placing them at greater risk for premature death, poor 

functional status, unnecessary hospitalizations, adverse drug events, and nursing home 

58 Harris, Y., and J. K. Cooper (2006). “Depressive symptoms in older people predict nursing home 

admission”, Journal of the American Geriatrics Society, 54(4):593-597.

59 U.S. Centers for Disease Control and Prevention (2008). The State of Mental Health and Aging in 

America, Healthy Aging Program, Issue Brief #1. 60 Unützer J, Schoenbaum M, et al. (2009). “Health care costs associated with depression in medically ill 

fee-for-service Medicare participants”, Journal of the American Geriatric Society, 57:3, 375–584. 61 Program to Encourage Rewarding Lives for Seniors (2012). Description available at: 

http://www.pearlsprogram.org/ 62 Brady, T.J., et al. 2013. “A Meta-analysis of Health Status, Health Behaviors, and Health Care 

Utilization Outcomes of the Chronic Disease Self-Management Program.” Prev Chronic Dis 10:120112. 63 Centers for Medicare & Medicaid Services, The characteristics and perceptions of the Medicare 

population. Data from the 2012 Medicare Current Beneficiary Survey. [Table 2.6a Self-Reported Health 

Conditions and Risk Factors of Non-institutionalized Medicare Beneficiaries, by Living Arrangement 

and Age, 2012]. http://www.cms.gov/Research-Statistics-Data-and-Systems/Research/MCBS/DataTables-Items/2012CNP.html. Accessed 23 October, 2014.

20 

 
placement.

64, 65 Chronic conditions also impact health care costs: 93 percent of Medicare 

expenditures are for beneficiaries with chronic conditions.66

CDSME programs have been shown repeatedly, through multiple studies (including 

randomized control experiments, with both English and Spanish speaking populations) to 

be effective at helping participants adopt healthy behaviors and improve their 

psychological and physical health status.

67 Some evidence suggests that CDSME 

programs may also reduce the use of hospital care and emergency room services, as well 

as reduce health care costs in older adults.68

CDSMEs emphasize an individual’s role in managing his/her chronic condition(s). The 

in-person programs consist of a series of workshops that are conducted once a week for 

two and a half hours over six to seven weeks in community settings such as churches, 

libraries, YW/MCAs, senior centers, public housing projects, health centers and 

cooperative extension programs. People with differing chronic health conditions attend 

workshops together, and the workshops are facilitated by two trained leaders. One or both 

of the leaders are non-health professionals or lay people with one or more chronic 

conditions themselves. Topics covered in the training include: 1) techniques to deal with 

problems such as frustration, fatigue, pain and isolation; 2) appropriate exercise for 

maintaining and improving strength, flexibility, and endurance; 3) appropriate use of 

medications; 4) communicating effectively with health professionals; and 5) nutrition. 

AoA funds CDSME through competitive grants awarded to states. External experts 

review project proposals, and AoA awards grants for periods of up to three years. In FY 

2013, AoA tracked the progress of the 22 state grantees funded through the Prevention 

and Public Health Fund (PPHF) in September 2012. These three-year grants are allowing 

states to provide CDSME programs to older adults and adults with disabilities to help 

them better manage chronic conditions. All of the grantees identified underserved target 

populations and partnering organizations to reach these populations including tribal 

entities, Centers for Independent Living, and a variety of minority organizations. The 

funding is also fostering the development of comprehensive, integrated delivery systems 

64 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. http://www. ncbi.nlm.nih.

gov/pmc/ articles/PMC2150598/ 65 Kramarow E, Lubitz J, Lentzner H, et al. Trends in the health of older Americans, 1970–2005. Health Aff 

(Millwood). 2007 Sep–Oct;26(5):1417-25. http://content.healthaffairs. org/content/ 26/5/1417.full.

pdf+html 66 Nawrocki J. CMS Provides Data on Care for Chronic Conditions to Find Better Care Models. NetNews. April 

2, 2013 http://health.wolterskluwerlb.com/2013/04/cms-provides-data-on-care-for-chronic-conditions-tohelp-find-better-care-models/ 67 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 SelfManagement Program. Prev Chronic Dis 2013;10:120112. http://dx.doi.org/10.5888/pcd10.120112 68 Ory, M. G., et al. 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

21 

 
to embed and sustain these programs within the long-term services and supports and 

health care systems. 

By September 30, 2013, grantees had reached 34,982 participants and 25,989 

“completers” (i.e., who attended at least four out of six classes, a retention rate of 74

percent). Grantees were successful in reaching their targeted, underserved populations; of 

those participants reporting relevant data, 56 percent were age 60 or older, 57 percent 

reported having multiple chronic conditions, 45 percent reported a disability, and 48 

percent were racial/ethnic minorities.

Through financing from the FY2013 PPHF, AoA also funded a National Resource Center 

to assist states, the aging, disability and public health networks and their partners to 

increase access to and sustain evidence-based prevention programs, particularly CDSME 

programs, that improve the health and quality of life of older adults and adults with 

disabilities. The Center also serves as a national clearinghouse of tools and information 

on CDSME. 

Under the auspices of the Center, a National Study of CDSMP was completed in 2013. 

The study included over 1,100 participants recruited from 145 workshops in 17 states. 

Data were collected at baseline, six, and twelve months. The study documented the 

following positive, significant improvements relevant to the Institute for Healthcare 

Improvement’s Triple Aim: better health—improvement in self-reported health, less 

depression, and better quality of life; better care—improved communication with 

physicians, medication compliance, and health literacy; and lower health cost—more than 

$360 per person net savings after factoring in program costs.69 

The PPHF also financed a contract to help expand access and sustainability of diabetes 

self-management programs and to provide technical assistance to area agencies on aging 

and community-based organizations on general business acumen skills/issues, including 

situational analysis reports, onsite support, gap analysis services, and process 

implementation. 

Behavioral Health 

Good mental and behavioral health is essential to overall health. Mental and behavioral 

health issues, such as depression, anxiety, substance abuse and misuse, and suicidal 

thoughts or actions, are not a normal part of aging – yet one in four persons aged 55 and 

over have experienced a behavioral health disorder.70 Behavioral health issues can 

greatly impact the independence, health, and well-being of older adults and their family 

caregivers. Untreated mental and behavioral health disorders can exacerbate health 

69 . Ahn S et al. The Impact of Chronic Disease Self-Management Programs: Healthcare Savings through a 

Community-Based Intervention. BMC Public Health. 2013. 13:1141. 70 Jeste DV, Alexopoulos GS, Bartels SJ, et al. Consensus statement on the upcoming crisis in geriatric 

mental health: Research agenda for the next 2 decades. Archives of General Psychiatry. 1999; 56(9):848-

853.2. 

22 

 
conditions,71 decrease life expectancy,72 and increase overall healthcare costs.73 

Distinctive barriers to the treatment of mental and behavioral health disorders among the 

older adult population exist, such as discrimination, under-diagnosis, and inappropriate 

treatment.

The good news is that prevention, brief intervention, self-directed treatment, and recovery 

from mental and behavioral health disorders are possible for individuals of all ages, 

including older adults. While the 2006 reauthorization of the OAA included new 

provisions focused on the prevention and treatment of mental health disorders, these is no 

funding in the OAA specifically designated for prevention, intervention, and treatment 

services. States and communities have had to be creative in how they support these 

programs and services. Many aging network providers are working closely with 

behavioral health, primary care, and other partners to connect older adults with existing 

mental and behavioral health resources. In addition, some providers are delivering 

evidence-based community interventions, such as the Program to Encourage Rewarding 

Lives for Seniors (PEARLS), using a braided funding approach (i.e., use a combination 

of funds, such as those from the OAA – Title III-D, Substance Abuse and Mental Health 

Administration block grants, private foundations, etc.). 

Beginning in June 2010, and continuing through FY 2013, AoA and the Substance Abuse 

and Mental Health Services Administration (SAMHSA) formally partnered to provide 

technical assistance aimed at increasing states’ capacities for reaching older adults who 

are at-risk for behavioral health disorders. This partnership supported the development of 

a variety of tangible materials, such as epidemiological profiles, issue briefs, webinars, 

and a series of five older adult policy academy regional meetings (attended by 43 states, 

DC, PR, and the VI). The materials developed through this partnership have been 

successful in helping many states enhance their efforts to reach older adults who are atrisk for behavioral health disorders. 

In June 2014, ACL partnered with CMS and VHA to issue a Funding Opportunity 

Announcement to help states plan for a No Wrong Door System for All Payers and All 

Populations. These No Wrong Door planning grants sets the stage for improved access, 

more effective and efficient systems and better outcomes for people who need long-term 

care services and supports. The vision for the NWD System governing body is to 

coordinate the on-going development, implementation, financing, evaluation and 

continual improvement of the state's NWD System. For successful state grantees, the 

planning process must involve meaningful input from key stakeholders, including state 

authorities administering mental health services. 

71 U.S. Department of Health and Human Services, Mental Health: A Report of the Surgeon General 

(Rockville, MD: 1999).

72 Husaini, B,A, et. Al (2000). Prevalence and cost of treating mental disorders among elderly recipients of 

Medicare services. Psychiatric Services, 51, 1245-1247. 73 Katon,W., Ciechanowski, P. (2002). Impact of major depression on chronic medical illness. Journal of 

Psychosomatic Research, 53, 859-863.

23 

 
Caregiver Services

Families are the nation’s primary providers of long-term care, but a number of factors 

including financial constraints, work and family demands, and the many challenges of

providing care place great pressure on family caregivers. Caregiving responsibilities 

demand time and money from families who often are strapped for both. AoA’s caregiver 

programs provide services that address the needs of unpaid, informal caregivers, allowing 

many of them to continue to work while providing critically needed care. 

Better support for informal caregivers is critical because often it is their availability - 

whether they are informal family caregivers or unrelated friends and neighbors who 

volunteer their time - that determines whether an older person can remain in his or her 

home. In 2009, approximately 43.5 million adult caregivers provided uncompensated 

care to those 50 years of age and older.74 In other words, approximately 19 percent of all 

adults provided care to someone age 50 years and older.75 AARP estimated the 

economic cost of replacing unpaid caregiving in 2009 to be about $450 billion, an 

increase from $375 billion in 2007 (cost if that care had to be replaced with paid 

services).76 A more recent study by the Rand Corporation estimated the economic cost of 

replacing unpaid caregiving in to be about $522 billion annually.77 The cost to replace 

that care with unskilled paid care at minimum wage was estimated at $221 billion, while 

replacing it with skilled nursing care could cost $642 billion, annually.

The demands of caregiving can be considerable. Recent research has demonstrated that 

caregiving tasks can, and do, go well beyond providing regular assistance with activities 

of daily living (ADLs) and instrumental activities of daily living (IADLs). A 2012 study 

by AARP and United Hospital Fund revealed that, while family caregivers continue to 

perform the traditional ADL/IADL supports, their roles are expanding dramatically to 

include performing medical/nursing tasks of the type and complexity typically seen only 

in hospitals and other acute care settings.78 

Such demands on family caregivers can lead to a breakdown of their health, and the 

illness, hospitalization, or even death and can increase the risk for institutionalization of 

the care recipient. Caregivers suffer from higher rates of depression than non-caregivers 

of the same age, and research indicates that caregivers suffer a mortality rate that is 63 

74 Caregiving in the U.S.: A Focused Look at Those Caring for Someone Age 50 or Older. National 

Alliance for Caregiving. November 2009.

http://www.caregiving.org/pdf/research/FINALRegularExSum50plus.pdf 75 Ibid. 76 Valuing the Invaluable: 2011 Update, The Growing Contributions and Costs of Family Caregiving. 

AARP Public Policy Institute. July 2011. http://assets.aarp.org/rgcenter/ppi/ltc/i51-caregiving.pdf 77 The Opportunity Costs of Informal Elder-Care in the United States. The Rand Corporation. 2014. 

http://www.rand.org/pubs/external_publications/EP66196.html. 78 Home Alone: Family Caregivers Providing Complex Chronic Care. AARP and United Hospital Fund. 

October 2012. http://www.aarp.org/content/dam/aarp/research/public_policy_institute/health/homealone-family-caregivers-providing-complex-chronic-care-rev-AARP-ppi-health.pdf 

24 

 
percent higher than non-caregivers.79 Providing support that makes caregiving easier for

family caregivers, such as information, counseling and training, respite care, or 

supplemental services, is critical to sustaining caregivers’ ability to continue in that role. 

Seventy-seven percent of the caregivers served by OAA programs report that these 

services allow them to provide care longer than they otherwise could.80 

At the same time, AoA recognizes that it must also address the growing need for more 

caregivers every day. By 2020, it is projected that there will be 17.8 million noninstitutionalized seniors age 65 and over with one or more ADL limitations, an increase 

of 3.7 million seniors (or a 26 percent increase between 2013 and 2020) needing 

caregiver assistance.81 

National Family Caregiver Support Program

(Title III-E of OAA; FY 2013: $145,586,000) 

The National Family Caregiver Support Program (NFCSP) provides grants to states and 

territories, based on their share of the population age 70 and over, to fund a range of 

supports that assist family and informal caregivers to care for their loved ones at home 

for as long as possible. The NFCSP includes five basic system components: information; 

access assistance; counseling and training; respite care; and supplemental services. These 

services work in conjunction with other OAA services - including transportation services, 

homemaker services, home-delivered meals, and adult day care - to provide a coordinated 

set of supports for seniors which caregivers can access on their behalf. 

The NFCSP provides a variety of supports to family and informal caregivers. In FY 

2013, services provided included:82 

• Access Assistance Services, which provided over 1.15 million contacts to 

caregivers assisting them in locating services from a variety of public and private 

agencies.

79 Schulz R, Beach SR. Caregiving as a risk factor for mortality. The Caregiver Health Effects study. 

JAMA December 15, 1999; 282:2215-9. 80 2013 National Survey of Older Americans Act Participants. http://www.agid.acl.gov 81 U.S. Census Bureau, Population Division, 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, 2013. Released June 2014, accessed 27 August 2014; 

U.S. Census Bureau, “2014 National Population Projections,” Table 1. Projected Population by Single 

Year of Age, Sex, Race, and Hispanic Origin for the United States: 2014 to 2060. Released December 

2014, http://www.census.gov/population/projections/data/national/2014/downloadablefiles.html. 

Accessed 08 January 2015; and 

Centers for Medicare & Medicaid Services, The characteristics and perceptions of the Medicare 

population. Data from the 2012 Medicare Current Beneficiary Survey. [Table 2.5a Perceived Health and 

Functioning of Non-institutionalized Medicare Beneficiaries, by Living Arrangement and Age, 2012]. 

http://www.cms.gov/Research-Statistics-Data-and-Systems/Research/MCBS/Data-TablesItems/2012CNP.html. Accessed 23 October, 2014. 82 AoA’s FY 2013 State Program Report l. 

25 

 
• Counseling and Training Services, which provided nearly 125,948 caregivers 

with counseling, peer support groups, and training to help them better cope with 

the stresses of caregiving. 

• Respite Care Service, which provided over 63,000 caregivers with 5.9 million 

hours of temporary relief - at home, or in an adult day care or nursing home 

setting - from their caregiving responsibilities. This number represents only 0.15 

percent of the estimated 43.5 million caregivers83 who provide uncompensated 

care for older Americans.

Family and other informal caregivers are the backbone of America’s long-term care 

system. On a daily basis, these individuals, the majority of whom are women, assist 

relatives and other loved ones with tasks ranging from personal care and homemaking to 

more complex health-related interventions like medication administration and wound 

care. Data from AoA’s 2014 National Survey of OAA Participants show that, 20 percent 

of caregivers are assisting two or more individuals. Seventy percent of Title III 

caregivers are 60 or older, making them more vulnerable to a decline in their own health, 

and 28 percent describe their own health as fair to poor.84 The demands of caregiving can 

lead to a breakdown of the caregiver’s health. Nationally, approximately 11 percent of 

caregivers report that caregiving has caused their physical health to decline.85 Caregivers 

often experience conflicts between work and caregiving. Among working caregivers 

caring for a family member or friend, 69 percent report having to rearrange their work 

schedule, decrease their hours or take an unpaid leave in order to meet their caregiving 

responsibilities.86

Survey results for caregivers served by the NFCSP indicate that the types of supports 

provided through the NFCSP can enable them to provide care longer (77 percent) while 

often continuing to work,87 thereby avoiding or delaying the need for institutional care 

for their loved ones. Additionally, another study indicates that counseling and support 

for caregivers of individuals with Alzheimer’s disease can permit the care recipient to 

stay at home at significantly less cost, on average, for an additional year before being 

admitted to a nursing home.88

83 Valuing the Invaluable: 2011 Update, The Growing Contributions and Costs of Family Caregiving. 

AARP Public Policy Institute. July 2011. http://assets.aarp.org/rgcenter/ppi/ltc/i51-caregiving.pdf 84 2014 National Survey of Older Americans Act Participants. http://www.agid.acl.gov. 85 Center on Aging Society. (2005) How Do Family Caregivers Fare? A Closer Look at Their 

Experiences. (Data Profile, Number 3). Washington, DC: Georgetown University. 86 Valuing the Invaluable: 2011 Update: The Economic Value of Family Caregiving. AARP Public Policy 

Institute. 87 2014 National Survey of Older Americans Act participants. 88 Mittelman, M., Ferris, S., Shulman, E., Steinberg, G., Levin, B. (1996). A family intervention to delay 

nursing home placement of patients with Alzheimer's disease - A randomized controlled trial. The 

Journal of the American Association, 276(21), 1725-1731.

26 

 
Additionally, data from AoA’s national surveys of caregivers of elderly clients also 

reveal that OAA services, including those provided through the NFCSP, are effective in 

helping caregivers keep their loved ones at home. Approximately 77 percent of 

caregivers of program clients reported in 2013 that services enabled them to provide care 

longer than otherwise would have been possible.89 Caregivers receiving services were 

also asked whether the care recipient would have been able to live in the same residence 

if the services had not been available. Over 40 percent of the caregivers indicated that the 

care recipient would be unable to remain at home without the support services. Those 

respondents were then asked to identify where the care recipient would be living without 

services. A significant majority of those caregivers, 77 percent, indicated that the care 

recipient would most likely be living in a nursing home or assisted living (see the chart 

below). 

(Based on responses from care recipients unable to live independently)

89 Ibid.

27 

 
Lifespan Respite Care

(FY 2013: $2,351,000) 

Family caregiving for persons with disabilities occurs across the age spectrum from birth 

to death, with caregivers often being called upon to provide care to individuals of varying 

ages and disabilities. Most do so willingly, and often for many years. AARP estimated 

in 2009 that 65.7 million people served as unpaid family caregivers to an adult or child 

with special needs. For many of these caregivers, providing care can take a toll: a 

majority of caregivers (51 percent) caring for someone over age 18 have medium or high 

levels of burden and 31 percent of all family caregivers indicated they experienced high 

levels of stress.90

Numerous studies have shown respite to be among the most frequently requested 

supportive service for family caregivers.91 92 Respite is second only to direct financial 

assistance as a key policy priority of surveyed family caregivers. Even though respite 

services are often the preferred mode of family caregiver support, they are often under 

used, difficult to find and access, and are often unaffordable or in short supply. A 2009 

survey found that “finding time for myself” was reported by 32 percent of family 

caregivers along with managing both physical and emotional stress (34 percent) and 

balancing work and family responsibilities (27 percent). Despite these compelling 

numbers, nearly 90 percent of family caregivers receive no respite at all.93 

The barriers to accessing and using respite services are often significant for specific 

populations such as family caregivers of individuals with Multiple Sclerosis, persons with 

intellectual and developmental disabilities, and for caregivers of veterans and individuals 

with Alzheimer’s disease, spinal cord injuries, autism, and serious emotional disorders.94

95 The population-specific barriers reported by caregivers include provider shortages and 

inadequate training, mistrust of formal service delivery systems, hesitancy to ask for help 

and lack of awareness of available programs and supports. 

The Lifespan Respite Care program, authorized under the Lifespan Respite Care Act of 

2006, focuses on easing the burdens of caregiving by providing grants to eligible state 

organizations to improve the quality of, and access to, respite care for family caregivers 

of children or adults of any age with special needs while promoting the statewide 

dissemination and coordination of community-based respite care services. Unlike the 

NFCSP, which focuses on broad caregiver support via a number of services, Lifespan 

Respite Care Programs focus on providing a mechanism for coordinating needed 

90 National Alliance for Caregiving and AARP. Caregiving in the U.S.: A Focused Look at Those Caring 

for the 50+. 2009. http://www.aarp.org/research/surveys/care/ltc/hc/articles/caregiving_09.html 91 The Arc. (2011). Still in the Shadows with Their Future Uncertain: A Report on Family and Individual 

Needs for Disability Supports (FINDS 2011). Wash, DC: Author

92 National Family Caregivers Association. (2011). Allsup Family Caregiver Survey. Kensington, MD.

93 National Alliance for Caregiving and AARP, 2009.

94 National Alliance for Caregiving. (2012). Multiple Sclerosis Caregivers. Washington, DC: Author.

95 The Arc, 2011.

28 

 
infrastructure changes at state and local levels, and on filling gaps by putting in place 

coordinated systems of accessible, community-based respite care services for family 

caregivers of children and adults with special needs. 

The systems funded through the Lifespan Respite Care Program seek to better coordinate 

respite care services for family caregivers; support the training and recruitment of respite 

care workers and volunteers; and improve the provision of information, outreach, and 

access assistance to better enable family members to understand and avail themselves of 

available respite services. More importantly, Lifespan Respite Programs seek to identify 

and fill gaps in services. Within this context, Lifespan Respite Care Program grantees 

have focused their efforts in a number of broad areas, including: 

• Conducting needs assessments/environmental scans to determine the respite 

funding streams available, existing programs, populations served and gaps in each 

area;

• Broadening stakeholder collaborations to ensure representation of all age and 

disability groups, as well as the broadest possible cross section of the provider 

network; 

• Integrating lifespan respite principles and practice into statewide activities designed 

to improve systems and services for family caregivers of individuals of all ages 

with disabilities;

• Engaging respite consumers to inform project activities; 

• Capacity building and network development at the local level to recruit and train 

volunteers to fill gaps in respite services, particularly in rural areas through 

partnerships with universities, community-based organizations and communities of 

faith; and

• Developing and delivering gap-filling and emergency respite services via a range of 

participant-directed methods, voucher programs and other modalities designed to 

maximize choice and control.

The Lifespan Respite Care Program also supports Technical Assistance Resource Center 

(TARC) activities as authorized by statute. To date, the Lifespan Respite TARC has 

greatly expanded and enhanced a national database on lifespan respite care; provided 

extensive training, technical assistance and other print and electronic resources to 

grantees and state, community, and nonprofit respite care programs; and conducted 

public information, referral, and education programs on respite care. 

Respite care services are highly valued by caregivers. By providing opportunities for 

family caregivers to receive this much needed short-term relief, the Lifespan Respite 

Care program helps to sustain family caregiver health and well-being, reduces the 

29 
likelihood of abuse and neglect, and allows care recipients to remain in their own homes 

for as long as possible. 

Since 2009, AoA has held competitive grant competitions each year to make Lifespan 

Respite Program funds available to states interested in enhancing or building statewide 

programs. To date, thirty-one states and the District of Columbia have received grants of 

up to $200,000 each for three year projects. These projects have enabled the grantees to 

establish or enhance state infrastructures necessary to more effectively address the respite 

and related needs of family caregivers across the lifespan.

Competitive expansion supplements were awarded to a total of ten states (eight in FY 

2011 and two in FY 2012) to focus specifically on providing respite services to meet 

demand, fill identified service gaps, and assess the impact of respite services on 

consumers. Finally, in FY 2012 and FY 2013, a total of 15 states received Integration and 

Sustainability Grants, thus enabling them to continue their work by focusing grant 

activities on service provision, respite care workforce development and training, 

performance measurement, and further program integration efforts. Examples of grantee 

accomplishments include: 

• Development or enhancement of training programs for respite care providers and 

volunteers to expand the cadre of trained respite professionals; 

• Replication and expansion of respite care delivery models with a particular focus 

on person centered planning and consumer direction; 

• Expansion of toll-free “helplines” to provide caregivers with information about 

available respite care programs.

• The development and adoption of statewide respite care strategic plans and/or 

policies to guide future development of respite and other caregiver support 

services statewide;

• Development and deployment of marketing and awareness campaigns designed to 

educate caregivers about the importance of their work and the necessity to take a 

break;

• Development and launch of dedicated web sites to facilitate access to information 

about, and referral to, respite care services;

• The creation and/or expansion of participant-directed respite service options, 

including voucher programs; 

30 
• Mini-grant programs to promote the development of unique community-based 

respite care options; 

• The development of respite care programs and services within communities of 

faith;

• The development of data collection methodologies to track service provision and 

outcomes development; and 

• The delivery of respite services to nearly 2000 previously unserved family 

caregivers.

Competitive grants for Lifespan Respite Care funds are awarded to eligible state 

organizations with a 25 percent matching requirement. Eligible state agencies include any 

of the following: the state agency that administers OAA programs; the state’s Medicaid 

program; or any other state-level agency designated by the governor. Additionally, the 

eligible state agency must work in collaboration with Aging and Disability Resource 

Centers and a public or private non-profit statewide respite care coalition or organization. 

Priority consideration is given to applicants demonstrating the greatest likelihood of 

implementing or enhancing lifespan respite care statewide and are building or improving 

the capacity of their long-term care systems to respond to the comprehensive needs of 

care recipients.

Alzheimer’s Disease Supportive Services Program

(FY 2013: $3,785,653) 

Established under Section 398 of the Public Health Services Act, as amended, (42 U.S.C. 

280c-3), the Alzheimer’s Disease Supportive Services Program (ADSSP) funds 

competitive grants to states to expand the availability of evidence-based diagnostic and 

support services for persons with the disease, their families, and their caregivers, as well 

as to improve the responsiveness of home and community-based services systems to 

persons with dementia. The primary components of the ADSSP program include 

delivering evidence-based supportive services; translating and replicating evidencebased interventions for persons with dementia and their caregivers at the community 

level; incorporating evidence-based research in the formulation of innovative projects; 

and advancing changes to a state’s overall system of home and community-based care. 

ADSSP expands the aging services network’s capacity to assist those with dementia and 

their families by providing individualized and public information, education, and referrals 

about diagnostic, treatment and related services; as well as sources of assistance for 

services and legal rights assistance for people affected by dementia throughout a state’s 

long term services and support system. 

31 
The most recent grant projects are designed to ensure that states provide people with 

dementia and their family caregivers with access to a sustainable home and communitybased services (HCBS) system that is dementia capable. Such a system meets the unique 

needs of each person with dementia by: 1) identifying those with a possible dementia and 

recommending follow up with a physician; 2) ensuring that the staff they encounter have 

appropriate training, understand the unique needs/services available and knowing how to 

communicate with them; and 3) providing quality, person-centered services that help 

them remain independent and safe in their communities. In 2013, Arizona, California, 

Illinois, Maine and Oregon received three-year dementia capability project awards. 

Through projects funded in prior years, seventeen states continue to translate and 

implement eight dementia specific evidence-based interventions into practice. One 

example of these promising evidence-based interventions is the New York University 

caregiver intervention, a spousal caregiver support program that, in a randomized-control 

trial, delayed institutionalization of persons with dementia by an average of 557 days.96 

In 2012, the average nursing home cost was $222 daily for a semi-private room and $248 

daily for a private room ($81,030 and $90,520 annually), which would mean an average 

savings of between $124,000 and $138,000 in institutional costs per person with 

dementia.97 California, Florida, Georgia, Minnesota, and Utah are currently translating 

this intervention. Preliminary results indicate findings similar to those from the original 

study. 

Overall, these demonstrations offer direct services and other supports to thousands of 

families, as well as supporting the continuous quality improvement and evaluation of 

long- term services and supports. Family caregivers remain the major source of support 

for most people with Alzheimer’s disease. The nature of the disease - a slow loss of 

cognitive and functional/physical independence - means that most people with 

Alzheimer’s disease are cared for in the community for years. They may access a variety 

of services from many different systems including the aging, medical, and mental health 

service systems. As the number of people with Alzheimer’s disease grows, it is 

increasingly important that service delivery and health care systems are responsive to 

persons with dementia and are effectively coordinated. It is also important to ensure the 

availability of dementia capable community-based long term services and supports. 

96 Mittleman M, et al. (1996). “A Family Intervention to Delay Nursing Home Placement of Patients with 

Alzheimer’s Disease: a randomized, controlled trial,” Journal of the American Medical Association, 276; 

1725-1731. 97 Metlife. (November 2012), “MetLife Market Survey of Nursing Home, Assisted Living, Adult Day 

Services, and Home Care Costs”,p.4, Accessed 5 June, 2013 from: 

https://www.metlife.com/assets/cao/mmi/publications/studies/2012/studies/mmi-2012-market-survey-longterm-care-costs.pdf. 

32 

 
PART II: OLDER AMERICAN INDIANS, ALASKA 

NATIVES & NATIVE HAWAIIANS

Nutrition and Supportive Services

(FY 2013: $27,601,000) 

Native American Nutrition and Supportive Services provides grants to eligible tribal 

organizations for the delivery of nutrition and home and community-based supportive 

services to Native American, Alaskan Native, and Native Hawaiian elders. An estimated 

591,000 persons age 60 and over identify themselves as Native American or Alaska 

Native alone or in combination with another racial group.98 Over 291,000 of those elders 

identify as Native American or Alaskan Native with no other racial group99. 

In the United States, the number of adults aged 65 years or older increased by 14.8% (5.2 

million) between 2000 and 2010. This growth of the overall older adult population is also 

evident in Indian Country. Between 2000 and 2010, the number of older American 

Indian and Alaska Native (AI/AN) adults increased by 40.5%, a growth that is 2.7 times 

greater than that of the overall population of older adults over the same 10-year period.100

In addition, this rapidly growing population is also experiencing some of the highest rates 

of disability,101 chronic disease, and poverty102 in the United States. Because of the 

combined factors of an aging population and high disability rates, AI/ANs have a great 

need for LTSS access in their communities.

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, personal care, help with chores, and

other supportive services. Currently, AoA’s congregate meal program reaches nearly onequarter of eligible Native American seniors in participating tribal organizations, homedelivered meals reach 12 percent of such persons, and supportive services reach 

41 percent of such persons.103 These programs, which can help to reduce the need for 

98 U.S. Census Bureau, 2012 American Community Survey. S0201: Selected Population Profile In The 

United States. http://factfinder.census.gov. Accessed 12 January 2015. And 2010 Census Summary File 

2. DP-1-Geography-United States POPGROUP-American Indian and Alaska Native alone or in 

combination with one or more other races (300, A01-Z99) & (100-299) or (300, A01-Z99) or (400-

999): Profile of General Population and Housing Characteristics: 2010. Accessed 26 August 2013. 99 Administration for Community Living, http://www.agid.acl.gov/DataGlance/. Data-at-a-Glance: 

American Community Survey (ACS) Public Use Microdata Sample (PUMS) 1-Year Files (2012), 

accessed January, 08, 2015. 100 Administration on Aging, U.S. Population by Age: 65+ Minority Population Comparison using Census 

2000 and Census 2010 (July 1, 2011). 101 National Council on Disability, “Understanding Disabilities in American Indian and Alaska Native 

Communities: Toolkit Guide” (2003). 102 Centers for Disease Control and Prevention, “CDC Health Disparities and Inequalities Report – United 

States” (2013). 103 Title VI of the Older Americans Act permits tribes to establish age of eligibility for services below age 

60. Calculation based on eligible population as reported in grantee applications. 

33 

 
costly nursing home care and medical interventions, are responsive to the cultural 

diversity of Native American communities and are an important part of each 

community’s comprehensive services. 

Services provided by this program in FY 2013 include:104 

• Transportation Services, which provided over 661,435 rides to meal sites, 

medical appointments, pharmacies, grocery stores, and other critical activities.

• Home-Delivered Nutrition Services, under which nearly 2.6 million meals were 

provided to over 25,000 homebound Native American elders; the program also 

provides critical social contacts that help to reduce the risk of depression and 

isolation experienced by many home-bound Native American elders.

• Congregate Nutrition Services, which provided 2.4 million meals to over 

52,00 Native American elders in community-based settings, as well as an 

opportunity for elders to socialize and participate in a variety of activities, 

including cultural and wellness programs. 

• Information, Referral and Outreach Services, which provided over 920,000 hours 

of outreach and information on services and programs to Native American elders 

and their families, thereby, empowering them to make informed choices about 

their service and care needs.

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, e-newsletters, telephone and written consultations, and through the 

Native American Resource Centers (funded under Aging Network Support Activities).

Eligible tribal organizations receive nutrition and supportive services formula grants 

based on their share of the American Indian, Alaskan Native, and Native Hawaiian 

population age 60 and over. Tribal organizations must represent at least 50 Native 

American elders age 60 and over to receive funding. There is no requirement for 

matching funds. In addition, tribes may decide the age at which a member is considered 

an elder and thus eligible for services. 

Caregiver Support Services

(FY 2013: $6,031,000) 

Native American Caregiver Support Services provide grants to eligible tribal 

organizations to provide support for family and informal caregivers of Native American, 

104 Title VI FY 2013 data. 

34 

 
Alaskan Native and Native Hawaiian elders. This program, which helps to reduce the 

need for costly nursing home care and medical interventions, is responsive to the cultural 

diversity of Native American communities and represents an important part of each 

community’s comprehensive services. 

Native American Caregiver Support Services funding is allocated to eligible tribal 

organizations based on their share of the American Indian, Alaskan Native, and Native 

Hawaiian population aged 60 and over. Tribal organizations must represent at least 

50 Native American elders age 60 and over and be receiving a grant under Title VI Part 

A or B to receive funding. There is no requirement for matching funds. Tribes may also 

decide the age at which a member is considered an elder and thus eligible for services. In 

addition, there is no limit on the percentage of funds that can be used for services to 

grandparents caring for grandchildren. 

Grants assist American Indian, Alaskan Native and Native Hawaiian families caring for 

older relatives with chronic illness or disability and grandparents caring for 

grandchildren. The program provides a variety of direct services that meet a range of 

caregiver needs, including information and outreach, access assistance, individual 

counseling, support groups and training, respite care, and other supplemental services. In 

FY 2013 Tribal grantees provided over 95,000 hours of respite care, over 17,000 hours of 

caregiver training, and assisted 21,000 caregivers to access needed services.

105 Tribal 

organizations coordinate with other programs, including the Volunteers In Service To 

America (VISTA) program, to help support and create sustainable caregiver programs in 

Native American communities (many of which are geographically isolated). A core value 

of the Native American Caregiver Support Services, as expressed by tribal leaders, is that 

the program should not replace the tradition of families caring for their elders. Rather, it 

provides support that strengthens the family caregiver role. 

105 Ibid.

35 

 
PART III: PROTECTION OF VULNERABLE OLDER 

ADULTS 

Protection of Vulnerable Americans consists of several distinct but complementary 

programs designed to prevent, detect, and respond to elder abuse, neglect, and 

exploitation. As the population of older Americans increases, the problem of elder abuse, 

neglect, and exploitation continues to grow. While there is no single set of national elder 

abuse prevalence data, the number of reported cases of elder abuse, neglect, and 

exploitation are on the rise. A 2004 national survey of State Adult Protective Services

(APS) programs conducted by AoA’s National Center on Elder Abuse showed a 

16 percent increase in the number of elder abuse cases from an identical study conducted 

in 2000.106 According to a 1998 national incidence study (the only such study ever 

conducted), 84 percent of all elder abuse incidents go unreported, meaning that for every 

reported case of abuse there are over five that go unreported.107 Together, these data 

suggest that a minimum of 5 million elders are abused, neglected, and/or exploited 

annually. 

The negative effects of abuse, neglect, and exploitation on the health and independence 

of seniors is extensive. Research has demonstrated that older victims of even modest 

forms of abuse have dramatically higher (300 percent) morbidity and mortality rates than 

non-abused older people.108 Additional adverse health impacts include an increased 

likelihood of heart attacks, dementia, depression, chronic diseases and psychological 

distress. The result of these unnecessary health problems is a growing number of seniors 

who access the healthcare system more frequently (including emergency room visits and 

hospital admissions), and are ultimately forced to leave their homes and communities 

prematurely.109 Protection of Vulnerable Adults programs address this problem through a 

full array of services designed to prevent, detect, and respond to elder abuse, neglect, and 

exploitation, both at home and in institutional settings. 

106 Teaster, Pamela, et al. The 2004 Survey of State Adult Protective Services: Abuse of Adults 60 Years of 

Age and Older. http://www.ncea.aoa.gov/NCEAroot/Main_Site/pdf/2-14-

06%20FINAL%2060+REPORT.pdf 107 Tatara, Toshio, et al. The National Elder Abuse Incidence Study Final Report. 1998. 

http://www.aoa.gov/AoARoot/AoA_Programs/Elder_Rights/Elder_Abuse/docs/ABuseReport_Full.pdf 108 Lachs, M.S., Williams, C.S., O'Brien, S., Pillemer, K.A., & Charlson, M.E. (1998). “The Mortality of 

Elder Mistreatment.” JAMA. 280: 428-432. and Baker, M.W. (2007). “Elder Mistreatment: Risk, 

Vulnerability, and Early Mortality.” Journal of the American Psychiatric Nurses Association, Vol. 12, 

No. 6, 313-321. 

109 Lachs M. S., Williams C., O'Brien S., Hurst L., Kossack A., Siegal A., et al. (1997). “ED use by older 

victims of family violence.” Annals of Emergency Medicine. 30:448-454.

36 

 
Prevention of Elder Abuse and Neglect

(FY 2013: $4,773,000) 

The Prevention of Elder Abuse and Neglect program (Title VII, Section 721) provides 

state formula grants for training and education, promoting public awareness of elder 

abuse, and supports state and local elder abuse prevention coalitions and multidisciplinary teams. These activities are important elements of AoA’s enhanced focus in 

FY 2013 on 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 and local level is demonstrated by 

the fact that states significantly leverage OAA funds to obtain other funding for these 

activities, including Social Services Block Grant and state general funds. Annually, more 

than $28 million of expenditures for elder abuse prevention services come from nonOAA funds, a ratio of nearly $7 of non-OAA funds for every $1 investment of federal

funds. 

Examples of State elder abuse prevention activities include: 

• In Kentucky, the statewide network of Local Coordinating Councils on Elder 

Abuse has developed ―visor cards for law enforcement officers, which contain 

contact information and resource information to assist victims of elder abuse. 

Kentucky also produced Fraud Fighter forms that were distributed to thousands of 

seniors to help in the prevention of exploitation and scam artists. Other public 

awareness activities included renting billboards with elder abuse awareness 

messages and the state reporting number, hosting community trainings on the 

various forms of elder abuse, as well as other events and items to raise awareness 

in communities.

• Lifespan, out of Rochester, New York, used OAA funding to support training of 

non-traditional reporters, such as hairdressers, store clerks, and others who have 

frequent contact with the elderly, on what to look for and how to report suspected 

cases of elder abuse. Additionally, a series of television ads was developed and 

aired, which has resulted in an increased awareness of the problem of elder abuse.

• The Wisconsin Bureau of Aging and Disability Resources developed, in 

collaboration with the National Clearinghouse on Later Life, information 

designed to raise awareness of caregivers who have experienced abuse in the 

family, as well as of the risks and signs of abuse in later life. The information is 

available at: http://dhfs.wisconsin.gov/aps/Publications/publications.htm. 

The Prevention of Elder Abuse and Neglect program demonstrates AoA’s ongoing 

commitment to protecting the rights of vulnerable seniors and promoting their dignity and 

autonomy. Through education efforts, exposing problems that would otherwise be hidden 

37 
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. 

National Center on Elder Abuse

To support and enhance the activities of state and local programs to prevent Elder Abuse, 

Neglect, and Exploitation, AoA funds the National Center on Elder Abuse (NCEA). NCEA 

disseminates information to professionals and the public and provides technical assistance 

and training to States and community-based organizations. The NCEA makes available news 

and resources; collaborates on research; provides consultation, education, and training; 

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 development. NCEA also facilitates the exchange of strategies 

for uncovering and prosecuting fraud in areas such as telemarketing and sweepstakes scams. 

In FY 2013, the NCEA:

• NCEA produced and distributed periodic e-newsletter on elder abuse. They released 

three editions to over 2700 e-news subscribers. 

• A podcast series on “Elder Abuse Risk Factors” was created by NCEA in partnership 

with National Adult Protective Services Association and National Committee for the 

Prevention of Elder Abuse, reaching . 

• Through NCEA email, voicemail, and Facebook, over 175 technical assistance 

requests were received and processed, averaging 29 per month.

• Redesigned the promising practices database to better gather best practices from the 

field. 

National Legal Assistance and Support Projects

National Legal Resource Center

(FY 2013: $798,461) 

National Legal Assistance and Support grants fund a comprehensive national legal 

assistance support system serving professionals and advocates working in legal and aging 

services networks. These grants collectively form the National Legal Resource Center 

(NLRC) which is designed to empower professionals in aging and legal networks with 

the tools and resources necessary to provide older clients and consumers with high 

quality legal assistance in areas of critical importance to their independence, health, and 

financial security. 

As a streamlined and accessible point of entry, the NLRC supports the leadership, 

knowledge, and systems capacity of legal and aging provider organizations in order to 

enhance the quality, cost effectiveness, and accessibility of legal assistance and elder 

38 
rights protections available to older persons with social or economic needs. The audience 

targeted to receive support services through the NLRC includes a broad range of legal, 

elder rights, and aging services professionals and advocates. These include legal 

assistance providers, legal assistance developers, long-term care ombudsmen, state unit 

on aging directors, AAA and ADRC personnel, senior legal helplines (SLHs), and others 

involved in protecting the rights of older persons. 

 

The NLRC provides core resource support through a strategic combination of case 

consultation, training, and technical assistance on a broad range of legal issues and 

systems development issues. Examples of common legal issues on which the NLRC 

provides assistance include preventing the loss of a senior’s home through foreclosure; 

protecting against consumer scams and creditor harassment; addressing elder abuse in the 

community and in long-term care facilities; and difficulties in accessing public benefits 

essential to financial security, independence, and health. The NLRC also provides 

technical assistance on the efficient, cost-effective, and targeted provision of state-wide 

legal and elder rights advocacy services.

In FY 2013, economic circumstances gave rise to a host of legal challenges for older 

consumers and the legal providers who serve them. In response to an increasing demand 

for legal resource support, the NLRC provided training and case consultation to over 

10,714 aging and legal service professionals nationwide. NLRC partners also provided 

important technical support in the implementation of the Model Approaches projects in 

31 states, featuring the provision of expertise in legal needs and capacity assessments, 

effective targeting and outreach methodologies, statewide reporting systems, and legal 

service delivery standards. With regard to technical support directed at SLHs, the NLRC 

provided assistance to 24 SLHs on various service deliver issues, including outreach, case 

management, data collection, and outcome measurement. 

An essential structural feature of the NLRC is that the combined efforts of several 

partnering organizations with high levels of subject matter expertise is required to 

achieve its broad resource support objectives. Through effective collaborations, 

interlocking work plans, and the leveraging of organizational resources, NLRC partners 

have demonstrated the ability to achieve effective national coverage on high priority legal 

issues areas. In FY 2013, over 97 percent of professionals responding to surveys rated the 

quality and usefulness of the support service provided by the NLRC as either good or 

excellent. 

In addition, the NLRC website continues to serve as a single entry point into a national 

legal assistance support system providing high quality resources and expertise on a broad 

range of legal and systems development issues: www.nlrc.gov. 

39 
Model Approaches to Statewide Legal Assistance Systems

(FY 2013: $1,966,323) 

The Model Approaches to Statewide Legal Assistance Systems (Model Approaches) 

demonstration grants represent an innovative departure from ACL’s past approach to the 

funding of Senior Legal Helplines (SLHs). Thirty-one states have been awarded Model 

Approaches grants, which seek to address the nationwide challenge of coordinating what 

are often fragmented and inconsistent legal service delivery systems that do not always 

provide access to quality services for older Americans who are most in need. Model 

Approaches helps states develop and implement cost-effective, replicable approaches for 

integrating SLHs and other essential low cost mechanisms into the broader spectrum of 

state legal service delivery networks. Ultimately, legal assistance provided through wellintegrated and cost-effective service delivery systems as demonstrated through Model 

Approaches directly impacts the ability of seniors to remain independent, healthy, and 

financially secure in their homes and communities.

Model Approaches features strong leadership at the state level to achieve its service 

delivery integration objectives. State legal assistance developers have demonstrated 

effective leadership in incorporating the use of SLHs and other low-cost mechanisms into 

the state legal services planning and development process. Key project partners and 

service delivery components also include Title III-B legal services providers, private bar 

pro-bono attorneys, law school clinics, and self-help sites. By promoting the seamless 

integration of these vital legal service delivery components, Model Approaches enables 

seniors most in need to access quality legal services in priority legal issue areas involving 

income security, healthcare financing, consumer fraud, housing and foreclosure 

prevention, and elder abuse. This approach is also designed to increase the leveraging of 

limited resources within statewide legal service delivery systems.

In addition, by ensuring strong leadership at the state level, Model Approaches projects 

have created important partnerships and linkages between the existing legal assistance 

community and the broader community-based aging and elder rights networks, including 

AAAs, ADRC, state long-term care ombudsmen, and Adult Protective Services. 

As a key centerpiece of the Model Approaches projects, SLHs assist seniors in accessing 

quality legal services to ensure their rights and enhance their independence and financial 

security. In 2013, Model Approaches projects assisted 29, 466 older consumers with the 

most social or economic needs on a wide range of priority legal issues related to public 

benefits, health care, housing, advance planning, and consumer protection. Some recent 

examples of the success of SLHs’ experience in assisting seniors include:

A 93 year-old woman with a very low income called a SLH seeking assistance with a 

termination notice. She had recently come home from a hospital admission and brief stay 

in a rehab facility convalescing from a fall. The hospital and her doctor cleared her to 

return home. She had prearranged a support system that included a visiting nurse, a 

housekeeper/shopper, and regular visits by her daughter and son. The SLH lawyer 

40 
helped the client write a letter of response to the Housing Manager asserting her rights 

under the Federal Fair Housing Act. The letter resulted in the rescission of the 

termination notice and allowed the client to stay in her residence.

A 71 year-old man and his wife were struggling to pay their adjustable rate mortgage on a 

fixed income. They applied for a mortgage modification through a lender designated by 

the federal government to offer loan modifications to qualified homeowners. Due to 

inaction on the part of the lender, interest and late fees continued to accrue on the loan 

balance. A SLH attorney called the lender reminding them of federal rules governing 

loan modifications and provided additional documentation. Two weeks later, the lender 

offered the senior a mortgage modification, which resulted in a 20% reduction in the 

monthly mortgage. 

A 64 year-old woman was granted a portion of her ex-husband’s pension in her divorce 

decree. She desperately needed the pension income to pay her monthly bills, but could 

not afford to hire an attorney to draft the necessary Qualified Domestic Relations Order 

(QDRO) that would allow her to receive the benefits. The HelpLine attorney drafted a 

QDRO pursuant to the rules and regulations of the ex-spouse’s pension plan, and the 

woman immediately began to receive monthly payments. 

An elderly woman with very limited English speaking ability, called the SLH after a 

wage execution was placed on her limited wages and she immediately began falling 

behind on her bills. The SLH attorney prepared a Modification of Wage Execution form 

asking that her payment obligation be reduced by half. The advocate then guided her on 

how to file the form, what to expect in court and what evidence she should be prepared to 

present, including a budget showing that she could not afford her very basic expenses 

without a reduction in the execution amount. The client attended court on her own and, 

armed with the advocate’s guidance, successfully persuaded the judge to reduce the 

amount of her wage execution by half. 

In addition to providing assistance on priority legal issues, SLHs under Model 

Approaches have been very successful in reaching low income populations with over 76 

percent of older clients having incomes at or below 200 percent of the federal poverty 

guidelines. Minority clients receiving assistance through SLHs in the last reporting 

period constituted 30 percent of all clients served. These figures illustrate the 

effectiveness of Model Approaches states in reaching key target populations under the 

OAA with much needed “priority” legal assistance.

An important purpose of the Model Approaches demonstrations is to position SLHs as 

coordinated and essential components of high quality and high impact legal service 

delivery systems that effectively target scarce resources to older persons most in need. 

Model Approaches partners across the country recognize the enormous value of the 

network relationships that have been forged in pursuit of essential project goals and 

objectives. Several Model Approaches states with completed grant award cycles (e.g. 

CT, FL, IA, KY, MD, MI, ND, NV, and PA) demonstrate that SLHs continue to serve 

41 
seniors as well-integrated and essential components of statewide senior legal services 

delivery systems, thus illustrating the sustainability of these projects beyond the 

demonstration period. 

In FY 2013, ACL awarded seven new Model Approaches Phase II grants to continue the 

evolution of legal service delivery systems implemented through previous Model 

Approaches projects towards higher levels of capacity, performance, and service delivery 

impact. Model Approaches Phase II projects are primarily focused on enhancing legal 

responses to complex issues that emerge from elder abuse, neglect, and financial 

exploitation. In addition, these new projects are expanding outreach to older adults in the 

greatest social or economic need and implementing legal data collection/reporting 

systems that demonstrate the beneficial impact of legal services on the independence, 

health, and financial security of older adults. 

Pension Counseling and Information Program

(FY 2013: $1,616,769) 

 

In 1992, Congress directed AoA to develop demonstration projects specifically designed

to help individuals with pension problems. These demonstrations were so successful that 

Congress established pension counseling as a permanent program under Title II of the 

OAA in 2000. 

 

Today, there are more than 700,000 private (as well as thousands of public) pension and 

retirement plans in the United States. Thousands of Americans reach retirement age each 

year, only to be told that they will not receive the pension benefits they expected. 

Because individuals have generally worked for several employers, which may have 

merged, sold their plans, or gone bankrupt, it is very difficult for most persons to know 

where to get help in finding out whether or not they are receiving all of the pension 

benefits to which they are entitled. 

 

Benefits from employer-sponsored pensions and retirement savings plans are as critical 

today to the retirement security of Americans as they were when the pension counseling 

program was first established. The pension questions which people face are just as 

complex, and good help is just as hard to find – even more so for those with only modest 

benefits at stake. The role of the Pension Counseling and Information Program is to help 

ensure that all older Americans have access to the help they need in order to secure the 

employer-sponsored retirement benefits they have earned --- benefits that are critical to 

their ability to live independently and with dignity after a lifetime of productive 

employment. The Pension Counseling and Information Program provides help that 

would be otherwise unavailable, by assisting individuals in understanding and exercising 

their pension rights. The program promotes the financial security of older individuals by 

offering them the help they need to receive the pension benefits they have earned. The 

income, in turn, provides increased opportunities for choice and independence. 

 

42 
AoA currently funds six regional counseling projects covering 29 states and a technical 

assistance resource center to assist older Americans in accessing information about their 

retirement benefits and to help them negotiate with former employers or pension plans 

for due compensation. The projects help with cases that private pension professionals are 

reluctant to take, where the benefits in question are small, as is often the case with lowincome workers and those with limited English proficiency, but to whom these modest 

amounts make a huge difference in maintaining their financial security and independence.

 

Data show that since the program’s inception in 1993, the Pension Counseling projects 

have recovered $190 million in retirement benefits for 50,000 retirees. With a relatively 

small federal investment, the program has brought in a return of more than $8.00 for 

every Federal dollar invested in the program. These recoveries demonstrate that pension 

counseling is not only necessary, but that it can be provided efficiently and effectively. 

The significance of the projects’ work is best illustrated through presentation of two 

typical cases resolved during this period: 

 

• A low-income senior contacted one of the regional counseling projects for 

assistance with locating a lost pension. He’d worked for a company from the late 

1980s through the early 1990s and remembered being told he may be entitled to a 

pension at retirement. The senior could not find any contact information for his 

former employer. The counseling project researched the issue, located the 

employer – which had since merged with another company – and guided the 

individual through the claims process. The senior was approved for a pension of 

approximately $150 per month for the duration of his life. Without the project’s 

assistance, it is likely that this low-income senior would not have received the 

benefit he had earned during his employment. 

• An elderly widow sought assistance from another of the regional counseling 

projects to determine whether she was entitled to any benefits as the surviving 

spouse of a participant in a construction trades pension plan. Though she knew 

what her late husband had done for a living, she was uninformed of the plan’s 

identity and of her rights. A project staff investigation located the correct plan 

and helped the senior apply for survivor benefits. Her claim was immediately 

approved, and she now receives a lifetime monthly survivor benefit of $342.25, 

with an estimated actuarial value of nearly $62,550.00, significantly impacting 

her economic security and quality of life. 

• A retiree had selected a pension payment option that would provide a certain 

amount until he started receiving Social Security, at which point the pension plan 

would begin reducing his benefits. Upon reaching 65, the retiree called the plan 

to notify them he had begun to receive his Social Security. However, the plan 

assured him that his pension benefit did not need to be reduced. The retiree 

believed this and made financial decisions based on the amount that the plan told 

him he was entitled to. Eleven years later the plan came back to the retiree and 

told him that his pension should have been reduced, and demanded that he pay 

43 
back $120,000 to make up for the overpayments that were the result of the plan’s 

mistake. Not surprisingly, he did not have $120,000. The retiree contacted a 

pension counseling project, which negotiated with the plan to obtain a waiver of 

this repayment on the grounds that it would cause the retiree a significant 

financial hardship. The plan ultimately forgave the entire overpayment thanks to 

the project’s efforts.

Even when Pension Counseling projects are unable to secure benefits for clients, the 

information and assistance the projects provide can bring peace of mind to vulnerable 

elderly individuals, often after months or even years of searching for answers. By 

producing fact sheets and other publications, hosting websites, and conducting outreach 

and education efforts, Pension Counseling projects also provide indirect services to tens 

of thousands of seniors and their families. 

 

A critical component of the program is the National Pension Assistance Resource Center 

(the Center) which provides support to the counseling projects and facilitates 

coordination among the projects, SUAs, AAAs, legal services providers, and others by 

providing substantive legal training, technical assistance, and programmatic consultation. 

The Center also assists individuals in states not currently served by AoA’s pension 

counseling projects by providing nationwide referral and information services, both by 

telephone and through the PensionHelp America website, a nationwide database of 

pension assistance and information resources: http://www.PensionHelp.org. 

Senior Medicare Patrol Program

(FY 2013: $8,875,274) 

The Senior Medicare Patrol (SMP) program serves a unique role in the HHS’ efforts to 

identify and prevent health care fraud in the Medicare. The mission of the SMP program 

is to empower and assist Medicare beneficiaries, their families, and caregivers to prevent, 

detect, and report healthcare fraud, errors, and abuse through outreach, counseling, and 

education. The SMP program provides competitive grants to entities in 54 states and 

territories to support a national network of volunteers whose purpose is to educate 

Medicare beneficiaries on preventing and identifying healthcare fraud and abuse. 

Activities are carried out in partnership with the Centers for Medicare & Medicaid 

Services (CMS), the Office of Inspector General (OIG), healthcare providers, and other 

aging and elder rights professionals from around the country. 

Annually, the OIG analyzes the Performance data housed in the SMARTFACTS data 

tracking system. This data is published as a report on the SMP program. This report for

Calendar Year 2013 110 shows that SMP projects: 

• Had 5,406 active volunteers who worked 105,235 hours to educate beneficiaries 

about how to prevent Medicare and Medicaid fraud; 

110 Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2013; p. 77. 

https://oig.hhs.gov/reports-and-publications/hcfac/index.asp . 

44 

 
• Educated 501,405 beneficiaries in 14,924 group education sessions and held 

148,235 one-on-one counseling sessions with or on behalf of beneficiaries; 

• Conducted 10,545 community outreach education events; and

• Resolved 114,387 requests for information or assistance from beneficiaries.

In addition, the report shows that since the program’s inception in 1997, SMP projects 

have:

• Educated nearly 4.5 million beneficiaries in approximately 124,000 group 

education sessions and held over 1.4 million -one-on-one counseling sessions; 

• Conducted nearly 184,000 community outreach education events; and 

• Documented over $121.3 million in savings, including Medicare and Medicaid 

funds recovered, beneficiary savings, and other savings directly attributable to the 

project as a result of beneficiary complaints. 

Health Care Fraud and Abuse Control (HCFAC)

(FY 2013: $10,865,469) 

The Administration for Community Living (ACL) has received Health Care Fraud and 

Abuse Control (HCFAC) funding since FY 1997, as authorized by the Health Insurance 

Portability and Accountability Act (HIPAA) of 1996 (P.L. 104-191), as a partner in the 

Department’s efforts to fight fraud, waste and abuse in the Medicare and Medicaid

programs. HCFAC funds provide Federal support (including infrastructure, technical 

assistance, program support and capacity building) to the Senior Medicare Patrol (SMP) 

program. 

HCFAC funds allow for 7.6 FTE at ACL to maintain effective oversight of and 

partnerships with each of the 54 SMP Projects. HCFAC funding also supports the SMP 

Resource Center (the Center), which provides training, technical assistance, support and 

information to SMP grantees. The Center has focused on: 

 

• information and strategies to increase awareness of current scams and fraud 

schemes, such as wheelchair and scooter fraud; 

• outreach strategies for educating minority and non-English speaking individuals, 

information and training, including fraud awareness information; 

• volunteer recruitment and training; 

• education to the traditionally hard to reach populations; and 

45 
• partnership strategies to involve health care providers, family caregivers, and 

health care professionals. 

HCFAC funding also supported additional grants which include a research grant that 

would quantify or measure the effect of prevention methods currently used in the SMP 

program and an Integration grant that would support the SMP program expand the reach 

of the current SMP program by supporting the development of outreach and education 

strategies aimed at integrating traditionally hard-to-reach populations, such as Medicare 

beneficiaries under age 65; Lesbian, Gay, Bisexual, and Transgender (LGBT) seniors; 

and American Indian/Alaska Native seniors. 

46 
Long-Term Care Ombudsman Program

(FY 2013: $15,869,941)111

The Long-Term Care Ombudsman Program serves individuals living in long-term care 

facilities (nursing homes, board and care, assisted living and similar settings); and works 

to resolve resident problems related to inadequate care, violation of rights, and quality of 

life. Ombudsmen also advocate at the local, state and national levels to promote policies 

and consumer protections to improve residents’ care and quality of life. 

Begun in 1972 as a demonstration program, the Ombudsman Program today exists in all 

states, the District of Columbia, Puerto Rico and Guam, under the authorization of the 

OAA. Each state has an Office of the State Long-Term Care Ombudsman (Office), 

headed by a full-time state long-term care ombudsman (state ombudsman) who directs 

the program statewide. Thousands of local ombudsman staff and volunteers, designated 

by the state ombudsman as representatives, assist residents and their families by resolving 

complaints and providing information related to long-term care services and supports. 

Long-term care ombudsmen are the local problem-solvers for individuals living in longterm care facilities and is an invaluable resource to residents, their families and facility 

staff. 

Section 712 of the Older Americans Act requires the state ombudsmen to: 

• Identify, investigate and resolve complaints made on behalf of residents;

• Provided information to residents about long-term care services;

• Ensure that residents have regular and timely access to ombudsman services;

• Represent the interests of residents before governmental agencies and seek 

administrative, legal and other remedies to protect residents; and

• Analyze, comment on, and recommend changes in laws and regulations pertaining 

to the health, safety, welfare and rights of residents.

The following provides data for FY 2013 from the Long-Term Care Ombudsman 

Program nationwide, based on state and local level activities, and are collected annually 

by AoA from state ombudsmen through the National Ombudsman Reporting System 

(NORS). 

Complaint Investigation and Resolution 

Long-term care ombudsmen provide an alternative dispute resolution service, resolving 

complaints for or on behalf of long-term care facility residents. 

 Ombudsmen nationwide completed resolution work on 190,592 complaints. 

111 This amount reflects Title VII-2 designated as Ombudsman Program Activity funds. States also utilize 

other Older Americans Act and other funding sources to operate the Ombudsman program in their states 

(see Figure 1, below).

47 

 
 Ombudsmen resolved or partially resolved 73 percent of these complaints to the 

satisfaction of the resident or complainant. 

 

 Of the 123,666 cases closed by ombudsmen,112 89,760 (73 percent) were 

associated with nursing facility settings. Of the remaining cases, 31,047 (25 

percent) were related to board and care and other similar facilities (including 

assisted living); and 2,859 (two percent) were associated with non-facility settings 

or services to facility residents by an outside provider. 

 Most cases were initiated by residents or friends and relatives of residents, with the 

residents themselves initiating 39 percent of cases in nursing facilities and 32 

percent in board and care and other similar facilities (including assisted living). 

 Ombudsmen proactively identified issues in nearly 13 percent of cases in all 

settings. 

 

The five most frequent nursing facility complaints were: 

• improper eviction or inadequate discharge/planning; 

• unanswered requests for assistance;

• lack of respect for residents, poor staff attitudes; 

• quality of life, specifically resident/roommate conflict 

• administration and organization of medications; 

The five most frequent board and care complaints were:

• quality, quantity, variation and choice of food; 

• administration and organization of medications; 

• inadequate or no discharge/eviction notice or planning; 

• lack of respect for residents, poor staff attitudes and 

building or equipment in disrepair or hazardous. 

Improper Eviction/Inadequate Discharge Planning – a troubling trend: 

Long-term care ombudsmen are often the primary responders to complaints about 

eviction or inadequate discharge/planning. This complaint has consistently been among 

the top ten complaint issues investigated and responded to by long-term care 

112 In FY 2013, ombudsmen opened 124,958 new cases (a case contains one or more complaints 

originating from the same person(s), and completed resolution work on 123,666 closed cases, containing 

190,592 complaints. 

48 

 
ombudsmen. It has been the number one nursing home complaint topic over the past 

three years, and the third most common complaint of board and care residents. 

State ombudsmen reported reasons for the growth in eviction complaints 

 Increased complexity of residents’ needs, especially with regards to supporting 

individuals with dementia or persons with other behavioral health needs, which 

require additional staff training to learn best approaches 

 Family and resident lack of understanding of Medicaid requirements which has 

made some nursing home residents ineligible and therefore lacking a payment 

source; or 

 Financial exploitation, where a responsible party chooses to not pay the bill. 

State ombudsmen reported several barriers to satisfactory resolution of eviction 

complaints the most common include: the involuntary discharge notice issued to the 

resident is often faulty, with substantive errors that interfere with the residents’ ability to 

understand and access available protections/appeal rights; a lack of available resources 

(including legal services) to assist residents and families to respond to and appeal the 

eviction; admission to the hospital and the facility then refuses to readmit in accordance 

with federal regulation and/or an administrative ruling. Eviction from what is often 

considered the resident’s home creates risk of displacement from their community, family 

and friends, a risk of homelessness and unnecessary and costly hospitalizations. 

Ombudsmen Advocacy Efforts - Evictions and Improper Discharge Planning 

 Response to Prolonged Hospitalizations: One state is initiating a “Let Me Return 

Home” campaign designed to address the systemic problem of residents’ being 

sent to the hospital from the nursing home and then not re-admitted once the 

medical issue has resolved. The state ombudsman collaborated with the 

department of health and provider organizations to develop a training program for 

hospital discharge planners. The materials developed provided a summary of 

federal regulations as well as advocacy tools and resources. The goal is to 

operationalize the important regulatory protections for residents through provider 

education. This project is now in its “roll-out” phase with local ombudsmen 

providing presentations and training for hospital and nursing facility staff. 

 Response to Financial Exploitation: One state noted that their office receives 

many more involuntary discharge notices and requests for consultations with 

facility staff regarding lack of payment of the nursing facility bill. Too many 

times, the issue of non-payment arises despite that fact that a fiduciary—

conservator, attorney in fact or representative payee—has been appointed. To 

work towards resolution of this issue, the state ombudsman participated with other 

stakeholders to review the current adult abuse system, criminal statutes and 

49 
resources available to assist victims of elder abuse, neglect and exploitation. The 

state ombudsman participation ensured that the resident perspective and issues 

particularly relevant to long-term care were discussed. A report outlining 

safeguards from financial exploitation, revisions to guardianship and abuse and 

neglect laws were among the recommendations submitted to the Governor and the 

legislature for further action.

Ombudsman Presence in Facilities and Empowerment of Families and Residents

In addition to receiving, responding to and resolving complaints, ombudsmen carry out a 

variety of duties designed to prevent problems; including providing routine visits to 

residents, consultations and technical assistance to residents, their families and facility 

staff. In FY 2013, ombudsmen staff and volunteers nationwide provided: 

 Routine visits to provide a regular presence to facility residents, visiting 

residents of 70 percent of nursing facilities and 29 percent of board and care 

and similar homes (including assisted living) at least quarterly.

 335,088 consultations to individuals, including: alternatives to institutional care; 

information on Medicaid; transfer, discharge and eviction; residents’ rights; and 

federal and state rules and policies impacting residents. 

 129,718 consultations to long-term care facility staff on a wide range of issues, 

including residents’ rights, person-centered care practices, and transfer and 

discharge issues.

 Resident and family council support – providing technical assistance, training and 

information to resident councils (21,812 sessions) and family councils (2371 

sessions);

 Trained long-term care facility staff (5417 sessions);

 Educated the community (11,506 sessions); and 

 Served as resident advocates and provided information to surveyors as part of 

long-term care facility surveys conducted by regulatory agencies (participating in 

16,237 survey related activities). 

Ombudsman as a Resource During a Facility Closure

The following is just one example of the important roles and follow-up provided by 

ombudsman program services: 

A local Ombudsman Program assisted with back to back closures of two assisted living 

facilities after the licensing agency terminated the facilities' license. These closures 

50 
required the cooperation of the Ombudsman Program, Adult Protective Services, the 

health department, law enforcement, the Veterans Administration and the state licensing 

agency. The Ombudsman Program served as the lead coordinator due to their familiarity 

with the facilities and prior canvassing the region (a four county area) for the best options 

available for the residents. During the day of the first relocation, the Ombudsman noticed 

one of the residents sitting in a room and appearing ill. The facility owner and staff 

refused to assist with care, food, and packing of resident's properties. The Ombudsman 

requested of law enforcement to call Emergency Medical Services (EMS) to transport the 

resident to the hospital. The resident was admitted to the hospital's Intensive Care Unit. 

The Ombudsman received accolades from the assisting agencies for the attention and 

action provided on behalf of the resident. After the remaining 25 residents moved to 

new homes, the Ombudsman visited all residents within two weeks to determine if they 

were satisfied with their new homes. Three of the residents did not like their placement 

and asked to move. The Ombudsmen diligently worked with the residents and their 

families and were successful in assisting with a satisfactory placement. This experience 

lead to the Ombudsman to develop resident relocation protocols which includes that 

the Relocation Team meet after each closure to review actions taken and further refine 

the process.

Systemic Advocacy, including work on laws, regulations and government policies 

A vital long-term care ombudsman function is systemic advocacy: analyzing, 

commenting on and recommending changes in laws, regulations, and government 

policies and actions to benefit long-term care residents. The following are a few examples 

of long-term care ombudsman systems advocacy efforts: 

 Seeking legislative changes to strength protections against illegal or improper 

evictions; development of consumer fact sheets and training of ombudsmen on 

transfer and discharge rights 

 Participation in multi-disciplinary task forces to develop comprehensive strategies 

to prevent and respond to abuse, neglect and exploitation. 

 Recommending laws and government actions to improve on the services provided 

in long-term care facilities, including consumer protections such as the 

development of model disclosure standards to assist individuals to compare 

services prior to admission to a facility

 Training of facility staff on abuse and neglect prevention, resident rights and 

chemical and physical restraint reduction practices. 

51 
A daughter was in search of a quality board and care home for her parents. She wanted to 

evaluate the options and look at the compliance history of various facilities as part of her 

decision making process. She requested the inspection records from the Department of 

Health (DoH) but was told that she would need to put her request in writing and that they 

would have to manually review and redact the resident names in the file, charge her for 

the copies and she would have to wait 10 days to receive the information. The daughter 

was feeling under pressure to find a home for her parents and felt that 10 days was too 

long and that this information should be readily available on their website (27 other states 

currently have this capability). The daughter contacted the State Ombudsman who worked 

with her, senior advocates and the media to seek support for a bill to require that facility 

inspections be posted on the DoH website (similar to what is available for nursing 

homes). They were successful in securing passage of a law which goes into effect in 

2015. This law requires the DoH to post the annual inspections of all board and care, 

assisted living and similar settings on their website. Access to inspection reports is one 

critical component of selecting a long-term care facility and this law will support 

individuals to be well-informed consumers. 

Providing Ombudsman Services 

There are 53 state ombudsmen (50 states, plus the District of Columbia, Puerto Rico, and 

Guam). In most states, the office of the state long-term care ombudsman is housed 

within the state unit on aging or another state agency. In others, the office is housed in a 

private non-profit agency. Most states have contracts with or through area agencies on 

aging to provide direct ombudsman services to residents locally. There are 575 

designated local entities across the nation.

In FY 2013, long-term care ombudsman services to residents were provided by 1,233 

full-time equivalent staff and 8,290 volunteers, trained and certified to investigate and 

resolve complaints. An additional 3,992 volunteers also served residents or assisted in 

program operations in ways other than complaint resolution. 

Program Funding 

Total FY 2013 funding from all sources for the ombudsman program nationwide was 

$92,501,893, an overall increase of 1.9 percent from the FY 2012 level. 

The federal government is the primary entity funding the Ombudsman Program, 

providing 56 percent of total funding in FY 2013. States provided 37 percent of funds, 

and other non-federal sources funded the remaining seven percent. Figure 1 shows the 

percentage of total program funding by source 

52 
Figure 1 - FY 2013 Expenditures by Category:

Where Long-Term Care Facility Residents Live

Increasingly, long-term care residents live in residential settings other than nursing 

homes, including board and care homes and assisted living (known by various names 

under state laws). While the number of beds and facilities in nursing homes are relatively 

stagnant, the growth of beds in these other residential settings is steadily increasing. 

Federal policy continues to accelerate the growth of home and community-based longterm care services. In many states, Medicaid funding provides services in these nonnursing home residential settings as part of the “home and community-based services” 

array. 

National Long-Term Care Ombudsman Resource Center Activities

In order to effectively advocate for residents, ombudsmen must remain up-to-date on the 

latest long-term care developments. Therefore, AoA supports the National Ombudsman 

Resource Center (NORC), which provides training, technical assistance, and program 

management expertise to state and local ombudsmen. In FY 2013, the NORC was 

53 
operated by the National Consumer Voice for Quality Long-Term Care (formerly 

NCCNHR), in conjunction with the National Association of States United for Aging and 

Disabilities (NASUAD).

In FY 2013, NORC provided ombudsmen with training from national experts on such 

issues as:

• Volunteer management training and technical assistance;

• Training on strategies to combat illegal evictions;

• Long-term services, supports and housing: 

• Technical assistance and training on new service provisions through managed 

care and other home and community based services settings; 

• Support for CMS nursing home quality initiatives such as:

o Reduction of antipsychotic medication use in nursing homes; 

o Promotion of CMS developed training on person-centered dementia care 

and abuse neglect and exploitation prevention 

The NORC provided access to quarterly orientation training activities for all new state 

ombudsmen and developed resource materials, the NORC website 

(www.ltcombudsman.org), and monthly newsletters, customized for long-term care 

ombudsman staff and volunteers. 

AoA’s Office of Long-Term Care Ombudsman Programs Activities

During the fiscal year, the Office of Long-Term Care Ombudsman Programs within AoA 

achieved several important goals which will strengthen the ability of Long-Term Care 

Ombudsman programs to serve residents of long-term care facilities: 

1. Notice of Proposed Rule Making for State Long-Term Care Ombudsman Programs 

The Administration on Aging posted a Notice of Proposed Rule Making in June 2013, 

designed to support States and territories in their implementation of the OAA and in 

serving long-term care facility residents through effective the Long-Term Care 

Ombudsman programs. Publication of the final rule is anticipated for early 2015. 

Since its creation in the 1970s, the functions of Long-Term Care Ombudsman programs 

have been delineated in the Act. However, in the absence of regulations, there has been 

significant variation in the effectiveness of these programs among States. AoA 

anticipates that this rule will strengthen the ability of Long-Term Care Ombudsman 

programs to be effective problem-solvers for older adults and people with disabilities 

who live in our nation’s long-term care facilities.

2. Program Evaluation Design 

The Older Americans Act requires AoA to conduct evaluations of OAA programs. To 

54 
that end, AoA completed an evaluation design that proposed an evidence-based approach 

for determining program efficiency and effectiveness and developed logic models to 

guide program evaluation, The final report ”Evaluation Study Design for Long-Term 

Care Ombudsman Programs under the Older Americans Act: Research Design Options” 

can be found at: 

http://www.aoa.acl.gov/Program_Results/docs/LTCOP%20Evaluation%20Study%20Des

ign_01312013.pdf. 

3. Joint Guidance issued with Centers for Medicare and Medicaid Services

In June of 2013, the Centers for Medicare and Medicaid Services (CMS) and the 

Administration on Aging issued joint guidance and training regarding the use of 

Medicaid administrative funding to reimburse for certain activities performed by State 

Long-Term Care Ombudsman programs. This funding mechanism creates opportunities 

for Ombudsman programs to increase access to services to individuals applying for or 

receiving Medicaid.

4. Duals Demonstration Ombudsman Programs 

AoA assisted CMS in designing a funding opportunity for Duals Demonstration 

Ombudsman Programs (Duals Ombudsman Programs) to ensure that states who are 

piloting integrated Medicare and Medicaid service models offer an independent advocate 

and problem-solver to beneficiaries. Duals Ombudsman Programs provide: services to 

empower beneficiaries and support their engagement; investigation and resolution of 

beneficiary problems with services (including health, behavioral health, as well as longterm supports and services; and systems-level analysis and recommendations.

ACL partners with CMS to provide technical assistance and support to these Dual 

Ombudsman programs. Of the five states with this Duals Ombudsman service, three are 

housed within Long-Term Care Ombudsman programs which have expanded their 

services to include problem-solving with and for individuals receiving services through a 

Financial Alignment Initiative.

Program Results and Challenges

Value of volunteers – Over $20 million donated in FY 2013. Volunteers designated to act 

on behalf of the State Long-Term Care Ombudsman add an invaluable service which 

benefits residents, their families and facility staff. Volunteers across the county donated 

their time, talents and energy to visit residents, listen to their concerns and take action. 

For some residents the ombudsman may be their only visitor. Volunteer ombudsmen 

frequently provide the routine ombudsman presence in many facilities and provide costeffective complaint resolution. The Independent Sector places the value of the volunteer 

time at $ 22.55 per hour placing the value of 904,596 hours at $20,398,639. 

Ombudsmen solve problems at the facility level -- Long-term care ombudsman programs 

resolve hundreds of thousands of complaints every year on behalf of long-term care 

55 
facility residents. The largest group that requested ombudsman assistance in resolving 

complaints were residents themselves, indicating that residents depend on ombudsmen to 

help them resolve their concerns. By resolving the vast majority of these complaints to 

the satisfaction of the resident or complainant, the work of ombudsmen improved the 

quality of life and quality of care for many residents of our nation’s long-term care 

facilities. Ombudsman complaint resolution is often conducted without outside 

intervention which can save on regulatory and legal costs while achieving the resident’s 

desired outcome. 

Home and community-based services are increasing demands for ombudsman services -- 

Long-term care services and supports continue to change over time; services that were 

once only available in a nursing home can now be received in an individual’s home or in 

a setting such as assisted living or similar. Federal policy, including Medicaid waivers to 

pay for community-based long-term care and demonstration grants to provide managed 

long-term care for persons receiving both Medicare and Medicaid are creating new 

challenges and opportunities for Ombudsman programs. Currently 13 states have 

expanded their laws to provide for Ombudsman services to individuals receiving in-home 

care, while other programs are expanding to provide Ombudsman services to individuals 

on managed care plans. As these services expand and provide more options for longterm care residents, State Ombudsmen work to ensure that their interests and concerns are 

represented. Reported concerns include access to long-term care services and supports in 

the community, support services while transitioning from a nursing home to a community 

setting, consumer protections and oversight of service providers, and abuse, neglect and 

exploitation prevention. 

Long-term care ombudsman programs are credible sources of information --

Ombudsman programs served as a credible source of information for residents (including 

through resident councils), their families (including through family councils), and facility 

staff. Based on their extensive experience resolving resident problems, ombudsmen 

represented resident interests to policymakers, influencing public policy related to longterm care.

Ombudsman programs leverage federal dollars -- Federal funds leveraged resources 

from other sources for ombudsman programs. During FY 2013, 44 percent of program 

funds came from non-federal sources. 

56 
PART IV: SUPPORTING THE NATIONAL 

AGING SERVICES NETWORK

Older Americans and Americans with disabilities face a vast array of choices when trying 

to determine the right services and supports to assist them to remain active and 

independent in their communities. As the number of choices available to assist them 

grows, so too does the complexity of navigating these programs and selecting among 

them to determine which best suit the needs of each individual. 

A key part of AoA’s emphasis on community living is providing consumers with the 

information and assistance they need to make decisions about their independence and 

connecting them with the right services. An Aging and Disability Resource Centers

(ADRCs) system helps to address this need by providing information, outreach, and 

assistance to seniors and people with disabilities so that they can access the services 

necessary for their independence. ADRCs serve as community-level “one stop shop” 

entry points into long-term care - including home and community-based services that can 

enable people to remain in their homes - for people of all ages who have chronic 

conditions and disabilities. 

Aging and Disability Resource Centers/No Wrong Door System

(FY 2013: $6,095,000) 

Aging and Disability Resource Centers (ADRCs)/No Wrong Door System113 supports 

state efforts to help individuals access long-term services and supports (LTSS) as well as 

develop a more efficient, and cost-effective access system into LTSS at the communitylevel. The current LTSS System involves numerous funding streams administered by 

multiple federal, state and local agencies using different, often fragmented and 

duplicative, access processes involving screening, intake, needs assessment, service 

planning, and eligibility determination. Individuals trying to access LTSS frequently find 

themselves confronted with a bewildering maze of organizations and bureaucratic 

requirements at a time when they are vulnerable or in crisis. This often results in people 

making decisions based on incomplete, and sometimes inaccurate, information about 

their options. This can lead to decisions to purchase and/or use LTSS options that are 

less than optimal for the individual and more expensive than necessary, including 

decisions to use expensive options such as nursing facility care that can quickly exhaust 

an individual’s personal resources and result in their spending down to Medicaid. 

113 In a “No Wrong Door” entry system, multiple agencies retain responsibility for their respective services 

while coordinating with each other to integrate access to those services through a single, standardized entry 

process that is administered and overseen by a coordinating entity (Allison Armor-Garb, Point of Entry 

Systems for Long-Term Care: State Case Studies, prepared for the New York City Department of Aging, 

2004).

57 

 
In response to this challenge facing our citizens and our nation, AoA and the Centers for 

Medicare & Medicaid Services worked collaboratively in 2003 to create a joint funding 

opportunity to support state efforts to create “one-stop-shop” access programs for people 

seeking LTSS. This initiative, known as the ADRC Program, was designed to provide 

consumers with “visible and trusted” sources of information, one-on-one counseling, and 

streamlined access to services and supports. ADRCs grew out of best practice 

innovations known as “No Wrong Door” (NWD) and “Single Points of Entry” programs, 

where people of all ages may turn for objective information on their long-term services 

and support options. 

Another major development in the evolution of the ADRC model occurred in 2008 when 

the Veterans Health Administration (VHA) – the nation’s largest health care system - 

recognized the value of ADRCs in helping consumers develop person-centered plans and 

direct their own care. In that year, the VHA entered into formal funding agreements with 

ADRCs to serve as the VHA’s designated entity for delivering the Veterans-Directed 

Home and Community Based Services Program (VD-HCBS). 

In 2010, the Affordable Care Act provided $50 million dollars over five years to support 

the further development of the ADRC Program. The Affordable Care Act also funded the 

CMS Balancing Incentive Program to incentivize states to rebalance their Medicaid 

LTSS spending and required participating states to make changes to their LTSS Systems, 

including developing statewide NWD programs. In 2012, recognizing the 

accomplishments of both the ADRC and Balancing Incentive Program initiatives, as well 

as the lessons learned from the experience of states, ACL, CMS and the VHA issued a 

special funding opportunity – known as the 2012 “ADRC Part A Grant Program.” With 

the 2012 funding opportunity announcement, ACL officially adopted the “No Wrong 

Door” System for the ADRC Part A grants. Lessons learned from these grants 

demonstrated that no one agency or network could successfully implement a LTSS access 

system for all populations and all payers without having multiple agencies and 

organizations at the state and local level formally involved in the system's operations. 

The national aging services network needs to include agencies and organizations that 

serve or represent the interests of different LTSS populations. 

The ACL/CMS/VHA vision is that each state will have a single statewide NWD System 

to LTSS for all populations and all payers. To support this effort, CMS and ACL 

continue to collaborate in developing current and relevant guidance on Medicaid 

administrative funding that could be available to support No Wrong Door systems that 

include Aging and Disability Resource Centers (ADRCs) and provide Person-Centered 

Counseling. The NWD System will make it easy for people of all ages, disabilities and 

income levels to learn about and access the services and supports they need. The NWD 

System will also provide states with a vehicle for better coordinating and integrating the 

multiple access functions associated with their various state administered programs that 

pay for LTSS.

58 
The NWD System functions include: 

• Public Outreach and Coordination with Key Referral Sources; 

• Person Centered Counseling; 

• Streamlined Access to Public LTSS Programs; and,

• State Governance and Administration. 

Public Outreach and Coordination with Key Referral Sources 

To be a “visible” source of individualized counseling and help with accessing LTSS, the 

NWD System must proactively engage in public education to promote broad public 

awareness of the resources that are available from the NWD System. The goal is for 

citizens of the state to know where they can turn to for unbiased and "trusted" help in 

understanding and accessing the LTSS options that are available in their communities. A 

NWD System’s public education efforts should give special attention to underserved and 

hard-to-reach populations, including people with hearing and visual impairments and 

limited English speaking populations. 

A fully operational NWD System will have formal linkages between and among all the 

major pathways that people travel while transitioning from one health care setting to 

another or from one public program payer to another. These pathways represent critical 

junctures where decisions are made – usually in a time of crisis - that often determines 

whether a person is permanently institutionalized or transitioned back to the community. 

Among the key sources of referral the NWD System must have formal linkages with all 

of the following entities: Information and Referral Entities; Nursing Homes and other 

Institutions; Acute Care Systems; and VA Medical Centers.

Person Centered Counseling 

Person Centered Counseling (PCC) is the NWD System term for person centered 

planning which is an approach when working with individuals that is now being required 

in the LTSS System under multiple Medicaid regulations, including the Person-Centered 

Planning provisions in the recently issued Home and Community Based (HCBS) 

“Settings Rule”

Through the use of PCC, the NWD System will empower individuals to make informed 

choices about their LTSS options consistent with their personal goals, and to successfully 

navigate the various organizations, agencies and other resources in their communities that 

provide LTSS. PCC is very different from and requires a different skill set compared to 

tradition case management and other commonly used techniques for counseling 

individuals with LTSS needs, and it will take time for our current LTSS workforce to 

develop the knowledge and skills required to fully embrace and effectively use PCC. The 

NWD System PCC function involves five basic steps: 1) conducting a personal interview; 

2) developing a person-centered plan; 3) facilitating access to private services and 

supports; 4) facilitating streamlined assess to public programs; and 5) conducting 

59 
ongoing follow-up. These components involve a fluid process where individuals can 

access different components at various stages. 

Streamlined Access to Public LTSS Programs 

NWD System's Streamlined Access to Public Programs function includes all the 

processes and requirements associated with conducting formal assessments and/or 

determining an individual’s eligibility that are required by any of the state administered 

programs that provide LTSS to any of the NWD System population. All these public 

access processes and requirements must be part of, and integrated into, the state’s NWD 

System's streamlined access function, so states can use their NWD System as a vehicle 

for optimally coordinating and integrating these processes to make them more efficient 

and effective, and more seamless and responsive for consumers. 

The NWD System person centered counselors can help ensure applications are "camera 

ready" when they reach the Medicaid office, thereby reducing the burden of the 

application process for both Medicaid staff and consumers. Even if the NWD System 

person centered counselor is not designated to do the preliminary assessment, the data 

gathered by the NWD System person centered counselor during the PCC process should 

be fed into the preliminary assessment and then automatically transferred into the final 

assessment process.

State Governance and Administration 

The governance and administration of a NWD System must involve a collaborative effort 

among multiple state agencies, since no one state agency has the authority or expertise to 

carry out all of the functions involved in a NWD System as described in this FOA. The 

NWD System is a critical component of any well-developed, person-centered state LTSS 

System, and therefore, its governance and oversight should be lodged in a Cabinet level 

body - either a new or existing one - and should be part of the state's oversight of its 

LTSS System. The NWD System governing body should be responsible for coordinating 

the on-going development, implementation, financing, evaluation and continual 

improvement of the state's NWD System. It must include representatives from the State 

Medicaid Agency, the State Unit on Aging, and the state agencies that serve or represent 

the interests of individuals with physical disabilities, individuals with intellectual and 

developmental disabilities, and the state authorities administering mental health services.

A robust Management Information System (MIS) that builds on and leverages existing 

state MIS systems is essential for a state to be able to effectively and efficiently gather 

and manage information from the many entities that will be carrying out NWD System 

functions, as well as from individual consumers who use the NWD System. 

The NWD System’s Continuous Quality Improvement (CQI) process must involve 

getting input and feedback from the many different customers who use or interact with 

the NWD System, including individuals and their families, system partners, advocates, 

providers and professionals in the health and LTSS systems, on the responsiveness of the 

60 
NWD System to their varying needs. The CQI process should also involve the 

administration of a complaint and grievance processes and tracking and addressing 

complaints and grievances. To be effective, the CQI process needs to include 

performance goals and indicators related to their NWD System’s key aims.

ACL and CMS have invested over $100 million in the ADRC/NWD program since 2003. 

As a result of these investments: 

• 509 sites have been established across 50 states, two territories, and Washington, 

DC.

• Thirty-three states and territories have achieved statewide coverage, and an 

additional 13 states have achieved 50 percent or more of statewide coverage. 

• 42 states/territories with ADRC programs sites currently conduct care transitions 

through formal intervention. 

• At least 41 states/territories with a system used for publicly accessible website 

• 133 sites in 29 states/territories reported serving clients with institutional 

transition from nursing facility (both MFP and non-MFP related), 97 sites in 24 

states/territories reported serving clients with institutional transition from nursing 

facility related to MFP, and 99 sites in 25 states/territories reported serving clients 

with institutional transition related to MFP. 

ADRCs will continue, with Department of Veterans Affairs (VA) funding, to serve 

clients under the current ACL/VA partnership. In FY 2008, the VA and AoA began 

working together to develop the Veterans Directed Home and Community-Based 

Services Program (VD-HCBS), which is designed to serve veterans of any age who are at 

risk of admission to a nursing home by providing them the opportunity to self-direct their 

care and access services to help them remain in the community. Rather than build a 

separate infrastructure to serve veterans, the VA made a strategic decision to use the 

aging and disability network infrastructure – including using the ADRC as the integrated 

access point to empower the veterans to set-up their own service plan for long-term 

supports and services – as a delivery vehicle for VD-HCBS. Since inception of the 

program the VA has invested over $41 million to provide VDHCBS and expand access to 

this program with the goal of moving nationwide. HHS and the VA have worked 

together to develop program guidelines/national standards, web-based tools to track 

program activities and implement a national training program for the VD-HCBS. 

Currently, 28 states and the District of Columbia are operating VD-HCBS programs with 

48 operational VAMCs, 104 operational AAA/ADRCs and over 1,500 veterans served 

with 23 percent under age 60. 

 

Aging Network Support Program Activities

(FY 2013: $7,432,000) 

Aging Network Support Activities provide competitive grants and contracts to support 

ongoing activities of national significance which help seniors and their families to obtain 

information about their care options and benefits, and which provide technical assistance 

61 
to help states, tribes, and community providers of aging services to develop service 

systems that help older people remain independent and able to live in their own homes 

and communities. These activities provide critical and ongoing support for the national 

aging services network and help support the activities of AoA’s core service delivery 

programs. 

Competitive grants, cooperative agreements, and contracts for Aging Network Support 

Activities are awarded to eligible public or private agencies and organizations, states and area 

agencies on aging (AAAs), institutions of higher learning, and other organizations 

representing and/or serving older people, including faith-based organizations. Grantees are 

required to provide a match equal to 25 percent of the project’s total cost. Project proposals 

are reviewed by external experts, and project awards are made for periods of one to four 

years. 

National Eldercare Locator 

Older Americans and their caregivers face a complicated array of choices and decisions 

about health care, pensions, insurance, housing, financial management, and long-term 

care. The Eldercare Locator, created in 1991, helps seniors and their families navigate 

this complex environment by connecting those needing assistance with state and local 

agencies on aging 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 phone line and website both connect those in need to 

providers in every zip code in the nation. The Eldercare Locator served over 239,000 

callers and 738,234 website users in FY2013. 

National Alzheimer’s Call Center

The National Alzheimer’s Call Center is a national information and counseling service 

for persons with Alzheimer’s disease, their family members, and informal caregivers. In 

the 12-month period ending January 31, 2014, the National Alzheimer’s Call Center 

handled nearly 300,000 calls through its national and local partners, and its on-line 

message board community recorded over 5 million page views and over 100,000 

individual postings. 

The National Alzheimer’s Call Center is available to people in all states, 24 hours a day, 

7 days a week, 365 days a year to provide expert advice, care consultation, and 

information and referrals at the national and local levels regarding Alzheimer’s disease. 

Trained professional customer service staff and masters degree social workers are 

available at all times. The Call Center is accessible by telephone, website or e-mail at no 

cost to the caller. Services focus on consumers, not professionals. Information provided 

may include basic information on caregiving; handling legal issues; resources for longdistance caregiving; and tips for working with the medical community. Local 

community-based organizations are directly involved to ensure local, on-the-ground 

capacity to respond to emergencies and on-going needs of Alzheimer’s patients, their 

families, and informal caregivers. The Call Center has multilingual capacity and 

62 
responds to inquiries in at least 140 languages through its own bilingual staff and with the 

use of a language interpretation service.

National Education and Resource Center on Women and Retirement Planning

The National Education and Resource Center on Women and Retirement Planning, 

established in 1998, provides women with access to a one-stop gateway that integrates 

financial information and resources on retirement, health, and planning for long-term 

care. This project has made user-friendly financial education and retirement planning 

tools available to traditionally hard-to-reach women, including low-income women, 

women of color, women with limited English speaking proficiency, rural, and other 

“underserved” women. Information is offered through financial and retirement planning 

programs, workshops tailored to meet women’s special needs, and publications in hard 

copy and web-based formats. Since its establishment, the Center has conducted more 

than 20,000 workshops on strategies to access financial and retirement planning 

information for women and disseminated financial and retirement planning information 

tailored to the specific needs of hard-to-reach women, in addition to materials designed to 

identify and prevent fraud and financial exploitation among older individuals. 

National Minority Aging Organizations Technical Assistance Centers

The National Minority Aging Organizations (NMAO) Technical Assistance Centers 

Program works to reduce or eliminate health disparities among racial and ethnic minority 

older individuals. These Centers design and disseminate front line 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, 

and American Indian and Alaska Native elders.

 

AoA awarded individual cooperative agreements to four national organizations to 

continue partnering as a consortium, with the goal of assisting the Aging Network 

effectively serve an increasingly diverse older population. Each consortium partner pilots 

practical, nontraditional, community-based intervention for reaching their target 

population of older adults who experience barriers to accessing home and communitybased services. Interventions focus on barriers due to language and low literacy, as well 

as those directly related to cultural diversity. Strategies developed under this program 

incorporate the latest technology and facilitate the generation and dissemination of 

knowledge in forms that can assist racial and ethnic minority older individuals to practice 

positive health behaviors and strengthen their capacity to maintain active, independent 

life styles. Examples of products resulting from these grants include culturally 

appropriate model workshops on identifying resources for caregivers and navigating 

community systems of services, and on helping the Aging Network understand and 

respect cultural differences.

63 
Appendix

Formula Grant Funding 

Allocation by 

State, Territory and 

Tribal Organization

U.S. Administration on Aging 

Department of Health and Human Services

64 
65 
State

Supportive 

Services

Congregate 

Meals

Home 

Meals

Preventive 

Services NFCSP Total Title III

Alabama $5,347,830 $6,068,408 $3,177,759 $312,653 $2,220,390 $17,127,040 

Alaska $1,728,330 $2,068,203 $1,021,362 $98,657 $723,620 $5,640,172 

Arizona $6,505,240 $8,135,056 $4,296,544 $380,319 $3,063,358 $22,380,517 

Arkansas $3,464,888 $4,163,564 $1,995,550 $198,557 $1,423,632 $11,246,191 

California $34,222,255 $39,623,562 $20,927,250 $2,000,744 $14,711,105 $111,484,916 

Colorado $4,111,937 $5,410,449 $2,857,538 $240,398 $1,856,698 $14,477,020 

Connecticut $4,358,913 $5,241,452 $2,402,675 $245,092 $1,749,484 $13,997,616 

Delaware $1,728,330 $2,068,203 $1,021,362 $98,657 $723,620 $5,640,172 

District of Columbia $1,728,330 $2,068,203 $1,021,362 $98,657 $723,620 $5,640,172 

Florida $25,001,310 $28,468,480 $15,035,675 $1,461,664 $11,527,293 $81,494,422 

Georgia $7,827,657 $10,014,735 $5,289,299 $457,632 $3,418,391 $27,007,714 

Hawaii $1,728,330 $2,068,203 $1,021,362 $98,657 $723,620 $5,640,172 

Idaho $1,728,330 $2,068,203 $1,021,362 $98,657 $723,620 $5,640,172 

Illinois $14,375,088 $17,286,541 $7,751,933 $789,367 $5,540,545 $45,743,474 

Indiana $6,855,949 $8,105,861 $4,062,628 $400,823 $2,878,077 $22,303,338 

Iowa $4,216,933 $5,081,501 $2,105,057 $217,951 $1,607,487 $13,228,929 

Kansas $3,397,503 $4,089,903 $1,788,240 $179,893 $1,320,014 $10,775,553 

Kentucky $4,692,372 $5,570,252 $2,830,077 $274,333 $1,950,378 $15,317,412 

Louisiana $4,746,436 $5,645,998 $2,744,355 $277,493 $1,887,778 $15,302,060 

Maine $1,728,330 $2,068,203 $1,028,376 $98,847 $723,620 $5,647,376 

Maryland $5,797,027 $6,666,347 $3,520,842 $338,915 $2,398,426 $18,721,557 

Massachusetts $8,124,430 $9,780,267 $4,339,413 $436,805 $3,135,868 $25,816,783 

Michigan $11,139,629 $12,926,499 $6,584,877 $651,262 $4,652,840 $35,955,107 

Minnesota $5,442,946 $6,398,439 $3,309,491 $318,214 $2,390,107 $17,859,197 

Mississippi $3,238,958 $3,891,114 $1,841,271 $184,167 $1,286,333 $10,441,843 

Missouri $7,045,013 $8,467,047 $3,986,638 $397,190 $2,877,048 $22,772,936 

Montana $1,728,330 $2,068,203 $1,021,362 $98,657 $723,620 $5,640,172 

Nebraska $2,271,269 $2,738,802 $1,165,501 $117,210 $871,922 $7,164,704 

Nevada $2,436,001 $3,109,985 $1,642,544 $142,417 $1,064,959 $8,395,906 

New Hampshire $1,728,330 $2,068,203 $1,021,362 $98,657 $723,620 $5,640,172 

New Jersey $10,157,125 $12,190,488 $5,650,333 $582,711 $4,097,131 $32,677,788 

New Mexico $2,044,878 $2,511,415 $1,326,408 $119,550 $909,221 $6,911,472 

New York $24,032,984 $28,963,855 $12,498,399 $1,291,839 $9,063,268 $75,850,345 

North Carolina $9,272,300 $11,542,567 $6,096,226 $542,091 $4,166,899 $31,620,083 

North Dakota $1,728,330 $2,068,203 $1,021,362 $98,657 $723,620 $5,640,172 

Ohio $13,674,310 $16,393,785 $7,783,568 $784,410 $5,629,924 $44,265,997 

Oklahoma $4,234,162 $5,080,736 $2,418,704 $241,578 $1,722,263 $13,697,443 

Oregon $4,091,730 $5,034,431 $2,658,943 $239,217 $1,820,218 $13,844,539 

Pennsylvania $17,695,572 $21,279,716 $9,152,573 $955,835 $6,876,661 $55,960,357 

Rhode Island $1,728,330 $2,068,203 $1,021,362 $98,657 $723,620 $5,640,172 

South Carolina $4,742,125 $5,968,512 $3,152,280 $277,242 $2,104,546 $16,244,705 

South Dakota $1,728,330 $2,068,203 $1,021,362 $98,657 $723,620 $5,640,172 

Tennessee $6,690,497 $7,942,564 $4,194,879 $391,150 $2,866,541 $22,085,631 

Texas $20,116,440 $24,742,235 $13,067,653 $1,176,078 $8,808,631 $67,911,037 

Utah $1,847,519 $2,332,537 $1,231,933 $108,013 $852,599 $6,372,601 

Vermont $1,728,330 $2,068,203 $1,021,362 $98,657 $723,620 $5,640,172 

Virginia $7,783,845 $9,237,708 $4,878,911 $455,071 $3,290,920 $25,646,455 

Washington $6,383,529 $7,951,293 $4,199,488 $373,204 $2,807,974 $21,715,488 

West Virginia $2,744,933 $3,305,947 $1,431,503 $143,708 $1,008,212 $8,634,303 

Wisconsin $6,324,483 $7,586,993 $3,726,193 $367,345 $2,709,247 $20,714,261 

Wyoming $1,728,330 $2,068,203 $1,021,362 $98,657 $723,620 $5,640,172 

American Samoa $467,446 $594,843 $136,498 $12,332 $90,453 $1,301,572 

Guam $864,165 $1,034,101 $510,681 $49,328 $361,810 $2,820,085 

Northern Mariana Islands $216,042 $258,525 $127,670 $12,332 $90,453 $705,022 

Puerto Rico $4,329,829 $4,883,248 $2,579,096 $253,137 $1,846,036 $13,891,346 

Virgin Islands $864,165 $1,034,101 $510,681 $49,328 $361,810 $2,820,085 

TOTAL $345,665,953 $413,640,501 $204,272,497 $19,731,329 $144,724,010 $1,128,034,290 

66 
State Ombudsman Elder Abuse Total Title VII

Alabama $246,892 $76,215 $323,107 

Alaska $79,350 $23,843 $103,193 

Arizona $333,813 $89,944 $423,757 

Arkansas $155,042 $48,157 $203,199 

California $1,625,913 $471,073 $2,096,986 

Colorado $222,012 $59,819 $281,831 

Connecticut $186,673 $59,907 $246,580 

Delaware $79,350 $23,843 $103,193 

District of Columbia $79,350 $23,843 $103,193 

Florida $1,168,176 $344,252 $1,512,428 

Georgia $410,945 $110,726 $521,671 

Hawaii $79,350 $23,843 $103,193 

Idaho $79,350 $23,843 $103,193 

Illinois $602,276 $197,384 $799,660 

Indiana $315,640 $98,224 $413,864 

Iowa $163,550 $55,927 $219,477 

Kansas $138,935 $45,843 $184,778 

Kentucky $219,879 $66,595 $286,474 

Louisiana $213,219 $68,518 $281,737 

Maine $79,898 $23,843 $103,741 

Maryland $273,547 $78,087 $351,634 

Massachusetts $337,145 $109,606 $446,751 

Michigan $511,603 $160,862 $672,465 

Minnesota $257,126 $76,347 $333,473 

Mississippi $143,055 $45,198 $188,253 

Missouri $309,736 $97,643 $407,379 

Montana $79,350 $23,843 $103,193 

Nebraska $90,552 $29,770 $120,322 

Nevada $127,615 $34,385 $162,000 

New Hampshire $79,350 $23,843 $103,193 

New Jersey $438,995 $143,950 $582,945 

New Mexico $103,054 $27,766 $130,820 

New York $971,046 $318,066 $1,289,112 

North Carolina $473,638 $127,617 $601,255 

North Dakota $79,350 $23,843 $103,193 

Ohio $604,734 $197,185 $801,919 

Oklahoma $187,918 $60,208 $248,126 

Oregon $206,583 $56,795 $263,378 

Pennsylvania $711,097 $242,944 $954,041 

Rhode Island $79,350 $23,843 $103,193 

South Carolina $244,912 $65,989 $310,901 

South Dakota $79,350 $23,843 $103,193 

Tennessee $325,915 $91,810 $417,725 

Texas $1,015,273 $274,281 $1,289,554 

Utah $95,714 $25,789 $121,503 

Vermont $79,350 $23,843 $103,193 

Virginia $379,060 $102,820 $481,880 

Washington $326,273 $87,911 $414,184 

West Virginia $111,219 $36,736 $147,955 

Wisconsin $289,501 $90,309 $379,810 

Wyoming $79,350 $23,843 $103,193 

American Samoa $9,919 $2,980 $12,899 

Guam $39,675 $11,922 $51,597 

Northern Mariana Islands $9,919 $2,980 $12,899 

Puerto Rico $200,379 $54,217 $254,596 

Virgin Islands $39,675 $11,922 $51,597 

TOTAL $15,869,941 $4,768,638 $20,638,579 

67 
State Tribe No. Grantee Name TITLE6 A/B TITLE6 C NSIP

AK 01 Aleutian Pribilof Islands Association $88,310 $25,350 $15,340

AK 02 Association of Village Council Presidents $127,490 $14,098

AK 03 Bristol Bay Native Association $127,490 $44,370 $3,830

AK 04 Central Council Tlingit & Haida Indian Tribes of AK $167,410 $50,710 $1,742

AK 06 Copper River Native Association $77,770 $19,010 $2,106

AK 07 Hoonah Indian Association $68,540 $12,670 $1,306

AK 08 Kodiak Area Native Association (Northern Section) $70,000 $12,670 $1,171

AK 09 Kodiak Area Native Association (Southern Section) $68,540 $12,670 $1,158

AK 10 Metlakatla Indian Community $88,310 $25,350 $1,146

AK 11 Native Village of Barrow $88,310 $25,350 $11,883

AK 12 Tanana Chiefs Conference for Kuskokwim subregion $68,540 $12,670 $2,626

AK 13 Tanana Chiefs Conference for Lower Yukon Subregion $68,540 $12,670 $4,230

AK 14 Tanana Chiefs Conference for Yukon Flats Subregion $68,540 $12,670 $3,562

AK 15 Tanana Chiefs Conference for Yukon Koyukuk Subregion $77,770 $19,010 $2,717

AK 16 Tanana Chiefs Conference for Yukon Tanana Subregion $68,540 $12,670 $2,629

AK 17 Fairbanks Native Association $127,490 $44,370

AK 19 Maniilaq Association $127,490 $44,370 $32,653

AK 20 Native Villiage of Unalakleet $68,540 $12,670 $8,039

AK 21 Chugachmiut $77,770 $19,010 $4,932

AK 22 Arctic Slope Native Association, Limited $68,540 $12,670 $11,882

AK 23 Denakkanaaga, Inc. $77,770 $19,010

AK 24 Klawock Cooperative Association $68,540 $12,670 $1,138

AK 25 Kootznoowoo Inc. $68,540 $12,670 $1,216

AK 26 Gwichyaa Zhee Gwich'in Tribal Government $68,540 $12,670 $4,181

AK 27 Native Village of Point Hope $68,540 $12,670 $4,264

AK 28 Seldovia Village Tribe, IRA $68,540 $687

AK 30 Sitka Tribes of Alaska $88,310 $25,350 $1,441

AK 32 Ketchikan Indian Community $127,490 $44,370 $1,902

AK 33 Kuskokwim Native Association $77,770 $19,010 $2,247

AK 35 Southcentral Foundation $167,410 $50,710 $10,664

AK 36 Kenaitze Indian Tribe $110,070 $38,040 $4,042

AK 37 Wrangell Cooperative Association $68,540 $12,670 $1,576

AK 38 Native Village of Savoonga $68,540 $12,670 $9,462

AK 39 Native Village of Gambell $68,540 $12,670 $2,393

AK 40 Native Village of Eyak $68,540 $12,670 $790

AK 41 Organized Village of Kake $68,540 $12,670 $1,642

AK 42 Chickaloon Native Village $77,770 $2,091

AK 43 Yakutat Tlingit Tribe & Craig Community Association $68,540 $12,670 $1,990

AK 44 Galena Village (aka Louden Village Council) $68,540 $12,670 $7,165

AK 45 Asa'carsarmiut Tribal Council $68,540 $650

AK 46 Orutsararmuit Native Council $88,310 $9,680

AK Total Total $3,499,850 $766,790 $196,271

AL 01 Poarch Creek Indians $127,490 $44,370 $20,266

AL Total Total $127,490 $44,370 $20,266

AZ 02 Colorado River Indian Tribes $99,520 $31,690 $8,187

AZ 03 Gila River Indian Community $127,490 $44,370 $14,979

AZ 04 Hopi Tribe $127,490 $44,370 $11,036

AZ 05 Hualapai Tribe $77,770 $19,010 $8,869

AZ 06 Navajo Nation $167,410 $50,710 $52,594

AZ 07 Pascua Yaqui Tribe $127,490 $44,370 $40,380

AZ 09 Salt River Pima-Maricopa Indian Community $99,520 $31,690 $6,984

AZ 10 San Carlos Apache Tribe $127,490 $44,370 $5,992

AZ 11 Tohono o'Odham Nation $127,490 $44,370 $3,216

AZ 12 White Mountain Apache Tribe $127,490 $44,370 $25,495

AZ 13 Ak-Chin Indian Community $68,540 $12,670 $1,871

AZ 14 Yavapai Apache Tribe $77,770 $3,048

AZ 15 Havasupai Tribe $68,540 $12,670 $11,432

AZ 16 Inter-Tribal Council of Arizona, Inc. $68,540 $12,670 $1,441

AZ 17 Cocopah Indian Tribe $68,540 $13,650

68 
State Tribe No. Grantee Name TITLE6 A/B TITLE6 C NSIP

AZ 18 Quechan Indian Tribe $77,770 $19,010 $14,581

AZ Total Total $1,638,860 $456,340 $223,755

CA 01 Bishop Tribal Council $77,770 $19,010 $19,635

CA 02 Blue Lake Rancheria $77,770 $19,010 $23,477

CA 06 Karuk Tribe of California $77,770 $19,010 $3,290

CA 07 Pit River Tribal Office $68,540 $4,155

CA 08 Picayune Rancheria of the Chukchansi Indians $68,540 $8,029

CA 09 Riverside-San Bernardino Co. Indian Health-for Morongo $68,540 $12,670 $7,088

CA 10 Riverside-San Bernardino Co. Indian Health-for $68,540 $12,670 $5,208

CA 11 Riverside-San Bernardino Co. Indian Health-for Soboba $68,540 $12,670 $8,345

CA 12 Sonoma County Indian Health Project - Sonoma $68,540 $8,483

CA 13 Southern Indian Health Council, Inc. $68,540 $12,670 $10,611

CA 15 Toiyabe Indian Health Project, Inc. - Northern $68,540 $12,670 $6,891

CA 16 Tule River Indian Health Center, Inc. $77,770 $19,010 $17,201

CA 17 Coast Indian Community of Resighini Rancheria $77,770 $19,010 $7,963

CA 18 United Indian Health Services for Smith River $88,310 $25,350 $10,631

CA 20 Indian Senior Center, Inc. $77,770 $19,010 $10,737

CA 21 Sonoma County Indian Health Project - Manchester $68,540 $2,836

CA 25 Pala Band of Mission Indians $77,770 $13,045

CA 26 Redding Rancheria $127,490 $44,370 $5,511

CA 28 Toiyabe Indian Health Project, Inc. - Southern $68,540 $12,670 $7,655

CA 29 Hoopa Valley Tribe, K'ima:w Medical Center $77,770 $7,045

CA 30 Round Valley Indian Tribes $88,310 $3,409

CA 31 Fort Mojave Indian Tribe $68,540 $12,670 $4,818

CA 33 CA Indian Manpower Consortium, Inc. - Chico, $68,540 $12,670 $6,869

CA 34 CA Indian Manpower Consortium, Inc. - Big Sandy, $68,540 $12,670 $7,113

CA 35 CA Indian Manpower Consortium, Inc. - Berry Creek, $68,540 $12,670 $4,377

CA 36 CA Indian Manpower Consortium, Inc. - Coyote Valley, $77,770 $19,010 $4,114

CA 37 CA Indian Manpower Consortium, Inc. - Enterprise, $77,770 $19,010 $4,951

CA 38 Santa Ynez Band of Mission Indians $68,540 $2,076

CA Total Total $2,109,910 $348,500 $225,563

CO 01 Southern Ute Indian Tribe $77,770 $19,010 $3,277

CO 02 Ute Mountain Ute Tribe $77,770 $11,098

CO Total Total $155,540 $19,010 $14,375

HI 01 Alu Like, Inc. $1,505,000 $50,710 $28,053

HI 02 Hana Health $77,770 $571

HI Total Total $1,582,770 $50,710 $28,624

IA 01 Sac & Fox Tribe of the Mississippi in Iowa $88,310 $25,350 $5,965

IA Total Total $88,310 $25,350 $5,965

ID 01 Coeur d'Alene Tribe $77,770 $19,010 $15,921

ID 02 Nez Perce Tribe $110,070 $38,040 $23,781

ID 03 Shoshone-Bannock Tribes $127,490 $44,370 $17,099

ID Total Total $315,330 $101,420 $56,801

KS 01 The Kickapoo Tribe in Kansas $68,540 $12,670 $11,714

KS 02 Prairie Band of Potawatomi Nation $88,310 $25,350 $17,181

KS 03 Iowa Tribe of Kansas and Nebraska $68,540 $12,670 $5,815

KS Total Total $225,390 $50,690 $34,710

LA 01 Institute for Indian Development, Inc. $77,770 $4,394

LA Total Total $77,770 $4,394

MA 01 Wampanoag Tribe of Gay Head (Aquinnah) $68,540 $12,670 $638

MA Total Total $68,540 $12,670 $638

ME 01 Pleasant Point Passamaquoddy Tribe $88,310 $25,350 $19,145

ME 02 Penobscot Indian Nation $77,770 $4,799

ME 04 Aroostook Band of Micmacs $68,540 $12,670 $1,086

ME Total Total $234,620 $38,020 $25,030

MI 01 Grand Traverse Band of Ottawa & Chippewa Indians $88,310 $25,350 $12,951

MI 02 Inter-Tribal Council of Michigan, Inc. $77,770 $19,010 $4,780

MI 03 Keweenaw Bay Indian Community $77,770 $19,010 $12,521

MI 04 Sault Ste. Marie Tribe of Chippewa Indians $127,490 $18,008

69 
State Tribe No. Grantee Name TITLE6 A/B TITLE6 C NSIP

MI 05 Little Traverse Bay Bands of Odawa Indians $77,770 $4,044

MI 07 Bay Mills Indian Community $77,770 $19,010 $5,196

MI 08 Pokagon Band of Potawatomi Indians $77,770 $2,619

MI 09 Little River Band of Ottawa Indians $88,310 $25,350 $4,626

MI 10 Nottawaseppi Huron Band of the Potawatomi $68,540 $12,670 $3,294

MI Total Total $761,500 $120,400 $68,039

MN 01 Bois Forte Reservation Tribal Government $77,770 $19,010 $7,293

MN 02 Fond du Lac Band of Lake Superior Chippewa $110,070 $38,040 $45,980

MN 03 Leech Lake Band of Ojibwe $167,410 $50,710 $20,678

MN 07 Red Lake Band of Chippewa Indians $110,070 $20,057

MN 08 White Earth Reservation Tribal Council $99,520 $31,690 $10,891

MN 09 Grand Portage Band of Lake Superior Chippewa $68,540 $3,761

MN 10 Mille Lacs Band of Ojibwe $77,770 $19,010 $20,998

MN Total Total $711,150 $158,460 $129,658

MO 99 Eastern Shawnee Tribe of Oklahoma $88,310 $25,350 $14,166

MO Total Total $88,310 $25,350 $14,166

MS 01 Mississippi Band of Choctaw Indians $127,490 $44,370 $17,771

MS Total Total $127,490 $44,370 $17,771

MT 01 Assiniboine and Sioux Tribes $110,070 $38,040 $32,643

MT 02 Blackfeet Tribe - Eagle Shield Center $127,490 $44,370 $26,261

MT 03 Chippewa Cree Tribe $99,520 $31,690 $46,310

MT 04 Confederated Salish and Kootenai Tribes $127,490 $44,370 $4,407

MT 05 Fort Belknap Indian Community $99,520 $31,690 $15,418

MT 06 Northern Cheyenne Elderly Program $99,520 $31,690 $21,777

MT 07 Crow Tribal Elders Program $127,490 $44,370 $44,090

MT Total Total $791,100 $266,220 $190,906

NC 01 Eastern Band of Cherokee Indians $167,410 $50,710 $40,566

NC Total Total $167,410 $50,710 $40,566

ND 01 Spirit Lake Tribe $88,310 $25,350 $14,964

ND 02 Standing Rock Sioux Tribe $127,490 $44,370 $94,486

ND 03 Three Affiliated Tribes $127,490 $44,370 $12,793

ND 04 Trenton Indian Service Area $88,310 $25,350 $2,572

ND 05 Turtle Mountain Band of Chippewa Indians $127,490 $44,370 $16,646

ND Total Total $559,090 $183,810 $141,461

NE 01 Omaha Tribe of Nebraska $77,770 $19,010 $8,763

NE 02 Santee Sioux Nation $68,540 $2,187

NE 03 Winnebago Senior Citizen Center $77,770 $19,010 $19,265

NE Total Total $224,080 $38,020 $30,215

NM 01 Eight Northern Indian Pueblos Council (Picuris, etc.) $167,410 $50,710 $17,154

NM 02 Eight N. Indian Pueblos Council(San Ildefonso, etc.) $88,310 $25,350 $8,900

NM 03 Five Sandoval Indian Pueblos, Inc. $88,310 $17,875

NM 04 Jicarilla Apache Nation $99,520 $31,690 $17,533

NM 05 Laguna Rainbow Corporation $127,490 $44,370 $16,610

NM 06 Mescalero Apache Tribe $88,310 $9,161

NM 07 Pueblo de Cochiti $77,770 $19,010 $6,618

NM 09 Pueblo of Isleta $110,070 $38,040 $20,044

NM 10 Pueblo of Jemez $99,520 $31,690 $7,194

NM 11 Pueblo of San Felipe $99,520 $31,690 $19,106

NM 12 Pueblo of Taos $99,520 $31,690 $8,611

NM 13 Zuni Tribe $127,490 $44,370 $24,296

NM 14 Ohkay Owingeh Senior Citizens Program $127,490 $44,370 $12,771

NM 15 Santa Clara Pueblo $167,410 $50,710 $16,964

NM 16 Santo Domingo Pueblo $127,490 $44,370 $13,753

NM 17 Pueblo of Tesuque $68,540 $12,670 $5,948

NM 18 Pueblo of Acoma $88,310 $25,350 $11,580

NM Total Total $1,852,480 $526,080 $234,118

NV 01 Fallon Paiute-Shoshone Tribes $77,770 $19,010 $18,149

NV 02 Inter-Tribal Council of Nevada, Inc. (McDermitt, etc.) $77,770 $19,010 $6,634

NV 03 Inter-Tribal Council of Nevada, Inc. (Duckwater, etc.) $77,770 $19,010 $3,421

70 
State Tribe No. Grantee Name TITLE6 A/B TITLE6 C NSIP

NV 04 Inter-Tribal Council of Nevada, Inc. (Ely, etc.) $68,540 $12,670 $5,699

NV 05 Shoshone-Paiute Tribes $77,770 $19,010 $7,144

NV 06 Walker River Paiute Tribe $77,770 $8,692

NV 07 Washoe Tribe of Nevada and California $77,770 $19,010 $40,718

NV 08 Yerington Paiute Tribe $68,540 $6,392

NV 09 Pyramid Lake Paiute Tribe $88,310 $25,350 $4,731

NV 10 Elko Band Council $68,540 $12,670 $6,994

NV 11 Reno-Sparks Indian Colony $77,770 $19,010 $11,443

NV Total Total $838,320 $164,750 $120,017

NY 01 St. Regis Mohawk Tribe $127,490 $44,370 $9,214

NY 02 Seneca Nation of Indians $127,490 $44,370 $15,244

NY 04 Oneida Indian Nation $68,540 $12,670 $3,588

NY 05 Shinnecock Indian Nation $68,540 $12,670 $3,902

NY Total Total $392,060 $114,080 $31,948

OK 01 Apache Tribe of Oklahoma $127,490 $44,370 $7,483

OK 02 Caddo Nation of Oklahoma $77,770 $19,010 $2,480

OK 03 Cherokee Nation $168,476 $52,979 $38,827

OK 04 Cheyenne & Arapaho Tribes $127,490 $44,370 $10,474

OK 06 Choctaw Nation of Oklahoma $167,410 $50,710 $30,957

OK 07 Citizen Potawatomi Nation $167,410 $50,710 $11,218

OK 08 Comanche Nation $127,490 $44,370 $17,103

OK 09 Delaware Nation $78,960 $12,670 $6,906

OK 10 Iowa Tribe of Oklahoma $127,490 $44,370 $8,932

OK 12 Kickapoo Tribe of Oklahoma $100,000 $19,010 $14,905

OK 13 Kiowa Tribe of Oklahoma $127,490 $44,370 $6,168

OK 14 Miami Tribe of Oklahoma $110,070 $38,040 $26,233

OK 15 Muscogee (Creek) Nation $167,410 $50,710 $141,246

OK 17 Otoe-Missouria Tribe of Indians $70,000 $12,670 $7,993

OK 18 Ottawa Tribe of Oklahoma $127,490 $44,370 $28,554

OK 19 Pawnee Nation of Oklahoma $80,000 $19,010 $10,964

OK 20 Peoria Tribe of Indians of Oklahoma $99,520 $31,690 $12,032

OK 21 Ponca Tribe of Oklahoma $77,770 $19,010 $9,393

OK 22 Quapaw Tribe of Oklahoma $110,070 $38,040 $18,539

OK 23 Sac and Fox Nation $77,770 $19,010 $11,990

OK 24 Seminole Nation of Oklahoma $167,410 $50,710 $13,139

OK 25 Seneca-Cayuga Tribe of Oklahoma $127,490 $44,370 $2,709

OK 26 Wichita and Affiliated Tribes $127,490 $44,370 $7,612

OK 27 Wyandotte Nation $127,490 $44,370 $16,323

OK 28 Absentee Shawnee Tribe $167,410 $50,710 $27,080

OK 29 Fort Sill Apache Tribe $99,520 $31,690 $6,187

OK 31 United Keetoowah Band of Cherokee Indians $127,490 $44,370 $18,047

OK 32 Chickasaw Nation $167,410 $50,710 $108,488

OK 33 Kaw Nation $77,770 $21,697

OK 34 Osage Nation of Oklahoma $167,410 $50,710 $60,213

OK 35 Delaware Tribes of Indians $127,490 $4,517

OK 36 Alabama-Quassarte Tribal Town $68,540 $12,670 $538

OK Total Total $3,870,496 $1,124,169 $708,947

OR 01 Confederated Tribes of Siletz Indians of Oregon $99,520 $31,690 $1,006

OR 02 Confederated Tribes of the Umatilla Indian Reservation $110,070 $38,040 $7,792

OR 03 Confederated Tribes of Warm Springs $99,520 $31,690 $38,651

OR 04 Confederated Tribes of Grand Ronde $88,310 $25,350 $10,312

OR 05 The Klamath Tribes $127,490 $44,370 $3,074

OR 06 Confed. Tribes of Coos, Lower Umpqua & $77,770 $19,010 $7,034

OR Total Total $602,680 $190,150 $67,869

RI 01 Narragansett Indian Tribe $88,310 $25,350 $2,033

RI Total Total $88,310 $25,350 $2,033

SC 01 Catawba Indian Nation Eldercare Program $77,770 $19,010 $6,626

SC Total Total $77,770 $19,010 $6,626

SD 01 Cheyenne River Elderly Nutrition Services, Inc. $127,490 $44,370 $9,928

71 
State Tribe No. Grantee Name TITLE6 A/B TITLE6 C NSIP

SD 02 Crow Creek Sioux Tribe $77,770 $16,525

SD 03 Lower Brule Sioux Tribe $77,770 $19,010 $12,594

SD 04 Oglala Sioux Tribe $167,410 $50,710 $116,421

SD 05 Rosebud Sioux Tribe $167,410 $50,710 $61,220

SD 06 Sisseton Wahpeton Oyate of $127,490 $28,868

SD 08 Yankton Sioux Tribe $88,310 $25,350 $8,251

SD Total Total $833,650 $190,150 $253,807

TX 01 The Alabama-Coushatta Tribe of Texas $77,770 $19,010 $8,177

TX 02 Kickapoo Traditional Tribe of Texas $68,540 $14,784

TX Total Total $146,310 $19,010 $22,961

UT 01 Ute Indian Tribe, Unitah & Ouray $88,310 $25,350 $6,565

UT Total Total $88,310 $25,350 $6,565

WA 01 Confederated Tribes of the Colville Reservation $127,490 $44,370 $13,869

WA 02 Lower Elwha Klallam Tribe $77,770 $19,010 $6,243

WA 03 Lummi Tribe $110,070 $38,040 $13,440

WA 04 Makah Nation $77,770 $19,010 $7,524

WA 05 Muckleshoot Indian Tribe $127,490 $44,370 $27,044

WA 09 Puyallup Tribe of Indians $127,490 $5,229

WA 10 Quinault Indian Nation $99,520 $31,690 $23,560

WA 13 Swinomish Indian Tribal Community $68,540 $12,670 $5,842

WA 14 Spokane Tribe of Indians $77,770 $19,010 $13,139

WA 16 The Tulalip Tribes $127,490 $10,875

WA 17 Jamestown S'Klallam Tribe $77,770 $19,010 $2,196

WA 19 Quileute Tribal Council $77,770 $19,010 $4,733

WA 20 S. Puget Intertribal Planning Agency - Shoalwater Bay $88,310 $25,350 $6,482

WA 21 Stillaguamish Tribe of Indians $88,310 $25,350 $790

WA 22 Upper Skagit Indian Tribe $68,540 $12,670 $2,447

WA 24 The Suquamish Tribe $88,310 $25,350 $47,113

WA 25 Port Gamble S'Klallam Tribe $68,540 $12,670 $3,252

WA 26 Samish Indian Nation $77,770 $19,010 $2,441

WA 27 Cowlitz Indian Tribe $88,310 $25,350 $4,724

WA 28 Skokomish Indian Tribe $88,310 $25,350 $2,271

WA 29 Confederated Tribes of the Chehalis Reservation $88,310 $25,350 $2,311

WA 30 Nooksack Indian Tribe $77,770 $19,010 $7,900

WA 31 Yakama Nation $68,540 $12,670 $2,703

WA 32 Snoqualmie Tribe $68,540 $12,670 $260

WA 33 S. Puget Intertribal Planning Agency - Nisqually $110,070 $38,040 $3,435

WA 34 S. Puget Intertribal Planning Agency - Squaxin Island $68,540 $12,670 $11,909

WA Total Total $2,315,110 $557,700 $231,732

WI 01 Bad River Band of Lake Superior Chippewa $77,770 $19,010 $11,028

WI 02 Forest County Potawatomi Community $77,770 $19,010 $13,357

WI 03 Lac Courte Oreilles Band of Lake Superior Chippewa $88,310 $25,350 $10,068

WI 04 Lac du Flambeau Band of Lake Superior Chippewa $88,310 $25,350 $20,275

WI 05 Menominee Indian Tribe of Wisconsin $127,490 $44,370 $1,567

WI 06 Oneida Tribe Elder Services $127,490 $44,370 $6,467

WI 07 Red Cliff Band of Lake Superior Chippewa $77,770 $19,010 $13,403

WI 08 St. Croix Chippewa Indians of Wisconsin $77,770 $19,010 $4,067

WI 09 Stockbridge-Munsee Community $77,770 $19,010 $2,199

WI 10 Ho-Chunk Nation $99,520 $31,690 $10,372

WI Total Total $919,970 $266,180 $92,803

WY 01 Northern Arapaho Tribe $77,770 $9,709

WY 03 Eastern Shoshone Tribe $88,310 $11,635

WY Total Total $166,080 $21,344

Total Total Total $25,746,056 $6,023,189 $3,269,944

72 
State Tribe No. Grantee Name TITLE6 A/B TITLE6 C NSIP

AK 01 Aleutian Pribilof Islands Association $88,310 $25,350 $15,340

AK 02 Association of Village Council Presidents $127,490 $14,098

AK 03 Bristol Bay Native Association $127,490 $44,370 $3,830

AK 04 Central Council Tlingit & Haida Indian Tribes of AK $167,410 $50,710 $1,742

AK 06 Copper River Native Association $77,770 $19,010 $2,106

AK 07 Hoonah Indian Association $68,540 $12,670 $1,306

AK 08 Kodiak Area Native Association (Northern Section) $70,000 $12,670 $1,171

AK 09 Kodiak Area Native Association (Southern Section) $68,540 $12,670 $1,158

AK 10 Metlakatla Indian Community $88,310 $25,350 $1,146

AK 11 Native Village of Barrow $88,310 $25,350 $11,883

AK 12 Tanana Chiefs Conference for Kuskokwim subregion $68,540 $12,670 $2,626

AK 13 Tanana Chiefs Conference for Lower Yukon Subregion $68,540 $12,670 $4,230

AK 14 Tanana Chiefs Conference for Yukon Flats Subregion $68,540 $12,670 $3,562

AK 15 Tanana Chiefs Conference for Yukon Koyukuk Subregion $77,770 $19,010 $2,717

AK 16 Tanana Chiefs Conference for Yukon Tanana Subregion $68,540 $12,670 $2,629

AK 17 Fairbanks Native Association $127,490 $44,370

AK 19 Maniilaq Association $127,490 $44,370 $32,653

AK 20 Native Villiage of Unalakleet $68,540 $12,670 $8,039

AK 21 Chugachmiut $77,770 $19,010 $4,932

AK 22 Arctic Slope Native Association, Limited $68,540 $12,670 $11,882

AK 23 Denakkanaaga, Inc. $77,770 $19,010

AK 24 Klawock Cooperative Association $68,540 $12,670 $1,138

AK 25 Kootznoowoo Inc. $68,540 $12,670 $1,216

AK 26 Gwichyaa Zhee Gwich'in Tribal Government $68,540 $12,670 $4,181

AK 27 Native Village of Point Hope $68,540 $12,670 $4,264

AK 28 Seldovia Village Tribe, IRA $68,540 $687

AK 30 Sitka Tribes of Alaska $88,310 $25,350 $1,441

AK 32 Ketchikan Indian Community $127,490 $44,370 $1,902

AK 33 Kuskokwim Native Association $77,770 $19,010 $2,247

AK 35 Southcentral Foundation $167,410 $50,710 $10,664

AK 36 Kenaitze Indian Tribe $110,070 $38,040 $4,042

AK 37 Wrangell Cooperative Association $68,540 $12,670 $1,576

AK 38 Native Village of Savoonga $68,540 $12,670 $9,462

AK 39 Native Village of Gambell $68,540 $12,670 $2,393

AK 40 Native Village of Eyak $68,540 $12,670 $790

AK 41 Organized Village of Kake $68,540 $12,670 $1,642

AK 42 Chickaloon Native Village $77,770 $2,091

AK 43 Yakutat Tlingit Tribe & Craig Community Association $68,540 $12,670 $1,990

AK 44 Galena Village (aka Louden Village Council) $68,540 $12,670 $7,165

AK 45 Asa'carsarmiut Tribal Council $68,540 $650

AK 46 Orutsararmuit Native Council $88,310 $9,680

AK Total Total $3,499,850 $766,790 $196,271

AL 01 Poarch Creek Indians $127,490 $44,370 $20,266

AL Total Total $127,490 $44,370 $20,266

AZ 02 Colorado River Indian Tribes $99,520 $31,690 $8,187

AZ 03 Gila River Indian Community $127,490 $44,370 $14,979

AZ 04 Hopi Tribe $127,490 $44,370 $11,036

AZ 05 Hualapai Tribe $77,770 $19,010 $8,869

AZ 06 Navajo Nation $167,410 $50,710 $52,594

AZ 07 Pascua Yaqui Tribe $127,490 $44,370 $40,380

AZ 09 Salt River Pima-Maricopa Indian Community $99,520 $31,690 $6,984

AZ 10 San Carlos Apache Tribe $127,490 $44,370 $5,992

AZ 11 Tohono o'Odham Nation $127,490 $44,370 $3,216

AZ 12 White Mountain Apache Tribe $127,490 $44,370 $25,495

AZ 13 Ak-Chin Indian Community $68,540 $12,670 $1,871

AZ 14 Yavapai Apache Tribe $77,770 $3,048

AZ 15 Havasupai Tribe $68,540 $12,670 $11,432

73 
State Tribe No. Grantee Name TITLE6 A/B TITLE6 C NSIP

AZ 16 Inter-Tribal Council of Arizona, Inc. $68,540 $12,670 $1,441

AZ 17 Cocopah Indian Tribe $68,540 $13,650

AZ 18 Quechan Indian Tribe $77,770 $19,010 $14,581

AZ Total Total $1,638,860 $456,340 $223,755

CA 01 Bishop Tribal Council $77,770 $19,010 $19,635

CA 02 Blue Lake Rancheria $77,770 $19,010 $23,477

CA 06 Karuk Tribe of California $77,770 $19,010 $3,290

CA 07 Pit River Tribal Office $68,540 $4,155

CA 08 Picayune Rancheria of the Chukchansi Indians $68,540 $8,029

CA 09 Riverside-San Bernardino Co. Indian Health-for Morongo $68,540 $12,670 $7,088

CA 10 Riverside-San Bernardino Co. Indian Health-for $68,540 $12,670 $5,208

CA 11 Riverside-San Bernardino Co. Indian Health-for Soboba $68,540 $12,670 $8,345

CA 12 Sonoma County Indian Health Project - Sonoma $68,540 $8,483

CA 13 Southern Indian Health Council, Inc. $68,540 $12,670 $10,611

CA 15 Toiyabe Indian Health Project, Inc. - Northern $68,540 $12,670 $6,891

CA 16 Tule River Indian Health Center, Inc. $77,770 $19,010 $17,201

CA 17 Coast Indian Community of Resighini Rancheria $77,770 $19,010 $7,963

CA 18 United Indian Health Services for Smith River $88,310 $25,350 $10,631

CA 20 Indian Senior Center, Inc. $77,770 $19,010 $10,737

CA 21 Sonoma County Indian Health Project - Manchester $68,540 $2,836

CA 25 Pala Band of Mission Indians $77,770 $13,045

CA 26 Redding Rancheria $127,490 $44,370 $5,511

CA 28 Toiyabe Indian Health Project, Inc. - Southern $68,540 $12,670 $7,655

CA 29 Hoopa Valley Tribe, K'ima:w Medical Center $77,770 $7,045

CA 30 Round Valley Indian Tribes $88,310 $3,409

CA 31 Fort Mojave Indian Tribe $68,540 $12,670 $4,818

CA 33 CA Indian Manpower Consortium, Inc. - Chico, $68,540 $12,670 $6,869

CA 34 CA Indian Manpower Consortium, Inc. - Big Sandy, $68,540 $12,670 $7,113

CA 35 CA Indian Manpower Consortium, Inc. - Berry Creek, $68,540 $12,670 $4,377

CA 36 CA Indian Manpower Consortium, Inc. - Coyote Valley, $77,770 $19,010 $4,114

CA 37 CA Indian Manpower Consortium, Inc. - Enterprise, $77,770 $19,010 $4,951

CA 38 Santa Ynez Band of Mission Indians $68,540 $2,076

CA Total Total $2,109,910 $348,500 $225,563

CO 01 Southern Ute Indian Tribe $77,770 $19,010 $3,277

CO 02 Ute Mountain Ute Tribe $77,770 $11,098

CO Total Total $155,540 $19,010 $14,375

HI 01 Alu Like, Inc. $1,505,000 $50,710 $28,053

HI 02 Hana Health $77,770 $571

HI Total Total $1,582,770 $50,710 $28,624

IA 01 Sac & Fox Tribe of the Mississippi in Iowa $88,310 $25,350 $5,965

IA Total Total $88,310 $25,350 $5,965

ID 01 Coeur d'Alene Tribe $77,770 $19,010 $15,921

ID 02 Nez Perce Tribe $110,070 $38,040 $23,781

ID 03 Shoshone-Bannock Tribes $127,490 $44,370 $17,099

ID Total Total $315,330 $101,420 $56,801

KS 01 The Kickapoo Tribe in Kansas $68,540 $12,670 $11,714

KS 02 Prairie Band of Potawatomi Nation $88,310 $25,350 $17,181

KS 03 Iowa Tribe of Kansas and Nebraska $68,540 $12,670 $5,815

KS Total Total $225,390 $50,690 $34,710

LA 01 Institute for Indian Development, Inc. $77,770 $4,394

LA Total Total $77,770 $4,394

MA 01 Wampanoag Tribe of Gay Head (Aquinnah) $68,540 $12,670 $638

MA Total Total $68,540 $12,670 $638

ME 01 Pleasant Point Passamaquoddy Tribe $88,310 $25,350 $19,145

ME 02 Penobscot Indian Nation $77,770 $4,799

ME 04 Aroostook Band of Micmacs $68,540 $12,670 $1,086

ME Total Total $234,620 $38,020 $25,030

MI 01 Grand Traverse Band of Ottawa & Chippewa Indians $88,310 $25,350 $12,951

MI 02 Inter-Tribal Council of Michigan, Inc. $77,770 $19,010 $4,780

74 
State Tribe No. Grantee Name TITLE6 A/B TITLE6 C NSIP

MI 03 Keweenaw Bay Indian Community $77,770 $19,010 $12,521

MI 04 Sault Ste. Marie Tribe of Chippewa Indians $127,490 $18,008

MI 05 Little Traverse Bay Bands of Odawa Indians $77,770 $4,044

MI 07 Bay Mills Indian Community $77,770 $19,010 $5,196

MI 08 Pokagon Band of Potawatomi Indians $77,770 $2,619

MI 09 Little River Band of Ottawa Indians $88,310 $25,350 $4,626

MI 10 Nottawaseppi Huron Band of the Potawatomi $68,540 $12,670 $3,294

MI Total Total $761,500 $120,400 $68,039

MN 01 Bois Forte Reservation Tribal Government $77,770 $19,010 $7,293

MN 02 Fond du Lac Band of Lake Superior Chippewa $110,070 $38,040 $45,980

MN 03 Leech Lake Band of Ojibwe $167,410 $50,710 $20,678

MN 07 Red Lake Band of Chippewa Indians $110,070 $20,057

MN 08 White Earth Reservation Tribal Council $99,520 $31,690 $10,891

MN 09 Grand Portage Band of Lake Superior Chippewa $68,540 $3,761

MN 10 Mille Lacs Band of Ojibwe $77,770 $19,010 $20,998

MN Total Total $711,150 $158,460 $129,658

MO 99 Eastern Shawnee Tribe of Oklahoma $88,310 $25,350 $14,166

MO Total Total $88,310 $25,350 $14,166

MS 01 Mississippi Band of Choctaw Indians $127,490 $44,370 $17,771

MS Total Total $127,490 $44,370 $17,771

MT 01 Assiniboine and Sioux Tribes $110,070 $38,040 $32,643

MT 02 Blackfeet Tribe - Eagle Shield Center $127,490 $44,370 $26,261

MT 03 Chippewa Cree Tribe $99,520 $31,690 $46,310

MT 04 Confederated Salish and Kootenai Tribes $127,490 $44,370 $4,407

MT 05 Fort Belknap Indian Community $99,520 $31,690 $15,418

MT 06 Northern Cheyenne Elderly Program $99,520 $31,690 $21,777

MT 07 Crow Tribal Elders Program $127,490 $44,370 $44,090

MT Total Total $791,100 $266,220 $190,906

NC 01 Eastern Band of Cherokee Indians $167,410 $50,710 $40,566

NC Total Total $167,410 $50,710 $40,566

ND 01 Spirit Lake Tribe $88,310 $25,350 $14,964

ND 02 Standing Rock Sioux Tribe $127,490 $44,370 $94,486

ND 03 Three Affiliated Tribes $127,490 $44,370 $12,793

ND 04 Trenton Indian Service Area $88,310 $25,350 $2,572

ND 05 Turtle Mountain Band of Chippewa Indians $127,490 $44,370 $16,646

ND Total Total $559,090 $183,810 $141,461

NE 01 Omaha Tribe of Nebraska $77,770 $19,010 $8,763

NE 02 Santee Sioux Nation $68,540 $2,187

NE 03 Winnebago Senior Citizen Center $77,770 $19,010 $19,265

NE Total Total $224,080 $38,020 $30,215

NM 01 Eight Northern Indian Pueblos Council (Picuris, etc.) $167,410 $50,710 $17,154

NM 02 Eight N. Indian Pueblos Council(San Ildefonso, etc.) $88,310 $25,350 $8,900

NM 03 Five Sandoval Indian Pueblos, Inc. $88,310 $17,875

NM 04 Jicarilla Apache Nation $99,520 $31,690 $17,533

NM 05 Laguna Rainbow Corporation $127,490 $44,370 $16,610

NM 06 Mescalero Apache Tribe $88,310 $9,161

NM 07 Pueblo de Cochiti $77,770 $19,010 $6,618

NM 09 Pueblo of Isleta $110,070 $38,040 $20,044

NM 10 Pueblo of Jemez $99,520 $31,690 $7,194

NM 11 Pueblo of San Felipe $99,520 $31,690 $19,106

NM 12 Pueblo of Taos $99,520 $31,690 $8,611

NM 13 Zuni Tribe $127,490 $44,370 $24,296

NM 14 Ohkay Owingeh Senior Citizens Program $127,490 $44,370 $12,771

NM 15 Santa Clara Pueblo $167,410 $50,710 $16,964

NM 16 Santo Domingo Pueblo $127,490 $44,370 $13,753

NM 17 Pueblo of Tesuque $68,540 $12,670 $5,948

NM 18 Pueblo of Acoma $88,310 $25,350 $11,580

NM Total Total $1,852,480 $526,080 $234,118

NV 01 Fallon Paiute-Shoshone Tribes $77,770 $19,010 $18,149

75 
State Tribe No. Grantee Name TITLE6 A/B TITLE6 C NSIP

NV 02 Inter-Tribal Council of Nevada, Inc. (McDermitt, etc.) $77,770 $19,010 $6,634

NV 03 Inter-Tribal Council of Nevada, Inc. (Duckwater, etc.) $77,770 $19,010 $3,421

NV 04 Inter-Tribal Council of Nevada, Inc. (Ely, etc.) $68,540 $12,670 $5,699

NV 05 Shoshone-Paiute Tribes $77,770 $19,010 $7,144

NV 06 Walker River Paiute Tribe $77,770 $8,692

NV 07 Washoe Tribe of Nevada and California $77,770 $19,010 $40,718

NV 08 Yerington Paiute Tribe $68,540 $6,392

NV 09 Pyramid Lake Paiute Tribe $88,310 $25,350 $4,731

NV 10 Elko Band Council $68,540 $12,670 $6,994

NV 11 Reno-Sparks Indian Colony $77,770 $19,010 $11,443

NV Total Total $838,320 $164,750 $120,017

NY 01 St. Regis Mohawk Tribe $127,490 $44,370 $9,214

NY 02 Seneca Nation of Indians $127,490 $44,370 $15,244

NY 04 Oneida Indian Nation $68,540 $12,670 $3,588

NY 05 Shinnecock Indian Nation $68,540 $12,670 $3,902

NY Total Total $392,060 $114,080 $31,948

OK 01 Apache Tribe of Oklahoma $127,490 $44,370 $7,483

OK 02 Caddo Nation of Oklahoma $77,770 $19,010 $2,480

OK 03 Cherokee Nation $168,476 $52,979 $38,827

OK 04 Cheyenne & Arapaho Tribes $127,490 $44,370 $10,474

OK 06 Choctaw Nation of Oklahoma $167,410 $50,710 $30,957

OK 07 Citizen Potawatomi Nation $167,410 $50,710 $11,218

OK 08 Comanche Nation $127,490 $44,370 $17,103

OK 09 Delaware Nation $78,960 $12,670 $6,906

OK 10 Iowa Tribe of Oklahoma $127,490 $44,370 $8,932

OK 12 Kickapoo Tribe of Oklahoma $100,000 $19,010 $14,905

OK 13 Kiowa Tribe of Oklahoma $127,490 $44,370 $6,168

OK 14 Miami Tribe of Oklahoma $110,070 $38,040 $26,233

OK 15 Muscogee (Creek) Nation $167,410 $50,710 $141,246

OK 17 Otoe-Missouria Tribe of Indians $70,000 $12,670 $7,993

OK 18 Ottawa Tribe of Oklahoma $127,490 $44,370 $28,554

OK 19 Pawnee Nation of Oklahoma $80,000 $19,010 $10,964

OK 20 Peoria Tribe of Indians of Oklahoma $99,520 $31,690 $12,032

OK 21 Ponca Tribe of Oklahoma $77,770 $19,010 $9,393

OK 22 Quapaw Tribe of Oklahoma $110,070 $38,040 $18,539

OK 23 Sac and Fox Nation $77,770 $19,010 $11,990

OK 24 Seminole Nation of Oklahoma $167,410 $50,710 $13,139

OK 25 Seneca-Cayuga Tribe of Oklahoma $127,490 $44,370 $2,709

OK 26 Wichita and Affiliated Tribes $127,490 $44,370 $7,612

OK 27 Wyandotte Nation $127,490 $44,370 $16,323

OK 28 Absentee Shawnee Tribe $167,410 $50,710 $27,080

OK 29 Fort Sill Apache Tribe $99,520 $31,690 $6,187

OK 31 United Keetoowah Band of Cherokee Indians $127,490 $44,370 $18,047

OK 32 Chickasaw Nation $167,410 $50,710 $108,488

OK 33 Kaw Nation $77,770 $21,697

OK 34 Osage Nation of Oklahoma $167,410 $50,710 $60,213

OK 35 Delaware Tribes of Indians $127,490 $4,517

OK 36 Alabama-Quassarte Tribal Town $68,540 $12,670 $538

OK Total Total $3,870,496 $1,124,169 $708,947

OR 01 Confederated Tribes of Siletz Indians of Oregon $99,520 $31,690 $1,006

OR 02 Confederated Tribes of the Umatilla Indian Reservation $110,070 $38,040 $7,792

OR 03 Confederated Tribes of Warm Springs $99,520 $31,690 $38,651

OR 04 Confederated Tribes of Grand Ronde $88,310 $25,350 $10,312

OR 05 The Klamath Tribes $127,490 $44,370 $3,074

OR 06 Confed. Tribes of Coos, Lower Umpqua & $77,770 $19,010 $7,034

OR Total Total $602,680 $190,150 $67,869

RI 01 Narragansett Indian Tribe $88,310 $25,350 $2,033

RI Total Total $88,310 $25,350 $2,033

SC 01 Catawba Indian Nation Eldercare Program $77,770 $19,010 $6,626

76 
State Tribe No. Grantee Name TITLE6 A/B TITLE6 C NSIP

SC Total Total $77,770 $19,010 $6,626

SD 01 Cheyenne River Elderly Nutrition Services, Inc. $127,490 $44,370 $9,928

SD 02 Crow Creek Sioux Tribe $77,770 $16,525

SD 03 Lower Brule Sioux Tribe $77,770 $19,010 $12,594

SD 04 Oglala Sioux Tribe $167,410 $50,710 $116,421

SD 05 Rosebud Sioux Tribe $167,410 $50,710 $61,220

SD 06 Sisseton Wahpeton Oyate of $127,490 $28,868

SD 08 Yankton Sioux Tribe $88,310 $25,350 $8,251

SD Total Total $833,650 $190,150 $253,807

TX 01 The Alabama-Coushatta Tribe of Texas $77,770 $19,010 $8,177

TX 02 Kickapoo Traditional Tribe of Texas $68,540 $14,784

TX Total Total $146,310 $19,010 $22,961

UT 01 Ute Indian Tribe, Unitah & Ouray $88,310 $25,350 $6,565

UT Total Total $88,310 $25,350 $6,565

WA 01 Confederated Tribes of the Colville Reservation $127,490 $44,370 $13,869

WA 02 Lower Elwha Klallam Tribe $77,770 $19,010 $6,243

WA 03 Lummi Tribe $110,070 $38,040 $13,440

WA 04 Makah Nation $77,770 $19,010 $7,524

WA 05 Muckleshoot Indian Tribe $127,490 $44,370 $27,044

WA 09 Puyallup Tribe of Indians $127,490 $5,229

WA 10 Quinault Indian Nation $99,520 $31,690 $23,560

WA 13 Swinomish Indian Tribal Community $68,540 $12,670 $5,842

WA 14 Spokane Tribe of Indians $77,770 $19,010 $13,139

WA 16 The Tulalip Tribes $127,490 $10,875

WA 17 Jamestown S'Klallam Tribe $77,770 $19,010 $2,196

WA 19 Quileute Tribal Council $77,770 $19,010 $4,733

WA 20 S. Puget Intertribal Planning Agency - Shoalwater Bay $88,310 $25,350 $6,482

WA 21 Stillaguamish Tribe of Indians $88,310 $25,350 $790

WA 22 Upper Skagit Indian Tribe $68,540 $12,670 $2,447

WA 24 The Suquamish Tribe $88,310 $25,350 $47,113

WA 25 Port Gamble S'Klallam Tribe $68,540 $12,670 $3,252

WA 26 Samish Indian Nation $77,770 $19,010 $2,441

WA 27 Cowlitz Indian Tribe $88,310 $25,350 $4,724

WA 28 Skokomish Indian Tribe $88,310 $25,350 $2,271

WA 29 Confederated Tribes of the Chehalis Reservation $88,310 $25,350 $2,311

WA 30 Nooksack Indian Tribe $77,770 $19,010 $7,900

WA 31 Yakama Nation $68,540 $12,670 $2,703

WA 32 Snoqualmie Tribe $68,540 $12,670 $260

WA 33 S. Puget Intertribal Planning Agency - Nisqually $110,070 $38,040 $3,435

WA 34 S. Puget Intertribal Planning Agency - Squaxin Island $68,540 $12,670 $11,909

WA Total Total $2,315,110 $557,700 $231,732

WI 01 Bad River Band of Lake Superior Chippewa $77,770 $19,010 $11,028

WI 02 Forest County Potawatomi Community $77,770 $19,010 $13,357

WI 03 Lac Courte Oreilles Band of Lake Superior Chippewa $88,310 $25,350 $10,068

WI 04 Lac du Flambeau Band of Lake Superior Chippewa $88,310 $25,350 $20,275

WI 05 Menominee Indian Tribe of Wisconsin $127,490 $44,370 $1,567

WI 06 Oneida Tribe Elder Services $127,490 $44,370 $6,467

WI 07 Red Cliff Band of Lake Superior Chippewa $77,770 $19,010 $13,403

WI 08 St. Croix Chippewa Indians of Wisconsin $77,770 $19,010 $4,067

WI 09 Stockbridge-Munsee Community $77,770 $19,010 $2,199

WI 10 Ho-Chunk Nation $99,520 $31,690 $10,372

WI Total Total $919,970 $266,180 $92,803

WY 01 Northern Arapaho Tribe $77,770 $9,709

WY 03 Eastern Shoshone Tribe $88,310 $11,635

WY Total Total $166,080 $21,344

Total Total Total $25,746,056 $6,023,189 $3,269,944

77