EVALUATION OF THE 

ACL TITLE VI PROGRAMS 

FINAL REPORT

March 2021
MEANINGFUL STAKEHOLDER ENGAGEMENT

II EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT
TABLE OF CONTENTS

BACKGROUND 1

WHAT IS TITLE VI? 1

PREPARING TO EVALUATE: ACL TITLE VI EVALUABILITY ASSESSMENT 2

WHAT IS THE EVALUATION OF THE ACL TITLE VI PROGRAMS? 4

TITLE VI EVALUATION GRANTEES MAP 6

EVALUATION TIMELINE 7

KEY ACHIEVEMENTS 8

EVALUATION TRAINING AND TECHNICAL ASSISTANCE 9

MEANINGFUL STAKEHOLDER ENGAGEMENT 15

INSIGHTS: TRAINING AND TECHNICAL ASSISTANCE 19

METHODS 21

WHAT WE’VE LEARNED 26

PROGRAM CONTEXT 26

PROGRAM IMPLEMENTATION 28

WHO IS A CAREGIVER? 36

PROGRAM IMPACT 39

IMPACT OF COVID-19 AND TITLE VI EVALUATION GRANTEE RESPONSE 47

DISCUSSION 51

COULD TITLE VI REDUCE HEALTHCARE COSTS? 55

RECOMMENDATIONS 56

REFERENCES 61

APPENDICES

A.TITLE VI EVALUATION LOGIC MODEL 

B.METHODS (COMPREHENSIVE) 

C.TABLE OF ENGAGEMENT ACTIVITIES 

This report was prepared by ICF for the U.S. Department of Health and Human Services 

(HHS), Administration for Community Living (ACL)/Administration on Aging (AoA) under 

contract number HHSP233201750007A. 

ICF would like to acknowledge the invaluable contributions of many individuals from ACL, 

the Title VI Evaluation Steering Committee, and the Evaluation Working Group that provided 

guidance and feedback throughout the evaluation, as well as the members of the ICF 

evaluation team. 

In addition, we would like to acknowledge and thank the 12 tribes and organizations serving 

Indigenous elders that participated in the evaluation.

Title VI Evaluation Working Group

Jolene Birchum

Sara Candelaria

Miguel Cordova

Karen Eddy

Alyssa Ford

Joseph Fragua

Wilson Green

Alfred Harney

Marisela Hernandez

Jeffrey Jojola

Rita Jojola

Dorothy Kawaglia

Christina Lente

Angie Matt

Dorece McKinney

Raynell Miller

Arlene Naganashe

Monica Naranjo

Tamela OkulyShananaquet

Angel Pacheco

Nikki Pollock

Mary Roberts

Frederick Sabaquie Jr.

Sara Tadgerson

Leslie Tanoue

Diane Teeple

Sharon Teeple

Titania Tenoria

Monica Toya

Christopher Whistler

Nathan Whistler 

Administration for Community Living

Kristen Hudgins

Susan Jenkins

Cynthia LaCounte

Kristen Robinson

Title VI Evaluation Steering Committee

Collette Adamsen

Laurai Atcitty

Kathryn Braun

Bonnie Carroll-Ginnis

Paula Carter

Larry Curley

James DeLacruz

Wendell Holt

Brenda House

Rita Jojola

Karen Leekity

Jordan Lewis

Jean Lloyd

Angie Matt

Elizabeth Meahl

Marianne Mills

Charmaine Mix

Shelley Muneoka

Nikki Pollock

Leslie Tanoue

Mary Wolf

Shelly Zylestra

ACKNOWLEDGMENTS 

ICF Evaluation Team

Gretchen Clarke

Elizabeth Douglas

Marnie House

Sofia Campos Vidal Pires

Elizabeth Vaughn 

Recommended Citation 

Administration for Community Living. (2021). Evaluation of the ACL Title VI Programs. Washington, DC: Author.
MEANINGFUL STAKEHOLDER ENGAGEMENT

VI EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT
BACKGROUND

EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT 1

WHAT IS TITLE VI?

In 1965, the Older Americans Act (OAA) was authorized to protect the well-being of older Americans. The 

OAA promotes community and home-based services to support independent living; physical and mental 

health; suitable housing; and restorative services for those requiring institutional care and retirement in 

“health, honor, and dignity” (OAA Title I, Sec. 101: 42 U.S.C. 3001). 

In 1978, the OAA was amended to include home- and community-based supportive services for older 

American Indian, Alaska Native, and Native Hawaiian (AI/AN/NH) populations. This amendment, Title VI, 

recognizes that older AI/AN/NHs are a “vital resource entitled to all benefits and services available” (OAA Title 

VI, Sec. 602: 42 U.S.C. 3057a). 

Title VI provides nutrition and supportive services for elders, including congregate and home-delivered 

meals, information referral services, transportation, and other services. The program also provides caregiver 

services for individuals providing care for elders or for elders raising grandchildren or caring for adult children 

with disabilities. Services include information and outreach, respite care, and other related services. 

SUPPORTING ELDERS AND CAREGIVERS

Title VI provides services through three programs: Part A (Indian Program), Part B (Native Hawaiian Program), 

and Part C (Native American Caregiver Support Program).

BACKGROUND

The Administration for Community Living (ACL) within the Administration on Aging (AoA), administers the Title 

VI programs. For the 2017–2020 grant cycle, ACL awarded the following grants: 

270 233 3-year grants for Nutrition and 

Supportive Services 

3-year grants for the Caregiver 

Support Program 

In 2017, ACL contracted ICF to conduct the Evaluation of ACL’s AI/AN/NH Title VI Grant Program. This report 

presents a comprehensive summary of findings from all 5 years of the evaluation.

NUTRITION AND SUPPORTIVE SERVICES FOR ELDERS

Part A—Serves federally recognized tribes with at 

least 50 members ages 60 years and older.

▶ Congregate and home-delivered meals

▶ Information and assistance

▶ Case management

▶ Transportation

▶ Health promotion

▶ Other supportive services (e.g., homemaker, personal care, legal assistance) 

Part B—Serves public or nonprofit organizations 

that serve Native Hawaiians and represent at least 

50 individuals ages 60 years and older.

CAREGIVER SUPPORT SERVICES

Part C—Serves all programs with Parts A or B, 

providing support to caregivers of elders, elders 

caring for adult children with disabilities, and 

grandparents raising grandchildren.

▶ Information and outreach

▶ Access assistance

▶ Counseling, training, and support groups

▶ Respite services

▶ Other supplemental 

services
2 EVALUATION OF THE ACL TITLE VI PROGRAMS — FINAL REPORT

PREPARING TO EVALUATE: 

ACL TITLE VI EVALUABILITY 

ASSESSMENT

Prior to the launch of the evaluation, in 2014, ACL contracted ICF to conduct an evaluability assessment (EA) 

of the Title VI programs. EAs are used to guide and inform investments in evaluation and research. The EA 

was designed to: 

▶ Describe the characteristics, context, activities, 

processes, implementation, and intended 

outcomes of the Title VI nutrition, supportive, 

and caregiver support services 

▶ Assess the feasibility of, and best approaches 

for, conducting a full-scale evaluation of the 

Title VI programs 

As part of the EA, ACL and ICF convened a 20-member stakeholder advisory group (Steering Committee) 

of tribal, local, national, and state partners to the ACL Title VI programs. The Steering Committee provided 

input and guidance on conducting the evaluation in a culturally responsive way. Among other activities, ACL, 

ICF, and the Steering Committee worked together to develop a Title VI program logic model (Appendix A). 

Creating the logic model helped the team develop a shared understanding of the Title VI programs, including: 

▶ Resources and activities intended to meet 

program goals

▶ Extent of program implementation 

The EA also helped ACL jointly explore, with the Steering Committee, how Title VI program activities support 

the dignity, self-respect, and cultural identity of tribal and Indigenous1

 elders and communities (ACL, 2015). 

Because many Indigenous communities do not conceptualize their programming in the linear frame laid out 

by a logic model, ACL, ICF, and the Steering Committee also collaborated to develop a medicine wheel for 

the Title VI programs representing the four quadrants of Indigenous practice: spiritual, mental, emotional, 

and physical (Figure 1). Each quadrant is housed within the context of community, family/friends, and 

intergenerational connection—reflecting the importance and interconnectedness of each to the spiritual, 

mental, emotional, and physical well-being of Indigenous communities and elders and to the overall goals of 

the Title VI programs. In addition, each quadrant of the medicine wheel reflects the expected outcomes of the 

Title VI programs on program participants.

The medicine wheel was developed to: 

▶ Ensure that the evaluation would be anchored 

in and reflective of the cultures, values, and 

traditions of the Indigenous communities 

receiving Title VI program funds

▶ Ensure that the dimensions of well-being 

identified by Indigenous stakeholders 

were defined

▶ Operationalize the measurement of these 

dimensions and concepts (ACL, 2015). 

By emphasizing the interconnectedness of elders’ well-being to that of family and community, the Title VI 

program medicine wheel helped to ground the Evaluation of the ACL Title VI programs within the framework 

of an Indigenous worldview (LaFrance & Nichols, 2010). The medicine wheel also helped the evaluation 

team think holistically about the different domains that the Title VI Programs impact and how to meaningfully 

assess, in a culturally respectful way, Title VI outcomes.

1

With respect for racial, ethnic, and cultural identity, all instances of “Indigenous” are capitalized throughout this report.
EVALUATION OF THE ACL TITLE VI PROGRAMS — FINAL REPORT 3

FIGURE 1. TITLE VI EVALUATION MEDICINE WHEEL

▶ Increase in empowerment

▶ Increase in cultural/ 

community integration

▶ Ability to maintain 

independence

▶ Decrease in risk of 

nursing home placement

▶ Increase in staff knowledge 

and skills

▶ Decrease in mental overload 

▶ Increase in social contacts

▶ Increase in social 

connectedness

▶ Decrease in social 

isolation

▶ Increase in physical safety

▶ Increase in food security

▶ Maintenance of overall health

▶ Maintenance of nutritional intake

▶ Maintenance of 

meal/service satisfaction

▶ Maintenance of 

physical activity
BACKGROUND

4 EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT

WHAT IS THE EVALUATION OF THE ACL TITLE VI PROGRAMS?

Forty years after the federal government established 

Title VI under the OAA, the Evaluation of the ACL Title 

VI Programs provided an opportunity to understand the 

value and impact that Title VI programs have had on 

elder program participants, caregivers of elders, elders 

raising grandchildren or caring for adult children with 

disabilities, and program staff. The evaluation included an 

implementation study and an outcomes study.

The evaluation used a mix of information that grantees 

already collect (i.e., secondary data) as well as new 

sources of information (i.e., primary data) to describe the 

implementation and outcomes across nutrition services, 

supportive services, and caregiver support services.

Title VI Grantees

In collaboration with ACL and the Steering Committee, ICF recruited Title VI grantees to participate in the 

evaluation. On May 16, 2017, ICF and ACL released a request for proposals (RFP) to all Title VI program 

grantees. Written with guidance from the Steering Committee, the RFP included a simple, user-friendly form 

for interested grantees to complete. ICF hosted a webinar for all Title VI directors to introduce the evaluation, 

including timeline, confidentiality and data ownership, and requirements for participation. During the webinar, 

ICF walked attendees through the RFP and answered questions. To further support engagement, ICF and 

ACL developed a one-pager and a frequently asked questions (FAQ) document that grantees could share with 

their tribal or governing body. The application requested a letter of support from grantees’ tribal governing 

council chair or administrator. 

Ultimately, 12 Title VI grantees representing 4 Title VI regions and 6 states participated in the evaluation. ACL 

provided funding to compensate tribes for participation in the evaluation, including costs associated with 

participant recruitment, data collection, and analysis/dissemination efforts. In addition, ACL and ICF provided 

grantees with training and technical assistance (TTA) to meet their own data needs. 

SNAPSHOT OF THE EVALUATION OF THE ACL TITLE VI PROGRAMS

1. How do tribes2 operate their Title VI 

programs?

2. What is the effect of Title VI programs 

on elders in the community? Are there 

differences nationally or by tribe/tribal 

groups?

3. Do Title VI programs that rely only on

Title VI funds have a different impact

than programs that have money from

other programs or agencies? 

Primary Data

• Staff, Caregiver, Elder Focus

Groups

• Staff, Elder Interviews

Secondary Data

• Elder Needs Assessment

• Title VI Program Survey

• Program Performance Reports

• Title VI Applications

TWO STUDIES: 

IMPLEMENTATION 

& OUTCOMES

EVALUATION 

QUESTIONS

REPORTING & 

DISSEMINATION

IMPLEMENTATION STUDY 

The purpose of this study was 

to understand the context of 

the Title VI programs, including 

barriers and facilitators to 

program implementation.

OUTCOMES STUDY 

This study assessed the impact of 

the Title VI programs, particularly 

on elders and the community.

2Although ACL frequently uses “tribes” to reference Title VI grantees, it is recognized that Title VI grantees include tribes, tribal organizations, and organizations serving NHs.
EVALUATION OF THE ACL TITLE VI PROGRAMS — FINAL REPORT 5

ETHICAL CONSIDERATIONS 

AND REGULATORY REVIEW

Office of Management and 

Budget Clearance

In 2017, ICF prepared an Evaluation of the ACL 

Title VI Programs Office of Management and 

Budget (OMB) Information Collection Request 

package. The OMB package included standard 

forms; a comprehensive supporting statement; 

60- and 30-day Federal Register notices; and a 

list of attachments, including the data collection 

instruments. The summary statement described 

the objectives of the Evaluation of the ACL Title VI 

Programs, the evaluation questions being pursued, 

and the data elements to be collected. OMB 

approved the evaluation on February 5, 2018.

Institutional Review Board Review 

and Approval

To ensure the protection of human subjects, 

including the confidentiality of data compiled 

and collected during the evaluation, the ICF 

Institutional Review Board (IRB) reviewed the 

data collection protocols and instruments prior 

to the collection of protected data. This review 

ensured compliance with the spirit and letter of 

U.S. Department of Health and Human Services 

regulations governing such projects. The ICF IRB 

approved the evaluation, which included both 

the original protocol (approved on March 1, 2017) 

and a modified protocol (approved on February 9, 

2018). ICF also received continuing annual review 

approvals (on January 15, 2019; November 25, 

2019; and October 9, 2020).

Local-Level Tribal Review and Approval

In addition to the ICF IRB, ICF worked with each 

evaluation grantee to identify and obtain the 

local-level approvals necessary to participate 

in the Evaluation of the ACL Title VI Programs 

through an IRB, institution at large, or other 

governing or advisory body, such as the tribal 

council. Each of the evaluation grantees obtained 

a letter of commitment from its respective 

governing body, as well as a tribal resolution, and 

signed a data transfer agreement confirming the 

tribe’s commitment to participate in the evaluation 

and share its Title VI data with ICF. 

Evaluation Working Group

The evaluation grantees formed a new 

stakeholder group—the Evaluation Working 

Group (EWG). Each grantee identified two 

to three staff members from their Title VI 

program to serve on the EWG throughout 

the 3-year period, including the Title VI 

program director and one or two other 

staff members to serve as “community 

researchers.” The community researcher, 

in collaboration with the program director, 

was the local Title VI staff member who 

supported the evaluation team with 

participant recruitment and data collection. 

EWG members:

Attended the annual EWG in-person 

meetings and virtual trainings

Participated in quarterly technical 

assistance calls with evaluation 

liaisons

Recruited participants to take part in 

focus groups and interviews

Provided local-level insight 

to support data analysis and 

interpretation.

In addition, Title VI directors (and other 

Title VI staff) participated in an interview 

and a focus group to share their experience 

with the Title VI program, including 

operations, successes, and challenges.

ACL and ICF met regularly 

with the EWG to share updates 

regarding the evaluation and to 

seek guidance on next steps, 

such as appropriate methods for 

recruiting elders and caregivers 

for focus groups. The EWG 

provided important cultural and 

topical expertise, and advised 

on local data collection and TTA 

needs, interpretation of evaluation 

data, and approaches to 

disseminate evaluation findings.
BACKGROUND

6 EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT

1. Fairbanks Native Association; 

Fairbanks, Alaska

2. Orutsararmiut Native Council;

Bethel, Alaska

3. ALU LIKE, Inc.; Honolulu, Hawaii

4. Bay Mills Indian Community; 

Bay Mills, Michigan

5. Little Traverse Bay Bands of Odawa 

Indians; Harbor Springs, Michigan

6. Shoshone-Paiute Tribes; 

Owyhee, Nevada

7. Walker River Paiute Tribe; Schurz, Nevada

8. Eight Northern Indian Pueblos Council; 

 Ohkay Owingeh, New Mexico

9. Pueblo of Isleta; Isleta, New Mexico

10. Pueblo of Jemez; 

Jemez Pueblo, New Mexico

11. Pueblo of San Felipe; 

San Felipe Pueblo, New Mexico

12. Spokane Tribe of Indians; 

Wellpinit, Washington

12 Grantees

Title VI Regions 4 Represented (X, IX, VI, V) 

States 

Represented 

(Alaska, Hawaii, Michigan, Nevada, 

New Mexico, Washington)

6 

TITLE VI EVALUATION GRANTEES MAP
BACKGROUND

EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT 7

ELIGIBILITY CRITERIA 

Title VI grantees eligible to participate in the Evaluation of the ACL Title VI Programs included those that met 

the following criteria: 

▶ Received Title VI Part A/B awards on April 1, 2017 (with or without Part C)

▶ Participated in the 2016 National Resource Center on Native American Aging/University of North Dakota 

(NRCNAA/UND) Identifying Our Needs: A Survey of Elders assessment (NRCNAA Elder Needs Assessment)

▶ Had a signed Tribal Resolution permitting the tribal organization to (1) apply for participation in the 

Evaluation of the ACL Title VI Programs and (2) share the tribe’s NRCNAA Elder Needs Assessment 2016 

and 2019 data with ICF

▶ Were able to identify 2–3 program staff representatives to participate in the EWG, including the Title VI 

program director and at least one other person to be known as the community researcher, who would organize 

evaluation efforts in the community with support and guidance from the evaluation team

EVALUATION TIMELINE

The Title VI evaluation spanned 5 years. The first year (2016–2017) focused on evaluation planning and 

preparation for data collection, including recruiting grantees to participate in the evaluation. Years 2–4 

focused on data collection, TTA provision, and evaluation capacity building. The final year of the evaluation, 

year 5, included continued TTA and final data analyses and reporting. 
8 EVALUATION OF THE ACL TITLE VI PROGRAMS — FINAL REPORT

KEY ACHIEVEMENTS 

A PR I L 20 17 

Data analysis plan and 

IT security plan

JULY 2017

Evaluation grantees 

announced and Notice 

of Awards 

SEPTEMBER 2017

• First in-person EWG 

meeting and training

• Steering Committee 

in-person meeting at the 

National Title VI Training 

and Technical Assistance

Conference

• Tribal-level approvals for

accessing Cycle VI Elder 

Needs Assessment data

FEBRUARY 2018

• Year 1 Interim Report

• OMB approval 

• ICF IRB continuing 

approval 

• EWG webinar 

AUGUST 2017

Kicko call with the 

evaluation grantees

SEPTEMBER 15,

2016

Evaluation kickoff 

N OVEMBER 2016

Final evaluation plan

JANUARY 2017

Final data collection

instruments

MARCH 2017 

• ICF IRB approval 

• Final evaluation TTA plan

M AY 20 17 

• Webinar for Title VI 

directors

• RFP for Title VI grantees 

to participate in the 

evaluation

NOVEMBER 2017

Presentation at the 

American Public Health 

Association Annual Meeting

FEBRUARY–

MARCH 2018

Title VI program sta 

interviews 

M A RCH 20 1 8 

On-site data analysis 

at NRCNAA

MAY–JUNE 2018

Year 1 site visits, including 

focus groups and 

interviews with elders and 

evaluation and data needs 

assessments 

AU G US T 20 1 8 

• Second in-person EWG 

meeting and training

• Steering Committee 

in-person meeting at the 

National Title VI Training 

and Technical Assistance

Conference

NOVEMBER 2018

EWG webinar 

JANUARY 2019

• ICF IRB continuing 

approval

• Steering Committee

webinar 

FEBRUARY 2019

EWG webinar 

MARCH 2019

Year 2 Interim Report 

MARCH–MAY 2019

Year 2 site visits, 

including focus groups 

and interviews with 

caregivers, an evaluation 

needs assessment, and 

a caregiver program 

assessment

JULY 2019

Title VI Evaluation Toolkit 

and the Title VI Infographic 

Toolkit developed

AUGUST 2019

• Third in-person EWG 

meeting and training

• Steering Committee 

in-person meeting at the 

National Title VI Training 

and Technical Assistance

Conference

O C TO B E R 20 1 9 

• EWG webinar 

• Presentation at the 

American Evaluation

Association national 

conference

NOVEMBER 2019

ICF IRB continuing approval

JANUARY 2020

Steering Committee 

webinar

FEBRUARY 2020

Tribal-level approvals for 

accessing Cycle VI/VII Elder 

Needs Assessment data

MARCH 2020

• Year 3 Interim Report 

• ICF IRB modifi cations

approval 

JUNE 2020

Year 3 program sta 

interviews 

AUGUST 2020

• Data triangulation 

sessions with ACL

• Webinar for Title VI 

directors

• Title VI Evaluation Toolkit 

shared with all Title VI 

grantees

SEPTEMBER 2020

Manuscript submitted to an 

academic journal for peer 

review

O C TO B E R 2020 

• Virtual EWG meeting and

training

• Webinar for Title VI 

directors

• Title VI Infographic Toolkit 

shared with all Title VI 

grantees

• ICF IRB continuing 

approval

FEBRUARY 2021

Briefi ngs with Title VI 

stakeholders 
TRAINING AND TECHNICAL ASSISTANCE

EVALUATION OF THE ACL TITLE VI PROGRAMS — FINAL REPORT 9

As part of the Evaluation of the ACL Title VI 

Programs, ICF provided TTA to support grantees’ 

engagement in the evaluation and to build 

local understanding and use of program data 

for program monitoring and improvement. To 

ensure cultural responsiveness, ICF used a 

comprehensive and tailored approach to TTA, 

including (1) an assigned evaluation liaison for 

each grantee, (2) quarterly technical assistance 

calls, (3) annual site visits, (4) virtual and in-person 

trainings, and (5) evaluation tools and resources. 

ICF’s TTA was designed to provide holistic support 

to grantees in developing evaluation capacity and 

integrating monitoring and evaluation into their 

local programming. 

EVALUATION TRAINING 

AND TECHNICAL ASSISTANCE

Aligned with the concept of a culturally 

responsive evaluator serving as “a 

trusted teacher who can help facilitate 

capacity building with the community 

being evaluated and the project 

members carrying out the grant or 

program being evaluated,” ICF assigned 

a dedicated evaluation liaison to each 

evaluation grantee (Bowman et al., 2015).
10 EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT

EVALUATION TRAINING AND TECHNICAL ASSISTANCE

UNDERSTANDING GRANTEES’ NEEDS

To develop trainings and materials that would support data collection, empower and build evaluation capacity, 

and support the use and dissemination of evaluation findings, ICF first assessed grantees’ evaluation capacity. 

This process allowed ICF to better understand grantees’ needs and questions related to program monitoring 

and evaluation. The ICF evaluation team used several assessment methods, including: 

▶ Evaluation and data needs assessment—The ICF team conducted an evaluation and data needs 

assessment to catalog information related to grantees’ program stakeholders, goals and related outcomes 

and measures, service delivery, and evaluation and data support needs. The needs assessment supported 

understanding of the grantees’ evaluation and data processes, including strengths and barriers to 

implementation. The assessments were conducted during the year 1 site visits through conversations with 

program directors and staff as well as direct program observation. Grantees also provided examples of 

their tracking and monitoring forms, including meal preparation tracking sheets, participation sign-in sheets, 

home-delivered meal and transportation mileage logs, and elder satisfaction surveys.

▶ Evaluation tool needs assessment—During the year 2 site visits, ICF facilitated conversations with 

grantees to understand what evaluation tools or resources would be useful for them, such as “off-the-shelf” 

evaluation tools that they could use to assess their program, including elders’ and caregivers’ needs 

and satisfaction with program services. ICF liaisons provided examples of possible evaluation tools (e.g., 

surveys, talking circle guides, interview guides, and checklists) to support grantees in identifying what tools 

would and would not be useful to them. In addition, liaisons asked grantees what questions they had about 

their program to understand the type of information the evaluation tool(s) should be designed to gather. 

▶ Quarterly liaison calls—ICF liaisons met quarterly with the Title VI grantees participating in the evaluation 

(evaluation grantees). The calls provided additional opportunities to continue conversations begun during 

the site visits and to further understand grantees’ evolving evaluation capacity and questions related to 

local program evaluation.

ASSESSMENT PROCESS

EVALUATION 

AND DATA NEEDS 

ASSESSMENT

UNDERSTANDING 

OF GRANTEE NEEDS

ACTIONABLE TOOLS 

AND SUPPORTS
EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT 11

EVALUATION TRAINING AND TECHNICAL ASSISTANCE

ONE-ON-ONE SUPPORT

ICF facilitated grantee participation in the evaluation with one-on-one technical assistance. Through 

assigned evaluation liaisons who served as dedicated points of contact for the evaluation grantees, ICF 

developed trusting professional relationships with the grantees, which facilitated their active engagement 

and ensured a more culturally responsive evaluation.

Assigned Evaluation Liaisons

ICF assigned an evaluation liaison to each evaluation grantee. Liaisons supported grantees in data collection 

efforts within their communities, provided tailored TTA related to data collection and analysis, reviewed 

grantees’ data with them to illustrate approaches to analysis and use, and served as a regular connection to 

and resource on the evaluation.

Technical Assistance Calls

Starting in the first year of the evaluation, ICF liaisons held quarterly one-on-one calls with evaluation 

grantees. The calls were an opportunity for liaisons and program staff to get to know one another, to learn 

more about the services provided by the local Title VI programs and any challenges, as well as to further 

understand grantees’ evolving evaluation capacity and questions related to local program evaluation. The 

calls were also an opportunity to collaboratively plan annual site visit agendas and activities.

In-Person Site Visits

ICF conducted site visits in the first and second years of the evaluation to better understand local-level 

programs and to facilitate data collection.3

 Prior to the site visits, ICF hosted webinars to support grantees in 

preparing for the visits, and liaisons met one-on-one with grantees to collaboratively plan the visits. The site 

visits provided time for liaisons to better understand the cultural context of grantees’ programs, learn about 

the design and delivery of services and the populations they serve, and provide intensive TTA. During site 

visits, ICF liaisons frequently were invited to meet with tribal leadership and participate in or attend activities, 

such as joining in congregate meals; attending health education presentations; playing bingo with the elders; 

touring the local communities; and participating in group exercise, song and dance, and community wellness 

walks. As described below, the year 1 and 2 site visits focused on the two main Title VI programs.

▶ Year 1 Site Visits, 2018—The year 1 site visits were an opportunity to better understand the context 

and local implementation of Title VI Part A/B, Native American Elder Nutrition and Supportive Services. 

ICF liaisons learned more about the local Title VI programs, community context, service populations, 

infrastructure, and program data needs. ICF also conducted interviews and focus groups with elders 

participating in the congregate and home-delivered meal programs to understand elders’ perceptions of 

the program, including whether and how it meets their needs. 

▶ Year 2 Site Visits, 2019—During the year 2 site visits, ICF worked with the grantees to better understand 

Title VI Part C, Native American Caregiver Support Program. ICF conducted interviews and focus groups 

with informal (i.e., unpaid) caregivers, including caregivers of elders, grandparents raising grandchildren, 

and elders caring for adult children with a disability, to understand their experience with the program, 

including how the program supports them and any unmet needs they may have.

3Although site visits had been planned for spring 2020, due to the COVID-19 pandemic, these site visits had to be canceled. Interviews and other data collection activities with 

Title VI staff were conducted virtually.
12 EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT

TRAININGS

ICF held virtual and in-person trainings to build familiarity, 

understanding, and capacity for evaluation at the local 

program level. Trainings were iterative and built on one 

another to maximize knowledge and skill development.

Virtual Trainings: ICF delivered biannual virtual 

trainings for the EWG throughout the evaluation. The 

webinars were designed to introduce grantees to 

key evaluation concepts and provided a virtual space 

for the ICF evaluation team and grantees to meet 

as a collective group. Topics and trainings included 

preparing for site visits and incorporating evaluation 

into local programming. 

In-Person Meetings: In each year of the evaluation, ICF conducted a full-day, in-person training on evaluationrelated topics for the EWG.4

 The annual meetings provided an opportunity to continue to build relationships 

with grantees as well as offer interactive and hands-on learning on a variety of evaluation topics, such as 

an introduction to program evaluation, data collection methods and analysis approaches, and how to use 

evaluation data for continuous quality improvement. Following best practices of adult learning, ICF integrated 

diverse formats and styles into the trainings to engage grantees with a mixture of presentations, skills 

application, and games to reinforce learning. 

▶ 2017 EWG In-Person Meeting, Prior Lake, 

Minnesota—The first in-person meeting was an 

opportunity for the ICF evaluation team, ACL, 

and grantees to get to know one another and 

begin developing relationships built on trust and 

collaboration. ICF provided an orientation on the 

Title VI evaluation and an introduction to program 

evaluation (Evaluation 101). ICF also facilitated 

discussions to understand the evaluation grantees’ 

experiences with evaluation and their concerns 

and recommendations for the Title VI evaluation. 

Because the evaluation grantees would support 

recruitment of elders and caregivers to participate in 

the evaluation, ICF provided training on protecting 

participants’ rights (human subjects’ protection).

▶ 2018 EWG In-Person Meeting, Washington, D.C.—

Building on feedback provided by the grantees 

following the first in-person meeting and grantee 

evaluation needs identified during the first site 

visit, ICF developed training sessions to build 

understanding of how to use local program data to 

inform program planning. Each session included 

opportunities for grantees to practice their new 

knowledge and skills with hands-on activities. The 

meeting also provided an opportunity to debrief the 

year 1 site visits, including what participants liked, 

learned, and would prefer to see done differently. 

▶ 2019 EWG In-Person Meeting, Minneapolis, 

Minnesota—The third in-person meeting was an 

opportunity to continue to support and grow the 

grantees’ use of evaluation to inform local program 

planning and delivery. ICF provided hands-on training, 

including a review of program evaluation as well as 

sessions on how to read data tables and charts and 

how to conduct thematic analysis of, for example, 

elder intake assessments. During the meeting, ICF 

also introduced new tools developed to further 

support the grantees with local program evaluation.

▶ 2020 EWG Meeting, Virtual—Due to the COVID-19 

pandemic, the fourth EWG annual meeting was 

a virtual event, held over 2 days. Using a digital 

whiteboard and a teleconferencing platform, 

ICF facilitated an interactive meeting in which 

the evaluation team (grantees, ACL, ICF) could 

collaborate in real time. ICF led grantees through 

a data gallery walk to gather insights from the 

grantees on evaluation findings. Grantees reflected 

on key data to identify conclusions (why the 

findings are relevant) and recommendations for 

next steps from their perspective as local program 

implementors. ICF also facilitated an evaluation 

debrief with the grantees to understand the 

grantees’ overall experiences participating in the 

Evaluation of the ACL Title VI Programs. 

4Although an in-person meeting was planned for 2020, it was delivered as a virtual training due to the COVID-19 pandemic.

VIRTUAL TRAINING TOPICS

▶ Evaluation Grantee Kickoff and Welcome

▶ Prepping for Your Year 1 Site Visit—Elder 

Focus Groups

▶ Everyday Evaluations With Introductions to 

Surveys, Focus Groups, and Interviews

▶ Preparing for Your Second Site Visit—

Caregiver Focus Groups 

▶ Using the Title VI Evaluation Tool and 

Infographic

EVALUATION TRAINING AND TECHNICAL ASSISTANCE
EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT 13

USER-FRIENDLY TOOLS 

AND RESOURCES

ICF developed tools and resources to support 

grantees in better understanding the role of 

evaluation in program planning and identifying 

opportunities for incorporating evaluation within 

their program. Grantees repeatedly shared a 

common need to understand whether and how 

their program services were meeting the needs 

of program recipients, including elders and 

caregivers, as well as a need to showcase the 

depth and breadth of their local Title VI program. 

In response, ICF developed several tools and 

resources to make evaluation accessible and 

relevant for program staff. 

Evaluation one-pagers—ICF developed 

handouts as user-friendly resources to 

accompany evaluation trainings. Handouts used 

plain language and covered a range of topics, 

including program improvement and resources 

for evaluation, which provided information on 

evaluation topics (e.g., program evaluation, data 

collection methods, data analysis, sharing of 

findings) and links to open access evaluation 

resources. ICF also developed separate handouts 

for commonly used evaluation methods, including 

focus groups, interviews, and surveys. These 

one-pagers included a brief introduction to the 

method; a discussion of benefits and limitations; 

considerations for implementation, including 

recruitment and collecting and analyzing results; 

and links/references for additional information. 

The processes we learned helped 

[us] gather more data about our 

elders and the program. We built 

stronger relationships with our 

elders because we learned more 

about them and their needs.” 

—Title VI Program Director

Program 

Improvement 

one-pager, 2019 

BUILDING EVALUATION 

CAPACITY

Trainings were an opportunity 

to build the EWG’s evaluation 

knowledge and skills. Topics 

included: 

▶ Human Subjects’ Protection & 

Participants’ Rights 

▶ Evaluation 101—Using Data to 

Inform Programming

▶ Getting the Most Out of Your 

Program Data

▶ Moderating Focus Groups 

▶ Recruiting for and Administering 

Surveys 

▶ Same Data, Same Message—

Reading and Interpreting Data

▶ Reading Between the Lines—

Basic Thematic Analysis

▶ Sharing Your Findings

▶ Sharing Your Story—Introducing 

the Title VI Infographic Toolkit 

EVALUATION TRAINING AND TECHNICAL ASSISTANCE
14 EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT

Title VI Evaluation Toolkit—ICF developed the Evaluation Toolkit as a ready-to-use resource to help grantees 

assess the needs and satisfaction of their elders and caregivers with program services. It includes:

▶ Two surveys—to assess elder and caregiver use and satisfaction with program services (Nutrition and 

Supportive Services Elder Survey and Caregiver Survey).

▶ Survey response spreadsheet—to help program staff analyze survey responses with autogenerated data 

visualizations (e.g., tables and charts).

▶ User guide—to help program staff with step-by-step guidance through each stage of the evaluation 

process, from planning to collecting data to reviewing and using their findings. 

Title VI Infographic Toolkit—The infographic toolkit was developed to help Title VI program staff summarize 

and share their program data in a visual and engaging way. Grantees can input their local program data, 

including their program performance and reporting (PPR) data and their NRCNAA Elder Needs Assessment 

data, to generate a tailored infographic that they can use to support local stakeholder engagement and 

program monitoring. The toolkit includes: 

▶ Title VI infographic—Sections include an overview of Title VI, a profile of elders’ health based on local data, 

localized data on program delivery, and program improvement practices.

▶ Data worksheet—An Excel worksheet to support grantees in calculating their program data for the infographic. 

▶ User guide—The guide provides step-by-step instructions to support grantees in using the infographic.

LISTENING AND REFINING 

Although TTA was developed after assessing grantee needs, it was important to understand whether the 

trainings and resources ultimately met the needs of grantees. ICF regularly encouraged grantees to share 

their feedback on TTA provided, including the utility of the information as well as their satisfaction with the 

delivery mechanism(s). ICF liaisons facilitated debriefs at the conclusions of site visits, webinars, and the EWG 

annual meetings. Grantee feedback was used as part of a continuous quality improvement cycle and informed 

the next iteration of trainings and resource and tool development. For example, the Title VI evaluation and 

infographic toolkits were shared with the EWG in August 2019. As the EWG used the tools, ICF compiled and 

used their feedback to refine the tools before they were shared with all Title VI grantees in the fall of 2020.

We completed input of the 27 surveys for 

Nutrition and Supportive. [We were] able to 

look at the chart/graphs and find it absolutely 

amazing. It shows us an eye-opening view of 

how our program stands. I love it.” 

—Title VI Program Staff

The tool helped us to realize our success 

and helped with knowing where we can 

improve services.” 

—Title VI Program Director 

I love that they [Title VI Evaluation Toolkit 

and infographic] are customizable and can 

reflect programs. No one-size-fits-all!” 

—Title VI Program Director

The infographic ... will help me paint a 

picture for leadership. Data, such as 

numbers, raw data, is good but to have 

visualization for them to relate to is 

awesome.” 

—Title VI Program Director

In the beginning, I was uncertain as to what the evaluation would entail. Now, I am glad our tribe 

participated because we are so much more informed.” 

—Title VI Program Director

EVALUATION TRAINING AND TECHNICAL ASSISTANCE
EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT 15

MEANINGFUL STAKEHOLDER 

ENGAGEMENT

The Evaluation of the ACL Title VI Programs used a participatory action research approach centered on 

empowerment and community participation.5 ICF and ACL prioritized partnerships with key stakeholders, 

including program participants as well as local, state, and federal agencies that support Title VI programs 

(Figure 2).

PARTICIPATORY ACTION RESEARCH

▶ Promotes a community-driven and culturally responsive approach to evaluation design 

and implementation

▶ Empowers and involves local stakeholders at every step, helping to identify evaluation questions 

important to them and involving stakeholders in interpretation of findings 

▶ Supports local evaluation capacity building

FIGURE 2. TITLE VI STAKEHOLDERS

S

T

E

E

R

I

NG

COMMITT

FEDERAL LEVEL

n4a, National Indian Council on Aging, 

National Resource Centers, ACL

STATE LEVEL

Adult Protective Services, Area 

Agencies on Aging, States’ Units 

on Aging

LOCAL LEVEL

Title VI Program Participants (elders, 

caregivers, staff, tribal services, 

community health representatives)

5Participatory action research is a process of collective inquiry in which evaluators and stakeholders work together to address questions of importance through data collection, 

reflection, and action (Israel, et. al., 1998).
MEANINGFUL STAKEHOLDER ENGAGEMENT

16 EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT

FIGURE 3. THE TITLE VI EVALUATION—A PARTICIPATORY APPROACH

STEERING 

COMMITTEE

▶ Guidance

▶ Program & Cultural 

Expertise

▶ Coordination

▶ Dissemination

ACL

▶ Technical Director

▶ Funder

ICF

▶ TTA

▶ Evaluator

EWG

▶ TTA Needs

▶ Local Expertise

Steering Committee: To ensure meaningful engagement throughout all phases of the evaluation, from 

planning to implementation to dissemination, ICF and ACL convened a 17-member Steering Committee, 

with representatives from each of the three partner levels—local, state, and federal. Over the course of the 

evaluation, the Steering Committee provided input and guidance to ensure each phase of the evaluation 

was culturally responsive. The Steering Committee informed the development of the evaluation plan, data 

collection instruments, and protocols, and provided insight on opportunities to streamline data collection as 

well as strategies to recruit and engage evaluation participants. In addition, the Steering Committee guided 

dissemination by providing insight on specific audiences to target outreach, the most important information, 

and how best to share it with those audiences.

Evaluation Working Group: The Title VI grantees participating in the evaluation formed the EWG. Whereas 

the Steering Committee provided critical input and guidance, especially during the early stages of the 

evaluation, the EWG was central to the implementation. The EWG provided insight on local grantee-specific 

tailoring, including culturally appropriate methods for recruiting elder and caregiver focus group participants 

and local evaluation TTA needs. 

This collaborative approach among the Steering Committee, the EWG, ACL, and ICF (Figure 3) ensured the 

evaluation was meaningful and held, at its center, the needs of those most impacted by Title VI—the Title VI 

grantees. In addition, the Steering Committee and the EWG, as the experts in the delivery and implementation 

of the Title VI programs, provided critical insight into interpreting the data collected and recommendations 

on sharing evaluation findings. Appendix C presents a table of engagement activities conducted throughout 

the evaluation.

NATIONAL RESOURCE CENTERS ON NATIVE AMERICAN ELDERS

As part of the Title VI Evaluation Steering Committee, ICF worked closely with the National Resource 

Center on Native American Aging (University of North Dakota), the National Resource Center for 

Alaska Native Elders (University of Alaska), and the National Resource Center for Native Hawaiian 

Elders, Hã Kũpuna (University of Hawaii). As experts in the field of aging and in their role supporting 

Title VI program grantees, the resource centers provided topical expertise and opportunities for 

coordination and dissemination of evaluation activities and findings.

PARTNER ROLES
MEANINGFUL STAKEHOLDER ENGAGEMENT

EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT 17

OPPORTUNITIES FOR ENGAGEMENT

Virtual meetings

ICF hosted virtual meetings (group calls and webinars) at key steps throughout the evaluation to gather 

insight and guidance from the Steering Committee and the EWG. During these meetings, the Steering 

Committee, for example, reviewed data collection instruments (e.g., focus group and interview guides) and 

provided recommendations on culturally relevant approaches to participant recruitment. Meetings were 

also an opportunity to share evaluation updates as well as for committee members to share information and 

resources among themselves.

E-letters

ICF composed biannual “e-letters” to the Steering Committee. In addition to sharing evaluation updates, 

including emerging themes from data collection and upcoming evaluation activities, the e-letters were an 

opportunity to share draft plans and seek input from the Steering Committee. 

Annual in-person meetings

At the 2017, 2018, and 2019 National Title VI Training and Technical Assistance conferences, ICF organized a 

no-host lunch with the Steering Committee. These informal meetings were an opportunity to gather in-person, 

develop relationships, and share updates on the evaluation.

ACTIONABLE DISSEMINATION

Providing useful and actionable information is a key element of participatory evaluation. ICF developed a 

dissemination plan that identified priority audiences, key content, and appropriate communication channels 

to ensure meaningful dissemination. Products were designed to be accessible to all stakeholders using plain 

language and, where appropriate, data visualizations and imagery to convey findings and recommendations 

that were meaningful and actionable. Throughout the evaluation, ICF shared real-time evaluation updates with 

key stakeholders, including the Steering Committee, the EWG, and ACL, via regular e-letters, presentations 

and trainings at national conferences, briefs, and annual interim reports.

E-letters

In between virtual and in-person Steering Committee and EWG meetings, the e-letters kept stakeholders 

engaged and informed as to progress on the evaluation, evaluation capacity building and technical assistance 

opportunities, and upcoming evaluation activities. 

Briefs

ICF developed a series of evaluation briefs, including one-pagers, such as In Their Own Words: Elders on 

the Title VI Program; In Their Own Words: Caregivers on the Title VI Program; and In Their Own Words: 

Staff on the Title VI Program, and memos. The In Their Own Words one-pagers highlighted the experiences 

and perspectives of Title VI elders, caregivers, and staff and were an important way to share the impact 

of the Title VI programs in a relatable and deeply personal way. In addition, ICF shared data memos with 

ACL to rapidly share evaluation findings. For example, following the completion of the year 3 program staff 

interviews, which were completed in the midst of the COVID-19 pandemic, ICF developed a “COVID Memo,” 

which outlined the ways in which program staff had altered their programs in response to the pandemic as 

well as the most pressing challenges and needs, as expressed by program staff. 
MEANINGFUL STAKEHOLDER ENGAGEMENT

18 EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT

National trainings

ICF facilitated workshops during the National Title VI Training and Technical Assistance annual conferences 

as well as throughout the year as part of the Title VI webinar series. The trainings, with accompanying Title 

VI-specific tools and resources developed in response to the needs of the evaluation grantees, were an 

opportunity to build the evaluation capacity of all Title VI program grantees and their partners in the aging 

community. Trainings included:

▶ Program Evaluation 101: Did You Know It’s Required? (2017 National Title VI Training and Technical 

Assistance Conference)

▶ Everyday Evaluation: Some Tools and Tips to Get You Started (2018 National Title VI Training and Technical 

Assistance Conference)

▶ We’ve Got Tools: How to Evaluate and Show Off Your Title VI Program (2019 National Title VI Training and 

Technical Assistance Conference)

▶ We’ve Got Tools: Introducing the Title VI Evaluation Toolkit (2020 Title VI Webinar Series)

▶ Sharing Your Story: Introducing the Title VI Infographic Toolkit (2020 Title VI Webinar Series)

Interim reports

Annual interim reports (Year 1, Year 2, Year 3) were an important way to keep stakeholders engaged with the 

evaluation and emerging findings in near real time. To ensure the reports met the needs of program stakeholders, 

ICF asked the Steering Committee and the EWG to share the kinds of reports, both in format and content, that 

would be useful to them. ICF developed a short questionnaire with possible report options (e.g., standard 50-page 

narrative report, high-level summary, 10- to 15-page snapshot-style report) and asked the Steering Committee 

and the EWG to share their preferences. In response to their feedback, ICF designed snapshot-style reports that 

emphasized readability and accessibility using best practices of data visualization. The reports distilled critical 

program information and shared findings in a clear and concise manner relatable to all program stakeholders.

Detailed appendices, including data collection and analyses methods, accompanied the reports.

▶ Large-print for elders—In addition to the interim reports, ICF developed large-print summary versions of 

the reports. These two-page summaries were printed on a single, oversized page, in large font, to be easier 

for Title VI elder stakeholders to read.

Conference presentations

National conferences, including the American Public Health Association (APHA) Annual Meeting and the 

American Evaluation Association (AEA) Annual Conference, were an opportunity to build awareness of 

the role and impact of the Title VI programs beyond the aging community as well as share approaches 

to conducting a rigorous program and impact evaluation that is participatory and culturally relevant. 

Presentations included:

▶ Empowering Tribal Communities: A National Evaluation of Aging Services (APHA 2017)

▶ Working Together for Change: Using Participatory Action Research from Design to Dissemination in an 

Evaluation with Older Americans (AEA 2019)

BUILDING KNOWLEDGE AND CAPACITY

▶ Presentations at professional conferences built awareness of the importance of the Title VI 

programs and approaches to culturally relevant evaluation.

▶ Trainings at the National Title VI Training and Technical Assistance conferences supported 

evaluation capacity building beyond the evaluation grantees to all Title VI program grantees.
BACKGROUND

In conducting the Evaluation of the ACL Title VI Programs, ICF identified several key insights and lessons 

learned, including best practices for TTA provision, to build evaluation and program monitoring capacity. 

EVALUATION CAPACITY BUILDING

To develop evaluation knowledge, understanding, and use at the local program level, evaluation training 

and tools should be approachable and accessible to program staff who may have limited prior experience 

with program evaluation. This includes:

▶ Evaluation as “everyday”—For grantees to engage with and incorporate evaluation into their program 

implementation, evaluation must be accessible. This means foregoing “evaluation speak” in favor of 

everyday language that is understandable and relatable to their program context. Grantees appreciated 

and responded to specific examples of what program monitoring or evaluation could look like for, say, 

their congregate or home-delivered meal program. By using everyday language and providing real-life 

examples grounded in the experiences of local Title VI programs, grantees recognized the value and 

power of evaluation.

It was an empowering experience to see how data can be leveraged.”

—Title VI Program Director

▶ Tailored TA—Assigned evaluation liaisons were able to support grantees with one-on-one TA tailored 

to the unique needs of each grantee. By working with the same grantees throughout the evaluation, 

liaisons gained deep insight and knowledge of local programs. Evaluation liaisons developed trusting 

relationships with grantees’ program staff, which facilitated their engagement with the evaluation 

as well as their willingness to ask questions and share needs and challenges. Liaisons, in turn, 

through their deeper understanding of the local programs, were better able to support grantees with 

actionable recommendations. 

We finally get hands-on training and actual tools we can use!”

—Title VI Program Director

▶ Easy-to-use tools and resources—To help grantees engage with evaluation in a meaningful way, ICF 

developed tools to address the questions grantees had shared about their program (e.g., Are they meeting 

the needs of elders? Of caregivers?), and these tools could be easily integrated into existing program 

operations. All resources were customizable and included a user’s guide with step-by-step instructions, 

including screenshots when appropriate.

INSIGHTS: TRAINING AND 

TECHNICAL ASSISTANCE 

EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT 19
INSIGHTS: TRAINING AND TECHNICAL ASSISTANCE

I honestly love the graph charts. It is a very helpful tool for our program and shows us exactly what our 

elders' needs are.”

—Title VI Program Director

▶ Accessible reports and materials—Data visualizations can relay information in a way that is more 

accessible and understandable for non-evaluators. ICF used snapshot-style reports and infographics, 

which use data visualizations, to distill critical program information and share findings in a clear and 

concise manner with all program stakeholders. Not only did these reports help grantees understand the 

scope, impact, and opportunities for their programs, the reports served as engagement tools grantees 

could share with their tribe. 

Infographics help people understand better, especially tribal leadership.”

—Title VI Program Director

▶ Hands-on trainings—In-person and virtual trainings provided an opportunity to introduce grantees 

to evaluation, including program monitoring, and methods and opportunities for incorporating it into 

program implementation. During the first in-person EWG training, grantees expressed a need for 

more hands-on activities and opportunities to learn from one another. Subsequent trainings included 

opportunities for grantees to reflect on and share their experiences as well as applied learning activities, 

such as “quiz bowl” and data gallery walks, which allowed grantees to practice what they were learning 

in a safe and supportive environment. 

I’ve never been to a conference/training where real tools were provided that can be 

applied immediately!”

—Title VI Program Director

20 EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT

PROMOTING CULTURALLY RESPONSIVE EVALUATION 

AND TECHNICAL ASSISTANCE

▶ Use evaluation frameworks such as the medicine wheel that are meaningful to the community 

▶ Facilitate stakeholder engagement with ongoing opportunities for communication and feedback 

among stakeholders

▶ Provide opportunities for storytelling to promote community voice

▶ Ground TTA in local needs
METHODS

EVALUATION OF THE ACL TITLE VI PROGRAMS — FINAL REPORT 21

The Evaluation of the ACL Title VI Programs used a mixed methods approach, which included both the 

implementation study and the outcomes study, to assess the impact of the Title VI programs. 

The evaluation relied on information that already existed (secondary data) and information specifically 

collected for the purpose of the evaluation (primary data) to ensure that the objectives of the evaluation were 

achieved. Data planning, collection, analysis, and reporting happened throughout the course of the evaluation 

(Figure 4). 

DATA DESCRIPTION

Table 1, on the following page, provides a description of each data source and when the Title VI evaluation 

used them. ICF secured all relevant human subjects and data approvals (e.g., IRB, OMB, tribal) prior to data 

collection and abstraction.

THE TITLE VI EVALUATION SOUGHT TO UNDERSTAND THE FOLLOWING:

▶ How do tribes operate their Title VI programs?

▶ What is the effect of Title VI programs on elders in the community?

▶ Do Title VI programs that rely only on Title VI funds have a different impact than programs that have 

money from other programs/agencies?

FIGURE 4. DATA COLLECTION AND ANALYSIS PROCESS

DATA 

COLLECTION

 ANALYSIS TRIANGULATION DISSEMINATION

1 2 3 4

STEP STEP STEP STEP

METHODS
22 EVALUATION OF THE ACL TITLE VI PROGRAMS — FINAL REPORT

METHODS

Data Description 

Primary Data

Program Staff 

Interviews 

The interviews with Title VI program staff assessed the nature, context, 

implementation, and management of Title VI programs; documented the 

challenges and barriers to program implementation; and gathered detailed 

information about the funding of activities (e.g., sole vs. blended funds, how funds 

are leveraged). Collected data included Title VI program structure, resources, and 

activities; Title VI management structure; perceptions of met and unmet needs 

across Title VI service areas; barriers to Title VI services provision; and strengths 

and resources of the Title VI program. 

Data Collection: ICF conducted 12 semi-structured telephone interviews in 2018 and 

11 in 2020 (one grantee was unable to be interviewed due to program staff turnover).

Elder Focus 

Groups/Interviews

The elder focus groups and interviews assessed elders’ experiences and 

satisfaction with service delivery as well as Title VI program’s outcomes from 

elders’ perspectives. Data included elders’ met and unmet needs, perceptions 

of their well-being (e.g., physical, mental, emotional, and spiritual, as well 

as their quality of life and independence), community integration and social 

connectedness, and experiences with and perceptions of services.

Data Collection: ICF conducted 18 focus groups (n = 161) and 34 semi-structured 

telephone interviews (n = 36) in 2018.

Caregiver Focus 

Groups/Interviews

The caregiver focus groups and interviews assessed informal (unpaid) caregivers’ 

experiences and satisfaction with service delivery and program experience as 

well as Title VI program outcomes from caregivers’ perspectives. Data included 

linkage to needed services, ability to provide care, perceptions of caregiver 

well-being (e.g., physical, mental, emotional, and spiritual, as well as quality of 

life and independence), community integration and social connectedness, and 

experiences with and perceptions of services.

Data Collection: ICF conducted 8 focus groups (n = 42) and 11 semi-structured 

telephone interviews (n = 11) in 2019.

Evaluation and Data 

Needs Assessment

The evaluation and data needs assessment cataloged information related to 

grantees’ program stakeholders, program goals and related outcomes and 

measures, service delivery, and evaluation and data support needs. Primarily 

designed to inform TTA provision, the evaluation and data needs assessment 

process supported understanding the Title VI programs’ evaluation and data 

processes at the site level.

Data Collection: ICF conducted 12 assessments during year 2 (2018) site visits 

through program observation and conversations with program staff.

Caregiver Program 

Assessment

The caregiver program assessment cataloged information related to grantees’ 

caregiver programs, including program participants, services provided, and 

program monitoring and evaluation. The caregiver program assessment 

supported a thorough understanding of the Part C Caregiver Support Program as 

it is implemented at the local level.

Data Collection: ICF conducted 11 assessments during year 3 (2019) site visits 

through conversations with program staff.

TABLE 1. OVERVIEW OF THE TITLE VI EVALUATION DATA SOURCES 
METHODS

EVALUATION OF THE ACL TITLE VI PROGRAMS — FINAL REPORT 23

OVERVIEW OF THE TITLE VI EVALUATION DATA SOURCES – cont’d

Data Description 

Secondary Data

NRCNAA Elder 

Needs Assessment

The NRCNAA Elder Needs Assessment includes information related to the 

health status of elders within grantees’ service areas, including domains related 

to demographics, overall health and wellness, healthcare access, weight and 

physical activity, and social functioning. It also includes domains related to 

caregiving, including whether elders have a family caregiver, whether they are 

raising grandchildren, and what are their current and anticipated future use of 

caregiver services. 

Data Abstraction: The NRCNAA Elder Needs Assessment survey and data are 

administered by NRCNAA/UND. NRCNAA supported Cycle VI data collection 

from April 2014 to March 2017 and Cycle VII data from April 2017 to March 2020. 

Aggregated data reports were shared with ICF in 2018. ICF abstracted 

disaggregated data for the 12 evaluation grantees in 2018 during a visit to UND 

and, in 2020, for the 8 evaluation grantees who secured a tribal resolution during 

the data collection window.6

n4a Title VI Program 

Survey

The Title VI Program Survey gathers information from program staff about which 

services are available, how the services are delivered, partnerships established 

to support service delivery, strategies for record keeping and budgeting, and 

challenges experienced with Title VI implementation.

Data Abstraction: The Title VI Program Survey is collected and administered by 

Scripps Gerontology Center and n4a (Scripps) approximately every 3 years. ICF 

obtained the 2016 survey data for the 12 evaluation grantees in 2018, following 

informed consent by the evaluation grantees.

Title VI Program 

Performance Report 

(PPR)

The PPR collects information annually on the number of clients and service units 

for Title VI nutrition, supportive, and caregiver support services delivered by each 

Title VI grantee.

Data Abstraction: The Title VI PPR is maintained by ACL. ICF accessed the 

2010–2017 (averages) data report, by tribe, for Parts A/B and C in 2019 and the 

2018 report for Parts A/B and C in 2020. 

Title VI Grant 

Application

The Title VI grant applications collect information about plans for services for 

each Title VI grantee. The application includes general information about the 

population served and plans for nutrition services, information/referral and 

assistance services, supportive services, and caregiver services. 

Data Abstraction: ICF accessed and abstracted the Title VI grant applications for 

fiscal year 2017 in 2018.

Publicly Available 

Data

Publicly available data sources (e.g., U.S. Census) were also used to better inform 

the analysis and interpretation of evaluation findings. 

Data Abstraction: ICF accessed and abstracted secondary data in 2020.

6Due to closures caused by the COVID-19 pandemic, four grantees were unable to complete the resolution and data transfer process.
24 EVALUATION OF THE ACL TITLE VI PROGRAMS — FINAL REPORT

METHODS

DATA ANALYSIS

To analyze the data, ICF used a mixed methods approach, including thematic analysis of all qualitative data, 

descriptive and statistical analysis of quantitative data, and data triangulation. 

Qualitative Data

ICF used the following four-step process to analyze qualitative data, including interview and focus group data: 

1. Data capture and management. Audio recordings from each interview and focus group were transcribed 

and imported into the qualitative software package ATLAS.ti 7.5.18 to analyze the data for themes, patterns, 

and interrelationships relevant to the evaluation questions. 

2. Codebook development. Codebook development was a multistep and iterative process that involved 

developing and defining codes and pretests to refine the codes and definitions. 

3. Code application. ICF applied codes to the transcripts and produced output documents associated with 

each code and subcode. 

4. Analysis and documentation of themes. ICF used thematic analysis to review output documents and 

produced a comprehensive summary memo identifying key themes and relationships among themes.

Quantitative Data

Each quantitative data source was processed independently as well as merged and analyzed in combination 

to allow further understanding of Title VI context, characteristics, and impact. 

NRCNAA Elder Needs Assessment—ICF conducted an initial aggregated data analysis (exploration) and 

a disaggregated data analysis (in-depth). Whereas the aggregated data analysis (data by grantee) allowed 

the study of the evaluation grantees’ characteristics and how they compare to the overall Title VI grantees, 

the disaggregated data analysis allowed more in-depth study of program outcomes and impact. Analyses 

included descriptive (averages and frequencies), statistical, and inferential analysis to allow for comparisons 

between subgroups and test associations. All data management, cleaning, preparation, and analysis were 

completed using SAS® v 9.4.

n4a Title VI Program Survey—ICF conducted an initial descriptive analysis, including frequencies and 

means. Key indicators were used to generate averages for the Title VI grantees and merged to other program 

datasets to support impact analysis.

PPR—ICF generated averages for the eight Title VI grantees and merged them to other program datasets 

(e.g., n4a, Elder Needs Assessment, other secondary datasets) to support impact analysis. 

Publicly Available Data—ICF used key indicators to generate averages for the eight Title VI grantees with 

disaggregated Elder Needs Assessment data and for the overall Title VI sample using ZIP codes. These 

secondary indicators were merged to other program datasets (e.g., PPR, n4a, Elder Needs Assessment) to 

support impact analysis.
EVALUATION OF THE ACL TITLE VI PROGRAMS — FINAL REPORT 25

METHODS

Triangulation

Following preliminary analyses of qualitative and quantitative data, ICF conducted data triangulation 

to support synthesis and understanding of findings. This included reviewing common themes from the 

qualitative and quantitative data analyses to identify interconnecting themes as well as points where the data 

diverge. ICF used the following triangulation process:

1. For each data source, ICF identified all major and minor themes, including subthemes.

2. ICF cross-walked all themes to the relevant evaluation question(s). 

3. ICF conducted cluster analysis—by evaluation question, grouping themes by affinity—to articulate findings, 

conclusions, and recommendations using a what, so what, now what methodology:

a. What are the grouped themes saying? (Findings)

b. So what do the findings suggest; why are they important? (Conclusions)

c. Now what are possible next steps? (Recommendations)

For the final year of the evaluation, ICF facilitated two rounds of data triangulation, one with ACL and one 

with the evaluation grantees, using a virtual whiteboard to facilitate the triangulation process and allow for 

real-time interactivity. 

A detailed description of the data sources, collection, analyses, and triangulation is provided in the 

comprehensive Methods (Appendix B).
WHAT WE’VE LEARNED

26 EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT

Over the course of the evaluation (2017–2020), the evaluation team focused on understanding the Title VI 

Part A/B program, Nutrition and Supportive Services, and the Part C program, Caregiver Support Services, 

based on all available data sources for the Evaluation of the ACL Title VI Programs (see Methods), including the 

perspectives of elders, informal caregivers, and program staff. The evaluation team analyzed and considered 

these data sources collectively to develop a comprehensive picture of the Title VI programs. This report 

section includes key findings from the evaluation designed to describe and demonstrate the implementation 

and impact of the Title VI programs. Findings are presented in the following subsections: (1) program context, 

(2) program implementation, and (3) program impact. Unless otherwise noted, findings reflect the experience 

and context of the evaluation grantees. Where secondary data is presented, the data source is identified. 

PROGRAM CONTEXT

The 12 Title VI evaluation grantees, like the more 

than 275 Title VI grantees, are diverse and varied in 

geography, climate, cultural norms, and traditions, as 

well as in program size and structure. Although most 

evaluation grantees provide Title VI services from one 

central site location, two evaluation grantees provide 

services across multiple site locations—one does so 

across four pueblos in northern New Mexico, and 

the other provides services across multiple Hawaiian 

Islands. Some grantee sites are located within a short 

driving distance of a town or city, whereas others are 

in remote, service-isolated areas. 

Each Title VI evaluation grantee is unique; however, evaluation grantees share many important characteristics 

with each other and with Title VI grantees in general. Because of this, the evaluation grantees may be 

considered representative of Title VI grantees as a whole. These similarities include the characteristics 

of the elders served—such as age, employment status, and living status (Figure 5)—as well as contextual 

factors, including number of grantees in rural settings and poverty rates among community members. An 

exception is that evaluation grantees, collectively, serve a greater number of AN and NH elders than do 

Title VI grantees (i.e., 30% in the case of evaluation grantees versus 9% for other grantees). In terms of the 

overall number of grantees, the 12 Title VI evaluation grantees represent 4 percent of all Title VI programs and 

10 percent of those who participate in the NRCNAA Elder Needs Assessment. 

ELDER HEALTH AND NUTRITION

Overall, as described, Title VI evaluation elders are similar to those of other Title VI grantees. Although elders 

in both groups experience challenges related to their health and overall well-being, including challenges 

with activities of daily living (ADL) and instrumental activities of daily living (IADL), they also largely report 

feeling happy.

Title VI evaluation grantees include a 

similar number of rural communities 

compared to tribes nationwide (70%).

Census, 2017

Title VI evaluation grantees experience 

similar rates of poverty (13.3) 

compared to tribes nationwide (15.6).

Small Area Income and Poverty Estimates, 2017

WHAT WE’VE LEARNED
EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT 27

WHAT WE’VE LEARNED

FIGURE 5. EVALUATION GRANTEE ELDERS AND TITLE VI GRANTEE 

ELDERS SHARE IMPORTANT CHARACTERISTICS

Data Source: NRCNAA Elder Needs Assessment

TITLE VI GRANTEES

42%

61%

31%

AN/NH 9%

29%

34%

EVALUATION GRANTEES ELDER 

CHARACTERISTICS

Age 

(> 70 years old) 45%

67% Female

27% Employed

30%

22% Lives Alone

Has a 

Family Caregiver 37%

Primary Caregiver 

of Child 7% 10%
28 EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT

WHAT WE’VE LEARNED

PROGRAM IMPLEMENTATION

To maximize program service delivery, the Title VI evaluation grantees draw upon various available local 

resources, including support from their tribe/parent organization and partnerships with local social service 

providers in their community. ICF considered all available data sources from the Evaluation of the ACL Title VI 

Programs (Table 1) to provide an overall picture of Title VI program implementation. 

Program Management and Staffing

Staffing Structure

All evaluation grantees have a program director 

and at least one other staff member, most often 

a cook or driver. The staffing structure otherwise 

varies across grantees, particularly when providing 

caregiver support services. Most evaluation 

grantees do not have a dedicated caregiver program 

coordinator; instead, caregiver support duties are 

spread among the program director and other 

staff. Other common staff positions include activity 

directors, office managers, and case managers. 

Because Title VI teams are typically small, staff must work together to manage an array of responsibilities 

and are often cross-trained to step in as needed to ensure service delivery. This often means the director 

may help serve meals while the cook helps with elder transport. Such cross-training also helps to address 

challenges that may arise from staff turnover—a common occurrence across evaluation grantees.

Program Structure/Organization

Title VI program services typically are delivered 

through elder or senior programs within a tribe 

or other Indigenous community organization. 

Most of the evaluation grantees operate their 

program as an independent department within 

their tribe/organization but coordinate to a 

varying extent with other tribal departments or 

local programs. In addition, half of the evaluation 

grantees have an elder advisory board or 

committee that help direct program activities. 

34%

58%

54%

54%

On average, evaluation grantees employ 

four staff members to support their 

Title VI programs. 

Data Source: PPR, 2018

More than one-third of evaluation 

grantees (34%) have a designated 

caregiver program coordinator. 

Program directors reported 

that their Title VI program is 

administered as an independent 

division of the tribe, tribal 

consortium, or intertribal council. 

Program directors reported that 

their Title VI program has an 

advisory board or committee.

Evaluation grantees reported they 

have a formal relationship with 

their tribal health department. 

Data Source: n4a Title VI Program Survey 

We’re all cross-trained in the various aspects of the program. Just so that we can ensure that service 

continues even though one of us may not be here or the cook is out or both cooks are out, we all can 

step up and cook. We can all drive the vehicle. We can all conduct the interviews. We can all conduct 

application assistance. We’re all cross-trained in pretty much every aspect of our program.” 

—Title VI Program Director
EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT 29

WHAT WE’VE LEARNED

Program Resources

For many evaluation grantees, Title VI funding does not cover the full cost of their program service delivery. 

Several program directors emphasized the limited nature of Title VI funding and suggested that Title VI 

funding supports a small proportion of their overall Title VI program implementation or that it covers service 

provision for a limited period, not lasting through a full year. Two program directors estimated that Title VI 

funding covers only one-quarter of their Title VI services. 

LIMITED FUNDING

We’re expected to provide certain services, but, of course, number one, the funding is not nearly 

adequate to do all that’s expected. To sum everything up, there’s a lot expected of a Title VI program 

without adequate funding.” 

—Title VI Program Director

As a result, most evaluation grantees rely on additional funding streams to support services and staffing 

for their Title VI programs. Outside funding sources vary across grantees. In most cases, the tribe is a major 

source of additional funding used to sustain Title VI service provision throughout the year. Most grantees also 

seek additional grants (e.g., from federal and state agencies, and foundations) to support their program; these 

are typically topical grants, such as for elder abuse prevention or that address health issues like diabetes. Some 

grantees also host community fundraising events, such as raffles, bake or craft sales, or annual events or dinners. 

A few grantees receive small donations of funding or resources (e.g., produce from a community garden, gift 

certificates, or supplies) and occasional support from volunteers, who help with activities, such as large events. 

Most evaluation grantees (75%) reported they do not bill Medicaid for any home- or community-based services. 

FILLING IN THE GAPS: SUPPORT FROM THE TRIBE

Let me tell you this, if we didn’t have our tribe supporting and supplementing our program, we wouldn’t 

be where we are.”

—Title VI Program Director

If it wasn’t for the investment from the tribe, there’s no way we could do it with just Title VI dollars ...

(Otherwise) our services would be probably a third of what we’re providing. So, the funding is great, but 

it’s just not enough to have the capacity to do everything that’s required.”

—Title VI Program Director

SUPPORT FROM THE TRIBE VARIES FROM YEAR TO YEAR

Although funding from tribes provide crucial support, some grantees report it is not always a 

consistent or reliable source because it largely depends on the priorities of tribal governance. For 

most evaluation grantees, elections occur on a 1- to 2-year election cycle. As priorities and funding 

levels fluctuate, Title VI program directors report that they must reshape the scope and range of 

Title VI service provision.
30 EVALUATION OF THE ACL TITLE VI PROGRAMS — FINAL REPORT

TITLE VI FUNDING: 

A LIMITED BUT 

CRITICAL RESOURCE

Title VI programs often provide 

the following: 

▶ Sole source of nutritious meals 

for elders per day

▶ Sole means of transportation 

for elders, such as for shopping 

and medical appointments

COMMONLY REPORTED 

SUPPLEMENTAL 

FUNDING SOURCES:

▶ Tribe (general funding)

▶ State and other federal funding:

• U.S. Department of 

Agriculture reimbursement 

for meals

• OAA Nutrition Services 

Improvement Program 

• Medicare Improvement for 

Patients and Providers Act 

• AmeriCorps services for 

elders

• Diverse grants (e.g., to 

prevent elder abuse or 

address health issues, such 

as diabetes) 

▶ Fundraising (e.g., raffles, bake 

or craft sales)

▶ Local nonprofits, associations, 

and community organizations

▶ Individual donations

14% of evaluation grantees are solely 

funded by Title VI, receiving no other 

financial support to maintain their 

programs.

Data Source: n4a Title VI Program Survey

Despite the limitations of Title VI funding, evaluation 

grantee program directors report that this funding is 

essential because it provides a foundation for Title VI 

program service delivery. Title VI funding helps to ensure 

that basic services for elders and caregivers in need can 

be provided with consistency. 

So, you think about not just our program but other 

programs . . . how do they survive with just Title VI 

funding when it’s not sufficient? But, at the same time 

. . . it’s an integral part of our funding because we 

take that away and we’re taking away the meat and 

the bones of the program . . . . And why we’re even 

in existence. So, while it’s so minimal, I think it’s really 

important that we have it.” 

—Title VI Program Director

Nearly 70% of evaluation grantees 

receive additional funding from the local 

Title III organization or Area Agency on 

Aging (AAA).7

Data Source: n4a Title VI Program Survey

$577,933

—Average program budget of which 53% is Title VI 

funding (Parts A/B and C)

Data Source: n4a Title VI Program Survey 

14%

LACK OF BUDGET OVERSIGHT

Program staff often lack control of, or access to, 

their Title VI budgets, making it difficult to plan 

independently.

69%

7

Title III authorizes grants to 56 State Units on Aging (SUAs) and 629 AAAs to act as advocates 

on behalf of, and to coordinate programs for, older persons. Title III services are available to all 

persons ages 60 and older but are targeted at those with the greatest economic or social need, 

particularly low-income and minority persons, older individuals with limited English proficiency, 

and older persons residing in rural areas (CRS, 2018). https://fas.org/sgp/crs/misc/R43414.pdf
WHAT WE’VE LEARNED

EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT 31

Importance of Collaboration and Partnerships

In the context of limited funding and other resources, partnerships played a critical role in helping evaluation 

grantees sustain and, in some cases, expand Title VI service delivery. As noted, all evaluation grantees 

have some level of partnership with other tribal departments and agencies, as well as with a variety of local, 

state, and other organizations or groups. Key program partners internal to the tribe often include housing, 

transportation, utilities, and health and wellness departments. For example, grantees often work with their 

tribal transportation department to provide or supplement transportation services for elders. Trainings for 

program staff, elders, and caregivers on specific topics, such as Medicare coverage and home safety tips, are 

often provided by partners such as AARP. 

Some evaluation grantees also coordinate with local Title III programs. For example, at one grantee site, 

the Title III program provides home-delivered meals and the entrée for the congregate meal, which is then 

supplemented with side dishes (e.g., soup, vegetables, and dessert) through Title VI Part A funding.

84% of Title VI evaluation grantees receive support from non-Title VI program staff who 

help to implement program activities and services (e.g., a dietitian or wellness coach). 

Data Source: n4a Title VI Program Survey

If there’s a need for us to reach out to other programs within the tribal organization, we do that, and we 

built a strong partnership with the community care services. We collaborate with the community care 

services . . . we do a lot of educating of the local programs and other community service programs who 

can help our elders as well.” 

—Title VI Program Director

84%

TITLE VI PROGRAM PARTNERS

Title VI programs partner with other agencies to provide services to elders: 

▶ Tribal health department

▶ Nontribal health department

▶ U.S. Department of Veterans Affairs

▶ Transportation agencies

▶ Nursing homes and assisted-living facilities

▶ State health insurance assistance programs

▶ Adult protective services

▶ AARP
WHAT WE’VE LEARNED

32 EVALUATION OF THE ACL TITLE VI PROGRAMS — FINAL REPORT

Program Delivery

Nutrition and Supportive Services for Elders

All evaluation grantees provide core nutrition and supportive services for elders, including congregate 

and home-delivered meals, and information and referral services. Some grantees also provide other 

supportive services, such as transportation, personal care, help with chores and tasks in the home, nutrition 

education for elders, trips/outings, bank and bill pay, and shopping assistance. A few grantees offer cultural, 

language, and traditional dance as activities for elders to participate in. In addition, a few programs provide 

intergenerational activities that pair elders with youth. 

On average each year, evaluation grantees 

serve the following: Meal programs are the focal point around 

which other services are organized.

For our elders . . . nutrition is always big. 

That, we’re able to do, but sometimes home 

delivery is a greater need than we can 

necessarily provide for. So, I know there are 

some gaps in our service area because we 

just can’t get to some people.” 

—Title VI Project Director

WHAT IS PART A/B?

The Indian Program (Part A) and Native Hawaiian Program (Part B) authorize grantees to provide nutrition 

and supportive services to tribal elders to reduce hunger and food insecurity, promote socialization, and 

improve health and well-being. Grantees are required to provide congregate and home-delivered meals 

and supportive services, including information and assistance. Other supportive services, such as case 

management, transportation, and health promotion and wellness, although not required, are encouraged.

Congregate meals—Hot meals served in 

a group setting for elders often include 

activities and speakers.

Home-delivered meals—Balanced meals 

that are delivered 5 days a week to 

home-bound elders.

Information and assistance—Information 

to elders on available services and 

hands-on support to help elders access 

services.

Case management—Assessment of 

elders’ needs and ongoing support to help 

maintain elders’ health and well-being. 

Transportation—Transport to and from 

congregate meals and activities, medical 

services, outings, and social events. 

Health promotion and wellness—

Activities that often include evidencebased programs to help elders stay healthy 

and active.

522 Part A/B clients (nutrition and 

supportive services)

189 Congregate meal elders

76 Home-delivered meal elders

Data Source: PPR, 2018
WHAT WE’VE LEARNED

EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT 33

Some grantees who are in remote or isolated 

locations or who have multiple program sites 

address relatively complicated service delivery 

needs, often with limited staff, vehicles, and 

other needed resources. For example, some 

provide home-delivered meals or in-home 

services for elders over long distances and wide 

service areas. Others face issues such as road 

closures due to winter weather, which may delay 

meal delivery to elders or interrupt delivery of 

food or supplies from city locations. Lack of 

cell phone service in rural service areas also 

complicates the delivery process. 

SUPPORTIVE SERVICES PROVIDED

▶ Information referral/assistance

▶ Transportation

▶ Trips/outings

▶ Bank and bill pay

▶ Shopping assistance

▶ Home care and help with chores

▶ Health promotion and wellness 

activities

▶ Case management

▶ Outreach (e.g., flyers, announcements, 

informal conversations)

▶ Special events

▶ Presentations 

▶ Exercise/fitness

▶ Cultural activities (e.g., language 

education, traditional music/dance, 

intergenerational activities)

Data Source: PPR, 2018

TRAVEL FOR SERVICE DELIVERY

The average round trip for homedelivered meal service requires about 

3 hours, including driver stops for meal 

delivery or related activity.

The greatest distance that Title VI 

program staff travel to provide services is 

about 24 miles one way. 

Data Source: n4a Title VI Program Survey

MORE THAN TWO -THIRDS OF 

PROGRAMS PROVIDE:

Elder abuse prevention and 

intervention services, including case 

management for victims of abuse or 

neglect and community education. 

TYPES OF OUTREACH PROVIDED

Program directors provide outreach for elders and 

caregivers in various ways.

Data Source: n4a Title VI Program Survey and Title VI Program 

Staff Interviews

NUTRITION SERVICES PROVIDED

11 of 12 grantees provide 

congregate meals

11 of 12 grantees* provide 

home-delivered meals

*One grantee partners with its Title III program to provide 

home-delivered meals

489

Median number of elders eligible 

to receive Title VI services 

(range: 149–15,016).

Data Source: Title VI Program Applications
WHAT WE’VE LEARNED

Caregiver Support Services

The range of Part C, Caregiver Support Services, 

provided varies considerably across the evaluation 

grantees. The majority provide information, 

outreach, and assistance to support caregivers in 

accessing services (Figure 6). Counseling, support 

groups, and caregiver trainings are less frequently 

provided. The range and types of caregiver 

services provided did not depend on how long 

grantees had been receiving Part C funding. 

Respite

▶ Respite coverage is typically provided in the 

home by a respite provider, often a family 

member or close friend.

▶ Usually a voucher or stipend is provided to the 

main caregiver to support a respite provider for 

a limited number of hours per week or month.

Supplemental Services 

▶ Of those, an average of 13 caregivers per 

grantee were served in 2019.

▶ Services often include durable equipment 

(e.g., walker, portable commodes), lending 

closets, and disposable supplies, such as adult 

diapers, wipes, and gloves.

• Half of the evaluation grantees have 

received Part C funding for more than 

10 years.

• The other half have received Part C 

funding for 5 years or less.

WHAT IS PART C?

The Native American Caregiver Support Program (Part C) supports unpaid family caregivers in caring for 

an elder family member, a grandchild, or an adult with disabilities. The OAA authorizes grantees to provide 

caregiver support services, including information; assistance; counseling, support groups, and training; 

respite; and supplemental services.

Information—Provides information to 

caregivers on available services, often 

through public service announcements, 

health fairs, and program brochures.

Respite—Provides temporary support 

so caregivers can have a break from 

caregiving.

Assistance—Includes hands-on support 

to help caregivers access services and 

case management.

Supplemental services—Offered on a 

limited basis, these may include home 

modifications (e.g., handrails), assistive 

technologies, or consumable supplies 

(e.g., gloves and adult diapers).

Counseling, support groups, and 

training—Supports caregivers in decisionmaking and problem-solving related to 

their role as caregivers. Trainings often 

focus on stress relief and financial literacy.

Although the OAA defines Part C as delivery of all five of these services, not all Title VI grantees 

implement these services.

64% Evaluation grantees provide 

respite services. 82% Evaluation grantees maintain a roster of caregivers served.

34 EVALUATION OF THE ACL TITLE VI PROGRAMS — FINAL REPORT
WHAT WE’VE LEARNED

EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT 35

FIGURE 6. PART C SERVICES PROVIDED BY EVALUATION GRANTEES

All evaluation grantees report partnering or collaborating with a variety of local, state, and other 

organizations or groups to help provide services for caregivers.

Examples of Partners 

▶ Tribal housing departments

▶ Tribal or state transportation departments

▶ Local utility departments

▶ Health and wellness programs (e.g., Indian Health 

Service, local clinics, hospitals, local and state 

health departments)

▶ State and national organizations (e.g., Alzheimer’s 

Association, American Heart Association, AARP, 

U.S. Department of Veterans Affairs)

GRANDPARENTS RAISING 

GRANDCHILDREN

Nearly three-quarters of evaluation 

grantees provide support to 

grandparents raising grandchildren. 

IDENTIFYING CAREGIVERS

Caregivers are identified via selfselection; staff-directed outreach; and 

referrals through family, peers, clinics, 

and other community and tribal agencies. 
WHAT WE’VE LEARNED

36 EVALUATION OF THE ACL TITLE VI PROGRAMS — FINAL REPORT

TITLE VI DEFINITION 

Family Caregiver 

▶ An adult family member or unrelated 

individual who provides informal in-home 

and community care to an individual who 

is older, an individual of any age with 

Alzheimer’s disease, or an individual with 

a related disorder with neurological and 

organic brain dysfunction 

Grandparent Raising 

Grandchildren 

▶ A grandparent or step-grandparent 

▶ Age 55 or older and 

• Lives with the child (under age 18) 

• Is the primary caregiver 

Older Relative Who Provides 

Care for an Adult (ages 18–59) 

With Disabilities 

▶ A parent, grandparent, or other relative 

by blood or marriage 

▶ Age 55 or older and 

• Lives with the individual with 

disabilities (ages 18–59) 

• Is the primary caregiver

WHO IS A CAREGIVER?

WHAT WE LEARNED

Caregivers do not self-identify as caregivers. 

▶ Many caregivers do not identify themselves as 

“caregivers.” They view caregiving as a natural extension 

of their responsibility to their family. 

▶ Caregivers often do not think they are eligible for 

caregiver services or support.

I think, number one, the caregivers don’t really know 

that they’re caregivers in the community. They’re 

just so used to taking care of somebody that they 

don’t consider themselves to be that precious to that 

individual. So, they need to be identified, I think.”

—Title VI Program Staff Member

Caregivers are family. 

▶ Caregivers work hard to meet the needs of an ill or 

disabled family member to avoid placing loved ones in a 

care facility. 

▶ Caregivers often fall into the caregiving role without the 

training or knowledge to support them. Many tasks can 

be challenging, such as safely lifting a disabled family 

member, administering medical care at home, navigating 

medical or insurance processes, or recognizing the signs 

of depression in a loved one suffering from chronic illness.

Caregivers are elders. 

▶ In many cases, caregivers are elders themselves caring 

for other elders (e.g., spouse, siblings, or cousins) as well 

as grandparents raising grandchildren.

I think a lot of the problem is people are living too 

long now, and now it’s people like us that are actually 

old that are taking care of people that are older.”

—Title VI Caregiver
WHAT WE’VE LEARNED

EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT 37

Program Monitoring and Evaluation 

Program tracking and performance monitoring vary considerably across grantees. All Title VI evaluation 

grantees collect some program data as part of their annual PPR to ACL, which requires grantees to track the 

number of clients and number of units by service category. Examples include: 

▶ Number of congregate and home-delivered meal clients and units served

▶ Transportation mileage.

Some grantees also have local-level reporting 

requirements, such as monthly program reports for their 

tribal council, department head, or other funders (e.g., 

state). In addition, all of the evaluation grantees conduct 

elder intake assessments to collect information on 

demographics, nutrition, and caregiving needs of elders, 

which is used to direct service and supports for them.

Grantees reported several challenges that impact the 

delivery of nutrition and supportive services as well as 

caregiver support services. Grantees, along with ACL, 

also have identified strategies to overcome difficulties and 

ensure Title VI service provision. 

PROGRAM DIRECTORS 

DESCRIBED CHALLENGES 

WITH ACL REPORTING 

REQUIREMENTS, INCLUDING:

• Understanding what data to 

collect

• Aligning data collection with 

other reporting requirements 

(e.g., local or state reports)

TITLE VI EVALUATION GRANTEES ARE GROWING THEIR PROGRAMS*

Several evaluation grantees reported program growth over the Title VI grant cycle (2017–2020), such as the 

addition of new program services or program sites. The changes often included enhancements to the core 

nutrition, supportive, and caregiver support services. 

Expanded Services

▶ Increased number of meals provided (e.g., from 

two to three meals per week)

▶ Increased referral options for caregivers to 

include referrals to local mental health providers 

and other local support services

▶ Increased number of site locations for 

congregate meals and activities for elders

New Activities

An elder/youth mentorship program

An exercise program for elders 

A support group for caregivers 

supporting elders with dementia

Strategies Used to Expand Programming

▶ Assessing community needs to understand 

elder and caregiver needs

▶ Engaging an elder council to provide input and 

guidance on program change

▶ Leveraging funding, guidance, and other 

resources through partnerships with 

organizations and individuals in the community 

▶ Researching available community resources and 

local groups to enhance referral options

And to my advantage, in my group of elders, 

we have monthly elder council meetings 

where they decide the direction and what the 

(program) focus will be as we move forward. 

And they have a very strong voice.”

—Title VI Program Director

*These changes are unrelated to program changes associated with the COVID-19 pandemic. 
38 EVALUATION OF THE ACL TITLE VI PROGRAMS — FINAL REPORT

CHALLENGES

Limited Funding/Resources. Limited 

funding impacts grantees’ ability 

to provide a full range of Title VI 

services to meet the needs of their 

community. Limited resources 

also impact opportunities to hire or 

retain qualified program staff, provide 

ongoing staff training, or provide living 

wages to support Title VI staff and 

reduce turnover.

Small Teams and Staff Turnover. 

Title VI teams are typically small, and 

some grantees experience frequent 

staff turnover, which can disrupt 

service provision as well as efforts 

to expand and improve program 

elements. For example, one-third 

of evaluation grantees experienced 

turnover of program directors or other 

staff midway through the Title VI grant 

cycle (2017–2020).

Lack of Understanding of Title VI 

Services. Across evaluation grantees, 

understanding of Title VI program 

requirements and service categories 

varies. Grantees often report 

confusion regarding what qualifies as 

a Title VI service, and their knowledge 

of Part C guidelines and required 

services, including what constitutes 

the five required services and who is 

eligible for caregiver support services, 

is particularly limited.

Outreach and Participant 

Recruitment. Program staff described 

difficulty raising awareness and 

engaging with elders and caregivers. 

In particular, they noted that 

caregivers often do not self-identify 

as caregivers, and that there is 

both a lack of awareness among 

caregivers as to available supports 

and a reluctance among caregivers to 

seek assistance.

SOLUTIONS

Supplemental Funding. Many evaluation grantees obtain 

supplemental funding from their tribe; other federal, state, 

and local grants; donations; and fundraisers to bridge the 

gap between Title VI funding and actual program costs.

If we don’t have tribal supplementation a lot of the services 

that are offered will be very limited to nonexistent .... We’re 

able to do a lot more because of the supplemental funding."

 —Title VI Program Director 

Partnerships and Collaboration. Grantees rely on partnerships 

with other tribal departments, community organizations, health 

centers, topical experts (e.g., health educators), and others who 

provide resources and expertise to complement program efforts. 

I’m a firm believer in partners. I’ve got quite a few. So, 

my partners have been keeping us very, very busy.”

—Title VI Program Director

Strong, Integrated Teams. Several program directors described 

having highly dedicated, collaborative, and solution-oriented 

teams. Such dedication, combined with efforts to cross-train staff 

to ensure that each staff member can perform an array of tasks, 

helps to promote ongoing and uninterrupted service delivery.

I’m lucky to have a staff who has that true commitment 

and that true compassion to be able to become family to 

a lot of the clients we serve.” 

—Title VI Program Director 

TTA. Since learning of grantee confusion regarding the Part C 

program as a result of this evaluation, ACL has begun developing 

additional guidelines and resources to support Title VI grantees.

Increased and More Targeted Recruitment. Program staff 

increased one-on-one outreach to engage eligible elders and 

caregivers and to build awareness of Title VI program services. 

One grantee developed a brochure targeted to caregivers with 

examples of caregiving and listing available caregiver services 

and supports.

One day (the program director) approached me and told 

me, I know you’re doing a lot for your parents. So, he 

invited me to come over, so I started coming over.” 

—Title VI Caregiver

FINDING SOLUTIONS TO PROGRAM CHALLENGES
WHAT WE’VE LEARNED

EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT 39

PROGRAM IMPACT

Title VI Programs Are Serving Elders Most in Need

As described, the OAA is the primary federal support for the delivery of social and nutrition services for older 

adults. As part of the OAA, Title VI authorizes funds to reach AI/AN/NH elders most in need of support to 

reduce hunger, avoid food insecurity, and ensure overall health and wellness. The core Title VI services—

congregate and home-delivered meals, supportive services, and caregiver support services—are designed 

to promote health, socialization, independent functioning, and quality of life. Together, these services help to 

keep elders in their homes and communities.

Consistent with the intent of the Title VI programs, elders using at least one Title VI service (Title VI elders) 

tend to be elders in greater need of support compared to elders not participating in Title VI services 

(non-Title VI elders). Specifically, Title VI elders are older, have lower income, and are more likely to have 

difficulty with ADLs and IADLs (Figure 7).8 Also, Title VI elders more often have a health condition affecting 

their nutrition and more often report having a family caregiver who provides them with needed support.

Elders Receiving Title VI Services Experience Fewer Hospitalizations and Falls

Elders receiving any Title VI services experienced significantly fewer hospitalizations and falls per year in 

comparison with elders who did not receive or participate in Title VI services. This difference is even more 

pronounced for elders served by grantees who provide a higher number of services9 compared to elders served 

by grantees with lower levels of service provision (53% fewer hospitalizations and 45% fewer falls; see Figure 8).

 

 

8ADLs are basic actions that independently functioning individuals perform on a daily basis. These may include bathing, dressing, transferring (moving to and from a bed or a chair), and 

caring for incontinence. Many public programs determine eligibility for services according to a person’s need for help with ADLs. IADLs are activities that are not necessary for basic 

functioning but are necessary to live independently. These activities may include doing light housework; taking medication; preparing and cleaning up after meals; shopping for groceries or 

clothes; using the telephone; managing money; taking care of pets; using communication devices; getting around the community; and responding to emergency alerts, such as fire alarms.

9Guided by Title VI program regulations, high service provision grantees were defined as providing 5 or more days per week of congregate meals, more than 120 meals per client annually 

for home-delivered meals, and 4 or more supportive services.

Data Source: NRCNAA Elder Needs Assessment

FIGURE 7. ELDERS USING TITLE VI SERVICES HAVE GREATER NEED OF SUPPORT 

FIGURE 8. ELDERS USING ANY TITLE VI SERVICE 

EXPERIENCE FEWER HOSPITALIZATIONS AND FALLS*

Data Source: NRCNAA Elder Needs Assessment 

TITLE VI IMPACT 

Elders receiving Title VI 

services experienced 36% 

fewer hospitalizations and 

10% fewer falls per year. 

Data Source: NRCNAA Elder 

Needs Assessment 

*Statistically Significant Relationship at p < 0.05
WHAT WE’VE LEARNED

40 EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT

Elders who receive congregate and/or home-delivered meals also experience fewer hospitalizations and 

falls in comparison to elders not receiving these services (Figure 9). Elders served by grantees who provide 

a higher number of nutrition services have the lowest average number of hospitalizations and falls in 

comparison to other elders.

Elders Participating in Title VI Services Experience Greater Social and 

Cultural Connectedness

Elders participating in Title VI services are more likely to engage in cultural practices on a monthly basis 

and report more instances of social activity compared to elders who do not participate in Title VI services 

(Figure 10). The difference was greater in the case of elders served by grantees who provided higher numbers 

of services (Figure 11).

*Statistically Significant Relationship at p < 0.05 Data Source: NRCNAA Elder Needs Assessment 

FIGURE 9. ELDERS WHO USE NUTRITION SERVICES EXPERIENCE FEWER 

HOSPITALIZATIONS AND FALLS*

Data Source: NRCNAA Elder Needs Assessment 

FIGURE 10. ELDERS PARTICIPATING IN TITLE VI SERVICES PARTICIPATE IN MORE 

CULTURAL PRACTICES AND SOCIAL ACTIVITIES

More elders using Title VI services participated in cultural practices at least once a month compared to 

elders who did not use Title VI services (79% versus 65%). Elders using Title VI services also had a higher 

number of socializations per month.
WHAT WE’VE LEARNED

EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT 41

Title VI Programs Provide Opportunities for Improved Health and 

Wellness and Social/Cultural Connectedness

Promote Physical Health

Title VI nutrition services fulfill a critical need for elders, in some cases providing the only hot, nutritious meal 

in an elder’s day. Balanced and nutritious meals help elders maintain their health, avoid illness, and improve 

their overall well-being.

Nearly 70% of program directors 

reported they are able to meet at 

least some of their elders’ needs 

(e.g., nutrition, transportation, 

referrals). 

Of elders’ needs met, 66% are 

congregate and home-delivered 

meals. 

Data Source: n4a Title VI Program Survey 

You know, homebound . . . elderly might not 

have a balanced meal in the home. Maybe 

that’s the only meal that they get in the day.”

—Title VI Elder

Home-delivered and congregate meals 

are the most used Title VI service and the 

service having the most significant impact 

on elders.”

—Title VI Program Director

Provide Social and Cultural Connection 

For many elders who participate in congregate meals, the communal dining experience provides far more than 

a meal—it provides a much-needed chance for elders to tell stories about their lives, ask questions, and share 

their concerns or needs with Title VI program staff. The congregate meal is an event that improves elders’ 

moods and provides opportunities for friendship and a sense of belonging to the community. Similarly, for 

homebound elders, a visit from a meal delivery driver provides them with much-needed social contact and 

support from a caring staff member. For many homebound elders, meal delivery sends a powerful message 

that they are not alone or forgotten. Elders also appreciate that grantees often serve traditional, native food, 

providing for cultural connection.

When you’re home alone, you might fix 

something but you’re not happy because 

you know you’re all alone, sitting there trying 

to eat that meal. And when you’re here, you 

have people around you talking, laughing, 

and seem to enjoy the meal.”

—Title VI Elder

We come here and share. Everybody is 

eating it. It makes you feel good . . . . It’s 

the way the cook prepares it. The native 

culture, you have it here and we all share that 

because we can’t go home to do that, have 

the native food.”

—Title VI Elder

Not High Service 

Provision Grantees

High Service 

Provision Grantees

6 11

Socializations 

per month

Socializations 

per month

57% 86%

Data Source: NRCNAA Elder Needs Assessment 

FIGURE 11. ELDERS FROM HIGH SERVICE PROVISION GRANTEES PARTICIPATE IN MORE 

CULTURAL AND SOCIAL ACTIVITIES

69%

66%
WHAT WE’VE LEARNED

42 EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT

[I like best] that somebody comes into my 

house when I’m really down, and they take 

the time to come in and say hello and give 

you a hug.”

—Title VI Elder

I’d be very, very down if somebody didn’t 

stop to see me every day. Some days are 

long, long, long when you’re not feeling 

good. And them coming in personally to 

check on you . . . and I rely on them coming 

to see I’m alright and if I tell them something, 

they’ll go do it for me.”

—Title VI Elder

Relieve Stress and Promote Mental Well-Being

Title VI nutrition services provide elders with “something to look forward to” and relieve stress and burden. 

Grantees with more robust service provision had higher reports of elders feeling happy most of the time. 

Elders receiving meals (congregate or home-delivered) from higher service provision grantees were more 

likely to report feeling happy than elders from lower service provision grantees. Receiving nutrition services 

was, itself, a positive predictor of elders’ mental well-being.10 For many elders, due to illness or disability, 

cooking can be difficult, and Title VI relieves them of worry about preparing a meal. Moreover, the meal 

service reduces the burden on family caregivers, which often relieves stress for elders. 

[The program is] something to look forward 

to. Sometimes you don’t have anything to 

look forward to in the daytime. I know I get 

that way sometimes.”

—Title VI Elder

I’m disabled and I can’t prepare good meals 

for myself, you know, that’s why I count on 

the delivery system there to provide me with 

beneficial meals like that.”

—Title VI Elder

And we just think the world of our drivers . . . 

They’re checking on us . . . and that’s safety, 

and they’re eyeballing us and making sure, 

things like that. I think that’s a plus for us.”

—Title VI Elder

I have my daughter who I live with and [the 

meal delivery] helps quite a bit because she 

prepares my breakfast and my dinners, and 

this . . . just gives her a chance to go and do 

things on her own that she wants to do . . . . 

And it makes me feel better that she can do 

other things.”

—Title VI Elder

I would say it helps me growing old. To grow 

old and to be neglected would be really . . . 

I’m searching for the right word. It would be 

disastrous.”

—Title VI Elder

10Inferential analysis revealed that elders from grantees with overall high service provision for congregate meals and home-delivered meals may expect to report feeling happier 

(β1 = 0.09, p < 0.05; and β1 = 0.11, p < 0.05, respectively) compared to elders from a lower service provision grantee. See Appendix B (Methods) for additional details.

11Statistically significant relationship (p < 0.05) between grantees’ high service provision and elders’ mental well-being. Controlled for county poverty rate, rurality, and percentage 

of elders older than 70 years of age.

TITLE VI IMPACT

A robust nutrition program positively predicts elders’ mental well-being.11

6% fewer elders reported a meal inadequacy and/or eating alone between Cycle VI and Cycle VII.

Data Source: NRCNAA Elder Needs Assessment
WHAT WE’VE LEARNED

EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT 43

Supportive Services

Title VI programs provide supportive services for elders, including information and assistance, outreach, case 

management and transportation, and homemaker and chore support, among others. Services reported to 

be the most helpful to elders were transportation, social and cultural activities, educational opportunities, 

physical activities, and linkages and referrals to supports. 

Transportation 

Many elders emphasized the importance of transportation 

services, which help them access medical appointments, 

go shopping, run errands, and attend congregate meals. 

Across all Title VI programs, elders need transportation 

support, particularly in rural communities that do not have 

centralized services. Although recognized as critical, not all 

programs are able to provide this service.

Transportation plays a big role over here, 

having them pick us up or take us home, 

or even taking you to your appointments 

or wherever you want to go to make an 

appointment at the tribal office or whatever.”

—Title VI Elder

It’s very hard to get around and all that. And 

if that transportation was not there either, we 

won’t be able to come over here.”

—Title VI Elder

Social and Cultural Activities

Elders appreciate that the Title VI programs offer them activities and opportunities for social and cultural 

connection, such as language programs, exposure to cultural practices, peer sharing and learning, and 

intergenerational experiences. Many elders see this as a valuable way to keep their culture alive. 

Since I’ve been in the program, I’ve been 

getting into learning about the culture. I am 

just starting to hula, which I never did in my 

whole life.”

—Title VI Elder

. . . but truly the Native American community is 

a family. We are a family and those values are 

here and the senior center promotes that. And 

it’s the glue moving that culturally forward, so 

that’s the big importance there, too.”

—Title VI Elder

Because when you think about it, if we don’t 

grab onto it now, it’s just going to fade away. 

We have to do it now because a lot of it is 

already gone, so we have to start doing it 

now within ourselves.”

—Title VI Elder

It’s a lot of camaraderie here. People getting 

along, making new friends, etcetera. So, 

friendship—that’s one of the main things. You 

get to see people, meet people, talk with 

people. A building is just a building, but the 

people make the place a place. And there’s 

some pretty good people around. That’s the 

main reason why I come.”

—Title VI Elder

In 2018, evaluation grantees 

provided elders with, on average, 

more than 6,400 rides. 

Data Source: PPR, 2018
WHAT WE’VE LEARNED

44 EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT

Educational Opportunities

Elders also participate in educational opportunities through Title VI, including “lunch and learns,” which focus 

on nutrition, Medicaid services, and substance abuse, among other topics. Nutrition education, for example, 

guides elders in selecting healthier foods and promoting their physical health.

But since we had the talk, I’m more aware of 

the food I’m putting in my mouth. I’m kind of 

paying attention to what’s going on and the 

sugar part of it, cutting that out, cutting down 

on it.”

—Title VI Elder

I guess it’s about being well-informed about 

what we’re supposed to do at our age, and 

when we have people come to speak to us 

and tell us about our high blood pressure, 

about our diabetes. So, that’s good, that 

keeps us well-informed, and I like that.”

—Title VI Elder

Physical Activity

In addition, many programs offer physical activities and exercise opportunities, including Senior Olympics. 

Elders enjoy these and shared that these activities help keep them physically and mentally active.

We did a line dance here and it’s an exercise. 

You know when you exercise your legs 

and stuff, that’s really helpful. So, I’m glad 

somebody brought that exercise because we 

need that as we age.”

—Title VI Elder

They always tell me, my doctors, to not 

just sit around. I just need to move around, 

exercise . . . . And we really need that, no 

matter what age we are, we need that 

regular exercise.”

—Title VI Elder

Linkages/Referrals

Many elders reported appreciating assistance in being linked to other needed resources and supports 

through their Title VI program. 

. . . what I think is so neat is if I needed 

handrails in my house, I know she’d know 

where the resources are at. She’s a good 

resource person for us seniors. All we have 

to do is pick up the phone and she’ll direct us 

or check on it herself.”

—Title VI Elder

But I appreciate everything that happens 

here, the staff, they’re very attentive. And 

they’re very observant in terms of, at least, 

help. They’ll ask you . . . they’ll address your 

issue: ‘How are you doing, what’s happening, 

do you need help?’”

—Title VI Elder
WHAT WE’VE LEARNED

EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT 45

Caregiver Support Services

Caregiver support services are essential because they provide relief to caregivers and help improve their 

overall quality of life. 

Information and Assistance

Caregivers genuinely feel connected to and supported by Title VI program staff and rely on staff to support 

them. Program staff share useful resources and information about available caregiver services and provide 

referrals to ensure better care for caregivers and their family members. 

They’ve got tons of information. Anything 

you want to know, they bend over backwards 

and get it for you. If they aren’t able to have 

somebody come in for you, they give you 

information to rural resources or things 

like that.”

—Title VI Caregiver

[The staff member] is so caring, and she 

always gets right back with you. That’s 

important because you’re already frustrated 

or lacking sleep, and she always tries to find 

a resource for you. That’s what I like about 

her. And she comes out to visit. She checks 

up on the person that needs the care and the 

providers, as well, to see if there’s anything 

she could help out with.”

—Title VI Caregiver

Respite

For the programs that offer respite services, caregivers reported that this service provided them with an 

opportunity to take a needed break from the challenging work of caregiving and to attend to other aspects of 

their lives. 

I know as a caregiver I need time for myself. 

It’s hard to take care of somebody else 

and not take care of yourself. How do you 

be strong for them when you can’t even 

take care of your own self? With mom, it’s 

good that somebody else comes in. And, 

that I take time out for me, and I go do what I 

need to do.”

—Title VI Caregiver

My mom liked to argue, especially when her 

dementia got worse, and [the respite] gave 

me a little bit of a break from her. I hate to 

say that.”

—Title VI Caregiver

One-third of evaluation grantees believe they are meeting caregivers’ needs 

for respite services. 33%
WHAT WE’VE LEARNED

46 EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT

Counseling/Support Groups/Training

Of the two programs that offered caregiver support groups as part of their Part C services, caregivers shared 

that the support groups helped them manage the stress of caregiving. The support groups helped caregivers 

learn from other caregivers who face similar issues and gave them renewed strength to continue providing care. 

It’s most helpful for us as caregivers to 

take time away from our home, away from 

our clients or patients that we care for. I’m 

a 24/7 caregiver and to just get away for 

those few minutes over here and then to 

share our difficulties amongst ourselves. And 

as a caregiver, how to survive and take care 

of ourself.”

—Title VI Caregiver

So, I thoroughly appreciate coming [to the 

caregiver group]. Because . . . of course, 

everything that we share amongst each other 

and all that stays here. And leaves that here 

for us to again kind of begin to be whole and 

start our journey again.”

—Title VI Caregiver

Supplemental Services

A few caregivers reported that the Title VI program provided them with equipment, such as wheelchairs or 

walkers, a simple but critical resource that helped them support their care recipient to remain as independent 

as possible. 

This last week, she needed a walker. They provided that ASAP, and we didn’t have to worry about 

spending our own money, having to run around town and find it . . . . That walker enables her to be 

independent instead of having to rely on somebody to help carry her to the bathroom.”

—Title VI Caregiver
IMPACT OF COVID-19

EVALUATION OF THE ACL TITLE VI PROGRAMS — FINAL REPORT 47

During the winter of 2020, the SARS-CoV-2 virus emerged, which led to the COVID-19 pandemic. Due 

to structural and systemic inequities disproportionately impacting communities of color, Title VI elders, 

because of their age and race, were especially vulnerable. During the evaluation, Title VI evaluation grantees 

(e.g., program directors and staff) described their experiences related to the COVID-19 pandemic, including 

the impact that the pandemic had on their communities and the strategies they implemented in response. 

Although in-person services were generally suspended, many grantees attempted to continue service 

delivery in creative ways, such as by shifting congregate meal provision to meal delivery or pickup, and by 

sending information and materials for activities home to elders and caregivers. Some grantees also offered 

new services or supported elders in new ways, such as by purchasing and delivering household cleaning 

supplies and by helping elders with miscellaneous tasks, including taking mail to the post office. 

NUTRITION AND SUPPORTIVE SERVICES FOR ELDERS

Suspended congregate meals and other in-person activities. All grantees suspended in-person 

congregate meals and other in-person activities, such as educational events or physical activity 

programs, for elders and caregivers. However, most grantees continued to provide meals for congregate 

participants by expanding their home-delivered meal program or establishing a socially distanced drive-up/

pickup approach that allowed elders to safely collect meals to take home.

Expansion of home-delivered meals. Nearly all grantees continued (and expanded) their meal 

delivery service. Some grantees expanded their home-delivered meal program during the pandemic 

to include elders who normally participated in congregate meals and, in the case of many grantees, elders 

who had not previously participated in the nutrition program. 

[Elders] are really appreciative of the fact that we’re able to deliver the meals to them. Just the 

opportunity for the elders to come and talk, even if it’s with the screen door closed. Just to say 

hi and how things are going and touch base with them. They really appreciate the fact that the 

meals are there for them.”

—Title VI Program Director

In some cases, cooks, drivers, and other Title VI staff were considered “essential workers” and 

continued to perform their jobs as before—preparing hot meals for elders multiple days per week. 

In other cases, cooks and drivers were temporarily or permanently laid off during partial or full 

shutdowns in grantee communities.

IMPACT OF COVID-19 

AND TITLE VI EVALUATION 

GRANTEE RESPONSE
IMPACT OF COVID-19

48 EVALUATION OF THE ACL TITLE VI PROGRAMS — FINAL REPORT

Increased demand for meals. Many grantees reported a significant increase in the overall demand for 

meals, with some reporting an increase of almost twice the number of elders needing meal support. 

[We are] getting a lot of people that never came before to our program. A lot of new faces we 

were seeing.”

—Title VI Program Director

Delivery of food boxes. During the early stage of the pandemic shutdown, when programs were not 

providing daily meal service, several grantees packaged and delivered 2-week food boxes to elders. 

Some grantees continued to provide weekly or biweekly food boxes in addition to home-delivered meals or 

drive-through pickups to help meet the increased demand for nutrition support.

Limited availability of supplies. Several grantees reported a loss of critical resources and supplies 

from vendors, such as food containers, paper products, and Styrofoam food trays, making meal 

provision more difficult. Others reported shortages of supplies for elders, such as tissues, paper towels, toilet 

paper, and cleaning products. 

Suspended transportation for elders. In the case of grantees who normally provide transportation 

services for elders (e.g., taking elders to medical appointments, the post office, the senior center, and 

shopping), grantees had to suspend these services. 

CAREGIVER SUPPORT SERVICES

Reduced caregiver program. Most grantees reported that caregiver support services, such as respite 

care and other in-home services, had been suspended. In one case, due to a community lockdown, 

caregivers who resided outside the community were not permitted to come into the community if they were 

not tribal members.

As congregate meals shifted to home delivery, the meal delivery schedule for one grantee 

increased from 10 deliveries per day to more than 60 deliveries per day.

One grantee reported that the combined number of home-delivered and congregate pickup meals 

provided during the prior month (April 2020) was equivalent to the total number of meals they 

provided in the previous grant year. 

Food boxes included an estimated 25 

to 40 pounds of shelf-stable food that 

elders and/or caregivers could use to 

quickly prepare meals.

In most cases, drivers continued to deliver meals and, in some cases, go grocery shopping 

or deliver mail for elders.

Some grantees delivered between 150 

and 250 food boxes to elders. In some 

cases, volunteers who were “willing to 

come out and help us serve our most 

vulnerable” helped with deliveries.
IMPACT OF COVID-19

EVALUATION OF THE ACL TITLE VI PROGRAMS — FINAL REPORT 49

COMBATING ELDER ISOLATION 

Canceled social and community events. Grantees were forced to cancel a range of in-person 

events, including special events planned for elders. In the case of one grantee, a 24th annual 

elders luncheon was canceled. More broadly, tribes canceled a range of community events (e.g., holiday 

celebrations, powwows, rodeos), which led to a sense of disrupted routine and decreased social connection 

and engagement for elders and their families. 

So, we had a real busy life going on prior to the pandemic . . . it has really changed our lifestyles a lot. 

We can’t go out and do a lot of things we’ve done before. Like within the community, they had to cancel 

our 4th of July events. There would be a powwow and rodeo and food vendors everywhere . . . now all 

of that has been canceled. And all community events came to a halt, which affected all of us as well 

as our elders.”

—Title VI Program Director

I think in this whole thing the difficulty that we’ve found is the issues with the social isolation. There 

continues to be a decline amongst our elders because we were always about encouraging them to 

leave their homes, to get out and be physical. And now we’ve done the opposite . . . we’re telling them 

‘stay home, don’t go anywhere.’ So, it’s a lot for them.”

—Title VI Program Director

. . . a lot of the elders are taking it really hard . . . that they’re homebound and they’re not allowed to 

leave. Or they can’t have family around to go visit them. Some of the elders that were already isolated 

as it was or that depended on somebody to be there with them, don’t have that assistance right now. 

So, I think that’s probably one of the hardest things going on right now.”

—Title VI Program Director

Increased check-ins. Many program staff 

described being concerned about elders’ 

emotional well-being and them feeling isolated, 

forgotten, or afraid. Staff shared various strategies 

to enhance opportunities for social connection, 

including: 

▶ Reaching out by phone more often to check on 

elders and address concerns and fears

▶ Organizing volunteers to make phone calls to 

elders to share news and assess needs

▶ Visiting in person while maintaining 

social distance.

Primarily, [elders] just want somebody to speak 

with. So, our conversations . . . sometimes 

15–20 minutes, they really enjoy it. They 

express to me that they have so much gratitude 

to our staff because they . . . were afraid.”

—Title VI Program Director

SOCIALLY DISTANCED ACTIVITIES

▶ Coloring books, word games

▶ Materials to participate in a community 

hummingbird coloring contest

▶ Small wooden structure to paint, such 

as a bird house

▶ Stress ball

▶ Plant pot with seeds

▶ Decorating sand 

ACTIVIT Y CARE PACK AGES 

▶ Gave elders “something to look 

forward to”

▶ Helped to “keep them occupied . . . 

to try to get themselves out of those 

moods of depression.”

—Title VI Program Directors
IMPACT OF COVID-19

50 EVALUATION OF THE ACL TITLE VI PROGRAMS — FINAL REPORT

Delivery of activity care packages. Several grantees worked to ensure elders received care packages 

that included activities and materials to help keep them engaged, occupied, in positive spirits, and 

connected to the community. 

 What can we do from a distance—we’ve been talking about maybe having small groups, doing 

conference calls with small groups. And singing—even if it’s a short time . . . we’re just trying to figure 

that out safely.” 

—Title VI Program Director

NEW SAFETY PROTOCOLS

New safety protocols. For programs that continued to deliver meals to elders’ homes or to provide 

other supports involving interaction with drivers, grantees took precautions to avoid exposing 

themselves or elders to the virus. This included wearing a mask and gloves during home visits and 

encouraging social distancing with elders. 

We just deliver with our protective gear on, we don’t go completely in the house. They have a little 

table by the door. We don’t go all the way in; we just leave it there. They tell us to stay at least 6 feet 

from them.”

—Title VI Driver

Elders need to be reminded to follow physical distancing guidelines: “Then another [elder] sees 

somebody out, then they come out, and then it becomes a group of eight people in a matter of a minute 

that have to be reminded to kind of keep their distance and everything. And it’s hard because they all 

want that connectivity.”

—Title VI Program Director

STAFFING

Reduced staffing/work from home. Most grantees were required by their tribe or organization to limit 

the number of staff in their offices, maintain safe social distancing, or work remotely. This depended 

on whether the tribe was partially or completely shut down. Some program directors reported having to 

temporarily lay off staff. 

Working remotely has been difficult, if not impossible, for some staff due to: 

▶ Lack of proper equipment at home (e.g., computers, phones)

▶ Insufficient program funds for supports such as business cell phones or laptops 

Our program has been deemed an essential program. So, while everyone else can be laid off or go 

home and work from home, we have to still report here to provide for our elders, whether it be a hot 

meal; whether it be helping them with bringing their mail from their home to the post office; whether it 

be providing information to them, which we still try to do if we know of it. And we know the information 

needs to get out there to the community; we still provide that.”

—Title VI Program Director
DISCUSSION

EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT 51

Program Implementation 

The 12 Title VI evaluation grantees varied in their program context, including program setting and cultural norms, 

and in their approach to program implementation. In terms of staffing, all grantees maintained a program director 

and one other staff member who fulfilled the various duties of program implementation. Whether other staff 

positions and roles were used and, if so, which ones—such as cook, driver, caregiver coordinator, and activity 

director, among others — varied by grantee. As part of their program structure, half of the evaluation grantees 

relied on an elder advisory board or committee to help direct program activities, whereas others did not have 

such a resource. All evaluation grantees provided core nutrition and supportive services for elders, including 

congregate and home-delivered meals as well as information and referral services. However, only some 

grantees provided additional supportive services, such as transportation, personal care, help with chores 

and tasks in the home, nutrition education, shopping assistance, and others. In addition, the implementation 

of Part C, Caregiver Support Services, reflected substantial variation across evaluation grantees, including 

incomplete implementation in most cases. Many of the grantees provided information, outreach, and assistance 

to support caregivers in accessing services. Some provided respite services, whereas counseling, support 

groups, and caregiver trainings were provided less frequently. Overall, although the OAA defines Part C as 

delivery of all five of these services, not all Title VI grantees are implementing these services.

Program context and community-specific needs accounted for variation in program implementation approaches 

to an extent, but grantees also faced common implementation challenges. These primarily included funding 

and resource limitations, frequent staff turnover and difficulty recruiting skilled staff, confusion among program 

staff about Title VI service definitions and requirements, limited capacity for program tracking and performance 

monitoring, and difficulty building awareness of their Title VI programs as well as encouraging elders and 

caregivers to participate.

Program staff responded to these challenges by developing 

strategies that drew on their community’s strengths and 

resources. Strategies included (1) building diverse partnerships 

with individuals, tribal departments, and community 

organizations to create efficiencies, leverage resources, 

and enhance service delivery; (2) identifying supplemental 

funding sources within and beyond Indigenous communities; 

(3) creating strong Title VI program teams through cross-training, 

collaboration, and dedication to meeting elders’ and caregivers’ 

needs; and (4) seeking technical assistance from ACL to 

understand the Title VI program and implementation strategies.

Although these approaches have enhanced program 

implementation in some cases, the persistent challenges 

that grantees face point to several implications and related 

considerations to guide program implementation going forward. 

GRANTEES FACED COMMON 

PROGRAM IMPLEMENTATION 

CHALLENGES

▶ Funding and resource limitation

▶ Frequent staff turnover

▶ Uncertainty of Title VI service 

definitions and eligibility

▶ Limited performance 

monitoring

▶ Difficulty reaching out to elders 

and caregivers

DISCUSSION
DISCUSSION

52 EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT

Key Considerations 

Funding and Resource Limitations

Many evaluation grantees described funding and resource limitations as one of the most substantial 

challenges they face in implementing their Title VI programs. The limited nature of Title VI funding requires 

that program directors and staff identify ways of leveraging other supports, including partnerships and 

other supplementary resources to expand the reach of their programs to elders and caregivers in need. 

Program directors and other staff pursue such partnerships and resources, but with varying levels of 

success from year to year. For example, because supplemental funding from the tribe is not always a reliable 

resource, some grantees have substantially reduced Title VI service provision during years with limited 

funding. Overall, despite efforts to fill gaps, grantees are often forced to limit service provision because 

of insufficient funding. 

An additional consequence is that limited funding results in lower funding for staff salaries, which can 

undermine efforts to attract skilled staff (e.g., staff trained in data management systems) and promote staff 

retention. Grantees would benefit from TTA that would help them develop their business acumen and 

capacity to leverage and build partnerships, which would produce more stable and robust service provision. 

Also tied to budget management and oversight, program staff often lack control of, or access to, their 

Title VI budgets, making it difficult to plan independently. In some cases, grantee staff must coordinate with 

tribal finance departments, which may not have insight about Title VI program services. This can lead to 

difficulties tracking available funding and managing program spending effectively. 

Understanding the Title VI Program

As described, most program staff lack understanding of Title VI service definitions and requirements, 

particularly in the case of Part C, Caregiver Support Services. Without a complete understanding of Title VI 

program definitions, requirements, and eligibility criteria, grantees are not able to optimize program 

implementation, which can result in implementation inefficiencies and lower quality service delivery. 

Particularly in a context of limited funding and resources, program staff need clear and detailed guidance to 

prioritize their efforts, maximize program implementation, and ensure high-quality service delivery. In addition, 

when staff are uncertain about service definitions, requirements, and eligibility criteria, they will be less able 

to meet the requirements of the grant or to ensure compliance. 

Grantee Capacity for Program Performance Monitoring

Regarding performance monitoring, accuracy in reporting is limited because program staff lack a thorough 

understanding of the Title VI program and reporting requirements. Evaluation grantees are also limited 

in performance monitoring capacity, including data systems and other resources, staff support, and 

knowledge. In addition, program staff may not recognize that data can be leveraged to tell an important 

story about their programs. This extends to a lack of recognition that such stories can build awareness 

about the importance of the Title VI program among Indigenous communities, leadership, and other 

program stakeholders; highlight program successes and needs; and attract partnerships, funding, and 

other resources to maximize program implementation. Moreover, to the extent that grantee reporting is 

incomplete, inconsistent, or inaccurate, this can lead to difficulty comparing programs based on performance 

monitoring data. In other words, an “apples to apples” review of the data across programs is not possible. 

High-quality and consistently collected program implementation data are needed to inform and drive program 

improvement going forward. 
DISCUSSION

EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT 53

Program Outreach and Recruitment

Program staff described difficulty building awareness and 

engagement with elders and caregivers. Caregivers often 

do not self-identify as caregivers, and there is both a lack of 

awareness among caregivers as to available supports and a 

reluctance among caregivers to seek assistance. Program staff 

have increased one-on-one outreach and other strategies that 

have helped to engage eligible elders and caregivers and to 

build awareness of Title VI program services. For example, 

one grantee developed a brochure targeted to caregivers that 

provided caregiving examples to help them understand their 

role as a caregiver. However, efforts to increase outreach are 

uneven, and grantees need guidance to address challenges 

surrounding outreach and recruitment. Without effective 

outreach and recruitment efforts, program implementation 

has not been maximized. 

Addressing these common challenges would enhance opportunities to maximize program implementation 

and promote more consistent performance monitoring and reporting. Grantees would benefit from receiving 

additional TTA from ACL on Title VI program implementation goals and recommended implementation 

approaches, including program definitions, requirements, and eligibility criteria; outreach and recruitment 

strategies; and performance monitoring and reporting strategies. This guidance should address what counts 

as a program service, who counts as an eligible client, and priorities for service delivery. As noted, grantees 

need support to improve their understanding of Part C Caregiver Support Services, especially. Program staff 

would benefit not only from receiving basic guidance on Title VI requirements and eligibility criteria but also 

on strategies to maximize implementation in context-specific ways. For example, although some grantees 

may not be able to implement a robust respite program reaching all caregivers in need, a more limited respite 

program or a focus on delivering information and assistance to caregivers may be feasible. In recognition of 

the need for guidance on the Title VI programs, ACL has developed TTA to support grantees with Title VI 

service delivery, including guidance specifically related to Part C. Additional and ongoing TTA on these 

topics will be critical to maximize program implementation and high-quality service provision.

Program Service

Nutrition and Supportive Services

The Title VI program is reaching elders who most need the program, including elders who have lower 

incomes, are older, and are less independent. For those elders receiving Title VI Part A/B Nutrition and 

Supportive Services, the benefits are significant. Based on a variety of data sources, including elders’ own 

perspectives, these Title VI programs have helped elders make healthier choices and live independently 

longer—a key program goal. The program has also provided significant opportunities for elders to socialize 

and feel connected with their community and culture. Specifically, participation in congregate meals, 

supportive services, and other Title VI activities has enhanced friendships; increased social and cultural 

connectedness, feelings of protection, and happiness; created a sense of “something to look forward to”; and 

decreased isolation. Even for homebound elders, simply having a meal dropped at one’s home is protective 

and leads to a feeling of being cared for and of greater connection with the community. 

PROGRAM 

IMPLEMENTATION 

TTA SHOULD INCLUDE 

GUIDANCE ON

▶ What counts as program 

service

▶ Who counts as eligible 

clients

▶ Priorities for service 

delivery
DISCUSSION

54 EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT

Elders Make Healthier Choices and Live Independently Longer

Social connection leads to improved mental health, a sense of well-being, and improved quality of life. 

Moreover, elders receiving Title VI services experienced significantly fewer hospitalizations and falls 

per year (36% and 10% fewer, respectively) compared with elders who did not receive or participate in 

Title VI services. This difference is even greater for elders served by grantees who provide more robust 

services compared with elders served by grantees who provide less robust services. 

Based on findings related to program implementation, a greater number of elders could benefit from Title VI 

nutrition and supportive services. Without these supports, elders may be at greater risk of experiencing a 

sense of isolation, decreased well-being, lack of connectedness, less ability to live independently, and greater 

likelihood of experiencing hospitalizations and falls. 

Caregiver Support Services

Title VI Caregiver Support Services help caregivers by providing relief from the stress of caregiving and by 

helping improve caregivers’ overall quality of life. Caregivers genuinely feel connected to and supported by 

Title VI program staff and feel they can rely on staff to support them. Program staff share useful resources 

and information about available caregiver services and provide referrals to ensure better care for caregivers 

and their family members. For the programs that offer respite services, this service has provided caregivers 

with needed breaks from the challenging work of caregiving, prevented burnout, and allowed caregivers to 

refocus on other areas of their lives. 

In the case of grantees who provide access to lending closets with durable equipment (e.g., wheelchairs, 

walkers, portable commodes), this has been a valued service for caregivers, helping to ensure that elders 

remain independent and in their homes. In addition, although caregiver support groups and trainings are 

infrequently provided, caregivers reported that these resources improved their emotional well-being, 

camaraderie through social connection, and stress relief. 

Variability in Caregiver Programing

Based on findings related to program implementation, caregiver support service provision varies 

considerably across evaluation grantees. As noted, more consistent and complete program implementation 

is needed as well as improved outreach and participant recruitment. Grantees may not be accurately 

identifying eligible subpopulations of caregivers (e.g., grandparents caring for grandchildren) and recognizing 

their distinct needs. In addition, participant recruitment is complicated by the fact that family caregivers do not 

recognize themselves as caregivers. Addressing these issues could provide opportunities to reach a greater 

number of caregivers who could benefit from Title VI Caregiver Support Services. Without these supports, 

caregivers are more at risk of experiencing increased burden and stress, decreased resiliency, and increased 

financial burden because of caregiving.
TRAINING AND TECHNICAL ASSISTANCE

EVALUATION OF THE ACL TITLE VI PROGRAMS — FINAL REPORT 55

By providing nutrition and supportive services to 

promote the independence and well-being of tribal 

elders, Title VI may also be reducing healthcare 

costs. ICF conducted an exploratory analysis and 

found that elders using Title VI services reported 

an average of 36 percent fewer hospital visits (for 

all causes) and 10 percent fewer falls per person 

per year1

 than elders not using Title VI services.

Fewer Hospitalizations and Fewer Falls 

= Healthcare Savings

For a Title VI program that serves 500 elders, 

this could translate to 185 fewer hospital visits 

and 50 fewer falls per year.

This is a possible annual savings of up to 

$64,900 for treatment of falls5 and $2.5 million 

for hospitalizations.6

After subtracting the cost of running the Title VI 

program,7 there could be an overall savings of up 

to $2.36 million per Title VI program per year. 

Although further exploration of Title VI services 

and usage costs is needed (e.g., the cost of 

maintaining facilities and staffing, as well as 

additional sources of funding), these preliminary 

findings suggest that Title VI programs have the 

potential to help contain the growing financial 

burden of elders’ hospitalizations and falls.

FALLS AND OLDER ADULTS

Of Title VI elders, 40% 

reported a fall and 21% 

reported a hospitalization 

in the last year.1

In the United States, 

1 in every 4 elders (> 65yo) 

reports falling each year.2

Every 11 seconds, an older 

adult is treated in the 

emergency room for a fall.3

Falls are the leading cause 

of injury-related death among 

older adults.4

1. 0.85 and 1.22 average hospitalizations and 0.99 and 1.09 average falls per year for elders using Title VI services and elders not using Title VI services, respectively. National 

Resource Center on Native American Aging, University of North Dakota, Elder Needs Assessment Cycle VII Survey (2017–2020). Elder Data from eight evaluation grantees. 

2. Moreland B, Kakara R, Henry A. Trends in Nonfatal Falls and Fall-Related Injuries Among Adults Aged ≥65 Years — United States, 2012–2018. MMWR Morb Mortal Wkly Rep 

2020;69:875–881. DOI: http://dx.doi.org/10.15585/mmwr.mm6927a5external icon

3. Burns ER, Kakara R. Deaths from Falls Among Adults ≥65 Years—United States, 2007–2016. MMWR Morb Mortal Wkly Rep 2018; 67:509–514. DOI: http://dx.doi.org/10.15585/

mmwr.mm6718a1external icon. 

4. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online].

5. The estimated and adjusted cost of a fall is $1,297 excluding hospitalization cost to avoid overlapping hospitalization estimates (December 2019). Ref.: Florence, C. S., Bergen, 

G., Atherly, A., Burns, E., Stevens, J., & Drake, C. (2018). Medical Costs of Fatal and Nonfatal Falls in Older Adults. Journal of the American Geriatrics Society, 66(4), 693–698. 

https://doi.org/10.1111/jgs.15304

6. The average hospital cost for adults ages 65–84 (younger seniors) is $14,997 per stay, and for adults age 85 and older (older seniors), the average cost is $11,601 per stay. 

Ref.: HCUPnet, Healthcare Cost and Utilization Project. Agency for Healthcare Research and Quality, Rockville, MD. https://hcupnet.ahrq.gov/. For more information about HCUP 

data see http://www.hcup-us.ahrq.gov. For overall program estimation saving associated with hospitalizations, we considered a program serving 500 seniors and assumed a 

distribution of 2 older seniors (total of $858,500 saved for 74 elders hospitalizations prevented) to 3 younger seniors (total of $1.66 million saved for 111 elders hospitalizations 

prevented), proximal to the distribution reported in the Elder Needs Assessment Cycle VI data report. 

7. Program cost was estimated to be $160,290 and was based on the average 2017 Title VI funding for programs serving 401–500 elders and receiving Parts A/B and C funding. 

COULD TITLE VI REDUCE 

HEALTHCARE COSTS?
RECOMMENDATIONS

56 EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT

RECOMMENDATIONS

The Evaluation of the ACL Title VI Programs provided valuable insight into the overall impact of the Title VI 

programs as well as to how grantees implement their Title VI programs at the local level. These findings also 

reveal opportunities to better support and guide grantees in program implementation with TTA as well as 

opportunities for further study. 

TTA TO FACILITATE TITLE VI IMPLEMENTATION

These recommendations are intended to address challenges related to uncertainty over Title VI service 

definitions and eligibility, and performance monitoring. They center on providing enhanced guidance and TTA for 

Title VI grantee staff, promoting skill building for Title VI staff working in various roles, improving the accessibility 

of resources for grantees, and creating opportunities for grantee collaboration and resource sharing.

Develop standardized definitions for each Title VI service. 

To support grantees in better understanding the range and scope of Title VI services, definitions of service 

categories should be in plain language and include examples of eligible and ineligible services, activities, and 

participants. Service category definitions and examples should be used consistently across Title VI regions 

and trainings (e.g., Title VI cluster trainings) to promote broad understanding across all Title VI grantees. 

▶ For example, to demystify Part C, Caregiver Support Services, ACL should develop clear, plain language 

definitions of the required caregiver support service categories and the range of allowable services and 

activities for each service category, as well as provide examples of and rationale for each. 

Update the Title VI manual. 

Because the main written resource available to grantees is the Title VI manual, ACL should update it to 

enhance accessibility and usability. Revisions may include ensuring the use of plain language throughout. In 

sections in which plain language is not possible (e.g., in instances of presenting language from the OAA), the 

manual could use callout boxes to present the main points. Title VI program service definitions and sections 

should include examples grounded in local program implementation. Additionally, hyperlinking sections 

would allow users to quickly access chapters of particular relevance or interest to them.

Develop Title VI training tracts. 

To enhance program implementation and respond to grantee requests for training on particular topics, ACL 

should develop trainings to increase understanding of the Title VI programs as well as to promote fidelity of 

program implementation. Trainings should be standardized across Title VI regions and accessible in a variety 

of formats (e.g., online, in-person, recorded, and archived). ACL should consider developing a set of training 

tracts for specific grantee program staff/roles, including program directors and support staff (e.g., cooks, 

drivers, finance managers). See textbox on the following page for recommended training topics.

▶ For program directors: Trainings should include discussion of program requirements, eligibility, and 

implementation expectations for Part A/B, Nutrition and Supportive Services, and Part C, Caregiver Support 

Services programs. They should also include the basics of program management and budgeting, and 

strategies to develop partnerships, leverage resources, and conduct program monitoring and reporting.
EVALUATION OF THE ACL TITLE VI PROGRAMS — FINAL REPORT 57

▶ For support staff: Trainings should include discussion of 

issues relevant to Title VI program staff in different roles, 

such as finance directors, administrative support staff, 

cooks, caregiver coordinators, and drivers. For example, 

program directors and other program staff have requested 

training on topics including budget requirements, timelines, 

and allowable expenses, as well as recommendations 

for designing meal plans to promote elder nutrition and 

ensure proper food storage, handling, and preparation; 

understanding and supporting the needs of caregivers 

and grandparents caring for grandchildren; and addressing 

issues related to transportation.

Promote evidence-based interventions.

ACL currently hosts the Aging and Disability Evidence-Based 

Programs and Practices initiative, which helps the public learn 

more about available evidence-based programs and practices 

(EBPP) in the areas of aging and disability and determine 

which of these may best meet their needs. Additional guidance 

specifically tailored to the needs of Title VI grantees would be 

useful. Guidance should include plain language and address 

the importance of using EBPPs and promising practices. The 

guidance could feature EBPPs and promising practices that 

have been used with success among Title VI grantees, grantee 

spotlights, and actionable guidance.

Develop a Title VI resources and TA hub. 

ACL should develop a platform to host TTA resources for 

grantees, including written guidance, fact sheets or onepagers, recorded webinars, and asynchronous trainings. 

Recommended features of the hub include the following: 

▶ Topical resources library. Provide a virtual library in which 

resources would be organized by topic, such as program 

management, program services, and program monitoring. 

The library should be easily accessible to all Title VI 

grantees and program staff.

▶ TTA query system. Provide a query system through which 

grantees could submit TA requests or questions, and 

subject matter experts (SMEs) could log TA requests, report 

outcomes of TA, and monitor followup to address TTA as 

needed. The platform could be supported by a pool of ACL 

SMEs and also serve to facilitate grantee collaboration 

via virtual bulletin boards, chat features, and other 

communication mechanisms.

▶ Community of practice. Develop a community of practice 

to create opportunities for more experienced grantees 

to share and support other grantees in developing their 

Title VI programs. 

RECOMMENDED TITLE VI 

TRAINING TOPICS

▶ Introduction to the Title VI 

Programs: Title VI program 

definitions, requirements, 

allowable services, and participant 

eligibility for each service type

▶ The Caregiver Support Program:

In-depth guidance on required 

Caregiver Support Services, 

including all five required services

▶ Performance Monitoring 

and Reporting: How to 

collect accurate information 

on Title VI service delivery, 

including caregiver clients 

(e.g., grandparents raising 

grandchildren, spouse caring for 

spouse) and services 

▶ Program Planning, Outreach, 

and Recruitment: How to use 

grantee program data and other 

resources to (1) inform program 

planning and meet elder and 

caregiver needs and (2) inform 

targeted outreach and participant 

recruitment efforts, including 

helping family caregivers see 

themselves as caregivers and 

access available services 

▶ Managing a Title VI Program:

Fundamentals of program 

management, including program 

planning, managing staff, 

building partnerships, leveraging 

resources, and enhancing 

business acumen

▶ Title VI for Finance Directors: An 

introduction to the Title VI grant, 

including budgeting requirements, 

timeline, and allowable expenses

▶ Menu Planning and Preparation:

Designing meal plans to 

promote elder nutrition and food 

preparation (e.g., food safety: 

proper food storage and handling)
RECOMMENDATIONS

58 EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT

SUPPORTING PROGRAM SERVICE AND REACH

Recommendations related to program service aim to promote evaluation findings, such as the positive health 

outcomes among elders who participate in the Title VI programs. These recommendations also suggest 

opportunities to expand Title VI services to better meet the needs of elders and caregivers at the grantee, 

program, and national levels. 

Nutrition and Supportive Services

Promote Title VI program impact. 

The evaluation identified several key findings related to elder health and well-being. Elders using Title VI 

services have greater cultural and social connectedness, and experience, as a whole, fewer hospitalizations 

and falls per year compared to elders not participating in Title VI services. ACL should promote dissemination 

of these findings to build awareness in the field, inform other practitioners, and potentially strengthen 

professional relationships across similar programs. Dissemination also would help build awareness among 

stakeholders of the importance of the Title VI program and facilitate partnership building and collaboration 

within and beyond the Title VI programs. 

▶ Leverage resources and partnerships. ACL should use the evaluation findings to deepen existing 

partnerships and collaborations as well as identify new partners who share similar goals and outcomes. 

Leveraging resources and partnerships will help Title VI grantees address unmet needs that elders 

receiving Title VI identified, including increased opportunities for socialization, transportation for daily 

activities (e.g., medical, shopping), additional meals per week, and homemaker and personal care 

attendant services.

Caregiver Support Services

Conduct a caregiver survey. 

ACL should consider implementation of a cross-site representative caregiver survey to understand caregiver 

needs at the national program level. Survey findings could help further refine and tailor program guidance to 

best support grantees in addressing the needs of caregivers. 

▶ Localized caregiver needs assessment. ACL should consider supporting grantees in conducting a 

community caregiver needs assessment at the community/grantee level, similar to the NRCNAA Elder 

Needs Assessment, to better understand local caregiver health, social demographics, and needs for 

service. Combined with TTA in the Part C program (as described in the previous section), grantees would be 

better able to meet caregiver needs.

Develop a caregiver awareness campaign. 

The evaluation found that all grantees faced challenges in outreach to caregivers, that caregivers did not see 

themselves as such, and that caregivers were largely unaware of available services and supports. ACL should 

consider developing a national campaign to build awareness of how caregivers are defined in the Title VI 

program as well as the services available to support informal caregivers. Program materials could include flyer 

templates and public service announcement language that grantees could tailor to fit their local community 

and program context. A Who is a Caregiver campaign would increase understanding of the different forms of 

caregiving among both program staff and community members.
RECOMMENDATIONS

EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT 59

AREAS FOR FURTHER STUDY

Recommendations for further study build from the evaluation’s promising findings and will support ACL in 

understanding whether and how these associations hold on a broader scale. Suggested areas for further 

study include the following:

Cost-benefit study. 

Building on the evaluation findings, which suggest that the Title VI program has the potential to limit 

the growing social and financial burden of falls and hospitalizations among elders, ACL should consider 

conducting a cost-benefit study to further explore this issue. ICF recommends a mixed methods approach, 

including (1) review and abstraction of existing data systems (e.g., the OAA Performance System, the 

Healthcare Cost and Utilization Project) and (2) key informant interviews to identify and monetize all relevant 

costs (e.g., all program expenditures, use of resources, and investments) and benefits (e.g., decrease in falls 

and hospitalizations and increase in well-being). This will support ACL in better understanding the return on 

investment that Title VI provides, as well as its drivers.

Dose-response study. 

Those grantees the evaluation identified as higher service providers were associated with better 

social–emotional and physical outcomes for elders compared to programs with more limited services. 

Further research could help determine whether there is best practice for service delivery in which positive 

outcomes associated with Title VI services are maximized and whether those practices vary by population 

demographic (e.g., working elders vs. retired elders, elders raising grandchildren, elder age) and setting 

(e.g., congregate vs. home-delivered meals). Results could inform updates to national recommendations for 

maintaining optimal health for elders and caregivers (e.g., related to nutrition, socialization, physical activity, 

or other issues) as well as Title VI service guidelines and implementation. 

Attribution study for all grantees. 

Elders participating in Title VI services experienced better outcomes for falls, hospitalizations, and 

connectedness than elders who did not receive or participate in Title VI services. Future research should 

build on these findings to assess whether this finding is consistent when all Title VI grantees are included in a 

similar study. The Elder Needs Assessment dataset, housed at NRCNAA/UND, presents a unique opportunity 

to study these outcomes on a broader scale, beyond the evaluation grantees. The attribution study could 

include the full, disaggregated Elder Needs Assessment data, coupled with qualitative data collection with 

grantee communities to contextualize the findings and to improve understanding of Title VI program impact. 

Variables to consider as part of the study include age; gender; race (i.e., AI/AN/NH); level and type of service 

use; and contextual factors, such as grantee location, degree of exposure to services, and funding structure 

for the program. Such a study could determine on a broader scale any variation in outcomes at the individual 

level (e.g., AI vs. AN/NH) and grantee program level (e.g., differences based on programs that are funded by 

sole or multiple sources). 

Caregiver study. 

The evaluation identified promising indicators related to caregiver well-being. ACL should consider an 

outcomes study to further understand the impact of Title VI on caregiver well-being and quality of life, 

and whether and how this leads to better outcomes for elders. Similar to the Evaluation of the ACL Title VI 

Programs, a mixed methods approach, including a national, cross-site caregiver survey (as recommended 

above), would provide context related to caregiver experiences from their perspective. In addition, the study 

could identify promising practices for caregiver services that other Title VI grantees could adapt or replicate. 

If ACL wanted to identify and share promising practices more quickly with the Title VI community, an EA could 

serve as an initial step before conducting an outcomes study related to caregiver support services. 
RECOMMENDATIONS

60 EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT

Focused outcomes study. 

ACL should consider a focused outcomes study to understand more about the positive outcomes that are 

associated with Title VI programs as well as other outcomes that Title VI programs may be impacting but for 

which data were limited. For example, the evaluation identified that elders participating in Title VI services 

are more likely to engage in cultural practices on a monthly basis and to report more instances of social 

activity compared to elders who do not participate in Title VI services. Secondary data related to social 

connectedness were limited and may not comprehensively measure the full construct, limiting the ability 

to identify what elements of the program (e.g., people, processes, systems) were responsible for increased 

connectedness. In addition, it is reasonable, given the reduction in hospitalizations and falls that were found 

for elders receiving Title VI services, that Title VI may positively impact other outcomes related to chronic 

disease. Similar to the attribution study described above, the full disaggregated NRCNAA Elder Needs 

Assessment dataset, in addition to other data collection instruments (e.g., social connectedness scale for 

older adults, chronic disease management scale), present an opportunity for further study across a larger pool 

of elders and Title VI programs. By better understanding which outcomes the Title VI programs impact and 

how, ACL can refine program design and delivery to enhance these effects. 

Evaluability assessments. 

EAs are useful methods for identifying promising practices quickly and disseminating information rapidly. For 

example, the final year of data collection coincided with the COVID-19 pandemic. Evaluation grantees shared 

insight on how they pivoted program implementation to continue to support elders in this new environment. 

ACL should consider conducting an EA to identify new promising practices for service delivery, including 

remote and distance delivery. These findings would have implications beyond the scope of the COVID-19 

pandemic and could support grantees in continuing critical support to elders and caregivers in the face of 

future pandemics or natural disasters. The EA should include focus groups and interviews with a panel of 

key stakeholders (e.g., local, state, national program providers) to identify promising practices and program 

adaptations and to share findings rapidly. 

Crosswalk and align data sources. 

ACL has access to a deep pool of data related to the Title VI programs, including the PPR (by ACL), the Elder 

Needs Assessment (by NRCNAA/UND), and the Title VI Program Survey (by n4a/Scripps). Together, these 

datasets house valuable information related to program scope and needs as well as elder health and service 

utilization. ACL should conduct a crosswalk of current datasets and identify opportunities for streamlining 

data collection (so as to minimize burden on participants) as well as for refining questions to (1) ensure clarity 

(e.g., eliminating double-barreled questions) and (2) align with national datasets, such as the Behavioral Risk 

Factor and Surveillance Study, to facilitate comparisons between Title VI and national samples.
MEANINGFUL STAKEHOLDER ENGAGEMENT

EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT 61

REFERENCES

Administration for Community Living. Administration on Aging (AoA): Older Americans Act. Retrieved from 

https://acl.gov/about-acl/authorizing-statutes/older-americans-act

Administration for Community Living. Office for American Indian, Alaska Natives and Native Hawaiian 

Programs. In Administration on Aging (AoA). Retrieved from https://acl.gov/programs/services-nativeamericans-oaa-title-vi

Administration for Community Living. (2015). Evaluability assessment of the Title VI Grant Program. 

Washington, DC: Author. 

Bowman, N. R., Francis, C. D., & Tyndall, M. (2015). Culturally responsive indigenous evaluation: A practical 

approach for evaluating indigenous projects in tribal reservation contexts. In S. Hood, R. Hopson, & H. Frierson: 

Continuing the journey to reposition culture and cultural context in evaluation theory and practice (pp. 335–

359). Information Age Publishing, Inc. Retrieved from http://lead.wceruw.org/Bowman-bookChapter.pdf

Israel, B., Schulz, A. J., Parker, E. A., & Becker, A. B. (1998). Review of community-based research: Assessing 

partnership approaches to improve public health. Annual Review of Public Health, 19, 173–202.

LaFrance, J., Nichols, R. (2010). Reframing evaluation: Defining an Indigenous evaluation framework. The 

Canadian Journal of Program Evaluation, 23, 13–31.

FOR MORE INFORMATION, CONTACT:

Kristen (Krissy) Hudgins, Ph.D.

Social Science Analyst, Office of Performance 

and Evaluation

Administration for Community Living

Telephone: 202-795-7732

Email: Kristen.Hudgins@acl.hhs.gov

Gretchen Clarke, M.P.H.

Manager, Title VI Evaluation

ICF

Telephone: 907-747-7124

Email: Gretchen.Clarke@icf.com
62 EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT

MEANINGFUL STAKEHOLDER ENGAGEMENT

64 EVALUATION OF THE ACL TITLE VI PROGRAMS—FINAL REPORT